Spinal anaesthesia is the primary anaesthetic technique for many types of surgery. Adjuncts to the local anaesthetics (LA) used in spinal anaesthesia can exhibit undesirable side-effects, limiting their use, but magnesium may have advantages in this respect. We sought randomized control trials (RCTs) in patients undergoing all types of surgery and in women in labour to compare the effect of intrathecal magnesium sulphate ± LA ± lipophilic opioid (experimental group) with the use of either intrathecal lipophilic opioids ± LA or LA only (control group). The primary outcome was the duration of spinal anaesthesia. Secondary outcomes were: onset and time to maximal sensory blockade, onset of motor block, and duration of sensory and motor blockade. We found 15 RCTs comprising 980 patients. The duration of spinal anaesthesia was significantly increased in the experimental group [standardized mean difference (SMD) -1.05 (-1.70, -0.41) (P = 0.001)], compared with the control group. This increased duration of spinal anaesthesia was seen in non-obstetric studies, SMD -1.38 (-2.11, -0.66) (P = 0.0002), but not in obstetric studies, SMD -0.55 (-1.87, 0.77) (P = 0.41). There was no delay in the onset of sensory or motor blockade. The incidence of hypotension and pruritus was similar in both groups. Heterogeneity was high in all outcome measures. The duration of spinal anaesthesia may be increased by the addition of magnesium to lipophilic opioids ± LA.

Background Hypotension following spinal anesthesia for Cesarean delivery is common. Fluid loading is recommended to prevent hypotension, but preload is often ineffective. In non-pregnant patients, coloading has been shown to better maintain cardiac output after spinal anesthesia. The purpose of this meta-analysis was to determine whether the timing of the fluid infusion, before (preload) or during (coload) induction of spinal anesthesia for Cesarean delivery, influences the incidence of maternal hypotension or neonatal outcome. Methods We retrieved randomized controlled trials that compared a fluid preload with coload in patients undergoing spinal anesthesia for elective Cesarean delivery. We graded the articles for quality of reporting (maximum score = 5) and recorded the incidence of hypotension, lowest blood pressure, the incidence of maternal nausea and vomiting, umbilical cord pH, and Apgar scores. We combined the results using random effects modelling. Results We retrieved eight studies comprised of 518 patients. The median quality score for the published studies was three. The incidence of hypotension in the coload group was 159/268 (59.3%) compared with 156/250 (62.4%) in the preload group (odds ratio [OR] = 0.93; 95% confidence interval [CI] 0.54-1.6). There were no significant differences between groups in any of the other outcomes. Conclusions It is unnecessary to delay surgery in order to deliver a preload of fluid. Regardless of the fluid loading strategy, the incidence of maternal hypotension is high. Prophylactic or therapeutic vasopressors may be required in a significant proportion of patients. RésuméContexte L'hypotension est un phe´nome`ne courant a`la suite d'une rachianesthe´sie pour un accouchement par ce´sarienne. Il est recommande´d'administrer une charge liquidienne pour pre´venir l'hypotension, mais la pre´-charge est souvent peu efficace. Chez les patients et patientes non enceintes, il a e´te´de´montre´que la co-charge maintenait mieux le de´bit cardiaque apre`s une rachianesthe´sie. L'objectif de cette me´ta-analyse e´tait de de´terminer si le moment de perfusion liquidienne, soit avant (pre´-charge) ou pendant (co-charge) l'induction de la rachianesthe´sie pour un accouchement par ce´sarienne, influençait l'incidence d'hypotension chez la me`re ou le devenir du nouveau-ne´. Méthode Nous avons extrait des e´tudes randomise´es contrôle´es comparant une pre´-charge a`une co-charge liquidienne chez des patientes subissant une rachianesthe´sie pour un accouchement par ce´sarienne non urgent. Nous avons attribue´une note aux articles selon la qualite´de la pre´sentation (score maximal = 5) et note´l'incidence d'hypotension, la tension arte´rielle la plus basse, l'incidence de nause´es et vomissements chez la me`re, le pH du sang du cordon ombilical et les scores d'Apgar. Nous avons combine´les re´sultats a`l'aide d'un mode`le a`effets ale´atoires. 123Can J Anesth/J Can Anesth (2010) 57:24-31 DOI 10.1007 Résultats Nous avons retenu huit e´tudes comprenant 518 patientes. Le score ...

BSCPB offers analgesic efficacy in the early postoperative period for up to 24 h after thyroid surgery, with reduced length of hospital stay, but without any beneficial effect on PONV.

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Background Clinical identification of lumbar spinous processes is inaccurate in most patients. The purpose of this study was to determine the number of patients required to train anesthesiologists in the use of ultrasound imaging to accurately identify the lumbar spinous processes. Methods In this pilot study, two anesthesiologists studied patients scheduled for a diagnostic computed tomography (CT) scan, including the lumbar spine. Before the CT scan, the anesthesiologist completed a systematic ultrasound scan of the lumbar spine and placed a radio-opaque marker at a designated level. The actual level was determined by a radiologist after reviewing the CT scans. The primary outcome was the number of procedures each anesthesiologist needed (by cumulative sum analysis) to be able to identify the designated spinous process 90% of the time. Secondary outcomes included the overall success rate, the magnitude of the failures (number of segments from the designated spinous process), and the incidence of spinal anomalies and their effect on reliability.Results We studied 74 patients. One anesthesiologist required 36 patients to meet reliability criteria, whereas the other required 22 patients. The overall accuracy rate was 68%. There were only two patients where the marker was placed more than one segment from the designated spinous process. The incidence of lumbar spine anomalies was 6.8% (n = 5), and 80% (n = 4) of these were associated with inaccurate marker placement. Conclusions It is possible to use ultrasound scanning to accurately identify the lumbar spinous processes in unselected patients. This result suggests that, with appropriate training, this tool can be used to enhance the accuracy of needle placement during neuraxial techniques.

Blocking of the round window can be used to control symptoms of superior semicircular canal dehiscence syndrome in patients who present solely with symptoms of conductive hyperacusis. This technique provides an alternative to resurfacing techniques. The procedure is simple to perform, reversible and can be undertaken as day-case surgery.

A new cause of sound and pressure induced vertigo, superior canal dehisence, is described. Auditory manifestations include hyperacusis to bone-conducted sounds and conductive hearing loss with normal acoustic reflexes. The diagnosis is reached by a directed history, documentation of upward and torsional nystagmus evoked by sound and pressure, and radiology. Acoustic reflexes and VEMP (vestibular evoked myogenic potentials) aid in the identification of patients with an apparent conductive loss with normal acoustic reflexes or have an asymptomatic dehiscense on radiology. Treatment involves avoidance of the precipitating stimuli. Surgical treatment, by resurfacing the dehiscence, is considered in patients with more severe symptoms.

Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute 'Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.