Department of Public Health, University of Western Australia, Western, Crawley, Australia. firstname.lastname@example.org
Lancet. 2002 Apr 13;359(9314):1276-82.
BACKGROUND: Epidural block is widely used to manage major abdominal surgery and postoperative analgesia, but its risks and benefits are uncertain. We compared adverse outcomes in high-risk patients managed for major surgery with epidural block or alternative analgesic regimens with general anaesthesia in a multicentre randomised trial.
METHODS: 915 patients undergoing major abdominal surgery with one of nine defined comorbid states to identify high-risk status were randomly assigned intraoperative epidural anaesthesia and postoperative epidural analgesia for 72 h with general anaesthesia (site of epidural selected to provide optimum block) or control. The primary endpoint was death at 30 days or major postsurgical morbidity. Analysis by intention to treat involved 447 patients assigned epidural and 441 control.
FINDINGS: 255 patients (57.1%) in the epidural group and 268 (60.7%) in the control group had at least one morbidity endpoint or died (p=0.29). Mortality at 30 days was low in both groups (epidural 23 [5.1%], control 19 [4.3%], p=0.67). Only one of eight categories of morbid endpoints in individual systems (respiratory failure) occurred less frequently in patients managed with epidural techniques (23% vs 30%, p=0.02). Postoperative epidural analgesia was associated with lower pain scores during the first 3 postoperative days. There were no major adverse consequences of epidural-catheter insertion.
INTERPRETATION: Most adverse morbid outcomes in high-risk patients undergoing major abdominal surgery are not reduced by use of combined epidural and general anaesthesia and postoperative epidural analgesia. However, the improvement in analgesia, reduction in respiratory failure, and the low risk of serious adverse consequences suggest that many high-risk patients undergoing major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative epidural analgesia.
You can post and discuss any recent or interesting journal articles here.
When quoting an article, please post only the abstract and perhaps a link to the main article. We cannot publish entire articles here because of copyright reasons. Members are then encouraged to read the abstract and/or the entire articles from a printed journal, and discuss the issues on this board.
Preoxygenation Is More Effective in the 25[degrees] Head-up Position Than in the Supine Position in Severely Obese Patients: A Randomized Controlled Study. Anesthesiology. 102(6):1110-1115, June 2005. Dixon, Benjamin J. M.B.B.S. *; Dixon, John B. M.B.B.S., Ph.D., F.R.A.C.G.P. +; Carden, Jennifer R. M.B.B.S., F.A.N.Z.C.A. ++; Burn, Anthony J. M.B.B.S., F.A.N.Z.C.A. ++; Schachter, Linda M. M.B.B.S., F.R.A.C.P.; Playfair, Julie M. R.N.; Laurie, Cheryl P. R.N., R.M. ; O'Brien, Paul E. M.D., F.R.A.C.S. #
Abstract: Background: Class III obese patients have altered respiratory mechanics, which are further impaired in the supine position. The authors explored the hypothesis that preoxygenation in the 25[degrees] head-up position allows a greater safety margin for induction of anesthesia than the supine position.
Methods: A randomized controlled trial measured oxygen saturation and the desaturation safety period after 3 min of preoxygenation in 42 consecutive (male:female 13:29) severely obese (body mass index > 40 kg/m2) patients who were undergoing laparoscopic adjustable gastric band surgery and were randomly assigned to the supine position or the 25[degrees] head-up position. Serial arterial blood gases were taken before and after preoxygenation and 90 s after induction. After induction, ventilation was delayed until blood oxygen saturation reached 92%, and this desaturation safety period was recorded.
Results: The mean body mass indexes for the supine and 25[degrees] head-up groups were 47.3 and 44.9 kg/m2, respectively (P = 0.18). The group randomly assigned to the 25[degrees] head-up position achieved higher preinduction oxygen tensions (442 +/- 104 vs. 360 +/- 99 mmHg; P = 0.012) and took longer to reach an oxygen saturation of 92% (201 +/- 55 vs. 155 +/- 69 s; P = 0.023). There was a strong positive correlation between the induction oxygen tension achieved and the time to reach an oxygen saturation of 92% (r = 0.51, P = 0.001). There were no adverse events associated with the study.
Conclusion: Preoxygenation in the 25[degrees] head-up position achieves 23% higher oxygen tensions, allowing a clinically significant increase in the desaturation safety period-greater time for intubation and airway control. Induction in the 25[degrees] head-up position may provide a greater safety margin for airway control.
The views posted on Gasbag.net are those of the members posting it and do not necessarily reflect the views of Gasbag.net or of established medical opinion. You use the advice given on this forum at your own risk. This forum is NOT a substitute for a thourough reading of relevent literature and should not be used as your sole method of determining your clinical practice.
Google has now entered the academic literature and is indexing a huge amount of literature. If you are used to doing internet searches using Google, then Scholar Google is an easy way to find articles in academic literature.
This is a member-based discussion forum for all things related to anesthesia. It is open to all practitioners of anesthesia from anywhere in the world.
If you are just starting at this forum, you should check out the files. Here you will find out how to register, edit your profile, post topics, read topics, and do nifty things like get email notification of selected topics, send personal messages (PMs) to other members, and upload pictures and other files to the forum.
Forum Etiquette: All members are free to ask for opinions and post topics to the forum. Please keep posts on-topic (that is, relating to anesthesia).
Feel free to disagree with any point of view expressed but please refrain from making personal insults or disparaging remarks about any members. This is called flaming and is viewed as a violation of forum rules. If you do spot a post that is insulting/sexist/racist/personal or otherwise offensive, please report it to the moderator by clicking on the "Report to Moderator" link at the lower right of each post.
Use Smilies liberally. On text-based forums, such as this, posts can sometimes be misinterpreted as insulting, because we are not able to see the members face and therefore judge his/her mood. Smilies are the little emotion-icons that help you express your non-verbal cues when posting. They are invaluble for clarifying posts that could otherwise be misconstrued as negative.
Enjoy the forum. I hope this forum will be of benefit to the entire international anesthesia community.
Your Own Privacy On This Forum: Your email address needs to be valid for registration to Gasbag.net, and it is a useful tool for other members to contact you. Your email address will never be revealed to any third party by Gasbag.net.
I suggest you go into your profile (use the button) and check the "Hide email address from public" in the "Account Related Settings" menu at left. This will ensure that your email address is not displayed to non-members.
Patients' Privacy On This Forum If you are posting details about a clinical scenario, please ensure that you do not reveal the identity of any patients involved. This goes beyond the patient's name. I ask that you ensure you do not reveal any details about any patient that may make them identifiable to other members.
Once you have registered and logged in, please take a moment to configure your personal profile.
Click on the Profile button in the top menu and use the options to personalise.
I suggest you enter your real name in the Account-Related Settings. This is the name that is displayed on the forum for other members to see. Of course, if you wish to remain anonymous, you can choose any nickname you wish to display.
Also in Account-Related Settings, I suggest you click on the "Hide Email Address from Public" to protect your privacy.
You can also choose an avatar to display, a small picture that is displayed with your username. This is under the Forum Profile Information option. You can choose one of the avatars built into the forum, or upload your own. Maximum size is 100x100 pixels.
Just under the avatar option, you can enter your location. I suggest you enter your city and country. This information is also displayed with your posts, and helps other members know where you practice. Remember this is an international forum, so keep the location broad rather than a specific hospital or suburb.
As always, please refer to the HELP icon for more details.
I'm not sure what other's practices are, but this is what I have found to be useful and hopefully scientific:
When presented with a patient who has a possible antibiotic allergy, eg penicillin and requries a similar antibiotic eg a cephalosporin some people advocate a IV test dose before a full dose is given.
This would minimise the effects of an anaphylactiod reaction, which is dose-related, but not a true anaphylactic reaction which can be triggered by a minimal amount of antigen.
My practice has been to give a tiny bleb of antibiotic as an intradermal injection, essentially making it a skin test. If there is no weal or flare 10mm or larger after 20 minutes, then I feel confident giving the full dose IV.
The advantage of this is that the antigen is not given as a systemic dose and thereby triggering a systemic reaction. It remains localised causing a local reaction only, yet still giving the required information.
I realise that even very dilute skin tests can cause anaphylaxis, but this technique is still safer than giving an IV "test dose".
For a variety of reasons, the anaesthetists in Canberra (and I suspect most of Australia) are moving away from epidural blocks for hip and knee replacement surgery. The main concern is the higher-than-we-thought incidence of major spinal cord complications probably secondary to the use of Clexane post-op in these patients.
We have had a huge shift to GA plus fascia iliac blocks (3-in-one lumbar plexus blocks).
The fascia iliac block is put in either before induction, or during the emergence period.
The technique is to use a sterile epidural kit and threading an epidural catheter into the fascia iliaca compartment. This lies about 4cm lateral to the femoral artery. The 2 "pops" are felt as the fascia lata and then the fascia iliaca. Theoretically the higher you thread the catheter, the more of the lumbar plexus (in particular the lat. cut. n of the thigh) you can block. A weak solution (eg bupivacaine 0.125%) is run in at 10mL/hr with boluses if required)
The advantages are very easy insertion, almost risk-free (well away from the femoral artery and even lateral to the femoral nerve), no hemodynamic consequences of sympathetic blockade, and no narcotic involved. Patients usually require a morphine PCA as well, but their narcotic requirements are markedly reduced.
The disadvantages are variable efficacy (there is no guarantee that your catheter will feed caphalad), and a difficulty in fixation leading to early failure if dislodged.
I am interested in international experiences with epidurals in this patient group and others experience with fascia iliac blocks.
The "Ask an Expert" board is for problem solving. If you have a difficult clinical case coming up that you want some expert opinion with, post the scenario on this board.
If you consider yourself an expert or at least very experienced in the area covered by the topics, feel free to offer advice as to management.
Please read our Disclaimer in the News Section - bottom line is that you use the advice provided here at your own risk, and the advice posted here is in no way a substitute for a thourough reading of the relevent literature.
Please also read our Privacy Issues post - keep all patient details confidential.
Even so, this board should help us in those "unique" and sticky situations that the literature may not cover.