Anesthesia For Ambulatory Surgery Research Articles

Co-Induction of Anaesthesia with Desflurane Improves Intubating Conditions after Low-Dose Rocuronium

Objective: To assess the impact of co-induction of anaesthesia with desflurane on the intubating conditions after low-dose rocuronium 0.3 mg/kg (equivalent to 1 × ED95, the dose of neuromuscular blocking agent that produces an average of 95% neuromuscular block; a typical intubating dose is 2 × ED95). Design: A prospective, double-blind, randomised, placebo-controlled clinical trial carried out in surgical patients. Patients: 120 adult patients (American Society of Anaesthesiologists grades I or II) undergoing general anaesthesia for ambulatory surgery. Methods: Patients were randomised to four groups (n = 30 each) as follows: group A (control group) — desflurane 1 minimum alveolar concentration (MAC), i.e. 6% inspired concentration by volume, no myorelaxant; group B — desflurane 1 MAC and rocuronium 1 × ED95; group C — no desflurane and rocuronium 1 × ED95; group D (reference group) — no desflurane and rocuronium 2 × ED95. In all patients anaesthesia was induced with thiopental 5 mg/kg and fentanyl 2 μg/kg. After loss of consciousness, saline (group A) or the respective dose of rocuronium (groups B to D) was injected over 5 seconds and the patients were ventilated for 3 minutes via face mask with 1 MAC desflurane in O2 (groups A and B) or with O2 alone (groups C and D). Thereafter, all patients were intubated by the same experienced anaesthetist and the intubating conditions were assessed according to the criteria proposed by the Copenhagen Consensus Conference. Results: Without the concomitant administration of desflurane, the intubating conditions after rocuronium 0.3 mg/kg were good or excellent in only seven patients and not acceptable in 23. Adding desflurane at an inspired concentration of 1 MAC to this induction regimen significantly improved the intubating conditions; good or excellent conditions were now observed in 26 patients and unacceptable intubating conditions in only four patients (group C vs group B: p < 0.01). The rate of clinically acceptable intubating conditions in group B did not differ from those obtained after the usual intubating dose of rocuronium 0.6 mg/kg in group D (26 patients vs 30 patients, respectively). Conclusions: After co-induction of anaesthesia with desflurane, reduced doses of rocuronium (1 × ED95) are sufficient to obtain good to excellent intubating conditions in elective situations. This may be of clinical interest for short surgical procedures or ambulatory surgery.

Total intravenous or balanced anaesthesia in ambulatory surgery?

General anaesthesia is still the most common anaesthetic technique in the ambulatory surgery setting. With the introduction of propofol, total intravenous anaesthesia gained widespread acceptance. Recently, the combination with remifentanil, an ultra-short acting opioid analgesic, allowed even more control over the duration of the anaesthetic. In comparison to propofol, however, the new inhalational anaesthetics desflurane and sevoflurane possess a pharmacokinetic profile that is preferable to that of propofol. Initial studies show that these pharmacokinetic advantages lead to a faster short-term recovery, although both substances have been associated with a higher incidence of postoperative nausea and vomiting. No differences have so far been demonstrated in respect to long-term recovery, discharge from the post-anaesthesia care unit and discharge from the ambulatory care centre. Currently the anaesthesiologist has the possibility to choose his preferred anaesthetic technique based on individual patient needs, the surgery performed and the side-effects each technique may have. However, in contrast to the situation at the beginning of the 1990s total intravenous anaesthesia is not the technique that fits all needs but balanced anaesthesia presents an alternative.

Room 224-226, 10/17/2000 10: 30 AM - 12: 00 PM (PD) Transport to PACU after General Anesthesia in Ambulatory Surgery: Comparison of Nasal Cannula O2Versus Room Air

<b>Room 224-226, 10/17/2000 10: 30 AM - 12: 00 PM (PD) Transport to PACU after General Anesthesia in Ambulatory Surgery: Comparison of Nasal Cannula O2Versus Room Air</b>

Restricted Spinal Anaesthesia for Ambulatory Surgery: A Pilot Study

KUUSNIEMI, K. S.; PIHLAJAMÄKI, K. K.; IRJALA, J. K.; JAAKKOLA, P. W.; PITKÄNEN, M. T.; KORKEILA, J. E. Author Information

Recent developments in regional anesthesia for ambulatory surgery

The use of regional anesthesia techniques is increasing in popularity because they reduce the incidence of postoperative complications, including nausea, vomiting, and pain, and decrease the recovery time and hospital stay. This article reviews the recent developments in regional anesthesia techniques and the modifications necessary to adapt them for ambulatory surgery.

A Cost Comparison of Methohexital and Propofol for Ambulatory Anesthesia

Methohexital is eliminated more rapidly than thiopental, and early recovery compares favorably with propofol.We designed this study to evaluate the recovery profile when methohexital was used as an alternative to propofol for the induction of anesthesia before either sevoflurane or desflurane in combination with nitrous oxide. One hundred twenty patients were assigned randomly to one of four anesthetic groups: (I) methohexitaldesflurane, (II) methohexital-sevoflurane, (III) propofoldesflurane, or (IV) propofol-sevoflurane. Recovery times after the anesthetic drugs, as well as the perioperative side effect profiles, were similar in all four groups. A cost-minimization analysis revealed that methohexital was less costly for the induction of anesthesia. At the fresh gas flow rates used during this study, the costs of the volatile anesthetics for maintenance of anesthesia did not differ among the four groups. However, at low flow rates (<or=to1 L/min), the methohexital-desflurane group would have been the least expensive anesthetic technique. In conclusion, methohexital is a cost-effective alternative to propofol for the induction of anesthesia in the ambulatory setting. At low fresh gas flow rates, the methohexital-desflurane combination was the most cost-effective for the induction and maintenance of general anesthesia. Implications: Using methohexital as an alternative to propofol for the induction of anesthesia for ambulatory surgery seems to reduce drug costs. When fresh gas flow rates <or=to1 L/min are used, the combination of methohexital for the induction and desflurane for maintenance may be the most cost-effective general anesthetic technique for ambulatory surgery. (Anesth Analg 1999;89:311-6)

Restricted spinal anaesthesia for ambulatory surgery: a pilot study

Restricted spinal anaesthesia for ambulatory surgery: a pilot study

Volatile versus intravenous anaesthetic techniques for ambulatory anaesthesia

This review considers the role played by volatile and intravenous agents in the induction and maintenance of anaesthesia for ambulatory surgery. The speed and ease of induction, maintenance and recovery, and associated advantages such as the facilitation of airway manoeuvres, side-effect profiles and economic influences are considered.

Epidural, spinal, and combined spinal epidural anesthesia for ambulatory surgery

Regional anesthetic techniques are rapidly evolving to meet the needs of an ever increasing day surgery patient population. Rapidity and control of onset and offset of anesthesia with minimal side effects are now required of regional anesthetic techniques if these are to compete with general anesthesia. Spinal, epidural, and combined spinal epidural (CSE) anesthesia for the day surgery patient are discussed below. Epidural anesthesia has been a useful anesthetic for the day surgery patient, but is being supplanted by spinal and combined spinal epidural anesthesia. Lidocaine has been the traditional drug of choice for intrathecal use in day surgery patients. Recently, use of lidocaine has been questioned after reports of neurotoxicity and its association with transient radicular irritation (TRI), a recently described syndrome of radiating back pain following spinal anesthesia. Mepivacaine is a longer acting local anesthetic that has been looked at as an alternative to lidocaine but has been found to be associated with TRI as well. Meperidine, an opiate with local anesthetic properties has found some application, but was associated with inadequate motor blockade in clinical studies. Combinations of local anesthetics, opiates, and other drugs along with advances in needles and needle sets are areas of active research interest.

Optimizing spinal anesthesia for ambulatory surgery.

Spinal anesthesia is used for ambulatory surgical procedures. We provide an overview of the use of local anesthetics, use of continuous techniques, and use of adjuncts for optimization of spinal anesthesia for ambulatory surgery. Review of current literature and critical analysis of selected manuscripts. Small doses of lidocaine (approximately 40 mg) and bupivacaine (approximately 7.5 mg) are appropriate for ambulatory surgery. Increasing concentration of local anesthetic solution may result in increased duration of anesthesia and recovery. While use of hyperbaric solutions consistently produce more cephalad sensory block, use of isobaric solutions provide adequate sensory and motor block for lower extremity surgical procedures. The use of continuous techniques may provide valuable anesthetic titration, as small doses of spinal anesthetics may produce highly variable results. Epinephrine is not recommended as an adjunct due to prolongation of recovery time. In contrast, intrathecal fentanyl may prolong surgical anesthesia without prolonging recovery. Ambulatory spinal anesthesia may be optimized by selection of dose, concentration, and baricity of local anesthetic. Use of a continuous technique or an intrathecal adjunct may also be valuable means to optimize spinal anesthesia for ambulatory surgery.

Selective spinal anaesthesia in ambulatory surgery

Background and objectives: selective spinal anaesthesia (SSA) is preferable in day hospital surgery. The present investigation aims to confirm the usefulness and safety of this technique. Methods: 250 patients (ASA I–II, mean age 42 ± 3 years) scheduled for day-hospital surgery were enrolled in our study. The puncture was performed with the patients in a lateral position, the ill side down; for proctological surgery the puncture was performed in a sitting position. A 27G Whitacre needle was always used and 1% hyperbaric bupivacaine was administered in 30 s or more, preceded by a single dose of fentanyl (20 μg) injected very slowly. The position was maintained for 10 min. Hemodynamic parameters (SBP, DBP, HR) and pulsoximetry were recorded before anaesthesia (T 0), 5 min after subarachnoid injection (T 1) and then every 15 min (T n) up to the completion of the surgical procedure. In the last 100 patients enrolled in our study haemodynamic data (CI, EF, SVRI, MAP,HR) were recorded by using a non invasive bioimpedenzometric method, before anaesthesia (T a), after 15 min (T b), 60 min (T c) and 240 min (T d). The postoperative course was evaluated from the end of surgery on, with regard to analgesic consumption and residual analgesic degree. The incidence of adverse effects was evaluated. Results: the level and degree of anaesthesia was excellent in 183 and good in 67 patients. SBP, DBP, HR and pulsoximetry showed an excellent stability during the study. Haemodynamic stability was confirmed by data obtained with bioimpedenzometry that showed significant variations in CI ( P < 0.001), SVN ( P < 0.0001) at T b and T c as to basal five values. Postoperative analgesia was excellent and the incidence of side effects very low. Conclusions: we believe that the method is suitable for day-hospital surgery because it is easy to execute and provides an excellent degree of surgical anaesthesia, cardiovascular stability, postoperative analgesia and patient safety.

Remifentanil Compared with Alfentanil for Ambulatory Surgery Using Total Intravenous Anesthesia

The purpose of this study was to test the hypothesis that using a 1:4 ratio of remifentanil to alfentanil, a remifentanil infusion would provide better suppression of intraoperative responses and comparable recovery profiles after ambulatory laparoscopic surgery than an alfentanil infusion, as part of total intravenous anesthesia. Two hundred ASA physical status I, II, or III adult patients participated in this multicenter, double-blind, parallel group study. Patients were randomly assigned 2:1 to either the remifentanil-propofol or alfentanil-propofol regimens. The anesthesia sequence was propofol (2 mg/kg intravenously [IV] followed by 150 micro g [centered dot] kg (-1) [centered dot] min-1), and either remifentanil (1 micro g/kg IV followed by 0.5 micro g [centered dot] kg-1 [centered dot] min-1) or alfentanil (20 micro g/kg IV followed by 2 micro g [centered dot] kg-1 [centered dot] min (-1)), and vecuronium. After trocar insertion, infusion rates were decreased (propofol to 75 micro g [centered dot] kg-1 [centered dot] min-1; remifentanil to 0.25 micro g [centered dot] kg-1 [centered dot] min-1; alfentanil to 1 micro g [centered dot] kg-1 [centered dot] min-1). Alfentanil and propofol were discontinued at 10 and 5 min, respectively, before the anticipated end of surgery (last surgical suture); remifentanil was discontinued at the end of surgery. Recovery times were calculated from the end of surgery. The median duration of surgery was similar between groups (39 min for remifentanil versus 34 min for alfentanil). A smaller proportion of remifentanil patients than alfentanil patients had any intraoperative responses (53% vs 71%, P = 0.029), had responses to trocar insertion (11% vs 32%, P < 0.001), or required dosage adjustments during maintenance (24% vs 41%, P < 0.05). Early awakening times were similar. Remifentanil patients qualified for Phase 1 discharge later and were given postoperative analgesics sooner than alfentanil patients (P < 0.05). Actual discharge times from the ambulatory center were similar between groups (174 min for remifentanil versus 204 min for alfentanil) (P = 0.06). In conclusion, remifentanil can be used for maintenance of anesthesia in a 1:4 ratio compared with alfentanil, for total IV anesthesia in ambulatory surgery. This dose of remifentanil provides more effective suppression of intraoperative responses and does not result in prolonged awakening. (Anesth Analg 1997;84:515-21)

Remifentanil Compared with Alfentanil for Ambulatory Surgery Using Total Intravenous Anesthesia

The purpose of this study was to test the hypothesis that using a 1:4 ratio of remifentanil to alfentanil, a remifentanil infusion would provide better suppression of intraoperative responses and comparable recovery profiles after ambulatory laparoscopic surgery than an alfentanil infusion, as part of total intravenous anesthesia. Two hundred ASA physical status I, II, or III adult patients participated in this multicenter, double-blind, parallel group study. Patients were randomly assigned 2:1 to either the remifentanil-propofol or alfentanil-propofol regimens. The anesthesia sequence was propofol (2 mg/kg intravenously [IV] followed by 150 micrograms.kg-1.min-1), and either remifentanil (1 microgram/kg IV followed by 0.5 microgram.kg-1.min-1)of alfentanil (20 micrograms/kg IV followed by 2 micrograms.kg-1.min-1), and vecuronium. After trocar insertion, infusion rates were decreased (propofol to 75 micrograms.kg-1.min-1; remifentanil to 0.25 microgram.kg-1.min-1; alfentanil to 1 microgram.kg-1.min-1). Alfentanil and propofol were discontinued at 10 and 5 min, respectively, before the anticipated end of surgery (last surgical suture); remifentanil was discontinued at the end of surgery. Recovery times were calculated from the end of surgery. The median duration of surgery was similar between groups (39 min for remifentanil versus 34 min for alfentanil). A smaller proportion of remifentanil patients than alfentanil patients had any intraoperative responses (53% vs 71%, P = 0.029), had responses to trocar insertion (11% vs 32%, P < 0.001), or required dosage adjustments during maintenance (24% vs 41%, P < 0.05). Early awakening times were similar. Remifentanil patients qualified for Phase 1 discharge later and were given postoperative analgesics sooner than alfentanil patients (P < 0.05). Actual discharge times from the ambulatory center were similar between groups (174 min for remifentanil versus 204 min for alfentanil) (P = 0.06). In conclusion, remifentanil can be used for maintenance of anesthesia in a 1:4 ratio compared with alfentanil, for total IV anesthesia in ambulatory surgery. This dose of remifentanil provides more effective suppression of intraoperative responses and does not result in prolonged awakening.

An Experience in Anesthesia for Ambulatory Surgery

An Experience in Anesthesia for Ambulatory Surgery

Incidence of nausea and vomiting in outpatients undergoing general anesthesia in relation to selection of intraoperative opioid

Study Objective: To measure the incidence of nausea and vomiting in outpatients in relation to selection of, or withholding of, intraoperative opioid. Design: Prospective, randomized, double-blind control trial. Setting: University general hospital. Patients: 200 unpremedicated ASA status 1 and 11 patients, 8 to 80 years old, undergoing general anesthesia for ambulatory surgery. Intervention: Patients were randomized to four groups, three of which received equipotent doses of different opioids intravenously (IV) during induction of anesthesia. Group 1 received nalbuphine 0.25 mg/kg, Group 2, alfentanil 20 ug/kg; Group 3, fentanyl 2 ug/kg; and Group 4, normal saline. Measurements and Main Results: We evaluated (1) incidence and severity of nausea and vomiting in the postanesthesia care unit (PACU) and over the next 24 hours; (2) time to PACU discharge; (3) need for antiemetic therapy; and (4) need for analgesic rescue in the PACU. The incidences of nausea and vomiting were similar in all groups, as were time to discharge, antiemetic, and nonsteroidal antiinflammatory drug requirements. The highest incidences of nausea and vomiting occurred at 6 hours in all groups (23 % and 9.5%, respectively). Group 1 required lower rescue doses of morphine in the PACU but this result may have been an artifact due to employing the mixed agonist-antagonist opioid, nalbuphine, in this group. Conclusions: Opioid administration at the doses employed during induction of anesthesia does not promote postoperative nausea or vomiting, nor increase length of stay in the PACU.

Comparison of intranasal midazolam and sufentanil premedication in pediatric outpatients*

Intranasally administered midazolam was compared with sufentanil as a premedicant for 60 patients, aged 1/2 to 6 years, undergoing outpatient surgery of 2 hours or less. Thirty minutes before anesthetic induction (halothane in 50% nitrous oxide/oxygen), patients were randomly assigned to receive either intranasal midazolam (0.2 mg/kg) or sufentanil (2 microg/kg). A "blinded" observer evaluated preoperative emotional state, response to premedication, induction, and emergence from anesthesia and side effects. Children who had not previously cried were more likely to cry when midazolam was administered compared with sufentanil (71% versus 20%, p = 0.0031). Of 31 midazolam patients, 20 experienced nasal irritation. Approximately 15 to 20 minutes after drug administration, most patients in both groups could be comfortably separated from their parents. The sufentanil group appeared to be more sedated and more cooperative during induction of anesthesia. Vital signs and oxygen saturation did not change significantly with either medication before or after surgery, although two sufentanil patients had a moderate reduction in ventilatory compliance after anesthetic induction. Sufentanil was associated with more nausea and vomiting than midazolam (34% versus 6%, p < 0.02). Both intranasal midazolam and sufentanil provide rapid, safe, and effective sedation in small children before anesthesia for ambulatory surgery. Sufentanil provided somewhat better conditions for induction and emergence. Midazolam causes more nasal irritation during instillation, and sufentanil causes more postoperative nausea and vomiting. Both drugs enabled patients to be separated from their parents with a minimum of distress. Patients in the midazolam group were discharged approximately 40 minutes earlier (p <0.005).

Highlights from ASA panels on anaesthesia for ambulatory surgery: Anaesthesia for ambulatory surgery: postanaesthesia care unit issues

Physicians involved in the care of the outpatient have recognized that the level of medical services rendered in the postoperative period impact on patient outcome and must be addressed with the same level of intensity as preoperative and intraoperative management. The Panel on Ambulatory Surgery: Postanaesthesia Care Unit Issues highlighted concerns related to malignant hyperpyrexia, postoperative nausea and vomiting, pain management and regional techniques, discharge criteria and patient outcome following ambulatory surgery.

Anesthesia for Ambulatory Surgery

Anesthesia for Ambulatory Surgery

Anesthesia for Ambulatory Surgery

Anesthesia for Ambulatory Surgery

Anesthesia for Ambulatory Surgery

Anesthesia for Ambulatory Surgery