Postanesthesia Recovery Room Research Articles

The 33rd Rovenstine Lecture. What I have learned from 9 years and 9,000 papers.

The 33rd Rovenstine Lecture. What I have learned from 9 years and 9,000 papers.

The Effects of Ketorolac and Fentanyl on Postoperative Vomiting and Analgesic Requirements in Children Undergoing Strabismus Surgery

Fifty-four ASA I and II children 1 to 10 yr of age under-going strabismus surgery were randomized to receive in a double-blind fashion intravenous ketorolac (0.9 mg/kg), fentanyl (1 micro gram/kg), or saline placebo (2 mL) during a standardized general anesthetic. Patients received no analgesic or antiemetics intraoperatively except for the study drug. Patients receiving ketorolac or placebo compared to fentanyl had a significantly lower incidence of postoperative vomiting in the day surgery unit (DSU) (P = 0.03) and overall (DSU plus home) (P = 0.005). The severity (number of episodes) of postoperative vomiting was significantly lower in the DSU, at home (first 24 h after hospital discharge), and overall for patients receiving ketorolac or placebo compared to fentanyl (P < 0.01). Postoperative pain scores and frequency of acetaminophen administration did not differ among the study groups, suggesting that the intraoperative use of ketorolac or fentanyl during pediatric strabismus surgery is unnecessary. No patients required fentanyl postoperatively, indicating that rectal acetaminophen administered in the postanesthesia recovery room provides sufficient analgesia for pediatric strabismus surgery. In conclusion, neither ketorolac nor fentanyl was associated with less postoperative vomiting or analgesic requirements compared to saline placebo administered during pediatric strabismus surgery. Fentanyl should be avoided, as it was associated with a significantly greater incidence of postoperative vomiting compared to ketorolac or placebo. (Anesth Analg 1995;80:1129-33)

Selective Use of the Intensive Care Unit Following Carotid Endarterectomy

The purpose of this study was to develop criteria by which selected patients can be observed solely on the ward following carotid endarterectomy (CEA). One hundred consecutive CEA patients were retrospectively reviewed. Preoperative medical conditions were identified, and the postanesthesia recovery room course was reviewed in an attempt to predict the need for intensive care unit (ICU) level care. Forty-four of our 100 patients developed perioperative complications or conditions that required some intervention. Conditions included hypertension in 23, hypotension in nine, arrhythmias in six, and myocardial ischemia in two. Complications included nonfatal cerebrovascular accident (CVA) in one, fatal CVA in one, and postoperative bleeding in two. Sixteen patients required ICU level intervention (hypertension in five, hypotension in five, arrhythmias in two, nonfatal CVA in one, fatal CVA in one, and postoperative bleeding in two. Fifteen of the 16 were identified in the recovery room. Fifty-three patients had a medical history of significant hypertension (42), cardiac disease (27), and/or recent CVA (seven). Thirty-six (68%) of these patients required perioperative intervention in some form; 12 (23%) required ICU level therapy. Eight of 47 (17%) patients without a significant medical history required intervention; only four (9%) required ICU level care. All eight patients were identified in recovery. Only 16 of 100 CEA patients required ICU level care. Fifteen of 16 were identified in recovery. Certain patients identified in the recovery room can be followed safely in a less intense and costly setting.

Reactivation of Phantom Limb Pain after Combined Interscalene Brachial Plexus Block and General Anesthesia

Reactivation of Phantom Limb Pain after Combined Interscalene Brachial Plexus Block and General Anesthesia

Post-anaesthetic complications

Increasing emphasis on the unsafe period of time following emergence from anaesthesia has been aided by the use of anaesthetic morbidity studies. The analysis of such studies supports the contention that the prognosis of post-anaesthetic complications appears to be related to the availability of a post-anaesthetic recovery room and the observation of formal standards for post-anaesthesia care. Although it is extremely difficult to prove that patient safety is enhanced by the adoption of these standards, there is an intuitive logic to the assumption that the availability of minimal equipment in the PACU and the training of staff working in these units will help to optimize safety for patients recovering from anaesthesia.

Hypoxemic Episodes of Patients in a Postanesthesia Care Unit

The incidence, degree, and duration of acute hypoxemia were evaluated with continuous arterial hemoglobin oxygen saturation monitoring by pulse oximetry in 100 postoperative patients during 40 percent oxygen administration by aerosol face tent from postanesthetic recovery room admission to discharge. Saturations were recorded by pulse oximeters (Nellcor-N 200) with desaturations of < or = 92 percent for > or = 30 s considered significant. On recovery room admission, 15 percent of patients were experiencing episodes of desaturation. Low admission saturations correlated positively with patient age and body weight, American Society of Anesthesiologists class, patients having received general anesthesia, and with greater volumes of intraoperative intravenous fluids, particularly > 1,500 ml. Later desaturations to 86.7 +/- 4.6 percent (72 to 91 percent) at 32 +/- 54 min after admission for 5.2 +/- 12.6 min occurred in 25 percent of patients and correlated positively with peripheral surgical procedures, low oxygen saturation on admission, duration of anesthesia, and volume of intraoperative intravenous fluids. Desaturation durations were longer for female subjects and correlated positively with body weight and intravenous fluid volume. Significant arterial hemoglobin oxygen desaturations occurred despite prophylactic oxygen administration by aerosol face tent during short-term postoperative recovery room care.

Adequacy of general anesthesia for cesarean section.

To assess the adequacy of the general anesthesia commonly employed for Cesarean section, we used isolated forearm technique to study 30 parturients (physical status ASA I/II, aged 17-35 yr) scheduled for nonemergent abdominal delivery. Anesthesia was induced with intravenous thiopental (3 mg/kg, 250 mg maximum) and succinylcholine (1.5 mg/kg), and then proceeded with a mixture of 50% N2O, 50% O2, and 0.5% halothane at a flow of 5 L/min and end-tidal CO2 at 40 mm Hg. Paralysis was maintained with a 0.1% succinylcholine infusion. When eyelash reflex disappeared, patients received taped instruction via headphones at 1-min intervals for 10 min. The tapes instructed patients to flex fingers if they were able to hear, to make a fist or squeeze the investigator's hand if they felt pain, to remember six target words, and to respond with specific physical signals during later interviews. Three sets of tapes assigned at random were used in the study. For signs of inadequate anesthesia, other variables such as eye centering, pupil size, sweating, and lacrimation were concomitantly monitored at the time of induction, laryngoscopy/intubation, and skin incision, and then at 1-min intervals for 10 min. Brain activity was also monitored by means of computerized aperiodic analysis of electroencephalogram Lifescan). Patients were interviewed in the postanesthesia recovery room and again 24 h later. At the time of skin incision, 96.7% of patients (29/30) signaled awareness by flexing fingers, 86.7% (26/30) exhibited lacrimation, and 80% (24/30) made a fist or squeezed the investigator's hand, indicating pain perception.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidural Fentanyl Does Not Influence Intravenous PCA Requirements in the Post-Caesarean Patient

Forty ASA physical status I or II patients scheduled for elective Caesarean delivery were studied to determine the effect of epidural fentanyl on post-Caesarean delivery analgesic requirements as administered by intravenous patient-controlled analgesia (PCA). Following delivery of the infant, under epidural anaesthesia with lidocaine 2% with 1/200,000 epinephrine, patients were randomly assigned to receive either 10 ml of preservative-free normal saline via the epidural catheter or 100 micrograms of fentanyl with 8 ml preservative-free normal saline in a double-blinded fashion. On arrival in the post-anesthesia recovery room (PAR), patients were provided with intravenous PCA meperidine 12.5 mg every eight minutes as needed. Patients were visited at intervals over the next 24 hr to determine if any differences in narcotic requirements, demands for narcotics, or severity of pain were noted. No differences were observed in any values between the groups. It is concluded that a single bolus of epidural fentanyl does not provide an advantage for postoperative pain relief in this patient population.

Incidence of hypoxemia in the postanesthetic recovery room in patients having undergone intravenous sedation for outpatient oral surgery

Incidence of hypoxemia in the postanesthetic recovery room in patients having undergone intravenous sedation for outpatient oral surgery

Effect of an Automated Sink on Handwashing Practices and Attitudes in High-Risk Units

To assess the effects of an automated sink on handwashing practices and attitudes of staff. Quasi-experimental crossover design. Two high-risk patient care areas, one postanesthesia recovery room (Site 1), and one neonatal intensive care unit (Site 2) in two tertiary care hospitals. All patient care staff on study units; approximately 55 individuals. An automated sink was installed to replace one handwashing sink for about five weeks; the sink was then crossed-over for an equivalent time period to the other location. Handwashing practices of all unit staff were observed in three two-hour observation periods/week. Questionnaires were distributed to staff two weeks after sink installation and at the study's end. One thousand, six hundred ten handwashes were observed. Handwashing practices differed significantly by site. For both sites, hands were washed significantly better but significantly less often with the automated sink (all p less than .001). Staff expressed negative attitudes, however, about certain features of the sink, and these negative attitudes increased over the study period. Automated devices must be flexible enough to allow adjustments based on staff acceptance. Application of new technology to improve hand hygiene requires a multifaceted approach to behavior change.

Epidural fentanyl does not influence intravenous PCA requirements in the post-Caesarean patient

Forty ASA physical status I or II patients scheduled for elective Caesarean delivery were studied to determine the effect of epidural fentanyl on post-Caesarean delivery analgesic requirements as administered by intravenous patient-controlled analgesia (PCA). Following delivery of the infant, under epidural anaesthesia with lidocaine 2% with 1/200,000 epinephrine, patients were randomly assigned to receive either 10 ml of preservative-free normal saline via the epidural catheter or 100 micrograms of fentanyl with 8 ml preservative-free normal saline in a double-blinded fashion. On arrival in the post-anesthesia recovery room (PAR), patients were provided with intravenous PCA meperidine 12.5 mg every eight minutes as needed. Patients were visited at intervals over the next 24 hr to determine if any differences in narcotic requirements, demands for narcotics, or severity of pain were noted. No differences were observed in any values between the groups. It is concluded that a single bolus of epidural fentanyl does not provide an advantage for postoperative pain relief in this patient population.

Antiemetic prophylaxis with promethazine or droperidol in paediatric outpatient strabismus surgery

This randomized, double-blind study evaluated the antiemetic efficacy and the side-effects of promethazine pretreatment (0.5 mg.kg-1 IV + 0.5 mg.kg-1 IM) versus droperidol + placebo pretreatment (droperidol, 0.075 mg.kg-1 IV + physiological saline, 0.02 ml.kg-1 IM). One hundred unpremedicated ASA physical status I children ranging from two to ten years, and undergoing outpatient strabismus surgery were studied. All children received inhalational anaesthesia with halothane, nitrous oxide and oxygen. Neither opioids nor muscle relaxants were used. The incidence of vomiting and/or retching and the incidence of side-effects were determined in the post-anaesthesia recovery room (PARR), in the short-stay surgical unit (SSSU), and after discharge from the hospital (including the journey and the stay at home during the first postoperative day). Promethazine and droperidol were equally effective in reducing the incidence of vomiting before discharge to two and eight per cent respectively. On the contrary, the incidence of vomiting after discharge and overall were significantly less with promethazine (ten and ten per cent) than with droperidol pretreatment (54 and 56 per cent) (P less than 0.0001). Promethazine permitted the time to discharge from the hospital to be reduced to an average of three hours, without increasing the incidence of vomiting postdischarge. Promethazine pretreatment is much less expensive than droperidol pretreatment. The incidence of restlessness was significantly less with droperidol (eight per cent) than with promethazine (36 per cent) (P less than 0.001). Promethazine pretreatment demands the use of an analgesic like acetaminophen in order to reduce the incidence of postoperative pain and restlessness.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence of hypoxemia in the postanesthetic recovery room in patients having undergone intravenous sedation for outpatient oral surgery

This study prospectively quantitated the incidence of hypoxia in outpatients in a postanesthetic recovery unit following intravenous (IV) sedation. After identifying the high incidence of hypoxia by the use of pulse oximetry, supplemental oxygen was given to another group of patients and the incidence of the hypoxia was again monitored. Twenty of 100 patients experienced hypoxic episodes in the postanesthetic recovery unit when no supplemental oxygen was administered; only 3 of an additional 100 patients who received supplemental oxygen had episodes of hypoxia. The difference between the groups receiving and not receiving supplemental oxygen was both clinically and statistically significant. As result of this study, the use of supplemental oxygen is recommended for all patients undergoing IV sedation for outpatient oral surgery.

Intravenous droperidol decreases nausea and vomiting after alfentanil anesthesia without increasing recovery time

The frequency rate of nausea and vomiting after an alfentanil-based anesthetic is high, with reported frequencies of 38% to 68%. This study was undertaken to evaluate the efficacy of low-dose and moderate-dose droperidol in decreasing the frequency of postoperative nausea and vomiting and to evaluate whether droperidol has any effect on .slowing recovery after a standard alfentanil-based anesthetic. Sixty normal adults who were scheduled to undergo short .surgical procedures requiring general anesthesia were assigned randomly in a double-blind manner to one of three groups of 20: (1) control—normal saline; (2) droperidol 10 μg/kg; or (3) droperidol 20 μg/kg. A standard alfentanil-based anesthetic was used, and the study drug was given immediately after induction of anesthesia. In the postanesthesia recovery room, all patients were evaluated according to the Aldrete score, noting the time to achieve a score of 10. Presence or absence and severity of nausea and vomiting were noted. To assess psychomotor recovery, a Trieger dot test was performed by every patient preoperatively, at the time of an Aldrete score of 10, and upon discharge from the recovery room. There was no statistical difference between the groups in age, sex, type of procedure, weight, total dose of alfentanil, or duration of anesthetic. The frequency of nausea and vomiting was significantly less ( p < 0.05) for the 20 μg/kg group (5%) than for the 10 μg/kg group (25%) or the control group (40%). A dose-response relationship zvas evident for the antiemetic effect of droperidol. An analog scale for severity of nausea and vomiting also demonstrated a dose response effect. The time to an Aldrete score o f 10 and the time to discharge from the recovery room were not statistically different between the groups. Trieger dot scores, used to evaluate recovery of psychomotor skills, did not demonstrate a statistical difference between the groups. The conclusions are that droperidol given during alfentanil-based anesthesia does prevent nausea and vomiting in a dose-dependent manner and has no apparent effect on recovery from anesthesia.

Lidocaïne en aérosol après l’amygdalectomie chez 1’enfant

Post-tonsillectomy analgesia was compared using ten per cent aerosol lidocaine or 1.5 mg.kg-1 intramuscular codeine. Thirty ASA physical status I or II children between two and ten years of age were assigned, in a random fashion, to one of two groups: Group A received codeine 1.5 mg.kg-1 intramuscularly, Group B received a total dose of 4 mg.kg-1 of ten per cent aerosol lidocaine on the tonsillar beds. For both groups, the treatment was administered at the end of the surgical procedure. The postoperative comfort state was assessed on a global scale using the following statement: (1) comfortable = 1, (2) agitation = 2, (3) uncontrollable = 3. Assessment of postoperative comfort was recorded after 20 min in the post-anaesthetic recovery room. Blood samples for lidocaine concentration estimation were obtained at 5, 7.5, 10, and 15 min after administration. Finally, the time of recovery was recorded. The immediate post-anaesthetic comfort observed with ten per cent aerosol lidocaine was statistically superior to that obtained with 1.5 mg.kg-1 intramuscular codeine. The maximal systemic lidocaine concentration which was 2.1 +/- 0.2 micrograms.ml-1 was well below the accepted toxic level of 5.3 micrograms.ml-1. The recovery room times were not statistically different between the two groups. In conclusion, 4 mg.kg-1 of ten per cent aerosol lidocaine applied directly on the tonsillar beds was shown a superior immediate post-tonsillectomy analgesic technique.

Timing of caudal block placement in relation to surgery does not affect duration of postoperative analgesia in paediatric ambulatory patients

The purpose of this study was to determine if the timing of caudal block placement in relation to surgery affected either the duration of postoperative pain relief or the discharge time in children undergoing brief ambulatory surgical procedures. Forty ASA physical status I or II children ages 18 mo to 11 yr were randomly assigned to one of two groups. Group 1 patients received a caudal block with 0.5 ml.kg-1 of bupivacaine 0.25 per cent following the induction of anaesthesia but before the onset of surgery. Group 2 patients received a similar block at the completion of surgery but before emergence from general anaesthesia. An experienced observer, who was not aware of the timing of block placement, observed all patients from arrival to the post-anaesthetic recovery room until discharge from the ambulatory surgery unit. Pain was assessed at five-minute intervals using an Objective Pain Scale. No statistically significant differences were noted between Group 1 and Group 2 patients with regard to their postoperative pain/discomfort scores, the need for postoperative narcotic analgesia, or the time required for either group to meet standard discharge criteria. It is concluded that the duration of postoperative analgesia is not impaired by placing the caudal block prior to the start of a brief surgical procedure.

Metoclopramide Reduces the Incidence of Vomiting Following Strabismus Surgery in Children

This randomized, double-blind study evaluated the efficacy of metoclopramide administered at the completion of surgery as an antiemetic agent in pediatric patients undergoing ambulatory strabismus surgery; 126 unpremedicated ASA Physical Status 1 and 2 children ranging in age from 2 to 18 yr served as subjects. All received general anesthesia with halothane, N2O, and O2; tracheal intubation was facilitated with intravenous (iv) atracurium 0.5 mg/kg. Intravenous atropine 0.02 mg/kg and lactated Ringer's solution with 5% dextrose equivalent to 4 h of maintenance fluids were administered during surgery. Neither opioids nor droperidol were given intraoperatively. At the completion of surgery, residual muscle paralysis was reversed with atropine 0.02 mg/kg (maximum dose 1.0 mg) and neostigmine 0.07 mg/kg (maximum dose 5.0 mg), and the stomach was decompressed prior to tracheal extubation. After the patient had been transferred to the postanesthesia recovery room (PARR) either metoclopramide 0.15 mg/kg or normal saline was administered intravenously to the children over a 1-min period. A research associate monitored the children for the incidence of post-operative vomiting and the time required for each child to meet discharge criteria from Short Stay Recovery Unit (SSRU). If a child vomited more than three times in both the PARR and SSRU, the vomiting was construed to be severe and the patient was offered further antiemetic treatment with iv droperidol 70 micrograms/kg. The incidence of postoperative vomiting in the metoclopramide group was 37% versus 59% in the placebo group (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Epidural Fentanyl by Continuous Infusion for Relief of Postoperative Pain

Data from the charts of 40 patients in whom a continuous epidural infusion of fentanyl had been used to effect postoperative pain relief were retrospectively reviewed. Of these patients, 39 out of 40 (97.5%) reported adequate analgesia at an average fentanyl infusion rate of 1.3 micrograms/kg/h. After discharge from the postanesthesia recovery room, each patient was sent to a general medical-surgical nursing floor with standard orders for medications to be administered as required. The overall incidence of side effects was low, and, in particular, respiratory depression was not noted. In our experience, this analgesia technique is safe, effective, and could be readily introduced into most community hospital settings.

Decreases in Arterial Oxygen Saturation in Paediatric Outpatients During Transfer to the Postanaesthetic Recovery Room

Decreases in Arterial Oxygen Saturation in Paediatric Outpatients During Transfer to the Postanaesthetic Recovery Room

Decreases in arterial oxygen saturation in paediatric outpatients during transfer to the postanaesthetic recovery room.

Arterial oxygen saturation was measured by pulse oximetry in two groups of paediatric outpatients breathing room air during transport from the operating room to the postanaesthetic recovery room. In Group I (n = 60) readiness for transfer from OR to PARR was decided clinically. In Group II (n = 50) additional criteria of oxygen saturation (SaOe) greater than or equal to 98 per cent with end-tidal gas N2O less than or equal to 10 per cent and CO2 less than or equal to 45 mmHg were met. A higher incidence of desaturation (SaO2 less than or equal to 90 per cent) occurred in Group I (27 per cent) than in Group II (eight per cent) (P less than 0.05). More children under 2 yr desaturated in Group I (50 per cent) than Group II (17 per cent) (P greater than 0.05 less than 0.10). Twenty-two patients in each group had a recent history of upper respiratory tract infections. In these patients, desaturation was more marked in those in Group I (32 per cent) than in Group II (five per cent) (P less than 0.05). Within each group, the incidence of desaturation during transport was similar in patients with or without a recent URI.