Cumulative glucocorticoid exposure in patients receiving epidural steroid injections: A single-centre retrospective evaluation on 581 procedures against existing clinical recommendations.

Background: The purpose of the study was to review the cumulative corticosteroid doses received from epidural and non-epidural-based pain interventions in a cohort of patients undergoing epidural steroid injections (ESIs) with comparison to safe dosing recommendations. Methods: Retrospective analysis was undertaken for all 349 patients who underwent a total of 581 ESIs at a single-centre, tertiary hospital in South Australia between 2017 and 2019. The primary outcome was the yearly dose analysis of cumulative steroid doses in methylprednisolone equivalents (MDPE) administered from epidural and non-epidural interventions in post-menopausal women, interpreted against maximum recommended doses. Results: The annual limit of 200 â€‹mg for postmenopausal women was exceeded in 4.7% of the time (11/235) from ESIs alone, with a significant rise to 15.3% (46/300) when non-ESI injections were included in cumulative dose totals(p â€‹< â€‹0.001). Of the 173 participants of post-menopausal female age, 4.1% (7/173) received cumulative corticosteroid doses above the 3-year 400 â€‹mg MPDE limit from ESIs alone, with a statistically significant increase to 13.9% (24/173) when non-epidural steroid injections were again included in cumulative dose totals (p â€‹< â€‹0.001). The mean â€‹± â€‹standard deviation administered MPDE per epidural steroid injection across the whole study cohort was 72 â€‹± â€‹22 â€‹mg, nearly double the recommended dose of 40 â€‹mg. Conclusions: Our study underpins the need for vigilance when considering steroid-based pain interventions, wherein both the individual and cumulative steroid exposure should be considered.

High-flow nasal cannula versus standard oxygen therapy assisting sedation during endoscopic retrograde cholangiopancreatography in high risk cases (OTHER): study protocol of a randomised multicentric trial.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an increasingly common intervention in the treatment of pancreaticobiliary disorders. Patients are often elderly with complex co-morbidities. While monitored anaesthesia care with sedation is commonly used for most cases, few would require general anaesthesia with an endotracheal tube. Both low-flow and high-flow nasal cannulas (HFNC) are established ways of delivering supplemental oxygen, but it is unclear whether one technique is better than the other. HFNC seems a promising tool for advanced procedures but evidence to support its application in high-risk ERCP cases is limited. The rate of oxygen desaturation during endoscopy has been reported to be as high as 11%-50% and the method of oxygen delivery for ERCP merits further study. METHODS/DESIGN: This is a prospective, randomised, multicentre trial comparing the efficacy of oxygen supplementation through HFNC versus low-flow nasal cannula during ERCP, in a cohort of patients at risk of adverse respiratory events. A total of 132 patients will be recruited across three sites and randomly assigned to either the low-flow or the HFNC group. The primary outcome is the proportion of patients experiencing hypoxia, defined by any event of SpO2 < 90%. The secondary outcomes include parameters centred on oxygenation, requirement of airway manoeuvres, successful completion of procedure, perioperative complications, patient satisfaction and cost analysis of the consumables. An intention-to-treat principle will be applied while analysing. DISCUSSION: The demand for ERCPs is likely to increase in the future with the aging population. Our study results may lead to improved outcomes and reduce airway-related complications in patients undergoing ERCPs. The results will be presented at national and international meetings and published in peer-reviewed journals. TRIAL REGISTRATION: www.ANZCTR.org.au, CTRN12619000397112. Registered on 12 March 2019.

LMA® Gastro™ Airway for endoscopic retrograde cholangiopancreatography: a retrospective observational analysis.

BACKGROUND: Various airway techniques have been employed for endoscopic procedures, with an aim to optimise patient outcomes by improving airway control and preventing hypoxia whilst avoiding the need for intubation. The LMA® Gastro™ Airway, a novel dual channel supraglottic airway technique, has been described as such a device. Its utility alongside sedation with low flow nasal cannula and general anaesthesia (GA) with intubation for endoscopic retrograde cholangiopancreatography (ERCP) procedures was evaluated. METHODS: Details of all the ERCPs performed in our institution from March 2017 to June 2018 were carefully recorded in the patients' electronic case records. Data on the successful completion of ERCP through LMA® Gastro™ Airway; any difficulty encountered by the gastroenterologists; and adverse events were recorded. Episodes of hypoxia (SpO2 < 92%) and haemodynamic parameters were compared across the three groups: LMA® Gastro™ vs. sedation with low flow nasal cannula vs. GA with an endotracheal tube (ETT). RESULTS: One hundred seventy-seven ERCP procedures were performed during the study period. The LMA® Gastro™ Airway was employed in 64 procedures (36%) on 59 patients. Of these 64 procedures, ERCP was successfully completed with LMA® Gastro™ Airway in 63 (98%) instances, with only one case requiring conversion to an endotracheal tube. This instance followed difficulty in negotiating the endoscope through LMA® Gastro™ Airway. No episodes of hypoxia or hypercapnia were documented in both LMA® Gastro™ and GA with ETT groups. One sedation case with nasal cannula was noted to have hypoxia. Adverse intraoperative events were recognised in 2 cases of LMA® Gastro™: one had minimal blood stained secretions from the oral cavity that resolved with suctioning; the other developed mild laryngospasm which resolved spontaneously within a few minutes. CONCLUSION: In patients undergoing ERCP, the LMA® Gastro™ airway demonstrated a high success rate for ERCP completion. Ventilation was well maintained with minimal intraoperative and postoperative adverse events. This technique may have a role in higher risk groups such as high ASA (American Society of Anesthesiologists) status, or those with potential airway difficulties such as high body mass index and those with known or suspected sleep apnoea.

The intraoperative use of non-opioid adjuvant analgesic agents: a survey of anaesthetists in Australia and New Zealand.

BACKGROUND: Opioids have long been the mainstay of drugs used for intra-operative analgesia. Due to their well-known short and long term side effects, the use of non-opioid analgesics has often been encouraged to decrease the dose of opioid required and minimise these side effects. The trends in using non-opioid adjuvants among Australian Anaesthetists have not been examined before. This study has attempted to determine the use of non-opioid analgesics as part of an opioid sparing practice among anaesthetists across Australia and New Zealand. METHODS: A survey was distributed to 985 anaesthetists in Australia and New Zealand. The questions focused on frequency of use of different adjuvants and any reasons for not using individual agents. The agents surveyed were paracetamol, dexamethasone, non-steroidal anti-inflammatory agents (NSAIDs), tramadol, ketamine, anticonvulsants, intravenous lidocaine, systemic alpha 2 agonists, magnesium sulphate, and beta blockers. Descriptive statistics were used and data are expressed as a percentage of response for each drug. RESULTS: The response rate was 33.4%. Paracetamol was the most frequently used; with 72% of the respondents describing frequent usage (defined as usage above 70% of the time); followed by parecoxib (42% reported frequent usage) and dexamethasone (35% reported frequent usage). Other adjuvants were used much less commonly, with anaesthetists reporting their frequent usage at less than 10%. The majority of respondents suggested that they would never consider dexmedetomidine, magnesium, esmolol, pregabalin or gabapentin. Perceived disincentives for the use of analgesic adjuvants varied. The main concerns were side effects, lack of evidence for benefit, and anaesthetists' experience. The latter two were the major factors for magnesium, dexmedetomidine and esmolol. CONCLUSION: The uptake of tramadol, lidocaine and magnesium amongst respondents from anaesthetists in Australia and New Zealand was poor. Gabapentin, pregabalin, dexmedetomidine and esmolol use was relatively rare. Most anaesthetists need substantial evidence before introducing a non-opioid adjuvant into their routine practice. Future trials should focus on assessing the opioid sparing benefits and relative risk of using individual non-opioid adjuvants in the perioperative period for specific procedures and patient populations.