Many commonly held dogmas of anesthesia are passed down from mentor to student and eventually become institutional "knowledge" because people have never questioned them. We know, however, that it's always incumbent upon practitioners to ask the most important question we can ever ask, which is why, and to review the research ourselves. Here are a few examples of anesthesia dogmas that should be banished.

Dogma No. 1: Women who are breastfeeding should "pump and dump" for 24 hours after being given a general anesthetic.

The reality: The total dose of anesthetic drugs ingested by breastfeeding infants is negligible, as is the intestinal absorption of these drugs by suckling infants. That's why many experts say the best advice for nursing mothers is to continue breastfeeding as soon as they're awake enough to safely do so (see osmag.net/xMFu6J and osmag.net/J6tzJN). The only exceptions are premature infants and those suffering from apnea, as respiratory depression problems could arise. In those cases, it's a good idea to consider waiting 24 hours.

WRIST ASSESSMENT Four strong twitches aren't enough to preclude the need for reversal agents.

Dogma No. 2: You do not have to reverse muscle relaxant if you detect 4 strong twitches in a train-of-four (TOF) assessment.

The reality: The consensus of data suggests that we should be reversing all patients who are dosed with non-depolarizing muscle relaxant. TOF ratios of less than 0.9 are associated with post-op residual paralysis complications. But in a meta-analysis, Naguib, et al., (osmag.net/MtkZ6K) discovered providers' estimates of the rate of residual paralysis based on a TOF ratio of less than 0.9 was 34.8%, meaning that 65.2% were at risk for complications had they been extubated.

Another study (osmag.net/nQ5HGk) found that only 37% of anesthesia providers could detect fade visually, and only 57% could detect it manually. Clearly, TOF assessments are unreliable, which suggests that residual blockade is probably a common cause of respiratory difficulties in the PACU. The only accurate way to determine 0.9 or higher TOF ratio is with objective EMG, MMG or acceleromyography (AMG), but some patients above 0.9 will still display residual paralysis (osmag.net/VTjm2K).

Many believe that if a case goes a certain number of hours, there's no reason to reverse. But the available data doesn't support this assumption either. Caldwell, et al., (osmag.net/Jx9VZr) assessed the degree of neuromuscular blockade (NMBD) for up to 4 hours after a single dose of vecuronium (0.1 mg/kg). The TOF ratio was less than 0.75 in

• 4 of 20 patients at 2 hours,
• 3 of 10 patients at 3 hours, and
• 1 of 20 patients at 4 hours.

A large clinical study (osmag.net/EWqpE6) examined the incidence of residual paralysis after a single intubating dose of an intermediate-acting NMBD and no reversal. Among patients arriving in the PACU, TOF ratios of 0.7 and 0.9 were observed in 16% and 45%, respectively. In patients tested 2 hours after the NMBD administration, TOF ratios of 0.7 and 0.9 were noted in 10% and 37% of patients, respectively.

Murphy, et al., (osmag.net/Jw7pGX) demonstrated that small degrees of residual paralysis (TOF ratios of 0.7—0.9) are associated with impaired pharyngeal function and increased risk of aspiration; weakness of upper airway muscles and airway obstruction; attenuation of the hypoxic ventilatory response (about 30%); and unpleasant symptoms of muscle weakness.

Finally, another study (osmag.net/spRFE6) found that patients who are left to spontaneously recover from such blockade are 6 times as likely to need reintubation within 48 hours of surgery. And a 2012 analysis (osmag.net/zEZk8S) found that reintubation requiring admission to the ICU was associated with a 90-fold higher risk for in-hospital mortality.

DON'T TEST Even a tiny dose of cephalosporins could bring on anaphylaxis.

Dogma No. 3: You should always give an IV test dose of Ancef to patients who've had anaphylactic reactions to penicillin, to make sure they don't react. The idea is that if there is true cross-reactivity with Ancef (cephalosporins), you'll see a small area of reaction with a test dose of about 1cc IV, and this will guide you not to give the rest.

The reality: In a small percentage of patients, even a tiny dose of cephalosporins could result in full-blown anaphylaxis. Hence the current recommendation is to not give any cephalosporins to patients with known IgE-mediated reactions to penicillin.

At least 300 patients (or about 0.001%) treated with penicillin die from anaphylaxis each year. Interestingly, about 70% have had penicillin previously without issue (osmag.net/Fhv4UU), and it's estimated that the true cross reactivity with first-generation cephalosporins is about 1% (osmag.net/qUN6Zt).

Allergies to penicillin are about 25% IgE-mediated and 75% non-IgE-mediated (osmag.net/ysTVM7). IgE-mediated reactions can result in anaphylaxis, urticaria and angioedema. Since penicillin IgE reaction is an all-or-nothing proposition, it won't matter if you give 1 cc or the whole dose of Ancef. In 1% of patients it could result in full-blown anaphylaxis.

PREEMPTIVE REGIMEN
What's in Your Multimodal Cocktail?

MIX MASTER Dr. Sabatelli's multimodal approach addresses pain ahead of time.

The spike in patient satisfaction scores at the Blue Springs Surgery Center in Orange City, Fla., have coincided with the arrival of anesthesiologist Daniel Sabatelli, MD, and the multimodal cocktail he's been administering to pre-op ortho, general and GYN surgery patients.

"Our patients are much more comfortable in the recovery room, and on average the patients are being discharged within 30 minutes," says Clinical Director Enivette G. Ramirez, RN. "It's a positive effect that's clearly attributable to Dr. Sabatelli's preemptive analgesia regimen, as PACU nurses who've worked when he has another provider covering for him will attest."

The regimen, which relies on anti-inflammatories and other non-narcotic agents, works multiple pathways to block post-op pain. Here's an outline:

• dexamethasone IV, about 1 hour pre-op,
• ketorolac IV, about 1 hour pre-op,
• acetaminophen orally or IV, about 2 hours pre-op,
• consider ketamine at anesthesia induction, and
• consider oral clonidine, gabapentin or additional pre-op meds for select cases.

Dr. Sabatelli's multimodal approach also recommends the following options:

• the use of peripheral nerve blocks with long-acting local anesthetics, as appropriate,
• the application of long-acting local anesthetics at the surgical site,
• a bolus dose of hydromorphone at the beginning of surgery,
• avoiding narcotic redosing during, at the end of or after a case, and
• a combination of reduced-dose intramuscular ketorolac and low-dose oral oxycodone for post-op pain.

— David Bernard