Postanesthesia Discharge Scoring Research Articles

Development and Validation of a Discharge Assessment Scale for Outpatients Undergoing Sedative Anesthesia in the Ambulatory Postanesthesia Care Unit: A Comprehensive Delphi Study

PurposeThe purpose of this study was to develop a discharge assessment scale tailored for outpatients undergoing sedative anesthesia treatment in the ambulatory postanesthesia care unit and validate its agreement with the Post-Anesthetic Discharge Scoring System. DesignThe Delphi method. MethodsA Delphi survey was conducted with 30 experts focusing on the evaluation of outpatient discharges following treatment under ambulatory anesthesia. Subsequently, a cross-sectional observational study employing convenience sampling selected 2,579 outpatients who had undergone painless ambulatory gastrointestinal endoscopy at a tertiary hospital to analyze the level of agreement with the Post-Anesthesia Discharge Scoring System. FindingsThe study conducted three rounds of expert consultations to create the ambulatory discharge assessment scale. Twenty-five experts from 12 provinces and municipalities in our country were interviewed. The discharge assessment form encompassed five aspects: consciousness level, vital signs, directional stability, mobility, and adverse reactions. According to the scale, if the total score exceeded 9 points, with none of the items scoring 0 points, the ambulatory patient could be discharged from the hospital with the accompaniment of family members. Patients assessed using this newly constructed scale were able to leave the hospital earlier compared to those assessed using the comparative scale. No significant differences were observed in vital signs at the time of discharge or the occurrence of adverse events within 24 hours after the procedure. ConclusionsThis assessment tool for discharging ambulatory patients after the ambulatory anesthesia from the postanesthesia outpatient care unit can be considered a valuable addition to formalize the discharge process in outpatient services.

The Difference in Time to Discharge Between Daytime and Nighttime Administration of Ketamine in Children.

The objective of this study was to compare the time to discharge between daytime and nighttime ketamine administration to children undergoing primary facial repair in the emergency department (ED). This retrospective, cross-sectional study was performed in a sample of children aged younger than 18 years and requiring sedation for primary facial repair in 2019. Children who received ketamine for reasons other than facial repair were excluded. All patients were initially injected with 4 mg/kg of ketamine intramuscularly and additionally injected if sedation failed. The time of injection and awakening were recorded in the electronic medical record system by nurses in charge, and the level of wakefulness was determined with a postanesthesia discharge scoring system administered by physicians. A total of 562 cases of ketamine administration were divided into 2 groups: daytime and nighttime. We defined daytime and nighttime as 8 a.m. and 8 p.m./sunrise and sunset, respectively. They found that there were no significant differences between 2 groups in each standard (95% confidence interval, -4.55-4.55; P = 0.877 and 95% confidence interval, -6.41-2.41; P = 0.487, respectively). The findings of the study suggest that the time of ketamine injection has no relationship to duration of sedation for primary facial repair in children.

Patient Comfort During Postop Period in Breast Cancer Surgeries: A Randomized Controlled Trial Comparing Opioid and Opioid-Free Anesthesia.

Anesthetic management practices have advanced to opioid-free anesthesia (OFA) often replacing opioids in oncologic surgeries. The study was conducted to find the quality of recovery (QoR) of patients undergoing breast cancer surgeries receiving OFA. A double-blinded, randomized controlled study was conducted with 60 patients randomized to group OFA and group OA (opioid anesthesia). Group OFA received one-time dosing of ketamine 0.3 mg/kg, lignocaine 1.5 mg/kg, and dexmedetomidine 1 mcg/kg. Group OA received fentanyl 2mcg/kg. Intraoperatively, Group OFA received dexmedetomidine 0.4 mcg/kg/h and theOA group received fentanyl 0.5 mcg/kg/h infusion.Bispectral index (BIS), hemodynamics, muscle relaxant administration, and sevoflurane concentration were noted. A modified QoR-40 score was used to assess the quality of recovery in the postoperative period. A higher QoR-40 score was found in the OA group (median 182, IQR 178-186) compared to the OFA group (median 180, IQR 178-184). Out of the five components, the patient's emotional state was better in the group OA (39.9±2.77) than in the OFA group (37.9±2.77). The patient's physical comfort was found to be better in the group OFA (52.52±3.23) compared to group OA (50.93±3.23). Physical independence, psychological support, and pain were comparable between the two groups. Patients in group OFA received less sevoflurane, a muscle relaxant, and showed a mild reduction in heart rate and mean arterial pressure (MAP) when compared to group OA. The time taken to reach a Modified Aldrete score of 9 was high in OFA (11.47±2.16) and (9.17±1.09) when compared to group OA. No significant differences were noted with the visual analog score (VAS) score, Ramsay sedation score, and modified post-anesthesia discharge scoring system (PADSS) score. We conclude that the quality of recovery of patients receiving opioid-free methods of anesthesia was not inferior to OA in patients undergoing breast cancer surgeries.

Spinal Anaesthesia for Ambulatory Perianal Surgeries: A Comparison between Short Acting and Long Acting Local Anaesthetics

Introduction: Chloroprocaine (ester group) is a preservativefree local anaesthetic which is available as isobaric solution. It is being recently popularised in spinal anaesthesia for its shorter duration of action which plays a significant role in the early ambulation and voiding functions, which is the primary essence in ambulatory surgery. Intrathecal Bupivacaine is the most commonly used drug for its block characteristics, taking into account not only the fast initiation of sensory and motor blockade but also faster sensory and motor regression. Aim: To compare the block characteristics between 1% Chloroprocaine and 0.5% Bupivacaine in patients undergoing perianal surgeries under spinal anaesthesia. Materials and Methods: This randomised, interventional double blinded study was carried out in Chettinad Hospital and Research Institute, Kelambakkam, Chennai, Tamil Nadu, India, from April 2020 to August 2021. The patients were split into two groups of 34 each. Group-1: Patients received 30 mg of 1% Chloroprocaine intrathecally. Group-2: Patients received 10 mg of 0.5% Bupivacaine intrathecally. In both the groups the onset, duration of both sensory and motor blocks, intraoperative haemodynamic, two segment regression time, time to ambulation and micturition, the time to eligibility for discharge from hospital was evaluated. Independent sample t-test, chi-square test and Fisher’s-Exact test were employed to compare the distribution of qualitative variables between the groups. Results: Total of 68 participants 31 (45.6%) males and 37 (54.4%) females), 34 in each group 1 and group 2 were analysed. Both groups contained maximum patients in >45 years age group, 12 (35.2%) in each group. Demographic and anthropometric parameters of patients in both the groups were comparable. Mean time of ambulation after spinal anaesthesia in the Group-1 was 137.65±9.15 minutes and in Group-2 was 193.38±8.14 minutes (p-value <0.05). Mean time taken to return of voiding function the Group-1 was 157.06±16.05 minutes and in Group-2 was 213.53±10.26 minutes (p-value <0.05). Mean time taken for Post-Anaesthetic Discharge Scoring System (PADSS) score >9 in Group-1 was significantly less (165.29±13.59 minutes) than Group-2 (219.41±9.52 minutes). Mean time duration for request of first rescue analgesic in Group-1 was significantly faster (104.71±8.69 minutes) than Group-2 (157.79±8.81 minutes). There was no significant difference in haemodynamic changes between the study groups. Conclusion: Chloroprocaine has proved to be better than bupivacaine. It has proven to provide adequate surgical anaesthesia, it leads to early regression of motor and sensory blocks, faster un-assisted ambulation and micturition. Time to rescue analgesia was earlier in the Group-1 when compared to Group-2.

Risk factors for patient selection in ambulatory laparoscopic cholecystectomy: A Single-centre experience.

Backgrounds:Ambulatory laparoscopic cholecystectomy (LC) reduces healthcare cost and increases hospital bed capacity. Currently, there is no consensus on patient selection for ambulatory LC. Evaluation of risk factors for ambulatory discharge is essential.Materials and Methods:Consecutive patients who underwent LC in our centre throughout 2019 were collected. We evaluated the discharge fitness using the Post-Anaesthetic Discharge Scoring System at 8 h after the operation. The relations between pre-operative variables and dischargeable possibilities were analysed for screening risk factors. Furthermore, we performed a literature review to summarise all published information.Results:Six hundred and forty-one cases were included in this study. American Society of Anaesthesiologist (ASA) grading (odds ratio OR = 0.415, P = 0.001) and leucocytes (OR = 0.80, P < 0.001) significantly predicted the fitness of discharge. ASA contributed to lower activity (P = 0.002) and intake/output (P = 0.006) scores. Leucocytes influence the vital sign (P < 0.001) and pain or post-operative nausea and vomiting (PONV) (P < 0.001) scores. The prolonged operation could predict the inabilities of discharge with a cut-off value of 55 min by dropping vital signs (P = 0.011), activity (P < 0.001) and pain or PONV (P = 0.012) scores. Male sex (OR: 1.702, P = 0.010), body mass index (BMI) (OR: 1.087, P = 0.008), leucocytes (OR: 1.075, P = 0.017) and C-reactive protein (CRP) (OR: 1.018, P = 0.003) were predictors for prolonged operation (>55 min).Conclusions:We suggest that pre-operative ASA grading III and leucocytes are risk factors for the fitness of ambulatory discharge after LC and intraoperative time. Male, BMI and CRP predict complicated surgery, and they should be considered preoperatively.

Ambulatory robot-assisted laparoscopic radical prostatectomy with extended recovery by total extraperitoneal approach.

To evaluate the feasibility of performing robot-assisted laparoscopic radical prostatectomy in an ambulatory with extended recovery setting by using a total extraperitoneal approach. Patients with low- to intermediate-risk, prostate cancer were prospectively recruited in the ambulatory robot-assisted laparoscopic radical prostatectomy with extended recovery by total extraperitoneal approach group (n=30), and a matched-pair inpatient surgery control group by total extraperitoneal approach (n=20). Objective discharge criteria were based on the postanesthesia discharge scoring system. All patients underwent preoperative counseling on preoperative preparation and postoperative care. There were no statistically significant differences between the ambulatory with extended recovery-total extraperitoneal approach and inpatient-total extraperitoneal approach groups in patient factors (age, body mass index, American Society of Anesthesiologists score, Charlson Comorbidity Index), disease factors (prostate-specific antigen, clinical Tstage, biopsy Gleason score, prostate volume) and peri-operative parameters (operative time, blood loss, Trendelenburg angle). All total extraperitoneal robot-assisted laparoscopic radical prostatectomy patients (ambulatory with extended recovery and inpatient surgery groups) met the postanesthesia discharge scoring system discharge criteria ≤23h from admission. The mean hospital stays for ambulatory with extended recovery-total extraperitoneal and inpatient-total extraperitoneal groups were 20.3 and 52.4h, respectively (P<0.001). A total of 29 of 30 patients (97%) in the ambulatory with extended recovery-total extraperitoneal group were discharged ≤23h of admission. This is the first prospective evaluation of robot-assisted laparoscopic radical prostatectomy by the total extraperitoneal approach, showing that the short-stay ambulatory with extended recovery approach is safe, feasible and with a high success rate. Total extraperitoneal surgical approach is a critical factor for the success of the ambulatory with extended recovery protocol.

Computerized 4-choice reaction time test for the measurement of psychomotor recovery after general anesthesia.

The recovery of patients after general anesthesia is usually estimated by using clinical scores. Since there is a lack of objective methods for assessing psychomotor recovery, the aim of this study was to evaluate three psychological tests for this purpose. Patients, scheduled for ambulatory gynecological surgery, underwent 3 standard psychological tests before (T1), 15min after the surgery (T2) and on discharge from the recovery room (T3). The tests used were Wechsler memory scale (test 1, working memory capacity), d2-test (test 2, concentration endurance) and computer-based 4-choice-reaction time (4CRT, test 3, reaction time) as well as Postanesthesia Discharge Scoring System (PADSS). The same test battery was used in healthy female volunteers, all test results were compared at the different time points. In 109 patients, working memory capacity and concentration (tests 1 and 2) decreased, the reaction time (test 3) was prolonged at T2 in comparison with T1 and T3 (P < 0.01). PADSS increased from 8 (T2) to 10 (T3) (medians, P < 0.001). Fifty-seven healthy volunteers demonstrated a practice effect in all 3 tests through the course of the study (P <0.01). 4CRT test had shortest duration and enabled computerized data processing. All three tests objectively assess the recovery of psychomotor function in patients after general anesthesia, the computer-based 4CRT seems to be the most convenient for the clinical routine.

Deep Sedation or Paracervical Block for Daycare Gynecological Procedures: A Prospective, Comparative Study.

Context:Many minor gynecological procedures are done for diagnostic and therapeutic reasons. A balance has to be struck between ability to discharge a patient at the earliest with minimum procedure-related discomfort to ensure patient safety as well as satisfaction.Aim:This prospective randomized study was designed to compare deep sedation versus paracervical block for minor gynecological surgeries comparing the time to discharge readiness, pain after the procedure, and overall patient satisfaction.Setting and Design:This prospective randomized comparative study was conducted at a tertiary level hospital after institutional ethics committee approval and registry of trial at CTRI (India).Methods:Seventy young women underwent minor gynecological procedures under these two modes of anesthesia. Time to discharge readiness from hospital to home was assessed using modified postanesthesia discharge score system (PADSS). Pain after procedure as well as patient satisfaction was evaluated. Patients were also asked whether they would recommend the same anesthetic technique for the procedure in the future. Answers were noted on a Likert scale.Results:Patients were ready to be discharged faster in deep sedation group compared to paracervical block group based upon modified PADSS score (1 h 9.6 min vs. 1 h 18 min) (P = 0.005). Pain in the perioperative period was analyzed using repeated-measures ANOVA and found to be significantly lesser in deep sedation group when considered till 80 min after surgery. The mean satisfaction score in patients who underwent deep sedation was 91.24 (standard deviation [SD] 2.8) compared to patients given paracervical block which was low at 64.67 (SD 15.8). All patients given deep sedation were ready to recommend the anesthesia technique as compared to only 53.3% of patients who were given paracervical block.Conclusions:Deep sedation may be preferred over paracervical block for daycare minor gynecological procedures.

Readiness for Discharge After F&amp;A Surgery Using Peripheral Nerve Blocks

Category: Other Introduction/Purpose: Neuraxial anesthesia is often viewed as superior to general anesthesia (GA), but there are concerns that it may prolong length of stay (LOS). Most studies comparing the two anesthesias were performed in the absence of peripheral nerve blocks (PNBs), which when used as an analgesic adjunct may overcome the associated negative side effects of GA and allow decreased LOS. We hypothesized that patients given PNBs and GA would be discharged sooner than patients given PNBs and spinal anesthesia plus sedation, without increased incidence of adverse side effects such as pain, opioid administration and nausea. Methods: A single-center triple-blinded randomized controlled trial of 36 consecutive patients receiving elective F&amp;A surgery predicted to take 1-3 hours under planned PNB with either spinal or GA was performed (see table 1. for demographics).The primary outcome was time to meet criteria for home discharge. The a priori clinically relevant difference with 80% power was determined to be 45 minutes. Patients were assessed after admission to the PACU and at 15-minute intervals thereafter. Once an Aldrete score=9 (scale signifying patient no longer needs intensive monitoring) was obtained, patients were transferred to Phase II and assessed until the post anesthesia discharge scoring system, a home readiness scale, was =9. Actual time to discharge was also recorded.Additional outcomes included a series of baseline characterizations which were assessed pre-and post-operatively, and again during Phase II.The primary outcome was compared using multivariable unconditional quantile regression. Various regressions were performed on secondary outcomes. Results: After adjustment for age and surgical duration, patients given GA plus PNB were ready for discharge from PACU 39 minutes prior to patients given neuraxial anesthesia plus PNB, but this difference did not reach the clinically relevant a priori selected difference of 45 minutes (Table 1). However, the adjusted median time to meet ambulation discharge criteria was 52 minutes fewer (p = 0.003) (Table 1). Patients met discharge criteria substantially sooner than their time until actual discharge which was not different between groups (Table 1). Pain scores at rest were higher among GA patients at 1 hour in the PACU (adjusted difference in means [95% CI]: 2.1 [1.0, 3.2], p &lt; 0.001). Subsequent pain scores and all other secondary outcomes were not different. Conclusion: GA with PNB patients were ready for discharge 39 minutes earlier, but that difference may not be clinically significant. Although patients met criteria for discharge sooner due to a significantly more rapid ability to ambulate, they were not discharged sooner because PACU staff was not acclimated to the earlier readiness and so did not push for earlier discharge. These findings suggest that GA plus PNB leads to earlier discharge with similar side effects as spinal plus PNB. Therefore, the use of GA with PNB for foot and ankle surgeries could save the hospital and the patient time and resources.

Comparison of propofol alone and in combination with ketamine or fentanyl for sedation in endoscopic ultrasonography

BackgroundWe evaluated whether the addition of a small dose of ketamine or fentanyl would lead to a reduction in the total dose of propofol consumed without compromising the safety and recovery of patients having endoscopic ultrasonography (EUS).MethodsA total of 210 adult patients undergoing elective EUS under sedation were included in the study. Patients were randomized into three groups. Patients were premedicated intravenously with normal saline in group 1, 50 µg fentanyl in group 2, and 0.5 mg/kg ketamine in group 3. All patients received intravenous propofol for sedation. Propofol consumption in mg/kg/h was noted. The incidence of hypotension, bradycardia, desaturation, and coughing was noted. The time to achieve a Post Anesthesia Discharge Score (PADS) of 10 was also noted.ResultsThere were 68 patients in group 1, 70 in group 2, and 72 in group 3. The amount of propofol consumed was significantly higher in group 1 (9.25 [7.3–13.2]) than in group 2 (8.8 [6.8–12.2]) and group 3 (7.6 [5.7–9.8]). Patient hemodynamics and oxygenation were well maintained and comparable in all groups. The time to achieve a PADS of 10 was significantly higher in group 3 compared to the other two groups.ConclusionsThe use of 50 µg fentanyl or 0.5 mg/kg ketamine in a single dose during EUS reduces the dose of propofol required for sedation. However, unlike the addition of fentanyl, the addition of ketamine increased the time to recovery. Thus, 50 µg fentanyl is a good additive to propofol infusion for sedation during EUS to reduce the requirement for propofol without affecting the time to recovery.

Novel anesthetic technique for combined intracavitary and interstitial brachytherapy for cervix cancer in an outpatient setting.

PurposeTo determine the feasibility and safety of outpatient combined intracavitary and interstitial brachytherapy for cervix cancer with sedation and local anesthesia.Material and methodsWe included patients diagnosed with non-metastatic cervix cancer and have completed brachytherapy between December 2015 and December 2016. Moderate to deep sedation was achieved using intravenous midazolam, propofol, fentanyl, and oxycodone. Local anesthesia was achieved with 2% lignocaine gel and a paracervical block containing a mixture of 1% ropivacaine, 2% lignocaine, and 1 : 1,000 adrenaline. Ceftriaxone and ondansetron were given prophylactically. Physiologic monitoring was performed throughout and pain scores were recorded using the Numeric Rating Scale. Follow-up was conducted at 8 weeks from the last fraction of brachytherapy. The feasibility and safety endpoints were a post-anesthesia discharge score (PADS) of 9 or above, and no grade 3 or above adverse events, respectively.ResultsA total of thirty-five brachytherapy insertions were carried out on nine patients. The median age of the patients was 56 years (range, 40-65). Eight patients had American Society of Anesthesiologists’ physical status of I or II, and one had a status of III. The mean duration of the insertion was 39 minutes (standard deviation [SD] = 14), during which no adverse events occurred. There was no significant nausea or vomiting post-sedation. The median pain scores post-insertion and during recovery were 0 (range, 0-6) and 0 (range, 0-7), respectively. At discharge, all patients had pain scores of 0 and maximum PADS of 10. The mean time to discharge was 4.1 hours (SD = 0.95). There were no brachytherapy-related admissions or complications.ConclusionsOutpatient combined intracavitary and interstitial brachytherapy for cervix cancer with sedation and local anesthesia is feasible and safe. This could potentially lead to significant cost savings.

Percutaneous Nephrolithotomy under Thoracic Paravertebral Block: A Preliminary Report

Background: The second look percutaneous nephrolithotomy (PCNL) is usually done under general anesthesia. Thoracic paravertebral block has been shown to provide sufficient postoperative analgesia for a variety of thoracic and upper abdominal surgeries. Objectives: We propose a case series study for performing the second look PCNL under paravertebral block (PVB) and conscious sedation using dexmedetomidine. Methods: 33 patients scheduled for second look PCNL received PVB at the level of T 11, 15 ml of 0.5 % of bupivacaine was injected under ultrasonographic guidance. During the procedure, the patients received conscious sedation with dexmedetomidine (initial infusion of 1 μg/kg/h, followed by a maintenance infusion of 0.2 μg/kg/h). We measured the rate of success of the anesthetic technique, the level of sedation and hemodynamics. The time to complete recovery using (MPADSS), postoperative paracetamol consumption and postoperative intensity of pain using VAS. Results: the anesthetic technique was satisfactory in 30 patients. The median (IQ) patient’s satisfaction with the anesthetic technique was 6 (6:7). The median (IQ) surgeon’s satisfaction with the anesthetic technique was 7 (6:7). Complete recovery from sedation using the modified post anesthesia discharge scoring system (time to score 10) was achieved within 40 (30:52.5) min. The mean MAP and heart rate were significantly decreased in comparison to baseline value. Conclusion: We concluded that the anesthetic technique with PVB and conscious sedation with dexmedetomidine for patients undergoing second look PCN provided sufficient sedation, adequate analgesia, minimal side effects, and rapid recovery.

A comparison of dexmedetomidine with propofol versus esmolol with propofol to attenuate the hemodynamic stress responses after electroconvulsive therapy

Background:Modified electroconvulsive therapy (ECT) under anesthesia is an important modality in the treatment of severe, persistent depression; bipolar disorder and schizophrenia; especially in cases resistant to pharmacologic therapy.Aim:The aim of the present study is to compare the effects of dexmedetomidine and esmolol on patients' hemodynamics, motor seizure duration, and recovery times following ECT.Materials and Methods:Ninety cases aged between 18 and 50 years of the American Society of Anesthesiologists grade I and II; were randomly divided into three groups of 30 each. Group A received normal saline (placebo), Group B received dexmedetomidine 1 μg/kg, and Group C received esmolol 1 mg/kg; followed by induction with propofol 1 mg/kg and muscle relaxation with succinylcholine 0.75 mg/kg. Hemodynamic parameters at baseline, after study drug infusion, after induction, and after ECT application were recorded at different time intervals. The motor seizure duration using arm isolation method and recovery times using postanesthesia discharge scoring system were noted.Results:The maximum increase in hemodynamic parameters was seen following the ECT current application. Post-ECT rise in mean arterial blood pressure and heart rate in dexmedetomidine group was significantly less as compared to esmolol and control group at 2, 4, 6, and 8 min using unpaired t-test. There was no significant difference in motor seizure activity duration, emergence, and recovery times among the three groups.Conclusions:Both dexmedetomidine and esmolol attenuate the hyperdynamic response to ECT without affecting the seizure duration, but dexmedetomidine has a more favorable response in view of stable vitals, smooth emergence and no adverse effect on recovery duration.

Randomized Comparison of Isoflurane versus Sevoflurane and Desflurane for Maintenance of Ambulatory Anesthesia.

Background:Ambulatory surgeries demand safe anesthesia with faster recovery which makes it expensive due to the cost of inhalational anesthetic agents such as sevoflurane and desflurane. Isoflurane is inexpensive agent but can cause delayed recovery. The aim of this study was to evaluate cost-benefit ratio of all three agent with respect to recovery and safety profileMaterials and Methods:Patients posted for elective ambulatory surgeries were divided into three groups. Suitable size laryngeal mask airway was inserted following induction with propofol and vecuronium. Anesthesia was maintained on low-flow anesthesia with inhalational agent as isoflurane for Group I, sevoflurane for Group II and Group III received desflurane. Patients were monitored for recovery as per modified Aldrete score and as per postanesthesia discharge scoring system for discharge from hospital. Cost analysis was done by Dion's formula. Statistical analysis was done with analysis of variance for recovery profile, Chi-square test for safety profile and Kruskal Wallis test for cost comparison between groups.Results:Patient characteristics and duration of anesthesia were similar in all three groups. Time to eye-opening was significantly less with desflurane than sevoflurane and isoflurane (P = 0.001). Time to home readiness was similar in all three groups (P = 0.451). The incidence of airway irritation, pain, and nausea/vomiting was similar in all three groups. Cost of Group I was statistically lower than other two groups (P = 0.00).Conclusion:Home readiness and safety profile were comparable between agents; the cost involved was the least with isoflurane.

Application of Discharge Criteria for Home Readiness Using Bispectral and Supraglottic Airway Devices in Day-care Surgery without Using Muscle Relaxants.

Introduction:The availability of rapid and short-acting intravenous and volatile anesthetics has facilitated early recovery that is why nowadays ambulatory surgery is becoming more common. If the criteria used to discharge patients from the Postanesthesia Care Unit (PACU) are met in the operating room (OR), it would be appropriate to consider bypassing the PACU and transferring the patient directly to the step-down unit. This process is known as “fast-tracking” after ambulatory surgery.Aims:To compare hemodynamic characteristics and recovery profile as per fast-track criteria (FTC) of recovery and postanesthesia discharge scoring system (PADSS) between sevoflurane and desflurane.Materials and Methods:One hundred American Society of Anesthesiologists Class I–II patients aged 20–50 years were randomly divided into two groups. Following anesthesia induction with injection propofol and injection dexmedetomidine airway was secured with i-gel, Group D (n = 50) received desflurane + dexmedetomidine + O2 + N2O and Group S (n = 50) received sevoflurane in place of desflurane. Emergence time was noted and FTC was evaluated in the OR, Score >12 is considered as shifting criteria for ambulatory surgery unit (ASU). PADSS was noted in ASU at an interval of 15 min for 3 h and Score >9 is considered as ready to discharge home.Results:Response to pain, verbal commands, and spontaneous eye opening in Group D was shorter than that in Group S (P = 0.001). Mean time to achieve FTC score >12 was 15 min in both the groups. Eighty-six percent of patients were ready to go home between 60 and 90 min using PADSS.Conclusion:We concluded that early recovery is faster for desflurane, and there is no difference in ready to go home time between desflurane and sevoflurane.

COMPARATIVE STUDY BETWEEN KETOFOL VERSUS PROPOFOL ANESTHESIA FOR UTERINE CERVICAL DILATION AND CURRETTAGE

Background: Ketofol (propofol-ketamine admixture) is used to compensate the hemodynamic chanages due to an induction of anesthesia. Uterine cervical dilation and curettage is a common procedure in day- care surgery. Objective: Comparing the effectiveness of sub-dissociative dose of Ketamine ,in ketofol [group -I]on intraoperative hemodynamic stability, O2%, pain ,anesthesia loading dose- verbal response time , incremental anesthesia ,last dose – verbal response time , surgeon's satisfaction and patient's satisfaction versus propofol alone [group-II]. Patients and method: Two hundred females, ASA I & II scheduled for uterine cervical dilation and curettage, were assigned to I or II groups. Intra-operatively the heart rate, non invasive blood pressure and O2% were monitored and recorded at baseline time, 5th, 10th, 15th and 20th minutes. In recovery room, the pain was assesed by visual analogue scale and the patient's and surgeon's satisfactions were assesed and discharge criteria by Aldrete scoring system and post anesthesia discharge scoring system. Results: The demographic characteristics, the duration of surgical procedure, and anesthesia loading dose - verbal response time showed no statistical difference, but incremental dose - verbal response time was significantly longer in group-I than group-II. Hemodynamic stability statistically had showed no significant differences. The ASS and PDSS were significantly higher in group-II than group-I at 5th but insignificant and equal at 10th minute. Pain was significantly lower in the group-I at 5th and 10th minutes than group-II. Conclusion: The combination of propofol and sub-dissociate dose of Ketamine [Ketofol] was superior to Propofol alone and provided adequate sedation and analgesia for brief painful procedures.

Editorial introductions

Editorial introductions

Evaluation of the pediatric post anesthesia discharge scoring system in an ambulatory surgery unit.

To optimize the care pathway for children scheduled for ambulatory surgery, a pediatric postanesthetic discharge scoring system (Ped-PADSS) was developed from a score used in adults. The objective of this study was to evaluate this score prospectively on a cohort of children who had a day case surgical procedure. This was a single center prospective observational study. Inclusion criteria were predefined as follows: children aged 6months-16years at the time of the study, with a scheduled day surgery. Discharge was validated by Ped-PADSS scores ≥9, obtained at one hour intervals, after the return from the operating room and with the agreement of the surgeon. The duration of postoperative hospitalization was compared with data collected before the implementation of the score using the Student's t-test. From February to July 2012, 1060 children were included. One hour after the return from the operating room, 97.2% of children were dischargeable using Ped-PADSS. Two hours after the return from the operating room, 99.8% of children were dischargeable. The median postoperative hospital stay (n=1041) was reduced by 69min compared to the median stay before using the output score (n=150) (P<0.01). The Ped-PADSS score allows for the majority of children to be discharged 1h after their return from the postanesthesia care unit. Children who were discharged using the Ped-PADSS score returned home in safe and optimal conditions.

Reliability of the surgical Pleth index for assessment of postoperative pain: a pilot study.

Postoperative pain control is essential and may have a beneficial effect on postoperative outcome and morbidity. Analgesia quality is controlled using tools such as a Numerical Rating Scale (NRS). These tools require cooperation and often fail in the presence of reduced awareness. The Surgical Pleth index (SPI) has been introduced as a monitoring tool for intraoperative pain under general anaesthesia. We investigated the correlation between SPI and pain intensity, analgesic consumption and fitness for discharge in the postanaesthesia care unit. An observational study. The central postanaesthesia care unit of our tertiary care hospital. Written informed consent was obtained from 100 patients scheduled for elective surgery under general anaesthesia. Patients below the age of 18 years and those with an abnormal cardiac rhythm were excluded from the study. Patients were interviewed every 10 min for 2 h. Pain intensity measured by NRS, discomfort and Aldrete and Post-Anaesthetic Discharge Scoring System (PADSS) scores were noted. SPI and total dose of opioids administered were recorded. A total of 1300 pain measurements were recorded; 482 (37%) reflected no or mild pain (NRS 0 to 3), 532 (41%) moderate pain (NRS 4 to 6) and 286 (22%) severe pain (NRS 7 to 10). Both NRS (r = 0.62, P < 0.001) and SPI (r = 0.38, P < 0.001) correlated significantly with total opioid consumption. SPI showed a moderate correlation with NRS (r = 0.49, P < 0.001). Receiver operating characteristic analysis showed moderate sensitivity and specificity for discrimination between low and moderate pain (NRS ≤3) (sensitivity 67%, specificity 69% for SPI ≤45), and between moderate and severe pain (NRS >6) (sensitivity 72%, specificity 72% for SPI ≥57). SPI and NRS showed weak negative correlations with Aldrete and PADSS scores. Sensitivity and specificity of SPI to discriminate between low, moderate and severe pain levels was moderate. Both NRS and SPI correlated significantly with total opioid consumption.

Intrathecal Hyperbaric Ropivacaine for Day Case Pelvic, Perineal and Lower Limb Surgeries – A Prospective Study

Background: The rationale of this study was to evaluate the efficacy of intrathecal hyperbaric ropivacaine for day case pelvic, perenial and lower limb surgeries. Methods: Seventy ASA physical status I-II patients undergoing the above mentioned surgeries were enrolled for the study. Hyperbaric ropivacaine in a dose of 15 mg was injected intrathecally in each of the patients. The primary outcome variables of the study were- duration of sensory and motor block. Secondary outcome variables were- time for onset of sensory block to T10 dermatomal level and motor block to Bromage Score 3, maximum spread of sensory block, time to reach maximum sensory level, quality of intraoperative analgesia and muscle relaxation, time to mobilize, time to spontaneous voiding and side effects. Results: The mean time for onset of sensory block to T10 dermatome level and motor block to Bromage Score 3 were 3.25 + 0.84 mins and 5.12 + 0.76 mins respectively. The median value of HSL was T5 (T4 - T6) and mean time to reach HSL was 9.08 + 1.05 mins. The total duration of sensory and motor block (mean) were 132.22 + 8.44 mins and 104 + 8.56 mins respectively. The time needed to mobilize the patients and spontaneous voiding (mean) were 206 + 9.26 and 230 + 10.33 mins respectively. Based on Modified Postanesthesia Discharge Scoring System (PADS) in addition to spontaneous micturition, 61 (87.14%) patients were discharged on the same day of operation. Conclusion: Results have demonstrated that 15 mg of hyperbaric ropivacaine when injected intrathecally is sufficient to produce anesthesia for day case pelvic, perineal and lower limb surgeries. Keywords: intrathecal, ropivacaine, day case surgery, Modified Postanesthesia Discharge Scoring System (PADS)