The edition · Anaesthesiology
Intravenous dexamethasone comes out first for rebound pain after a single-shot block
A network meta-analysis ranks eight prophylactic strategies and finds pre-emptive opioids probably worse than nothing; plus which postoperative complication carries most of the deaths in an African cohort, a fragile opioid-free signal in cardiac surgery, and where to put the electrodes.
The edition in brief
The anaesthesiology desk opens with a network meta-analysis of 24 randomised trials and 2,130 patients comparing eight strategies for preventing rebound pain after single-injection peripheral nerve block. Intravenous dexamethasone ranked first for reducing rebound pain incidence, surface under the cumulative ranking curve 0.91, and was judged definitely superior to control; perineural dexamethasone and dexmedetomidine ranked highest for delaying onset and prolonging time to rescue analgesia, while pre-emptive opioids were probably inferior to control. Certainty of evidence ranged from very low to moderate. An analysis of 10,748 patients from the African Surgical Outcome Study, 222 of whom died within 30 days, found pulmonary embolism carried the highest adjusted odds of death (odds ratio 484) but severe bloodstream infection carried the largest attributable fraction at 13.7% — the complication whose prevention would save most lives. The OFACAR trial randomised 320 cardiac surgical patients to opioid-free anaesthesia or sufentanil: the composite complication endpoint favoured opioid-free care, risk ratio 0.90 (95% CI 0.80 to 0.99), with a fragility index of 1, and no deaths against six. A three-arm caesarean trial found a lateral quadratus lumborum block reduced early resting pain compared with intrathecal morphine, and the combination reduced it further. A pearl covers pre-operative clear fluids. The edition closes with a trial showing abductor digiti minimi monitoring is equivalent to adductor pollicis on the non-dominant hand but recovers 20 to 25% faster on the dominant one.
For rebound pain, give the dexamethasone intravenously
Add intravenous dexamethasone for single-injection blocks and drop pre-emptive opioids, which ranked worse than doing nothing.
Bloodstream infection carries more postoperative deaths than anything else
Target bloodstream infection and the recognition of postoperative deterioration — that is where one in seven postoperative deaths sits.
Opioid-free cardiac anaesthesia: a real signal on a very thin margin
Treat this as a reason to run the larger trial, not to change a cardiac anaesthetic technique — though the reduction in digestive complications is the part worth watching.
Quadratus lumborum block alongside intrathecal morphine, not instead of it
Add a quadratus lumborum block to intrathecal morphine for better early pain after caesarean; do not use it as a replacement on this evidence.
Two hours for clear fluids is a floor, not a target
Replace 'nil by mouth from midnight' with an instruction to drink clear fluids until two hours before the scheduled time, and make someone responsible for re-offering when the list slips.
Monitor the little finger if you must, but use the non-dominant hand
Put the train-of-four electrodes on the non-dominant arm; on the dominant hand the little finger reads recovery early.
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