Postanesthesia Recovery Room Research Articles

Catheter-over-needle method facilitates effective continuous infraclavicular block

To the Editor, We read with great interest the excellent article written by Dr. Lecours et al. which reported an observational cohort study of all ultrasound-guided single-injection infraclavicular blocks (ICBs) performed over a two-year period at their institution. The authors observed that ultrasound-guided ICB performed with a single injection posterior to the axillary artery is a reasonably safe technique associated with a high success rate regardless of the expertise of the anesthesiologist performing the block. Experience within our institution is consistent with this observation, and we would agree strongly that ICB performed by single injection posterior to the axillary artery is safe and effective. Further, this provides an excellent approach for placement of a continuous catheter using a catheter-over-needle technique. Here, with written consent from the patient, we report our recent experience of placing an infraclavicular catheter utilizing a 21G 9 95-mm catheter-over-needle unit (MultiSet UPK NanoLine 21156-40E, Pajunk, Germany) for a planned re-implantation of thumb after a rope-related farming accident. A high-frequency linear ultrasound transducer (13-6 MHz HFL38, M-Turbo ; SonoSite, Bothell, WA, USA) was placed in the deltopectoral grove parasagittally, where the axillary artery and the lateral cord of brachial plexus in its lateral aspect were easily identified (Figure). After raising a local anesthetic wheal, the catheter-over-needle unit was inserted cephalad to the probe and advanced in-plane caudally or inferiorly at approximately 45 to 60 from the ultrasound probe axis, through the pectoral muscles and toward the parasagittal plane between the axillary artery and the lateral cord. Hydrodissection with dextrose 5% in water was used to create sufficient space between the lateral cord and axillary artery to advance the needle/catheter unit into a more advantageous position, posterior to the axillary artery and directly adjacent to the posterior cord. Once the tip of the needle was positioned, and, following negative aspiration of blood or air, 20 mL of local anesthetic was injected to open the perivascular space. The needle was removed from the outer catheter, and a flexible, 20G 9 75-mm inner catheter was inserted through the cannula and Luer-locked onto the 18G catheter sheath such that both catheters were in situ. Before securing the catheter in place with a dressing (e.g., Tegaderm), a further 10 mL of local anesthetic was injected through the catheter to complete the block and confirm the spread. Instead of the planned thumb reimplantation, debridement of the thumb was performed. In the post anesthetic recovery room, a local anesthetic infusion was commenced and continued at 1 mL hr with an 8 mL bolus every hour until the next morning when the infraclavicular catheter was removed and the patient transitioned to oral analgesia. Throughout the infusion, the patient was pain-free, and the catheter remained in place with intact and dry dressings, as was our experience with an interscalene catheter placed using the catheterover-needle method. We have used this approach to place five infraclavicular catheters over the last three months, and in each case, the pain management was excellent. Catheter insertion has been uncomplicated and all have been removed as planned. Editor’s Note: The authors of the article: Can J Anesth 2013; 60: 244-52, respectfully declined an invitation to submit a reply to the above Letter to the Editor.

English

BACKGROUND AND OBJECTIVES: Present clinical study was conducted to evaluate advantages of field block for inguinal hernia repair, with respect to duration and quality of analgesia, haemodynamic stability, and speed of recovery by using 1% lidocaine with adrenaline. METHODS: Study was conducted on 50 patients posted for elective inguinal hernia repair. Field block was instituted with 1% lidocaine with adrenaline with mean volume of 35.48 ml to block ilioinguinal, iliohypogastric, genital branch of genitofemoral nerve with subcutaneous infiltration. Patients were observed for duration and quality of analgesia. Haemodynamic stability with PR, systolic and diastolic BP. Post anaesthesia recovery was assessed by using “criteria for fast track eligibility for ambulatory anaesthesia” after the surgery. Duration of analgesia was assessed with subjective complaint of pain (duration of onset of analgesia till the subjective complaint of pain). RESULTS: In the present study, the quality of analgesia was excellent in 72% of cases, good in 16%, fair in 8% and poor in 4%. The mean duration of analgesia was 201.02 min (160 min to 280 min). All patients were haemodynamically stable throughout the surgery. Using fast tract eligibility criteria for recovery all the patient had a score of 12 at 0 min and all of them had score of > 12 at 15 min and 30 min and were ready to be shifted toward from the OR bypassing the post anaesthesia recovery room. CONCLUSION: Thus field block for inguinal hernia repair is a safe technique, that provides excellent quality and prolonged analgesia, with rapid recovery and minimal to nil complications.

Effect of gender on pain perception and analgesic consumption in laparoscopic cholecystectomy: An observational study

Background:Evidence regarding gender affecting the response to pain and its treatment is inconsistent in literature. The objective of this prospective, observational study was to determine the effect of gender on pain perception and postoperative analgesic consumption in patients undergoing laparoscopic cholecystectomy.Materials and Methods:We recruited 60 male and 60 female patients undergoing elective laparoscopic cholecystectomy. Patients were observed for additional intraoperative and postoperative analgesia. Numerical rating scale was documented at 10 min interval for 1 h in post-anesthesia recovery room and at 4, 8, and 12 h postoperatively. Boluses of tramadol given as rescue analgesia were also noted. There were no dropouts.Results:The mean pain scores were significantly higher in female patients at 20 and 30 min following surgery. Mean dose of tramadol consumption was significantly higher in female patients for the first postoperative hour (P = 0.002), but not in the later period.Conclusion:Female patients exhibited greater intensity of pain and required higher doses of analgesics compared to males in in the immediate postoperative period in order to achieve a similar degree of analgesia.

Avaliação de website sobre assistência de enfermagem na sala de recuperação pós-anestésica

OBJETIVOS: Desenvolver um website sobre a assistência de enfermagem em sala de recuperação pós-anestésica e avaliar o conteúdo, apresentação e atualização das informações. MÉODOS: Foi utilizada metodologia de Clement Mok, DADI, composta por definição, arquitetura, design e implementação. A avaliação do website foi realizada por enfermeiros por meio de um questionário contendo itens sobre autoridade, conteúdo geral, apresentação e confiabilidade das informações. Para a análise dos dados, foi utilizada a estatística descritiva. RESULTADOS: Os resultados foram satisfatórios, tendo como aprovação de 99,67%. Comprovou-se que a construção e disponibilização de informações sobre a temática referida no website são confiáveis e válidas. CONCLUSÃO: A importância e a relevância da World Wide Web para a transmissão de informações, em especial, para a enfermagem permitem uma aproximação do conhecimento científico à prática de atualização e de troca de experiências, independente da localização geográfica.

A Dose-Ranging Study of the Effect of Transversus Abdominis Block on Postoperative Quality of Recovery and Analgesia After Outpatient Laparoscopy

Postoperative pain can delay functional recovery after outpatient surgery. Multimodal analgesia can improve pain and possibly improve quality of recovery. In this study, we evaluated the dose-dependent effects of a preoperative transversus abdominis plane (TAP) block on patient recovery using the Quality of Recovery 40 (QoR-40) questionnaire after ambulatory gynecological laparoscopic surgery. Global QoR-40 scores range from 40 to 200, representing very poor to outstanding quality of recovery, respectively. Healthy women undergoing outpatient gynecological laparoscopy were randomly allocated to receive a preoperative TAP block using saline, ropivacaine 0.25%, or ropivacaine 0.5%. Needle placement for the TAP blocks was performed using ultrasound guidance and 15 mL of the study solution was injected bilaterally by a blinded investigator. QoR-40 score and analgesic use were assessed 24 hours postoperatively. The primary outcome was global QoR-40 score at 24 hours after surgery. Data were analyzed using the Kruskal-Wallis test. Post hoc pairwise comparisons were made using the Dunn test with P values and 95% confidence intervals Bonferroni corrected for 6 comparisons. Seventy-five subjects were enrolled and 70 subjects completed the study. The median (range) for the QoR-40 score after the TAP block was 157 (127-193), 173 (133-195), and 172 (130-196) for the saline group and 0.25% and 0.5% ropivacaine groups, respectively. The median difference (99.2% confidence interval) in QoR-40 score for 0.5% bupivacaine (16 [1-30], P=0.03) and 0.25% bupivacaine (17 [2-31], P=0.01) was more than saline but not significantly different between ropivacaine groups (-1 [-16 to 12], P=1.0). Increased global QoR-40 scores correlated with decreased area under the pain score time curve during postanesthesia recovery room stay (ρ=-0.56, 99.2% upper confidence limit [UCL]=-0.28), 24-hour opioid consumption (ρ=-0.61, 99.2% UCL=-0.34), pain score (0-10 scale) at 24 hours (ρ=-0.53, 99.2% UCL=-0.25), and time to discharge readiness (ρ=-0.65, 99.2% UCL=-0.42). The aforementioned variables were lower in the TAP block groups receiving ropivacaine compared with saline. The TAP block is an effective adjunct in a multimodal analgesic strategy for ambulatory laparoscopic procedures. TAP blocks with ropivacaine 0.25% and 0.5% reduced pain, decreased opioid consumption, and provided earlier discharge readiness that was associated with better quality of recovery.

Clinical observation of the effects of dexmedetomidine hydrochloride on cadiovascularcardiovascular response to tracheal extubation

Objective To observe the effects of dexmedetomidine hydrochloride on cardiovascular response to tracheal extubation. Methods One hundred ASA Ⅱ or IE patients regardless of sex aged 30 yr ～60 yr with a standard body weight±20% scheduled for gastrointestinal surgery under general anesthesia were randomly divided into 2 groups (n=50):propofol group (group P) and dexmedetomidine hydrochloride group (group D). Patients were transported into the postanesthetic recovery room after surgery. Patients in group P were maintained with propofol with a plasma target concentration at 1 mg/L. Patients in group D were injected loading dose and maintenance dose of dexmedetomidine hydrochloride at the rate of 0.5 μg/kg (10 in infusion) and 0.5 μg·kg-1·h-1, respectively. All infusions were discontinued when patients of both groups restored spontaneous breathing. BP, HR, and cough response were recorded at preoperative period (T0), immediately transportd into postanesthetic recovery room (T1), 10 mins after administration (T2), spontaneous breathing (T3), extubation (T4), 10 mins after extubation (T5). End -tidal anesthetic concentration, spontaneous breathing time, eyes open time given stimulation, extubation time, visual analog score and side effects were recorded. Results SBP, DBP and HR at T4 were respectively (124±15), (79±11),(74±10) mm Hg(l mm Hg=0.133 kPa) in group D. SBP, DBP and HR at T4 were respectively(143±21 ),(87±13),(93±8) mm Hg(P<0.05). SBP, DBP and HR at T5 were respectively (120± 13.5),(75±8),(75±9) mm Hg in group D. DBP and HR were respectively (128±22), (80±12),(83±10) mm Hg (P<0.05). Spontaneous breathing and eyes open time was (4±3),(4±4) min in group D, which were (6±5),(8±5) min in group P (P<0.05). The cough response was 3 case in group D, which was 23 case in group P (P<0.05).VAS score were (3.6±2.0) in group D, which were(5.5±3.l) in group P(P<0.05). Compared with T0, SBP and DBP at T4 were respectively (143±21),(87±13) mm Hg in group P(P<0.05), HR at T4 and T5 were respectively (93±8) beats/min and (83±10) beats/min in group P (P<0.05). Conclusion Dexmedetomidine (DEX) hydrochloride could efficiently prevent the adverse cardiovascular response to tracheal extubation and improve the quality of extubation. Key words: Dexmedetomidine hydrochloride; Extubation; Cough; Adverse cardiovascular response

Combined Catechol-O-Methyltransferase and μ-Opioid Receptor Gene Polymorphisms Affect Morphine Postoperative Analgesia and Central Side Effects

Previous studies have generated controversial results regarding the influence of the genetic variations of μ-opioid receptors on morphine analgesia and opioid-related side effects in the postoperative period. Few studies have been conducted attempting to assess the combined effects of variation within ≥2 genes in relation to morphine response. In this study, we investigated whether combined catechol-O-methyltransferase and μ-opioid receptor polymorphisms contribute to the morphine response in postoperative analgesia. One hundred two surgical patients were enrolled in this prospective, observational study. All patients received general anesthesia and were screened for μ-opioid receptor polymorphism A118G (Asn40Asp) and catechol-O-methyltransferase G1947A (Val158Met) polymorphism using a blood sample of DNA. Patient-controlled analgesia was provided postoperatively and morphine consumption was observed. Any pain at rest or side effects were measured with rating scales. The heterozygous patients with μ-opioid receptor A118G and catechol-O-methyltransferase G1947A mutation consumed significantly less morphine in the postanesthetic recovery room and 48 hours after surgery compared with homozygous patients of the A118 variant. Nausea and sedation scores were also significantly lower during all observed postoperative periods for heterozygous patients and only 2 patients (18%) from this group received antinausea treatment. This study has demonstrated the importance of the gene-gene approach in understanding the morphine response in patients after lower abdominal surgery. More studies are needed to characterize the combined effects of multiple genes and demographic as well as clinical variables in predicting the correct morphine dosage and corresponding opioid-related side effects.

Social support in the post-abortion recovery room: evidence from patients, support persons and nurses in a Vancouver clinic

Background The benefits of social support in post-surgical recovery are well documented; social support decreases preoperative stress and postoperative recovery time. However, a paucity of studies have examined the effect of social support in the context of pregnancy termination. This study is the first to examine the effect of postoperative accompaniment from the patient, support person and nurses' perspective. Study Design This study was carried out in two phases. In Phase I, no accompaniment was allowed in the post-anesthesia recovery room (PAR); in Phase II, accompaniment was permitted. All participants completed pre- and postoperative questionnaires. Results The perception of accompaniment was overwhelmingly positive in patients and support people. Patients in Phase II demonstrated a high (over 95%) acceptance of accompaniment in the recovery room. It was found that 96.8% reported they would choose to be accompanied in the recovery room again if they had to have another abortion. Support persons felt very strongly that their presence was helpful to the patient. The decrease in pre- to postoperative anxiety levels was significantly greater in those women who were accompanied. However, overall, nurses demonstrated a negative attitude towards accompaniment in the recovery room. Conclusion In summary, the presence of a support person in the PAR was perceived in a positive manner by patients and support people. However, the reasoning behind the negative opinion of nurses requires further study before PAR accompaniment can be considered a possibility in the context of pregnancy termination.

Cost-effectiveness analysis on spinal anesthesia versus local anesthesia plus sedation for loop colostomy closure

Studies in the area of health economics are still poorly explored and it is known that the cost savings in this area is becoming more necessary, provided that strict criteria. To perform a cost-effectiveness analysis of spinal anesthesia versus local anesthesia plus sedation for loop colostomy closure. This was a randomized clinical trial with 50 patients undergoing loop colostomy closure either under spinal anesthesia (n = 25) or under local anesthesia plus sedation (n = 25). The duration of the operation, time spent in the post-anesthesia recovery room, pain, postoperative complications, length of hospital stay, laboratory and imaging examinations and need for rehospitalization and reoperation were analyzed. The direct medical costs were analyzed. A decision tree model was constructed. The outcome measures were mean cost and cost per local and systemic postoperative complications avoided. Incremental cost-effectiveness ratios were presented. Duration of operation: 146 +/- 111.5 min. vs 105 +/- 23.6 min. (P = 0.012); mean time spent in post-anesthesia recovery room: 145 +/- 110.8 min. vs 36.8 +/- 34.6 min. (P<0.001). Immediate postoperative pain was lower with local anesthesia plus sedation (P<0.05). Local and systemic complications were fewer with local anesthesia plus sedation (P = 0.209). Hospitalization + rehospitalization: 4.5 +/- 4.1 days vs 2.9 +/- 2.2 days (P<0.0001); mean spending per patient: R$ 5,038.05 vs 2,665.57 (P<0.001). Incremental cost-effectiveness ratio: R$ -474.78, indicating that the strategy with local anesthesia plus sedation is cost saving. In the present investigation, loop colostomy closure under local anesthesia plus sedation was effective and appeared to be a dominant strategy, compared with the same surgical procedure under spinal anesthesia.

General anaesthesia for MRI in children with hypotonia: a case series

To characterize the safety of general anaesthesia, used to facilitate MRI in children with clinical hypotonia, and to determine whether this technique could be performed safely as an outpatient procedure. All children (age <or=12 years) who underwent MRI with general anaesthesia as a part of their diagnostic work-up for hypotonia at Mayo Clinic, Rochester, Minnesota, USA, between 1 January 2000 and 31 December 2006, were identified. Demographics, medical history, anaesthetic details, postanaesthetic disposition and the disease state identified as the cause of hypotonia, if available, were recorded. Thirty-seven children underwent 38 general anaesthetics. Age was 2.7 +/- 2.3 years (range, 8 days-9 years). A volatile anaesthetic was employed in 37 out of 38 instances and nitrous oxide was used in 31. Three children experienced minor intraprocedural adverse events, and three children experienced minor adverse events in the postanaesthesia recovery room. No child required an unanticipated hospital admission or was re-admitted following discharge due to adverse events. A specific causative disease process was eventually identified in 17 children and represented a diverse group of disorders; a final diagnosis was never obtained in the remaining 20 children. Use of general anaesthesia to facilitate MRI in children with clinical hypotonia appears to be a well tolerated practice. No major peri-procedural adverse events were noted, and all minor adverse events were either easily treated or resolved spontaneously.

Concepção dos enfermeiros sobre o conteúdo do website sala de recuperação pós-anestésica

O presente artigo tem por objetivo identificar a concepção de enfermeiros acerca do conteúdo de website sobre sala de recuperação pósanestésica (SRPA). Pesquisa de campo, descritiva, realizada durante o 8º Congresso Brasileiro de Enfermagem em Centro Cirúrgico, Recuperação Anestésica e Centro de Material e Esterilização com docentes de enfermagem e enfermeiros. 95,65% dos enfermeiros consideraram importante um website com disponibilização de informações sobre SRPA e apresentou uma grande diversidade entre os assuntos que devem fazer parte do conteúdo do website, porém todos os aspectos devem ser abordados desde que sejam informações seguras e confiáveis. É importante saber a opinião e expecta tivas de enfermeiros relacionadas a um website que disponibilize informações sobre SRPA.

Cirurgia bariátrica: existe necessidade de internação em unidade de terapia intensiva?

The purpose of this study was to determine the place of stay at postoperative and to verify medical-surgical complications that would justify admission to the intensive care unit, including death. Cross-over, prospective, open study that evaluated 120 patients who were submitted to primary bariatric surgery by video laparoscopy from May 2007 to April 2008 in a tertiary hospital. The Aldrete Kroulik index was used for release from the post-anesthesia recovery room and to define where the patient should be routinely referred for postoperative. Among the 120 patients, 83 were women and 37 men with a mean age ranging from 35.4 ± 10.5 years (18 to 66 years), body mass index 45.6 ± 10.5. The time between hospital admission and start of surgery was 140.7 ± 81.8 minutes, surgery time was 105 ± 28.6 minutes, time of post-anesthesia recovery room was between 125 ± 38 minutes and length of hospital stay was 47.7 ± 12.4 hours, with 100% of the patients walking in 24 hours. The Aldrete and Kroulik index in the post-anesthesia recovery room achieved scores of 10 to 120 minutes in all patients, with a 100% survival . Using the Aldrete and Kroulik index in the post-anesthesia of gastric bypass by video laparoscopy in primary bariatric surgery, no patient was admitted in intensive care unit and no major complication was observed.

Temperature Control in Conventional Abdominal Surgery: Comparison between Conductive and the Association of Conductive and Convective Warming

Intraoperative hypothermia is a common complication, and its development is favored by abdominal surgeries. The efficacy of the association of conductive and convective warming methods in the prevention of hypothermia, and its effects during postoperative recovery were the objectives of this study.Forty-three patients of both genders, ages 18 to 88 years, undergoing xyphopubic laparotomy under general anesthesia and monitoring of the esophageal temperature were randomly divided in two groups, according to the warming method: COND (n = 24), circulating-water mattress at 37 degrees C on the back, and COND + CONV (n = 19), circulating-water mattress associated with warm air blanket at 42 degrees C over the thorax and upper limbs. Weight, gender age, duration of surgery and anesthesia, temperature on anesthetic induction (Mi), consecutive hours (M1, M2), end of surgery (Mes) and anesthesia (Mea), and admission (M(a-REC)) and discharge (M(d-REC)) from the post-anesthetic recovery room (PARR), besides the postoperative incidence of tremors and complaints of cold, were analyzed.Both groups were similar regarding all parameters analyzed, except temperatures on M2, M3, M4, Mes, and Mea. The temperature of patients in the COND group decreased from the second hour of anesthetic induction on, but in the COND + CONV group it only happened in the fourth hour. Patients in the COND group presented hypothermia upon admission and discharge from the PARR.The association of different warming methods delayed the beginning and reduced the severity of intraoperative hypothermia, but it did not reduce the complaints of feeling cold and tremors.

Transfusion-Related Acute Lung Injury (Trali) after Mastectomy with Microsurgical Breast Reconstruction

After its description more than 20 years ago, TRALI--Transfusion Related Acute Lung Injury--became the main cause of transfusion-related morbidity and mortality in the United States and England. Since reliable data on its epidemiology in Brazil are not available, the difficulty to diagnose, varied clinical presentation, and absence of specific laboratory data, case reports are important. This is the first report of this transfusion reaction indexed in the LILACS data base.A 36-year old female underwent mastectomy with microsurgical breast reconstruction under general anesthesia. Immediately after the transfusion of one unit of packed red blood cells in the post-anesthetic recovery room, she developed respiratory failure, which did not require reintubation. Supportive treatment was instituted in the intensive care unit after other diagnostic hypotheses were ruled out. She had a favorable evolution and was discharged from the hospital without sequelae.The importance of judicious blood transfusion is emphasized since, although disease transmission is rare, TRALI is not, but it is underestimated due to the diversity of diagnostic hypotheses. Therefore, the knowledge of this disorder and its dissemination, especially in our country, is important.

Entry-instrument used in the patient's evaluation in a post-anaesthetic recovery room: a matter of great concern: care continuity

OBJECTIVE: To know the nurses' evaluation about the continuity of nursing care. METHODS: Fifty-nine nurses from two Hospitals (I and II) were interviewed. The questions addressed the following issues: the difficulties they face to obtain the necessary information to provide patient care in the immediate post-operative period; what is the best strategy to receive information related to this period; and what is their evaluation about the entry-instrument of the post anaesthetic recovery. RESULTS: Difficulties in Hospital I: the instrument was often not included in the patient record and changing shifts over the telephone. Hospital II: incomplete completion of the instrument. Best strategy in Hospital I: entry-instrument associated to the shift change over the telephone. Hospital II: to aggregate the several means of information. Both groups evaluated the entry instrument and reported that it helps in the planning because it is a way to document patient care. They considered the aspects contained in the instrument as important and pertinent. CONCLUSIONS: This instrument consists of an efficient strategy for patient care continuity, in spite of the difficulties described above.

Elaboração e aplicação de um instrumento de avaliação no pós-operatório imediato com base no protocolo do Advanced Trauma Life Suport

OBJETIVO: Elaborar e aplicar um instrumento de avaliação do paciente no pós-operatório imediato (POI) de anestesia geral baseado no protocolo do Advanced Trauma Life Suport. MÉTODOS: Foi criado um instrumento baseado no ABCDE do Trauma e aplicado na Sala de Recuperação Pós-Anestésica em todos os pacientes adultos submetidos a cirurgias sob efeito de anestesia geral no período de setembro a novembro de 2007. RESULTADOS: Observou-se que 93,5% dos pacientes tinham vias aéreas pérvias, porém 92,2% necessitaram de oxigênio suplementar. Houve alteração na ausculta pulmonar de 15,6% dos pacientes, hipotensão em 16,9% e hipotermia em 23,4%. Observou-se também uma diferença estatisticamente significativa sugerindo que as mulheres apresentam melhores condições de recuperação que os homens. CONCLUSÃO: O exame físico na seqüência proposta pelo ABCDE do Trauma permitiu identificar as principais alterações fisiológicas no POI contribuindo para a assistência de enfermagem.

Management Plan to Reduce Risks in Perioperative Care of Patients with Presumed Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea (OSA) has been associated with increased perioperative morbidity and mortality. We initiated a protocol designed to screen patients preoperatively and monitor them postoperatively. The goal was to identify patients who were at risk for oxygen desaturation after discharge from the postanesthesia recovery room (PACU). Patients without previously diagnosed OSA presenting to the preoperative evaluation clinic were assessed over a 10.5-month period using a validated prediction rule to identify patients thought to be at high risk of OSA (sleep apnea clinical score, SACS > or = 15). Following surgery, patients were monitored in the PACU for significant respiratory events: apnea, increased FiO2 requirement, pain-sedation mismatch, or episodes of desaturation. Patients were placed in 3 groups based on their SACS and the presence or absence of recurrent PACU respiratory events (group 1: SACS < 15, no recurrent events; group 2: SACS > or =15, no recurrent events; and group 3: SACS > or = 15, recurrent events.) The number of oxygen desaturations > or = 4% per hour, the oxygen desaturation index (ODI), was calculated for each patient for 24 to 48 hours after PACU discharge. An ODI > 10 was the threshold chosen to indicate a high frequency of oxygen desaturation. The percentage of patients with ODI > 10 differed significantly across the 3 study groups (12%, 37%, and 57%, for groups 1-3, p = 0.005). Mean ODI in group 1 was significantly different from groups 2 and 3 (5.8 compared to 10.0 group 2 and 11.4 group 3 with p = 0.001). We have shown that combining preoperative screening is useful for identifying patients at risk for oxygen desaturation after PACU discharge.

Parents in the post-anesthetic recovery room: who bendefits most?

Parents in the post-anesthetic recovery room: who bendefits most?

Momento da extubação e evolução pós-operatória de toracotomia

Early tracheal extubation following surgical procedures favors clinical evolution of patients and reduces incidence and time of stay in the Intensive Care Unit (ICU), minimizing hospital costs. Immediate postoperative period of pulmonary resections often takes place in the ICU and patients are kept intubated. This study evaluated hospital records of patients submitted to thoracotomy and a correlation between extubation time, postoperative evolution and ICU stay was established. Retrospective cohort study of records of 121 patients submitted to pulmonary parenchyma resection (not biopsies) was carried out. Stay in the ICU and time of tracheal extubation were related. Postoperative evolution was classified as good or bad according to occurrence of some of the following conditions: infections, respiratory disorders (reintubation, bronchospasm, acute pulmonary edema, need of tracheotomy, atelectasis, fistulae), re-operation due to bleeding and death. Among the two groups preoperative conditions, anesthetic physical status (American Society of Anesthesiologists--ASA criteria), presence of associated diseases, respiratory functional evaluation and duration of surgery were analyzed. Relative risk was used to evaluate effect of time of extubation (immediate or non-immediate) on the postoperative evolution of patients. Patient distribution related to extubation time was: 81% immediate extubation, 15% non-immediate extubation and 4% not extubated. Destination after surgery was: 73% ICU and 27% post-anesthetic recovery room. Incidence of associated diseases (arterial hypertension, diabetes, obstructive or restrictive pulmonary disease and cardiopathy) among the immediately extubated group and non-immediately extubated group was 37% and 41.6%, respectively. Related to ASA physical status: 62% ASA 1 or 2 in the immediately extubated group and 58.3% ASA 1 or 2 in the non- immediately extubated group. Surgical time was (mean +/- standard deviation) 372.34 +/- 107.84 minutes and 432.61 +/- 117.30 minutes in immediately extubated and non- immediately extubated group, respectively. Relative risk of immediate extubation leading to a poor evolution was of 0.81, while non- immediate extubation leading to a poor evolution was of 1.5. Safe immediate tracheal extubation of patients submitted to pulmonary resection surgery is possible. This kind of management favors postoperative recuperation out of ICU, which results in patients and hospital benefits, mainly referred to costs.

OESOPHAGEAL TEMPERATURE MONITORING DURING GENERAL ANAESTHESIA

This study aimed to demonstrate the oesophageal temperature changes with the time during general anaesthesia for the routine surgical work, and to see the effects of patient’s gender or age, and the effects of neuromuscular blockade on these changes, also to compare oesophageal temperature changes with mean skin temperature changes during general anaesthesia, and to assess the problem of unintentional intraoperative hypothermia with its complications in the postanaesthetic recovery room. Fifty three ASA (I-II) unpremedicated randomly selected patients (26 males and 27 females) undergoing different routine elective surgical operations under general anaesthesia in the University Hospital Medical College in Baghdad between August -September 2001. Anaesthesia was induced by intravenous (iv) thiopentone 4-5 mg /kg and fentanyl 1-2 g/kg, and maintained with either 2-3 % halothane in oxygen without neuromuscular blockade in spontaneously ventilated by mask (4 patients)or manually assisted ventilation through a tube in 17 patients, while it was maintained by 0.5-1% halothane in oxygen and the muscle paralysis was done by either suxamethonium 1 mg/kg bolus iv followed by infusion of 4-10mg\min. of 0.1% suxamethonium solution to 16 patients, or by iv pancuronium 0.1 mg /kg (16patients), then endotracheal intubation was done and ventilation was mechanically controlled. Neostigmine 40g/kg and atropine 20 g/kg were given iv at the ends of operation to reverse residual blockade of pancuronium where it was given. Monitoring of the oesophageal and skin temperatures was started ten minutes after induction of anaesthesia as a baseline, repeated every ten minutes until the end of halothane administration and the last measurements were taken just before discharging the patient from the recovery room, other vital signs were also monitored like noninvasive blood pressure, ECG, and pulse oximetry at the perioperative periods. The means for the ambient temperature and the relative humidity of the operating theatre were also recorded. Postanaesthetic shivering when observed, was scored (0-3), pulse oximetry was used to assess oxygenation status. The postanaesthetic recovery time was measured from the moment of closing the halothane vaporizer at the end of the operation until the patient got 10 degrees according to Aldrete &Kronlik postanaesthetic recovery score. Oesophageal temperature increase above the baseline occurred in 7.54% (4/53) of the patients with mean increase was 1.035C  0.797 (SD) range was 0.2-3.4C, while the temperature decrease below the baseline occurred in 92.45 % ( 49/53) of the patients, with mean decrease was 1.7 C  0.67 (SD), the range was 1 - 3.4 C .The decrease became significant ( P < 0.05) at 20-150 minutes after induction in oesophageal temperature and at 30-140 minutes in mean skin temperature. At all time periods after induction the oesophageal temperature readings were significantly (P<0.05) above those of the mean skin temperature. Changes in oesophageal temperature showed no significant difference between males and females, but there was significant (P<0.05) difference between different age groups up to 90 minutes after induction, however significant differences were seen between patients who had spontaneous or assisted ventilation with 2-3% halothane in oxygen, and those who received muscle relaxants in addition to 0.5-1% halothane in oxygen with controlled ventilation