Postoperative Recovery Profile Research Articles

Tramadol vs dexmedetomidine for emergence agitation control in pediatric patients undergoing adenotonsillectomy with sevoflurane anesthesia: prospective randomized controlled clinical study

BackgroundThis study was designed to compare the efficacy of an intraoperative single dose administration of tramadol and dexmedetomidine on hemodynamics and postoperative recovery profile including pain, sedation, emerge reactions in pediatric patients undergoing adenotonsillectomy with sevoflurane anesthesia.MethodsSeventy-seven patient, aged 2–12, undergoing adenotonsillectomy with sevoflurane anesthesia was enrolled in this study. Patients were randomly assigned to receive either intravenous 2 mg/kg tramadol (Group T; n = 39) or 1 μg/kg dexmedetomidine (Group D; n = 38) after intubation. Heart rates (HR), mean arterial pressure (MAP) were recorded before induction, at induction and every 5 min after induction. Observational pain scores (OPS), pediatric anesthesia emergence delirium (PAED) scores, percentage of patients with OPS ≥ 4 or PAED scale items 4 or 5 with an intensity of 3 or 4, and Ramsay sedation scores (RSS) were recorded on arrival to the postoperative care unit (PACU) and at 5, 10, 15, 30, 45, 60 min. Extubation time and time to reach Alderete score > 9 were recorded.ResultsDexmedetomidine significantly decreased the HR and MAP 10 and 15 min after induction; increased the RSS 15, 30 and 45 min after arrival to PACU. OPS and PAED scores and percentage of patients with OPS ≥ 4 or PAED scale items 4 or 5 with an intensity of 3 or 4 in both groups did not show any significant difference. Extubation time and time to have Alderete score > 9 was significantly longer in Group D.ConclusionBoth tramadol and dexmedetomidine were effective for controlling pain and emergence agitation. When compared with tramadol intraoperative hypotension, bradycardia and prolonged sedation were problems related with dexmedetomidine administration.Trial registrationRetrospectively registered, registration number: ISRCTN89326952 registration date: 14.07.2016

The Effects of Dexmedetomidine or Remifentanil Continuous Infusion on End- Tidal Sevoflurane Concentration in Patients Undergoing Laparoscopic Cholecestectomies, Monitored by Bispectral Analysis

Background and Objective: Owing to the hemodynamic response to pneumoperitoneum, laparoscopic is not devoid of risk; adjuvants have been used to decrease the dose of volatile agents and their side effects and to blunt the hemodynamic response. This study was designed to compare the effect of dexmedetomidine and remifentanil on sevoflurane expired fraction concentration (EF sevo) in general anesthesia, monitored by BIS. Hemodynamic response, postoperative recovery profile, analgesic requirements and PONV were also recorded. Patients and methods: General anesthesia induction with propofol 2.5 mg/kg rocuronium bromide 0.6 mgkg and sevoflurane 1-1.5 MAC. Tracheal intubation was performed and patients were mechanically ventilated. Patients were allocated to Groups D or R. Group D (≤ 40) was the dexmedetomidine group, they received dexmedetomidine diluted with 0.9% NaCl to a concentration of 4 ugmL in 50 mL (an initial loading dose of 0.7 ug/kg given for a 10 min period followed by 0.5 ug/kg/h). Group D (n=40) was the dexmedetomidine group, they received dexmedetomidine (Precedex, 200 ug per 2 mL; Abbott, USA) (an initial loading dose of 0.7 ug/kg given for a 10 min period followed by 0.4 ug/kg/h). Group R (n=40) was the remifentanil group and received an intravenous (i.v.) remifentanil (an initial loading dose of 0.7 ug/kg given for a 10 min period followed by 0.2 ug/kg/h). The infusion was stopped 15 min before the end of surgery. sevoflurane concentration adjusted to maintain BIS between 40 and 60. The parameters evaluated (BIS, SBP, DBP, MAP, HR, and EF sevo) were expressed as mean and standard deviation at 15 min before induction, during induction of anesthesia, 15 min later, during pneumperitonium, after release of insufflation and 15 min after release of insufflation. Statistical analysis: Student’s t-test is a test of significance used for comparison of quantitative variables between two groups of normally distributed data, while Mann Whitney's test was used for comparison of quantitative variables between two groups of not normally distributed data. Chi-square test (χ2) was used to study association between qualitative variables. Whenever any of the expected cells were less than five, Fischer’s Exact test with Yates correction was used. P-value of <0.05 was considered statistically significant. Results: No patients had marked hypotension MAP less than 60 mmHg or bradycardia HR less than 45 in both groups but there were significant decrease in HR and MAP between the two groups during induction, 15 min after induction, during pneumperitonium, aftert release of insufflation and 15 min after release of insufflation, extubation time, spontaneous eye movement, eye movement to verbal stimuli, spontaneous arm movement, purposeful movement and time of discharge to recovery room were significantly lower in group R than group D, However group R showed significantly higher EF sevo 15 min after induc, BSI during insufflation of CO2, EF sevo during insufflation of CO2, BSI after release. CO2, EF sevo after release of CO2, BSI before end of surgery and EF sevo before end of surgery than group D. Conclusion: Both dexmedetomidine and remifentanil reduce the anesthetic requirement and depress the hemodynamic response during pneumoperitoneum with more significant decrease in EF sevo in the D group, however dexmedetomidine provides better postoperative analgesia and less incidence of PONV.

Dexmedetomidine in preeclamptic patients undergoing caesarean section under general anesthesia

Background Dexmedetomidine is used as a sedative in surgical and other procedures in nonintubated adult and pediatric patients. It has been successfully used in laboring parturients as it provides maternal hemodynamic stability and anxiolysis. Aim The aim of this study is to assess the effects of dexmedetomidine in preeclampsia patients under general anesthesia as regards: pressor response to laryngoscopy and intubation, doses of anesthetic agents, muscle relaxants and narcotics, uterine contractility and neonatal effect, postoperative recovery, and postoperative analgesic requirements. Patients and methods This study was carried out on 60 parturients with preeclampsia who were scheduled for elective caesarean delivery. Patients were divided randomly into two groups: DEX group, patients received 1 µg/kg intravenous dexmedetomidine 10 min before induction and a maintenance dose with 0.4 µg/kg/h during surgery, and the control group: patients did not receive dexmedetomidine (n=30/group). Changes in maternal heart rate, mean arterial blood pressure, time from induction to delivery, full anesthesia time (especially during stress of intubation), and depth of anesthesia were monitored by bispectral index. The total dose of propofol, rocuronium and fentanyl consumption, uterine contraction after placental delivery, Apgar score, postoperative recovery profile, postoperative pain, and postoperative analgesia were also assessed. Results Heart rate was significantly lower in the DEX group than in the control group. The mean arterial blood pressure was significantly lower in the DEX group than in the control group from the induction till after extubation. Also there was significant decrease in the total consumption of propofol, fentanyl, and muscle relaxant in the DEX group than in the control group, while both groups were comparable in uterine contraction, Apgar score, and awareness. Conclusion This study suggests the effective use of dexmedetomidine in pre-eclamptic patients undergoing elective cesarean as it stabilizes the maternal hemodynamic parameters during intubation and after intubation with negligible effect on the fetus.

The effect of perioperative esmolol on early postoperative pain: A systematic review and meta-analysis.

Esmolol has been shown to improve postoperative pain and reduce opioid requirements. The aim of this systematic review was to evaluate the effect of perioperative esmolol as an adjunct on early postoperative pain intensity, recovery profile, and anesthetic requirement. Databases were searched for randomized placebo-controlled trials evaluating the effects of esmolol during general anesthesia. Primary outcomes were related to early postoperative pain whereas secondary outcomes were related to emergence time, postoperative nausea and vomiting, and intraoperative anesthetic requirement. Nineteen trials were identified involving 936 patients (esmolol = 470, placebo = 466). In esmolol group, numeric pain scores at rest in the immediate postoperative period were reduced by 1.16 (95% confidence interval [CI]: 1.97–0.35, I2 = 96.7%) out of 10. Opioid consumption was also decreased in the postanesthesia care unit compared with placebo, mean difference of 5.1 mg (95% CI: 7.0–3.2, I2 = 96.9%) morphine IV equivalents; a 69% reduction in opioid rescue dosing was noted (odds ratio [OR]: 0.31, 95% CI: 0.16–0.80, I2 = 0.0%). A 61% reduction in postoperative nausea and vomiting was also evident (OR: 0.39, 95% CI: 0.20–0.75, I2 = 60.7%). A reduction in propofol induction dose was noted in the esmolol group (mean difference: −0.53 mg/kg, 95% CI: −0.63–−0.44, I2 = 0.0%). A decrease in end-tidal desflurane equivalent (mean difference: 1.70%, 95% CI: −2.39–−1.02, I2 = 92.0%) and intraoperative opioid usage (fentanyl equivalent, mean difference: 440 μg, 95% CI: −637–−244, I2 = 99.6%) was observed in esmolol group. Esmolol had no effect on the emergence time. Perioperative esmolol as an adjunct may reduce postoperative pain intensity, opioid consumption, and postoperative nausea vomiting. Given the heterogeneity, larger clinical trials are warranted to confirm these findings.

Effects of Intraperitoneal Local Anaesthetics Bupivacaine and Ropivacaine versus Placebo on Postoperative Pain after Laparoscopic Cholecystectomy: A Randomised Double Blind Study.

Laparoscopic Cholecystectomy (LC) is the most frequently performed elective daycare surgery and provision of postoperative pain relief is of importance. After laparoscopic cholecystectomy shoulder and abdominal pain causes considerable distress. Visceral pain during coughing, respiration and mobilization increases morbidity, hospital stay and costs. To compare the analgesic efficacy of intraperitoneally instilled equipotent concentrations of bupivacaine and ropivacaine versus placebo in relieving postoperative pain after laparoscopic cholecystectomy when used as a part of multimodal analgesia. In this randomised, prospective, double blind, placebo controlled study, 90 ASA Class I or II patients were randomly divided into three groups of 30 each. Group S received intraperitoneal infiltration with 35 ml of 0.9% normal saline, Group B with 35 ml of 0.25% bupivacaine and Group R with 35 ml of 0.375% ropivacaine. All groups received standard general endotracheal anaesthesia and analgesia with IV paracetamol 15 mg/kg and diclofenac 1.5 mg/kg. Numerical Rating Scale (NRS) score of analgesia at rest and on cough/movement, duration of analgesia, haemodynamic parameters, need for a rescue analgesic (IV tramadol 1 mg/kg) was recorded and adverse effects of procedure and drugs if any were monitored. Data was analysed with SPSS statistical software version 21.0. One way ANOVA or the Kruskal-Wallis test was used to compare continuous data across all three groups as appropriate. Subsequent analysis of continuous data between two groups was achieved by Tukey's post hoc test. Significance was accepted as p<0.05. The mean NRS was <5 till only four hours in Group S, till eight hours in Group B and till 16 hours in Group R. The duration of analgesia was 13.47±1.38 hours in Group R, 7.93±1.44 hours in Group B and 4.47±0.86 hours in Group S. Intraperitoneal infiltration of LA significantly reduces pain intensity scores in the early postoperative period after LC surgery and helps in improving the postoperative recovery profile and outcome. This makes LC surgery more amenable to day care surgical setup. Ropivacaine (0.375%) is more efficacious, longer acting with a higher intensity of postoperative analgesia than bupivacaine (0.25%).

Intravenous Dexmedetomidine Infusion Compared with that of Fentanyl in Patients Undergoing Arthroscopic Shoulder Surgery under General Anesthesia.

Background:Anesthesia for arthroscopic shoulder surgery is challenging due to the need for oligaemic surgical field as well as a good postoperative recovery profile.Aim:The present study was prospective, randomized to evaluate the efficacy of dexmdetomidine infusion compared to that of fentanyl in patients undergoing arthroscopic shoulder surgery under general anesthesia.Patients and Methods:A total of 60 patients aged from thirty to fifty years, American Society of Anesthesiologists Class I/II of either sex for arthroscopic shoulder surgery, were included. The patients were divided into two groups of 30 patients each. Group I received dexmedetomidine loading 1 μg/kg over 10 min followed by maintenance 0.5 μg/kg/h and Group II Fentanyl loading 1 μg/kg followed by maintenance 0.5 μg/kg/h.Measurements:Hemodynamic readings (Heart rate HR, and mean arterial blood pressure MAP) were recorded after the start of the study drug infusion (T1), after intubation (T2), then every 15 minutes till the end of surgery (T15, T30, T45, T60, T75, T90). In the PACU, MAP, and HR were recorded on arrival, after 30 min, 1 hr, and 2 hrs (R0, R30, R1 hr, R2 hr) Postoperative analgesia was assessed by visual analogue scale (VAS), Modified Observers's Assessment of Alertness and Sedation OAA/S was recorded on arrival to PACU.Results:This study showed that in the dexmedatomidine group there was statistically significant decrease of MAP and HR after drug infusion up to two hours in the recovery period, more sedation, better control of pain and surgeon satisfaction.Conclusion:Iv infusion of dexamedatomidine may be an attractive option during arthroscopic shoulder surgery as it provided a better hypotensive anesthesia by lowering MAP and HR which leads to better surgical field and surgeon satisfaction than iv infusion fentanyl along with a better postoperative VAS.

Abstract PR492

Background & Objectives: Spinal anaesthesia is a cheaper alternative to general anaesthesia for surgical procedures below the umbilicus. Bupivacaine is commonly used for spinal anaesthesia following the withdrawal of hyperbaric lidocaine. Pethidine, a lipophilic opioid with local anaesthetic activity is used for spinal. This study seeks to compare the immediate postoperative complications and recovery profile following spinal anaesthesia with pethidine and bupivacaine as sole agents. Materials & Methods: Fifty two ASA I and II patients, aged between 18 and 60 years, were randomized to receive spinal anaesthesia for short surgical procedures of the lower body. The patients were either given preservative-free pethidine 1mg/Kg (n=26) or 2.5mL isobaric 0.5% bupivacaine (n=26), and the time to recovery of pinprick sensation at S2, plantar flexion, proprioception of the big toe, and full motor recovery (Bromage score 0), were compared. Complications of pain, sedation, nausea and vomiting, pruritus and urinary retention in the immediate postoperative period were compared. Results: The time to return of pinprick sensation at S2 was 94.62±20.25 minutes and 205.96±31.05 minutes for pethidine and bupivacaine respectively. The time to return of plantar flexion between pethidine and bupivacaine was 92.88±12.01 minutes and 193.85± 39.56 minutes respectively. The mean time to recovery of proprioception of the big toe between pethidine and bupivacaine 31.15±9.41 minutes and 172.50±42.70 minutes respectively. The time it took for complete motor recovery (Bromage score 0), between pethidine and Bupivacaine, was 47.89±14.08 minutes and 221.73±44.72 minutes respectively. All the differences in recovery times were significant (p<0.0001). There was no significant difference in the incidence of pain and sedation. Four patients (15.38%) in the Bupivacaine group experienced mild and tolerable pain. There was no incidence of nausea and vomiting in either group. However, five patients (19.22%) in the pethidine group experienced pruritus, while bupivacaine group recorded none. Three patients (11.54%) in the Bupivacaine group also had urinary retention, while pethidine group had none. Conclusion: Pethidine exhibited a shorter recovery profile than bupivacaine and also caused no significant complications in the immediate postoperative period. Regional anaesthesia with pethidine should therefore be considered for short duration and ambulatory surgery as an alternative to lignocaine. Disclosure of Interest: None declared

Modifying a generic postoperative recovery profile instrument to an instrument specifically targeting coronary artery bypass grafting.

Patients may suffer from a wide range of postoperative symptoms after coronary artery bypass grafting. In-depth knowledge of the recovery process is a prerequisite for nursing interventions. However, we found no specific instrument covering the entire range and duration of postoperative symptoms related to this procedure. We therefore modified and extended the 19 items, generic Postoperative Recovery Profile questionnaire for the specific evaluation of the recovery after coronary artery bypass grafting. We here report on the development process of the new questionnaire. Procedure-specific symptoms were identified by a literature review and by experts. The content validity was assessed by healthcare professionals (n = 15), inpatients (n = 12) and outpatients (n = 4). A test run was done with inpatients (n = 10), which was followed by a test-retest reliability evaluation with inpatients (n = 24). We identified 15 new symptoms in the literature review and six in the content validity assessment. Only three of the 35 items had an acceptable content validity index, but all 35 items in the test run were reported by at least two patients. The questionnaire took 4-9 minutes to complete and was considered easy to use. The final instrument used in the reliability test included 22 new items, and 25 of the 35 items were satisfactory stable. To conclude, we developed a 35 items, procedure-specific questionnaire that was easy to use and may aid systematic assessment of the recovery after coronary artery bypass grafting.

A comparison of oral midazolam and oral dexmedetomidine as premedication in pediatric anesthesia.

Context:Oral premedication is widely used in pediatric anesthesia to provide preoperative anxiolysis and ensure smooth induction. Midazolam is currently the most commonly used premedicant, but newer drugs such as the α2-agonists have emerged as alternatives for premedication in children.Aims:The aim of this study was to compare clinical effects of oral midazolam and oral dexmedetomidine on preanesthetic sedation and postoperative recovery profile in children.Settings and Design:Randomized controlled trial.Materials and Methods:We performed a prospective, randomized, controlled study in 60 children, aged 1-7 years undergoing elective, minor, lower abdominal surgeries under general anesthesia. Patients were randomly assigned to receive either oral midazolam 0.75 mg/kg (Group M, n = 30) or oral dexmedetomidine 4 μg/kg (Group D, n = 30) 40 min prior to mask induction. Preoperative sedation and anxiolysis, the response at parental separation, quality of mask acceptance and recovery profile were compared for the two groups.Statistical Analysis Used:Results were analyzed using unpaired Student's t-test and Chi-squared test. P < 0.05 was considered statistically significant.Results:There was no significant difference in the levels of preoperative sedation and anxiolysis between the two groups, but the onset of sedation was significantly faster with midazolam (18.90 ± 3.68 min) than with dexmedetomidine (30.50 ± 4.44 min). Response to parental separation and quality of mask acceptance was comparable between two groups (P > 0.05). The incidence of postoperative agitation was significantly less in the dexmedetomidine group (P < 0.05).Conclusions:In this study, premedication with oral dexmedetomidine produced equally effective preoperative sedation and a better recovery from anesthesia in children in comparison to oral midazolam.

Effects of Intra-abdominally Instilled Isotonic Saline on Pain, Recovery, and Health-Related Quality-of-Life Following Laparoscopic Cholecystectomy: A Randomized Prospective Double-Blind Controlled Study.

The postoperative installation of isotonic saline in the abdomen has been suggested as a method to reduce the effect of local toxins, thereby reducing postoperative pain in patients undergoing laparoscopic surgery. The aim of this randomized prospective double-blind trial was to assess whether installation of isotonic saline can reduce postoperative pain and nausea following laparoscopic cholecystectomy (LC). Altogether 71 LC patients were randomized to either intra-abdominal instillation of isotonic saline group (S) (n = 36) or no saline (NS) group (n = 35) at the end of surgery. Data were collected by means of questionnaires. The postoperative recovery profile questionnaire was answered prior to surgery and 1 week postoperatively, SF-36 prior to surgery and at 1 month postoperatively, and a pain diary recording a Visual Analogue Scale score each day during the first week. The overall response rate was 94%. No significant differences were seen between the groups regarding abdominal and shoulder pain. However, the NS group reported more pain (NS = 53 %, S = 29 %) and fatigue (NS = 50%, S = 35%) than the S group postoperative day 7. Moreover, the most frequently reported problem in both groups 7 days after surgery was getting back to normal life (60%). Females reported a slower recovery profile than males and also more postoperative symptoms day 7. HRQoL results were similar between the groups. Instillation of isotonic saline does not improve recovery after laparoscopic cholecystectomy. Postoperative pain was more often reported in the NS group than in the S group, though the difference was not significant.

Patient Reported Outcome Measures (PROMs) after total hip- and knee replacement surgery evaluated by the Postoperative Recovery Profile questionnaire (PRP) – improving clinical quality and person-centeredness

Rationale and aims: The importance of evaluating postoperative recovery with consideration to the patient’s perspective has been emphasized. The aim of this study was to demonstrate how the recovery-specific Postoperative Recovery Profile (PRP) questionnaire can be used to evaluate patient-reported outcome measures (PROMs) after hip- and knee replacement in the enhancement of clinical quality and the person-centeredness of clinical services.Method: Patients undergoing primary total knee- and hip replacement were eligible for this longitudinal follow-up study. The participants completed the PRP questionnaire on repeated occasions. In this paper, data from Day 3 and Month 1 after discharge were used. The change in recovery, between the two measurement occasions, on item-, dimensional- and global levels, both for each patient and for the group, were evaluated.Results: A total number of 75 patients were included. One month after discharge the median PRP score was 13 (partly recovered) out of 19. Recovery changes towards lower levels of problems/difficulties were shown in both item-, dimensional- and global levels of recovery month 1 after discharge, as compared with Day 3. The group of patients was homogenous in change.Conclusions: We demonstrated that the PRP questionnaire can be used to evaluate postoperative recovery after hip- and knee replacement surgery on item-, dimensional- and global levels. Data from each recovery level can be useful for quality development and in informing increases in the person-centeredness of clinical services. The global population scores can be used to evaluate treatment effect on a group of patients. It can also be used to define endpoints in follow-up studies.

Comparison of intraoperative brain condition, hemodynamics and postoperative recovery between desflurane and sevoflurane in patients undergoing supratentorial craniotomy.

Background:Post operative recovery has been reported to be faster with desflurane than sevoflurane anesthesia in previous studies. The use of desflurane is often criticized in neurosurgery due to the concerns of cerebral vasodilation and increase in ICP and studies comparing desflurane and sevoflurane in neurosurgey are scarce. So we compared the intraoperative brain condition, hemodynamics and postoperative recovery in patients undergoing elective supratentorial craniotomy receiving either desflurane or sevoflurane.Materials and Methods:Fifty three patients between 18-60yr undergoing elective supratentorial craniotomy receiving N2O and oxygen (60%:40%) and 0.8-1.2 MAC of either desflurane or sevoflurane were randomized to group S (Sevoflurane) or group D (Desflurane). Subdural intra cranial pressure (ICP) was measured and brain condition was assessed.. Emergence time, tracheal extubation time and recovery time were recorded. Cognitive behavior was evaluated with Short Orientation Memory Concentration Test (SOMCT) and neurological outcome (at the time of discharge) was assessed using Glasgow Outcome Score (GOS) between the two groups.Results:The emergence time [Group D 7.4 ± 2.7 minutes vs. Group S 7.8 ± 3.7 minutes; P = 0.65], extubation time [Group D 11.8 ± 2.8 minutes vs. Group S 12.9 ± 4.9 minutes; P = 0.28] and recovery time [Group D 16.4 ± 2.6 minutes vs. Group S 17.1 ± 4.8 minutes; P = 0.50] were comparable between the two groups. There was no difference in ICP [Group D; 9.1 ± 4.3 mmHg vs. Group S; 10.9 ± 4.2 mmHg; P = 0.14] and brain condition between the two groups. Both groups had similar post-operative complications, hospital and ICU stay and GOS.Conclusion:In patients undergoing elective supratentorial craniotomy both sevoflurane and desflurane had similar intra-operative brain condition, hemodynamics and post operative recovery profile.

Patient-reported recovery after enhanced colorectal cancer surgery: a longitudinal six-month follow-up study

The concept of enhanced recovery after surgery (ERAS) is a modern regime of care, and numerous studies have proved its beneficial impact on recovery after colorectal surgery. However, little is known about patients' continuing recovery after discharge. Therefore, the purpose of this study was to describe patient-reported recovery after colorectal cancer surgery in the context of ERAS from the day of discharge until 1 and 6 months after surgery. Assessments were made at discharge, at 1 month and at 6 months after surgery using the questionnaire Postoperative Recovery Profile (PRP). In all, 119 patients recovering from abdominoperineal resection, rectal resection, or colonic resection completed all three assessments. The global score of recovery showed that no patient experienced being fully recovered at discharge. After rectal resection, patients frequently reported being not at all recovered. One month after surgery, patients recovering from colonic resection reported significant improvements regarding 11 of 17 questionnaire items, whereas abdominoperineal resection patients reported no significant improvements regarding any item. Instead, significantly higher levels of problems were reported in the items fatigue, muscle weakness and feeling down. Rectal resection patients reported significant improvements between 1 and 6 months after surgery regarding 7 of 19 items. However, the item gastrointestinal function distinguished, as patients reported significant deterioration towards higher levels of problems 6 months after surgery. This study elucidates the difference between groups of colorectal patients and the diverse patterns of their recovery, implying different needs in terms of prolonged support after discharge.

Effect of pre-warmed intravenous fluids on perioperative hypothermia and shivering after ambulatory surgery under monitored anesthesia care

The aim of this study was to evaluate the effects of pre-warmed (approximately 41 °C) intravenous fluids (IV) on perioperative hypothermia and postoperative shivering in female patients undergoing short, ambulatory urological surgery under monitored anesthesia care (MAC). Patients between the ages of 35 and 80 years were randomly assigned to either the pre-warmed (n = 27) or the room temperature (n = 26) group. According to group allocation, either pre-warmed IV fluids that had been stored in a warming cabinet for at least 8 h or room temperature IV fluids were administered intraoperatively up to approximately 600-700 ml, including a bolus infusion of 10 ml/kg within 20 min. Perioperative core temperatures at the tympanic membrane, postoperative shivering, subjective thermal comfort, and the use of forced-air warming interventions in the post-anesthesia care unit (PACU) were recorded. Mean core temperatures were significantly higher in the pre-warmed group than they were in the room temperature group after 10 ml/kg preload fluid was administered, at the end of the operation, and on admission to the PACU (p = 0.004, p = 0.02, and p = 0.008, respectively). The incidence of hypothermia (<36 °C) was significantly lower in the pre-warmed group (n = 4) than in the room temperature group (n = 11, p = 0.035) upon PACU admission. The postoperative shivering incidence was also significantly lower in the pre-warmed group (n = 2) than in the room temperature group (n = 8, p = 0.039). Infusion of pre-warmed IV fluid improved the postoperative recovery profile by decreasing hypothermia and shivering in female patients undergoing short, ambulatory urological surgery under MAC.

Patients Recovering From Abdominal Surgery Who Walked With Volunteers Had Improved Postoperative Recovery Profiles during Their Hospitalization

Early walking as part of a perioperative care program benefits patients who have had surgery. However, the impact of early walking by itself on the mental and physical recovery of postoperative patients has not been examined. We established a program called walking to recovery (WTR) in which college volunteers provided walking assistance to patients recovering after abdominal surgery. Patients who participated in the program were compared with patients who did not. The postoperative recovery profile survey (PRP-17) was administered on day of discharge to 15 participants and 15 non-participants. Medical records were reviewed to obtain indication for surgery, type of surgery, length of hospital stay, and postoperative complications. At 1month post-discharge, a short form (SF)-12v2 questionnaire was administered by telephone to assess postoperative quality of life as defined by mental and physical level of function and measured with the mental component score (MCS) and the physical component score (PCS). The average age of participants and non-participants was similar (48.9±9.8 vs. 51.4±8.7years; p=0.28). When the two groups were approximately matched by type and severity of surgery, participants had lower PRP-17 composite scores (9.9 vs. 12.5, p=0.003) and higher indicator sums (9.8 vs. 8.4, p=0.04) than non-participants, both of which indicate better postoperative recovery in participants. The mean immobilization score was significantly lower in participants (0.3 vs. 0.8, p=0.04). Postoperative length of stay and MCS did not differ between the two groups, but in participants there was a trend for higher scores in the PCS. Walking with volunteers was associated with a better PRP during the hospitalization period but not at 1month follow-up. The WTR program is a sustainable, cost-effective model program for other hospitals to emulate as part of the standard of care of postoperative patients.

Comparison of Propofol and Ketamine versus Propofol and Fentanyl for Puerperal Sterilization, A Randomized Clinical Trial.

Puerperal sterilization requires a rapid recovery of the mother so that she can take care of her child. Propofol with fentanyl (PF) is an option, but is associated with intraoperative hypotension, respiratory depression and an unsatisfactory postoperative recovery profile. Propofol with ketamine (PK) appears to be an alternative in terms of haemodynamic stability and analgesia. This randomized clinical trial involved 60 patients who were scheduled to undergo puerperal sterilization, who belonged to American society of anaesthesiologists (ASA) physical status 1. Patients were randomly allocated to receive either ketamine - propofol infusion in a concentration of 8mg/ml each (group PK) or fentanyl 2μg/kg intravenously, followed by an infusion of propofol in a concentration of 8mg/ml (group PF). In both the groups, the infusion was started at 300ml/hr till patient lost consciousness. Subsequently, the rate was set at 1.5ml/kg/hr for group PF and at 0.75ml/kg/hr for group PK. After the initial 10 minutes, the infusion rate was reduced to 1ml/kg/hr for group PF and to 0.5ml/kg/hr for group PK. Blood pressure and saturation were the primary outcomes which were measured. Patients from group PF recorded a significant drop in the systolic blood pressure from the 5(th) minute, in diastolic pressure from the 10(th) minute and transient oxygen desaturation, as compared to group PK. Patients in group PK had adequate surgical conditions and better recovery profiles in terms of pain and sedation. The combination of ketamine and propofol is a safe and possibly superior alternative to propofol - fentanyl combination in patients who undergo puerperal sterilization, in terms of haemodynamic stability and respiratory depression.

Effect of Intraoperative Dexmedetomidine on Postoperative Recovery Profile of Children Undergoing Surgery for Spinal Dysraphism

Smooth recovery from anesthesia is desirable in children undergoing surgery for spinal dysraphism who are nursed in prone position during the postoperative period. Dexmedetomidine may be beneficial in these children owing to its sedative, anxiolytic, and opioid-sparing properties with minimal respiratory depression. Thirty-six children with spinal dysraphism at lumbosacral area, aged 8 to 12 years, undergoing corrective surgery were randomized to receive either dexmedetomidine or volume-matched saline (placebo) after positioned prone until beginning of skin closure. Inspired concentration of sevoflurane was changed to keep the bispectral index score between 45 and 55. Perioperative hemodynamics, intraoperative fentanyl and sevoflurane consumption, and postoperative recovery profile and fentanyl consumption was observed by blinded observers. Postoperative pain, emergence agitation (EA), and discharge readiness from postanesthesia care unit was evaluated using the modified objective pain score, agitation Cole score, and modified Aldrete score, respectively. Fentanyl 0.5-1 µg/kg was administered for pain (objective pain score ≥4) or severe EA (agitation Cole score ≥4) lasting for >5 minutes. The 2 groups did not differ significantly with respect to demographics, duration of anesthesia, emergence, and extubation times. The intraoperative consumption of sevoflurane and fentanyl was significantly less in dexmedetomidine group (0.2±0.1 vs. 0.3±0.1 mL/min, P<0.0001 and 2.3±0.5 vs. 3.1±0.6 μg/kg, P=0.0001, respectively), along with a lower mean heart rate (P<0.001). The mean systolic blood pressure (P=0.98) and incidence of bradycardia and hypotension was comparable in between the 2 groups. Postoperatively, the children in dexmedetomidine group had significantly lower pain scores (P<0.0001), agitation scores (P<0.0001), and time to achieve full modified Aldrete score [0 (0 to 10) vs. 10 (0 to 20) min, P=0.001]. The postoperative consumption of fentanyl was significantly less in dexmedetomidine group [0 (0 to 1.04) vs. 0.88 (0 to 3) µg/kg, P=0.003], along with a longer time of first analgesic requirement [600 (5 to 2100) vs. 5 (5 to 185) min, P=0.0001]. The mean heart rate and systolic blood pressure were higher in placebo group (P<0.001), whereas no difference was observed in respiratory rate (P=0.73) and arterial oxygen saturation (P=0.36). The number of patients with postoperative nausea and vomiting was significantly lower in dexmedetomidine group [2 (11.1%) vs. 9 (50%), P=0.03]. Intraoperative use of dexmedetomidine in children undergoing spinal surgery results in a favorable recovery profile with reduced postoperative pain and EA, without adverse perioperative hemodynamic effects.

Effects of Dexmedetomidine on Postoperative Recovery Profile after Sevoflurane Anesthesia in Pediatric Patients: A Meta-analysis

Objective: We aim to evaluate whether dexmedetomidine can reduce incidence caused by sevoflurane anesthesia in pediatric patients systematically. Methods: We have searched the Cochrane Library, PubMed, EBSCO, Springer, Chinese Journal Full-text Database (CNKI), Chinese Biomedical Literature Database (CBM) and WanFang Data (all the materials selected from these databases range from the date of establishment of the databases to April 2013). Reference lists of all studies have also been checked. Two valuators performed the process of RCT, quality assessment, and data extraction with inclusion and exclusion criteria, and conduct the Meta-analysis with the software RevMan5.2. Results: The meta-analysis which including 27 randomized trials and 1882 children showed that dexmedetomidine extended the incidence of the children’s recovery time [MD=2.39, 95% CI (1.27, 3.51)] and discharge time [MD=6.09, 95% CI (3.42, 8.77)] compared with placebo. Nevertheless, there were no obvious differences in extubation time [MD=0.75, 95% CI (0.45, 1.05)]. While reducing the incidence of early emergence agitation, dexmedetomidine showed a large advantage [RR=0.31, 95% CI (0.26, 0.38)] and could reduce agitation score [MD=-0.89, 95% CI (-1.04, -0.74)], also could reduce pain score [MD=-2.66, 95% CI (-3.81, -1.51)], as well as the need for painkillers [RR=0.34, 95% CI (0.22, 0.52)]. What’s more, on reducing occurrence of nausea and vomiting [RR=0.59, 95% CI (0.36, 0.97)], occurrence of bucking [RR=0.39, 95% CI (0.23, 0.68)], dexmedetomidine also showed some preventive effects. There were no serious side effects on respiratory and circulatory system in all included studies. Conclusion: Dexmedetomidine can be used safely in children and improve the awakening quality after sevoflurane anesthesia.

Comparative evaluation of incidence of emergence agitation and post-operative recovery profile in paediatric patients after isoflurane, sevoflurane and desflurane anaesthesia

Background:Emergence agitation (EA), although well documented in the clinical literature, still has uncertainties and confusion abound on this subject because of the absence of a clear definition and lack of reliable and valid assessment tools.Aim:To compare the incidence and severity of EA and recovery characteristics in paediatric patients under isoflurane, sevoflurane or desflurane anaesthesia and evaluate the effect of age and duration of anaesthesia on the incidence of EA.Settings and Design:Randomized prospective double-blinded study.Methods:Seventy-five American Society of Anaesthesiologists I and II patients, aged between 4 months and 7 years, were included in the study. Patients were induced with sevoflurane and oxygen. Anaesthesia was maintained with O2 + N2O and isoflurane, sevoflurane or desflurane according to randomization. Caudal block and paracetamol suppository was administered before the surgical incision. In the Post-Anesthesia Care Unit (PACU), degree of agitation was assessed using the Paediatric Anaesthesia Emergence Delirium Scale. Aldrette score, Face, Legs, Activity, Cry, Consolability score and any adverse events were noted.Statistical Analysis:Chi-square/Fischer exact test was applied for categorical variables; for continuous variables, the analysis of variance/non-parametric Kruskall–Wallis test was applied. Two-sample t-test/non-parametric Wisconsin Mann–Whitney test was applied between the two groups. Statistical significance was determined at P<0.05.Results:Incidence and intensity of EA were comparable in all three groups. Age and duration of anaesthesia do not appear to have any bearing on the incidence of EA. Rapid emergence with sevoflurane and desflurane did not translate into early discharge from PACU.Conclusions:EA is a multifactorial syndrome. More well-conducted studies using validated scales and standardized protocols should be carried out to better understand this phenomenon.

Effect of patient sex on general anaesthesia and recovery

Numerous studies have shown that women emerge faster from general anaesthesia than men, and differ in their postoperative recovery profile. The extent and underlying mechanisms for these sex-related differences in general anaesthesia are unclear. In a multicentre, prospective, matched cohort study, 500 ASA physical status I or II patients of either sex undergoing general anaesthesia for elective surgery were recruited. All subjects received a general anaesthetic through inhalation. Anaesthetic drugs and doses used, bispectral index (BIS) scores, recovery times, pain scores, and 40-item quality of recovery (QoR-40) scores for 3 days after general anaesthesia were recorded. Women had higher BIS scores at similar concentrations of anaesthesia (P<0.05). Time to eye-opening (P<0.01) and time to obeying commands (P<0.01) were shorter in women. Duration of recovery room stay was longer in women, who also had higher pain scores and need for treatment of nausea and vomiting (all P<0.001). QoR-40 scores for the first 3 days after general anaesthesia were lower in women (P<0.001). Plasma progesterone concentrations in women negatively correlated with the time to eye-opening (ρ=-0.53, P=0.01). Patient sex is an independent factor influencing the response to anaesthesia and recovery after surgery. Women emerged faster from general anaesthesia but their overall quality of recovery was poorer. Female sex hormones, particularly progesterone, might be involved, with premenopausal women having faster recovery time but poor overall recovery.