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when a 20-G NexivaTM Closed IV Catheter System (BD, Oxford, UK) was flushed with saline 0.9% on the postoperative surgical ward. This cannula was used at induction of anaesthesia with crystalloid running via one of its ports throughout, but we can only presume it failed to flush effectively. Unfortunately the cannula was not subsequently used as an 18-G single-port cannula was then sited and used for the rest of the case. The maximum dead space of the two ports and extension tubing of a 20-G Nexiva cannula is 0.5 ml. If unflushed after a rapid sequence induction this device can potentially lead to the administration of 25 mg suxamethonium, which is well beyond its ED50 and could easily produce generalised paralysis in a 70-kg adult [2]. Our case confirms the recommentation of Bowman et al. [3] that the only way to avoid this potentially life-threatening complication is to flush all cannula ports (regardless of their type or whether there is fluid running via the second lumen) with saline after administration of drugs, and that this should be a standard of care in adults as well as children. T. G. J. Wojcikiewicz M. J. E. Peck Frimley Park Hospital Surrey, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.

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References 1. McDevitt L, Mowat IR. Transient paralysis after cyclizine administration. Anaesthesia 2013; 68: 1084. 2. Meistalman C, Plaud B, Donati F. Neuromuscular effects of succinylcholine on the vocal cords and adductor pollicis muscles. Anesthesia and Analgesia 1991; 73: 278–82. 3. Bowman S, Raghavan K, Walker IA. Residual anaesthesia drugs in intravenous lines – a silent threat? Anaesthesia 2013; 68: 557–61.

L. McDevitt East Surrey Hospital Surrey, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.

doi:10.1111/anae.12515

References A reply I thank Drs Norman and Wojcikiewicz for their comments on our report of transient paralysis after cyclizine administration [1]. Residual neuromuscular blocking drug in the cannula was considered at the time of respiratory arrest and was discussed afterwards as a possible cause [2]. However, after investigation, we decided that this was unlikely to be the case. All anaesthetic induction drugs were administered through the port on top of an 18-G cannula. Intravenous fluids and subsequent maintenance drugs were then run through extension tubing. The intravenous cyclizine was also administered through the extension tubing. The cyclizine was administered six hours after anaesthesia, during which time multiple medications and fluids had been given via the cannula. This led us to believe that it was highly unlikely that the transient paralysis was caused by residual neuromuscular blocking drug.

© 2013 The Association of Anaesthetists of Great Britain and Ireland

1. McDevitt L, Mowat IR. Transient paralysis after cyclizine administration. Anaesthesia 2013; 68: 1084. 2. Bowman S, Raghavan K, Walker IA. Residual anaesthesia drugs in intravenous lines – a silent threat? Anaesthesia 2013; 68: 557–61. doi:10.1111/anae.12518

Guidelines and use of dexamethasone for postoperative nausea and vomiting I am curious about the reasons that prompted the twin editorials on dexamethasone for postoperative nausea and vomiting (PONV) in September’s edition of Anaesthesia [1, 2], especially ‘the case against’ raised by Drs Hartle & Bartlett [2]. A number of published articles over the last 15 years provide evidence that a single prophylactic dose of the potent corticosteroid dexamethasone can safely reduce the likelihood of sickness after general anaesthesia. The use of dexamethasone as an antiemetic is recommended in the Royal College of Anaesthetists’ 2012 Basic Level

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Training guide [3] and in the Association of Paediatric Anaesthetists of Great Britain and Ireland’s 2008 guidelines [4]. In Reading, since 2004, we have used a PONV protocol based on Apfel et al.’s simplified scoring system of four factors (female sex, history of motion sickness or PONV, non-smoking and use of postoperative opioids) [5]; patients with any one of these are prescribed prophylactic antiemetics if they undergo general anaesthesia, and those with any three receive total intravenous anaesthesia (TIVA), rather than volatile agents. Dexamethasone has been the inexpensive first-line choice, partly because it enhances the patients’ mood, but also because it is a superior antiemetic to propofol TIVA in the first 24 hours postoperatively [6]. The combination of dexamethasone and ondansetron remains a popular choice for female non-smokers. Admissions for PONV after day-case surgery are rare. We have not seen gastric ulceration or psychiatric disturbance. A single dose of dexamethasone is administered to diabetics with prolonged PONV that interferes with oral intake of food, without disturbance of their blood sugar control. On visiting Kehlet’s group in Copenhagen, we learned that widespread use of dexamethasone was not associated with any increase in postoperative infection in arthroplasty patients. Neither editorial mentioned that use of dexamethasone as a prophylactic antiemetic lies outside the

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manufacturer’s marketing authorisation. The General Medical Council advises doctors to use drugs that are licensed for a particular indication in preference to those that lack a marketing authorisation for that purpose. In advocating elective treatment with a drug that is ‘offlabel’, specific informed consent should be sought from the patient pre-operatively [7]. The Royal College of Anaesthetists helpfully provide written information to this end, that can be provided for patients at pre-operative assessment clinics or by direction to the website [8].

5. Apfel CC, Laara E, Koivuranta M, Griem CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centres. Anesthesiology 1999; 91: 693–700. 6. Apfel CC, Korttila A, Abdula M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. New England Journal of Medicine 2004; 350: 2441–51. 7. Mackenzie JW. Whose licence is it anyway? Anaesthesia News 2010; 271: 17–8. 8. The Royal College of Anaesthetists. Risks associated with your anaesthetic. Section 1: feeling sick. 2013. http://www. rcoa.ac.uk/system/files/PI-Risk1_3.pdf (accessed 09/09/2013).

J. Mackenzie Royal Berkshire Hospital, Reading, UK Email: [email protected]

Regional anaesthesia and patients with abnormalities of coagulation

No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.

My congratulations to the Working Party for producing user-friendly guidance on the management of regional anaesthesia in patients with abnormalities of coagulation [1]. I wonder if the authors could clarify the recommendation that regional anaesthesia should not be performed for five days following the administration of ticagrelor. As a reversible, direct acting platelet ADP P2Y12 receptor with a half-life of 812 hours, following 48 hours (approximately five plasma half-lives) from last admission, the inhibitory platelet effect will almost completely have reversed. I am aware of anaesthetic departments in my region currently using two days as an acceptable time after drug administration to perform regional anaesthesia.

References 1. Kakodkar PS. Routine use of dexamethasone for postoperative nausea and vomiting; the case for. Anaesthesia 2013; 68: 889–891. 2. Bartlett R, Hartle AJ. Routine use of dexamethasone for postoperative nausea and vomiting; the case against. Anaesthesia 2013; 68: 892–96. 3. The Royal College of Anaesthetists. Basic Level training guide, 2012. https://www.rcoa.ac.uk/system/files/ TRG-CCT-AnnexB_1.pdf (accessed 09/ 09/2013). 4. Association of Paediatric Anaesthetists of Great Britain and Ireland. Guidelines on the prevention of post-operative vomiting in children, Spring, 2009. http://www.apagbi.org.uk/sites/defau lt/files/APA_Guidelines_on_the_Preven tion_of_Postoperative_Vomiting_in_Chil dren.pdf (accessed 09/09/2013).

doi:10.1111/anae.12513

© 2013 The Association of Anaesthetists of Great Britain and Ireland

Guidelines and use of dexamethasone for postoperative nausea and vomiting.

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