Telescoping Tracheal Tubes into Catheters Minimizes Epistaxis during Nasotracheal Intubation in Children.
Clinical Investigations
Watt, Stacey M.D. ; Pickhardt, Don M.D. ; Lerman, Jerrold M.D., F.R.C.P.C., F.A.N.Z.C.A. ; Armstrong, James M.D., F.R.C.P.C. ; Creighton, Paul R. D.D.S. ; Feldman, Leeshy 
Anesthesiology. 106(2):238-242, February 2007.

Abstract:
Background: Numerous strategies have been used to reduce epistaxis after nasotracheal intubation. The authors compared the severity of epistaxis after nasotracheal intubation in children with tubes at room temperature, warm tubes, and tubes telescoped into catheters.
Methods: Children who were scheduled for elective dental surgery were randomly assigned to undergo nasotracheal intubation using a tube at room temperature (control), warmed in saline, or whose distal end had been telescoped into a red rubber catheter. After an inhalational induction and intravenous propofol, a lubricated tube or red rubber catheter was inserted into the right naris. Tracheal intubation was achieved by direct laryngoscopy and tube placement using Magill forceps. The pharynx was swabbed for blood by an observer who was blind to the treatment. The severity of bleeding was rated using reference figures. Data were analyzed using Kruskal-Wallis and Fisher exact tests. P < 0.05 was accepted.
Results: The demographics of the three groups were similar. The estimated median area of the gauze in the catheter group that was covered with blood (0%) was significantly less than the areas in the control (40%) and warm (20%) groups. The incidence of clinically relevant bleeding (>= 40% of the gauze area covered in blood) in the catheter group (5%) was significantly less than in the control (56%) and warm (39%) groups. The incidence of no detectable blood in the catheter group (59%) was significantly greater than in the control (21%) and warm (26%) groups.
Conclusions: Telescoping the endotracheal tube into a catheter significantly reduces epistaxis in children undergoing nasotracheal intubation.

Intraoperative Awareness in a Regional Medical System: A Review of 3 Years' Data.
Clinical Investigations
Pollard, Richard J. M.D. ; Coyle, Joseph P. M.D. ; Gilbert, Richard L. M.D., M.B.A. ; Beck, Janet E. C.P.H.Q. 
Anesthesiology. 106(2):269-274, February 2007.

Abstract:
Background: Intraoperative awareness in patients undergoing general anesthesia is an infrequent but well-described adverse outcome. The reported incidence of this phenomenon is between 0.1% and 0.9%.
Methods: With institutional review board approval, the authors reviewed continuous quality improvement data from 3 yr (2002-2004) at the locations where the physician group provided anesthesia. Board-certified anesthesiologists supervising certified registered nurse anesthetists in the anesthesia care team model of practice delivered all anesthetics. Brain function monitors were not used in the operating room setting. Patients were interviewed twice during a 48-h postoperative period and, as part of that process, underwent a modified Brice interview to determine intraoperative awareness. All cases that met the criteria for awareness were examined by the continuous quality improvement committee to modify anesthetic practice and were included in this study.
Results: Data from 211,842 patients undergoing anesthesia were considered. Of these, the continuous quality improvement process followed up 177,468 (83.1%). Cases were not included in the study if the patient was younger than 18 yr, did not have a general anesthetic, or had a terminal event during the hospital course. By these criteria, a total of 87,361 patients followed by the continuous quality improvement process were at risk for awareness. Six patients reported instances of recall.
Conclusion: The incidence of intraoperative awareness in this large sample of patients from a regional medical center undergoing general anesthesia was 0.0068%, or 1 per 14,560 patients, substantially less than that reported in the recent literature.

Effective Reversal of Moderate Rocuronium- or Vecuronium-induced Neuromuscular Block with Sugammadex, a Selective Relaxant Binding Agent.
Clinical Investigations
Suy, Koen M.D. ; Morias, Karl M.D. ; Cammu, Guy M.D., Ph.D. ; Hans, Pol M.D. ; van Duijnhoven, Wilbert G. F. M.Sc. ; Heeringa, Marten Ph.D. ; Demeyer, Ignace M.D. 
Anesthesiology. 106(2):283-288, February 2007.

Abstract:
Background: Sugammadex rapidly reverses rocuronium-induced neuromuscular block. This study explored the dose-response relation of sugammadex given as a reversal agent at reappearance of the second muscle twitch after rocuronium- and vecuronium-induced block. A secondary objective was to investigate the safety of single doses of sugammadex.
Methods: In this two-center, phase II, dose-finding study, 80 patients (age >= 18 yr, American Society of Anesthesiologists physical status I or II, surgery >= 60 min requiring muscle relaxation for intubation) were randomly assigned to receive rocuronium (0.60 mg/kg) or vecuronium (0.10 mg/kg). Sugammadex or placebo was administered at reappearance of the second muscle twitch. The primary efficacy endpoint was time from starting sugammadex administration until recovery of the train-of-four ratio to 0.9.
Results: Compared with placebo, sugammadex produced dose-dependent decreases in mean time to recovery for all train-of-four ratios in the rocuronium and vecuronium groups. The mean time for recovery of the train-of-four ratio to 0.9 in the rocuronium group was 31.8 min after placebo compared with 3.7 and 1.1 min after 0.5 and 4.0 mg/kg sugammadex, respectively. The mean time for recovery of the train-of-four ratio to 0.9 in the vecuronium group was 48.8 min after placebo, compared with 2.5 and 1.4 min after 1.0 and 8.0 mg/kg sugammadex, respectively. Sugammadex was well tolerated.
Conclusion: Sugammadex rapidly reversed rocuronium- or vecuronium-induced neuromuscular block at reappearance of the second muscle twitch and was well tolerated. A dose-response relation was observed with sugammadex for reversal of both rocuronium- and vecuronium-induced neuromuscular block.

A Computer Model of Electrical Stimulation of Peripheral Nerves in Regional Anesthesia.
Pain and Regional Anesthesia
Johnson, Chad R. Ph.D. ; Barr, Roger C. Ph.D. ; Klein, Stephen M. M.D. 
Anesthesiology. 106(2):323-330, February 2007.

Abstract:
Background: Nerve stimulation for regional anesthesia can be modeled mathematically. The authors present a mathematical framework to model the underlying electrophysiology, the development of software to implement that framework, and examples of simulation results.
Methods: The mathematical framework includes descriptions of the needle, the resulting potential field, and the active nerve fiber. The latter requires a model of the individual membrane ionic currents. The model geometry is defined by a three-dimensional coordinate system that allows the needle to be manipulated as it is clinically and tracked in relation to the nerve fiber. The skin plane is included as an electrical boundary to current flow. The mathematical framework was implemented in the Matlab(R) (The MathWorks, Natick, MA) computing environment and organized around a graphical user interface. Simulations were performed using an insulated needle or an uninsulated needle inserted perpendicular to the skin with the nerve fiber at a depth of 2 cm. For each needle design, data were obtained with the needle as cathode or anode. Data are presented as current-distance maps that highlight combinations of current amplitude and tip-to-nerve distance that evoked a propagated response.
Results: With the needle tip positioned 2 mm proximal to the depth of the nerve, an insulated needle required a current greater than 0.457 mA for impulse propagation when attached to the cathode; when attached to the anode, the minimal current was 2.354 mA. In the same position, an uninsulated needle attached to the cathode required a current greater than 2.395 mA to generate a response. However, when an uninsulated needle was attached to the anode, currents up to 7 mA were inadequate to produce a propagated response. Of particular interest were combinations of current amplitude and needle position that activated the fiber but blocked impulse propagation for cathodal stimulation.
Conclusions: Mathematical modeling of nerve stimulation for regional anesthesia is possible and could be used to investigate new equipment or needle designs, test nerve localization protocols, enhance clinical and experimental data, and ultimately generate new hypotheses.

Estimating Anesthesia and Surgical Procedure Times from Medicare Anesthesia Claims.
Economics
Silber, Jeffrey H. M.D., Ph.D. ; Rosenbaum, Paul R. Ph.D. ; Zhang, Xuemei M.S. ; Even-Shoshan, Orit M.S. 
Anesthesiology. 106(2):346-355, February 2007.

Abstract:
Background: Procedure times are important variables that often are included in studies of quality and efficiency. However, due to the need for costly chart review, most studies are limited to single-institution analyses. In this article, the authors describe how well the anesthesia claim from Medicare can estimate chart times.
Methods: The authors abstracted information on time of induction and entrance to the recovery room ("anesthesia chart time") from the charts of 1,931 patients who underwent general and orthopedic surgical procedures in Pennsylvania. The authors then merged the associated bills from claims data supplied from Medicare (Part B data) that included a variable denoting the time in minutes for the anesthesia service. The authors also investigated the time from incision to closure ("surgical chart time") on a subset of 1,888 patients.
Results: Anesthesia claim time from Medicare was highly predictive of anesthesia chart time (Kendall's rank correlation [tau] = 0.85, P < 0.0001, median absolute error = 5.1 min) but somewhat less predictive of surgical chart time (Kendall's [tau] = 0.73, P < 0.0001, median absolute error = 13.8 min). When predicting chart time from Medicare bills, variables reflecting procedure type, comorbidities, and hospital type did not significantly improve the prediction, suggesting that errors in predicting the chart time from the anesthesia bill time are not related to these factors; however, the individual hospital did have some influence on these estimates.
Conclusions: Anesthesia chart time can be well estimated using Medicare claims, thereby facilitating studies with vastly larger sample sizes and much lower costs of data collection.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Does esomeprazole prevent post-operative nausea and vomiting?
J. Raeder, V. Dahl, E. Bjoernestad, G. Edlund, S. Modin, E. Naucler, R. Bergheim, J. Kilhamn
Acta Anaesthesiologica Scandinavica 51 (2), 217–225

Background: Esomeprazole is a potent proton pump inhibitor (PPI), reducing acid production as well as gastric juice volume. This study evaluated the possible beneficial effect of esomeprazole on reducing post-operative nausea and vomiting (PONV).
Methods: Patients undergoing laparoscopic or open gynaecological surgery, or laparoscopic cholecystectomy were randomized to receive three peri-operative doses double blindly of either esomeprazole 40 mg or placebo, given intravenously or orally. All patients were given a standardized anaesthesia regimen including fentanyl and sevoflurane/nitrous oxide.
Results: The study population consisted of 284 patients. Demographic data and known PONV risk factors were similar for the two treatment groups. PONV was observed in 77% of patients on esomeprazole vs. 81% on placebo (NS) and rescue antiemetic medication was needed in 56% vs. 53%, respectively (NS). The proportion of patients that vomited during 0–24 h was lower on esomeprazole than placebo (38% vs. 49%; NS), and the mean amount of vomit was significantly lower (52 vs. 86 g; P < 0.05). The use of neostigmine, use of opioids and type of surgery were significant risk factors for PONV (P < 0.05). The 24-h incidence of PONV was 63% after laparoscopic gynaecology, 80% after laparoscopic cholecystectomy and 88% after open gynaecological laparotomy, whereas laparoscopic cholecystectomy had the lowest risk when corrected for other risk factors of PONV.
Conclusion: Esomeprazole had no clinically relevant effect on the overall 24-h incidence of PONV. However, esomeprazole significantly reduced the total amount of vomit during 24-h post-operatively. This may be of value in patients with an increased risk of pulmonary aspiration.

Tracheal shortening during laparoscopic gynecologic surgery
J.-H. Kim, D.-M. Hong, A.-Y. Oh, S.-H. Han (2007)
Acta Anaesthesiologica Scandinavica 51 (2), 235–238

Background: During laparoscopic gynecologic surgery, pneumoperitoneum combined with the Trendelenburg position moves the carina towards the tip of the endotracheal tube (ETT), decreasing the margin of safety for the ETT position and increasing accidental endobronchial intubation. However, it remains to be established whether the tracheal length itself is actually changed. We conducted a prospective observational study to measure the change in the length of the trachea and the distance between the ETT tip and the carina in patients undergoing gynecologic laparoscopic surgery.
Methods: Twenty-three patients scheduled for laparoscopic gynecologic surgery were enrolled. In the neutral position, the tracheal length was measured using a fiberoptic bronchoscope. The distance between the ETT tip and the carina was also measured. The tracheal length and the distance between the ETT tip and the carina were measured again 10 min after carbon dioxide (CO2) pneumoperitoneum (12–14 mmHg) combined with the Trendelenburg position (15°).
Results: In the neutral position, the tracheal length was 11.09 ± 0.90 cm and the distance between the ETT tip and the carina was 3.36 ± 1.04 cm. After pneumoperitoneum combined with the Trendelenburg position, the distance between the ETT tip and the carina had decreased by 0.85 ± 0.28 cm. The tracheal length had also decreased by 0.42 ± 0.19 cm, which was equivalent to 49.7% of the decrease in the distance between the ETT tip and the carina.
Conclusions: These results suggest that tracheal shortening may contribute to a decrease in the distance between the ETT tip and the carina, increasing the risk of accidental endobronchial intubation during laparoscopic gynecologic surgery.

Dexpanthenol pastille and benzydamine hydrochloride spray for the prevention of post-operative sore throat
N. Gulhas, H. Canpolat, M. Cicek, S. Yologlu, T. Togal, M. Durmus, M. Ozcan Ersoy
Acta Anaesthesiologica Scandinavica 51 (2), 239–243

Background: In this study, we aimed to compare the effectiveness of dexpanthenol pastille and benzydamine hydrochloride spray on the prevention of a sore throat.
Methods: One hundred and eighty patients undergoing general anaesthesia, who were ASA I–II and with their ages ranging between 15 and 70 years, were randomly allocated to three groups, each consisting of 60 patients. For group B, four puffs of benzydamine hydrochloride were sprayed into the mouth initially 30 min before the operation and repeatedly 5 min before anaesthesia induction. For group D, two pastilles of dexpanthenol were administered orally to be sucked 30 min before the operation. For group P, four puffs of distilled water were sprayed into the mouth initially 30 min before the operation. Post-operatively, patients were evaluated for a sore throat for the duration of 24 h.
Results: The incidence of a sore throat was significantly lower for group D when compared with group B and group P. The incidence of a sore throat was similar for group B and group P. According to the sore throat grading system, the number of patients experiencing no complaints was significantly higher for group D when compared with group B and group P. The number of patients achieving moderate scores was significantly higher for group B when compared with group D.
Conclusion: The administration of 200 mg of dexpanthenol prophylactically before endotracheal intubation is effective in the prevention of post-operative sore throat.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Premedication with controlled-release oxycodone does not improve management of postoperative pain after day-case gynaecological laparoscopic surgery
R. Jokela, J. Ahonen, M. Valjus, T. Seppälä and K. Korttila
British Journal of Anaesthesia 2007 98(2):255-260

BACKGROUND: Controlled-release (CR) oxycodone provides an option for the prevention of postoperative pain. We designed this randomized double-blinded placebo controlled study to evaluate the control of pain after premedication with CR oxycodone 15 mg in addition to ibuprofen 800 mg orally in day-case gynaecological laparoscopic surgery.
METHODS: Sixty consenting patients were anaesthetized in a standardized fashion. Postoperative analgesia was provided by ibuprofen 800 mg twice a day in combination with fentanyl i.v. in the recovery room and normal-release (NR) oxycodone orally after the recovery room. The visual analogue scale (VAS) scores for pain and side-effects, and the amounts of postoperative analgesics were recorded for 24 h after discharge from the hospital. After a statistical analysis of the original study, we extended the study to investigate another 10 patients, who received CR oxycodone 15 mg orally in an open-labelled fashion 60 min before surgery. The plasma concentrations of oxycodone were measured from samples drawn before and 2, 4, 6 and 8 h after premedication.
RESULTS: The amounts of fentanyl [100 µg (0–330) in the CR oxycodone group; 125 µg (0–330) in the placebo group], NR oxycodone, or the VAS scores for pain during the first 24 h after the discharge from the hospital did not differ after the premedication with CR oxycodone or placebo. In the extension study group, the peak plasma concentration (Cmax) of oxycodone was 10.0 (4.6–14.7) ng ml–1, indicating possibly a sub-therapeutic level.
CONCLUSION: Oral premedication with CR oxycodone did not improve management of postoperative pain after day-case gynaecological laparoscopic surgery.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Performance of the PAXpress^TM vs the ProSeal^TM laryngeal mask airway during general anesthesia
Alexandre Lallo, MD FRCPC, Pierre Drolet, MD FRCPC and Mélanie Lacroix, MD FRCPC
Canadian Journal of Anesthesia 54:28-33 (2007)

Purpose: The PAXpressTM (PAX^TM) is a relatively new pharyngeal airway device that is easily inserted and effective in routine airway management. A prospective, randomized study was undertaken to compare the PAX^TM with the ProSeal^TM laryngeal mask airway (PLMA^TM) during anesthesia with positive pressure ventilation.
Methods: One hundred adult patients scheduled for elective surgery under general anesthesia were randomized to airway management with either the PAX^TM (n = 50) or the PLMA^TM (n = 50). All patients swallowed a methylene blue capsule before anesthesia. After insertion, leak and inspiratory pressures were measured. Fibrescopy was used to view the glottis. Devices were inspected for blood or methylene blue staining upon removal at the end of surgery. An interview was conducted postoperatively to evaluate the occurrence of sore throat, dysphagia and dysphonia.
Results: Insertion time was longer for the PAx^TM than for the PLMA^TM (52 ± 44s vs 34 ± 23 sec; P = 0.003). Leak pressure was lower while peak inspiratory pressures, and EtCO2 values were higher (P = 0.016; 0.027 and 0.04 respectively) with the PAx^TM. Both devices provided comparable fibreoptic viewing of the glottis. There were no differences with respect to the incidence or pattern of blue stains upon removal. Blood was seen more often on the PAx^TM (58% vs 19%) and dysphagia was also more frequent and severe with the PAX^TM.
Conclusion: In comparison with the PLMA^TM, PAX^TM insertion time is longer and the ventilatory characteristics of this new device may be marginally inferior. The PAX^TM is also more traumatic and is associated with more postoperative discomfort compared to the PLMATM.

Brief review: Neuromuscular monitoring: an update for the clinician
Thomas M. Hemmerling, MD DEAA and Nhien Le
Canadian Journal of Anesthesia 54:58-72 (2007)

Purpose: To review established techniques and to provide an update on new methods for clinical monitoring of neuromuscular function relevant to anesthesia.
Source: A PubMed search of relevant article for the period 1985–2005 was undertaken, and bibliographies were scanned for additional sources.
Principal findings: There is no substitute for objective neuromuscular monitoring; for research purposes, mechanomyography (MMG) is the gold standard; however, the most versatile method in the clinical setting is acceleromyography since it can be applied at various muscles and has a long track record of clinical utility. Kinemyography is valid to monitor recovery of neuromuscular transmission at the adductor pollicis muscle (AP), whereas phonomyography is easy to apply to various muscles and shows promising agreement with MMG. Monitoring of the corrugator supercilii muscle (CS) may be used to determine the earliest time for tracheal intubation as it reflects laryngeal relaxation better than monitoring at the AP. Recovery of neuromuscular transmission is best monitored at the AP, since it is the last muscle to recover from neuromuscular blockade (NMB). If train-of-four (TOF) stimulation is used, a TOF-ratio > 0.9 should be the target before awakening the patient. If surgery or the type of anesthesia necessitates NMB of a certain degree, e.g., TOF-ratio = 0.25, monitoring of muscles which best reflect the degree of NMB at the surgical site is preferable.
Conclusion: Objective methods should be used to monitor neuromuscular function in clinical anesthesia. Acceleromyography offers the best compromise with respect to ease of use, practicality, versatility, precision and applicability at various muscles. The CS is the optimal muscle to determine the earliest time for intubation, e.g., for rapid sequence induction.

PUB MED - TOP

Ambulatory anesthesia and the lack of consensus among Canadian pediatric anesthesiologists: a survey.
Abu-Shahwan, I. (2007).
Paediatr Anaesth (3): 223-9.

Background: The purpose of this study was to assess the current selection criteria for outpatient surgery in children among Canadian pediatric anesthesiologists.
Methods: A survey specifying 20 different medical situations was sent to 120 members of the Canadian Pediatric Anesthesia Society. Members were asked to indicate if they agreed or refused to provide anesthesia for children with one or more clinical condition or symptoms. Consensus was defined as a >70% majority opinion.
Results: Sixty-four pediatric anesthesiologists replied (53.3%). For 13 conditions there was no consensus among members. Seven scenarios resulted in a consensus of either providing or not providing anesthesia in an outpatient setting. The majority of members would agree to provide anesthesia for the following scenarios: (i) an asymptomatic child with recurrent otitis media, rectal temperature of 38 degrees C; (ii) the same child with chronic nasal discharge for bilateral myringotomy and tube placement; (iii) an asymptomatic child with sickle-cell disease (SCD) for cast change; (iv) an asymptomatic child with asthma and fever for bilateral myringotomy and tube placement (BMT); (v) a morbidly obese child with congested nose for BMT; and (vi) a child with well controlled insulin dependent diabetes mellitus for magnetic resonance imaging (MRI). Most members would refuse to provide outpatient anesthesia in an asymptomatic child with SCD for tonsillectomy.
Conclusion: Further studies are needed to establish evidence-based medicine to support guidelines that would allow one to select children safely for ambulatory surgery.

Antibiotic prophylaxis for arthroscopy of the knee: is it necessary?
Bert, J. M., D. Giannini, et al. (2007).
Arthroscopy 23(1): 4-6.

PURPOSE: Our purpose was to determine the incidence of infection after routine arthroscopic meniscectomy of the knee with and without preoperative prophylactic intravenous antibiotics.
METHODS: A retrospective review of 3,231 arthroscopic knee surgeries was performed at a physician-owned in-office ambulatory surgery center over a 3-year period, of which 2,780 were arthroscopic meniscectomies. The cases were evaluated with respect to the incidence of deep infection as evidenced by a positive joint aspirate. Approximately 30% of the patients had prophylactic intravenous antibiotics within 1 hour before the arthroscopic procedure.
RESULTS: The infection rate was 0.15% in those patients who received antibiotics and 0.16% in those who did not receive antibiotics (P = .59).
CONCLUSIONS: The results of this study confirm that there is no value in administering antibiotics before routine arthroscopic meniscectomy to prevent joint sepsis. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Regional anaesthesia versus general anaesthesia, morbidity and mortality.
Gulur, P., M. Nishimori, et al. (2006).
Best Pract Res Clin Anaesthesiol 20(2): 249-63.

The regional versus general anaesthesia debate is an age-old debate that has brought about few clear answers. Most concur that multiple factors including the patient, the surgery, the method of regional and general anaesthesia, and the quality of perioperative care, all influence surgical outcome. In this age of evidence-based medicine, the heterogenous data available need to be reconciled with the advances in perioperative care and the significant decline in complications associated with the surgical process as a whole. This review considers general issues such as the type of available evidence, and its limitations, particularly with regard to the relatively broad question of neuraxial versus general anaesthesia. It then assesses current evidence on regional versus general anaesthesia for specific scenarios such as hip fracture surgery, carotid endarterectomy, Caesarean section, ambulatory orthopaedic surgery, and postoperative cognitive dysfunction in elderly patients after non-cardiac surgery.

Recovery of older patients undergoing ambulatory anaesthesia with isoflurane or sevoflurane.
Mahajan, V. A., M. Ni Chonghaile, et al. (2007).
Eur J Anaesthesiol: 1-6.

SummaryBackground: Delayed recovery of cognitive function is a well-recognized phenomenon in older patients. The potential for the volatile anaesthetic used to contribute to alterations in postoperative cognitive function in older patients following minor surgical procedures has not been determined. We compared emergence from isoflurane and sevoflurane anaesthesia in older surgical patients undergoing urological procedures of short duration.
Methods: Seventy-one patients, 60 yr of age or older, undergoing anaesthesia expected to last less than 60 min for ambulatory surgery, were randomly assigned to receive isoflurane or sevoflurane. A standardized anaesthetic protocol was used, with intravenous fentanyl 1 mug kg^-1 and propofol 1.5-2.0 mg kg^-1 administered to induce anaesthesia. Anaesthesia was maintained with either sevoflurane or isoflurane in 65% nitrous oxide and oxygen. Early and intermediate recovery times were recorded. The mini mental state examination and digit repetition forwards and backwards were administered at baseline, and at 1, 3 and 6 h postoperatively, to assess cognitive function.
Results: There were no between-group differences in (sevoflurane vs. isoflurane, mean +/- standard error of the mean) times to removal of the laryngeal mask airway (7.7 +/- 0.6 vs. 7.1 +/- 0.4 min), verbal response time (10.1 +/- 0.7 vs. 9.9 +/- 0.7 min) and orientation (12.1 +/- 0.7 vs. 12.1 +/- 0.7 min). Intermediate recovery, as measured by time to readiness for discharge from the post anaesthesia care unit (44.9 +/- 1.5 vs. 44.3 +/- 1.5 min), was similar in the two groups. Postoperative indices of cognitive function and attention were comparably reduced at 1 h, but returned to baseline in both groups at 6 h.
Conclusions: Isoflurane and sevoflurane anaesthesia resulted in similar clinical and neurocognitive recovery profiles in older patients undergoing ambulatory surgical procedures of short duration.

Outpatient arthroscopic knee surgery under combined local and intravenous propofol anesthesia in children and adolescents.
Maldini, B. and M. Miskulin (2006).
Paediatr Anaesth 16(11): 1125-32.

BACKGROUND: This prospective observational study included a case series of children and adolescents receiving light intravenous propofol anesthesia combined with local anesthesia (LA) for arthroscopic knee procedures. The aim was to examine the merits of anesthesia, to discuss the indications for the procedure and to analyze recovery/discharge times from the postanesthesia care unit (PACU).
METHODS: A cohort of 147 children and adolescents (ASA 1 and 2) aged 12-18 years admitted for outpatient arthroscopic knee procedures between January 2004 and May 2005 were studied. After IV access in the operating theater, the patients received propofol (10 mg.ml(-1)). Arthroscopy was performed approximately 15 min after injecting local anesthetic (15 ml 2% lidocaine with epinephrine 1:200,000) partly at the site of insertion of the arthroscope and other instruments (5 ml), and the rest intra-articular. The following parameters were assessed: airway patency, propofol requirement, vital signs, procedure time, surgical operating conditions, patient satisfaction score, time to discharge, postoperative analgesia and adverse events.
RESULTS: Of 147 patients, 133 patients (90.5%) underwent arthroscopic knee surgery, whereas knee arthroscopy alone was performed in 14 patients (9.5%) without indication for operative treatment. The arthroscopy was well tolerated in 96.6% patients (no pain, movement or discomfort during the procedure) and only five patients required conversion to general anesthesia. Pain experienced during the injection of lidocaine was more severe than pain experienced during the surgical procedure itself (P < 0.001). The surgical evaluation of operative conditions (visualization and access to intra-articular structures) was generally satisfactory and completely acceptable. Almost 94% (138/147) of patients said they would have the same procedure again under the same type of anesthesia. The mean propfol induction dose was 1.4 mg.kg(-1) (range: 0.9-3.8) and mean propofol infusion rate 167 microg.kg(-1).min(-1) (range: 130-250). Movement was more likely at lower infusion rates (mean: 151 microg.kg(-1).min(-1)). The maximal decrease in respiratory rate was 5.9 +/- 5.1 br.min(-1) (27.2 +/- 21%) and no patient became hypoxic. Patients recovered to preoperative values at 9.8 +/- 7.5 min following infusion discontinuation. There were no respiratory or cardiovascular complications. The mean stay in PACU was 47 min (range: 32-150). As many as 71% (105/147) of patients required no analgesics during the first two postoperative hours.
CONCLUSIONS: The combination of light intravenous propofol anesthesia combined with local anesthesia for arthroscopic knee procedures provided effective sedation, good preservation of upper airway patency, rapid recovery and pain relief without major side effects and offers a good alternative to the methods already available. The majority of patients did not require postoperative analgesia.

Distraction with a hand-held video game reduces pediatric preoperative anxiety.
Patel, A., T. Schieble, et al. (2006).
Paediatr Anaesth 16(10): 1019-27.

BACKGROUND: Video games have received widespread application in health care for distraction and behavior modification therapy. Studies on the effect of cognitive distraction during the preoperative period are lacking. We evaluated the efficacy of an interactive distraction, a hand-held video game (VG) in reducing preoperative anxiety in children. METHODS: In a randomized, prospective study of 112 children aged 4-12 years undergoing outpatient surgery, anxiety was assessed after admission and again at mask induction of anesthesia, using the modified Yale Preoperative Anxiety Scale (mYPAS). Postoperative behavior changes were assessed with the Posthospital Behavior Questionnaire (PHBQ). Patients were randomly assigned to three groups: parent presence (PP), PP+a hand-held VG, and PP+0.5 mg.kg^-1 oral midazolam (M) given>20 min prior to entering the operating room.
RESULTS: There was a statistically significant increase in anxiety (P<0.01) in groups M and PP at induction of anesthesia compared with baseline, but not in VG group. VG patients demonstrated a decrease in anxiety from baseline (median change in mYPAS -3), the difference compared with PP (+11.8) was significant (P=0.04). The change in anxiety in the M group (+7.3) was not statistically different from other groups. Sixty-three percent of patients in VG group had no change or decrease in anxiety after treatment, compared with 26% in M group and 28% in PP group (P=0.01). There was no difference in anxiety changes between female and male patients.
CONCLUSIONS: A hand-held VG can be offered to most children as a low cost, easy to implement, portable, and effective method to reduce anxiety in the preoperative area and during induction of anesthesia. Distraction in a pleasurable and familiar activity provides anxiety relief, probably through cognitive and motor absorption.

Pain relief following breast augmentation surgery: a comparison between incisional patient-controlled regional analgesia and traditional oral analgesia.
Rawal, N., A. Gupta, et al. (2006).
Eur J Anaesthesiol 23(12): 1010-7.

BACKGROUND AND OBJECTIVES: Postoperative pain is a common problem following ambulatory breast augmentation surgery. This study was performed to compare standard of care (oral analgesics) with patient-controlled incisional regional analgesia (PCRA) for postoperative pain management at home for 48 h. A second aim was to compare the analgesic efficacy of ropivacaine 0.25% vs. 0.5%.
METHODS: Surgery was performed under local anaesthesia and monitored anesthesia care. Sixty adults (ASA 1-2) were randomized to one of two groups. Patients in Group PCRA could self-administer ropivacaine 0.25% 10 mL in the left breast and ropivacaine 0.5% in the right breast. Patients in Group T (tablets) received our standard of care treatment, i.e. oral paracetamol 1 g four times a day and oral ibuprofen 500 mg three times a day. Parameters measured included: analgesic requirements (in post-anesthesia care unit, PACU and post-discharge), pain intensity (visual analogue scale), patient satisfaction, global analgesia, side-effects, and quality of recovery.
RESULTS: Pain scores were significantly lower in Group PCRA compared to Group T at all time periods (P < 0.05). No differences were found in pain scores between the right and left breasts. Significantly more patients in Group T requested analgesics in the recovery unit (27 vs. 7; P = 0.001) and also at home (20 vs. 11; P < 0.02). More patients in the tablet group had nausea and vomiting (10 vs. 3; P < 0.05). Global analgesia on day 2 was significantly better in PCRA group; however, patient satisfaction was similar in both groups. More patients in the tablet group had sleep disturbance and woke up at night due to pain.
CONCLUSIONS: Pain relief after ambulatory breast augmentation is superior with incisional PCRA when compared to oral analgesic combination of paracetamol and ibuprofen. Incisional PCRA was associated with minimal side-effects and less sleep disturbance. There was no difference in the analgesic efficacy between ropivacaine 0.25% and 0.5%.

Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure.
Russon, K., A. M. Sardesai, et al. (2006).
Br J Anaesth 97(6): 869-73.

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.

Analgesic and antiemetic effect of ketorolac vs. betamethasone or dexamethasone after ambulatory surgery.
Thagaard, K. S., H. H. Jensen, et al. (2007).
Acta Anaesthesiol Scand.

Background: Glucocorticoids are known to provide slower onset and more prolonged duration of analgesic effect than ketorolac. In the present study, we wanted to evaluate the effect over time from a single dose of either intravenous (i.v.) dexamethasone or an intramuscular (i.m.) depot formulation of betamethasone compared with i.v. ketorolac.
Materials and methods: One hundred and seventy-nine patients admitted for mixed ambulatory surgery were included in the study. After induction of general i.v. anaesthesia, the patients were randomized to receive double-blindly either dexamethasone 4 mg i.v. (Group D) or betamethasone depot formulation 12 mg i.m. (Group B) or ketorolac 30 mg i.v. (Group K). Fentanyl was used for rescue analgesic medication in the post-operative care
unit (PACU) and codeine with paracetamol after discharge, for a study period of 3 days. Results: There was significantly less post-operative pain in the ketorolac group during the stay in the unit (88% with minor or less pain in Group K vs. 74% and 67% in Groups D and B, respectively, P < 0.05), significantly less need for rescue medication (P < 0.05) and significantly less nausea or vomiting (12% in Group K vs. 30% in the other groups pooled, P < 0.05). The ketorolac patients were significantly faster for ready discharge, median 165 min vs. 192 min and 203 min in Groups D and B, respectively (P < 0.01). There were no differences between the groups in perceived pain, nausea, vomiting or rescue analgesic consumption in the 4- to 72-h period.
Conclusion: Dexamethasone 4 mg or bethamethasone 12 mg did not provide prolonged post-operative analgesic effect compared with ketorolac 30 mg, which was superior for analgesia and antiemesis in the PACU.

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