Postanesthesia Care Unit Discharge Research Articles

Recovery and Complications After Tonsillectomy in Children

Ninety-six children received morphine 0.1 mg/kg (n = 47) or ketorolac 1 mg/kg (n = 49) intravenously (IV) in a prospective, randomized, double-blind fashion, after tonsillectomy. Recovery variables and complications were recorded while subjects were in the hospital and parent(s) were contacted 24 h and 14 days after surgery. There were no differences in demographics, surgical management, awakening time, oxygen requirements, or time to readiness for postanesthesia care unit (PACU) discharge or discharge home between the two groups. Ketorolac subjects had fewer emetic episodes than morphine subjects (median 1 vs 3; P = 0.006) and were less likely to have more than two episodes of emesis after PACU discharge (9/49 vs 22/47; P = 0.007). Ketorolac subjects had more major bleeding (bleeding requiring intervention; 5/49 vs 0/47, one-tailed P = 0.03) and more bleeding episodes (0.22 episodes/subject vs 0.04 episodes/subject, P < 0.05) in the first 24 h after surgery, but no greater overall incidence of bleeding than the morphine subjects. In children having tonsillectomy, ketorolac, compared to morphine, reduced the number of emetic episodes after PACU discharge, but did not hasten awakening, readiness for PACU discharge or discharge home, and increased the likelihood of major bleeding in the first 24 h after surgery. (Anesth Analg 1995;81:1136-41)

Preanesthetic Medication of Children with Midazolam Using the Biojector Jet Injector

A rapid, dependable, and economical technique to atraumatically sedate children before anesthesia that does not prolong postanesthesia care unit time remains elusive. The Biojector jet injection system uses carbon dioxide rather than a needle to deliver an intramuscular injection. The dose-response relationship when midazolam is administered was studied using this jet injector. Forty children (2.3 +/- 1.3 yr old) undergoing elective myringotomy and tube placement were randomly assigned to receive 0.05, 0.1, 0.15, 0.2, or 0.3 mg.kg-1 midazolam injected intramuscularly using the Biojector disposable syringe (0.006-inch orifice). Assessment of each child before, during, and 10 min after injection, on application of the anesthesia face mask, and every 15 min for 1 h after arrival to the postanesthesia care unit was made by an observer blinded to drug dosage. Face mask tolerance using doses > or = 0.1 mg.kg-1 midazolam was acceptable and statistically different from 0.05 mg/kg. Crying on injection tended to increase with increasing dose. All children were awake and arousable, meeting discharge criteria, after 30 min from arrival in the postanesthesia care unit. Midazolam (0.1-0.15 mg.kg-1) administered using jet injection effectively and rapidly produces sedation, in a manner acceptable to parents, without delaying postanesthesia care unit discharge.

Does monitoring end-tidal isoflurane concentration improve titration during general anesthesia?

Study Objective: To assess the value of end-tidal anesthetic gas monitoring with respect to intraoperative hemodynamic stability and recovery times. Design: Randomized blinded study. Setting: Operating rooms at a university teaching hospital. Patients: 120 ASA I and II patients receiving general anesthesia maintained with isoflurane and nitrous oxide (N 2O). Interventions: Following a standardized induction technique, patients were assigned to either an end-tidal isoflurane monitored (n = 60) or unmonitored (n = 60) group. During each operation, the anesthesiologist attempted to maintain an adequate “depth of anesthesia” by varying the administered concentration of isoflurane with or without information from an end-tidal isoflurane monitor. Intraoperative hemodynamic stability was assessed by determining the variation from a preincisional “baseline” mean arterial pressure (MAP) value established during a 10 minute interval immediately prior to the surgical incision. Recovery times were recorded from discontinuation of isoflurane and N 2O until awakening, orientation, and postanesthesia care unit discharge. Measurements and Main Results: Intraoperative hemodynamic stability was assessed in each patient and reported as the average error from the baseline MAP, absolute average error from the baseline MAP, coefficients of variation of heart rate (HR), systolic and diastolic MAP, and end-tidal isoflurane concentrations. Both study groups had similar intraoperative MAP and HR values, average error and coefficients of variation for the hemodynamic variables, as well as similar numbers of episodes of hypertension, hypotension, tachycardia, and bradycardia. Finally, the two groups were comparable with respect to early recovery times and postoperative side effects. Conclusions: This study suggests that end-tidal isoflurane monitoring does not improve the titration of isoflurane during general anesthesia.

Effect of Antagonism of Mivacurium-Induced Neuromuscular Block on Postoperative Emesis in Children

The routine use of cholinesterase inhibitors to antagonize residual neuromuscular block may be associated with increased postoperative emesis.Rapid spontaneous recovery from mivacurium may obviate the need for these drugs. In this randomized, double-blind, placebo-controlled study of 113 healthy children who had received mivacurium as part of a standardized anesthetic regimen, we compared the incidence of postoperative complications after spontaneous recovery and after the use of neostigmine-glycopyrrolate or edrophonium-atropine. The anesthetic regimen consisted of halothane, nitrous oxide, fentanyl, 2 micro gram/kg intravenous (IV), mivacurium in an initial dose of 0.2 mg/kg, followed by an infusion, adjusted to maintain >or=to1 evoked contraction response to a supramaximum train-of-four stimulus. At the end of the procedure, patients received by random assignment one of three drug combinations: 1) neostigmine 70 micro gram/kg + glycopyrrolate 10 micro gram/kg, IV, 2) edrophonium 1 mg/kg + atropine 10 micro gram/kg, IV, and 3) saline. The trachea was extubated when evoked responses to peripheral nerve stimulation and clinical signs of adequate neuromuscular recovery were present. Postoperative pain was treated with morphine and emesis with metoclopramide. There were no significant differences between the three groups with respect to age, surgery, intraoperative fentanyl, and mivacurium use, time from the end of surgery to tracheal extubation, postanesthesia care unit (PACU) arrival and discharge, or in postoperative oxygen saturation values and analgesic requirements. Compared to the placebo group, emesis occurred more often in the PACU in patients receiving the neostigmine-glycopyrrolate combination, but not after edrophonium-atropine. However, after discharge from the PACU, emesis rates were similar in the three study groups. We conclude that spontaneous recovery or reversal with edrophonium from a moderate degree of mivacurium-induced block may offer advantages over the use of neostigmine, without increasing time to PACU arrival. (Anesth Analg 1995;80:713-17)

Effect of intraoperative ketorolac on postanesthesia care unit comfort

The efficacy of intraoperatively administered ketorolac for the prophylactic treatment of pain in the postanesthesia care unit (PACU) was examined in a prospective, double-blinded study. Thirty patients undergoing general anesthesia for orthopedic or lower abdominal surgery were randomized into two groups. Both groups received equivalent doses of opioids intraoperatively. Upon surgical closure, one group received intramuscular (IM) ketorolac 60 mg (2 mL) and the other group received normal saline 2 mL, IM. The saline control group more frequently required opioid-analgesic supplementation in the PACU than did the ketorolac group ( P < 0.05). Time to first-required opioid dose in the PACU was 22 ± 8 versus 76 ± 11 min for the control group and ketorolac group, respectively ( P < 0.001). The ketorolac group reported significantly lower pain scores 1 hr after PACU admission ( P < 0.01). Time to PACU discharge was not different between groups. Intraoperatively administered ketorolac is an effective adjunct in the management of postoperative pain.