Article Notes
Why is this relevant?
Sore throat following endotracheal intubation is common (reported in up to 68%), and along with postoperative nausea & vomiting, negatively impacts postoperative well-being.
Small studies have previously suggested that IV dexamethasone reduces sore throat due to intubation. It is thought this occurs by reducing mucosal inflammation at the point of tracheal cuff contact, the presumed aetiology of the majority of post-ETT sore throat.
Kuriyama and Maeda conducted a systematic review and meta-analysis of 15 RCTs totalling 1,849 patients.
And they found?
Preoperative dexamethasone IV (~4-10 mg across the studies) reduced the incidence of sore throat by almost 40% (RR 95% CI 0.51-0.75) and mean severity by 1.1 (SMD 95% CI 1.8-0.3).
Take-home...
Given the established effectiveness of preoperative dexamethasone to safely reduce post-operative nausea and vomiting, this meta-analysis affirms another important indication for the routine use of dexamethasone in intubated patients who do not have contraindications to steroid use.
Daniel Jolley
What’s so special about Programmed Intermittent Epidural Boluses?
Programmed Intermittent Epidural Bolus (PIEB) techniques have been advocated as an improvement over continuous epidural infusions because of the potential to optimise local anaesthetic spread through the epidural space.
Other studies have suggested that PIEBs result in reduced local anaesthetic consumption, less motor block, fewer instrumental and cesarean deliveries and improved maternal satisfaction – however these have often occured in research environments and with equipment not representative of typical clinical practice.
What did they do?
This Duke University team randomized 120 parturients to epidural ropivacaine 0.1% + fentanyl 2 mcg/mL delivered either as PIEB (6mL q45min) or continuous infusion (8 mL/h). All subjects had access to patient controlled epidural analgesia (PCEA) for breakthrough pain, used as the marker of analgesia efficacy. The study used the commercially-available CADD Solis pump.
And they found...
There was no difference in PCEA volume between groups, or in any secondary outcome (physician interventions, hypotension, pain scores, satisfaction, duration, or delivery mode), EXCEPT for a greater motor block seen with the continuous infusion group (50% vs 28% Bromage < 5).
Bottom-line
This (relatively small) study did not find significant improvement in labor experience or outcome with PIEB using commercially available epidural pumps, although the reduction in motor blockade may
Pause for thought...
The big challenge with identifying benefit from PIEB techniques is that it introduces even more epidural variables (pump type, bolus volume, frequency, concentration & flow rate, lockouts, background infusions...) making it very difficult to compare the conlficting results of PIEB studies.
Read more in the growing Programmed Intermittent Epidural Bolus for Labour Analgesia article collection.
Daniel Jolley