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Case report from Yamaguchi, Japan describing a confirmed sugammadex anaphylaxis in a 50kg woman receiving 4mg/kg sugammadex.
Notably, follow-up skin prick testing strongly suggests #1 hypersensitivity to free sugammadex molecules, rather than the sugammadex-rocuronium complex, and #2 hypersensitivity appears to be dose-related.
Nakanishi T, Ishida K, Utada K et al. Anaphylaxis to sugammadex diagnosed by skin prick testing using both sugammadex and a sugammadex-rocuronium mixture. Anaesth Intensive Care. 2016 Jan 1; 44 (1): 122-4.
  Daniel Jolley
summary
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Why is this important?
First, because it identifies new novel risk factors for residual neuromuscular block (experienced surgeon, non-CRNA anesthesia provider...) and secondly, because the subtext reveals the lengths our specialty goes to avoid simply monitoring using qualitative NMB monitoring (TOFR)!
What did they find?
Rudolph et al. created a REsidual neuromuscular block Prediction Score (REPS) using Massachusetts General PACU data, applying covariate analysis to identify 10 risk factors, some more surprising than others:
1. Hepatic failure
2. Neurological disease
3. High-neostigmine dose > 60 mcg/kg
4. Metastatic solid tumour
5. Female sex
6. Less than 120 min between NMBD administration and extubation
7. Aminosteroid NMBD
8. BMI more than 35
9. Absence of nurse anaesthetist (CRNA)
10. Having an experienced surgeon
Be smart:
These risk factors might suggest patients who need more careful monitoring, but you will probably be better off just using qualitative monitoring routinely. The utility of REPS itself is only modest with NPV & PPVs of 85% each.
The other takeaway is that rNMB is still demonstratably common, occurring in 20% of this cohort!
Rudolph MI, Ng PY, Deng H et al. Comparison of a novel clinical score to estimate the risk of REsidual neuromuscular block Prediction Score and the last train-of-four count documented in the electronic anaesthesia record: A retrospective cohort study of electronic data on file. Eur J Anaesthesiol. 2018 Nov 1; 35 (11): 883-892.
  Daniel Jolley
pearl
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The majority of anesthesia-related cardiac arrests are due to respiratory events.
Hohn A, Machatschek JN, Franklin J et al. Incidence and risk factors of anaesthesia-related perioperative cardiac arrest: A 6-year observational study from a tertiary care university hospital. Eur J Anaesthesiol. 2018 Apr 1; 35 (4): 266-272.
  Daniel Jolley
comment
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While there is both utility and some interesting insights from the LAS VEGAS risk score research, it also seems to have largely confirmed that higher risk patients, having more invasive or major surgery, and those who misbehave intraoperatively are more likely to experience postoperative pulmonary complications...
Neto Ary Serpa AS From the Hospital Israelita Albert Einstein, São Paulo, Brazil (ASN, LGVC), Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands (SN, LGV da Costa, Hemmes Sabrine N T SNT et al. The LAS VEGAS risk score for prediction of postoperative pulmonary complications: An observational study. Eur J Anaesthesiol. 2018 Sep 1; 35 (9): 691-701.
  Daniel Jolley
pearl
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Clonidine improves post-operative analgesia, reduces nausea & vomiting, improves hemodynamic stability, does not prolong wakening, and does not improve cardiac outcomes.
Sanchez MC, De M, Forget P. What is the place of clonidine in anesthesia? Systematic review and meta-analyses of randomized controlled trials. J Clin Anesth. 2017 May 1; 38: 140-153.
  Daniel Jolley
pearl
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Sugammadex use does not avoid either the need or benefit of neuromuscular monitoring, although it does result in less residual neuromuscular block than neostigmine reversal.
Kotake Y, Ochiai R, Suzuki T et al. Reversal with sugammadex in the absence of monitoring did not preclude residual neuromuscular block. Anesth. Analg. 2013 Aug 1;117(2):345-51.
  Daniel Jolley
pearl
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Neostigmine administration after clinical recovery of neuromuscular function to TOFR ≥ 0.9 appears to be neither beneficial or detrimental.
Murphy GS, Szokol JW, Avram MJ et al. Neostigmine Administration after Spontaneous Recovery to a Train-of-Four Ratio of 0.9 to 1.0: A Randomized Controlled Trial of the Effect on Neuromuscular and Clinical Recovery. Anesthesiology. 2018 Jan 1; 128 (1): 27-37.
  Daniel Jolley
comment
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I agree with Allan. This is the best available evidence for Ephedrine vs Phenylephrine to treat hypotension post-spinals in LSCS.
Veeser M, Hofmann T, Roth R et al. Vasopressors for the management of hypotension after spinal anesthesia for elective caesarean section. Systematic review and cumulative meta-analysis. Acta Anaesthesiol Scand. 2012 Aug 1; 56 (7): 810-6.
  Chris Tan
pearl
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Use of intraoperative cerebral oximetry may reduce post-operative cognitive decline.
Zorrilla-Vaca A, Healy R, Grant MC et al. Intraoperative cerebral oximetry-based management for optimizing perioperative outcomes: a meta-analysis of randomized controlled trials. Can J Anaesth. 2018 May 1; 65 (5): 529-542.
  Daniel Jolley
pearl
1
Intubation using a tracheal stylet in the ETT significantly increases the incidence of post-operative sore throat.
Komasawa N, Nishihara I, Minami T. Effects of stylet use during tracheal intubation on postoperative pharyngeal pain in anesthetized patients: A prospective randomized controlled trial. J Clin Anesth. 2017 May 1; 38: 68-70.
  Daniel Jolley