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pearl
2
Muscle paralysis alone in an awake subject can cause significant drop in the Bispectral Index Score (BIS) to below that normally indicating unconsciousness and deep anaesthesia.
Schuller PJ, Newell S, Strickland PA et al. Response of bispectral index to neuromuscular block in awake volunteers†. Br J Anaesth. 2015 Jul 1;115 Suppl 1:i95-i103.
  Daniel Jolley
summary
3
Researchers induced awake paralysis in 10 volunteers using separately both suxamethonium and rocuronium. Both the BIS A2000 (2003) and BIS Vista monitor (2013) were tested.
BIS decreased immediately after paralysis and did not fully recover until muscle recovery. BIS values decreased to as low as 44, despite the subject being awake.
In more than half of the 20 trials the BIS value decreased to below 60 at some point. In one case this lasted for almost 4 minutes, representing 76% of the total paralysis time for that subject.
Schuller PJ, Newell S, Strickland PA et al. Response of bispectral index to neuromuscular block in awake volunteers†. Br J Anaesth. 2015 Jul 1;115 Suppl 1:i95-i103.
  Daniel Jolley
summary
1
Interesting editorial accompanying Dr Peter Schuller's excellent study of BIS values in awake, paralysed volunteers.
The editors make a very interesting point critiquing the probabilistic, database-based approach to processed-EEG awareness monitors like BIS: (emphasis added)
"This database-driven approach may have limitations, in particular for the detection of intraoperative wakefulness: it is very unlikely that data from an awake and paralyzed subject are included in this database. Therefore, the resulting anaesthesia index has not been trained with a dataset that contains this clinical situation..."
Schneider G Pilge S. Restrict relaxants, be aware, and know the limitations of your depth of anaesthesia monitor. Br J Anaesth. 2015 Jul 1;115 Suppl 1:i11-i12.
  Daniel Jolley
summary
3
Awareness occurred in 1 in 19,000 general anaesthetics, resulting in distress in 51% of cases and longterm harm in 41%. BIS monitoring was used in 5% of cases of awareness.
Cook TM, Andrade J, Bogod DG et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent, and medicolegal issues†‡ Br J Anaesth. 2014 Oct 1;113(4):560-74.
  Daniel Jolley
pearl
1
75% of cases of accidental awareness under general anaesthesia are likely preventable.
Cook TM, Andrade J, Bogod DG et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent, and medicolegal issues†‡ Br J Anaesth. 2014 Oct 1;113(4):560-74.
  Daniel Jolley
pearl
2
Experiencing paralysis during awareness under general anaesthesia, even without pain, is in particular associated with distress and longterm harm.
Cook TM, Andrade J, Bogod DG et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent, and medicolegal issues†‡ Br J Anaesth. 2014 Oct 1;113(4):560-74.
  Daniel Jolley
pearl
1
Even short periods of awareness during general anaesthesia commonly result in severe patient distress and longterm consequences.
Cook TM, Andrade J, Bogod DG et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent, and medicolegal issues†‡ Br J Anaesth. 2014 Oct 1;113(4):560-74.
  Daniel Jolley
pearl
1
The monoclonal antibody-fragment idarucizumab reliably reverses the thrombin-inhibitor anticoagulant dabigatran ('Pradaxa') within minutes of administration.
Pollack CV, Reilly PA, Eikelboom J et al. Idarucizumab for Dabigatran Reversal. N. Engl. J. Med. 2015 Aug 6;373(6):511-20.
  Daniel Jolley
pearl
0
No significant difference between plain or hyperbaric spinal bupivacaine, though the authors dismissed a faster onset in the hyperbaric group which may be of more practical benefit.
Heng SiaAlex TiongATFrom the Duke-NUS Graduate Medical School, Singapore, Singapore; Medical Board, Obstetrics Gynaecology, Women's Anaesthesia, KK Women's Children's Hospital, Singapore, Singapore; Clinical Research Institute, Singapore, , Tan KH, Sng BL et al. Hyperbaric versus plain bupivacaine for spinal anesthesia for cesarean delivery. Anesth. Analg. 2015 Jan 1; 120 (1): 132-140.
  Allan Palmer
pearl
1
Pre-operative oral carbohydrate decreases postoperative insulin resistance, speeds gastrointestinal functional recovery and reduces hospital stay, most significantly after major surgery.
Nygren J, Thorell A, Ljungqvist O. Preoperative oral carbohydrate therapy. Curr Opin Anaesthesiol. 2015 Jun 1;28(3):364-9.
  Daniel Jolley