Incidence and Predictors of Difficult and Impossible Mask Ventilation.
Kheterpal, Sachin M.D., M.B.A. ; Han, Richard M.D., M.P.H. ; Tremper, Kevin K. Ph.D., M.D. ; Shanks, Amy M.S. ; Tait, Alan R. Ph.D. ; O'Reilly, Michael M.D., M.S. ; Ludwig, Thomas A. M.D., M.S.
Anesthesiology. 105(5): 885-891, November 2006.

Background: Mask ventilation is an essential element of airway management that has rarely been studied as the primary outcome. The authors sought to determine the incidence and predictors of difficult and impossible mask ventilation.
Methods: A four-point scale to grade difficulty in performing mask ventilation (MV) is used at the authors' institution. They used a prospective, observational study to identify cases of grade 3 MV (inadequate, unstable, or requiring two providers), grade 4 MV (impossible to ventilate), and difficult intubation. Univariate and multivariate analyses of a variety of patient history and physical examination characteristics were used to establish risk factors for grade 3 and 4 MV.
Results: During a 24-month period, 22,660 attempts at MV were recorded. 313 cases (1.4%) of grade 3 MV, 37 cases (0.16%) of grade 4 MV, and 84 cases (0.37%) of grade 3 or 4 MV and difficult intubation were observed. Body mass index of 30 kg/m2 or greater, a beard, Mallampati classification III or IV, age of 57 yr or older, severely limited jaw protrusion, and snoring were identified as independent predictors for grade 3 MV. Snoring and thyromental distance of less than 6 cm were independent predictors for grade 4 MV. Limited or severely limited mandibular protrusion, abnormal neck anatomy, sleep apnea, snoring, and body mass index of 30 kg/m2 or greater were independent predictors of grade 3 or 4 MV and difficult intubation.
Conclusions: The authors observed the incidence of grade 3 MV to be 1.4%, similar to studies with the same definition of difficult MV. Presence of a beard is the only easily modifiable independent risk factor for difficult MV. The mandibular protrusion test may be an essential element of the airway examination.

Ambulatory Continuous Interscalene Nerve Blocks Decrease the Time to Discharge Readiness after Total Shoulder Arthroplasty: A Randomized, Triple-masked, Placebo-controlled Study.
Ilfeld, Brian M. M.D., M.S. ; Vandenborne, Krista Ph.D., P.T. ; Duncan, Pamela W. Ph.D., P.T. ; Sessler, Daniel I. M.D. ; Enneking, F Kayser M.D. ; Shuster, Jonathan J. Ph.D. ; Theriaque, Douglas W. M.S. ; Chmielewski, Terese L. Ph.D., P.T. ; Spadoni, Eugene H. P.T. ; Wright, Thomas W. M.D.
Anesthesiology. 105(5): 999-1007, November 2006.

Background: A continuous interscalene nerve block (CISB) may be used to provide analgesia after shoulder arthroplasty. Therefore, inpatient stays may be shortened if CISB (1) provides adequate analgesia without intravenous opioids and (2) improves shoulder mobilization. This study investigated the relationship between ambulatory CISB and the time to reach three discharge criteria after shoulder arthroplasty.
Methods: Preoperatively, patients received a CISB. All patients received a perineural 0.2% ropivacaine infusion from surgery until 06:00 the following morning, at which time they were randomly assigned either to continue perineural ropivacaine or to switch to normal saline. The primary endpoint was the time from the end of surgery until three discharge criteria were attained (adequate analgesia, independence from intravenous analgesics, and tolerance to 50% of shoulder motion targets). Patients were discharged home as early as the afternoon after surgery with their CISB using a portable infusion pump.
Results: Patients receiving perineural ropivacaine (n = 16) attained all three discharge criteria in a median (10th-90th percentiles) of 21 (16-41) h, compared with 51 (37-90) h for those receiving perineural normal saline (n = 13, P < 0.001). Unlike patients receiving perineural ropivacaine, patients receiving perineural normal saline often required intravenous morphine, but still experienced a higher degree of pain and tolerated less external rotation.
Conclusions: An ambulatory CISB considerably decreases the time until readiness for discharge after shoulder arthroplasty, primarily by providing potent analgesia that permits greater passive shoulder movement and the avoidance of intravenous opioids. Additional research is required to define the appropriate subset of patients and assess the incidence of complications associated with earlier discharge.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

None.

 

 

 

BRITISH JOURNAL OF ANAESTHESIA - TOP

A prospective, double-blind, randomized trial of caudal block using ropivacaine 0.2% with or without fentanyl 1 µg kg^-1 in children
Y. Kawaraguchi, T. Otomo, C. Ota, N. Uchida, A. Taniguchi and S. Inoue
British Journal of Anaesthesia 2006 97(6):858-861

Background. It has been reported that ropivacaine produces vasoconstriction in contrast to vasodilation produced by bupivacaine. It is possible that additives to ropivacaine can provide further analgesic advantages compared with bupivacaine. We thus evaluated whether the addition of fentanyl to ropivacaine prolonged the duration of analgesia after a single shot caudal block.
Methods. A total of 36 children undergoing surgical procedures below the umbilicus were randomly allocated to one of two groups: Group F received ropivacaine 0.2%, 1 ml kg^-1 with fentanyl 1 µg kg^-1 and Group S received ropivacaine 0.2%, 1 ml kg^-1 with saline. The analgesic effect of the caudal block was evaluated using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and sedation was assessed using the Steward score at 30 min after extubation and at 1, 2, 4, 6, 12 and 24 h. The first analgesic requirement time and side-effects in a 24 h period were also recorded.
Results. There were no differences in characteristics between the groups. The end-tidal concentration of sevoflurane at extubation in Group F was significantly lower than in Group S. However, there was no significant difference in time from discontinuation of the volatile anaesthetics to tracheal extubation. No statistical differences were found in the CHEOPS and Steward score, and the time to first analgesia. The incidence of postoperative vomiting was not significantly different.
Conclusion. We found that the addition of fentanyl 1 µg kg^-1 to ropivacaine 0.2% for caudal analgesia provides no further analgesic advantages over ropivacaine 0.2% alone.

Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure
K. Russon, A. M. Sardesai, S. Ridgway, J. Whitear, D. Sildown, S. Boswell, A. Chakrabarti and N. M. Denny
British Journal of Anaesthesia 2006 97(6):869-873

Background. There are logistical and financial advantages to undertaking shoulder surgery in a day case setting. However, this approach is limited by postoperative pain being inadequately controlled by oral medication alone. We describe a pilot study investigating the feasibility and acceptance of community based continuous interscalene brachial plexus blockade (CIBPB) to provide effective analgesia for day case shoulder surgery.
Methods. Phase 1 consisted of five patients who received CIBPB for shoulder surgery. Following an overnight hospital stay they were assessed for discharge home with the interscalene catheter in situ. Once the safety and feasibility of the approach was documented, five more patients were recruited to Phase 2. These patients had the adequacy of analgesia assessed in the postoperative period and were discharged home on the same day as surgery. A district nurse visited twice daily and removed the catheter on the third day. Patient satisfaction was assessed using a discovery interview.
Results. Nine of the 10 patients experienced good analgesia. One patient was re-admitted because the catheter fell out. No patient experienced complications and the discovery interviews showed that the patients were satisfied with their management and pleased to be treated as a day case.
Conclusions. POSSI proved that it was feasible to manage these patients in the community with support and training of the district nurses. Although extra community nursing hours are required, this technique has the potential for significant cost benefits with at least three bed days saved per patient.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Topical lidocaine and oral acetaminophen provide similar analgesia for myringotomy and tube placement in children
Sanjay M. Bhananker, MD FRCA, Lawrence Azavedo, MD FRCA, Johnna MacCormick, MD FRCSC and William Splinter, MD FRCPC
Canadian Journal of Anesthesia 53:1111-1116 (2006)

Purpose: Preoperative oral acetaminophen (30 mg·kg^-1) was compared with topical 2% lidocaine ear drops for postoperative analgesia following bilateral myringotomy and tube placement (BMT) in children.
Methods: In a randomized, prospective, double-blind trial, we studied 124 patients, six months to eight years, ASA physical status I or II, undergoing elective BMT under general anesthesia. The patients in Group I received acetaminophen 30 mg·kg^-1 orally in a grape flavoured syrup 30 to 60 min before surgery and 0.9% saline drops (placebo) in each ear upon insertion of tympanostomy tube. Patients in Group II received a placebo (grape flavoured syrup) before surgery and 2% lidocaine, 0.5 mL in each ear when ear tubes were inserted. Postoperative pain assessments were recorded every five minutes in the postanesthesia care unit, and every 15 min in the day care surgical unit (DCSU) using the modified Children’s Hospital of Eastern Ontario pain scale (mCHEOPS), a ten-point scale. Pain at home was documented by parents using a 0 (no pain) to 10 (worst pain imaginable) scale.
Results: The median (range) mCHEOPS scores in the DCSU at 15 and 30 min were similar, i.e., 5 (4–9) in the acetaminophen group and 4 (4–8) in the lidocaine group. The proportion of patients receiving supplemental analgesics in the 24 hr following surgery was similar in both groups (45% and 42% respectively).
Conclusion: Topical lidocaine and oral acetaminophen in a dose of 30 mg·kg^-1 provide similar analgesia following BMT.

Review article: The role of statins in reducing perioperative cardiac risk: physiologic and clinical perspectives
Nader N. Boushra, MD and Muhammad Muntazar, MD
Canadian Journal of Anesthesia 53:1126-1147 (2006)

Purpose: To review the pathobiology and clinical implications of coronary vulnerable atherosclerotic plaques (VAPs), to discuss the role of statin therapy in VAP stabilization, and the potential benefits of perioperative statin therapy (PST) in reducing perioperative risk of acute coronary syndromes (ACSs).
Source: MEDLINE search using "perioperative", "cardiac morbidity", "atherosclerosis", "vulnerable plaque", "statins" and combinations of these terms as keywords. The reference lists of relevant articles were further reviewed to identify additional citations.
Principal findings: The nonstenotic, yet rupture-prone VAP causes most myocardial infarctions (MIs) and other ACSs, both in the nonsurgical and surgical patients. Large clinical trials in both primary and secondary prevention and in patients with ACSs have demonstrated that statin therapy will reduce cardiovascular morbidity and mortality across a broad spectrum of patient subgroups. These trials also suggest, and laboratory investigations establish, that statins possess favourable vascular effects independent of cholesterol reduction. Statins appear to interfere specifically with the pathophysiologic mechanisms implicated in atherothrombotic disease. Statins reduce vascular inflammation, improve endothelial function, stabilize VAPs, and reduce platelet aggregability and thrombus formation. Recent studies have shown that PST is associated with a reduced incidence of perioperative and long-term cardiovascular complications in high-risk patients. Combined therapy with statins and ß-blockers is a conceptually valid strategy targeting critical steps in the pathogenesis of an ACS.
Conclusion: Emerging evidence for the efficacy and safety of PST is promising, especially when combined with ß-blocker therapy in patients at highest risk. Confirmation of this early evidence awaits the results of ongoing and future prospective randomized controlled trials.

PUB MED - TOP

      
Outcomes in day surgery.
Shnaider I,  Chung F.
Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
Curr Opin Anaesthesiol. 2006 Dec;19(6):622-9.

PURPOSE OF REVIEW: To summarize and examine the updated published results on the outcome measures that can be used to assess the quality of ambulatory surgery and anesthesia.
RECENT FINDINGS: Major morbidity and mortality following ambulatory surgery is exceedingly low. Cancellations and delays may have a negative impact on the patients, healthcare personnel and the organizations. Minor cardiovascular adverse events are the most common intraoperatively and are associated with preexisting cardiovascular diseases and elderly patients. Respiratory events postoperatively are associated with obesity, smoking and asthma. Also, pain is a common cause for longer postoperative stay, unanticipated admission and readmission. Postoperative nausea and vomiting occurs in 30% of patients and strongly affects patient satisfaction. Furthermore, prolonged stays are mainly caused by surgical factors, or minor symptoms like pain or nausea. Surgical factors are also the main causes of unanticipated hospital admission. The type of surgery and the 24 h postoperative symptoms may affect the degree of return to daily living function. Also, patient satisfaction affects the outcome of healthcare and the use of healthcare services.
SUMMARY: Ambulatory surgery, as currently practiced, provides quality care that is cost-effective. Minor adverse events such as pain and postoperative nausea and vomiting are still common, and improvement could be targeted in these areas.

Use of spinal anaesthesia in day surgery.
Korhonen AM.
Department of Intensive Care Medicine, Meilahti University Hospital, Finland.
Curr Opin Anaesthesiol. 2006 Dec;19(6):612-6.

PURPOSE OF REVIEW: An increasing number of day-case surgical patients is challenging the presently used methods of anaesthesia: reliable surgical anaesthesia should be fast, with rapid recovery and minimal side effects. To compete with modern ambulatory general anaesthesia a knowledge of special spinal anaesthesia techniques is essential. This review brings together important issues concerning the spinal technique, anaesthetic agents and benefits as well as the disadvantages of spinal anaesthesia in outpatients.
RECENT FINDINGS: For surgical procedures in one lower limb, a low dose of hyperbaric bupivacaine with standardized spinal anaesthesia technique produces a reliable block, with low incidence of side effects and home-readiness equal to spinal anaesthesia with lidocaine (50 mg) or general anaesthesia (desflurane), whereas ropivacaine has not shown benefits over spinal anaesthesia with bupivacaine. 'Walk-in, walk-out' spinals with an extremely low dose of lidocaine and opioids for gynaecological laparoscopy created the concept of selective spinal anaesthesia. Reintroduction of chloroprocaine may provide a solution for bilateral, short-acting spinal anaesthesia in the future.
SUMMARY: To produce reliable spinal anaesthesia with a reasonable recovery time it is essential to understand the factors affecting the spread of spinal block and to choose the optimal drug and adequate dose for specific surgical procedures.

Ambulatory anesthesia for the obese patient.
Servin F.
Service d'Anesthesie-Reanimation, Hopital Bichat, Paris, France.
Curr Opin Anaesthesiol. 2006 Dec;19(6):597-599.

PURPOSE OF REVIEW: Obese patients are more and more frequently proposed for elective surgery, including acts specifically aimed at curing this condition, i.e. bariatric surgery. Many of these acts present characteristics compatible with ambulatory treatment, but anesthesiologists are reluctant to treat the morbidly obese as outpatients due to lack of data on the safety of this approach. The purpose of this review is to present the information that could be found in the literature on the safety and feasibility of ambulatory procedures in obese patients, and outline the specificity of this population. RECENT FINDINGS: During the last few years, the risks of perioperative complications in this population have been estimated more precisely, specifically respiratory events. A better knowledge of the pharmacology of anesthetic drugs in this population allows optimization of general anesthesia protocols and the interest of regional anesthesia has also been outlined. A first study on gastric banding has demonstrated the suitability of the ambulatory setting for such a procedure.
SUMMARY: Ambulatory care in the obese patient is both feasible and well suited to this population provided a few specificities are taken into account.

Nitrous oxide in ambulatory anaesthesia: does it have a place in day surgical anaesthesia or is it just a threat for personnel and the global environment?
Smith I.
University Hospital of North Staffordshire, Stoke-on-Trent, Staffordshire, UK.
Curr Opin Anaesthesiol. 2006 Dec;19(6):592-6.

PURPOSE OF REVIEW: Nitrous oxide is by far the oldest anaesthetic still in routine use and its continued use is often questioned. Nitrous oxide is toxic with prolonged exposure, can damage the environment, causes pressure effects through expansion of closed air-filled spaces and has long been suspected of being harmful following chronic exposure to trace concentrations. What could possibly justify the continuing use of nitrous oxide? RECENT FINDINGS: This review will attempt to demonstrate that the harmful effects of nitrous oxide are limited and not relevant to the majority of ambulatory patients. The environmental effects of nitrous oxide derived from anaesthetic use are negligible and there is no convincing evidence of harm to personnel.
SUMMARY: Not only is nitrous oxide almost certainly less hazardous than is sometimes perceived, it has numerous benefits which are not easily replicated by possible alternatives. In particular, its use improves the quality and safety of induction and maintenance of anaesthesia and facilitates faster recovery with minimal adverse effects. All of these benefits are achieved while at the same time reducing overall costs. With few significant drawbacks and numerous advantages, there appears still to be a valuable place for nitrous oxide in modern ambulatory anaesthesia.

A comparison of cyclizine and granisetron alone and in combination for the prevention of postoperative nausea and vomiting.
Johns RA,  Hanousek J,  Montgomery JE.
Anaesthesia. 2006 Nov;61(11):1053-7.

Department of Anaesthetics, Derriford Hospital, Derriford Road, Plymouth PL6 8DH, UK.
We conducted a randomised double-blinded study of 960 women undergoing day-case surgery to determine whether combination anti-emetic therapy of granisetron and cyclizine was more effective at decreasing the incidence of postoperative nausea and vomiting than these agents used alone. The women were randomly allocated to three groups to receive intravenous granisetron 1 mg, cyclizine 50 mg or both before induction of general anaesthesia. The incidence of postoperative nausea and vomiting was 77/322 (24%) in the granisetron group, 73/316 (23%) in the cyclizine group and 53/322 (17%) in those women given both drugs (p = 0.04). There was no difference in the requirement for rescue anti-emetic drugs. There were no differences in the anaesthetic techniques used in the three groups. We conclude that the risk of postoperative nausea and vomiting is less with cyclizine and granisetron given together than with either given alone.

Twelve years' local experience in ambulatory anaesthesia.
Lai AK,  Ho V, Chow YF.
Department of Anaesthesia, Queen Elizabeth Hospital, Hong Kong. laikw2000@hotmail.com
Hong Kong Med J. 2006 Oct;12(5):339-44.

OBJECTIVES: To determine the incidence of adverse events after ambulatory anaesthesia (postoperative nausea and vomiting, postoperative pain, difficulty in movement), and to evaluate the level of satisfaction of patients with our service.
DESIGN: Retrospective study with questionnaire survey.
SETTING: Tertiary referral centre, Hong Kong.
PARTICIPANTS: All patients whose duly completed questionnaires were available.
MAIN OUTCOME MEASURES: Incidence of adverse events and level of patient satisfaction. RESULTS: A total of 9197 patients underwent surgery under general anaesthesia or neuraxial blockade by anaesthetists in ambulatory settings from October 1993 to December 2005: questionnaires filled out by 8231 of these patients were analysed, whereas 549 questionnaires were lost, and 417 patients could not be contacted. The response rate was 90%; 59% of the respondents were males, 50% were younger than 15 years and 5% older than 60 years. Fifty-one percent of surgery with anaesthetists' involvement was performed under general anaesthesia and 48.9% under general anaesthesia and regional blocks and 0.1% under neuraxial blockade. There were 3.3% of patients experienced postoperative nausea and vomiting, 60.2% experienced episodes of pain between the time of discharge and the time of interview, and 46% required analgesics. Nonetheless, 80% resumed normal activities within 5 hours after anaesthesia and 97.5% resumed normal diet the following morning. Over 99% rated our service as good or excellent.
CONCLUSION: Although ambulatory anaesthesia was associated with minor adverse events, patients could resume normal diet and daily activities quickly and were satisfied with the service.

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