Volume 7, Issue 11 S A M B A T A L K S - PAGE 3 April, 2008

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

A Comparison of Preoperative Anxiety in Female Patients with Mothers of Children Undergoing Surgery. [Report]
MacLaren, Jill PhD *+; Kain, Zeev N. MD, MBA *+++
Anesthesia & Analgesia. 106(3):810-813, March 2008.

We compared anxiety in mothers of children undergoing ambulatory surgery with female patients undergoing surgery themselves. We found that mothers were as anxious as patients undergoing major abdominal surgery and more anxious than patients undergoing minor surgery. Predictors of maternal anxiety were child age and maternal monitoring coping.

Car Accidents After Ambulatory Surgery in Patients Without an Escort.[Report]
Chung, Frances FRCPC; Assmann, Nicole FRCA
Anesthesia & Analgesia. 106(3):817-820, March 2008.

Occasionally, ambulatory surgical patients present without an escort for their procedure. This creates a dilemma for caregivers, and allowing patients to drive may have an impact on their safety. The Canadian Medical Protective Association is a mutual defense organization for 95% of Canadian physicians. The national database is a unique and extensive repository of medico-legal data. We scanned this database for malpractice patients who were discharged after an ambulatory surgery procedure and allowed to drive home with a poor outcome. From this database, two malpractice cases of patients who were discharged without an escort after an ambulatory surgical procedure were reported. Both had a car accident and sustained serious injuries. Based on this we do not recommend discharge without an escort after general anesthesia, regional anesthesia, monitored anesthesia or sedation. Driving after ambulatory surgery cannot be considered safe and caregivers need to verify a safe ride home.

Interactive Web Simulation for Propofol and Fospropofol, a New Propofol Prodrug. [Article]
Yavas, Sinan MD; Lizdas, David; Gravenstein, Nikolaus MD; Lampotang, Samsun PhD
Anesthesia & Analgesia. 106(3):880-883, March 2008.

Using pharmacokinetic and pharmacodynamic data published in the scientific literature, we have developed interactive on-line simulations to model administration of propofol and fospropofol, a new water-soluble prodrug formulation of propofol. The prodrug formulation of fospropofol leads to a delayed onset to peak concentrations of propofol. A comparison simulation that overlays administration of fospropofol and propofol allows clinicians to understand the differences of administering fospropofol and traditional propofol. The simulations have the added advantage of allowing for differences among patients documented in test studies and the use of different models.

Decision Support Increases Guideline Adherence for Prescribing Postoperative Nausea and Vomiting Prophylaxis. [Miscellaneous Article]
Kooij, Fabian O. MD *+; Klok, Toni MD *; Hollmann, Markus W. MD, PhD, DEAA +; Kal, Jasper E. MD, PhD *
Anesthesia & Analgesia. 106(3):893-898, March 2008.

BACKGROUND: Guidelines for postoperative nausea and vomiting (PONV) prevention are implemented widely but their effectiveness may be limited by poor adherence. We hypothesized that the use of an electronic decision support (DS) system would significantly improve guideline adherence.
METHODS: Medical information of all patients undergoing elective surgery in our regional teaching hospital is routinely entered in an anesthesia information management system at the preoperative screening clinic. Our departmental PONV prevention guidelines identifies patients as "high-risk" and thus eligible for PONV prophylaxis based on the presence of at least three of the following risk factors: female gender, history of PONV or motion sickness, nonsmoker status, and anticipated use of postoperative opioids. Using automated reminders, we studied the effect of DS on guidelines adherence using an off-on-off design. In these three study periods, we queried for all consecutive patients visiting the preoperative screening clinic who were eligible for PONV prophylaxis and studied how often it was prescribed correctly.
RESULTS: Between November 2005 and June 2006, 1340, 2715, and 1035 patients were included in the control, DS and post-DS periods, respectively. As a result of mandatory data entry of risk factors, the percentage of high-risk PONV patients increased from 28% in the control period to 32% and 31% in the DS and post-DS periods, respectively. During the control period, 38% of all high-risk patients were prescribed PONV prophylaxis. This increased to 73% during the DS period and decreased to 37% in the post-DS period.
CONCLUSION: Electronic DS increases guidelines adherence for the prescription of PONV prophylaxis in high-risk PONV patients.

Dehydration Induced by Bowel Preparation in Older Adults Does Not Result in Cognitive Dysfunction. [Miscellaneous Article]
Ackland, Gareth L. PhD, FRCA *; Harrington, Jane PhD +; Downie, Paul FRCA *; Holding, James W. FRCA *; Singh-Ranger, Deepak MRCS ++; Griva, Konstandina PhD [S]; Mythen, Michael G. MD, FRCA [//]; Newman, Stanton P. PhD [P]
Anesthesia & Analgesia. 106(3):924-929, March 2008.

BACKGROUND: Postoperative cognitive dysfunction occurs in a proportion of patients after noncardiac surgery. Older patients are particularly vulnerable. We hypothesized that dehydration, a common perioperative problem in the elderly, may provoke cognitive dysfunction. We used a clinical scenario free of surgical/anesthetic intervention to determine whether dehydration caused by bowel preparation results in cognitive changes.
METHODS: Thirty-eight patients of an age associated with a significant incidence of postoperative cognitive dysfunction were recruited in a prospective observational study. A further control group of 14 patients undergoing sigmoidoscopy, who did not receive any bowel preparation, were matched for age, education, and gender.
RESULTS: Loss of total body weight (1.5 kg [95% CI: 0.9-2.2]; P < 0.001) occurred in patients undergoing bowel preparation (2.0 [95% CI: 1.3-2.6] percent total body weight), whereas sigmoidoscopy patients' weight did not change (0.17 kg [95% CI: -0.2-0.6 kg]; P = 0.26). Total body water, derived from foot bioimpedance, indicated dehydration in the bowel preparation group only (mean impedance change 36 [Omega] [95% CI; 25-46], P < 0.001) with a calculated decrease of 2.6% in total body water (95% CI: 1.1-4.8; P < 0.001). Hematocrit increased after bowel preparation only (prebowel prep 0.41 [0.40-0.43] versus postbowel prep 0.43 [0.42-0.45]; P = 0.003). Despite this degree of dehydration, all cognitive tests were within 1 sd of the population mean of normal values. Repeated measures analysis of variance did not reveal significant changes for within group comparisons over time for motor speed (P = 0.51), executive function (P = 0.57), Trail Making Tests and recall (P = 0.88), other than a 3 s slowing in learning ability (Rey Auditory Verbal Learning Test; P = 0.04). Hydration status did not affect learning (P = 0.42), recall (P = 0.30) motor speed (P = 0.36), or executive function tests (P = 0.26).
CONCLUSION: Dehydration alone does not result in cognitive dysfunction.

Perioperative Versus Postoperative Celecoxib on Patient Outcomes After Major Plastic Surgery Procedures.[Miscellaneous Article]
Sun, Tiffany BS *+; Sacan, Ozlem MD *+; White, Paul F. PhD, MD, FANZCA *+; Coleman, Jayne MD *+; Rohrich, Rod J. MD, FACS *+; Kenkel, Jeffrey M. MD, FACS *+
Anesthesia & Analgesia. 106(3):950-958, March 2008.

BACKGROUND: Controversy continues to surround the use of cyclooxygenase (COX)-2 inhibitors in the perioperative period. We designed this randomized, double-blind, placebo-controlled study to examine the hypothesis that administration of celecoxib preoperatively or postoperatively and for 3 days after major plastic surgery would improve pain control and clinically important patient outcomes. Another objective of the study was to determine whether perioperative administration of celecoxib offered any advantages over postoperative administration alone.
METHODS: One hundred and twenty healthy consenting patients undergoing major plastic surgery (e.g., breast augmentation, abdominoplasty procedures) using a standardized general anesthetic technique were randomized to one of three treatment groups: 1) control group (n = 40) received two placebos orally before and after surgery, as well as one placebo BID for 3 days after surgery; 2) postoperative group (n = 40) received two placebos before surgery and 2 celecoxib 200 mg po after surgery, followed by one celecoxib 200 mg po BID on postoperative day #1, #2 and #3; and 3) perioperative group (n = 40) received 2 celecoxib 200 mg po 30-90 min before surgery, and two placebos after surgery, followed by one celecoxib 200 mg po BID on postoperative day #1, #2, and #3. Pain scores, the need for rescue analgesics, and side effects were recorded at specific time intervals in the postoperative period. Follow-up evaluations were performed at 24, 48, 72 h, and 7 days after surgery to assess postdischarge pain, analgesic requirements, return of bowel function, resumption of normal daily activities, quality of recovery, as well as patient satisfaction with pain management.
RESULTS: Compared with the control group, the two celecoxib groups had similar significant reductions in postoperative pain and need for opioid analgesics during the first three postoperative days (P < 0.01). Patients recovered bowel function 1 day earlier and resumed normal activities 2 days earlier in the celecoxib groups. In addition, patient satisfaction with pain management and quality of recovery were significantly improved in the celecoxib (versus control) groups (P < 0.05).
CONCLUSION: Celecoxib (400 mg po) administered on the day of surgery and for 3 days postoperatively is effective in improving postoperative pain management, as well as the speed and quality of recovery after major plastic surgery. However, perioperative administration offers no advantages over simply giving the drug after surgery.

Does Patient-Controlled Continuous Interscalene Block Improve Early Functional Rehabilitation After Open Shoulder Surgery? [Miscellaneous Article]
Hofmann-Kiefer, Klaus MD *; Eiser, Tim MD *; Chappell, Daniel MD *; Leuschner, Stephan MD ++; Conzen, Peter MD *; Schwender, Dirk MD +
Anesthesia & Analgesia. 106(3):991-996, March 2008.

BACKGROUND: Early mobilization after shoulder surgery plays a vital role in successful functional rehabilitation. However, postoperative pain often reduces, or even prevents, effective physiotherapy. We investigated the effect of analgesia via patient-controlled interscalene technique on early functional rehabilitation after open shoulder surgery.
METHODS: Eighty-seven patients were randomly assigned to one of two groups: patient-controlled continuous interscalene block (PCISB) and patient-controlled IV (opioid) analgesia (PCA). Interscalene block was performed preoperatively; otherwise analgesic protocols were started in the postanesthesia care unit and were continued for 72 h. Physiotherapy was performed for 60 min a day on day 2 and 3 after surgery according to a standardized protocol. Maximum mobility was defined as the range of motion that could be achieved with pain as the limiting factor. Efficiency of functional rehabilitation was evaluated 1 day before and 3 days after surgery with the help of a multimodal scoring system (Constant-Score) that evaluates pain, daily life activity, strength and range of motion. Maximum intensity of pain was also monitored via Visual Analog Scales for the first 72 h after surgery and during in-hospital physiotherapy.
RESULTS: Constant-Score rates were significantly improved by the interscalene block. However, no significant differences in mobility and strength sub-scores were observed between the groups. Compared with PCA, PCISB proved to be beneficial concerning pain at rest at 6 h (P < 0.001), 24 h (P = 0.044), and 72 h (P = 0.013) and for pain during physiotherapy at 48 h after surgery (P = 0.016).
CONCLUSION: Compared with opioid-based PCA, PCISB improved analgesia, but not function, during early rehabilitation of the shoulder joint.

Vasoconstriction and Analgesic Efficacy of Locally Infiltrated Levobupivacaine for Nasal Surgery. [Miscellaneous]
Demiraran, Yavuz MD *; Ozturk, Ozcan MD +; Guclu, Ender MD +; Iskender, Abdulkadir MD *; Ergin, Mehmet Hakan MD *; Tokmak, Abdurahman MD +
Anesthesia & Analgesia. 106(3):1008-1011, March 2008.

BACKGROUND: In this study, we compared the use of preincisional lidocaine 2% with epinephrine (LA) and levobupivacaine 0.25% plain (LB) for postoperative analgesia and vasoconstriction in patients undergoing nasal surgery.
METHODS: Sixty patients were randomly assigned to receive preincisional local infiltration under general anesthesia. Group LB received levobupivacaine 0.25%, and group LA received epinephrine plus lidocaine 2% (add volume injected). Intraoperative hemodynamic changes, pre- and postoperative hemoglobin and hematocrit values were recorded. Visual analog scale values 30 min and 1, 2, 8, 12, and 24 h postoperatively and the need for rescue analgesic treatment in the first 24 h of all patients was recorded.
RESULTS: At 30 min and 1, 2, 8, and 12 h postoperatively, visual analog scale values were lower in group LB than in group LA (P < 0.0001, P = 0.002, P = 0.023, P < 0.0001, and P = 0.011, respectively). The analgesic requirement was significantly lower in group LB when compared with that in group LA (P = 0.038). Group LB had significant differences between preoperative and postoperative hemoglobin and hematocrit values (P = 0.014 and 0.025). Group LA had significant differences between preoperative and postoperative hemoglobin and hematocrit values (P = 0.031 and 0.024).
CONCLUSIONS: We conclude that postoperative analgesia in nasal surgery with local infiltration of levobupivacaine was significantly more potent and longer lasting than that achieved by lidocaine plus epinephrine.

A Simplified Approach to Vertical Infraclavicular Brachial Plexus Blockade Using Hand-Held Doppler. [Report]
Renes, Steven MD *; Clark, Laura MD +; Gielen, Mathieu MD, PhD *; Spoormans, Huub MD ++; Giele, Janneke MSc *; Wadhwa, Anupama MD [S]
Anesthesia & Analgesia. 106(3):1012-1014, March 2008.

In this observational study, we used Doppler ultrasound during the performance of vertical infraclavicular brachial plexus blockade. The success rate at inserting the needle at the point where the sound of the subclavian artery via Doppler reached its maximum audibility was compared with that of the classical insertion point. In 89 of the 100 patients, the medial or posterior cord was found at first needle pass. Using the Doppler point for insertion resulted in a significantly more lateral entry point compared with the classical point (P < 0.001) and was associated with a high success rate of infraclavicular block.

A Novel Approach for Assessing Catheter Position After Ultrasound-Guided Placement of Continuous Interscalene Block. [Report]
Swenson, Jeffrey D. MD; Davis, Jennifer J. MD; DeCou, Jennifer A. MD
Anesthesia & Analgesia. 106(3):1015-1016, March 2008.

The increasing use of ultrasound has allowed anesthesiologists to perform nerve blocks with a high success rate and without nerve stimulation or eliciting a paresthesia. The ability to visualize peripheral nerve catheters using ultrasound is limited. We present a novel method to confirm the position of an interscalene catheter tip using injection of agitated contrast. The described technique is simple and allows timely assessment of catheter tip position.

The Relationship Between Bispectral Index and Propofol During Target-Controlled Infusion Anesthesia: A Comparative Study Between Children and Young Adults
Rigouzzo, Agnes MD *; Girault, Laure MD *; Louvet, Nicolas MD *; Servin, Frederique MD, PhD +; De-Smet, Tom ++; Piat, Veronique MD *; Seeman, Robert MD *; Murat, Isabelle MD, PhD *; Constant, Isabelle MD, PhD *
Anesthesia & Analgesia. 106(4):1109-1116, April 2008.

BACKGROUND: In this prospective study, we compared the relationship between propofol concentrations and bispectral index (BIS) in children versus young adults anesthetized with target-controlled infusion (TCI) of propofol.
METHODS: Forty-five prepubertal subjects (children) and 45 postpubertal subjects (adults) were studied. All patients were anesthetized with TCI of propofol, based on the Kataria et al.'s model for children and on the Schnider et al.'s model for adults. All data from the BIS and the TCI system were continuously recorded using Rugloop software. Remifentanil was continuously administered throughout the study (0.25 [mu]g [middle dot] kg-1 [middle dot] min-1). In all patients, after the end of surgery, a 12-min period with a stable target plasma concentration (Ct) of propofol, randomly assigned at 2, 3, 4, 5, and 6 [mu]g/mL, was performed. In addition, in most of the patients, another 12-min period was performed during which the BIS was targeted at 50 +/- 5. After each 12-min steady-state period, the Ct and BIS were noted and the plasma concentration of propofol was measured (Cm). The Ct and Cm corresponding to half maximal effect (BIS50) was determined by the Hill equation, and by targeting BIS at 50.
RESULTS: In children, as in adults, BIS values were highly correlated with the corresponding Ct or Cm of propofol following classical Emax dose-response curves. The ECt50 and the ECm50, derived from the dose-response curves, were higher in children than in adults: ECm50: 4.0 (3.6-4.5) [mu]g/mL vs 3.3 (3.0-3.7) [mu]g/mL [mean (95% CI)], P < 0.001; as well were the Ct and Cm clinically obtained when BIS was targeted at 50 (Cm50: 4.3 +/- 1.1 [mu]g/mL vs 3.4 +/- 1.2 [mu]g/mL, (mean +/- sd) P < 0.05, children versus adults). Cm was generally under-estimated by the Ct, and the bias was higher in children than in adults: 2.6 +/- 2.6 [mu]g/mL vs 1.7 +/- 1.6 [mu]g/mL (P = 0.05).
CONCLUSIONS: The good relationship between propofol and BIS demonstrated in children as in adults suggested a slightly lower sensitivity to propofol in children. As the predictability of plasma propofol concentrations with the classical pharmacokinetic/pharmacodynamic models is limited in children, a cerebral pharmacodynamic feedback, such as BIS, may be useful in this population.

The Effects of Oral Ondansetron Disintegrating Tablets for Prevention of At-Home Emesis in Pediatric Patients After Ear-Nose-Throat Surgery
Davis, Peter J. MD *+; Fertal, Kathleen M. RN, CCRC +; Boretsky, Karen R. MD *+; Fedel, Gina M. MD *+; Ingram, Michael D. MD *; Woelfel, Susan K. MD *+; Hoffmann, Paul C. RPh ++; Gurnaney, Harshad MD *+; Young, Michael C. MS *+
Anesthesia & Analgesia. 106(4):1117-1121, April 2008.

BACKGROUND: Tonsillectomy and adenoidectomy are associated with a frequent incidence of vomiting, both in the hospital and at home. We evaluated the effects of oral ondansetron disintegrating tablets (ODT) on the incidence of at-home emesis in children undergoing tonsillectomy with and without adenoidectomy and with and without bilateral myringotomy and tube insertion.
METHODS: All patients underwent inhaled mask induction with nitrous oxide, oxygen, and sevoflurane. Morphine, dexamethasone, and ondansetron were administered to all patients intraoperatively. Postoperative pain was treated with fentanyl or acetaminophen with codeine. Rescue antiemetics in the postanesthesia care unit or same day surgery unit were administered for three emetic episodes within 15 min, or upon patient or parent request. Patients were randomized for at-home administration of five doses of either ondansetron ODT or a placebo. All patients were followed for the first 3 days after surgery. At-home emesis was the primary outcome variable.
RESULTS: Two hundred and twenty-one patients were entered into the study, yielding 200 evaluable subjects. At-home emesis occurred in 15 (14.5%) of the 103 children who received ODT, and 31 (32%) of the 97 children in the placebo group, P = 0.004. Subgroup analysis demonstrated efficacy in patients who did not require rescue medication for nausea and vomiting while in the hospital, but did not demonstrate efficacy for patients who required rescue medication.
CONCLUSIONS: At-home use of ODT may prevent emesis in children during the first 3 days after tonsillectomy in children. Patients who require rescue after prophylactic treatment for nausea and vomiting in the hospital may not respond to prophylactic ondansatron ODT at home.

One-Year Experience with Day-of-Surgery Pregnancy Testing Before Elective Orthopedic Procedures.
Kahn, Richard L. MD *+; Stanton, Maureen A. RN *; Tong-Ngork, Sarani BS *; Liguori, Gregory A. MD *+; Edmonds, Chris R. MD *+; Levine, David S. MD *+
Anesthesia & Analgesia. 106(4):1127-1131, April 2008

BACKGROUND: Elective surgery is generally postponed in pregnancy. A policy of testing for urine human chorionic gonadotropin (hCG) in all women of childbearing age on the day of surgery was initiated at an elective orthopedic surgery facility. This is a retrospective report of our 1 yr experience and the associated costs.
METHODS: Records were reviewed from January 3, 2005, through January 2, 2006, to determine the number of urine hCG tests performed, and the disposition of all patients with a positive result. Costs were calculated using the charges for testing supplies and laboratory labor.
RESULTS: During the first year of policy implementation, 2588 of 2595 women of childbearing age underwent urine hCG testing. Five patients had a positive result, and surgery was cancelled. Of these five, three were previously unrecognized pregnancies, one an unrecognized asymptomatic ectopic pregnancy, and one a false-positive result in a perimenopausal woman. Three other women had a "weak positive" urine result, followed by a negative serum hCG. Surgery proceeded in all three. The calculated cost was $5.03 per urine test, and $3273 for each true positive result.
CONCLUSIONS: A policy of routinely performing urine hCG pregnancy tests in women of childbearing age on the day of surgery was effective in detecting unrecognized pregnancy. This resulted in a postponement of elective surgery in all cases. Of 2588 women tested, one had surgery postponed because of a false-positive result. The cost of $3273 per true positive test must be compared with the benefit.

Single-Dose Dexamethasone Reduces Dynamic Pain After Total Hip Arthroplasty
Kardash, Kenneth J. MD *; Sarrazin, Frederic BEng, MD *; Tessler, Michael J. MD *; Velly, Ana M. DDS, PhD +++
Anesthesia & Analgesia. 106(4):1253-1257, April 2008

BACKGROUND: Preoperative glucocorticoids reduce postoperative nausea but may also improve analgesia and decrease opioid consumption.
METHODS: Fifty consecutive patients undergoing elective, unilateral, primary total hip arthroplasty under spinal anesthesia with propofol sedation received in a randomized, double-blind, placebo-controlled manner either 40 mg of dexamethasone or saline placebo IV before the start of surgery. IV patient-controlled analgesia morphine, ibuprofen 400 mg po q6 h and acetaminophen 650 mg po q6 h were given for 48 h. Pain (0-10 numeric rating scale, NRS) at rest, side effects, and total cumulative patient-controlled analgesia morphine consumption were recorded q4 h for 48 h. Dynamic pain NRS score was recorded at 24 h. C-reactive protein levels were measured in a subgroup of 25 patients at 48 h.
RESULTS: The intraoperative sedation requirement with propofol was significantly increased in the dexamethasone group (234.6 +/- 160.1 vs 138.8 +/- 122.7 mg, P = 0.02). Dynamic pain was greatly reduced in the dexamethasone group (NRS score: 2.7, 95% CI: 2.2-3.1 vs 6.8, 6.4-7.2; P < 0.0001). There was no significant effect on pain at rest or cumulative morphine consumption at any time. C-reactive protein levels at 48 h were markedly reduced by dexamethasone (52.4 mg/mL, 28.2-76.6 vs 194.2, 168.9-219.4; P < 0.0001). Seven patients in the control group, but only one in the dexamethasone group, were treated for nausea (P = 0.05).
CONCLUSIONS: A single, preoperative IV dose of dexamethasone 40 mg has a prolonged suppressive effect on the inflammatory response and decreases dynamic pain 24 h after total hip arthroplasty.

A Prospective Randomized Trial on the Role of Perioperative Celecoxib Administration for Total Knee Arthroplasty: Improving Clinical Outcomes
Reuben, Scott S. MD *; Buvenandran, Asokumar MD +; Katz, Brennan DO *; Kroin, Jeffrey S. PhD +
Anesthesia & Analgesia. 106(4):1258-1264, April 2008.

BACKGROUND: Total knee arthroplasty (TKA) is associated with considerable postoperative pain, which, if unrelieved, may result in prolonged hospital stay, inability to participate in rehabilitation programs, poor outcomes, and greater use of healthcare resources. The hypothesis of this study is that perioperative administration of celecoxib will improve analgesic efficacy, with a resultant improvement in short- and long-term clinical outcomes after TKA.
METHODS: We studied 200 patients undergoing elective TKA in a prospective, randomized, double-blind, placebo-controlled fashion. All patients underwent a similar perioperative anesthetic/analgesic procedure. After completion of surgery, patients were started on an epidural infusion with patient-controlled epidural analgesia. Patients were instructed to keep their numerical rating score pain <=3. Patients were randomly assigned to one of two groups: celecoxib or placebo. The celecoxib group received celecoxib 100 mg orally twice a day 7 days before surgery. On the day of surgery, celecoxib 400 mg was administered 1-2 h before surgery and then 200 mg every 12 h for 10 postoperative days. The control group received matching placebo capsules at the same times. The primary objective of this study was to determine whether the perioperative use of celecoxib reduces the amount of postoperative opioid consumption. Secondary objectives were to determine whether celecoxib is associated with improved clinical outcomes and a reduction in opioid-related adverse effects.
RESULTS: The celecoxib group required less patient-controlled epidural analgesia over the 40-h postoperative period: placebo 232.8 +/- 2.0 mL, celecoxib 209.1 +/- 1.8 mL (P < 0.001). At home over days 4-10 after surgery, the celecoxib group had reduced pain intensity with movement (F = 109.7, P < 0.001) at all time points. The celecoxib group also consumed less oxycodone at home than placebo group (F = 417.8, P < 0.001). With active movement, range of motion (ROM) differed between the two groups over postoperative days 1-3 (F = 50.7, P < 0.001), with the celecoxib group having greater ROM at all time points. There was earlier achievement of 90 degrees knee flexion with celecoxib compared with placebo (P < 0.001). Celecoxib patients had a better overall Knee Society Score (93.3 +/- 0.6) than placebo patients (86.4 +/- 0.9) at 12-mo follow-up (P < 0.001). The incidence of side effects (nausea, vomiting, and pruritus) in the immediate postoperative period was less in the celecoxib group.
CONCLUSIONS: Perioperative use of celecoxib reduces postoperative pain, opioid consumption, opioid-related adverse effects, and is associated with long-term benefits including improved knee function and less time to achieve effective knee ROM after TKA.

ANESTHESIOLOGY - TOP

Incidence and Risk Factors for Perioperative Adverse Respiratory Events in Children Who Are Obese.
Clinical Investigations
Tait, Alan R. Ph.D. ; Voepel-Lewis, Terri M.S.N., R.N. ; Burke, Constance B.S.N., R.N. ; Kostrzewa, Amy M.D. ; Lewis, Ian M.B.B.S., M.R.C.P., F.R.C.A. 
Anesthesiology. 108(3):375-380, March 2008.

Abstract:
Background: Consistent with the increasing prevalence of obesity in the United States and many countries worldwide, anesthesiologists are now presented with a greater number of adult and pediatric patients who are significantly overweight. This prospective study was designed to examine the relation between age-adjusted body mass index, preoperative comorbidities, and perioperative outcome in children.
Methods: Children aged 2-18 yr undergoing noncardiac elective procedures were classified as overweight or obese based on their age- and sex-adjusted body mass index. Information was elicited regarding patient demographics, presence of comorbidities, and anesthetic technique. Data regarding the incidence and severity of perioperative adverse events were collected prospectively.
Results: Two thousand twenty-five children comprised the sample (1,380 normal weight, 351 overweight, and 294 obese). Obese children had a significantly higher prevalence of comorbidities than nonobese children, including asthma, hypertension, sleep apnea, and type II diabetes. Furthermore, obese children had a higher incidence of difficult mask ventilation, airway obstruction, major oxygen desaturation (>10% of baseline), and overall critical respiratory adverse events. Logistic regression analysis revealed several risk factors for adverse events, including procedures involving the airway, obesity, age younger than 10 yr, and a history of obstructive sleep apnea.
Conclusions: These results suggest that children presenting for elective surgical procedures who are obese have a greater prevalence of preexisting comorbid medical conditions and an increased incidence of perioperative adverse respiratory events compared with normal-weight children. Identification and awareness of risk factors for perioperative complications will be important in optimizing the anesthetic management of these children.

Metabolic Syndrome and Insulin Resistance: Perioperative Considerations.
Review Article
Bagry, Hema S. M.D., D.N.B., F.R.C.A. ; Raghavendran, Sreekrishna M.D., D.N.B., F.R.C.A. ; Carli, Franco M.D., M.Phil., F.R.C.A., F.R.C.P.C. 
Anesthesiology. 108(3):506-523, March 2008.

Abstract:
Metabolic syndrome represents a constellation of risk factors associated with increased incidence of cardiovascular disease and progression to diabetes mellitus. Insulin resistance, a state of decreased biologic response to physiologic concentrations of insulin, is a key component of this syndrome and seems to be the result of a primary defect at the skeletal muscle glucose transporter. Acute illness and the perioperative period are characterized by a state of insulin resistance that manifests as hyperglycemia and leads to various other metabolic and biochemical alterations that adversely affect end organ function. Hyperglycemia in acutely ill patients adversely affects outcome. Achieving euglycemia seems beneficial in certain clinical situations, but considerable disagreement exists regarding the target blood sugar levels, the duration of therapy, and the modality. Pharmacotherapy, exercise, and nutrition to improve insulin sensitivity seem promising but require further evaluation to confirm their efficacy for perioperative risk reduction. This review discusses the pathophysiology and the clinical implications of metabolic syndrome and insulin resistance in the acutely ill patient with an emphasis on perioperative modulation strategies.

Ultrasound Guidance May Reduce but Not Eliminate Complications of Peripheral Nerve Blocks
Hadzic, Admir M.D., Ph.D.; Sala-Blanch, Xavier M.D.; Xu, Daquan M.D., M.P.H.
Anesthesiology. 108(4):557-558, April 2008.

This Editorial View accompanies the following two articles: Loubert C, Williams SR, Hélie F, Arcand G: Complication during ultrasound-guided regional block: Accidental intravascular injection of local anesthetic. Anesthesiology 2008; 108:759-60; Zetlaoui PJ, Labbe J-P, Benhamou D: Ultrasound guidance for axillary plexus block does not prevent intravascular injection. Anesthesiology 2008; 108:761.

Cardiac Arrests and Deaths Associated with Malignant Hyperthermia in North America from 1987 to 2006: A Report from The North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States.
Larach, Marilyn Green M.D., F.A.A.P. ; Brandom, Barbara W. M.D. ; Allen, Gregory C. M.D., F.R.C.P.C. ; Gronert, Gerald A. M.D. ; Lehman, Erik B. M.S. 
Anesthesiology. 108(4):603-611, April 2008.

Abstract:
Background: The authors determined associated cardiac arrest and death rates in cases from Canada and the United States as reported to The North American Malignant Hyperthermia (MH) Registry and analyzed factors associated with a higher risk of poor outcomes.
Methods: The authors searched the database for AMRA (adverse metabolic/musculoskeletal reaction to anesthesia) reports with inclusion criteria as follows: event date between January 1, 1987, and December 31, 2006; "very likely" or "almost certain" MH as ranked by MH Clinical Grading Scale; location in Canada or the United States; and one or more anesthetic agents given. The exclusion criterion was a pathologic condition other than MH independently judged by the authors. Severe MH outcomes were analyzed as regards clinical history and presentation, using Wilcoxon rank sum tests for continuous variables and Pearson exact chi-square tests for categorical variables. A Bonferroni correction adjusted for multiple comparisons.
Results: Of 291 events, 8 (2.7%) resulted in cardiac arrests and 4 (1.4%) resulted in death. The median age in cases of cardiac arrest/death was 20 yr (range, 2-31 yr). Associated factors were muscular build (odds ratio, 18.7; P = 0.0016) and disseminated intravascular coagulation (odds ratio, 49.7; P < 0.0001). Increased risk of cardiac arrest/death was related to a longer time period between anesthetic induction and maximum end-tidal carbon dioxide (216 vs. 87 min; P = 0.003). Unrelated factors included patient or family history, anesthetic management, and the MH episode.
Conclusions: Modern US anesthetic practice did not prevent MH-associated cardiac arrest and death in predominantly young, healthy patients undergoing low- to intermediate-risk surgical procedures.

Success of Tracheal Intubation with Intubating Laryngeal Mask Airways: A Randomized Trial of the LMA Fastrach(TM) and LMA CTrach(TM).
Liu, Eugene H. F.R.C.A. ; Goy, Raymond W. F.A.N.Z.C.A. ; Lim, Yvonne M.Med. ; Chen, Fun-Gee F.A.N.Z.C.A. 
Anesthesiology. 108(4):621-626, April 2008.

Abstract:
Background: The LMA CTrach(TM) system (The Laryngeal Mask Company, Singapore) is a development of the LMA Fastrach(TM) system (The Laryngeal Mask Company, Singapore), with integrated fiberoptic bundles and a detachable liquid crystal display viewer. This randomized study of 271 patients compared tracheal intubation with these two systems.
Methods: In both groups, ventilation was optimized after insertion of the laryngeal mask conduit before proceeding further: intubation with the LMA Fastrach(TM), and optimizing the conduit placement and view and then intubation with the LMA CTrach(TM). The first-attempt and overall success rates of tracheal intubation, and the times required, were recorded.
Results: Tracheal intubation was successful on the first attempt in 93.3% of patients with the LMA CTrach(TM) and 67.9% of patients with the LMA Fastrach(TM) (P < 0.001). The success rates within three attempts were 100% with the LMA CTrach(TM) and 96.4% with the LMA Fastrach(TM) (P = 0.06). The median (interquartile range) time for the complete tracheal intubation process was 116 (82-156) s with the LMA CTrach(TM) and 100 (74-121) s with the LMA Fastrach(TM) (P = 0.002). There was no correlation between the grade of conventional laryngoscopy and success of intubation with either system.
Conclusions: The ability to view the glottis and optimize placement of the LMA CTrach(TM) under vision enabled a higher first-attempt success rate of tracheal intubation with the LMA CTrach(TM). However, more time is required with the LMA CTrach(TM), there are failed views in some patients, and its cost effectiveness remains unclear.

Ambulatory Continuous Femoral Nerve Blocks Decrease Time to Discharge Readiness after Tricompartment Total Knee Arthroplasty: A Randomized, Triple-masked, Placebo-controlled Study.
Ilfeld, Brian, Le, Linda, Meyer, R, Mariano, Edward, Vandenborne, Krista, Duncan, Pamela, Sessler, Daniel, Enneking, F, Shuster, Jonathan, Theriaque, Douglas, Berry, Linda, Spadoni, Eugene, Gearen, Peter
Anesthesiology. 108(4):703-713, April 2008.

Background: The authors tested the hypotheses that, compared with an overnight continuous femoral nerve block (cFNB), a 4-day ambulatory cFNB increases ambulation distance and decreases the time until three specific readiness-for-discharge criteria are met after tricompartment total knee arthroplasty.
Methods: Preoperatively, all patients received a cFNB (n = 50) and perineural ropivacaine 0.2% from surgery until the following morning, at which time they were randomly assigned to either continue perineural ropivacaine or switch to perineural normal saline. Primary endpoints included (1) time to attain three discharge criteria (adequate analgesia, independence from intravenous analgesics, and ambulation of at least 30 m) and (2) ambulatory distance in 6 min the afternoon after surgery. Patients were discharged with their cFNB and a portable infusion pump, and catheters were removed on postoperative day 4.
Results: Patients given 4 days of perineural ropivacaine attained all three discharge criteria in a median (25th-75th percentiles) of 25 (21-47) h, compared with 71 (46-89) h for those of the control group (estimated ratio, 0.47; 95% confidence interval, 0.32-0.67; P <0.001). Patients assigned to receive ropivacaine ambulated a median of 32 (17-47) m the afternoon after surgery, compared with 26 (13-35) m for those receiving normal saline (estimated ratio, 1.21; 95% confidence interval, 0.71-1.85; P = 0.42).
Conclusions: Compared with an overnight cFNB, a 4-day ambulatory cFNB decreases the time to reach three important discharge criteria by an estimated 53% after tricompartment total knee arthroplasty. However, the extended infusion did not increase ambulation distance the afternoon after surgery. (ClinicalTrials.gov No. NCT00135889.)

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Intrathecal low-dose hyperbaric bupivacaine-clonidine combination in outpatient knee arthroscopy: a randomized controlled trial
I. VAN TUIJL, M. J. M. M. GIEZEMAN, S. A. BRAITHWAITE, P. J. HENNIS, C. J. KALKMAN, W. A. VAN KLEI
Acta Anaesthesiologica Scandinavica 2008; 52 (3), 343–349

Background: Spinal anesthesia for knee arthroscopy can be produced with a low dose of bupivacaine, but additional intrathecal drugs are often required to lower the risk of failed blocks. We investigated the effect of the addition of clonidine (0, 15 or 30 μg) to 5 mg hyperbaric bupivacaine on the duration of the motor block, analgesic quality and ability to void after the surgery in a randomized controlled trial.
Methods: Seventy-five patients received spinal anesthesia using either 5 mg hyperbaric bupivacaine (B5C0), 5 mg hyperbaric bupivacaine with 15 μg clonidine (B5C15) or 5 mg hyperbaric bupivacaine with 30 μg clonidine (B5C30). The primary outcome was the duration of the motor block. Secondary outcomes included the time until spontaneous voiding, and the need for additional analgesia or general anesthesia.
Results: The mean time to complete regression of motor block was 70 (±43) min in group B5C0. Adding 15 and 30 μg of clonidine increased the motor block duration by 25 [95% confidence interval (CI): 2–48] and 34 (95% CI: 11–57) min, respectively, but resulted in better analgesic quality. The mean time until spontaneous voiding was 177 min in the B5C0 group. This time increased with 18 (95% CI −13 to 49) and 44 (95% CI 15–74) min in group B5C15 and group B5C30, respectively.
Conclusion: The addition of 15 μg clonidine to 5 mg of intrathecal hyperbaric bupivacaine prolongs the duration of motor block and improves the quality of the block.

Laparoscopic vs. small incision cholecystectomy: Implications for pulmonary function and pain. A randomized clinical trial
F. KEUS, U. AHMED ALI, G. J. NOORDERGRAAF, J. A. ROUKEMA, H. G. GOOSZEN, C. J. H. M. VAN LAARHOVEN
Acta Anaesthesiologica Scandinavica 2008; 52 (3), 363–373

Background: Upper abdominal surgery, including laparoscopic cholecystectomy (LC), is associated with post-operative pulmonary dysfunction. LC has, by consensus, become the treatment of choice for symptomatic cholecystolithiasis. The small-incision cholecystectomy (SIC), a procedure which does not require a pneumoperitoneum threatens to be lost to clinical practice even though there is evidence of equality. We hypothesized that the SIC technique should be equal and might even be superior to the LC when considering post-operative pulmonary function due to the short incision length.
Methods: A single-centre, randomized clinical trial was performed including patients scheduled for elective cholecystectomy. Pulmonary flow–volume curves were measured pre-operatively, post-operatively, and at follow up. Blood gas analyses were measured pre-operative, in the recovery phase and on post-operative day 1. Anaesthesia, analgesics, and peri-operative care were standardized by protocol. Post-operatively, patients and caregivers were blinded to the procedure.
Results: A total of 257 patients were analysed. There was one pulmonary complication (pneumonia) in the LC group. In both groups, similar reductions of approximately 20% in pulmonary function parameters occurred, with complete recovery to pre-operative values. Patients in the SIC group consumed more analgesia when compared with the LC group without impact on blood gas analysis. Patients converted to a conventional open technique showed significant differences in six of the eight parameters in pulmonary function tests.
Conclusion: When evaluated with strict methodology and standardization of care, no clinically relevant differences were found between SIC and LC regarding pulmonary function. Our results suggest that the popularity of the laparoscopic technique cannot be attributed to pulmonary preservation.

Blood volume is normal after pre-operative overnight fasting
M. JACOB, D. CHAPPELL, P. CONZEN, U. FINSTERER, M. REHM
Acta Anaesthesiologica Scandinavica 2008; 52 (4), 522–529

Background: Pre-operative fasting is assumed to cause a deficit in intravascular blood volume (BV), as a result of ongoing urine production and insensible perspiration. Standard regimes consist of volume loading prior or simultaneous to any anaesthetic procedure to minimise the risk of hypotension. However, fluid overload in the context of major abdominal surgery has been shown to deteriorate patient outcome. Our study aimed to quantify total intravascular BV after fasting by direct measurements and to compare it with calculated normal values in comparable non-fasted patients.
Methods: After 10 h of fasting, total plasma volume (PV) and red cell volume (RCV) were measured via the double-label technique (indocyanine green dilution and erythrocytes labelled with fluorescein, respectively) following induction of general anaesthesia in 53 gynaecological patients suffering from malignoma of the cervix. The corresponding normal values were calculated individually from age, body height and body weight.
Results: Measured BV, RCV and PV after fasting were 4123±589, 1244±196 and 2879±496 ml, respectively. The differences to the corresponding calculated normal values were not significant (3882±366, 1474±134 and 2413±232 ml, respectively). The measured haematocrit reflected a slight anaemic state (0.35±0.03).
Conclusion: Our data suggest that even after prolonged pre-operative fasting, cardio-pulmonary healthy patients remain intravascularly normovolaemic. Therefore, hypotension associated with induction of general or neuraxial anaesthesia should perhaps be treated with moderate doses of vasopressors rather than with undifferentiated volume loading.

Addition of ketamine to propofol for initiation of procedural anesthesia in children reduces propofol consumption and preserves hemodynamic stability
M. T. AOUAD, A. R. MOUSSA, C. M. DAGHER, S. A. MUWAKKIT, S. I. JABBOUR-KHOURY, R. A. ZBEIDY, M. R. ABBOUD, G. E. KANAZI
Acta Anaesthesiologica Scandinavica 2008; 52 (4), 561–565

Background: There is no ideal anesthesia protocol to perform short invasive procedures in pediatric oncology. The combination of propofol and ketamine may offer advantages over propofol alone.
Methods: In a prospective, randomized, double-blind study, we analyzed 63 consecutive procedures performed in 47 oncology children. All patients received 1 μg/kg fentanyl, followed by propofol 1 mg/kg in group P (n=33) or propofol 0.5 mg/kg and ketamine 0.5 mg/kg in group PK (n=30) for the initiation of anesthesia. The need for supplementation with propofol and/or fentanyl to maintain an adequate level of anesthesia was recorded. The hemodynamic and respiratory profile, recovery time and the occurrence of side effects were compared.
Results: Significantly more children required propofol (100% vs. 83.3%) and fentanyl (75.5% vs. 43.3%) rescue doses, and developed hypotension (63.6% vs. 23.4%) and bradycardia (48.5 vs. 23.4%) in group P compared with group PK, with a comparable incidence of respiratory adverse events and recovery times. However, 40% of children in group PK were agitated following recovery compared with 6% in group P.
Conclusions: The combination of propofol and ketamine for invasive procedures in pediatric oncology resulted in reduced propofol and fentanyl consumption and preserved hemodynamic stability, but more children in the combination group recovered with agitation.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Evaluation of a decision support system to predict preoperative investigations
B. V. S. Murthy, S. P. Lake and A. C. Fisher
British Journal of Anaesthesia 2008 100(3):315-321;

Background: We have developed the ‘Optimising Surgical Care and Assessment Record’ (OSCAR), a clinical decision support system, to help nurses in predicting necessary preoperative investigations before surgery. OSCAR applies the hospital’s protocols, which are based on the National Institute for Health and Clinical Excellence guidelines, to the patient’s medical history and surgical details before recommending required investigations.
Methods: We selected case notes of 50 patients randomly from the OSCAR system that were recorded between October 2006 and January 2007. To form a reference standard, these case histories were anonymized and then sent to 10 consultant anaesthetists across the country. They were asked to study the case history and choose which tests they would carry out and which they would not. Then we have evaluated OSCAR’s ability to predict the necessary investigations and the nurses’ judgement, in comparison with the reference standard.
Results: OSCAR’s ability to identify which investigations should be carried out, that is, its sensitivity, was 91.5% and its ability to identify which investigations not to carry out, that is, its specificity, was 82.7%. OSCAR was consistent in predicting investigations for differing severities of surgery, for ASA grade and gender. We were unable to demonstrate any overall difference between OSCAR and the nurse’s ability to predict preoperative investigations. When combining the nurse’s predictions with OSCAR’s recommendations, an even greater sensitivity of 98.2% could be achieved.
Conclusions: OSCAR’s prediction algorithm cannot replace the nurse’s judgement, but it can be used as a supplementary decision aid to promote consistency and improve accuracy.

Setting priorities for improving the preoperative assessment clinic: the patients' and the professionals' perspective
G. M. Edward, J. C. J. M. de Haes, F. J. Oort, L. C. Lemaire, M. W. Hollmann and B. Preckel
British Journal of Anaesthesia 2008 100(3):322-326

Background: The quality of the preoperative assessment clinic (PAC) is determined by many factors. Patients’ experiences are important indicators, but often overlooked. We prepare to set priorities to improve the PAC by obtaining detailed patients’ feedback on the quality of the PAC, and establishing the value patients and professionals attach to different care aspects, using the Patient Experiences with the Preoperative Assessment Clinic questionnaire.
Methods: The PAC’s standard of service was determined for five care aspects (dimensions), using patients’ feedback. The importance of a dimension to patients was determined by calculating the effects of the dimensions on patients’ overall appraisal. In addition, professionals were asked to rate the importance of the different care aspects.
Results: Patients had the most positive experiences with the nurse, and the least positive experiences with waiting. However, waiting was least important to patients. When combining the PAC’s standard of service with the value given to the dimensions by patients and professionals separately, we found in both instances that waiting was in greatest need of improvement. This was followed by reception, the anaesthetist, remaining experiences, and finally the nurse.
Conclusions: Quality improvement of the PAC can be achieved by obtaining patients’ feedback on the quality, determine a PAC’s standard of service, recognize service areas that require improvement, and identify actions appropriate to bring about improvement. The value patients and professionals attach to different aspects of care can then be used to prioritize improvements.

Ketamine gargle for attenuating postoperative sore throat
O. Canbay, N. Celebi, A. Sahin, V. Celiker, S. Ozgen and U. Aypar
British Journal of Anaesthesia 2008 100(4):490-493

Background: Tracheal intubation is a foremost cause of trauma to the airway mucosa, resulting in postoperative sore throat (POST) with reported incidences of 21–65%. We compared the effectiveness of ketamine gargles with placebo in preventing POST after endotracheal intubation.
Methods: Forty-six, ASA I–II, patients undergoing elective surgery for septorhinoplasty under general anaesthesia were enrolled in this prospective, randomized, placebo-controlled, single-blind study. Patients were randomly allocated into two groups of 23 subjects each: Group C, saline 30 ml; Group K, ketamine 40 mg in saline 30 ml. Patients were asked to gargle this mixture for 30 s, 5 min before induction of anaesthesia. POST was graded at 0, 2, 4, and 24 h after operation on a four-point scale (0–3).
Results: POST occurred more frequently in Group C, when compared with Group K, at 0, 2, and 24 h and significantly more patients suffered severe POST in Group C at 4 and 24 h compared with Group K (P<0.05).
Conclusions: Ketamine gargle significantly reduced the incidence and severity of POST.

Topical anaesthesia and intravenous cannulation success in paediatric patients: a randomized double-blind trial
G. Arendts, M. Stevens and M. Fry
British Journal of Anaesthesia 2008 100(4):521-524

Background: It is not known whether the choice of topical anaesthetic influences the likelihood of successful i.v. cannulation in the paediatric population. The null hypothesis of this study was that no difference exists in the initial success rate of cannulation between two commonly used topical anaesthetics.
Methods: A randomized double-blind trial conducted on patients between the age of 12 months and 12 yr presenting to a tertiary hospital emergency department. Patients requiring cannulation were randomized to either 4% amethocaine gel (AnGEL) or 5% lidocaine and prilocaine in a 1:1 emulsion (EMLA). The primary endpoint was success of initial attempt at i.v. cannulation.
Results: One hundred and seventy-seven patients were analysed of 203 enrolled. The success rate of AnGEL (73/97, 75%) and EMLA (59/80, 74%) did not significantly differ (21 0.05, P=0.82).
Conclusions: No difference exists in the cannulation success rates between the two anaesthetics. The choice of topical anaesthetic in paediatric cannulation should be based on other factors such as cost, time to anaesthesia, efficacy of the agent, and adverse effect profile.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Brief Review: The Cobra Perilaryngeal Airway (CobraPLA®) and the Streamlined Liner of Pharyngeal Airway (SLIPATM) supraglottic airwaysHedieh Hooshangi, MD and David T. Wong, MD
Canadian Journal of Anesthesia 55:177-185 (2008)

Purpose: To summarize the published literature related to two, new supraglottic airways (SGAs): the Cobra Perilaryngeal Airway (CobraPLA®) and the Streamlined Liner of Pharyngeal Airway (SLIPATM).
Source: We identified original articles, through searches on Medline and PubMed, using the keywords ‘Cobra’, ‘CobraPLA’, ‘Cobra-PLA’, ‘PLA’, and ‘SLIPA’.
Principal findings: Searches identified 28 publications evaluating the CobraPLA®, six of which were randomized, controlled trials. Five publications evaluated the SLIPATM, two of which were randomized, controlled trials. Studies compared the CobraPLA® with a number of SGAs, in regards to both efficacy and safety. While the CobraPLA® is comparable to the laryngeal mask airway (LMA) ClassicTM, with respect to insertion times and the incidence and severity of sore throat, the CobraPLA® is superior, with respect to airway sealing pressure, and has been used successfully in patients with limited mouth opening and limited head extension. Insertion times, first insertion success rates, recovery times, and hemodynamic responses, associated with insertion of the SLIPATM, are similar to those of the LMA ProsealTM. Although the SLIPATM has a unique reservoir chamber to contain regurgitated fluid, the extent of its protection against pulmonary aspiration has not been established in the clinical setting.
Conclusion: Both the CobraPLA® and the SLIPATM are intended for use during short procedures under general anesthesia, and have comparable efficacy and complication rates in comparison to the LMA ClassicTM. Both airways may be considered as primary SGA devices, and the CobraPLA® may be also be used as a rescue airway device.

Parents are reluctant to use technological means of communication in pediatric day care
Kimmo Murto, FRCPC, Gregory L Bryson, FRCP, Ibrahim Abushahwan, MD, Jim King, FRCPC, David Moher, PhD, Khaled El-Emam, PhD and William Splinter, FRCPC
Canadian Journal of Anesthesia 55:214-222 (2008)

Purpose: We hypothesized that advanced information and communication technology (ICT) would be acceptable to parents in a pediatric surgical, and diagnostic imaging day care setting.
Methods: After Ethics Committee approval, we distributed surveys, over a one-month period, to parents of children arriving for day care surgery or diagnostic imaging. Parents indicated their acceptance of various proposed modes of postoperative discussion of healthcare i.e.; face-to-face, videophone, or telephone. Parents were also asked to describe their receptiveness to scheduling non-emergency hospital appointments online and to receiving electronic media describing their child’s surgery and postoperative management. Parental education, income, and familiarity with the Internet were also assessed.
Results: A total of 451 surveys (84% response rate) were returned. Most parents (95%) had access to the Internet and 70% did their banking online. Forty-two percent of the parents had at least a university education and 63% had an annual family income > $50,000 Canadian. The majority of parents (98%) accepted face-to-face interaction, while only 35% and 37% of parents were receptive to videophone and telephone interviews, respectively. Computer availability (P = 0.001) and online banking (P = 0.011) were the only variables that predicted those parents who were in favour of using videophone technology. Parents were receptive to instruction electronic media (80%) and booking appointments online (61%).
Conclusions: A well-educated and technologically sophisticated parent population does not favour advanced communication technologies over simple, face-to-face interaction in an in-hospital setting. These parents are prepared to receive technology-based information about their child’s surgery and to schedule non-emergency hospital appointments online.

PUB MED - TOP

The Thai Anesthesia Incidents Study (THAI study) of ambulatory anesthesia: II. Anesthetic profiles and adverse events.
Punjasawadwong Y, Srisawasdi S, Werawatganon T, Taratarnkoolwatana K, Chau-in W, Vasinanukorn M.
2008 Feb;91(2):188-95.

BACKGROUND: There is a continuing trend to have more elective surgery performed on an outpatient basis.
OBJECTIVE: To determine anesthetic profiles and adverse events in practice of ambulatory anesthesia for elective surgery in different levels of hospitals across Thailand.
MATERIAL AND METHOD: A prospective descriptive study was conducted in 20 hospitals comprising seven university, five regional four general and four district hospitals across Thailand. Consecutive patients undergoing anesthesia for elective surgery were included. The included patients, classified as outpatients, were selected and extracted for summary of the result by using descriptive statistics.
RESULTS: The authors reported 7786 outpatients receiving anesthesia for elective surgery. The majority of patients were in ASA class 1 and 2 (96.2%) while the rest were in ASA class 3 (3.8%). Nearly 90% of the ASA class 3 patients were in university hospitals. The majority of patients (83.1%) did not receive premedication. Diazepam was used more frequently (11.5% vs. 0.1%) than other drugs. Noninvasive blood pressure monitoring and pulse oximetry were used in greater than 90%, while electrocardiogram (EKG) was used in 67.2% and end tidal CO2 in only 6.8%. The three most common anesthetic techniques were general anesthesia (including inhalation anesthetics), total intravenous anesthesia (TIVA), and monitored anesthesia care (MAC). Regional anesthesia was performed in 12% of cases. The three most common regional anesthetic techniques were brachial plexus block (7.1%), spinal anesthesia (2.21%), and other peripheral nerve blocks (2.06%). Propofol was the most common drug for induction. Succinylcholine was used for intubation in 8.8%. The three most common nondepolaring neuromuscular blocking agents were atracurium, cisatracurium, and vecuronium. Fentanyl was the most common drug used among opioids. The three most common volatile anesthetics were sevoflurane, halothane, and isolurane. Lidocaine was the most frequently used in 29.76% of cases, while bupivacaine in 7.9% and ropivacaine only in 0.05%. The majority of the events relating to respiratory system were hypoxia or oxygen desaturation (18:10,000), reintubation (2.6:10,000) and difficult intubation (2.6:10,000), pulmonary aspiration (2.6:10,000), and esophageal intubation (1.3:10,000). Other adverse events included awareness (1.3:10,000), suspected myocardial infarction or ischemia (1.3:10,000), and drug error (1.3:10,000). Five patients (0.06%) received unplanned hospital admission. No patients developed cardiac arrest or died. CONCLUSION: The incidence of major adverse events was low in ambulatory anesthesia for elective surgery when compared to the incidence in general surgical population. The majority of the events occurred in the respiratory system. The authors did not find any complications relating to regional anesthesia. Despite a low incidence of adverse events in ambulatory anesthesia, anesthesia personnel who are responsible for ambulatory anesthesia should have adequate knowledge and skills in selection and preparation of the patients. Therefore, a system of preanesthesia evaluation is very important.

The use of droperidol before and after the Food and Drug Administration black box warning: a survey of the members of the Society of Ambulatory Anesthesia.
Habib AS, Gan TJ.
2008 Feb;20(1):35-9.

STUDY OBJECTIVE: To determine the practice of members of the Society of Ambulatory Anesthesia (SAMBA) in the management of postoperative nausea and vomiting (PONV) before and after the Food and Drug Administration (FDA) black box warning on droperidol.
DESIGN: Survey questionnaire.
SETTING: The Society of Ambulatory Anesthesia.
MEASUREMENTS: After institutional review board approval, a survey was posted on the SAMBA Web site from June 1, 2005, until October 30, 2005. Visitors of the Web site were invited to participate in the survey. The survey was designed to elicit information about the management of PONV, particularly the use of droperidol, before and after the FDA black box warning. Participants were also asked about reasons for not using droperidol in their current practice and whether they believed that the black box warning was justified.
MAIN RESULTS: Two hundred ninety-five physicians of 1,179 eligible SAMBA members completed the survey for a 25% response rate. For PONV prophylaxis, the choice of droperidol as a first-line agent decreased from 47% to 5% after the black box warning appeared (P < 0.0001). Similarly, for treatment of established PONV, the choice of droperidol decreased from 38% to 8% during this same period (P < 0.0001). A total of 261 (92%) of responders did not believe that the black box warning was justified. CONCLUSIONS: Although most surveyed practitioners believed that the FDA black box warning on droperidol is not justified, the use of this cost-effective agent has significantly declined.

A model-predictive hypnosis control system under total intravenous anesthesia.
Sawaguchi Y, Furutani E, Shirakami G, Araki M, Fukuda K.
2008 Mar;55(3):874-87.

In ambulatory surgery, anesthetic drugs must be administered at a suitable rate to prevent adverse reactions after discharge from the hospital. To realize more appropriate anesthesia, we have developed a hypnosis control system, which administers propofol as an anesthetic drug to regulate the bispectral index (BIS), an electroencephalography (EEG)-derived index reflecting the hypnosis of a patient. This system consists of three functions: 1) a feedback controller using a model-predictive control method, which can adequately accommodate the effects of time delays; 2) a parameter estimation function of individual differences; and 3) a risk control function for preventing undesirable states such as drug overinfusion or intraoperative arousal. With the approval of the ethics committee of our institute, 79 clinical trials took place since July 2002. The results show that our system can reduce the total amount of propofol infusion and maintain the BIS more accurately than anesthesiologist's manual adjustment.

Aminophylline reversal of prolonged postoperative sedation induced by propofol.
Sakurai S, Fukunaga A, Fukuda K, Kasahara M, Ichinohe T, Kaneko Y.
2008;22(1):86-8. Epub 2008 Feb 27.

Propofol is frequently used for intravenous sedation or anesthesia in ambulatory and office-based anesthesia. Although awakening is usually rapid, there are instances of delayed recovery from propofol anesthesia. It has been reported that aminophylline antagonizes the sedative effects of several anesthetic and analgesic drugs. The case reports presented here demonstrate that intravenous aminophylline effectively reversed prolonged propofol-induced sedation/anesthesia in the postoperative period. There were no side effects or delayed re-sedation after the administration of aminophylline. Our study suggests that aminophylline could be a clinically useful propofol antagonist.

Office surgery incidents: what seven years of Florida data show us.
Coldiron BM, Healy C, Bene NI.
2008 Mar;34(3):285-91; discussion 291-2. Epub 2007 Dec 20.

BACKGROUND: In the wake of increased media attention focusing on human error in medicine, numerous state medical boards and legislatures have drafted, and are continuing to draft, regulations aimed at protecting patients undergoing procedures in the office setting. These regulations will have a considerable impact on patient access to medically necessary procedures, and any regulations should be based on good data. This report summarizes 7 years of prospective data from the state of Florida, the best data available on office surgery incidents.
OBJECTIVE: The objective was to determine the nature and incidence of hospital transfers and deaths resulting from office procedures.
b This study is a compilation of mandatory reporting by Florida physicians to a central agency of all in-office adverse incidents resulting in death, serious injury, or hospital transfer in the State of Florida from March 2000 to March 2007. Telephone and internet follow-up was conducted to determine reporting physician board certification, hospital privileges, and office accreditation.
RESULTS: In 7 years there were 31 deaths and 143 procedure-related complications and hospital transfers. Liposuction and liposuction with abdominoplasty or another cosmetic procedure resulted in 24 complications and 8 deaths. Of the offices reporting adverse incidents, 38.5% were accredited by an independent accrediting agency, 92.5% of the physicians were board-certified, and 96.6% had hospital privileges. A total of 58% (18/31) of the deaths and 61% (87/143) of the complications were associated with nonmedically necessary (cosmetic) procedures. A total of 78% (14/18) of these deaths were in ASA Class 1 patients. Plastic surgeons were responsible for 48% of all deaths (83% of cosmetic surgery deaths) and for 52% of all hospital transfers (83% of cosmetic surgery complications and hospital transfers).
CONCLUSION: Plastic surgeons were responsible for an inordinate number of deaths and hospital transfers. Requiring physician board certification and physician hospital privileges would not seem to increase safety, because most physicians already have these credentials, and physicians without these credentials were not responsible for a disproportionate share of incidents. These data do not show an emergent hazard to patients from medically necessary office surgery. Liposuction under general anesthesia deserves continued scrutiny because deaths due to this procedure continue to occur and this procedure can be performed with dilute local anesthesia, with which no deaths were reported. Mandatory reporting of office incidents should be strongly supported, as well as reporting of incidents that occur after surgery in the hospital outpatient department and ambulatory surgery center. These data should be available for analysis after protecting patient confidentiality. A national debate needs to occur to determine how many deaths and injuries are acceptable from cosmetic procedures performed under general and intravenous anesthesia.

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