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summary
1
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
1
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
1
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
pearl
1
Using an Aspect A-1000 BIS monitor, researchers demonstrated a drop in Bispectral Index Score in awake, paralysed volunteers to low values ranging from 9 to 64.
Messner M, Beese U, Romstöck J et al. The bispectral index declines during neuromuscular block in fully awake persons. Anesth. Analg. 2003 Aug 1;97(2):488-91, table of contents.
  Daniel Jolley
pearl
1
Reversal with sugammadex may dramatically reduce the incidence of post-operative residual paralysis.
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
1
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
pearl
1
Recovery of train of four ratio to > 0.9 signifies adequate recovery of muscle function after neuromuscular blockade.
Baumüller E, Schaller SJ, Chiquito Y et al. Postoperative impairment of motor function at train-of-four ratio ≥0.9 cannot be improved by sugammadex (1 mg kg-1). Br J Anaesth. 2015 May 1; 114 (5): 785-93.
  Daniel Jolley
summary
1
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
pearl
1
Reversal with sugammadex may reduce the incidence of post-operative residual paralysis and consequent morbidity.
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
1
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