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summary
1
This is the first published recommendation for perimortem cesarean sections in maternal cardiac arrest – from Katz, Dotters and Droegemueller (1986).
It was this recommendation that lead to the ‘4 minute rule’ for deciding to commence a CS in a resuscitation scenario, with the aim of delivering the baby within 5 minutes.
Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean delivery. Obstet Gynecol. 1986 Oct 1;68(4):571-6.
  Daniel Jolley
summary
0
McDonnell makes a concerning observation regarding the ageing maternity population and subsequent potential for increasing rates of maternal arrest:
With the change in the obstetric population characteristic to women being older, heavier, and having more complex medical problems during pregnancy, the number of women who become seriously unwell while pregnant is likely to increase.
McDonnell NJ. Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem Caesarean delivery. Br J Anaesth. 2009 Sep 1;103(3):406-9.
  Daniel Jolley
summary
1
McDonnell highlights the differences in managing the collapsed parturient, namely:
• Need to prevent aortocaval compression.
• Early securing of the airway.
• Rapid perimortem Caesarean delivery.
• Likelihood of a non-cardiac/pregnancy cause.
The two cases presented include arrest due to ruptured uterus and arrest possibly due to iatrogenic magnesium overdose. Both resulted in favorable, though not perfect, outcomes for mother and baby.
The need for delivery suite ‘perimortem cesarean section packs’ is also discussed, as well as the use of regular simulation training.
McDonnell NJ. Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem Caesarean delivery. Br J Anaesth. 2009 Sep 1;103(3):406-9.
  Daniel Jolley
pearl
1
Anesthesia with nitrous oxide preserves awake features of the EEG leading to inappropriately higher BIS values.
Foster BL Liley DT. Nitrous oxide paradoxically modulates slow electroencephalogram oscillations: implications for anesthesia monitoring. Anesth. Analg. 2011 Oct 1;113(4):758-65.
  Daniel Jolley
pearl
1
Propofol and thiopentone are physiochemically compatible when mixed.
Prankerd RJ Jones RD. Physicochemical compatibility of propofol with thiopental sodium. Am J Health Syst Pharm. 1996 Nov 1;53(21):2606-10.
  Daniel Jolley
pearl
1
Video-laryngoscopy in pediatric anesthesia improves glottis visualization but prolongs intubation time and increases failure.
Sun Y, Lu Y, Huang Y et al. Pediatric video laryngoscope versus direct laryngoscope: a meta-analysis of randomized controlled trials. Paediatr Anaesth. 2014 Oct 1; 24 (10): 1056-65.
  Daniel Jolley
pearl
1
The addition of ketamine to lignocaine-based IVRA (Bier's block) significantly improved analgesia and patient satisfaction without increasing side effects.
Abdel-Ghaffar HS, Kalefa MA, Imbaby AS. Efficacy of Ketamine as an Adjunct to Lidocaine in Intravenous Regional Anesthesia. Reg Anesth Pain Med. 2014 Sep 1; 39 (5): 418-22.
  Daniel Jolley
comment
0
The flaw with many closed loop TIVA-BIS studies, such as this one, is that they unquestionably assume reliability of BIS and are not powered for important morbidity or mortality outcomes.
This study while professing to show 'superiority' of a closed-loop system, really just shows that when given a monitor target the algorithm can more accurately and rapidly adjust the TIVA to maintain this. This may well be a good outcome, but does not necessarily equate to 'good' or safe anesthesia.
It's important to note that BIS has been validated essentially as an awareness alarm, not (yet) as a guide to appropriate depth of anesthesia.
Orliaguet GA, Lambert FB, Chazot T et al. Feasibility of Closed-loop Titration of Propofol and Remifentanil Guided by the Bispectral Monitor in Pediatric and Adolescent Patients: A Prospective Randomized Study. Anesthesiology. 2015 Apr 1;122(4):759-67.
  Daniel Jolley
pearl
1
Closed loop control of propofol/remi TIVA targeting BIS 40-60 is more precise than manual control.
Orliaguet GA, Lambert FB, Chazot T et al. Feasibility of Closed-loop Titration of Propofol and Remifentanil Guided by the Bispectral Monitor in Pediatric and Adolescent Patients: A Prospective Randomized Study. Anesthesiology. 2015 Apr 1;122(4):759-67.
  Daniel Jolley
pearl
1
In high risk cardiac surgery, anesthesia with either sevoflurane or TIVA results in comparable postoperative mortality and morbidity.
Landoni G, Guarracino F, Cariello C et al. Volatile compared with total intravenous anaesthesia in patients undergoing high-risk cardiac surgery: a randomized multicentre study. Br J Anaesth. 2014 Dec 1;113(6):955-63.
  Daniel Jolley