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.
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Multicenter Study
Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study.
Traumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubation practice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injury included in the prospective cohort study collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER-TBI) in 45 centres in 16 European countries. ⋯ In conclusion, patient and injury characteristics are key drivers of tracheal intubation. Between-centre differences were also substantial. Further studies are needed to improve the evidence base supporting recommendations for tracheal intubation.
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Propofol-based total intravenous anaesthesia is well known for its smooth, clear-headed recovery and anti-emetic properties, but there are also many lesser known beneficial properties that can potentially influence surgical outcome. We will discuss the anti-oxidant, anti-inflammatory and immunomodulatory effects of propofol and their roles in pain, organ protection and immunity. We will also discuss the use of propofol in cancer surgery, neurosurgery and older patients.
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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.