Postanesthesia Care Unit Discharge Research Articles

Haloperidol Plus Ondansetron Versus Ondansetron Alone for Prophylaxis of Postoperative Nausea and Vomiting

Haloperidol 1 mg and ondansetron 4 mg are equally safe and effective for postoperative nausea and vomiting prophylaxis. We compared the combination to ondansetron alone in a mixed surgical population. Two-hundred and sixty-eight adults undergoing general anesthesia received 4 mg ondansetron plus 1 mg haloperidol or saline in this randomized, double-blind protocol. Efficacy and safety data were obtained until 480 min after postanesthesia care unit entry. The combination had more complete responders (76.2% vs 59.2%), less nausea, less rescue, and longer time to rescue. Sedation, time to postanesthesia care unit discharge, and QTc prolongation were not different. No subject had dystonia, akathisia, or serious dysrhythmias. Postoperative nausea and vomiting prophylaxis with both drugs is significantly more effective and longer lasting than ondansetron alone. There is no detectable increase in side effects.

Haloperidol Versus Ondansetron for Prophylaxis of Postoperative Nausea and Vomiting

Haloperidol is effective for postoperative nausea and vomiting prophylaxis, but there are almost no data comparing it to 5-HT(3) antagonists. Two hundred forty-four adults were randomized to receive i.v. haloperidol 1 mg or ondansetron 4 mg, during general anesthesia. Nausea, vomiting, need for rescue, sedation, extrapyramidal effects, QTc intervals, and time to postanesthesia care unit discharge were evaluated with a third-party blind design. There was no intergroup difference in any measure of efficacy or toxicity. Haloperidol and ondansetron subjects (78.2% and 76.8%) had complete response. Postoperatively, prolonged QTc occurred in 28.9% and 22.1% (N.S.). In a mixed surgical population, the efficacy and toxicity of postoperative nausea and vomiting prophylaxis with haloperidol 1 mg was not significantly different from ondansetron 4 mg.

Successful Continuous Interscalene Analgesia for Ambulatory Shoulder Surgery in a Private Practice Setting

Large prospective studies evaluating continuous interscalene block for shoulder surgery have thus far been limited to inpatient and university teaching practices. Shoulder surgery is increasingly being performed on an outpatient basis. The aim of this case series was to prospectively evaluate a large series of interscalene catheters for ambulatory shoulder surgery in a private practice setting. A single operator placed nonstimulating catheters using a combination of ultrasound and nerve stimulation. Following postanesthesia care unit (PACU) discharge, opioid-like analgesic adjuvants other than tramadol were avoided unless patients experienced inadequate pain relief. All patients were assessed in the PACU, on the first postoperative morning, and at 3 weeks for catheter effectiveness and for acute and chronic complications. Pain scores and patient satisfaction were assessed in subgroups of 100 consecutive patients. Three hundred patients were studied. The first attempt catheter success rate was 96%. In all but 1 patient, ineffective catheters in the PACU were effectively reinserted. Thirteen patients experienced inadequate pain relief after leaving the PACU. Of these patients, 5 were rescued with additional ropivacaine, 3 had the catheter effectively reinserted, and 5 were managed with oral opioids. One patient required antibiotic treatment for catheter site infection. Neurological sequelae potentially attributable to the catheter were present in 3 patients at 3 weeks, and remained in 1 patient at 4 weeks. This patient's symptoms resolved at 6 months. Continuous interscalene block for ambulatory shoulder surgery in a private practice setting had a high success rate, a low complication rate, and enabled the avoidance of the use of potent opioids in 98% of patients.

Effect of propofol on emergence behavior in children after sevoflurane general anesthesia

Emergence agitation (EA) is a postoperative behavior that may occur in children undergoing general anesthesia with inhaled agents. The aim of the present study was to assess the effect of propofol administered at the end of sevoflurane anesthesia on the incidence and severity of EA in children undergoing magnetic resonance imaging (MRI). Eighty-four children, 2-7 years old, undergoing MRI were enrolled in this randomized double-blind study. No sedative premedication was administered prior to anesthesia induction. Anesthesia was induced and maintained with sevoflurane in N(2)O/O(2). Group P received propofol 1 mg.kg(-1) and group S received saline. Pediatric Anesthesia Emergence Delirium scale (PAEDs) was used to evaluate recovery characteristics upon awakening and during the first 30 min after emergence from anesthesia. Children with PAEDs >16 were considered agitated. EA was analyzed using the Mann-Whitney U-test. Demographic data and other side effects were analyzed using the Student's t-test. Eighty-three children completed the study. There were 42 children in group P. EA was diagnosed in two children in the propofol group (4.8%) and in 11 children in the placebo group (26.8%, P < 0.05). Time to achieving postanesthesia care unit discharge criteria was not different between the two groups. The addition of propofol 1 mg.kg(-1) can significantly decrease the incidence of EA after sevoflurane general anesthesia in children undergoing nonpainful procedures.

Instructions for Obtaining Journal CME Credit

Anesthesiology’s journal-based CME program is open to all readers. Members of the American Society of Anesthesiologists participate at a preferred rate, but you need not be an ASA member or a journal subscriber to take part in this CME activity. Please complete the following steps:The American Society of Anesthesiologists is approved by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education programs for physicians.The American Society of Anesthesiologists designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.Purpose: The focus of the journal-based CME program, and the articles chosen for the program, is to educate readers on current developments in the science and clinical practice of the specialty of Anesthesiology.Target Audience: Physicians and other medical professionals whose medical specialty is the practice of anesthesia.Learning Objectives: After reading this article, participants should have a better understanding of the effectiveness of continuous preperitoneal local anesthetic infusion for postoperative pain control.Authors – Marc Beaussier, M.D., Ph.D., Hanna El’Ayoubi, M.D., Eduardo Schiffer, M.D., Maxime Rollin, M.D., Yann Parc, M.D., Ph.D., Jean-Xavier Mazoit, M.D., Ph.D., Louisa Azizi, M.D., Pascal Gervaz, M.D., Serge Rohr, M.D., Ph.D., Celine Biermann, M.D., André Lienhart, M.D., Ph.D., and Jean-Jacques Eledjam, M.D., Ph.D. Grants or research support: Supported by a grant from AstraZeneca, Rueil Malmaison, France.Consultantships or honoraria: NoneAuthors – Henrik Kehlet, M.D., and Spencer S. Liu, M.D. Grants or research support: Dr. Kehlet has received a grant from AstraZeneca, Södertälje, Sweden, to study wound infusion of local anesthetics in knee and hip replacement.Consultantships or honoraria: Dr. Liu is a consultant to Anesiva, San Francisco, California.Question Writers – Peter L. Bailey, M.D., and Leslie C. Jameson, M.D. Drs. Bailey and Jameson have no grants, research support, or consultant positions, nor do they receive any honoraria from outside sources, which may create conflicts of interest concerning this CME program.Based on the article by Beaussier et al. entitled “Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal http://content.wkhealth.com/linkback/openurl?issn=0003–3022&amp;volume=107&amp;issue=3&amp;spage=369&amp;part=fulltextsurgery: A randomized, double-blind, placebo-controlled study” and http://content.wkhealth.com/linkback/openurl?issn=0003–3022&amp;volume=107&amp;issue=3&amp;spage=461&amp;part=fulltextits accompanying editorial by Kehlet and Liu entitled “Continuous local anesthetic wound infusion to improve postoperative outcome: Back to the periphery?” in the September issue of Anesthesiology, choose the one correct answer for each question:1. Which of the following statements about infusion of local anesthetic at the surgical incision site for open colorectal surgery is most likely true?A. Randomized controlled trials assessing effectiveness have not been performed.B. Mental function is impaired.C. The wound infection rate is similar to rates in patients without catheters.D. Patients are resistant to using the technique.2. Which statement comparing use of a continuous preperitoneal infusion of ropivacaine in combination with patient-controlled analgesia (PCA) morphine to PCA morphine alone for pain control in patients undergoing open colorectal surgery is most likely true?A. PCA morphine alone provides better analgesia during coughing.B. The combined therapy is associated with significant reductions in morphine consumption.C. The combined therapy is associated with significantly more postoperative nausea and vomiting.D. Six weeks after surgery, combined therapy is associated with significantly more residual wound pain.3. Which of the following statements about the preperitoneal infusion of ropivacaine in patients undergoing open colorectal surgery is most likely true?A. The local anesthetic is found only in tissue in the subdermal area of the incision.B. The cost of related disposable equipment exceeds $750 (US).C. Plasma concentrations of ropivacaine are greater after 48 h than after 24 h of infusion.D. Patients do not develop symptoms of local anesthetic toxicity.4. Which statement comparing use of a continuous preperitoneal infusion of ropivacaine in combination with patient-controlled analgesia (PCA) morphine to PCA morphine alone for pain control in patients undergoing open colorectal surgery is most likely true?A. Length of hospital stay is decreasedB. Time to return of bowel function is similarC. Time to postanesthesia care unit discharge is prolonged (Aldrete score of 8)D. Quality of sleep is similar5. Which statement about the effectiveness of preperitoneal infusion of local anesthetic is most likely true?A. It effectively blocks pain receptors on the peritoneum.B. Superficial placement of the catheter provides better pain relief than preperitoneal placement after open abdominal surgery.C. The combined technical failure rate of the catheter and the pump is 10%–20%.D. It is not effective for treatment of incisional pain after a cholecystectomy.

Intraoperative Sensorcaine Significantly Improves Postoperative Pain Management in Outpatient Reduction Mammaplasty

Breast reduction is one of the most frequently performed plastic surgical procedures in the United States; more than 160,500 patients underwent the procedure in 2005. Many outpatient reduction mammaplasty patients report the greatest postoperative discomfort in the first 48 hours. The authors' investigated the effect of intraoperative topical application of the long-acting local anesthetic agent bupivacaine (Sensorcaine or Marcaine) on postoperative pain, time to postanesthesia care unit discharge, and postoperative use of narcotic medication. In a prospective, randomized, single-blind trial, intraoperative use of Sensorcaine versus placebo (normal saline) was compared. Postoperative pain was quantified using the visual analogue scale, and time to discharge from the postanesthesia care unit was recorded. Patients documented their outpatient pain medication usage. Of the 37 patients enrolled in the study, 20 were treated with intraoperative topical Sensorcaine and 17 received placebo. Patients treated with Sensorcaine were discharged home significantly faster (2.9 hours versus 3.8 hours, p = 0.002). The control arm consistently had higher pain scores in the postanesthesia care unit (although not statistically significant) than the Sensorcaine group using the visual analogue scale system. Furthermore, patients receiving Sensorcaine required significantly less narcotic medication while recovering at home (mean, 3.5 tablets of Vicodin) than the control group (mean, 6.4 tablets; p = 0.001). There were no complications resulting from Sensorcaine usage. This prospective, randomized, single-blind study demonstrates that a single dose of intraoperative Sensorcaine provides a safe, inexpensive, and efficacious way to significantly shorten the length of postanesthesia care unit stay and significantly decrease postoperative opioid analgesic use in patients undergoing ambulatory reduction mammaplasty.

Treatment with Lavender Aromatherapy in the Post-Anesthesia Care Unit reduces Opioid Requirements of Morbidly Obese Patients Undergoing Laparoscopic Adjustable Gastric Banding

Parenteral administration of opioids and NSAIDs has been the mainstay for postoperative pain control in patients undergoing laparoscopic adjustable gastric banding (LAGB). Both classes of drugs, however, are associated with serious adverse effects. An addition of complimentary analgesic techniques may decrease requirement for traditional analgesics, thus reducing the incidence of side-effects. We designed the study to evaluate the effectiveness of Lavender aromatherapy in reducing opioid requirements after LAGB. A prospective randomized placebo controlled study was carried out on 54 patients undergoing LAGB. Upon arrival to the post-anesthesia care unit (PACU), patients in the study group were treated with lavender oil, which was applied to the oxygen face mask; the control group patients received nonscented baby oil. Postoperative pain was treated with morphine. Numerical rating scores (0-10) were used to measure the level of pain at 5, 30, and 60 min. Sedation was evaluated using the Observer Assessment of Alertness/Sedation scale (0-5). Data analyzed included the amount of opioids, NRS, OAA/S, PACU discharge time, as well as the incidence of side-effects. The two groups were comparable with regard to patient characteristics, intraoperative drug use, and surgical time. Significantly more patients in the Placebo group (PL) required analgesics for postoperative pain (22/27, 82%) than patients in the Lavender group (LAV) (12/26, 46%) (P = .007). Moreover, the LAV patients required significantly less morphine postoperatively than PL patients: 2.38 mg vs 4.26 mg, respectively (P = .04). There were no differences in the requirements for post-operative antiemetics, antihypertensives, or PACU discharge time. Our results suggest that lavender aromatherapy can be used to reduce the demand for opioids in the immediate postoperative period. Further studies are required to assess the effect of this therapy on clinically meaningful outcomes, such as the incidence of respiratory complications, delayed gastric emptying, length of hospital stay, or whether this therapy is applicable to other operations.

Opioid consumption in total intravenous anesthesia is reduced with dexmedetomidine: a comparative study with remifentanil in gynecologic videolaparoscopic surgery

Study Objective To evaluate the capacity of dexmedetomidine (DEX), an α 2 adrenergic agonist drug, as a substitute for remifentanil (REM), a potent opioid, in total intravenous anesthesia (TIVA), in patient undergoing gynecologic videolaparoscopy. Design Randomized, single-blinded study. Setting University-affiliated hospital. Patients 30 ASA physical status I and II women, patients (22-56 yrs), scheduled for gynecologic videolaparoscopy. Interventions Patients were anesthetized with DEX or REM in continuous venous infusion, associated with propofol, in a target-controlled infusion. Measurements Heart rate, mean blood pressure (MBP), systolic blood pressure (SBP), diastolic blood pressure (DBP), plasma glucose, and cortisol were determined before anesthetic induction, 5 minutes after tracheal intubations and 30 minutes after initial surgical incision. Extubation and orientation times, and postanesthesia care unit (PACU) discharge times were noted. Main Results Blood cortisol levels were higher in the DEX group than in the REM group at 30minutes after surgical incision. Cortisol levels decreased as a function of time in the REM group, whereas intheDEX group they decreased in the second sample and returned to basal levels at 30minutes. Hyperglycemia was higher in DEX than in REM during the second and third sample collection. However, glucose increased as a function of time in both groups. Analysis of MBP and DBP indicated adecrease in blood pressure at 5 minutes after tracheal intubations in both groups. At 30minutes afterincision, MBP and DBP returned to basal levels in the DEX group, whereas the variables were significantly lower in the REM group. There were significant differences between groups for systolic blood pressure and heart rate at 5 and 30 minutes after incision with a greater decrease in REM. The extubation and orientation times were significantly increased in the DEX group, when compared with those of the REM group. There were no differences in postanesthesia care unit discharge times between groups. Conclusions Dexmedetomidine was a clinically effective drug as a REM substitute in TIVA, during minimally invasive video gynecologic surgical procedures; however, patients anesthetized with DEX showed a more prolonged recovery time for some parameters such as orientation and extubation times.

Local anesthetic infiltration versus caudal epidural block for anorectal surgery: a randomized controlled trial

Study Objective To compare patient satisfaction with local anesthetic infiltration versus caudal epidural block for anorectal procedures. Design Randomized controlled trial. Setting Operating room and postanesthesia care unit (PACU). Patients 22 adult, ASA physical status I, II, and III patients scheduled for anorectal surgery. Interventions Patients were randomized to receive either local anesthetic infiltration (LAI) (n = 10) by the surgeon or caudal epidural block (CEB) (n = 12) by the anesthesiologist. Measurements The primary outcome was patient satisfaction with the anesthetic technique and pain relief 12 hours after the procedure on a 4-point Likert scale. Secondary outcomes included time to first analgesic request, time to reach a PACU discharge score (REACT score) of 10, time to ambulation, time to discharge home, and adverse events. Main Results More subjects in the CEB group (83.3%) were highly satisfied than in the LAI group (20%; P = 0.003), assessed 12 hours postoperatively by telephone interview. Subjects in the CEB group requested analgesia 423 minutes later (95% confidence interval, 286-560 min) than subjects in the LAI group. Differences in time to reach a REACT score of 10, time to ambulation, and time to discharge home were not statistically significant. Conclusions Caudal epidural block provides higher patient satisfaction and longer lasting analgesia than LAI without delaying discharge.

Fast-track anaesthesia for laparoscopic cholecystectomy

To evaluate the effects of sevoflurane and desflurane in combination with intravenous remifentanil on time for discharge from the postanaesthesia care unit and need for postanaesthesia care unit management after elective laparoscopic cholecystectomy. 231 ASA Grade I-II patients, undergoing elective laparoscopic cholecystectomy in seven University teaching hospital, were randomly allocated to receive a desflurane-remifentanil (n = 105) or sevoflurane-remifentanil (n = 126) anaesthetic. A blinded observer recorded times for emergence and postanaesthesia care unit discharge (achievement of an Aldrete score > or =9), number of patients eligible for postanaesthesia care unit discharge when exiting the operating room and occurrence of adverse events. Intraoperative cardiovascular stability was similar in the two groups. Emergence, response and extubation occurred earlier after desflurane (5.4 +/- 3 min, 5.5 +/- 3 min and 7.5 +/- 4 min) than sevoflurane (6.6 +/- 3.5 min, 7.2 +/- 4 min and 9.1 +/- 4.2 min) (P = 0.0005, 0.05 and 0.003, respectively). Postanaesthesia care unit bypass was possible in 44 desflurane-remifentanil patients (41%) and 55 sevoflurane- remifenatnil patients (43%) (P = 0.69), while postanaesthesia care unit discharge occurred after 46 min (25th-75th percentiles: 18-40 min) with desflurane and 64 min (25th-75th percentiles: 20-50 min) with sevoflurane (P = 0.04). Postoperative nausea and vomiting was observed in 40 desflurane-remifentanil patients (36%) and 53 sevoflurane-remifentanil patients (42%) (P = 0.42). Both the desflurane-remifentanil and sevoflurane-remifentanil combinations provide a similarly adequate intraoperative cardiovascular stability. Emergence and postanaesthesia care unit discharge were faster with desflurane-remifentanil than sevoflurane-remifentanil, but this was not associated with a larger proportion of postanaesthesia care unit bypass, confirming that no clinically relevant differences are present between the two agents.

Combination Propofol/Ketamine is a Safe and Efficient Anesthetic Approach to Anorectal Surgery

Concerns persist regarding respiratory complications from combination deep intravenous sedation and local anesthesia for prone position anorectal surgery. We examined the safety and efficacy of this approach by using a propofol-based and ketamine-based technique. A retrospective review was conducted on all patients undergoing anorectal surgery. Outcomes (perioperative times, specific complications) were compared with respect to operative position and anesthetic approach. Significance was determined using Student's t-test and chi-squared analysis. Surgery was performed on 448 patients during a three-year period. There was no significant difference in the two anesthetic groups with regard to age and gender. There were 19 anesthesia-related adverse events occurring in the study group (Monitored Anesthesia Care Group): nausea and vomiting (n = 8), airway obstruction necessitating conversion to general anesthesia (n = 2), excessive pain (n = 2), urinary retention (n = 5), and hospital readmission (n = 2). These occurred in <5 percent of those receiving the combination technique (19/407). Although there was no difference in total procedural time, there was a significant difference in total time spent in the operating room (P = 0.001) and in the hospital overall (P = 0.002). Of the patients receiving combination technique anesthesia, only 31 (7 percent) required the use of the postanesthesia care unit. All patients receiving general anesthesia (n = 23) required the postanesthesia care unit. Combination deep intravenous sedation with local anesthesia based on propofol and ketamine is a safe and effective technique for prone-position anorectal surgery. It results in decreased use of the postanesthesia care unit and earlier hospital discharge, reflecting a more efficient use of hospital resources.

Postoperative nausea and vomiting following inpatient surgeries in a teaching hospital: a retrospective database analysis

ABSTRACTObjective: To report the incidence of postoperative nausea and vomiting (PONV), to describe the use of anti-emetics both for the prophylaxis and treatment of PONV, and to assess resource utilization and duration of post-anesthesia care unit (PACU) stay.Research design and methods: We retrieved data from the Duke Anesthesia Peri-operative database. We included adult patients, who underwent inpatient surgery under general anesthesia with inhaled agents between January 2004 and February 2005, and had two or more risk factors for PONV documented preoperatively (female, previous history of PONV or motion sickness, non-smoker or use of postoperative opioid). Data on the use of prophylactic anti-emetics, the incidence of PONV, nausea scores, pain scores, and the use of rescue anti-emetics in PACU and in the period between PACU discharge and 24 h after surgery were recorded. Resource utilization and cost assessment was performed from the perspective of the hospital and included length and direct cost of PACU stay, as well as the acquisition costs of rescue anti-emetics in PACU. Descriptive statistics were used to summarize the demographic characteristics of patients. For group comparisons, data were analyzed with the t‐test for continuous data, and the Chi-square test for categorical data. Multiple linear regression models were used to evaluate the association between PONV and PACU length of stay adjusting for confounding factors.Results: A total of 3641 patients were included in the analysis. Of those, 2869 (79%) received prophylactic anti-emetics. In the PACU, nausea and vomiting were reported in 16% and 3% of the patients, respectively. Rescue anti-emetics were given to 26% of all patients. The incidence of vomiting was significantly less in patients who received PONV prophylaxis ( p = 0.03). In multiple linear regression models, the duration of PACU stay was longer by a mean of 25 min in patients who experienced PONV or received rescue anti-emetics in PACU ( p < 0.0001) despite the fact that the duration of surgery was shorter by a mean of 24 min in this group of patients ( p < 0.0001). Following PACU discharge, 40% of patients reported nausea, vomiting or needed rescue anti-emetics. PONV was associated with significantly increased resource utilization and costs of PACU stay ( p < 0.0001). Emesis was associated with greater incremental cost ($138) than nausea ($85), mainly from the longer duration of PACU stay.Conclusions: PONV remain a significant problem postoperatively and often persists beyond PACU discharge. The presence of PONV is associated with increased length of PACU stay and greater resource utilization and costs.

Bispectral index monitoring does not improve early recovery of geriatric outpatients undergoing brief surgical procedures

To assess if titration of sevoflurane using the bispectral index (BIS) monitor improves the early and intermediate recovery in geriatric outpatients undergoing brief urologic procedures under general anesthesia without muscle relaxants. After a standardized induction with propofol and fentanyl, a laryngeal mask airway was inserted and sevoflurane was administered in combination with 60% nitrous oxide in oxygen for maintenance of anesthesia in spontaneously breathing outpatients. In the Control group (n = 25), sevoflurane and fentanyl were titrated according to standard clinical practice. In the BIS-directed group (n = 25), sevoflurane was titrated to maintain a BIS value between 50 and 60, and supplemental fentanyl, 25 mug iv boluses were administered to treat tachypnea. The intraoperative anesthetic and analgesic requirements, as well as the times to eye opening, removal of the laryngeal mask airway device, response to simple commands, orientation to person and place, and postanesthesia care unit discharge eligibility (fast-track score of 14) were assessed at specific time intervals. The minimum alveolar concentration-hour of sevoflurane (0.25 +/- 0.15 and 0.31 +/- 0.2) and end-tidal concentrations of sevoflurane at the end of surgery (0.3 +/- 0.3 and 0.4 +/- 0.20%) did not differ significantly between the Control and BIS-directed groups, respectively. Although the percentage of patients requiring supplemental boluses of fentanyl was reduced in the BIS-directed group (16 vs 48%, P <0.05), the intraoperative BIS values and recovery times were similar in the two groups. In this non-paralyzed elderly outpatient surgery population, the use of BIS monitoring for titrating the maintenance anesthetic (sevoflurane) failed to improve the early recovery process.

THIS ARTICLE HAS BEEN RETRACTED: Early recovery, cognitive function and costs of a desflurane inhalational vs. a total intravenous anaesthesia regimen in long‐term surgery

Background: The purpose of the study was to compare time of recovery, return of cognitive function, post‐anaesthetic care unit (PACU) stay and costs of a propofol/remifentanil (TIVA) with a desflurane/fentanyl‐based anaesthesia (desflurane group) in surgical procedures lasting more than 150 min.Methods: Forty‐nine patients undergoing elective abdominal prostatectomy were allocated randomly to receive bispectal index (BIS)‐controlled desflurane/fentanyl (n = 24) or propofol/remifentanil (n = 25). Awakening, clinical recovery, direct drug acquisition and post‐operative pain treatment were documented. Cognitive skills were tested using the Mini‐Mental Status (MMST) test.Results: Extubation was significantly faster with desflurane (6.9 ± 3.5 min) than with TIVA (11.2 ± 4.0 min) as well as times for stating name and date of birth (desflurane: 6.1 ± 3.9 and 6.6 ± 4.0 min; TIVA: 12.4 ± 11.5 min and 13.4 ± 11.3 min). There were no significant differences in PACU discharge times or MMS scores between the groups. Significantly more patients suffered post‐operative nausea and vomiting (PONV) in the desflurane (33% vs. 0%) than the TIVA group. Overall costs were significantly higher in the TIVA (58.8 ± 11.6 €) than in the desflurane group (35.0 ± 5.7 €).Conclusion: Patients undergoing prolonged surgical procedures showed a faster early recovery after desflurane/fentanyl than using TIVA, whereas stay in the PACU and recovery of cognitive function were similar in both groups. Costs of a TIVA regimen were significantly higher than using a desflurane‐based anaesthesia technique.

Continuous Monitoring of Cerebral Oxygen Saturation in Elderly Patients Undergoing Major Abdominal Surgery Minimizes Brain Exposure to Potential Hypoxia

Elderly patients are more prone than younger patients to develop cerebral desaturation because of the reduced physiologic reserve that accompanies aging. To evaluate whether monitoring cerebral oxygen saturation (rSO(2)) minimizes intraoperative cerebral desaturation, we prospectively monitored rSO(2) in 122 elderly patients undergoing major abdominal surgery with general anesthesia. Patients were randomly allocated to an intervention group (the monitor was visible and rSO(2) was maintained at > or =75% of preinduction values; n = 56) or a control group (the monitor was blinded and anesthesia was managed routinely; n = 66). Cerebral desaturation (rSO(2) reduction <75% of baseline) was observed in 11 patients of the treatment group (20%) and 15 patients of the control group (23%) (P = 0.82). Mean (95% confidence intervals) values of mean rSO(2) were higher (66% [64%-68%]) and the area under the curve below 75% of baseline (AUCrSO2(2)< 75% of baseline) was lower (0.4 min% [0.1-0.8 min%]) in patients of the treatment group than in patients of the control group (61% [59%-63%] and 80 min% [2-144 min%], respectively; P = 0.002 and P = 0.017). When considering only patients developing intraoperative cerebral desaturation, a lower Mini Mental State Elimination (MMSE) score was observed at the seventh postoperative day in the control group (26 [25-30]) than in the treatment group (28 [26-30]) (P = 0.02), with a significant correlation between the AUCrSO(2) < 75% of baseline and postoperative decrease in MMSE score from preoperative values (r(2)= 0.25, P = 0.01). Patients of the control group with intraoperative cerebral desaturation also experienced a longer time to postanesthesia care unit (PACU) discharge (47 min [13-56 min]) and longer hospital stay (24 days [7-53] days) compared with patients of the treatment group (25 min [15-35 min] and 10 days [7-23 days], respectively; P = 0.01 and P = 0.007). Using rSO(2) monitoring to manage anesthesia in elderly patients undergoing major abdominal surgery reduces the potential exposure of the brain to hypoxia; this might be associated with decreased effects on cognitive function and shorter PACU and hospital stay.

Recovery from Bispectral Index-guided Anaesthesia in a Large Randomized Controlled Trial of Patients at High Risk of Awareness

Electroencephalographic monitors of anaesthetic depth are reported to assist anaesthetists in reducing recovery times. We explored the effect of bispectral index (BIS) monitoring on recovery times in a double-blind, randomized controlled trial of 2,463 patients at high risk of awareness. Patients were randomized to BIS-guided anaesthesia or routine care. In the BIS group, anaesthesia was adjusted to maintain a BIS value of 40-60 from the commencement of laryngoscopy to the start of wound closure, and 55-70 during wound closure. In the routine care group, anaesthesia was adjusted according to traditional clinical signs. In multivariate models, BIS monitoring, female gender, lower American Society of Anesthesiologists' physical status and shorter duration of anaesthesia predicted faster time to eye-opening after anaesthesia, and faster time to post-anaesthesia care unit discharge. BIS monitoring did not affect times to tracheal extubation among patients admitted to the intensive care unit. We conclude that BIS monitoring has statistically significant, but clinically modest, effects on recovery times in high risk surgical patients.

Under “real world” conditions, desflurane increases drug cost without speeding discharge after short ambulatory anesthesia compared to isoflurane

To compare the measured "real world" perioperative drug cost and recovery associated with desflurane- and isoflurane-based anesthesia in short (less than one hour) ambulatory surgery. We conducted a prospective, randomized, blinded trial with patients undergoing arthroscopic meniscectomy under general anesthesia. Following iv induction, patients received either isoflurane (group I; n = 25) or desflurane (group D; n = 20) for maintenance. The primary outcome variable was total perioperative drug cost per patient in Canadian dollars. Secondary outcome variables included volatile agent consumption and cost, adjuvant anesthetic and postanesthesia care unit (PACU) drug cost, readiness for PACU discharge, and incidence of adverse events. Total perioperative drug cost per patient was 14.58 +/- 6.83 Canadian dollars (mean +/- standard deviation) for group I, and 21.47 +/- 5.18 Canadian dollars for group D (P < 0.001). Isoflurane consumption per patient was 6.0 +/- 3.0 mL compared to 18.6 +/- 7.7 mL for desflurane (P < 0.0001); corresponding costs were 0.83 +/- 0.42 Canadian dollars vs 7.61 +/- 3.15 Canadian dollars (P < 0.0001). There were no differences in adjuvant anesthetic or PACU drug cost. All but one patient from each group were deemed ready for PACU discharge at 15 min postoperatively (Aldrete score >or= 9). One patient in group D experienced postoperative nausea. No other adverse events were noted. Measured total perioperative drug cost for a short ambulatory procedure (less than one hour) under general anesthesia was higher when desflurane rather than isoflurane was used for maintenance, essentially due to volatile agent cost. Desflurane use did not translate into faster PACU discharge under "real world" conditions.

Altered perceptions after upper and lower extremity blocks: an initial investigation

Background and objectives: Nerve blocks frequently produce unusual altered perceptions in the extremities. We examined perceptual changes experienced after peripheral blocks. Methods: Fifty consecutive patients having an upper or lower extremity block for surgery participated in this prospective study. Patients were divided into 2 groups: upper extremity (n = 20) and lower extremity (n = 30). Each group was asked a list of questions about perceptions of limb sensation, length, weight, and location and given a detailed 2-point discrimination test over the V 1-V 3 divisions of the trigeminal nerve prior to block and sedation. While the extremity was still blocked, the exam was repeated before postanesthesia care unit discharge. Results: In both groups, 98% of patients described altered limb perception. The perceptions in the upper extremity were: heaviness, 60%; numbness, 50%; warmth, 40%; pain, 30%; full or fat, 20%; floating, 5%; shorter, 0%; or thinner, 10%. The perceptions in the lower extremity were: numbness, 75%; heaviness, 46%; warmth, 33%; pain, 32%; full or fat, 36%; floating, 25%; shorter, 18%, or thinner, 7%. Upper extremity block patients were more likely to describe the limb as lighter ( P < .0001); the lower extremity group was more likely to describe the limb as numb ( P = .01) or floating ( P = .0002). There was no difference in the ability to correctly identify the location of the limb between the groups. There was no difference in 2-point discrimination between each assessment for either group. Conclusion: The results of this study confirm and quantify the perceptions experienced by patients undergoing upper and lower extremity blocks. These perceptions are prevalent. This knowledge is helpful in providing patients with accurate preoperative preparation. Further investigation is warranted to determine the neurologic etiology of these observations.

This Month in ANESTHESIOLOGY

This Month in ANESTHESIOLOGY

Propofol-ketamine versus propofol-fentanyl for outpatient laparoscopy : Comparison of postoperative nausea, emesis, analgesia, and recovery

Study objective To compare postoperative nausea, emesis, analgesia, and recovery between propofol-ketamine and propofol-fentanyl in outpatient laparoscopic tubal ligations with general anesthesia. Study design Prospective, randomized, blinded study. Setting Tertiary-care women’s hospital. Patients 120 ASA physical status I and II ambulatory patients scheduled for elective laparoscopic tubal ligation. Interventions Patients were randomized to two groups to receive either ketamine (1-1.5 mg/kg) or fentanyl (3-5 μg/kg). Measurements Measured variables included total dose of ketamine, fentanyl, propofol, and operating time. Vital signs, pain visual analog scale scores (VAS), nausea VAS, presence of emesis, treatment for nausea and vomiting, pruritus, sedation, and presence of dreaming were recorded on postanesthesia care unit (PACU) admission, PACU discharge, stepdown unit admission, and hospital discharge. Results are expressed as means ± SD or medians and analyzed using t -test, Chi-square, or Mann-Whitney (p < 0.05). Main results No differences were noted with respect to propofol dose, operating times, pain or nausea VAS scores, emesis, treatment for nausea and vomiting, pruritus, and sedation on PACU admission, PACU discharge, stepdown unit admission, and hospital discharge. The ketamine group had a higher heart rate, required more pain medication, and had a higher frequency of dreaming on PACU admission than the fentanyl group. These differences became insignificant on PACU discharge. Conclusions For outpatient laparoscopic tubal ligations with general anesthesia, propofol-ketamine does not improve postoperative nausea, emesis, analgesia or recovery compared with the propofol-fentanyl combination.