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pearl
1
PCEA with a continuous background is associated with longer second stage and greater instrumented delivery than PCEA without a background.
Heesen M, Böhmer J, Klöhr S et al. The Effect of Adding a Background Infusion to Patient-Controlled Epidural Labor Analgesia on Labor, Maternal, and Neonatal Outcomes: A Systematic Review and Meta-Analysis. Anesth. Analg. 2015 Jul 1; 121 (1): 149-158.
  David Belavy
comment
1
Is the prolonged effect thought due to Dexmetetomidine's high protein binding?
Tong Y, Ren H, Ding X et al. Analgesic effect and adverse events of dexmedetomidine as additive for pediatric caudal anesthesia: a meta-analysis. Paediatr Anaesth. 2014 Dec 1;24(12):1224-30.
  Pieter Peach
pearl
1
Priming with low-dose cisatracurium significantly speeds the onset of an intubating-dose of cisatracurium.
Lin SP, Chang KY, Chen YJ et al. Priming with rocuronium to accelerate the onset time of cisatracurium during intubation. J Chin Med Assoc. 2009 Jan 1;72(1):15-9.
  Daniel Jolley
summary
1
An audit of 115 parturients requiring spinal anesthesia for cesarean section in the setting of an inadequate, pre-existing epidural block. Median dose of 9.38 mg of bupivacaine + 15 mcg fentanyl was used. No patients received an epidural bolus within 30 min of their subarachnoid block.
There were no cases of total spinal block.
Because total spinal after inadequate epidurals had been 'not uncommon' in the department, the researchers had altered the department's practice to be:
1. Ensuring at least 30 min since last epidural bolus.
2. Reducing spinal dose by 20%. (NB: plain bupivacaine used)
3. Delay supine positioning for 2 min after spinal performed.
(Plus patient weight < 120 kg and height > 1.47 m)
Dadarkar P, Philip J, Weidner C et al. Spinal anesthesia for cesarean section following inadequate labor epidural analgesia: a retrospective audit. Int J Obstet Anesth. 2004 Oct 1;13(4):239-43.
  Daniel Jolley
pearl
1
There may still be an increased risk of total spinal block up to 90 minutes after the last epidural bolus.
Siddik-Sayyid SM, Gellad PH, Aouad MT. Total spinal block after spinal anesthesia following ongoing epidural analgesia for cesarean delivery. J Anesth. 2012 Apr 1;26(2):312-3.
  Daniel Jolley
comment
0
Far from earth-shattering, though what I find (possibly) interesting is the long delay between the last epidural dose and the (apparent) total spinal.
90 min seems like it should be well and truly long enough for any epidural bupivacaine to be absorbed – in fact, this is probably only a little shorter than the duration of said dose. It's possible that the total spinal was totally unrelated to the epidural, but that's probably wishful thinking.
Previous studies (Dadarkar, IJOA 2014) have suggested that waiting 30 min between last epidural dose and spinal is safe (audit of 115 patients in Dallas).
The take-away for me is that there's probably more patient variability than we'd like to admit.
Siddik-Sayyid SM, Gellad PH, Aouad MT. Total spinal block after spinal anesthesia following ongoing epidural analgesia for cesarean delivery. J Anesth. 2012 Apr 1;26(2):312-3.
  Daniel Jolley
summary
1
A case study describing a total spinal occurring in a 26 year old having an emergency caesarean section for failure to progress.
On arrival in theatre a block to pin prick was noted to T12, with the last epidural top-up having been 90 minutes earlier with only 5 mL of 0.25% bupivacaine. Total volume of epidural LA is not reported.
The epidural had partially dislodged, so anaesthesia was with 10.5 mg of spinal bupivacaine (equivalent to 2.1mL of 0.5%) resulting in a block to T6. 10 minutes later the patient became distressed, followed by respiratory arrest and unconsciousness.
Baby was delivered uneventfully and the mother made a full recovery. The authors ascribed the case to a total spinal resulting from cephalad spread of intrathecal bupivacaine.
Siddik-Sayyid SM, Gellad PH, Aouad MT. Total spinal block after spinal anesthesia following ongoing epidural analgesia for cesarean delivery. J Anesth. 2012 Apr 1;26(2):312-3.
  Daniel Jolley
comment
1
Though I don't generally trust propensity matched based studies, this one does rather support my pre-existing bias! One can get by with a GA but regional makes life easier for all concerned!
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.
  Allan Palmer
summary
1
A clear and nuanced critique of the Northern Territory government's policy of removing speed limits on sections of the Stuart Highway. Read explores evidence linking driving speed and posted speed limits with vehicle accidents and trauma, noting that for the Territory:
• Northern Territorians are "... three times more likely to die on the roads than people living in other parts of Australia, and at a rate that is equivalent to that in many low- and middle-income countries."
• After the last open speed limits were abolished in 2007, the "Australian road deaths database shows a decrease in fatalities of 3.4 per year on those NT roads..."
He concludes that the NT needs a stronger road safety package that includes removing unlimited speed limits along with driver fatigue, alcohol and seatbelt interventions.
Read DJ. Open speeds on Northern Territory roads: not so fast. Med. J. Aust. 2015 Jul 6;203(1):14-5.
  Daniel Jolley
pearl
1
Crash risk and trauma severity are directly related to vehicle speed and posted speed limit.
Read DJ. Open speeds on Northern Territory roads: not so fast. Med. J. Aust. 2015 Jul 6;203(1):14-5.
  Daniel Jolley