The edition · Anaesthesiology
One patient in four carries a label that makes their surgery worse
Across 13,646 UK surgical patients, a drug allergy label came with a 25% complication rate against 20% - and roughly nine in ten of those labels are thought to be wrong. Plus dexamethasone against ondansetron after caesarean, caudal blocks and hypospadias fistulas, what actually kills after surgery in Africa, and a resuscitation order that quietly withholds a nerve block.
The edition in brief
Today's anaesthesiology desk opens with antiemetic choice after caesarean delivery. A double-blind trial of 95 women on spinal anaesthesia with 150 micrograms of morphine and an enhanced recovery protocol found dexamethasone 8 mg and ondansetron 4 mg indistinguishable on the total number of medications needed for nausea, pain or pruritus in 24 hours (0.40 vs 0.23 per patient, P = .337), with no difference in pain scores - the opioid-sparing effect reported previously did not appear. An early-terminated multicentre randomised trial across 16 centres compared caudal with penile block in 161 children under two having hypospadias repair: urethrocutaneous fistula occurred in 8.9% against 7.3% (RR 0.98, 95% CI 0.35-2.76), while caudal block halved intraoperative opioid use and lowered recovery-room pain scores. Proximal meatal position, not block choice, carried the fistula risk (RR 2.8). Analysis of 10,748 patients in the African Surgical Outcome Study found pulmonary embolism, pulmonary oedema and bloodstream infection most strongly associated with 30-day in-hospital death, but severe bloodstream infection carried by far the largest attributable fraction at 13.7%. A cross-sectional study of 761,000 fracture admissions found do-not-resuscitate status associated with lower odds of regional analgesia for rib fractures (OR 0.76) but not hip fractures, with the effect strongest in the least frail patients (OR 0.34). The edition closes on drug allergy labels: among 13,646 patients across 21 UK hospitals, 29% carried at least one, and they had more postoperative complications (OR 1.21), more infections (OR 1.24) and three times the rate of allergic drug reactions, with no difference in mortality.
Dexamethasone did not beat ondansetron after caesarean, and did not spare opioids either
With intrathecal morphine and an enhanced recovery protocol in place, dexamethasone and ondansetron are interchangeable as first-line antiemetics after caesarean.
Caudal block did not cause hypospadias fistulas - the meatal position did
Caudal block remains a reasonable choice for hypospadias repair, with better analgesia and no severity-adjusted signal for fistula - but the question is not closed.
What is worth preventing after surgery in a low-resource system is not what is most lethal
Target bloodstream infection first - it accounts for more postoperative deaths than any other complication, even though pulmonary embolism is far more lethal per case.
A resuscitation order that reduces the chance of a comfort procedure
When you see a do-not-resuscitate order on a rib fracture chart, take it as a prompt to offer regional analgesia rather than to withhold it.
Three questions that resolve most allergy labels at the pre-op visit
Ask what happened, when, and whether they have taken it since - then write the answers into the allergy field, not just the label.
Drug allergy labels come with a fifth more postoperative complications
Treat an allergy label as a history to be taken, not a fact to be transcribed - and build a route to correct the ones that do not survive the questions.
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