Postanesthesia Recovery Unit Research Articles

Anesthesia recovery after ophthalmologic surgery at an ambulatory surgical center

To examine anesthesia recovery duration after ophthalmologic procedures performed at an ambulatory surgical center (ASC) and provide information that could be used to increase postanesthesia recovery unit efficiency. Ambulatory surgical center at tertiary medical center, Rochester, Minnesota, USA. Retrospective case series. Health records of adult patients having ophthalmologic procedures at an ASC from July 1, 2010, through September 30, 2016 were reviewed, and anesthesia recovery duration was calculated. Potential associations were assessed between clinical factors and prolonged recovery (upper 10th percentile of recovery duration by anesthesia type [general, intravenous sedation, or topical]). Among 20 116 procedures, the median recovery was 36minutes (interquartile range [IQR], 28 to 48); general anesthesia had the longest recovery (79 minutes; IQR, 52 to 104minutes) (P<.001). Recovery was longest for orbitotomy and strabismus procedures and shortest for cataract procedures. Female sex, obstructive sleep apnea, greater disease burden, longer procedures, and intraoperative fentanyl administration were associated with prolonged recovery. Patients with prolonged recovery had more severe pain episodes (pain score ≥7 [scale 0 to 10]; 138 patients [6.9%] versus 140 [0.8%]; P<.001) and received opioid analgesics during recovery (278 patients [13.8%] versus 293 [1.6%]; P<.001). Prolonged recovery involved higher rates of emergency department visits and hospitalizations in the first 48 postoperative hours and higher 30-day mortality rates. Anesthesia recovery after ophthalmologic procedures at an ASC was associated primarily with the procedure and anesthesia type. Prolonged recoveries were associated with intraoperative fentanyl use, severe postoperative pain, and postoperative opioid requirements.

ANALGESIC EFFECTIVENESS OF CONTINUOUS INTERSCALENE CATHETER USE FOR AMBULATORY SHOULDER SURGERY IN PEDIATRIC AND ADOLESCENT PATIENTS

BACKGROUND Continuous interscalene catheters are utilized for inpatient and outpatient postoperative pain control after shoulder surgery. Although prior studies have primarily been limited to adult populations, benefits of peripheral nerve catheters in ambulatory surgical centers have been shown to reduce post operative pain scores, opioid requirements, and post operative nausea. However, their use in a solely pediatric ambulatory setting has not been investigated. The purpose of this study was to retrospectively review the adverse events, analgesic effectiveness, and opioid use after continuous interscalene catheters for ambulatory shoulder surgery in pediatric and adolescent patients. METHODS A retrospective review was performed of 15 pediatric and adolescent patients (4 female, 11 male), mean age 16 years (range, 12-18 years), and mean weight 78.3 kg (range 53-130 kg), who underwent ultrasound-guided interscalene catheter placement for outpatient shoulder surgery from April 2017 through May 2018. All but one surgery were performed at a dedicated pediatric ambulatory surgery center. Catheters were initially dosed with 0.5% ropivacaine (n = 13) or 0.2% ropivacaine (n = 2) at volumes of 0.1-0.2ml/kg (total, 6-20 ml). By the conclusion of surgery, all catheters were continuously infusing 0.2% ropivacaine at 3-6ml/hr with the majority (n = 10) at 4ml/hr via elastomeric pumps. Time for catheter placement, intraoperative and postoperative intravenous opioids, post-anesthesia recovery unit (PACU) length of stay (LOS), PACU maximum pain scores and rescue medications for post-operative nausea and vomiting (PONV) were recorded. After discharge, all patients received multimodal analgesia (ibuprofen, acetaminophen, and rescue oxycodone). Patients were assessed on postoperative days (POD) 1-3 for numerical rating pain scores (0-10) at rest and with movement, supplemental oxycodone use in the past 24 hours, satisfaction, and adverse effects of treatment. RESULTS Catheter placement was 100% successful; no procedure had to be aborted during placement because of inability to place catheter. The average time for catheter placement was 11.8 minutes (range, 3-19 minutes). There were 3 adverse events, including one accidental catheter removal in PACU, one dressing failure requiring removal of catheter on POD 2, and one case of Horner’s Syndrome. There were no signs of infection, local anesthetic toxicity, or shortness of breath described in any patients. Short acting opioids (Alfentanil and Fentanyl) were used intraoperatively in all but 2 patients, with average dose of 8.5mcg/kg Alfentanil and 0.7mcg/kg Fentanyl. Two patients received long-acting opioids intraoperatively. The mean PACU maximum pain score was 1.4 (range, 0-9). Only 3 patients received rescue intravenous morphine in the PACU with a mean dose of 0.035mg/kg. Mean PACU LOS was 112 minutes (range, 85 – 210 minutes). No patients required any rescue PONV medications in the PACU. Mean pain scores for POD 1- 3 at rest were 2.1, 2.3, and 2.6, respectively; scores with movement were 3.6, 3, and 4.4, respectively. Mean doses (i.e., times of administration) of oxycodone on POD 1-3 respectively were 1.5, 1.3 and 0.5 (range 0-5 doses). All but one patient was very satisfied and would have the catheter placed again. CONCLUSIONS Outpatient use of continuous interscalene catheters in pediatric and adolescent patients provides excellent intraoperative and early postoperative analgesia during and following shoulder surgery. Their routine use should be considered as they minimize perioperative opioid use with minimal adverse events, adding only small delay to surgical time.

Continuous improvement of safety in the Intensive Care and Surgical environment according to UNE 179003:2013 standard: 8 years experience

Abstract Introduction The UNE 179003:2013 standard requires compliance with protocols to reduce the risks of patients from adverse events. Methods A description is presented of the procedure used in the Hospital Povisa to achieve UNE 179003:2010 certification for the intensive care unit, surgical division, and post-anaesthesia recovery unit (PARU). This was based on a risk management system, focusing on pro-active analysis using failure modes and effects analysis (FMEA) with the description of causes, consequences, risk weighting, and specific risk-minimising measures. A description is also presented of the analysis of reported adverse events (reactive analysis) in the Safety in Anesthesia and Resuscitation (SENSAR) notification system and the measures implemented over an eight-year period. Results The UNE 179003:2010 certification was obtained in July 2012, and the re-certification was achieved in July 2015. A total of 66 potential risks were established, which were weighted using a risk probability index (RPI), and measures were implemented that reduced this RPI by half. It also reflects the analysis of 1114 events declared in the SENSAR system over the past eight years, allowing for the introduction of 2681 measures, of which 98.4% are fully implemented. Conclusion The application of the risk management methodology allowed (a) to improve safety in the area of action by reducing the risk to which the patients are subject, and (b) to gain certification in the UNE 179003 standard.

Serratus-intercostal interfascial block as an opioid-saving strategy in supra-umbilical open surgery

Abstract Introduction The administration of local anaesthetic in the serratus-intercostal space provides adequate analgesia in non-reconstructive breast surgery. The aim of this study was to evaluate whether the blockage of the last intercostal nerves (T7–T11) can lead to opioid savings in supra-umbilical open surgery procedures. Material and methods A prospective observational study was conducted on patients undergoing open supra-umbilical surgery under general anaesthesia and with a serratus-intercostal plane block [modified Blocking the bRanches of IntercostaL nerves in the Middle Axillary line (BRILMA)] as an associated analgesic strategy. Post-operative pain was assessed with the numerical verbal scale (NVS 0–10) on admission to the post-anaesthesia recovery unit, at 6, 12, 24, and 48 h post-intervention and by need for analgesic rescues with opioids (2 mg iv of morphine, if values higher than 3 in NVS). Adverse events related to the technique were also recorded. The statistical package used in the analysis of the data was SPSS® for Windows. Results The study recruited 52 patients. Differences, with a p Conclusion The intercostal nerves block (T7–T11) in the serratus-intercostal space may constitute an opioid-sparing analgesic strategy in open supra-umbilical surgery.

Mejora continua de la seguridad en el ámbito de un Servicio de Anestesiología y Cuidados Intensivos a través de la certificación según la norma de UNE 179003:2013: 8 años de experiencia

IntroductionThe UNE 179003:2013 standard requires compliance with protocols to reduce the risks of patients from adverse events. MethodsA description is presented of the procedure used in the Hospital Povisa to achieve UNE 179003:2010 certification for the intensive care unit, surgical division, and post-anaesthesia recovery unit (PARU). This was based on a risk management system, focusing on pro-active analysis using failure modes and effects analysis (FMEA) with the description of causes, consequences, risk weighting, and specific risk-minimising measures. A description is also presented of the analysis of reported adverse events (reactive analysis) in the Safety in Anesthesia and Resuscitation (SENSAR) notification system and the measures implemented over an eight-year period. ResultsThe UNE 179003:2010 certification was obtained in July 2012, and the re-certification was achieved in July 2015. A total of 66 potential risks were established, which were weighted using a risk probability index (RPI), and measures were implemented that reduced this RPI by half. It also reflects the analysis of 1114 events declared in the SENSAR system over the past eight years, allowing for the introduction of 2681 measures, of which 98.4% are fully implemented. ConclusionThe application of the risk management methodology allowed (a) to improve safety in the area of action by reducing the risk to which the patients are subject, and (b) to gain certification in the UNE 179003 standard.

Postoperative Psychogenic Non-epileptic Seizure in the Post-Anesthesia Recovery Unit

Postoperative Psychogenic Non-epileptic Seizure in the Post-Anesthesia Recovery Unit

Prevalence and characterization of postoperative pain in the Postanaesthesia Care Unit

Abstract Introduction Immediate postoperative pain occurs initially after surgery, while the patient is in the Post-Anaesthesia Recovery Unit. Very few studies assess this pain in this most immediate phase. Objective Cross-sectional study of the prevalence and characteristics of immediate postoperative pain in patients after surgery. Material and methods Between August 2014 and February 2015, a sample of 503 patients from the Post-Anaesthesia Recovery Unit was followed. Immediate postoperative pain was assessed (by the patient and the researcher) using the visual analogue scale (VAS; range 0–10) on 5 occasions after surgery. The impact of numerous factors (age, gender, type of surgery, type of anaesthesia and analgesic) on the pain, as well as variation in vital signs and the presence of side effects, were analysed. Results Assessment of the pain showed overall VAS values of 2.2 ± 2.8 on all occasions. Pain was reported to be of greatest intensity 20 min after the patients’ arrival in the Post-Anaesthesia Recovery Unit (p Conclusions Studying the characteristics of postoperative pain at such an early stage allows for improved management. It helps to predict, according to the type of surgery and the anaesthesia used, those patients in which higher VAS values may be seen and to better adapt analgesic therapy.

Chemotherapy and Perioperative Nurses

The University Of Chicago Medicine (UCM) reestablished chemotherapy infused surgical cases following expansion of our oncology program. There was a need to update policy and guidelines related to safe handling of chemotherapy due to several changes including: post-operative patient disposition from the intensive care unit to the post-anesthesia recovery unit [PACU]; regulatory guideline revisions by National Institute for Occupational Safety Health (NIOSH) and other federal agencies; and recommendations by the Oncology Nurse Society (ONS) to minimize exposure to perioperative nurses when working with hazardous drugs.

The Effect of Gabapentin on Delayed Discharge from the Postanesthesia Care Unit: A Retrospective Analysis.

Enhanced recovery after surgery programs has incorporated gabapentin as part of a multimodal analgesia protocol. The preemptive use of gabapentin was found to be beneficial due to its opioid-sparing effect. However, excessive sedation and delayed discharge from postanesthesia recovery units are of concern. The aim of this study was to investigate whether preoperative gabapentin increased the length of stay in the recovery unit. This retrospective cross-sectional study was carried out over a period of 2 months in the postanesthesia care unit (PACU) of a tertiary care hospital in Canada. Two hundred and twenty-eight consecutive patients who underwent elective surgical procedures and who required a longer than 2-hour stay in the PACU were included. Prolonged stays caused by respiratory inadequacy, hemodynamic instability, nausea, vomiting, pain, and loss of consciousness were recorded. The data were collected from patients' charts and nursing flow sheets. All patients were grouped into those who received 300 mg gabapentin (n = 108), 600 mg gabapentin (n = 41), and no gabapentin (n = 139). No significant difference was observed between the groups in terms of opioid consumption, respiratory inadequacy, nausea, vomiting, and hemodynamic parameters. Gabapentin administration groups had significantly lower postoperative pain scores (P < 0.001). Decreased level of consciousness occurred significantly more often in a dose-dependent fashion in the gabapentin groups and led to a longer stay in the PACU (P < 0.001). In the setting of enhanced recovery after surgery, gabapentin did reduce pain scores, but at the cost of delayed discharge from the recovery room. Future studies are needed to evaluate the efficacy of gabapentin in this setting.

Estudio de la prevalencia y la caracterización del dolor postoperatorio inmediato en la Unidad de Recuperación Postanestésica

IntroductionImmediate postoperative pain occurs initially after surgery, while the patient is in the Post-Anaesthesia Recovery Unit. Very few studies assess this pain in this most immediate phase. ObjectiveCross-sectional study of the prevalence and characteristics of immediate postoperative pain in patients after surgery. Material and methodsBetween August 2014 and February 2015, a sample of 503 patients from the Post-Anaesthesia Recovery Unit was followed. Immediate postoperative pain was assessed (by the patient and the researcher) using the visual analogue scale (VAS; range 0-10) on 5 occasions after surgery. The impact of numerous factors (age, gender, type of surgery, type of anaesthesia and analgesic) on the pain, as well as variation in vital signs and the presence of side effects, were analysed. ResultsAssessment of the pain showed overall VAS values of 2.2±2.8 on all occasions. Pain was reported to be of greatest intensity 20min after the patients’ arrival in the Post-Anaesthesia Recovery Unit (P<.001). The VAS values reported by the researcher (1.4±2.0) were lower than those reported by the patients. Although there was a very strong correlation (R2=0.82; P<.001) and they followed a parallel distribution, there was moderate concordance (kappa=0.4). Plastic surgery and neurosurgery were the specialties with the highest percentages of VAS values in the strong intensity range (8-10). Patients with regional block techniques (with or without general anaesthesia) had lower VAS values than other general anaesthesia groups. Male patients and older patients displayed less pain than female and young patients, respectively (P<.001). ConclusionsStudying the characteristics of postoperative pain at such an early stage allows for improved management. It helps to predict, according to the type of surgery and the anaesthesia used, those patients in which higher VAS values may be seen and to better adapt analgesic therapy.

Rethinking Perianesthesia Orientation

To discover the best orientation method for perianesthesia nurses. Pilot study comparing two approaches to orientation. Nurses in one group were each assigned to a single preceptor, whom they followed regardless of which of the three distinct areas-the preoperative unit, postanesthesia recovery unit, or Phase II discharge unit-the preceptor was scheduled to work. In the second group, trainees remained in one area, with various preceptors, until proficiency was achieved. All trainees (n = 25) were surveyed. New registered nurses in the perianesthesia department prefer to remain in a single area until competency is achieved. Perianesthesia nursing has a distinct body of knowledge. Although conventional wisdom suggests that using a single preceptor for nursing orientation leads to better outcomes, our study indicates that allowing orientees to remain in one area until a level of competency is achieved may be more effective.

Does the incidence of sore throat postoperatively increase with the use of a traditional intubation blade or the GlideScope?

Study ObjectiveThe GlideScope video-guided laryngoscope is an alternative standard of care for rescue laryngoscopies when direct laryngoscopy is unsuccessful. During postoperative checks by an anesthesiologist, it was noticed that patients who reported sore throat often required GlideScope laryngoscopy. Consequently, it is difficult to determine whether postoperative sore throats are caused by irritation inflicted by multiple laryngoscopic attempts or the actual utilization of the GlideScope itself. The goal of this study was to determine whether the use of the GlideScope leads to a greater or lesser incidence of sore throat when compared with traditional laryngoscope blades used for intubation. DesignEligible patients scheduled for elective inpatient surgeries requiring endotracheal tube intubation were enrolled into this single-blinded prospective cohort study. χ2 Test, Fisher exact test, and t tests were used to compare differences across the primary end point and other demographic categories. SettingOperating rooms and postanesthesia recovery unit, Albany Medical Center, Albany, NY. PatientsThere were a total of 151 patients with American Society of Anesthesiologists grades 1 to 3 included in the study. InterventionsEighty-one patients were randomized to a control group that received traditional laryngoscopy via Macintosh/Miller blades and 70 patients received video-guided intubation via the GlideScope. MeasurementsThe incidence of postoperative sore throat was recorded via a yes/no questionnaire within 24 hours after extubation. Secondary parameters such as provider type, sex, and perceived difficulty were also recorded. Main resultsThere was no significant difference in the proportion of patients reporting sore throat by type of blade used (Mac/Miller 36.3% vs GlideScope 32.4%, P = .619). For secondary outcomes, women were significantly more likely to report sore throat as compared with men (men 24.3% vs women 43.2%, P = .015), and the provider type was significantly associated with the occurrence of postoperative sore throat (attendings 26.8% vs certified registered nurse anesthetists 52.3% vs third-year clinical anesthesia residents 30%, P = .012). ConclusionsUse of the GlideScope videolaryngoscopy was not significantly associated with increased occurrence of postoperative sore throat when compared with traditional intubation techniques. Our results may enable more trainees to acquire intubation skills with the GlideScope during an initial intubation attempt in patients with American Society of Anesthesiologist grades 1 to 3, with optimization of patient satisfaction in respect to postoperative sore throats. In addition, a provider's choice of intubation technique based on either Macintosh/Miller blades or the GlideScope does not significantly impact a patient's risk of postoperative sore throat.

Neurological Emergencies in the Post-Operative Anesthesia Care Unit: Identification and Management

When neurological emergencies present themselves, they often appear in clinical symptoms that occur much earlier and serve as a precursor to the actual problem. However, in the Post Anesthesia Recovery Unit (PACU), these early symptoms are often masked by pre- and intra-operative medications and prolonged anesthesia. We identified a need to create a focused neuro assessment educational resource to educate experienced and novice nurses to accurately assess, identify, and address clinical signs of an early neurological emergency.

Opioid-related adverse effects in children undergoing surgery: unequal burden on younger girls with higher doses of opioids.

Unpredictable interindividual variability in response to opioids results in inadequate analgesia and opioid-related adverse effects. The effects of the child's sex on opioid response have not been well studied. The aim of this study is to determine the effects of sex on opioid-related adverse effects in children undergoing tonsillectomy. Prospective observational clinical study. Outpatient pediatric surgery. Two hundred and seventy five children between 6 and 15 years of age undergoing outpatient tonsillectomy. All children received standard perioperative care with a standard intraoperative dose of morphine. Opioid-related analgesia and safety outcomes included incidences of respiratory depression (RD), postoperative nausea and vomiting (PONV) and incidence of prolonged stay in the, post-anesthesia recovery unit (PACU) due to opioid related adverse effects. Given the small sample of minority population, we focused our study on 219 white children. Significant morphine effect was observed in girls but not boys for PONV (P = 0.001) and prolonged PACU stay due to PONV (P = 0.010). Although the overall incidence of RD is not statistically different between boys and girls, the incidence of RD (52% vs 32%) and PONV (43% vs 4%) tended to be more in white girls than boys as the total perioperative morphine dose increased to 0.3 mg/kg or more. This study demonstrates that child's sex influences morphine's dose response and adverse effects. White girls have an unequal burden with higher incidences of PONV, RD, and prolonged PACU stays following tonsillectomy from PONV and RD as total morphine doses are increased.

Introduction of enhanced recovery for elective caesarean section enabling next day discharge: a tertiary centre experience

BackgroundThe widespread adoption of enhanced recovery programmes in various surgical specialties has resulted in patient benefits including reduced morbidity, reduced length of stay and an earlier return to normal activities. This evidence, along with the increased financial pressures in the UK National Health Service, has led many units to consider introducing such a programme for obstetric surgery. We report our experience in setting up an enhanced recovery programme for women undergoing elective caesarean section and a prospective analysis of factors that influence length of stay. MethodsAn enhanced recovery pathway was designed by a multidisciplinary team and introduced in March 2012. Factors influencing length of stay were determined using a log normal model. ResultsThe proportion of women discharged on Day 1 increased from 1.6% in the first quarter of 2012 to 25.2% in the first quarter of 2014. The 30-day readmission rate was 4.4% for those discharged on Day 1 and 5.6% for Day 2. Earlier gestation, multiple birth, intention to breast feed, longer surgery and more time in the post-anaesthesia recovery unit were all independently associated with a longer postoperative stay. Women presenting for obstetric surgery with the indication “one previous caesarean section” were more likely to leave hospital earlier compared to most other indications. ConclusionAn enhanced recovery programme was successfully introduced into our unit. Many of the interventions were straightforward and could be adopted easily elsewhere.

Fast track anesthesia for liver transplantation: Review of the current practice.

Historically, patients undergoing liver transplantation were left intubated and extubated in the intensive care unit (ICU) after a period of recovery. Proponents of this practice argued that these patients were critically ill and need time to be properly optimized from a physiological and pain standpoint prior to extubation. Recently, there has been a growing movement toward early extubation in transplant centers worldwide. Initially fueled by research into early extubation following cardiac surgery, extubation in the operating room or soon after arrival to the ICU, has been shown to be safe with proper patient selection. Additionally, as experience at determining appropriate candidates has improved, some institutions have developed systems to allow select patients to bypass the ICU entirely and be admitted to the surgical ward after transplant. We discuss the history of early extubation and the arguments in favor and against fast track anesthesia. We also described our practice of fast track anesthesia at Mayo Clinic Florida, in which, we extubate approximately 60% of our patients in the operating room and send them to the surgical ward after a period of time in the post anesthesia recovery unit.

Perioperative management of patients with left ventricular assist devices undergoing noncardiac procedures: a survey of current practices.

To describe perioperative management of patients with left ventricular assist devices (LVAD) in noncardiac procedures. Survey of (1) respondent demographic characteristics, (2) anesthetic practices for LVAD patients having endoscopies, and (3) low-risk surgeries requiring general anesthesia. Internet-based. Society of Cardiovascular Anesthesiologists membership. None. Inpatient endoscopic procedures were done mainly in the endoscopy suite (71.7%) by a solo practitioner or 1:1 staffing ratio 59% of the time. LVAD-specific support personnel were present in more than 80% of all procedures. Both endoscopy and surgical patients used post-anesthesia recovery units and intensive care units for recovery; however, compared with endoscopy patients, surgical patients recovered in the ICU more frequently (45.5% v 29.1%, p<0.001). In addition, 18% of endoscopy patients recovered on site. Regarding patient monitoring, more than 90% of responders used electrocardiogram, pulse oximetry, end-tidal CO2, and blood pressure monitors on LVAD patients. Responders reported using arterial catheters to monitor blood pressure in 49% of endoscopy cases and 71% of surgical patients. The reported use of invasive monitors by individual clinicians was related inversely to institutional LVAD volume (p = 0.04 and p = 0.01 in endoscopy and surgical procedures, respectively). This survey found heterogeneity in hospital resource utilization for noncardiac LVAD procedures. There was a decrease in the use of invasive monitors with increased institutional LVAD volume in both endoscopy and surgical procedures.

Fluid prescription practices of anesthesiologists managing patients undergoing elective colonoscopy: an observational study.

BackgroundRoutine fluid prescription is common practice amongst anesthesiologists caring for patients undergoing colonoscopy. However there is limited information about routine procedural fluid prescription practices of anesthesiologists in this setting. Routine fluid administration may also have important pharmaco-economic implications for the health care budget. Therefore we performed a prospective observational study assessing the fluid prescription practices of anesthesiologists caring for patients undergoing elective colonoscopy.MethodsWith Institutional Review Board approval, adult patients receiving procedural fluid intervention during elective colonoscopy were included. Data collected: size of intravenous cannula inserted, volumes of fluid administered, adverse events, procedure duration, and pharmaco-economic costs associated with fluid prescription. Anesthesiologists and gastroenterologists were blinded to the study.ResultsWe collected data on 289 patients who received fluid prescription by their attending anesthesiologist. Median patient age: 48 yrs (range 18–83), gender: 174 (60%) female; median duration of procedure: 24 minutes (range 12–48). Cannula size: 181 (63%) patients received a 22G cannula or smaller. Median volume of fluid administered during the colonoscopy was 325 ml (range 0 to 1000 ml). Median duration of the procedure: 25 minutes (range 12 to 48 minutes). Median volume of fluid administered in the post anaesthesia recovery unit: 450 ml (range 0 to 1000 ml). Fifteen patients (5%) became hypotensive during the procedure and two patients (<1%) developed hypotension in the PACU. There was no difference in the median fluid requirements between patients with hypotension and those without. Fluid volumes were strongly associated with increasing cannula diameter (p = 0.0001), however there was no association between fluid volumes administered and vasopressor use, peri-procedural adverse events, or procedure duration. At our institution fluid therapy currently cost about AUD$4.90 per patient: 1 L crystalloid $1.18 and fluid delivery set $3.77 Our institution performs over 9000 endoscopic procedures annually with fluid therapy costing about $45,000/year.ConclusionsRoutine fluid prescription by anesthesiologists managing patients undergoing colonoscopy was ineffective with low actual fluid volumes delivered during the procedure. There was no association between volumes of fluid delivered and procedural hypotension, adverse events, or procedure duration. Anesthesiologists should question the clinical and pharmaco-economic value of routine fluid administration for patients undergoing elective endoscopy.

Cryotherapy with dynamic intermittent compression for analgesia after anterior cruciate ligament reconstruction. Preliminary study

BackgroundCryotherapy is a useful adjunctive analgesic measure in patients with postoperative pain following anterior cruciate ligament (ACL) surgery. Either static permanent compression or dynamic intermittent compression can be added to increase the analgesic effect of cryotherapy. Our objective was to compare the efficacy of these two compression modalities combined with cryotherapy in relieving postoperative pain and restoring range of knee motion after ligament reconstruction surgery. HypothesisWhen combined with cryotherapy, a dynamic and intermittent compression is associated with decreased analgesic drug requirements, less postoperative pain, and better range of knee motion compared to static compression. Materials and methodsWe conducted a case-control study of consecutive patients who underwent anterior cruciate ligament reconstruction at a single institution over a 3-month period. Both groups received the same analgesic drug protocol. One group was managed with cryotherapy and dynamic intermittent compression (Game Ready®) and the other with cryotherapy and static compression (IceBand®). ResultsOf 39 patients, 20 received dynamic and 19 static compression. In the post-anaesthesia recovery unit, the mean visual analogue scale (VAS) pain score was 2.4 (range, 0–6) with dynamic compression and 2.7 (0–7) with static compression (P=0.3); corresponding values were 1.85 (0–9) vs. 3 (0–8) (P=0.16) after 6hours and 0.6 (0–3) vs. 1.14 (0–3) (P=0.12) at discharge. The cumulative mean tramadol dose per patient was 57.5mg (0–200mg) with dynamic compression and 128.6mg (0–250mg) with static compression (P=0.023); corresponding values for morphine were 0mg vs. 1.14mg (0–8mg) (P<0.05). Mean range of knee flexion at discharge was 90.5° (80°–100°) with dynamic compression and 84.5° (75°–90°) with static compression (P=0.0015). ConclusionDynamic intermittent compression combined with cryotherapy decreases analgesic drug requirements after ACL reconstruction and improves the postoperative recovery of range of knee motion. Level of evidenceLevel III, case-control study.

Genetics of Pain Perception, COMT and Postoperative Pain Management in Children

Effective perioperative analgesia is lacking for children owing to interindividual variations and underdosing of opioids caused by fear of adverse effects. We investigated the role of COMT SNPs on postoperative pain management in children. One hundred and forty nine children undergoing adenotonsillectomy were enrolled. The associations of four COMT SNPs (rs6269, rs4633, rs4818 and rs4680) with postoperative pain were analyzed and outcome measures included maximum pain scores, need for postoperative opioid interventions and postoperative morphine requirements. We detected an association of postoperative opioid intervention need with all four COMT SNPs. Minor allele carriers of COMT SNPs were approximately three-times more likely to require analgesic interventions than homozygotes of major alleles (p-value range: 0.0031-0.0127; odds ratio range: 2.6-3.1). In addition, significant association was detected between maximum Face, Leg, Activity, Consolability, Cry (FLACC) pain scores and three COMT SNPs (rs6269, rs4633 and rs4680). Haplotype 1 (ATCA: 51.3%) and Haplotype 2 (GCGG: 36.2%) are more frequent. Haplotype 2 was associated with higher odds of intravenous analgesic intervention need in postanesthesia recovery unit with an odds ratio of 2.6 (95% CI: 1.2-5.4; p-value = 0.022). COMT SNPs may play a significant role in interindividual variation in postoperative pain perception and postoperative morphine requirements in children. Original submitted 16 August 2013; Revision submitted 13 December 2013.