Studies, guidelines, pubs Flashcards

Question

NAP5

Answer 1

Awareness under general anaesthesia AAGA ~1:20,000 AAGA no NMB ~ 1: 136,000 AAGA with NMB ~1:8,000 Cardiothoracic ~1:8,600 GA Caesarean section ~1:670 - 2/3 induction or emergency, 1/3 maintenance - Paediatric cases, trauma and orthopaedics and plastics were under-represented Risk factors - Drug factors: ○ neuromuscular blockade § Significant risk factor (93% AAGA had NMB) § Associated with distress and psychological sequelae ○ Thiopental ○ TIVA twice as likely as volatile § usually due to disconnection or not using TCI § transitioning between maintenance techniques § when transferring patients - Patient factors: ○ female gender ○ age (younger adults but not children) ○ Obesity ○ previous AAGA ○ possibly difficult airway management - Subspecialties: ○ Obstetric § Most over represented § Usually induction for GACS ○ Cardiac § Usually due to interruption or deliberately light anaesthesia in setting of comorbidity ○ Thoracic ○ neurosurgical - Organisational factors: ○ Emergencies ○ out of hours operating ○ junior anaesthetist - The following were not risk factors for AAGA: ASA physical status, race, nitrous oxide

Answer 2

NAP5 AAGA ~1:20,000 AAGA no NMB ~ 1: 136,000 AAGA with NMB ~1:8,000 Cardiothoracic ~1:8,600 GA Caesarean section ~1:670 - 2/3 induction or emergency, 1/3 maintenance - Paediatric cases, trauma and orthopaedics and plastics were under-represented Risk factors - Drug factors: ○ neuromuscular blockade § Significant risk factor (93% AAGA had NMB) § Associated with distress and psychological sequelae ○ Thiopental ○ TIVA twice as likely as volatile § usually due to disconnection or not using TCI § transitioning between maintenance techniques § when transferring patients - Patient factors: ○ female gender ○ age (younger adults but not children) ○ Obesity ○ previous AAGA ○ possibly difficult airway management - Subspecialties: ○ Obstetric § Most over represented § Usually induction for GACS ○ Cardiac § Usually due to interruption or deliberately light anaesthesia in setting of comorbidity ○ Thoracic ○ neurosurgical - Organisational factors: ○ Emergencies ○ out of hours operating ○ junior anaesthetist - The following were not risk factors for AAGA: ASA physical status, race, nitrous oxide

Answer 3

Anaphylaxis

Answer 4

Perioperative cardiac arrest

Answer 5

Complications of regional - planning stages

Answer 6

Perioperative Ischaemic Evaluation Study: Metoprolol (2007) Non-cardiac surgery patients at risk of perioperative cardiovascular complications New metoprolol reduced the incidence of myocardial infarction but increased the incidence of death and stroke vs placebo

Answer 7

POISE 1 (2007) Non-cardiac surgery patients at risk of perioperative cardiovascular complications New metoprolol reduced the incidence of myocardial infarction but increased the incidence of death and stroke vs placebo

Answer 8

Perioperative Ischaemic Evaluation Study 2: Clonidine and aspirin (2013) Administration of low-dose clonidine (200mcg/day) in patients undergoing noncardiac surgery did not reduce the rate of the composite outcome of death or nonfatal myocardial infarction; it did, however, increase the risk of clinically important hypotension and nonfatal cardiac arrest. Administration of aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of a composite of death or nonfatal myocardial infarction but increased the risk of major bleeding.

Answer 9

POISE 2 (2013) (Perioperative Ischaemic Evaluation Study 2): Clonidine and aspirin Administration of low-dose clonidine (200mcg/day) in patients undergoing noncardiac surgery did not reduce the rate of the composite outcome of death or nonfatal myocardial infarction; it did, however, increase the risk of clinically important hypotension and nonfatal cardiac arrest. Administration of aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of a composite of death or nonfatal myocardial infarction but increased the risk of major bleeding.

Answer 10

Perioperative Ischaemic Evaluation Study 3: TXA (2022) Among patients undergoing noncardiac surgery, the incidence of the composite bleeding outcome was significantly lower with tranexamic acid than with placebo. Although the between-group difference in the composite cardiovascular outcome was small, the noninferiority of tranexamic acid was not established. Incidence of bleeding outcomes was significantly lower when patients received tranexamic acid, however, the non-inferior margin for cardiovascular outcomes was not met.

Answer 11

POISE 3 (Perioperative Ischaemic Evaluation Study 3): TXA (2022) Among patients undergoing noncardiac surgery, the incidence of the composite bleeding outcome was significantly lower with tranexamic acid than with placebo. Although the between-group difference in the composite cardiovascular outcome was small, the noninferiority of tranexamic acid was not established. Incidence of bleeding outcomes was significantly lower when patients received tranexamic acid, however, the non-inferior margin for cardiovascular outcomes was not met.

Answer 12

World maternal antifibrinolytic trial (2017) Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.

Answer 13

WOMAN (2017) World maternal antifibrinolytic trial Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.

Answer 14

Preoperative intravenous iron to treat anaemia before major abdominal surgery Preoperative intravenous iron was not superior to placebo to reduce need for blood transfusion when administered to patients with anaemia 10–42 days before elective major abdominal surgery.

Answer 15

PREVENTT Preoperative intravenous iron to treat anaemia before major abdominal surgery Preoperative intravenous iron was not superior to placebo to reduce need for blood transfusion when administered to patients with anaemia 10–42 days before elective major abdominal surgery.

Answer 16

High-Flow Oxygen for Children’s Airway Surgery Nasal high-flow oxygen during tubeless upper airway surgery did not reduce the proportion of interruptions of the procedures for rescue oxygenation compared with standard care. There were no differences in adverse events between the intervention groups. These results suggest that both approaches, nasal high-flow or standard oxygen, are suitable alternatives to maintain oxygenation in children undergoing upper airway surgery.

Answer 17

HAMSTER: High-Flow Oxygen for Children’s Airway Surgery Nasal high-flow oxygen during tubeless upper airway surgery did not reduce the proportion of interruptions of the procedures for rescue oxygenation compared with standard care. There were no differences in adverse events between the intervention groups. These results suggest that both approaches, nasal high-flow or standard oxygen, are suitable alternatives to maintain oxygenation in children undergoing upper airway surgery.

Answer 18

Dexamethasone for Cardiac Surgery Among patients undergoing cardiac surgery, high-dose dexamethasone (1mg/kg vs placebo) decreased intensive care unit stay but did not increase the number of home days during the first 30 days after surgery.

Answer 19

DECS-II Dexamethasone for Cardiac Surgery Among patients undergoing cardiac surgery, high-dose dexamethasone (1mg/kg vs placebo) decreased intensive care unit stay but did not increase the number of home days during the first 30 days after surgery.

Answer 20

Non-Anaemic iron deficiency and Treatment Outcomes after colorectal cancer surgery In adult patients without anaemia undergoing surgery for colorectal cancer, iron deficiency defined by transferrin saturation < 20% was not associated with worse patient outcomes and appeared to be associated with more days alive and at home on postoperative day 90. Iron deficiency and suboptimal iron stores do not appear associated with worse outcomes in this population, except for those patients with ferritin < 30 μg.l-1, who have a higher incidence of transfusion. We suggest iron deficiency be redefined as ferritin < 30 μg.l-1 in adult patients without anaemia undergoing surgery for colorectal cancer.

Answer 21

NATO: Non-Anaemic iron deficiency and Treatment Outcomes after colorectal cancer surgery In adult patients without anaemia undergoing surgery for colorectal cancer, iron deficiency defined by transferrin saturation < 20% was not associated with worse patient outcomes and appeared to be associated with more days alive and at home on postoperative day 90. Iron deficiency and suboptimal iron stores do not appear associated with worse outcomes in this population, except for those patients with ferritin < 30 μg.l-1, who have a higher incidence of transfusion. We suggest iron deficiency be redefined as ferritin < 30 μg.l-1 in adult patients without anaemia undergoing surgery for colorectal cancer.

Answer 22

Chewing Gum to Treat Postoperative Nausea and Vomiting in Female Patients Chewing gum cannot be recommended as an alternative to ondansetron for treatment of postoperative nausea and vomiting in female patients administered antiemetic prophylaxis

Answer 23

Chewy: Chewing Gum to Treat Postoperative Nausea and Vomiting in Female Patients Chewing gum cannot be recommended as an alternative to ondansetron for treatment of postoperative nausea and vomiting in female patients administered antiemetic prophylaxis

Answer 24

Short-term Outcomes in Infants after General Anesthesia with Low-dose Sevoflurane/Dexmedetomidine/Remifentanil versus Standard-dose Sevoflurane These early postoperative results suggest that in children less than 2 yr of age receiving greater than 2 h of general anesthesia, the low-dose sevoflurane/dexmedetomidine/remifentanil anesthesia technique and the standard sevoflurane anesthesia technique are broadly clinically similar, with no clear evidence to support choosing one technique over the other. Similar rates of intraoperative hypotension, bradycardia, light anesthesia events, postoperative pain scores, time to recovery, and morbidity and mortality

Answer 25

T-Rex: Short-term Outcomes in Infants after General Anesthesia with Low-dose Sevoflurane/Dexmedetomidine/Remifentanil versus Standard-dose Sevoflurane These early postoperative results suggest that in children less than 2 yr of age receiving greater than 2 h of general anesthesia, the low-dose sevoflurane/dexmedetomidine/remifentanil anesthesia technique and the standard sevoflurane anesthesia technique are broadly clinically similar, with no clear evidence to support choosing one technique over the other. Similar rates of intraoperative hypotension, bradycardia, light anesthesia events, postoperative pain scores, time to recovery, and morbidity and mortality

Answer 26

Perioperative ADministration of Dexamethasone and Infection trial aka Dexamethasone and surgical site infection in non-cardiac surgery (2021) Dexamethasone was noninferior to placebo with respect to the incidence of surgical-site infection within 30 days after nonurgent, noncardiac surgery. Postoperative nausea and vomiting in the first 24 hours after surgery occurred in 42.2% of patients in the dexamethasone group and in 53.9% in the placebo group. Hyperglycemic events in patients without diabetes occurred in 0.6% in the dexamethasone group and in 0.2% in the placebo group.

Answer 27

PADDI (2021) Dexamethasone and surgical site infection in non-cardiac surgery Dexamethasone was noninferior to placebo with respect to the incidence of surgical-site infection within 30 days after nonurgent, noncardiac surgery. Postoperative nausea and vomiting in the first 24 hours after surgery occurred in 42.2% of patients in the dexamethasone group and in 53.9% in the placebo group. Hyperglycemic events in patients without diabetes occurred in 0.6% in the dexamethasone group and in 0.2% in the placebo group.

Answer 28

Restrictive versus liberal fluid therapy in major abdominal surgery (2018) Among patients at increased risk for complications during major abdominal surgery, a restrictive fluid regimen was not associated with a higher rate of disability-free survival than a liberal fluid regimen and was associated with a higher rate of acute kidney injury.

Answer 29

RELIEF: (2018) Restrictive versus liberal fluid therapy in major abdominal surgery Among patients at increased risk for complications during major abdominal surgery, a restrictive fluid regimen was not associated with a higher rate of disability-free survival than a liberal fluid regimen and was associated with a higher rate of acute kidney injury.

Answer 30

General versus spinal anaesthesia for neonatal inguinal hernia repair (2016) Question: Does GA in early infancy affect neurodevelopmental outcome? At two and five years, there was no difference in neuro-developmental outcomes between the two groups, confirming that brief exposure to general anaesthesia in early childhood is very unlikely to have an impact on long term brain development.

Answer 31

GAS (2016): General versus spinal anaesthesia for neonatal inguinal hernia repair At two and five years, there was no difference in neuro-developmental outcomes between the two groups, confirming that brief exposure to general anaesthesia in early childhood is very unlikely to have an impact on long term brain development.

Answer 32

(2002) Combined epidural and general anaesthesia and postoperative epidural analgesia in major abdominal surgery in high risk patients Respiratory failure occurred less frequently in patients managed with epidural techniques Analgesia was improved Low risk of serious adverse consequences with epidural Other adverse morbid outcomes are not reduced High-risk patients undergoing major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative epidural analgesia

Answer 33

MASTER (2002) Combined epidural and general anaesthesia and postoperative epidural analgesia in major abdominal surgery in high risk patients Respiratory failure occurred less frequently in patients managed with epidural techniques Analgesia was improved Low risk of serious adverse consequences with epidural Other adverse morbid outcomes are not reduced High-risk patients undergoing major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative epidural analgesia

Answer 34

(2004) BIS-guided anaesthesia reduces the risk of awareness in at-risk adult surgical patients undergoing relaxant general anaesthesia. With a number needed to treat of 138

Answer 35

B-Aware (2004) BIS-guided anaesthesia reduces the risk of awareness in at-risk adult surgical patients undergoing relaxant general anaesthesia. With a number needed to treat of 138

Answer 36

REASON: (2010) Research into Elderly Patient Anaesthesia and Surgery Outcome Numbers Non-cardiac surgical patients aged 70 years or more in 23 hospitals in Australia and New Zealand 20% of patients had a complication within five days of surgery and 5% died within 30 days Those with a complication stayed a week longer in hospital, and 14% died within 30 days Patient factors often had a stronger association with mortality than the type of surgery Strategies are needed to reduce complications and mortality in older surgical patients

Answer 37

REASON: (2010) Research into Elderly Patient Anaesthesia and Surgery Outcome Numbers Non-cardiac surgical patients aged 70 years or more in 23 hospitals in Australia and New Zealand 20% of patients had a complication within five days of surgery and 5% died within 30 days Those with a complication stayed a week longer in hospital, and 14% died within 30 days Patient factors often had a stronger association with mortality than the type of surgery Strategies are needed to reduce complications and mortality in older surgical patients

Answer 38

Nitrous oxide-based vs nitrous oxide-free anaesthesia. The use of nitrous oxide was associated with more nausea and vomiting, and more pulmonary complications. Avoidance of nitrous oxide and the concomitant increase in inspired oxygen concentration decreases the incidence of complications after major surgery, but does not significantly affect the duration of hospital stay. The routine use of nitrous oxide in patients undergoing major surgery should be questioned.

Answer 39

ENIGMA The use of nitrous oxide was associated with more nausea and vomiting, and more pulmonary complications. Avoidance of nitrous oxide and the concomitant increase in inspired oxygen concentration decreases the incidence of complications after major surgery, but does not significantly affect the duration of hospital stay. The routine use of nitrous oxide in patients undergoing major surgery should be questioned.

Answer 40

Nitrous Oxide Anaesthesia and Cardiac Morbidity After Major Surgery Nitrous oxide-based vs nitrous oxide-free anaesthesia in high risk patients Nitrous oxide did not increase the risk of death and cardiovascular complications or surgical-site infection, the emetogenic effect of nitrous oxide can be controlled with antiemetic prophylaxis, and a desired effect of reduced volatile agent use was shown. This clarified the safety of nitrous oxide in clinical anaesthesia practice.

Answer 41

ENIGMA-II: Nitrous Oxide Anaesthesia and Cardiac Morbidity After Major Surgery Nitrous oxide-based vs nitrous oxide-free anaesthesia in high risk patients Nitrous oxide did not increase the risk of death and cardiovascular complications or surgical-site infection, the emetogenic effect of nitrous oxide can be controlled with antiemetic prophylaxis, and a desired effect of reduced volatile agent use was shown. This clarified the safety of nitrous oxide in clinical anaesthesia practice.

Answer 42

General anaesthesia versus local anaesthesia for carotid surgery No definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis.

Answer 43

GALA: General anaesthesia versus local anaesthesia for carotid surgery No definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis.

Answer 44

Hypothermia for moderate or severe neonatal encephalopathy in low-income and middle-income countries Therapeutic hypothermia did not reduce the combined outcome of death or disability at 18 months after neonatal encephalopathy in low-income and middle-income countries, but significantly increased death alone. Therapeutic hypothermia should not be offered as treatment for neonatal encephalopathy in low-income and middle-income countries, even when tertiary neonatal intensive care facilities are available.

Answer 45

HELIX: Hypothermia for moderate or severe neonatal encephalopathy in low-income and middle-income countries Therapeutic hypothermia did not reduce the combined outcome of death or disability at 18 months after neonatal encephalopathy in low-income and middle-income countries, but significantly increased death alone. Therapeutic hypothermia should not be offered as treatment for neonatal encephalopathy in low-income and middle-income countries, even when tertiary neonatal intensive care facilities are available.

Answer 46

Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury TXA safe in TBI and that treatment within three hours reduces head injury associated deaths

Answer 47

CRASH-3 TXA safe in TBI and that treatment within three hours reduces head injury associated deaths

Answer 48

Circulatory determination of death in the context of organ donation requires the absence of spontaneous movement, breathing and circulation. Absence of circulation is evidenced by absent arterial pulsatility for 5 minutes, using intra-arterial pressure monitoring and confirmed by clinical examination (absent heart sounds and/or absent central pulse). In cases without an arterial line, electrical asystole should be observed for 5 minutes on the electrocardiogram and confirmed by clinical examination. From

Answer 49

There is a minimum 4-hour observation period prior to neurological determination of death using clinical examination alone. Throughout this observation period, all preconditions are met, the patient has a Glasgow Coma Scale of 3, with pupils non-reactive to light, absent cough/tracheal reflex and apparent apnoea on a ventilator. Following an acute hypoxic-ischaemic encephalopathy or hypothermia (<35°C) of duration greater than 6 hours, there should be a waiting period of 24 hours before determination of death using clinical examination alone. From

Answer 50

* Solid food - of a low calorific nature (light meal) up to 6h proir * Clear liquids - up to 2 h prior * “SipTilSend” has not shown significant evidence for increased aspiration risk * Prescribed medications with 30ml water (vol includes liquid medications) * Enteral feeds in intubated patients continued UNLESS airway, thoracic or abdominal surgery (cease 6h prior)

Answer 51

12mo to 16y * Solid food - of a low calorific nature (light meal) up to 6h proir * Clear liquids (water, pulp free juice, carbohydrate drinks) of 3m/kg/hr up to 1h prior * Breast milk to 3h prior * Other milk/formula to 6h prior Infants to 12mo * Breast milk to 3h prior * Other milk/formula to 4h prior

Answer 52

In mechanically ventilated, critically ill patients receiving enteral nutrition does energy-dense feed (1.5kCal/ ml) compared with routine feed (1kCal/ml) made no difference in 90 day mortality or any secondary outcome * Survival time * 90-day cause specific mortality * ICU-free and hospital-free days (until D28) * Days free of organ support (until D28) * % ventilated, vasopressors or new RRT (D28) * % with Positive blood cultures * Antimicrobials received between randomisation & D28 GI tolerance and metabolic effects * Gastric residual volumes were significantly higher in the high energy group (250ml vs 180ml) * Regurgitation and vomiting were more prevalent in the high energy group (19 vs. 16%) * The use of insulin was more prevalent in the high energy group (56 vs 49%) * Prokinetic drug use was more prevalent in the high energy group (47 vs 40%) From

Answer 53

TARGET In mechanically ventilated, critically ill patients receiving enteral nutrition does energy-dense feed (1.5kCal/ ml) compared with routine feed (1kCal/ml) made no difference in 90 day mortality or any secondary outcome * Survival time * 90-day cause specific mortality * ICU-free and hospital-free days (until D28) * Days free of organ support (until D28) * % ventilated, vasopressors or new RRT (D28) * % with Positive blood cultures * Antimicrobials received between randomisation & D28 GI tolerance and metabolic effects * Gastric residual volumes were significantly higher in the high energy group (250ml vs 180ml) * Regurgitation and vomiting were more prevalent in the high energy group (19 vs. 16%) * The use of insulin was more prevalent in the high energy group (56 vs 49%) * Prokinetic drug use was more prevalent in the high energy group (47 vs 40%) From

Answer 54

APRICOT: Anaesthesia Practice in Children Observational Trial High incidence of critical respiratory events: young age, medical history, presence of airway hypersensitiy, ASA physical status are independent risk factors Children younger than 3 years and those with a medical history including prematurity, handicap (metabolic or genetic disorder, or neurological impairment), snoring, airway hypersensitivity, and a medical condition with fever or under medication are at increased risk of severe critical events

Answer 55

APRICOT: Anaesthesia Practice in Children Observational Trial High incidence of critical respiratory events: young age, medical history, presence of airway hypersensitiy, ASA physical status are independent risk factors Children younger than 3 years and those with a medical history including prematurity, handicap (metabolic or genetic disorder, or neurological impairment), snoring, airway hypersensitivity, and a medical condition with fever or under medication are at increased risk of severe critical events

Answer 56

Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone

Answer 57

In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes

Answer 58

At 6 months, decompressive craniectomy in patients with traumatic brain injury and refractory intracranial hypertension resulted in lower mortality and higher rates of vegetative state, lower severe disability, and upper severe disability than medical care. The rates of moderate disability and good recovery were similar in the two groups

Answer 59

Meta analysis: In patients treated with mechanical thrombectomy for anterior circulation acute ischemic stroke, general anesthesia and procedural sedation were associated with similar rates of functional independence and major periprocedural complications

Answer 60

AMETIS Meta analysis In patients treated with mechanical thrombectomy for anterior circulation acute ischemic stroke, general anesthesia and procedural sedation were associated with similar rates of functional independence and major periprocedural complications

Answer 61

DAWN Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone.

Answer 62

paraverterbal lower rate of complication with comparable analgesia safest block is one you are most familiar with

Answer 63

HEMOTION: liberal transfusion strategy (Hb 100 vs 70) did not reduce the risk of an unfavourable outcome at six months in critically ill patients with traumatic brain injury and anaemia TRAIN: Patients with acute brain injury and anemia randomized to a liberal transfusion strategy (Hb 90) were less likely to have an unfavorable neurological outcome than those randomized to a restrictive strategy (Hb 70)

Answer 64

B-UNAWARE (2008) Question: In patients at high risk of awareness, is the incidence of awareness reduced when following BIS guided protocol rather than End Tidal (ETAG protocol) Intervention: BIS 40-60 , ETAG MAC 0.7-1.3 Primary Outcome: No difference in awareness Not extrapolated to TIVA, only using volatile anaesthesia

Answer 65

2019 Question: In patients with TBI, does TXA (within 3hrs from injury), reduce head injury associated in hospital 28day mortality? Primary outcome: 28day in hospital TBI associated mortality – not significant overall BUT in subgroup of pts with mild to moderate TBI (GCS 9-15) – TXA reduce mortality ARR 1.64% Disability measure – no difference Complications – no increase in vaso-occlusive events or seizures Conclusion: Safe and may help reduce mortality in patients with mild to moderate TBI

Answer 66

MAGPIE = MAGnesium sulfate for Prevention of Eclampsia (2002) Magnesium sulfate can help decrease eclamptic seizures in patients with preeclampsia - good date to suggest it can decrease this rate by about 50% You should dose the mag somewhere between 4-6g loading dose and 1-2g/hr, but this is institution dependent It is also institution dependent regarding if preeclampsia without severe features needs mag (in MAGPIE, had same amount of decrease in eclamptic seizures as preeclampsia w/ SF) However, the number of those that get eclamptic seizures overall is low, and even lower in those with preeclampsia w/o SF, so there can be an argument for increased toxicity/side effects with increased NNT for those with PEC w/o SF and therefore forego it

Answer 67

International Consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia (AAGBI) – Anaesthesia 2018 · Phenylephrine infusion is recommended as ideal vasopressor. · Prophylactic infusion is superior to reactive boluses. · Start infusion 25-50mcg/min and titrate (15-30ml/hr of 100mcg/ml phenylephrine). · Considered OK for small ephedrine boluses if bradycardic when running phenylephrine. · Accepts agents primarily a-agonist with some b-agonist activity (metaraminol or noradrenaline) may actually be best insufficient data at present to recommend. · Animal studies showed ephedrine has optimal placental blood flow BUT ephedrine use associated with lower neonatal pH (likely 2nd activation foetal sympathetic metabolism). · Phenylephrine has best biochemical profile BUT no known improved clinical outcomes. · Aim sBP >90% baseline. · Duration of hypotension likely more important than severity important if occurs then <2mins. · ‘Noradrenaline is the primary catecholamine released by postganglionic adrenergic nerves. It is a potent α1-adrenergic agonist, with comparatively modest β-agonist activity. It causes marked vasoconstriction with some direct inotropic effects. Administration results in higher heart rates than with comparable doses of phenylephrine.’

Answer 68

UTD/AHA 2024: Continue aspirin long term Aim surg >6mo post PCI If <3mo DES, continue DAPT periop Otherwise, cease P2Y12i periop Clopidogrel 5 days Ticagrelor 3-5 If on DOAC only, add aspirin periop while DOAC withheld

Answer 69

Pre medication: Dexmedetomidine (AdjBW) * IN 2-3mcg/kg (max 150mcg) - 30-60 minutes Ketamine (IBW) * PO 5-10mg/kg - 10-20 minutes * IM 5mg/kg - 3-5 minutes Midazolam (TBW)* * PO 0.5mg/kg (max 20mg) - 15-30 minutes * Buccal 0.3mg/kg (max 10mg) - 10-15 minutes * Midazolam: risk of airway obstruction in OSA Consider risks versus specific benefits In severe OSA, reduce dose to 0.25mg/kg

Answer 70

ASPREE (2018) Among healthy adults who did not have an indication for aspirin use and were predominantly 70 years of age or older at enrollment, all-cause mortality was apparently higher among those who received daily low-dose aspirin than among those who received placebo, with 1.6 excess deaths per 1000 person-years occurring in the aspirin group after a median of 4.7 years, and cancer was the principal cause of the excess deaths. Other primary prevention trials of aspirin have not identified similar results, which suggests that the mortality results reported here should be interpreted with caution.

Answer 71

* The prevalence of high-risk gastric contents was 70% in women admitted for spontaneous labour and induction of labour, and 40% in women admitted for elective Caesarean delivery (although fasting duration for solids was ≥6 h in >98% of these women). Lower gestational age and increased fasting duration for solids were associated with lower likelihood of high-risk gastric contents. * The authors suggest that gastric ultrasound will be most helpful for decision-making about anaesthesia and airway management when fasting duration for solids is ≥8 h. Anaesthetists can probably assume that high-risk gastric contents are present when fasting < 8 h.

Studies, guidelines, pubs Flashcards

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