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summary
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Collection: The evidence for perimortem caesarean section
Cardiac arrest is rare in pregnancy (1 in 30,000) and resuscitation is founded on the same approach used for the non-pregnant patient, focusing on:
• Recognition
• Calling for help
• A B C (D)
• Good for mother = good for baby
However, unique to maternal resuscitation:
• Airway difficulties are more likely.
• Aortocaval compression dramatically impedes resuscitation – employ left lateral tilt!
• Consider perimortem cesarean section
The rationale for Perimortem Cesarean Section is:
• The presence of baby and gravid uterus severely limits resuscitation of the mother.
• Emergency cesarean section at cardiac arrest is done for the mother’s benefit, not the baby.
• A decision to perform emergency CS must be made within 4 minutes of arrest, and the baby delivered within 5 minutes. (Although there is some evidence of benefit when performed up to 10 minutes after arrest.)
• The only equipment required is a scalpel and an appropriately skilled doctor.
  Daniel Jolley
comment
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Seems pretty convincing. Doesnt block bladder spasm, which would be predictable via known anatomy.
Bryskin RB, Londergan B, Wheatley R et al. Transversus Abdominis Plane Block Versus Caudal Epidural for Lower Abdominal Surgery in Children: A Double-Blinded Randomized Controlled Trial. Anesth. Analg. 2015 Aug 1;121(2):471-8.
  Allan Palmer
summary
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Collection: Neuromuscular myths: the lies we tell ourselves
An extensive collection of research debunking a range of myths and misconceptions regarding the way we use neuromuscular blocking drugs.
• Myth 1: Modern relaxants are so reliable and predictable that monitoring is unnecessary.
• Myth 2: Post-op residual paralysis is neither common or important.
• Myth 3: Post-op residual paralysis is easy to identify.
• Myth 4: Sugammadex makes residual paralysis a non-issue. (it might, but only if it is routinely available and used!)
• Myth 5: Using propofol and remifentanil we can avoid relaxants for intubation all together.
• Myth 6: Neuromuscular blockade has no effect on BIS.
And bonus myth: deep relaxation is necessary for improving surgical access during laparoscopy.
  Daniel Jolley
summary
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A randomised controlled trial of 150 patients undergoing abdominal surgery. On admission to the PACU no patients having received sugammadex demonstrated residual paralysis, however 43% of patients reversed with neostigmine had TOF-ratio < 0.9.
Brueckmann B, Sasaki N, Grobara P et al. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth. 2015 Nov 1; 115 (5): 743-51.
  Daniel Jolley
summary
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Calabadion is a new heterocyclic molecule that offers rapid and complete reversal of both aminosteroids, such as rocuronium, and benzylisoquinoline NMBDS, such as cisatracurium.
Hoffmann U, Grosse-Sundrup M, Eikermann-Haerter K et al. Calabadion: A New Agent to Reverse the Effects of Benzylisoquinoline and Steroidal Neuromuscular-blocking Agents. Anesthesiology. 2013 Aug 1; 119 (2): 317-25.
  Daniel Jolley
summary
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An audit of pre-extubation residual paralysis before and after the introduction of sugammadex. Residual paralysis was significantly more common in those not reversed or reversed with neostigmine than in those reversed with sugammadex.
Patients receiving sugammadex were also less likely to desaturate in the PACU and had fewer post-operative chest x-ray changes.
Ledowski T, Hillyard S, O'Dea B et al. Introduction of sugammadex as standard reversal agent: Impact on the incidence of residual neuromuscular blockade and postoperative patient outcome. Indian J Anaesth. 2013 Jan 1;57(1):46-51.
  Daniel Jolley
summary
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In this review of published perimortem caesarean section cases more than half of the mothers survived to hospital discharge and almost 80% of these with favourable neurological outcome.
PM caesarean section was considered beneficial in 32% of cases.
Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert-based? Resuscitation. 2012 Oct 1;83(10):1191-200.
  Daniel Jolley
summary
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The 5-second Head Lift Test and the Tongue Depressor Test, often used to detect PORC in the PACU are of limited use for detecting TOFR < 0.9, having sensitivities of only 11% and 13% and specificities of 87% and 90% respectively.
The Head Lift Test cannot identify POCR with a TOFR > 0.5. Debaene’s study population demonstrated Positive and Negative Predictive Values of the Head Lift and Tongue Depressor Tests of only 53-58%!
Subjective, qualitative neuromuscular monitors fare no better: Tactile TOF Fade and Double Burst Stimulation (DBS) have similar sensitivities (11% and 13% respectively), although high specificities (99% each). This provides a good Positive Predictive Value (93% & 97%) but a very poor Negative Predictive Value (57% & 58%) (depending on the incidence of PORC).
Debaene B, Plaud B, Dilly MP et al. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003 May 1;98(5):1042-8.
  Daniel Jolley
summary
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Videira identified that in addition to the interval since last NMBD, anesthetists commonly used the adequacy of spontaneous minute ventilation as a decision heuristic for deciding on the need for reversal.
“The adequacy of the breathing pattern was also cited heavily … This visual cue may be erroneously interpreted as a sufficient sign for tracheal extubation, instead of a necessary one. This heuristic assesses function of the diaphragm, not of the upper airway muscles.”
Videira RL Vieira JE. What rules of thumb do clinicians use to decide whether to antagonize nondepolarizing neuromuscular blocking drugs? Anesth. Analg. 2011 Nov 1;113(5):1192-6.
  Daniel Jolley
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The authors conclude that one-quarter of PACU desaturations below 90%, almost-half of desaturations below 80%, and almost one-third of re-intubations could be attributable to intermediate NMBD.
Grosse-Sundrup M, Henneman JP, Sandberg WS et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ. 2012 Jan 1;345:e6329.
  Daniel Jolley