ADRENAL trial – to steroid or not to steroid in septic shock

The original:

An excellent summary:

Should we still be trying to modify the dysregulated immune response in sepsis? An interesting evolutionary perspective:

My verdict:

Although not improving (or worsening) mortality, if steroids reduce duration of shock and length of ICU stay then they are probably worth a go, given that the absolute possible increase in risk of noteworthy adverse outcomes is very low, although this must be borne in mind.  Could still argue it either way though. When we can genotype patients we may be able to identify those specific individuals in whom steroid may do significant benefit or harm. Or maybe not!

Erector spinae plane (ESP) block

For abdominal e.g laparotomy or thoracic dermatomes e.g. thoracotomy, rib fractures

Alternative to epidural

Patient awake – sitting or prone

Identify midline (in transverse plane)

Block at level of:

  • T7 level for abdominal cover, even rooftop
  • T5 for thoracic cover (T2 – T9)

Scan laterally so transverse process (TP) in in middle of screen.

Rotate probe vertically to para-sagital plane

Identify layers of subcutaneous tissue, trapezius, (+/- rhomboid), erector spinae (ES)- with articulates with transverse processes

Local anaesthetic at superior entry point. Deep infiltration to level of muscle.

Use Tuohy needle or regional catheter pack needle, in plane approach

Access ESP below ES muscle, adjacent to TP. Can hit it (original description) but more painful. Create space with saline.

Then threat catheter. Leave at least 10cm in the space. Load with 20ml of 0.375% l-bupivicaine to each side.

Then run infusion 0.25% l-bupivicaine at 10ml per hour (split between both sides).

–  NG @ LGH



Liver resection


Keep dry – almost no fluid prior to resection. CVP <5

Then catch up

A-line, CVC, +/- swan sheath

Consider iVC compression by surgeons if hypotensive

Muscle relaxant (consider infusion)

Analgesia options:

  • thoracic epidural
  • spinal diamorphine, wound infusion catheter (2.5mg/ml levo-bupivicaine @ 10ml/hr) + morphine PCA – caution (with liver impairment)
  • role for ESP block?


Anaesthetic considerations for robotic surgery

Key points:

Maintain muscle paralysis while robot is docked – consider infusion of relaxant

Meticulous positioning with pressure point protection

Difficult to access patient intra-op

Have enough slack on lines

If steep trendelunburg e.g. prostatectomy caution with fluids, raised ICP and IOP, airway oedema.

Recipe for radical prostatectomy:

GA, ETT, 2x IVI, a-line

O2/air/desflurane. MAC 0.8-1.0

Remifentanil (0.1-0.2mcg/kg/min) and atracurium infusion

<500ml prior to anastomosis, max 2000ml in total (if no significant blood loss).