Dexamethasone for all?

Dexamethasone is a drug that has many uses for a range of indications and patient groups. This month, the results of the STRIDE randomised controlled feasibility trial are reported. Kluger et al. recruited 79 participants with hip fracture undergoing surgery and randomised to dexamethasone 20 mg or placebo. They found a number of factors that will help design and complete a larger definitive study. Although delirium was less severe in the dexamethasone group, there was no difference in terms of its incidence. We look forward to a larger definitive trial in the future which is evidently scientifically valid and feasible. In the accompanying editorial, Abraham and Neuman dissect the STRIDE study and draw their own conclusions. They highlight the need for future trials to consider the possible risks associated with steroids, such as postoperative infections. The important point is that this is an area that has not been well studied, and this trial means that trialists working in this area will be better equipped to provide the definitive evidence that we need.

The PROSPECT papers always receive a lot of attention on social media which is probably due to their pragmatic methods and clinically relevant suggestions. This new contribution is aimed at patients undergoing total hip arthroplasty with seven core evidence-based recommendations. The key difference here is that most other guidelines focus on enhanced recovery or anaesthetic technique rather than the best analgesic regimen. In the accompanying editorial, Abdallah and McCartney list what’s old, what’s new and what continues to be missing. Will new iterations include items such as day case surgery, the approach to patients with chronic pain, second- or third-line strategies and novel blocks, not in widespread use at the time of this literature search? Time will tell.

During the first COVID-19 wave in the UK, the general anaesthesia rate for caesarean sections in the north-west decreased significantlyThis new study analyses the impact of increased regional anaesthesia use during the pandemic on the decision-to-delivery interval and neonatal outcomes for category-1 caesarean sections. They conclude that the there was a small, clinically unimportant increase in decision-to-delivery interval for category-1 caesarean section during the first wave of the COVID-19 pandemic (Fig. 1). This arguably supports the safe use of regional anaesthesia for category-1 caesarean section except in those cases which warrant the most urgent delivery. Just what then is a clinically significant decision-delivery interval? Mike Kinsella sets out the evidence, the problem with general anaesthesia and considerations for rapid achievement of delivery under general anaesthesia for category-1 caesarean section with fetal compromise. He argues that 30 min, embedded in audit and clinical practice though it is, is too long for cases where there is fetal compromise. He calls for a new 20min target which should be seen as a new clinically-relevant standard. Do you agree? Let us know!

Figure 1 The significant dependency of general anaesthesia (GA) on indication ordered by neonatal morbidity is shown using non-parametric regression (median slope: 1.03% (95%CI 0.09–1.86), Spearman’s rho correlation 0.81, p = 0.022). Chi-square trend analysis shows a significant 5.6% (95%CI 4.2–7.0); p < 0.0001) change in general anaesthesia rate per ordered indication category. There is a significant use of general anaesthesia for the top four indications combined with adverse neonatal outcomes (odds ratio 3.5 (95%CI 2.2–5.4); p < 0.0001). APH, antepartum haemorrhage; CTG, cardiotocography.

The 7th UK National Audit Project has now begun, and the aim will be to advance our knowledge and understanding of peri-operative cardiac arrests. This new article from Kane et al. lists the challenges faced, such as defining peri-operative cardiac arrest, determining the scope of study and conducting the project in the era of COVID-19. You can hear all about the issues raised in the editorial and much more by listening to the podcast, which is free! One area that has been studied extensively is myocardial injury following non-cardiac surgery and the influence of remote ischaemic preconditioning (RIPC). This new 1-year follow-up from a randomised controlled trial from Ekeloef et al. finds that RIPC did not reduce the occurrence of major adverse cardiovascular events within 1 year of hip fracture surgery (Fig. 2). Looking at individual components of the primary outcome, the preventive effect of RIPC on myocardial infarction seems to hold for 1 year. 

Figure 2 Effect of remote ischaemic preconditioning on 1-year clinical outcomes expressed as hazard ratios. Error bars indicate 95%CIs. MACE, major adverse cardiac event.

This new paper from Maranhao et al. has been available on early view since late 2020 and has attracted a lot of attention on social media. They undertook a systematic review and network meta-analysis to compare spinal needles and their respective odds of post dural puncture headache. They find that the 26-G atraumatic spinal needle is the most likely needle to enable successful insertion while avoiding PDPH. Where this needle is not available, as seems to be the case in most institutions according to Twitter, they provide a rank order to help clinicians select the best among the available options. Whether an intrathecal catheter for labour analgesia reduces the incidence of post-dural puncture headache or need for an epidural blood patch has been questioned. Orbach-Zinger et al. report their literature review and clinical management recommendations for intrathecal catheter use after accidental dural puncture in obstetric patients. Although such a catheter might provide effective and satisfactory labour analgesia, there are several important complications that usually negate their use. Eight clear recommendations are provided.

Elsewhere we have: a description of the new Anaesthesia Case Report (ACRE) checklista prospective study of persistent headache and low back pain following accidental dural puncture in the obstetric populationa retrospective study of labour epidural case volume and the rate of accidental dural puncture; and a narrative review of routinely collected data and patient-centred research in anaesthesia and peri-operative care

Last but by no means least is the penultimate Contemporary Classic article in the series which tackles the 2010s. Kumar et al. have picked a paper from Blanco et al. from 2013 which was the first to describe the serratus plane block. They discuss the identification of new potential sono-anatomic targets, undertaking exploratory studies and translating this pioneering research into clinical practice. They argue the work from Blanco et al. is a classic because it taught us important lessons about how to introduce a novel and potentially useful fascial plane block into clinical practice. It also greatly influenced the expansion in ultrasound-guided block techniques, which increases the likelihood that all surgical patients may one day have access to regional anaesthesia as part of their peri-operative pain management.

Congratulations to our new trainee fellow, Dr Cara Hughes! Cara is a clinical research fellow based at the Academic Unit of Anaesthesia at the University of Glasgow. We look forward to welcoming her to the team!

Mike Charlesworth and Andrew Klein