Avoidance of Nitrous Oxide for Patients Undergoing Major Surgery: A Randomized Controlled Trial.
Clinical Investigations
Myles, Paul S. M.B., B.S., M.P.H., M.D., F.C.A.R.C.S.I., F.A.N.Z.C.A. ; Leslie, Kate M.B., B.S., M.D., M.Epi., F.A.N.Z.C.A. ; Chan, Matthew T. V. M.B., B.S., F.A.N.Z.C.A. ; Forbes, Andrew M.Sc., Ph.D. ; Paech, Michael J. M.B., B.S., D.M., D.R.C.O.G., F.R.C.A., F.A.N.Z.C.A., F.F.P.M.A.N.Z.C.A. ; Peyton, Philip M.B., B.S., M.D., F.A.N.Z.C.A. ; Silbert, Brendan S. M.B., B.S., F.A.N.Z.C.A. ; Pascoe, Elaine B.Sc. ; the ENIGMA Trial Group 
Anesthesiology. 107(2):221-231, August 2007.

Abstract:
Background: Nitrous oxide is widely used in anesthesia, often administered at an inspired concentration around 70%. Although nitrous oxide interferes with vitamin B12, folate metabolism, and deoxyribonucleic acid synthesis and prevents the use of high inspired oxygen concentrations, the consequences of these effects are unclear.
Methods: Patients having major surgery expected to last at least 2 h were randomly assigned to nitrous oxide-free (80% oxygen, 20% nitrogen) or nitrous oxide-based (70% N2O, 30% oxygen) anesthesia. Patients and observers were blind to group identity. The primary endpoint was duration of hospital stay. Secondary endpoints included duration of intensive care stay and postoperative complications; the latter included severe nausea and vomiting, and the following major complications: pneumonia, pneumothorax, pulmonary embolism, wound infection, myocardial infarction, venous thromboembolism, stroke, awareness, and death within 30 days of surgery.
Results: Of 3,187 eligible patients, 2,050 consenting patients were recruited. Patients in the nitrous oxide-free group had significantly lower rates of major complications (odds ratio, 0.71; 95% confidence interval, 0.56-0.89; P = 0.003) and severe nausea and vomiting (odds ratio, 0.40; 95% confidence interval, 0.31-0.51; P < 0.001), but median duration of hospital stay did not differ substantially between groups (7.0 vs. 7.1 days; P = 0.06). Among patients admitted to the intensive care unit postoperatively, those in the nitrous oxide-free group were more likely to be discharged from the unit on any given day than those in the nitrous oxide group (hazard ratio, 1.35; 95% confidence interval, 1.05-1.73; P = 0.02).
Conclusions: Avoidance of nitrous oxide and the concomitant increase in inspired oxygen concentration decreases the incidence of complications after major surgery, but does not significantly affect the duration of hospital stay. The routine use of nitrous oxide in patients undergoing major surgery should be questioned.

Skin Reactions to Intradermal Neuromuscular Blocking Agent Injections: A Randomized Multicenter Trial in Healthy Volunteers.
Clinical Investigations
Mertes, Paul Michel M.D., Ph.D. ; Moneret-Vautrin, Denise Anne M.D., Ph.D. ; Leynadier, Francisque M.D. ; Laxenaire, Marie-Claire M.D. 
Anesthesiology. 107(2):245-252, August 2007.

Abstract:
Background: Numerous reports confirm the performance of intradermal tests for the diagnosis of anaphylaxis during anesthesia; however, there is controversy over their diagnostic value regarding the newer neuromuscular blocking agents (NMBAs).
Methods: One hundred eleven healthy volunteers were randomly assigned to receive intradermal injections of two NMBAs, at five increasing concentrations. A concentration was considered as a reactive concentration when it led to a positive reaction in more than 5% of the subjects. These concentrations were compared with the maximal concentration recommended for the diagnosis of sensitization to NMBAs.
Results: The maximal nonreactive concentrations were 10-3 m for suxamethonium; 10-4 m for pancuronium, vecuronium, rocuronium, and cisatracurium; and 10-5 m for atracurium and mivacurium. Except for mivacurium, these nonreactive concentrations were close to the maximal concentrations used for the diagnosis of sensitization against NMBAs. For mivacurium, the nonreactive concentrations were higher than the maximal concentration currently recommended in clinical practice.
Conclusion: The aminosteroidal NMBAs pancuronium, vecuronium, and rocuronium and the benzylisoquinoline cisatracurium have a similar potency to induce a nonspecific skin reactivity. If the criteria for positivity and the maximal concentrations of the commercially available compounds recommended by French practice guidelines are used, the risk of false-positive results is limited, and only minor modifications of these recommendations could be suggested. A slight reduction in the maximal concentration used for rocuronium from 1:100 to 1:200 and an increase from 1:1,000 to 1:200 for mivacurium can be proposed.

Immunoglobulin E Antibodies to Rocuronium: A New Diagnostic Tool.
Clinical Investigations
Ebo, Didier G. M.D., Ph.D. ; Venemalm, Lennart Ph.D. ; Bridts, Chris H. M.L.T. ; Degerbeck, Frederik M.Sc. ; Hagberg, Hans M.Sc. ; De Clerck, Luc S. M.D., Ph.D. ; Stevens, Wim J. M.D., Ph.D. 
Anesthesiology. 107(2):253-259, August 2007.

Abstract:
Background: Diagnosis of allergy from neuromuscular blocking agents is not always straightforward. The objectives of the current study were to investigate the value of quantification of immunoglobulin E (IgE) by ImmunoCAP (Phadia AB, Uppsala, Sweden) in the diagnosis of rocuronium allergy and to study whether IgE inhibition tests can predict clinical cross-reactivity between neuromuscular blocking agents.
Methods: Twenty-five rocuronium-allergic patients and 30 control individuals exposed to rocuronium during uneventful anesthesia were included. Thirty-two sera (total IgE > 1,500 kU/l) were analyzed for potential interference of elevated total IgE titers. Results were compared with quantification of IgE for suxamethonium, morphine, and pholcodine. Cross-reactivity between drugs was assessed by IgE inhibition and skin tests.
Results: Sensitivity of IgE for rocuronium, suxamethonium, morphine, and pholcodine was 68, 60, 88, and 86%, respectively. Specificity was 100% for suxamethonium, morphine, and pholcodine IgE and 93% for rocuronium IgE. ROC analysis between patients and control individuals changed the threshold to 0.13 kUa/l for rocuronium, 0.11 kUa/l for suxamethonium, 0.36 kUa/l for morphine, and 0.43 kUa/l for pholcodine. Corresponding sensitivity was 92, 72, 88, and 86%, respectively. Specificity was unaltered. Interference of elevated total IgE with quantification of IgE was demonstrated by the analysis in sera with a total IgE greater than 1,500 kU/l. IgE inhibition did not predict clinical relevant cross-reactivity.
Conclusions: The rocuronium ImmunoCAP constitutes a reliable technique to diagnose rocuronium allergy, provided an assay-specific decision threshold is applied. IgE assays based on compounds bearing ammonium epitopes are confirmed to represent reliable tools to diagnose rocuronium allergy. High total IgE titers were observed to affect specificity of the assays.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Effect of age on pulmonary gas exchange during laparoscopy in the Trendelenburg lithotomy position
O. Takahata, T. Kunisawa, M. Nagashima, K. Mamiya, K. Sakurai, S. Fujita, K. Fujimoto, H. Iwasaki
Acta Anaesthesiologica Scandinavica 2007; 51 (6), 687–692.

Background: Physiological changes in respiratory mechanics caused by aging may lead to a deterioration in pulmonary gas exchange, an increase in the alveolar–arterial oxygen gradient [(A–a)Do2] and a difference between the arterial carbon dioxide (CO₂) tension (PaCO₂) and expired end-tidal CO₂ tension (PETCO₂) [P(a-ET)CO₂] during laparoscopy in the Trendelenburg lithotomy position (TLP).
Methods:  The subjects were 51 gynecologic patients. Pressure-controlled ventilation was used to maintain PETCO₂, measured by the side stream method, within the range 4–4.67 kPa. During laparoscopy with CO₂ insufflation in TLP, the tidal volume was increased to keep PETCO₂ within ± 20% of the pre-insufflation value. The subjects were divided into three groups by age: young group (< 45 years); middle-aged group (45–64 years); and elderly group (≥ 65 years).
Results:  Before pneumoperitoneum (PPN), significant differences were found between the young and elderly groups in the arterial oxygen tension (Pao2), (A–a)Do2, PaCO₂ and P(a-ET)CO₂. In all groups, the peak inspiratory pressure and PaCO₂ increased progressively during PPN in TLP. P(a-ET)CO₂ increased gradually after starting CO₂ insufflation in TLP only in the elderly group.
Conclusions:  An increase in P(a-ET)CO₂ was seen during PPN in TLP in the elderly group. With CO₂ insufflation in TLP, the setting of mechanical ventilation based on the value of PETCO₂ (measured by the side stream method) should be determined with caution in elderly patients.

Tramadol does not prolong the effect of ropivacaine 7.5 mg/ml for axillary brachial plexus block
E. Kesimci, S. Izdes, M. Gozdemir, O. Kanbak
Acta Anaesthesiologica Scandinavica 2007; 51 (6), 736–741.

Background: The aim of this prospective, randomized, double-blind study was to evaluate the effect of the addition of tramadol to ropivacaine on the onset and duration of sensory and motor block, and duration of analgesia, for axillary brachial plexus block.
Methods: After institutional approval and informed consent had been obtained, 45 patients scheduled for forearm or hand surgery under axillary brachial plexus block were randomly allocated into two groups. The ropivacaine group received 40 ml of ropivacaine 7.5 mg/ml plus 2 ml of isotonic sodium chloride solution, and the tramadol group received 40 ml of ropivacaine 7.5 mg/ml plus 2 ml (100 mg) of tramadol. The onset and duration of sensory and motor block in the distribution of the musculocutaneous, radial, median and ulnar nerves, the duration of analgesia, the time to first pain medication, hemodynamics and side-effects were recorded.
Results: The addition of tramadol did not improve the speed of onset or increase the duration of sensory and motor block. The durations of analgesia were 631 ± 33 min and 633 ± 37 min (mean ± standard deviation) in the ropivacaine and tramadol groups, respectively (P > 0.05). Hemodynamic parameters and side-effects did not differ between the groups.
Conclusion: The addition of 100 mg of tramadol to 7.5 mg/ml of ropivacaine, for axillary brachial plexus block, does not prolong the duration of motor and sensory block and analgesia.

Single bolus of intravenous ketamine for anesthetic induction decreases oculocardiac reflex in children undergoing strabismus surgery
S. H. Choi, S. J. Lee, S. H. Kim, J. H. Kim, H. H. Kwon, Y. S. Shin, K. Y. Lee
Acta Anaesthesiologica Scandinavica 2007; 51 (6), 759–762.

Background: Oculocardiac reflex (OCR) is a major complication of pediatric strabismus surgery. The aim of the present study was to determine whether a single bolus of intravenous (i.v.) ketamine for anesthetic induction can decrease OCR in children undergoing strabismus surgery.
Methods: One hundred and twenty healthy children undergoing strabismus surgery were allocated to three groups using double-blind randomization. Anesthesia was induced with propofol 3 mg/kg in Group P, ketamine 1 mg/kg in Group K1, or ketamine 2 mg/kg in Group K2. Anesthesia was maintained with 3% sevoflurane in 50% N2O/O2 in all patients. The baseline heart rate was obtained 30 s prior to the first traction of the extraocular muscle (EOM). OCR was defined as a development of arrhythmia or a decrease of more than 20% of the baseline heart rate during EOM traction.
Results: The incidence of OCR was significantly lower in the ketamine groups (4/40 and 1/40 in Group K1 and K2, respectively) compared with the propofol group (14/40).
Conclusion: A single bolus of i.v. ketamine 1 or 2 mg/kg for anesthetic induction results in a lower incidence of OCR than propofol when combined with sevoflurane for maintenance in children undergoing strabismus surgery.

Anaesthetic considerations for patients with a pre-existing neurological deficit: are neuraxial techniques safe?
M. Vercauteren, L. Heytens
Acta Anaesthesiologica Scandinavica 2007; 51 (7), 831–838.

Pre-existing neurological and muscular disease may be a specific concern for anaesthetists as they need to consider the effect of anaesthesia upon the disease, vice versa, and the interaction of anaesthesia with the medication taken by the patient. Despite a lack of controlled studies, many anaesthetists, being afraid of a claim, will prefer general rather than regional anaesthesia in these patients. Nevertheless regional anaesthesia certainly merits its place because it offers undeniable advantages. A good pre-operative examination is very important while patients should also be informed about peri-operative implications of anaesthesia, surgery and stress. Paraesthesias, epinephrine and high concentrations of local anaesthetics should be avoided in the majority of the diseases. Some diseases may benefit from epidural anaesthesia while for others a spinal technique may be the technique of preference. Special attention should be paid to patients with spinal stenosis despite recent reassuring reports with respect to safety of regional anaesthetic techniques. Anaesthetists should not automatically take all responsibility in case of progressive or new deficit after the procedure.

Parental presence during induction enhances the effect of oral midazolam on emergence behavior of children undergoing general anesthesia
Y.-C. P. Arai, H. Ito, N. Kandatsu, S. Kurokawa, S. Kinugasa, T. Komatsu
Acta Anaesthesiologica Scandinavica 2007; 51 (7), 858–861.

Background: Pre-anesthetic anxiety and emergence agitation are major challenges for anesthesiologists in pediatric anesthesia. Thus, sedative premedication and parental presence during induction of anesthesia (PPIA) are used to treat pre-anesthetic anxiety in children. The aim of the present study was to test if a combination of mother presence and midazolam premedication is effective for improving emergence condition in children undergoing general anesthesia.
Methods: Sixty children were allocated to one of three groups: a sedative group (0.5 mg/kg oral midazolam), a PPIA group or a sedative and PPIA group. When anesthesia was induced with 7% sevoflurane in 100% oxygen, qualities of mask induction were rated. Anesthesia was maintained with sevoflurane (1.5–2.5%) in 60% oxygen and intravenous fentanyl 4 μg/kg. During emergence from anesthesia, the score of the child’s emergence behavior was rated.
Results: The children in the midazolam group showed a better quality of mask induction compared with those in the PPIA group, the addition of parental presence to oral midazolam did not provide additional improvement of mask induction. In contrast, the children in the midazolam + PPIA group were less agitated than those in the other groups at emergence from anesthesia.
Conclusion: Parental presence during induction of anesthesia enhanced the effect of oral midazolam on emergence behavior of children undergoing general anesthesia.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Comparison of desflurane with sevoflurane for the incidence of oculocardiac reflex in children undergoing strabismus surgery
A. Y. Oh, M. J. Yun, H. J. Kim and H. S. Kim
British Journal of Anaesthesia 2007; 99(2):262-265

Background: The oculocardiac reflex (OCR) is frequently observed during strabismus surgery. This study was designed to evaluate and compare the effect of sevoflurane and desflurane on the incidence of OCR.
Methods: After obtaining Institutional Review Board approval and informed consent from parents, we enrolled 237 paediatric patients, aged 2–10 yr, undergoing strabismus surgery. No premedication was given. Anaesthesia was induced with thiopental and rocuronium. Patients were randomly allocated to one of the two anaesthetic regimens. Group S (n = 123) received sevoflurane and Group D (n = 114) received desflurane, both with 60% N2O/O2 for maintenance of anaesthesia. The OCR was defined as a 20% decrease in heart rate (HR) from baseline values obtained immediately before muscle manipulation. If the HR did not increase after release of muscle tension, atropine 0.01 mg kg^-1 was administered.
Results: There were no significant differences between the two groups in age, sex, body weight, and the number of muscles operated upon. The mean values of baseline HR were 123 (16) min^-1 in Group S and 121 (18) in Group D (NS). The minimum HR was 106 (22) min^-1 in Group S and 103 (21) in Group D (NS). There was no difference in the incidence of OCR between sevoflurane (26.0%) and desflurane (28.0%) anaesthesia.
Conclusions: Both agents can be used safely during strabismus surgery in paediatric patients.

Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort
X. Combes, L. Andriamifidy, E. Dufresne, P. Suen, S. Sauvat, E. Scherrer, P. Feiss, J. Marty and P. Duvaldestin
British Journal of Anaesthesia 2007; 99(2):276-281

Background: Muscle relaxants facilitate tracheal intubation, but they are often not used for short peripheral surgical procedures. The consequences of this practice on the upper airway are still a matter of controversy. We therefore compared the incidence of post-intubation symptoms in a randomized study comparing patients intubated with or without the use of a muscle relaxant.
Methods: A total of 300 adult patients requiring tracheal intubation for scheduled peripheral surgery were randomly assigned in a double-blind study to an anaesthetic protocol that either included or did not include a muscle relaxant (rocuronium). The primary end-point was the rate of post-intubation symptoms 2 and 24 h after extubation. The secondary end-points were the intubation conditions score (Copenhagen Consensus Conference), the rate of difficult intubations (Intubation Difficulty Scale), and the incidence of adverse haemodynamic events.
Results: Post-intubation symptoms were more frequent in patients intubated without the use of a muscle relaxant, whether 2 h (57% vs 43% of patients; P < 0.05) or 24 h (38% vs 26% of patients; P < 0.05) after extubation. Intubation conditions were better when the muscle relaxant was used. In patients intubated without a muscle relaxant, difficult intubation was more common (12% vs 1%; P < 0.05), as were arterial hypotension or bradycardia requiring treatment (12% vs 3% of patients; P < 0.05).
Conclusions: The use of a muscle relaxant for tracheal intubation diminishes the incidence of adverse postoperative upper airway symptoms, results in better tracheal intubation conditions, and reduces the rate of adverse haemodynamic events.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Efficacy of preoxygenation using tidal volume and deep breathing techniques with and without prior maximal exhalation
Usharani Nimmagadda, MD, M. Ramez Salem, MD, Ninos J. Joseph, BSc and Istvan Miko, MD
Canadian Journal of Anesthesia 54:448-452 (2007)

Purpose: We evaluated the influence of prior maximal exhalation on preoxygenation in 15 adult volunteers using tidal volume breathing (TVB) for five minutes and deep breathing (DB) for two minutes with and without prior maximal exhalation.
Methods: Inspired and end-tidal oxygen, nitrogen and carbon dioxide were monitored continuously and recorded during room air breathing and at 30-sec intervals during 100% oxygen TVB or DB (rate of 8 breaths·min^-1).
Results: Tidal volume breathing with prior maximal exhalation resulted in an end-tidal oxygen concentration (ETO₂) slightly higher (P = 0.028) at 0.5 and 1.0 min as compared with TVB without prior maximal exhalation at the same time periods. Regardless of whether TVB was preceded by maximal exhalation or not, 2.5 min was required to reach a mean ETO₂ value of 90% or higher. With DB, there were no differences in ETO₂ values at any time period and 1.5 min was required to reach an ETO₂ of 90% or greater, with or without prior maximal exhalation.
Conclusions: Maximal exhalation prior to TVB slightly steepens the initial rise in ETO₂ during the first minute, but confers no real benefit if maximal preoxygenation is the goal. Maximal exhalation prior to DB has no added value in enhancing preoxygenation.

Priming with rocuronium accelerates neuromuscular block in children: a prospective randomized study
Matthias Bock, MD DEAA, Lars Haselmann, MD, Bernd W. Böttiger, MD PhD and Johann Motsch, MD PhD
Canadian Journal of Anesthesia 54:538-543 (2007)

Purpose: To determine the effects of a priming technique with respect to onset time and duration of action of rocuronium (1.5 x ED95, 2.0 x ED95) in a pediatric patient population.
Methods: Eighty-four children, age one to seven years undergoing elective pediatric surgery, were studied in a randomized controlled trial. Neuromuscular function was assessed by accelerometry in response to single-twitch stimulation to assess onset of neuromuscular block, followed by train-of-four (TOF) stimulation at the wrist every 15 sec. Children were randomly allocated to one of four groups: Groups 1 and 3 received saline placebo, followed one minute later by a single bolus dose of rocuronium 0.45 mg·kg^-1 iv (1.5 x ED95) and 0.6 mg kg^-1 iv (2.0 x ED95), respectively. Patients in Groups 2 and 4 received an initial dose of rocuronium 0.045 mg·kg^-1 iv and 0.06 mg·kg^-1 iv, respectively, followed one minute later by rocuronium 0.405 mg·kg^-1 and 0.54 mg·kg^-1iv, respectively.
Results: Rocuronium priming significantly accelerated the time to maximum rocuronium-induced neuromuscular block when compared to placebo [median (95% confidence interval)]: 122.5 (98–186) vs 92.5 (68–116) sec (1.5 x ED95, Group 1 vs Group 2, P < 0.05) and 85 (60–142) vs 55 (48–72) sec (2.0 x ED95, Group 3 vs Group 4, P < 0.05), respectively. Spontaneous recovery to a TOF-ratio 0.9 was dose-dependent and not influenced by priming.
Conclusion: Priming accelerated the onset of rocuronium in children. A priming interval of one minute and a cumulative dose of rocuronium 1.5 x ED95 resulted in an onset of neuromuscular block comparable to a single dose of rocuronium (2.0 x ED95).

Brachial plexus blocks: a review of approaches and techniques (REVIEW)
Quang Hieu De Tran, MD FRCPC, Antonio Clemente, MD, Julian Doan, MD and Roderick J. Finlayson, MD FRCPC
Canadian Journal of Anesthesia 54:662-674 (2007)

Purpose: The purpose of this narrative review is to summarize the evidence derived from randomized controlled trials (RCTs) regarding established approaches and techniques for brachial plexus anesthesia.
Source: Using the MEDLINE (January 1966 to November 2006) and EMBASE (January 1980 to November 2006) databases, key words "brachial plexus", "nerve blocks", "interscalene", "cervical paravertebral", "suprascapular", "supraclavicular", "infraclavicular", "axillary", "brachial canal" and "humeral canal" were searched for full text articles pertaining to the evaluation of recognized approaches and techniques for brachial plexus anesthesia. The search was limited to RCTs involving human subjects and published in the English language. Seventy-six RCTs were identified.
Principal findings: Many of the published studies were underpowered and contained various methodological limitations. We found that, for shoulder and proximal humeral surgery, interscalene and cervical paravertebral approaches to the brachial plexus appear to provide equally effective surgical anesthesia. Intersternocleidomastoid supraclavicular blocks are not associated with improved postoperative analgesia despite eliciting more complete anesthesia of the brachial plexus. For surgery at or below the elbow, an infraclavicular block may result in decreased performance time and block-related pain while providing similar efficacy compared to (multiple-stimulation) axillary and brachial canal approaches. With respect to technique, it is unclear if nerve stimulation provides a more effective interscalene block than elicitation of paresthesiae. For supraclavicular blocks, nerve stimulation with a minimal threshold of 0.9 mA is recommended, whereas a double-stimulation technique is optimal for infraclavicular blocks. For the axillary approach, a triple-stimulation technique, involving injections of the musculocutaneous, median and radial nerves, is the most effective option.
Conclusions: Published reports of RCTs provide evidence to formulate limited recommendations regarding optimal approaches and techniques for brachial plexus anesthesia. Further well-designed and meticulously executed RCTs are warranted, particularly in light of new techniques involving ultrasound or combining neurostimulation and echoguidance.

Repetitive generalized seizure-like activity during emergence from sevoflurane anesthesia
Arvind Mohanram, MD, Vikram Kumar, MD, Zafar Iqbal, MD, Sandeep Markan, MD and Paul S. Pagel, MD PhD
Canadian Journal of Anesthesia 54:657-661 (2007)

Purpose: Sevoflurane-induced seizures are most often described during mask induction of anesthesia when high concentrations of the volatile agent are administered concomitant with alveolar hyperventilation. The occurrence of seizure-like activity during emergence from sevoflurane anesthesia has been rarely reported.
Clinical features: We describe a patient who developed several episodes of generalized tonic-clonic seizure-like activity during and immediately after emergence from sevoflurane anesthesia and discuss the potential factors that contributed to this unusual complication. The patient was treated with intravenous propofol, midazolam, and phenytoin and required intensive care management before his neurologic status stabilized.
Conclusion: The report emphasizes that sevoflurane is capable of producing excitatory central nervous system (CNS) phenomena in spite of causing primarily CNS depressant effects.

PUB MED - TOP

Author: Zeitels, S. M.; Burns, J. A.
Year: 2007
Title: Office-based laryngeal laser surgery with local anesthesia
Journal: Curr Opin Otolaryngol Head Neck Surg
Volume: 15
Issue: 3
Pages: 141-7
Date: Jun
Abstract:
PURPOSE OF REVIEW: Office-based laryngeal laser surgery was created recently and is emerging as a reliable and practical method of treating a number of laryngeal lesions. This style of minimally invasive surgery is becoming increasingly popular in the United States and abroad.
RECENT FINDINGS: Fiber-based lasers and distal-chip flexible endoscopy have facilitated a new style of surgery. Epithelial diseases such as dysplasia and papillomatosis are well suited for treatment. Although the initial angiolytic laser used was a 585-nm pulsed-dye laser, the 532-nm pulsed-potassium-titanyl-phosphate laser has been demonstrated to be more effective. The 2013-nm Thulium laser shows promise as an office-based laser that simulates the properties of the carbon dioxide laser.
SUMMARY: Evolving technologies to enhance laryngoscopic imaging and lasers along with socioeconomic forces should lead to increasing numbers of laryngeal procedures being performed in the office with local anesthesia.
Notes: 1068-9508 (Print)
URL: Link
REMARKS:  The above study demonstrates that newer technologies will facilitate more procedures to be done safely in patients in an office-based setting. (K. BELANI, MD).

Reference Type: Journal Article
Record Number: 88
Author: Chandawarkar, R. Y.; Dutta, S.
Year: 2007
Title: Dynamics of hospital-based plastic surgery
Journal: Plast Reconstr Surg
Volume: 119
Issue: 2
Pages: 730-7; discussion 738
Date: Feb
Abstract:
BACKGROUND: Legislative regulations, decreasing reimbursements for office procedures, and malpractice premiums have transformed plastic surgery from an office-based specialty into a hospital-based one. Simultaneously, hospital economics has altered, wherein the "business model" has all but subsumed the old "medical care" model. Integration between plastic surgeons and the new hospital structure has been difficult for both. Limited understanding of the financial dynamics of hospital-based practices, unfamiliarity with the administrative processes, and resistance to accept and assimilate changes by both sides pose hurdles, in some situations even forcing plastic surgeons out of hospital settings.
METHODS: Using well-defined financial terminology, changing national development in health care policy, and hospital-based administrative strategies as a backdrop, this study finds common ground for the plastic surgery specialty to coapt with the hospital.
RESULTS: Key missing elements in the interaction between plastic surgeons and hospital administrations and ways of integrating these components are identified. To do so effectively, plastic surgeons must first understand the basic tenets of management that drive hospital administrators, participate at every level they can in guiding these processes, and assume leadership roles that will ultimately dictate the way they work and conduct their professional lives.
CONCLUSIONS: It is critical that plastic surgeons engage in important processes that govern the economics of hospital-based health care delivery. This commitment will also ensure that all three groups (the patients, physicians, and hospital administrators) achieve a degree of satisfaction. The message to plastic surgeons is clear: be proactive and lead a campaign of change.
Notes: 1529-4242 (Electronic)
Journal Article
URL: Link
REMARKS: The above study emphasizes that payors will continue to decrease reimbursement unless we are proactive. This study emphasizes the need for being proactive to ensure correct reimbursement. (K. Belani, MD).

Reference Type: Journal Article
Record Number: 85
Author: Clayman, M. A.; Clayman, S. M.; Steele, M. H.; Seagle, M. B.
Year: 2007
Title: Promoting a culture of patient safety: a review of the Florida moratoria data: what we have learned in 6 years and the need for continued patient education
Journal: Ann Plast Surg
Volume: 58
Issue: 3
Pages: 288-91
Date: Mar
Abstract: Patient safety and medical error reduction are topics of extreme importance. Although there has been considerable media controversy regarding reports of decreased patient safety and errors that have occurred in operating rooms of hospitals, ambulatory surgery centers, and doctors' offices, the majority of data across various specialties demonstrate a very low incidence of adverse events resulting from office-based surgery. Limited research has been conducted in patient safety on the topic of outpatient surgery. Since the release of the Institute of Medicine's (IOM) report To Err Is Human, significant progress has been made in patient safety. According to the IOM's report in 2000, between 48,000 and 98,000 annual US hospital deaths result from medical errors. Following the report, there have been numerous calls to improve patient safety and place it at the forefront of the national agenda. The Florida Board of Medicine restricted office procedures in 2000 after a series of incidents occurred in the outpatient setting. The objectives of this paper are to review the Florida moratoria data over the last 6 years to discuss what we have learned as a specialty and to continue a culture of safety in plastic surgery. One of the remaining challenges is the need to continually improve this culture of safety and emphasize the need for continued patient education, specifically related to esthetic procedures administered in nonclinical settings by amateur, unlicensed, or unqualified practitioners, with a misrepresentation of their credentials and training. This is a long-term proposition and one that has been driven foremost by our leaders in plastic surgery.
Notes: 0148-7043 (Print)
Journal Article
Review
URL: Link
REMARKS: Patient education is crucial especially when unregulated office-based surgery may be occurring in different counties. This is a call for practitioners to do what they can to increase patient safety. (K. BELANI, MD).

Reference Type: Journal Article
Record Number: 74
Author: Goessler, U. R.; Hein, G.; Verse, T.; Stuck, B. A.; Hormann, K.; Maurer, J. T.
Year: 2007
Title: Soft palate implants as a minimally invasive treatment for mild to moderate obstructive sleep apnea
Journal: Acta Otolaryngol
Volume: 127
Issue: 5
Pages: 527-31
Date: May
Short Title: Soft palate implants as a minimally invasive treatment for mild to moderate obstructive sleep apnea
Abstract:
CONCLUSION: The palatal implant method originally designed to reduce snoring can significantly reduce the apnea-hypopnea index (AHI) in some patients with mild to moderate obstructive sleep apnea (OSA) in a single office-based procedure.
OBJECTIVE: An initial study designed to evaluate the short-term efficacy and safety of palatal implants as primary treatment for patients with mild to moderate OSA.
MATERIALS AND METHODS: This was a prospective, non-randomized study of 16 previously untreated and undiagnosed patients with sleep apnea. The inclusion criteria were an AHI of 10-30/h and a body mass index (BMI) < or = 30.
RESULTS: The mean AHI was reduced following implantation, from 16.1 to 11.8 (p<0.01). A reduction in AHI was achieved in 13 patients (81%). Ten of 16 patients had their AHI reduced to <10.0. Snoring intensity decreased from 8.3+/-1.8 to 4.7+/-2.5 on a visual analog scale (p<0.001) and daytime sleepiness dropped from 7.2+/-2.5 to 4.6+/-3.2 on the Epworth Sleepiness Scale (p<0.05). No significant adverse events were reported.
Notes: 0001-6489 (Print)
Journal Article
Research Support, Non-U.S. Gov't
URL: Link
REMARKS: We encounter frequently patients with obstructive sleep apnea for surgical procedures. Newer tools to manage this problem are being tried. This study outlines the success of one such tool. (K.BELANI, MD).

Reference Type: Journal Article
Record Number: 40
Author: Harley, D. H.; Collins, D. R., Jr.
Year: 2007
Title: Patient Satisfaction After Blepharoplasty Performed as Office Surgery Using Oral Medication with the Patient Under Local Anesthesia
Journal: Aesthetic Plast Surg
Date: Aug 9
Abstract:
BACKGROUND: Blepharoplasty can be performed in the office setting using oral medication with the patient under local anesthesia. This article reviews the authors' experience with this approach, evaluating patient satisfaction and demonstrating why this technique has become their procedure of choice for selected healthy patients.
METHODS: The authors conducted a retrospective review of the 86 patients who underwent office-based blepharoplasty and mailed surveys to assess patient satisfaction with the procedure. RESULTS: Upper and lower blepharoplasties were performed with no major complications. The surveys were completed and returned by 83% of the patients. The survey results indicated that this procedure is well accepted and highly rated by patients. Many patients unwilling to undergo blepharoplasty outside the office were willing to have the procedure using this approach. A strong majority indicated that they would be referring friends and family for the procedure.
CONCLUSIONS: The fact that blepharoplasty can be performed in the office using oral medication with the patient under local anesthesia proves to be a strong determinant toward the final decision of patients to undergo surgery. This procedure meets the safety requirements outlined by the American Society of Plastic Surgeons (ASPS) and is desired by our patients for its many obvious advantages. Recommendations are provided to assist others who desire to use this safe and cost-effective method.
Notes: 0364-216X (Print)
Journal article
URL: Link
REMARKS: Another office procedure that can be done successfully in an office; note that the authors followed safety requirements as laid out by the ASPS. (K. BELANI, MD).

Reference Type: Journal Article
Record Number: 39
Author: Hausman, L. M.; Frost, E. A.
Year: 2007
Title: Office-based surgery: expanding the role of the anesthesiologist
Journal: Middle East J Anesthesiol
Volume: 19
Issue: 2
Pages: 291-310
Date: Jun
Short Title: Office-based surgery: expanding the role of the anesthesiologist
Accession Number: 17684872
Abstract: Office-based anesthesia (OBA) has developed in the United States as an important field for the anesthesia provider. Both the numbers and types of procedures performed in offices around the country have steadily increased, as has the invasiveness of these procedures. New anesthetic considerations arise. For example, most training programs have not addressed this area of practice. Indeed many practitioners are unfamiliar with practice outside the hospital operating room setting. Information as to how to provide quality care in a location where one may be the sole anesthesiologist must be readily available. Many of the safety mechanisms we take for granted in a hospital setting are often not present in a surgical office, and it becomes the responsibility of training centers to help in establishing standards. As the 'safety' of many surgical offices where anesthesia care is provided has been challenged, medical societies have begun to issue recommendations as to the standards of care that should exist. Different anesthetic techniques are also emerging that are appropriate to the office setting. But as office-based anesthesia continues to mature as a specialty, we the anesthesia providers, must be proactive in establishing guidelines and recommendations to ensure safe practice.
Notes: 0544-0440 (Print)
Journal Article
URL: Link
Author Address: Ambulatory Surgery, Mount Sinai Medical Center, New York, NY, USA.
REMARKS: Office - based surgery is being done globally; therefore it makes sense to follow patient safety guidelines at every location where surgery is done; it will be nice to have a global certification process for offices! (K. BELANI, MD).

Reference Type: Journal Article
Record Number: 14
Author: Ng, D.; Hutchinson, S.; Pohl, M.; Powell, B.
Year: 2007
Title: Sentinel lymph node biopsy for malignant melanoma as day surgery
Journal: J Plast Reconstr Aesthet Surg
Volume: 60
Issue: 6
Pages: 631-4
Short Title: Sentinel lymph node biopsy for malignant melanoma as day surgery
Accession Number: 17485050
Keywords: Ambulatory Surgical Procedures/*methods
Feasibility Studies
Humans
Length of Stay
Melanoma/*diagnosis
Patient Satisfaction
Postoperative Complications
Retrospective Studies
Sentinel Lymph Node Biopsy/*methods
Skin Neoplasms/*diagnosis
Time Factors
Abstract: Sentinel lymph node biopsy for malignant melanoma has been performed as day surgery at our hospital since August 2002. The aim of this retrospective study was to assess its feasibility compared to the inpatient procedure.
METHODS: A telephone survey and review of medical records was carried out for patients who had daycase, nonhead and neck sentinel lymph node biopsy for malignant melanoma over an 18-month period. A similar matched number of inpatients were reviewed, comparing waiting times, prolonged hospital stay, complication rates and overall satisfaction.
RESULTS: There were no significant differences between the two groups in terms of time from diagnosis to surgery, prolonged hospital stay and complication rates. However, in terms of overall satisfaction, 86.3% of daycase patients preferred their mode of admission whereas 52.9% of inpatients preferred their mode of admission (P=0.0003).
CONCLUSIONS: Sentinel lymph node biopsy (nonhead and neck) for malignant melanoma as day surgery is feasible and confers greater patient satisfaction, increased availability of inpatient beds and cost savings without compromising patient care.
Notes: 1748-6815 (Print)
Journal Article
URL: Link
Author Address: Melanoma Unit, Department of Plastic and Reconstructive Surgery, St George's Hospital, Blackshaw Road, London, UK. darren76@hotmail.com
REMARKS: This study clearly outlines patiient preference for day surgery on an ambulatory basis for the procedure studied. I am sure the same will be true for other surgical procedures that have the potential to be done on an ambulatory basis. (K. Belani, MD).

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