Anesthesia and analgesia
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Anesthesia and analgesia · Oct 2018
Meta AnalysisLaryngeal Mask Airway Versus Other Airway Devices for Anesthesia in Children With an Upper Respiratory Tract Infection: A Systematic Review and Meta-analysis of Respiratory Complications.
LMA use in children with URTIs reduces cough compared to intubation, but possibly not laryngospasm, although quality of evidence is poor.
pearl -
Anesthesia and analgesia · Oct 2018
Randomized Controlled TrialPreoperative Continuation Versus Interruption of Oral Hypoglycemics in Type 2 Diabetic Patients Undergoing Ambulatory Surgery: A Randomized Controlled Trial.
It’s likely safe to continue metformin and sulphonylureas in those fasting for day surgery, in the absence of renal impairment.
pearl -
Anesthesia and analgesia · Oct 2018
Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A Retrospective Analysis.
What did they do?
Markley et al. conducted a single-center retrospective cohort study of 23 years of data from a tertiary North American academic hospital. The investigators identified 129 patients meeting criteria, requiring elective Cesarean delivery (CD/CS) for suspected morbidly adherent placenta (MAP): placenta accreta, increta or percreta.
Why the fuss?
Historically there has been concern that neuraxial anaesthesia may add additional complexity when managing a major haemorrhage associated with MAP CS, by:
- Complicating large volume resuscitation in an awake patient.
- Accentuating hypotension due to sympathectic block.
- Having an unsecured airway in the event of intraoperative crisis.
- Creating neuraxial uncertainty when coagulopathy occurs.
And they found...
The majority of patients with morbidly adherent placentas can be safely managed with neuraxial anesthesia alone. GA conversion was also safe for those requiring it.
Of the 129 patients, 5% were electively given a GA. Of the 122 (95%) who received neuraxial anesthesia (NA), only 15 (12%) were converted to GA after delivery.1 There were three difficult intubations (AFOI, VL and bougie each) among the 22 GAs. NA was predominately combined-spinal epidural or epidural.
Of the 72 patients requiring hysterectomy, 21% (15) needed NA-GA conversion.
The only independent predictors for GA conversion were history of ≥3 previous CS and long surgical duration.
The big question
Although retrospective, this data again reassures that neuraxial anesthesia can be a safe and appropriate choice for cesarean delivery with placenta accreta, increta or percreta. The big question will be whether you are happy managing an emergent NA-GA conversion and intubation in the 1-in-8 requiring it (or 1-in-5 with hysterectomy) or plan for an elective GA pre-surgery.
summary
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Notably, a further 5 (4%) required GA conversion before delivery due to inadequate block. ↩
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Anesthesia and analgesia · Oct 2018
ReviewPatient Blood Management in Pediatric Cardiac Surgery: A Review.
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. ⋯ This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Anesthesia and analgesia · Oct 2018
Randomized Controlled Trial Comparative StudyResuscitation of Endotheliopathy and Bleeding in Thoracic Aortic Dissections: The VIPER-OCTA Randomized Clinical Pilot Trial.
Thoracic aorta dissection is an acute critical condition associated with shock-induced endotheliopathy, coagulopathy, massive bleeding, and significant morbidity and mortality. Our aim was to compare the effect of coagulation support with solvent/detergent-treated pooled plasma (OctaplasLG) versus standard fresh frozen plasma (FFP) on glycocalyx and endothelial injury, bleeding, and transfusion requirements. ⋯ In this randomized, clinical pilot trial of patients undergoing emergency surgery for thoracic aorta dissections, we found that OctaplasLG reduced glycocalyx and endothelial injury, reduced bleeding, transfusions, use of prohemostatics, and time on ventilator after surgery compared to standard FFP. An adequately powered multicenter trial is warranted to confirm the clinical importance of the findings.