Anaesthesia and intensive care
-
Anaesth Intensive Care · Mar 2012
EditorialSugammadex: restricted vs unrestricted or selective vs non-selective?
Neville Gibbs and Peter Kam outline three evidence-based indications for use of sugammadex in 2012, even with its high cost:
Early reversal of rocuronium when suxamethonium is contraindicated. For example in ECT for patients with a pseudocholinesterase deficiency or neuromuscular denervation conditions.
Reversal of rocuronium when even very mild residual neuromuscular block carries significant patient risk. For example, patients with neuromuscular disorders such as myotonic dystrophy or myasthenia gravis; and patients with severe pulmonary disease with limited reserve.
Unplanned early reversal of rocuronium during a failed intubation where rapid reversal may allow awakening of the patient.
Rescue from residual paralysis despite having given neostigmine.
-
Anaesth Intensive Care · Mar 2012
The influence of unrestricted use of sugammadex on clinical anaesthetic practice in a tertiary teaching hospital.
This retrospective audit identified an association between the introduction of unrestricted access to sugammadex and a fall in 'anaesthetic theatre time'. Mean hospital stay was also observed to be 0.8 days shorter after introduction of sugammadex, but was not statistically significant after adjusting for confounders.
summary -
Anaesth Intensive Care · Mar 2012
Case ReportsA persistent 'can't intubate, can't oxygenate' crisis despite rocuronium reversal with sugammadex.
An interesting CICO case study highlighting that while sugammadex will rapidly and completely reverse paralysis, this is only one consideration when managing an airway crisis. The use of any reversal agent in an airway crisis should be considered within the context of the case and a clear understanding of the objective of our actions.
Neuromuscular reversal will only improve a CICO scenario if spontaneous ventilation will improve patient oxygenation, otherwise return of muscle function may actually make other CICO interventions more difficult.
summary -
Anaesth Intensive Care · Mar 2012
Unrestricted access to sugammadex: impact on neuromuscular blocking agent choice, reversal practice and associated healthcare costs.
Ledowski et al. investigated the effect of unrestricted access to sugammadex in an Australian teaching hospital with a retrospective observational audit.
Use of both sugammadex and amino steroid relaxants increased dramatically, with average reversal costs per case increasing by AUS$85.
Although there was no change in anaesthesia, surgical or PACU time, there was a statistically significant decrease in median time from surgery to hospital discharge (0.2 days shorter) after introduction of sugammadex. Do to the nature of the study, it is nevertheless impossible to infer a causal link.
summary -
Anaesth Intensive Care · Mar 2012
Review Meta AnalysisPrevention of gastrointestinal bleeding due to stress ulceration: a review of current literature.
Our objective was to audit our current stress ulcer prophylaxis protocol (routine prescription of ranitidine and early enteral feeding) by identifying whether routine prescription of histamine-2 receptor antagonists or proton pump inhibitors as prophylaxis against stress-related mucosal disease and subsequent upper gastrointestinal bleeding is supported in the literature. We also aimed to ascertain what literature evidence supports the role of early enteral feeding as an adjunctive prophylactic therapy, as well as to search for burn-patient specific evidence, since burn patients are at high risk for developing this condition, with the aim of changing our practice. PubMed and Cochrane databases were searched for relevant articles, yielding seven randomised controlled trials comparing histamine-2 receptor antagonists and proton pump inhibitors in the prevention of upper gastrointestinal bleeding associated with stress-related mucosal disease and three separate meta-analyses. ⋯ However, enteral feeding was found to be safe and effective in preventing clinically significant upper gastrointestinal bleeding. Patients able to tolerate feeds demonstrated no additional benefit with concomitant pharmacological prophylactic therapy. Since all burn patients at the Royal Adelaide Hospital are fed from very early in their admission, the literature suggests that we, like our intensive care unit colleagues, should abolish our reliance on pharmacological prophylaxis, the routine prescription of which is not supported by the evidence.