Anaesthesia
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Review Meta Analysis
Prevention of hypotension after spinal anaesthesia for caesarean section: a systematic review and network meta-analysis of randomised controlled trials.
Why is this review important?
Although the importance of managing spinal anaesthesia-associated hypotension during caesarean section is well appreciated, there continues to be some debate over relative efficacy of interventions, whether vasopressors or fluid-loading.
Fitzgerald at al.'s review and network meta-analysis quantitatively compares a complete range of interventions across 109 studies.
What did they show?
Vasopressors were more effective at preventing intra-operative hypotension than fluid infusion techniques alone. Although there was no statistically significant difference in the incidence of hypotension among metaraminol, phenylephrine or noradrenaline/norepinephrine, metaraminol appeared the most effective (OR 0.04-0.26) and ephedrine the least (0.09-0.85). [vs Norepinephrine (OR 0.06-0.28), Phenylephrine (OR 0.11-0.29)]
Similarly, nausea and vomiting incidence was lower with vasopressors than other interventions. Phenylephrine more commonly caused bradycardia than other pressors, and ephedrine more commonly tachycardia. There was no significant difference in reactive hypertension.
The bottom-line...
The most effective way of preventing and managing maternal intraoperative hypotension is, as international guidelines already assert, alpha-agonist vasopressors. Using more complex protocols, such as phenylephrine or norepinephrine infusions, does not appear to offer benefit over metaraminol. Fluid infusions are at best a secondary intervention.
summary -
Previous studies on the safety of peri-operative transoesophageal echocardiography seem to suggest a low rate of associated morbidity and mortality. That said, there has been a paucity of prospective multicentre studies in this important area of clinical practice. We carried out a one-year prospective study in 2017, co-ordinated by the Association of Cardiothoracic Anaesthesia and Critical Care, to determine the rate and severity of complications associated with peri-operative transoesophageal echocardiography in anaesthetised cardiology and cardiac surgical patients. ⋯ These figures are higher than previously reported and suggest a high probability of death following the development of a complication (~40%). Most complications occurred in patients without known risk factors for transoesophageal echocardiography associated gastro-oesophageal injury. We suggest clinicians and departments review their procedural guidelines, especially in relation to probe insertion techniques, together with the information communicated to patients when the risks and benefits of such examinations are discussed.
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Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. ⋯ In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.