Volume 7, Issue 7 S A M B A T A L K S - PAGE 3 December, 2007

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

Continuous Peripheral Nerve Blockade for Inpatient and Outpatient Postoperative Analgesia in Children. [Miscellaneous Article]
Ganesh, Arjunan MBBS *+; Rose, John B. MD *+; Wells, Lawrence MD +++; Ganley, Theodore MD +++; Gurnaney, Harshad MD *+; Maxwell, Lynne G. MD *+; DiMaggio, Theresa MSN *; Milovcich, Karen MSN *; Scollon, Maureen MSN *; Feldman, Jeffrey M. MD *+; Cucchiaro, Giovanni MD *+
Anesthesia & Analgesia. 105(5):1234-1242, November 2007.

BACKGROUND: This is an audit of the continuous peripheral nerve blockade (CPNB) program that was implemented at our institution to provide postoperative analgesia after orthopedic procedures in children.
METHODS: We reviewed the departmental regional anesthesia registry and the medical records of consecutive children who received CPNB for postoperative analgesia at The Children's Hospital of Philadelphia between February 2003 and July 2006. Patients were prospectively followed until cessation of the effects of CPNB and/or resolution of any related complications. Data collected contemporaneously included presence of sensory and motor blockade, pain scores in inpatients, opioid administration, and complications related to CPNB.
RESULTS: A total of 226 peripheral nerve catheters were placed in 217 patients. One hundred eight patients (112 catheters) were discharged home with CPNB. The ages ranged from 4 to 18 yr (13.7 +/- 3.4). Local anesthetic solution (0.125% bupivacaine [n = 164], 0.1% ropivacaine [n = 12], or 0.15% ropivacaine [n = 27]) was infused at an initial rate of 2-12 mL/h based on patients' weights and locations of catheters. The mean duration of local anesthetic infusion was 48.4 +/- 29.3 h (range 0-160 h). The percentage of patients who did not require any opioids in the first 8, 24, and 48 h after surgery was 56%, 26%, and 21%, respectively. The incidence of nausea and vomiting was 14% (13% in outpatients, 15% in inpatients). Complications were noted in 2.8% of patients. Three patients had prolonged numbness (>24 h) that resolved spontaneously; one developed superficial cellulitis that resolved with a course of antibiotics; one had difficulty removing the catheter at home and one developed tinnitus 24 h after starting CPNB that resolved quickly after clamping of the catheter followed by removal.
CONCLUSION: It is feasible to implement a CPNB program to provide an alternative method of inpatient and outpatient postoperative analgesia after orthopedic surgery in children when appropriate expertise is available. Patient and family education along with frequent follow-up are crucial to detect and address adverse events promptly.

Intraoperative Esmolol Infusion in the Absence of Opioids Spares Postoperative Fentanyl in Patients Undergoing Ambulatory Laparoscopic Cholecystectomy. [Miscellaneous Article]
Collard, Vincent MD *; Mistraletti, Giovanni MD *; Taqi, Ali MD +; Asenjo, Juan Francisco MD *; Feldman, Liane S. MD +; Fried, Gerald M. MD +; Carli, Franco MD, MPhil *
Anesthesia & Analgesia. 105(5):1255-1262, November 2007.

BACKGROUND: The use of opioids during ambulatory surgery can delay hospital discharge or cause unexpected hospital admission. Preliminary studies using an intraoperative continuous infusion of esmolol in place of an opioid have inconsistently reported a postoperative opioid-sparing effect. In this study, we compared esmolol versus either intermittent fentanyl or continuous remifentanil on postoperative opioid-sparing, side effects, and time of discharge.
METHODS: Ninety patients (consisting of three groups) were enrolled in this prospective, randomized, and observer-blinded study. The control group (n = 30) received intermittent doses of fentanyl, the esmolol group (n = 30) received a continuous infusion of esmolol (5-15 [mu]g [middle dot] kg-1 [middle dot] min-1) and no supplemental opioids during surgery, and the remifentanil group (n = 30) received a continuous infusion of remifentanil (0.1-0.5 [mu]g [middle dot] kg-1 [middle dot] min-1). General anesthesia was standardized, and adjuvant medications included acetaminophen, ketorolac, local anesthetics in the skin incisions, dexamethasone, and droperidol. Postoperative analgesia included fentanyl.
RESULTS: The amount of fentanyl in the postanesthesia care unit was significantly less in the esmolol group, 91.5 +/- 42.7 [mu]g, compared with the other two groups, remifentanil, 237.8 +/- 54.7 [mu]g, control, 168.1 +/- 96.8 [mu]g (P < 0.0001). The incidence of nausea was more frequent in the control (66.7%) and remifentanil (67.9%) groups compared with the esmolol group (30%) (P < 0.01). The esmolol group reached the White-Song score of 12 of 14 faster than the remifentanil group (P < 0.01), and left the hospital 45-60 min earlier (P < 0.004).
CONCLUSIONS: Intraoperative IV infusion of esmolol contributes to a significant decrease in postoperative administration of fentanyl and ondansetron and facilitates earlier discharge.

The Clinical Impact of Preoperative Melatonin on Postoperative Outcomes in Patients Undergoing Abdominal Hysterectomy. [Miscellaneous Article]
Caumo, Wolnei MD, PhD *+; Torres, Fernanda MSc ++; Moreira, Nivio L. Jr MD [S]; Auzani, Jorge A. S. MD [S]; Monteiro, Cristiano A. MD [S]; Londero, Gustavo MD [S]; Ribeiro, Diego F. M. [//]; Hidalgo, Maria Paz L. MD, PhD [//]
Anesthesia & Analgesia. 105(5):1263-1271, November 2007.

BACKGROUND: Melatonin has sedative, analgesic, antiinflammatory, antioxidative, and chronobiotic effects. We determined the impact of oral melatonin premedication on anxiolysis, analgesia, and the potency of the rest/activity circadian rhythm.
METHODS: This randomized, double-blind, placebo-controlled study included 33 patients, ASA physical status I-II, undergoing abdominal hysterectomy. Patients were randomly assigned to receive either oral melatonin 5 mg (n = 17) or placebo (n = 16) the night before and 1 h before surgery. The analysis instruments were the Visual Analog Scale, the State-Trait Anxiety Inventory, and the actigraphy.
RESULTS: The number of patients that needed to be treated to prevent one additional patient reporting high postoperative anxiety and moderate to intense pain in the first 24 postoperative hours was 2.53 (95% CI, 1.41-12.22) and 2.20 (95% CI, 1.26-8.58), respectively. The number-needed-to-treat was 3 (95% CI, 1.35-5.0) to prevent high postoperative anxiety in patients with moderate to intense pain, when compared with 7.5 (95% CI, 1.36-[infinity]) in the absence of pain or mild pain. Also, the treated patients required less morphine by patient-controlled analgesia, as assessed by repeated measures ANOVA (F[1,31] = 6.05, P = 0.02). The rest/activity cycle, assessed by actigraphy, showed that the rhythmicity percentual of 24 h was higher in the intervention group in the first week after discharge ([21.16 +/- 8.90] versus placebo [14.00 +/- 7.10]; [t = -2.41, P = 0.02]).
CONCLUSIONS: This finding suggested that preoperative melatonin produced clinically relevant anxiolytic and analgesic effects, especially in the first 24 postoperative hours. Also, it improved the recovery of the potency of the rest/activity circadian rhythm.

Low-Dose Intravenous Midazolam Reduces Etomidate-Induced Myoclonus: A Prospective, Randomized Study in Patients Undergoing Elective Cardioversion. [Miscellaneous Article]
Huter, Lars MD; Schreiber, Torsten MD; Gugel, Michael MD; Schwarzkopf, Konrad MD
Anesthesia & Analgesia. 105(5):1298-1302, November 2007.

BACKGROUND: Myoclonic movements are a common problem in unpremedicated patients during induction of anesthesia with etomidate.
METHODS: In a double-blind fashion, 40 patients (ASA physical status III-IV) scheduled for elective cardioversion were randomly assigned to receive either 0.015 mg/kg midazolam or placebo 90 s before the injection of 0.3 mg/kg etomidate. Myoclonic movements and sedation were recorded on a scale between 0 and 3. Pulse oximetry, noninvasive arterial blood pressure, and heart rate were recorded during the study period.
RESULTS: Two patients (10%) in the midazolam group had myoclonic movements after the administration of etomidate, whereas 10 of the 20 patients (50%) receiving placebo experienced such movements (P = 0.006). No other differences were found between the groups; in particular, there was no difference in recovery 5 min after the administration of etomidate.
CONCLUSIONS: IV midazolam 0.015 mg/kg administered 90 s before induction of anesthesia with etomidate is effective in reducing myoclonic movements and does not prolong recovery in unpremedicated patients after short procedures.

The Safety and Efficacy of Fentanyl Iontophoretic Transdermal System Compared with Morphine Intravenous Patient-Controlled Analgesia for Postoperative Pain Management: An Analysis of Pooled Data from Three Randomized, Active-Controlled Clinical Studies. [Miscellaneous Article]
Viscusi, Eugene R. MD *; Siccardi, Matthew MS +; Damaraju, C V. PhD +; Hewitt, David J. MD +; Kershaw, Paul MD ++
Anesthesia & Analgesia. 105(5):1428-1436, November 2007.

BACKGROUND: Postoperative pain is often managed using IV patient-controlled analgesia (PCA). In this analysis of pooled data, we compared the safety and efficacy of the fentanyl iontophoretic transdermal system (ITS) with morphine IV PCA.
METHODS: Data were obtained from three multicenter, randomized, active-controlled trials (N = 1941). The primary efficacy measure was success ("good"/"excellent" ratings) on the 24-h patient global assessment of the method of pain control. Pain intensity, relative dosing ratios, discontinuation rates, and adverse events were assessed. Efficacy was evaluated across age, surgery type, and body mass index (BMI).
RESULTS: Comparable percentages of patients reported success on the 24-h patient global assessment of the method of pain control (fentanyl ITS, 80.5%; morphine IV PCA, 81.0%; difference = -0.5%; 95% confidence interval, -4.0% to 3.0%). Mean last pain intensity scores in the first 24 h were comparable (fentanyl ITS, 3.1; morphine IV PCA, 3.0; difference = 0.07; 95% confidence interval, -0.14 to 0.29). Relative dosing ratios of fentanyl to morphine overall and in subpopulations (age, BMI) were comparable over 6, 12, and 24 h. Fentanyl ITS was equally effective when compared with morphine IV PCA for patient subpopulations (age, surgery type, and BMI). Discontinuation rates and the incidence of adverse events were similar between groups.
CONCLUSIONS: These pooled data represent one of the largest head-to-head comparisons of fentanyl versus morphine in a postoperative acute pain setting. Results suggest that fentanyl ITS is effective across subpopulations defined by age and BMI, and support a consistent safety and efficacy profile of fentanyl delivered by fentanyl ITS for postoperative pain management.

A Randomized, Placebo-Controlled Trial of Preoperative Oral Pregabalin for Postoperative Pain Relief After Minor Gynecological Surgery. [Miscellaneous]
Paech, Michael J. DM *; Goy, Raymond FANZCA +; Chua, Sebastian MMed +; Scott, Karen FRCA +; Christmas, Tracey MRCP +; Doherty, Dorota A. PhD ++
Anesthesia & Analgesia. 105(5):1449-1453, November 2007.

BACKGROUND: Although pregabalin shows efficacy against neuropathic pain, very limited evidence supports postoperative analgesic efficacy. Our study objective was to investigate analgesic efficacy in an ambulatory day surgical population experiencing acute visceral pain. The null hypothesis was that there was no significant difference in pain relief between pregabalin and placebo.
METHODS: A randomized, double-blind, parallel-group, placebo-controlled trial was performed in 90 women having minor gynecological surgery involving the uterus. Patients received either oral pregabalin 100 mg (Group PG) or placebo (Group C) approximately 1 h before surgery. The primary outcome was pain score in the recovery unit and patients were followed for 24 h.
RESULTS: There was no significant difference between groups for pain experienced in the recovery room (median, interquartile range 16, 0-36 vs 10, 6.5-36 for Groups PG and C, respectively, P = 0.80) or thereafter; nor for recovery room fentanyl requirement (42% Group PG versus 27% Group C, P = 0.12) or the quality of recovery at 24 h postoperatively (median, interquartile range score 17, 17-18 Group PG versus 18, 16.5-18 Group C, P = 0.75). The incidence of posthospital discharge light-headedness, visual disturbance, and difficulty with walking was significantly higher in the pregabalin group.
CONCLUSIONS: A single preoperative dose of 100 mg pregabalin does not reduce acute pain or improve recovery after minor surgery involving only the uterus.

Transient Neurological Symptoms After Isobaric Subarachnoid Anesthesia with 2% Lidocaine: The Impact of Needle Type. [Miscellaneous Article]
Evron, Shmuel MD *+++; Gurstieva, Victoria RN, MPH [S]; Ezri, Tiberiu MD +++; Gladkov, Vladimir MD +; Shopin, Sergey MD +; Herman, Amir MSc [//]; Sidi, Ami MD [P]; Weitzman, Shimon MD, MPH [S]
Anesthesia & Analgesia. 105(5):1494-1499, November 2007.

BACKGROUND: The reported incidence of transient neurological symptoms (TNS) after subarachnoid lidocaine administration is as high as 40%. We designed this clinical trial to determine the incidence of TNS with two different pencil-point spinal needles: one-orifice (Atraucan) and two-orifice (Eldor) spinal needles.
METHODS: Ninety-nine ASA physical status I or II patients undergoing surgical procedures of the urinary bladder or prostate were prospectively allocated to receive spinal anesthesia with 40 mg, 2% isobaric lidocaine plus fentanyl injected through either a 26-gauge Atraucan (n = 52) or a 26-gauge Eldor (n = 47) spinal needle. During the first three postoperative days, patients were observed for postoperative complications, including TNS. The primary end-point for this trial was the percentage of TNS in both double- and single-orifice spinal needle procedures.
RESULTS: The incidence of TNS was higher when spinal anesthesia was done through the Atraucan needle (28.8% vs 8.5%, P = 0.006). Fifty percent of the patients in the double-orifice group versus 100% of the single-orifice group developed TNS after surgery in the lithotomy position (P = 0.014). The relative risk for developing TNS with the Eldor needle was 0.29 (95% CI: 0.07-0.75) compared with the Atraucan needle.
CONCLUSIONS: The use of a double-orifice spinal needle was associated with a lower incidence of TNS, which may have been due to the needle design.

A Prospective Evaluation of the POVOC Score for the Prediction of Postoperative Vomiting in Children. [Miscellaneous Article]
Kranke, Peter MD, PhD, MBA *; Eberhart, Leopold H. MD, PhD +; Toker, Hakki MD ++; Roewer, Norbert MD, PhD *; Wulf, Hinnerk MD, PhD +; Kiefer, Peter MD, PhD ++
Anesthesia & Analgesia. 105(6):1592-1597, December 2007.

BACKGROUND: A score to predict postoperative vomiting (PV) in children (POVOC score) has recently been published but has not yet undergone an external validation.
METHODS: We studied 673 patients (age 0-16 yr) undergoing a variety of surgical procedures (but excluding strabismus surgery, one of the risk factors according to the POVOC score) using standardized anesthesia techniques without administering antiemetics. The patients were prospectively screened for PV in the postoperative period and these incidences were compared with the predicted risk for PV according to the POVOC score. The POVOC score was evaluated with respect to its ease of use, discrimination, and calibration.
RESULTS: Complete data to predict the risk for PV could be obtained in 95% of patients. The actual observed incidences of PV were 3.4, 11.6, 28.2, and 42.3% for the presence of 0, 1, 2, or 3 risk factors, resulting in a regression line with a slope of 0.78 and an offset of 2.37. The area under the receiver operating characteristic curve was 0.72 (95% CI: 0.68-0.76).
CONCLUSIONS: Using the POVOC score, PV in pediatric patients can be predicted with sufficient accuracy comparable to the results in adult patients, even if one of the risk factors is not applicable.

Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting. [Article]
Gan, Tong J. MD *; Meyer, Tricia A. PharmD, MS +++; Apfel, Christian C. MD, PhD [S]; Chung, Frances FRCPC [//]; Davis, Peter J. MD [P]; Habib, Ashraf S. MB, FRCA *; Hooper, Vallire D. MSN, RN, CPAN, FAAN #; Kovac, Anthony L. MD **; Kranke, Peter MD, PhD, MBA ++; Myles, Paul MD ++++; Philip, Beverly K. MD [S][S]; Samsa, Gregory PhD [//][//]; Sessler, Daniel I. MD [P][P]; Temo, James CRNA, MSN, MBA ##; Tramer, Martin R. MD, DPhil ***; Vander Kolk, Craig MD +++; Watcha, Mehernoor MD ++++++
Anesthesia & Analgesia. 105(6):1615-1628, December 2007.

The present guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in postoperative nausea and vomiting (PONV) under the auspices of The Society of Ambulatory Anesthesia. The panel critically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. In brief, these guidelines identify risk factors for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic monotherapy and combination therapy regimens for PONV prophylaxis; recommend approaches for treatment of PONV when it occurs; and provide an algorithm for the management of individuals at increased risk for PONV.

The 8-Item Short-Form Health Survey and the Physical Comfort Composite Score of the Quality of Recovery 40-Item Scale Provide the Most Responsive Assessments of Pain, Physical Function, and Mental Function During the First 4 Days After Ambulatory Knee Surgery with Regional Anesthesia. [Miscellaneous Article]
Bost, James E. MS, PhD *; Williams, Brian A. MD, MBA +; Bottegal, Matthew T. BS ++; Dang, Qianyu PhD *; Rubio, Doris M. PhD *
Anesth. Analg. 2007 105: 1693-1700.

BACKGROUND: We evaluated the validity and responsiveness of three instruments: the numeric rating scale (NRS) pain score, the 8-item Short-Form Health Survey (SF-8), and the 40-item Quality of Recovery from Anesthesia (QoR) Survey in 154 outpatients undergoing anterior cruciate ligament reconstruction (ACLR). The objective was to provide a robust psychometric basis for outcome survey selection for surgical outpatients undergoing regional anesthesia without general anesthesia.
METHODS: Patients undergoing ACLR with a standardized spinal anesthesia plan were randomized to receive a perineural catheter with either placebo injection-infusion, or injection-infusion with levobupivacaine. Patients completed the NRS, SF-8, and QoR instruments for four postoperative days to evaluate pain, physical function, and mental function.
RESULTS: Regarding pain, neither the NRS nor the QoR offered advantages over the SF-8. Regarding physical function, the QoR physical independence composite offered no advantage over the SF-8 physical component summary. The QoR physical comfort composite assessed short-term changes in treatment-related side effects, and thus provided information not covered by the SF-8. Regarding mental function, the SF-8 mental component summary and QoR emotional state composite showed little change over the four days, although the latter measure showed higher responsiveness to change.
CONCLUSIONS: For ACLR outpatients receiving regional anesthesia, the SF-8 is sufficient to assess postoperative pain and physical function. Adding the QoR physical comfort composite will help assess short-term side effects.

Cardiovascular Thromboembolic Adverse Effects Associated with Cyclooxygenase-2 Selective Inhibitors and Nonselective Antiinflammatory Drugs.[Report]
Joshi, Girish P. MBBS, MD, FFARCSI *; Gertler, Ralph MD +; Fricker, Ruth MD ++
Anesthesia & Analgesia. 105(6):1793-1804, December 2007.

BACKGROUND: Concerns of increased cardiovascular (CV) thromboembolic adverse effects from nonsteroidal antiinflammatory drugs (NSAIDs, both nonselective [NS]-NSAIDs and cyclooxygenase [COX]-2 selective inhibitors) have prevented their use despite numerous benefits.
METHODS: In this descriptive review, we critically examine the randomized, active- and placebo-controlled studies, observational trials, and meta-analyses evaluating the CV adverse effects associated with long-term and short-term use of COX-2 selective inhibitors and NS-NSAIDs. The potential mechanisms for these CV effects are also presented.
RESULTS: Although the studies evaluating the CV risks have limitations, there appears to be an increased CV risk with both COX-2 selective inhibitors and NS-NSAIDs, particularly in high-risk patients. Therefore, the United States Food and Drug Administration has given a similar "boxed" warning highlighting the potential for increased risk of CV events associated with their use. Nevertheless, there are differences in the CV risks between COX-2 selective inhibitors (e.g., higher CV risk with rofecoxib than celecoxib) as well as differences in the CV risks between individual NS-NSAIDs (e.g., higher CV risks with diclofenac than naproxen).
CONCLUSIONS: Until long-term, prospective, randomized, adequately powered, clinical studies in relevant patient populations have been completed, the CV risks associated with the use of NSAIDs, especially in high-risk patients, will likely continue to be controversial. Nevertheless, the benefits of their short-term (e.g., perioperative) use in patients without CV risks probably outweigh their potential CV adverse effects. Finally, careful risk/benefit assessment should be undertaken and both COX-2 selective inhibitors and NS-NSAIDs should be used with caution in patients with CV risk factors.

ANESTHESIOLOGY - TOP

Laryngeal Mask Airway Is Associated with an Increased Incidence of Adverse Respiratory Events in Children with Recent Upper Respiratory Tract Infections.

Clinical Investigations
von Ungern-Sternberg, Britta S. M.D. ; Boda, Krisztina Ph.D. ; Schwab, Craig M.D. ; Sims, Craig M.D. ; Johnson, Chris M.D. ; Habre, Walid M.D., Ph.D. 
Anesthesiology. 107(5):714-719, November 2007.

Abstract:
Background: The laryngeal mask airway (LMA) has been advocated as an alternative technique to tracheal intubation for airway management of children with recent upper respiratory tract infections (URIs). The authors determined the occurrence of adverse respiratory events and identified the associated risk factors to assess the safety of LMA in children.
Methods: During a period of 5 months, parents of children scheduled to undergo general anesthesia with an LMA were asked to fill out a questionnaire regarding their child's medical history and potential symptoms of URI. In addition, all episodes of adverse respiratory events in the perioperative period (laryngospasm, bronchospasm, coughing, airway obstruction, and oxygen desaturation) as well as details of anesthesia management were recorded.
Results: Among the 831 children included in the study, 27% presented with a history of a recent URI within the last 2 weeks before anesthesia. The presence of a recent URI doubled the incidence of laryngospasm (odds ratio, 2.6; 95% confidence interval, 1.3-5.0), coughing (odds ratio, 2.7; 95% confidence interval, 1.7-4.3), and oxygen desaturation (odds ratio, 1.9; 95% confidence interval, 1.2-2.8). This incidence was even higher in young children; in those undergoing ear, nose, and throat surgery; and when there were multiple attempts to insert the LMA.
Conclusion: An LMA used in children with recent URIs was associated with a higher incidence of laryngospasm, cough, and oxygen desaturation compared with healthy children. However, the overall incidence of adverse respiratory events was low, suggesting that if anesthesiologists allow at least a 2-week interval after a URI, they can safely proceed with anesthesia using an LMA.

A Single Dose of Propofol at the End of Surgery for the Prevention of Emergence Agitation in Children Undergoing Strabismus Surgery during Sevoflurane Anesthesia.

Clinical Investigations
Aouad, Marie T. M.D. ; Yazbeck-Karam, Vanda G. M.D. ; Nasr, Viviane G. M.D. ; El-Khatib, Mohamad F. Ph.D. ; Kanazi, Ghassan E. M.D. ; Bleik, Jamal H. M.D.
Anesthesiology. 107(5):733-738, November 2007.

Abstract:
Background: Emergence agitation in children after sevoflurane is common. Different drugs have been used to decrease its occurrence with variable efficacy. The authors compared the incidence and severity of emergence agitation in children who received a single dose of propofol at the end of strabismus surgery versus children who received saline.
Methods: In this prospective, randomized, double-blind study, the authors enrolled 80 healthy children aged 2-6 yr. The children were randomly allocated to the propofol group (n = 41), which received 1 mg/kg propofol at the end of surgery, or to the saline group (n = 39), which received saline.
Results: The mean scores on the Pediatric Anesthesia Emergence Delirium scale were significantly lower in the propofol group compared with the saline group (8.6 +/- 3.9 vs. 11.5 +/- 4.5; P = 0.004). Also, the incidence of agitation was significantly lower in the propofol group compared with the saline group (19.5% vs. 47.2%; P = 0.01). A threshold score greater than 10 on the Pediatric Anesthesia Emergence Delirium scale was the best discriminator between presence and absence of emergence agitation. Times to removal of the laryngeal mask airway (10.6 +/- 1.5 vs. 9.4 +/- 1.9 min; P = 0.004) and emergence times (23.4 +/- 5.7 vs. 19.7 +/- 5 min; P = 0.004) were significantly longer in the propofol group. However, discharge times were similar between the two groups (propofol: 34.1 +/- 8.4 min; saline: 34.9 +/- 8.6 min). More parents in the propofol group were satisfied.
Conclusions: In children undergoing strabismus surgery, 1 mg/kg propofol at the end of surgery after discontinuation of sevoflurane decreases the incidence of agitation and improves parents' satisfaction without delaying discharge from the postanesthesia care unit.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Prospective randomized comparison of the new Laryngeal Tube Suction LTS II and the LMA-ProSeal for elective surgical interventions
H. V. Genzwuerker, S. Altmayer, J. Hinkelbein, C. Gernoth, T. Viergutz, H.
Ocker Acta Anaesthesiologica Scandinavica 51 (10), 1373–1377.

Background and aim: The Laryngeal Tube Suction (LTS) has recently undergone considerable changes in design. The new LTS II was compared with the LMA-ProSeal to determine device performance during general anaesthesia and controlled ventilation.
Methods: After Institutional Review Board approval, 100 elective surgical patients were randomized to be ventilated with LTS II or LMA-ProSeal. The number of attempts (maximum of two, and then other device tested) and time until first tidal volume were recorded. Ventilation was standardized (tidal volume, 7 ml/kg; respiratory rate, 12 breaths/min) and the resulting end-tidal CO2 was recorded. The airway leak pressure (maximum of 40 cmH2O) was measured at cuff pressures of 60 cmH2O. The ease of gastric tube insertion was evaluated. The devices were inspected for traces of blood after removal. Patients were questioned regarding post-operative complaints. The Mann–Whitney U-test was used to compare the groups.
Results: The demographic data, American Society of Anesthesiologists’ group, Mallampati score, and haemodynamic and respiratory variables were comparable for both groups of 50 patients. Insertion was successful in the first/second attempts in 44/4 patients for LTS II and in 43/6 patients for LMA-ProSeal. After two failed attempts, the other device was successfully used in one patient for LMA-ProSeal and in two patients for LTS II. The times until first tidal volume for LTS II and LMA-ProSeal were 25.0 ± 10.1 and 25.5 ± 11.5 s, respectively. The airway leak pressures were comparable: 33.1 (15–40) and 32.0 cmH2O (18–40 cmH2O) for LTS II and LMA-ProSeal, respectively. Gastric tube insertion failed in two patients in each group. Traces of blood were found in two patients with LTS II and in three patients with LMA-ProSeal. In both groups, post-operative complaints were mild and infrequent.
Conclusion: In this prospective randomized trial, LMA-ProSeal and LTS II were comparable in all respects.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Patient Experiences with the Preoperative Assessment Clinic (PEPAC): validation of an instrument to measure patient experiences
G. M. Edward, L. C. Lemaire, B. Preckel, F. J. Oort, M. J. L. Bucx, M. W. Hollmann and J. C. J. M. de Haes
British Journal of Anaesthesia 2007 99(5):666-672

Background: Presently, no comprehensive and validated questionnaire to measure patient experiences of the preoperative assessment clinic (PAC) is available. We developed and validated the Patient Experiences with the Preoperative Assessment Clinic (PEPAC) questionnaire, which can be used for quantitative measurements of patient experiences of the PAC.
Methods: We adapted the National Health Service outpatient questionnaire, incorporating questions specific for anaesthesiology. To make the PEPAC appropriate for quantitative measurements, dimensions and single items suitable for statistical analysis were constructed. Each dimension consists of multiple items measuring the same aspect of care. Reliability was established by computing Cronbach's alpha coefficients. Construct validity was assessed by correlating the dimensions with the patient's overall appraisal (Pearson's r). These dimensions should explain a substantial level of variance of the patients’ overall appraisal; therefore, regression analysis was performed.
Results: After a pilot phase, the questionnaire was sent to 700 consecutive patients (response 74%). Five scales measuring five dimensions of patient experiences were constructed. Cronbach's alpha ranged from 0.56 to 0.84, supporting reliability of the PEPAC. Correlations between the dimensions and patients' overall appraisal ranged from 0.22 to 0.56. Collectively, the five scales explained 51% of patients' overall appraisal.
Conclusions: The PEPAC is a comprehensive, reliable, and validated questionnaire to measure patient experiences with the PAC. It might be a useful tool to identify the service areas of the PAC that require improvement and to determine which actions can bring about improvement.

Randomized, double-blind study comparing the efficacy of moderate-dose metoclopramide and ondansetron for the prophylactic control of postoperative vomiting in children after tonsillectomy
C. M. Bolton, P. S. Myles, J. B. Carlin and T. Nolan
British Journal of Anaesthesia 2007 99(5):699-703

Background: Postoperative vomiting (POV) is a major cause of morbidity after tonsillectomy in children. It has been well established that anti-serotinergic agents are effective for the prophylactic control of POV in this patient group. It has been suggested that at moderate doses (0.5 mg kg–1), metoclopramide is also an effective agent. No study has been performed comparing the efficacy of an anti-serotinergic agent and moderate-dose metoclopramide.
Methods: A total of 557 children undergoing tonsillectomy with or without adenoidectomy were randomly allocated to receive either ondansetron 0.1 mg kg–1 or metoclopramide 0.5 mg kg–1. All received a standardized muscle-relaxant anaesthetic and dexamethasone 0.1 mg kg–1. The primary outcome was any vomit in the immediate postoperative period. Comparisons were made of the proportion in each group reaching the primary outcome and the time until their first vomit. The study was designed to detect equivalence.
Results: The incidence of vomiting in the group receiving ondansetron (25.3%) was 12% lower (95% CI 4.4–19.7) than those in metoclopramide (37.3%). The time until first vomit was significantly longer in the group receiving ondansetron (hazard ratio 0.61, 95% CI 0.45–0.82).
Conclusions: Although the incidence of vomiting was similar, when these results are compared with a pre-specified zone of equivalence of 0–15%, it cannot be concluded that the effect of metoclopramide is equivalent to ondansetron. Survival analysis indicated that those in the metoclopramide group vomited substantially earlier. It is concluded, therefore, that ondansetron 0.1 mg kg–1 is a superior drug to metoclopramide 0.5 mg kg–1 for the prophylactic control of POV in children undergoing tonsillectomy.

Alternative method for predicting optimal insertion depth of the laryngeal tube in children
J. T. Kim, S. Y. Jeon, C. S. Kim, S. D. Kim and H. S. Kim
British Journal of Anaesthesia 2007 99(5):704-707

Background: Little information is available about the accuracy of the teeth mark on the laryngeal tube (LT) as a guide to correct placement in children. The aim of this crossover study was to evaluate three methods for optimal insertion depth of the size (#) 2 tube in children weighing 12–25 kg.
Method: In 24 children, the LT #2 was consecutively inserted by three different methods: (A) until the thick teeth mark on the tube was aligned with the upper incisors, (B) until resistance was felt, and (C) by inserting to a depth, previously measured, of the curved distance between the cricoid cartilage and the upper incisor. In each case, the depth of insertion, the degree of effective ventilation, the presence of leakage, and the fibreoptic view were assessed.
Results: Insertion based on the teeth mark led to a shorter insertion depth and a greater incidence of inadequate ventilation compared with the other two methods. There was no difference in the adequacy of ventilation between methods B and C. The vocal cords were more easily identified with methods B (62.5%) and C (75%) than with method A (12.5%).
Conclusions: Insertion of the LT #2 aligned with the teeth mark can result in a shallow insertion depth and inadequate ventilation. The measured distance from the cricoid cartilage to the upper incisor offers alternative guidance for correct LT insertion.

Effect of communication on pain during intravenous cannulation: a randomized controlled trial
J. Dutt-Gupta, T. Bown and A. M. Cyna
British Journal of Anaesthesia 2007 99(6):871-875

Background: Clinicians frequently warn patients of discomfort before potentially painful procedures, despite the lack of evidence that such communications are helpful. We aimed to compare two communications (one with, and the other without, a warning of a ‘sting’) immediately before i.v. cannulation in order to measure differences in perceived pain by patients during the procedure.
Methods: Randomly assigned patients awaiting elective surgery received a communication immediately before i.v. cannulation consisting of either ‘I am going to apply the tourniquet and insert the needle in a few moments. It’s a sharp scratch and it may sting a little’ (Group S) or ‘I am going to apply the tourniquet on the arm. As I do this many people find the arm becomes heavy, numb and tingly. This allows the drip to be placed more comfortably’ (Group NS). Cannulation pain was measured by a 0–10 verbal numerical rating score (VNRS) and five-point Likert scale.
Results: Of 101 participants, 49 were allocated to Group S and 52 to Group NS. Median VNRS pain scores with inter-quartile ranges (IQR) were 1 and 2, respectively, for both groups. Median Likert scores were 3 in Group S and 2 in Group NS with an IQR of 1 for both groups (P = 0.13). Six participants vocalized pain in Group S and none in Group NS (P = 0.01). Three participants withdrew their arm spontaneously in Group S and none in Group NS (P = 0.11).
Conclusions: Warning patients of a ‘sting’ before i.v. cannulation may not be helpful.

Reduction of pain during induction with target-controlled propofol and remifentanil
J.-R. Lee, C.-W. Jung and Y.-H. Lee
British Journal of Anaesthesia 2007 99(6):876-880

Background: Pain on injection of propofol is unpleasant. We hypothesized that propofol infusion pain might be prevented by infusing remifentanil before starting the propofol infusion in a clinical setting where target-controlled infusions (TCI) of both drugs were used. A prospective, randomized, double-blind, placebo-controlled trial was performed to determine the effect-site concentration (Ce) of remifentanil to prevent the pain without producing complications.
Methods: A total of 128 patients undergoing general surgery were randomly allocated to receive normal saline (control) or remifentanil to a target Ce of 2 ng ml–1 (R2), 4 ng ml–1 (R4), or 6 ng ml–1 (R6) administered via TCI. After the target Ce was achieved, the infusion of propofol was started. Remifentanil-related complications were assessed during the remifentanil infusion, and pain caused by propofol was evaluated using a four-point scale during the propofol infusion.
Results: The incidence of pain was significantly lower in Groups R4 and R6 than in the control and R2 groups (12/32 and 6/31 vs 26/31 and 25/32, respectively, P<0.001). Pain was less severe in Groups R4 and R6 than in the control and R2 groups (P<0.001). However, both incidence and severity of pain were not different between Groups R4 and R6. No significant complications were observed during the study.
Conclusions: During induction of anaesthesia with TCI of propofol and remifentanil, a significant reduction in propofol infusion pain was achieved without significant complications by prior administration of remifentanil at a target Ce of 4 ng ml–1.

Responsive Contingency Planning: a novel system for anticipated difficulty in airway management in dental abscess
S. Darshane, P. Groom and P. Charters
British Journal of Anaesthesia 2007 99(6):898-905

Background: This study is of a novel system for management of anticipated difficult airway (Responsive Contingency Planning). It is based on the notion that almost all problems in airway management have already been experienced, so they can be anticipated and prepared for using ‘worst case’ planning.
Methods: Anaesthetic colleagues were introduced to the new system. Thirty-two patients with dental abscess were recruited for anaesthetic airway management based around the new scheme. Data collection involved a preoperative assessment of problems specific to dental abscess, fascia-spaces involved, details of the contingency planning process, laryngoscopy grade, and comments regarding the efficacy of the new system.
Results: No problems were encountered that had not been anticipated during planning and colleagues' comments about using the system were generally favourable. Examples are highlighted to suggest how the planning may have avoided certain complications (e.g. abscess rupture) and helped in dealing with others when they occurred. If trismus (2 cm inter-incisor distance) occurred with superficial infection alone, it always improved (to >2 cm) after induction of anaesthesia. In contrast, difficult laryngoscopy (grade 3 or 4) occurred in 6/15 cases of floor of mouth infection.
Conclusions: The system fulfilled expectations for its use at this stage of development. It can be easily updated for refinements, alternative techniques, and tailoring to any difficult airway scenario. Computerization should make it easier to use and flag-up inconsistencies. Floor of mouth infections in the presence of trismus are easily underestimated and require careful assessment.

Gabapentin: a multimodal perioperative drug? (REVIEW)
V. K. F. Kong and M. G. Irwin
British Journal of Anaesthesia 2007 99(6):775-786

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Dexamethasone reduces the severity of postoperative sore throat
Siji Thomas, MD and Suhara Beevi, MD
Canadian Journal of Anesthesia54:897-901 (2007)

Purpose: Dexamethasone may have potential advantages in the prevention of postoperative sore throat. We therefore undertook a study to evaluate the efficacy of intravenously administered dexamethasone in reducing the incidence and severity of postoperative sore throat in patients receiving general anesthesia with endotracheal intubation.
Methods: In a randomized, double-blind and placebo-controlled study, 120 patients receiving general anesthesia with endotracheal intubation were randomly assigned to two groups. Group 1 (control) patients received normal saline 2 mL iv and group 2 (D) patients received dexamethasone 8 mg iv. After surgery, visual analogue scale (VAS) scores at rest and with effort (swallowing movement) for postoperative sore throat were recorded by a blinded observer.
Results: The overall incidence of postoperative sore throat during the first 24 hr following surgery was lower in dexamethasone group (D) compared to the control group (C). Eleven (20%) patients in the dexamethasone group had postoperative sore throat, compared to 31 (56.3%) patients in the control group (P < 0.01). Postoperatively at one hour, three hours, six hours, 12 hr and 24 hr, the VAS scores for postoperative sore throat at rest and during effort were lower in the dexamethasone group (D) compared to the control group (P < 0.01) at corresponding time intervals.
Conclusion: Preoperative administration of dexamethasone 8 mg iv reduces the incidence and severity of postoperative sore throat in patients receiving general anesthesia with endotracheal intubation.

A review of approaches and techniques for lower extremity nerve blocks
Quang Hieu De Tran, MD FRCPC, Antonio Clemente, MD and Roderick J. Finlayson, MD FRCPC
Canadian Journal of Anesthesia 54:922-934 (2007)

Purpose: The purpose of this narrative review is to summarize the evidence derived from randomized controlled trials (RCTs) regarding approaches and techniques for lower extremity nerve blocks.
Source: Using the MEDLINE (January 1966 to April 2007) and EMBASE (January 1980 to April 2007) databases, medical subject heading (MeSH) terms "lumbosacral plexus", "femoral nerve", "obturator nerve", "saphenous nerve", "sciatic nerve", "peroneal nerve" and "tibial nerve" were searched and combined with the MESH term "nerve block" using the operator "and". Keywords "lumbar plexus", "psoas compartment", "psoas sheath", "sacral plexus", "fascia iliaca", "three-in-one", "3-in-1", "lateral femoral cutaneous", "posterior femoral cutaneous", "ankle" and "ankle block" were also queried and combined with the MESH term "nerve block". The search was limited to RCTs involving human subjects and published in the English language. Forty-six RCTs were identified.
Principal findings: Compared to its anterior counterpart (3-in- 1 block), the posterior approach to the lumbar plexus is more reliable when anesthesia of the obturator nerve is required. The fascia iliaca compartment block may also represent a better alternative than the 3-in-1 block because of improved efficacy and efficiency (quicker performance time, lower cost). For blockade of the sciatic nerve, the classic transgluteal approach constitutes a reliable method. Due to a potentially shorter time for sciatic nerve electrolocation and catheter placement than for the transgluteal approach, the subgluteal approach should also be considered. Compared to electrolocation of the peroneal nerve, electrostimulation of the tibial nerve may offer a higher success rate especially with the transgluteal and lateral popliteal approaches. Furthermore, when performing sciatic and femoral blocks with low volumes of local anesthetics, a multiple-injection technique should be used.
Conclusions: Published reports of RCTs provide evidence to formulate limited recommendations regarding optimal approaches and techniques for lower limb anesthesia. Further well-designed and meticulously executed RCTs are warranted, particularly in light of new techniques involving ultrasonographic guidance.

PUB MED - TOP

Developing an orthopedic ambulatory surgery center.
Buehler DA, Mattison TR, Mayberry DE.
Orthop Clin North Am. 2008 Jan;39(1):17-25.

Although there are risks, the potential benefits should encourage one to consider developing an orthopedic ambulatory surgery center (OASC). Patients should appreciate the enhanced care they experience at a surgery center. The orthopedist can enjoy the benefits of increased income, time savings, and productivity provided by the surgery center. This article discusses the complex and time-consuming demands of developing the OASC, and having it operate efficiently. It points out how experts can assist in developing and managing a highly efficient center, freeing the orthopedist to concentrate on performing surgery in an environment that is clinically, financially, and personally rewarding.

Pros and cons of the ambulatory surgery center joint venture.
Giannini D.
Orthop Clin North Am. 2008 Jan;39(1):11-5.

If a physician group has determined that it has a realistic patient base to establish an ambulatory surgery center, it may be beneficial to consider a partner to share the costs and risks of this new joint venture. Joint ventures can be a benefit or liability in the establishment of an ambulatory surgery center. This article discusses the advantages and disadvantages of a hospital physician-group joint venture.

Postoperative pain after ambulatory surgery.
Lux EA, Stamer U, Meissner W, Moser K, Neugebauer E, Wiebalck A.
Schmerz. 2007 Dec 9 [Epub ahead of print]

BACKGROUND: Outpatient surgeons were surveyed about the quality of postoperative pain therapy after outpatient interventions.
PATIENTS AND METHODS: Of 2,317 outpatient surgeons who received a questionnaire by mail, 419 responded. The return rate was 18.1%. The questionnaire collected data on the operative procedures and methods of anesthesia from 2004 and the analgesics, which were applied in the immediate postoperative period and at home. Methods and contents of quality control were registered.
RESULTS: The respondents indicated that the person responsible for the pain therapy was the surgeon in 74% of the practices, the anesthesiologist in 16%, and both in 10%. The drugs used in the practice were: novaminsulfone (34%), NSAIDs (28%), and opioids (36%). The drugs used for at-home care were: NSAIDs (58%), opioids (43%), novaminsulfone (32%), and mixed analgesics (28%). No analgesics were given by 6%, and 21% prescribed a supplementary antiemetic. Routine pain measurement was performed with pain scales in only 11% of the practices; among the certified practices, 48% performed pain measurement for quality control. Ninety-five percent of the surgeons were satisfied with the pain therapy.
CONCLUSION: This survey shows that the guidelines for acute pain therapy (http://www.awmf.de) are only partially implemented.

A randomised comparison of the single use LMA Flexible with the reusable LMA Flexible in paediatric dental day-case patients.
Flynn P, Ahmed FB, Mitchell V, Patel A, Clarke S.
Anaesthesia. 2007 Dec;62(12):1281-4.

In this study we compared the performance of the single use flexible laryngeal mask airway (LMA Flexible) with the original reusable LMA Flexible in paediatric dento-alveolar day-case surgery. The aim of the study was to determine whether these two supraglottic airway devices were clinically equivalent when used for simple dental extractions in children under general anaesthesia. This randomised comparative trial in 100 healthy children used first attempt airway insertion success as its primary outcome measure. Secondary outcomes included the adequacy of ventilation, incidence of airway obstruction and the requirement for device manipulation and the incidence of adverse airway outcomes during recovery from anaesthesia. No difference was found between the devices in first attempt insertion success rate (94% with reusable LMA Flexible and 90% with single use LMA Flexible, p = 0.358), and ease of insertion was also similar (p = 0.5). Both devices performed equally well during surgery, with no significant differences in episodes of intra-operative airway compromise (p = 0.387), and both the single use and reusable LMA Flexible displayed excellent recovery characteristics, with no occurrences of emergence airway obstruction. No blood was discovered within the inner LMA tube shaft in either device, implying that both protected against tracheobronchial soiling. We conclude therefore that the single use LMA Flexible is an acceptable alternative to the reusable LMA Flexible.

Publication Types:

• Comparative Study
• Randomized Controlled Trial

The effects of electronic documentation in the ambulatory surgery setting.
O'Meara E.
AORN J. 2007 Dec;86(6):970-9.

ELECTRONIC DOCUMENTATION can improve organizational processes in health care settings and may be of particular benefit to ambulatory surgery centers.
A DECISION SUPPORT SYSTEM (DSS) can be integrated with an electronic documentation system. A DSS can identify potential errors and deviations from best practices and provide electronic alerts for health care clinicians to support patient screening and care.
BARRIERS TO IMPLEMENTATION of a DSS include practitioner noncompliance with alerts and limitations in system design.
NURSES CAN BE INSTRUMENTAL in overcoming the barriers that prevent some clinicians from adopting these useful information systems. AORN J 86 (December 2007) 970-979. (c) AORN, Inc, 2007.

Fast-track anesthetic techniques for ambulatory surgery.
White PF, Eng M.
Curr Opin Anaesthesiol. 2007 Dec;20(6):545-57.

PURPOSE OF REVIEW: Improving perioperative efficiency and throughput has become increasingly important in facilitating the fast-track recovery process following ambulatory surgery. This review focuses on the important role played by the anesthesiologist as a perioperative physician in fast-track ambulatory surgery.
RECENT FINDINGS: A literature review of more than 200 peer-reviewed publications was used to develop evidence-based recommendations for optimizing recovery following ambulatory anesthesia. The choice of anesthetic technique should be tailored to the needs of the patient as well as the type of surgical procedure being performed in the ambulatory setting. The anesthetic decisions made by the anesthesiologist, as a key perioperative physician, are of critical importance in developing a successful fast-track ambulatory surgery program.
SUMMARY: The pivotal role played by the anesthesiologist as the key perioperative physician in facilitating the recovery process has assumed increased importance in the current outpatient fast-track recovery environment. The choice of premedication, anesthetic, analgesic and antiemetic drugs, as well as cardiovascular, hormonal and fluid therapies, can all influence the ability to fast-track outpatients after ambulatory surgery.

Are there any benefits from minimizing fasting and optimization of nutrition and fluid management for patients undergoing day surgery?
Nygren J, Thorell A, Ljungqvist O.
Curr Opin Anaesthesiol. 2007 Dec;20(6):540-4.

PURPOSE OF REVIEW: As a result of advances in anaesthesia and surgery, an increasing number of surgical procedures are currently possible in the ambulatory setting. Nausea/vomiting and sedation/drowsiness are often associated with delayed discharge and readmission. These symptoms are also related to pharmacological treatment as well as dehydration and fasting. The evidence that preoperative fasting and dehydration not only reduces preoperative well being, but may also affect postoperative recovery is currently being reviewed.
RECENT FINDINGS: In association with minor surgical procedures, rehydration with approximately 1 l fluid, and in cases with a moderate degree of surgery, such as laparoscopic surgery, 1-3 l fluid, given perioperatively will improve postoperative well being and recovery. Administration of a carbohydrate-rich beverage not only provides fluid but also counteracts the negative effects of preoperative fasting, which in turn reduces preoperative hunger and improves well being. Postoperatively, this treatment reduces insulin resistance, which may be relevant in surgery with significant postoperative stress response. Two studies on laparoscopic cholecystectomy demonstrate different results regarding effects on postoperative outcome and nausea/vomiting and further evaluation is required.
SUMMARY: When preoperative dehydration is corrected, postoperative well being and clinical outcome improves. Avoiding preoperative fasting by administration of carbohydrate-rich beverages improves preoperative well being while effects on postoperative recovery in patients undergoing ambulatory surgery need to be further evaluated.

Low-dose aspirin and clopidogrel: how to act in patients scheduled for day surgery.
Servin F.
Curr Opin Anaesthesiol. 2007 Dec;20(6):531-4.

PURPOSE OF REVIEW: With the increasing use of antiplatelet drug treatment, complications resulting from its interference with invasive procedures (surgery or regional anaesthesia) have become an everyday challenge to the surgical team. The purpose of this review is to examine the most recent findings and integrate them into the ambulatory surgery setting.
RECENT FINDINGS: Recent studies have outlined the risks of withholding antiplatelet drug treatment, but it is now generally considered to be preferable to withhold treatment than to maintain it. The role of low molecular weight heparins or short-life NSAIDs as bridge drugs is now discussed and their usefulness challenged.
SUMMARY: Most ambulatory surgical procedures present low bleeding risk. The current attitude in this setting is to maintain aspirin therapy and possible antiplatelet drug inhibitors throughout the perioperative period. High-risk patients proposed for high-risk surgery should not be treated as outpatients.

Should my outpatient center have a beta-blocker protocol?
Fleisher LA.
Curr Opin Anaesthesiol. 2007 Dec;20(6):526-30.

PURPOSE OF REVIEW: Perioperative beta-blockade has been advocated by multiple authors and recent guidelines as a strategy to reduce cardiac risk in noncardiac surgery. Knowledge about application of this treatment modality to the ambulatory surgery population is poor.
RECENT FINDINGS: Although the initial trial in patients with a positive stress test undergoing major vascular surgery demonstrated significantly fewer perioperative cardiac events among those randomized to perioperative beta-blocker therapy, more recent studies in patients without documented coronary artery disease undergoing major noncardiac surgical procedures were unable to demonstrate efficacy. Guidelines from the American Heart Association/American College of Cardiology have been reported and advocated class I recommendations for perioperative beta-blockade only for patients previously taking beta-blockers and those patients with a positive stress test undergoing vascular surgery. There was insufficient evidence to make a recommendation in low-risk surgery.
SUMMARY: Based upon the available evidence and guidelines, patients currently taking beta-blockers and undergoing ambulatory surgery should continue these agents and protocols employing this strategy should be beneficial. In patients who are not currently taking beta-blockers and in whom long-term therapy is not warranted, current evidence does not support instituting prophylactic therapy in the ambulatory surgery population.

Evidence-based medicine in day surgery.
Gupta A.
Curr Opin Anaesthesiol. 2007 Dec;20(6):520-5.

PURPOSE OF REVIEW: To present the evidence available for the management of pain, for the prevention of nausea and vomiting, and for the best anaesthetic technique during ambulatory surgery.
RECENT FINDINGS: Paracetamol and nonsteroidal anti-inflammatory drugs are effective analgesics with a low number needed to treat, and are recommended when not contraindicated. Droperidol, dexamethasone and ondansetron are equally effective in the prevention of postoperative nausea and vomiting during ambulatory surgery. The choice of the anaesthetic technique appears to play a minor role in recovery from anaesthesia or in the occurrence of minor postoperative complications or home discharge, except for the use of total intravenous anaesthesia for the prevention of postoperative nausea and vomiting.
SUMMARY: Pain should be prevented adequately and treated vigorously. Postoperative nausea and vomiting is common and should be prevented in the at-risk patient. The choice of inhalation agents during ambulatory surgery is of minor importance in recovery from anaesthesia.

Quality of care differs by patient characteristics: outcome disparities after ambulatory surgical procedures.
Menachemi N, Chukmaitov A, Brown LS, Saunders C, Brooks RG.
Am J Med Qual. 2007 Nov-Dec;22(6):395-401.

The surgery literature is filled with reports on racial or gender disparities in quality. However, whether patient demographics are risk factors for complications or death from ambulatory surgical procedures is unknown. This study explores whether racial, age, and gender outcome disparities exist after ambulatory surgeries. Patients studied included adults (>18 years) receiving common ambulatory surgical procedures (N = 3,174,436) in either a freestanding ambulatory surgical center or a hospital-based outpatient department during 1997-2004 in Florida. Results demonstrate that African Americans were at a significantly increased risk for either mortality or unexpected hospitalization in 4 of the 5 procedures examined, even after controlling for confounders. For women, unexpected hospital admission or mortality was less likely to occur after almost all procedures examined. Thus, many of the racial and gender disparities in the inpatient surgical literature are also observed in the ambulatory setting. More research is needed to determine the source of these disparities.

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