Article Notes

• Hide
  • Pearls
  • Summaries
  • Comments

summary
1
This retrospective propensity-matched cohort study, used 5 years of data to study 2,644 matched pairs-of-patients with a preoperative diagnosis of severe COPD.
Important exclusions were patients already ventilated, already with pulmonary infections, along with cardiac, emergency & transplant surgery, and those receiving repeat surgery within 30 days.
Receiving general anesthesia was associated with a 43% higher risk of respiratory infection (3.3% vs 2.3%, P = 0.0384), 133% greater risk of prolonged ventilation (2.1% vs 0.9%, P = 0.0008) and 44% greater risk of unplanned post-op intubation (2.6% vs 1.8%, P = 0.0487), when compared with regional anesthesia.
Nonetheless there was no significant mortality difference at 30 days (3.0% vs 2.7%, P = 0.6788).
The mix of regional techniques was 341 epidural, 1713 spinal, and 590 peripheral blocks. Notably, sub-group analysis of epidural-patients showed no difference in pulmonary complications or composite morbidity between epidural and general anesthesia. (Though given relatively small number of epidural patients, this might reflect a lack of power).
Hausman MS, Jewell ES, Engoren M. Regional Versus General Anesthesia in Surgical Patients with Chronic Obstructive Pulmonary Disease: Does Avoiding General Anesthesia Reduce the Risk of Postoperative Complications? Anesth. Analg. 2015 Jun 1; 120 (6): 1405-12.
  Daniel Jolley
pearl
1
In patients with chronic obstructive pulmonary disease, use of regional anesthesia is associated with less post-operative morbidity, though not mortality, when compared with general anesthesia.
Hausman MS, Jewell ES, Engoren M. Regional Versus General Anesthesia in Surgical Patients with Chronic Obstructive Pulmonary Disease: Does Avoiding General Anesthesia Reduce the Risk of Postoperative Complications? Anesth. Analg. 2015 Jun 1; 120 (6): 1405-12.
  Daniel Jolley
pearl
1
Negative post-anesthetic cognitive effects are still present one week after both desflurane or propofol anesthesia.
Lindqvist M, Schening A, Granstrom A et al. Cognitive recovery after ambulatory anaesthesia based on desflurane or propofol: a prospective randomised study. Acta Anaesthesiol Scand. 2014 Oct 1;58(9):1111-20.
  Daniel Jolley
summary
1
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.
Watts RW, London JA, van RM et al. The influence of unrestricted use of sugammadex on clinical anaesthetic practice in a tertiary teaching hospital. Anaesth Intensive Care. 2012 Mar 1;40(2):333-9.
  Daniel Jolley
pearl
1
Unrestricted access to sugammadex both increases the use of sugammadex and changes patterns of muscle relaxant drug choice by anaesthetists.
Watts RW, London JA, van RM et al. The influence of unrestricted use of sugammadex on clinical anaesthetic practice in a tertiary teaching hospital. Anaesth Intensive Care. 2012 Mar 1;40(2):333-9.
  Daniel Jolley
summary
1
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.
Ledowski T, Hillyard S, Kozman A et al. Unrestricted access to sugammadex: impact on neuromuscular blocking agent choice, reversal practice and associated healthcare costs. Anaesth Intensive Care. 2012 Mar 1;40(2):340-3.
  Daniel Jolley
summary
1
An early review and economic study of the cost effectiveness of sugammadex, concluding that it may be cost effective to routinely reverse with sugammadex if there are significant time savings in the operating theatre, but not if the time savings occur instead in the PACU.
The study assumed NHS costs of operating room time of £266/h (US$412/h) and PACU time of £20/h (US$31/h).
Paton F, Paulden M, Chambers D et al. Sugammadex compared with neostigmine/glycopyrrolate for routine reversal of neuromuscular block: a systematic review and economic evaluation. Br J Anaesth. 2010 Nov 1;105(5):558-67.
  Daniel Jolley
summary
1
Neville Gibbs and Peter Kam outline three evidence-based indications for use of sugammadex in 2012, even with its high cost:
1. Early reversal of rocuronium when suxamethonium is contraindicated. For example in ECT for patients with a pseudocholinesterase deficiency or neuromuscular denervation conditions.

2. 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.

3. Unplanned early reversal of rocuronium during a failed intubation where rapid reversal may allow awakening of the patient.

4. Rescue from residual paralysis despite having given neostigmine.
Gibbs NM Kam PC. Sugammadex: restricted vs unrestricted or selective vs non-selective? Anaesth Intensive Care. 2012 Mar 1;40(2):213-5.
  Daniel Jolley
pearl
1
Sugammadex is superior to neostigmine for reversal of rocuronium neuromuscular blockade.
Abrishami A, Ho J, Wong J et al. Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Cochrane Db Syst Rev. 2009 Jan 1(4):CD007362.
  Daniel Jolley
summary
1
Abrishami et al.'s Cochrane review of 18 RCTs totalling 1,300 patients confirmed the superiority of sugammadex compared with neostigmine at all studied levels of blockade. They identified sugammadex dosing of:
• 2 mg/kg - for reversal of rocuronium neuromuscular blockade at TOF-T2 reappearance.
• 4 mg/kg - for reversal at post-tetanic count of 1 to 2.
• 16 mg/kg - for reversal 3 to 5 minutes after a rocuronium intubating dose.
Importantly there was similar frequency of adverse events compared to neostigmine (< 1%), although overall small sample sizes mean no conclusion can be made regarding rare serious adverse events.
Abrishami A, Ho J, Wong J et al. Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Cochrane Db Syst Rev. 2009 Jan 1(4):CD007362.
  Daniel Jolley