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3
POISE showed that for every 1000 patients receiving metoprolol, 15 were prevented from suffering a myocardial infract, 3 from requiring cardiac revascularization along with 7 new cases of atrial fibrillation, but at a cost of causing an excess 8 deaths, 5 strokes, 53 hypotensive events and 42 episodes of bradycardia.
The harm associated with perioperative beta-blockade, at least in the form of non-titrated extended-release metoprolol, is greater than the demonstrated benefit. For every two cases of myocardial infract avoided there is one excess death.
POISE Study Group, Devereaux PJ, Yang H et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008 May 31;371(9627):1839-47.
  Daniel Jolley
pearl
1
Perioperative metoprolol in at-risk patients undergoing non-cardiac surgery reduced major cardiovascular adverse events but increased mortality.
POISE Study Group, Devereaux PJ, Yang H et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008 May 31;371(9627):1839-47.
  Daniel Jolley
pearl
1
Multiple labour epidural top-up boluses, caesarean section urgency or care by non-obstetric anaesthetists increase risk of failed epi anaesthesia.
Bauer ME, Kountanis JA, Tsen LC et al. Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials. Int J Obstet Anesth. 2012 Oct 1;21(4):294-309.
  Daniel Jolley
summary
1
Retrospective studies show that a single anesthesia exposure before age 3 may undermine language acquisition and abstract reasoning, and exposure to two or more anesthetics before age 2 almost doubles the risk of attention-deficit hyperactivity disorder, although in both cases causality has not yet been established.
Olsen EA Brambrink AM. Anesthesia for the young child undergoing ambulatory procedures: current concerns regarding harm to the developing brain. Curr Opin Anaesthesiol. 2013 Dec 1;26(6):677-84.
  Daniel Jolley
pearl
1
Anesthesia neurotoxicity may affect the developing human brain, however methodological challenges limit the conclusiveness of current evidence.
Olsen EA Brambrink AM. Anesthesia for the young child undergoing ambulatory procedures: current concerns regarding harm to the developing brain. Curr Opin Anaesthesiol. 2013 Dec 1;26(6):677-84.
  Daniel Jolley
summary
0
Nerve block duration may be extended by adrenaline, clonidine, dexmedetomidine, dexamethasone, and possibly midazolam, tramadol and magnesium. Other than adrenaline there is however no longterm data demonstrating safety. Intra-articular adjuvant benefit has been shown for tramadol, magnesium, dexmedetomidine, clonidine, ketamine, ketorolac and morphine, but the evidence is not strong enough to support routine use.
Barreveld A, Witte J, Chahal H et al. Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth. Analg. 2013 May 1;116(5):1141-61.
  Daniel Jolley
summary
1
Barreveld et al. show that LA administered either IV or via block; before, during or after surgery, significantly reduces postoperative pain and opioid consumption.
Specifically in:
• Total knee arthroplasty (femoral, sciatic and lumbar plexus b., single-shot or continuous)
• Total hip arthroplasty (continuous lumbar plexus; intra-articular LA)
• Knee arthroscopy (single-shot lumbar plexus; IA LA; single-shot femoral nerve ± sciatic).
• Arthroscopic shoulder surgery - interscalene b., single-shot or continuous. IA is not beneficial.
• Hand & forearm surgery - axillary b. offers analgesic benefits only on day of surgery.
• TAP block is beneficial for laparoscopic, open appendectomy, abdominal surgery, cesarean section, and TAH.
Barreveld A, Witte J, Chahal H et al. Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth. Analg. 2013 May 1;116(5):1141-61.
  Daniel Jolley
pearl
0
Intravenous lidocaine is efficacious and may be a suitable alternative to regional anesthesia when contraindicated or not performed.
Barreveld A, Witte J, Chahal H et al. Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth. Analg. 2013 May 1;116(5):1141-61.
  Daniel Jolley
pearl
0
Nerve blocks in general have a beneficial analgesic effect, regardless of whether pre- or post-incision, and are superior to intra-articular LA.
Barreveld A, Witte J, Chahal H et al. Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth. Analg. 2013 May 1;116(5):1141-61.
  Daniel Jolley
summary
1
Monitoring neuromuscular blockade with TOF at the eye muscles (orbicularis oculi) results in a 5 times greater risk (adjusted odds ratio) of postoperative residual curarization (PORC) than monitoring at the hand (adductor pollicis) when PORC is defined by TOFR < 90% using acceleromyography.
PORC was nonetheless common in both groups, occurring in 52% and 22% respectively.
Thilen SR, Hansen BE, Ramaiah R et al. Intraoperative neuromuscular monitoring site and residual paralysis. Anesthesiology. 2012 Nov 1;117(5):964-72.
  Daniel Jolley