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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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.
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Deaths following surgery are the third largest contributor to deaths globally, and in Africa are twice the global average. There is a need for a peri-operative research agenda to ensure co-ordinated, collaborative research efforts across Africa in order to decrease peri-operative mortality. ⋯ The top 10 research priorities identified were (1) Develop training standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (2) Develop minimum provision of care standards for peri-operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (3) Early identification and management of mothers at risk from peripartum haemorrhage in the peri-operative period; (4) The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri-operative care; (5) A facility audit/African World Health Organization situational analysis tool audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and level of training and knowledge of peri-operative healthcare providers (surgeons, anaesthetists and nurses); (6) Establishing evidence-based practice guidelines for peri-operative physicians in Africa; (7) Economic analysis of strategies to finance access to surgery in Africa; (8) Establishment of a minimum dataset surgical registry; (9) A quality improvement programme to improve implementation of the surgical safety checklist; and (10) Peri-operative outcomes associated with emergency surgery. These peri-operative research priorities provide the structure for an intermediate-term research agenda to improve peri-operative outcomes across Africa.