Volume 7, Issue 9 S A M B A T A L K S - PAGE 3 February, 2008

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

A Randomized, Controlled, Double-Blind Trial of Patient-Controlled Sedation with Propofol/Remifentanil Versus Midazolam/Fentanyl for Colonoscopy.
Mandel, Jeff, MD, MS, Tanner, Jonathan, MD, PhD, Lichtenstein, Gary, Metz, David, Katzka, David, Ginsberg, Gregory, Kochman, Michael
Anesthesia & Analgesia. 106(2):434-439, February 2008.

BACKGROUND: Patient-controlled sedation (PCS) with propofol has been advocated as a method for dealing with the narrow therapeutic window for moderate sedation, but previous studies have methodologic limitations. We hypothesized that, by using remifentanil in conjunction with propofol and using PCS in both arms of the study, we could demonstrate marked improvements in facility use compared with fentanyl plus midazolam.
METHODS: Fifty patients undergoing elective colonoscopy were randomized (with concealed allocation) to midazolam/fentanyl (group MF) or propofol/remifentanil (group PR) administered via PCS. Time intervals for sedation and recovery, perceptions by patient, nurse, and gastroenterologist, and need for anesthesiologist intervention were assessed.
RESULTS: Group PR patients were sedated and recovered significantly more rapidly than did group MF (P < 0.0001). In the group PR, recovery room time was actually shorter than procedure room time. Patient, nurse, and gastroenterologist perceptions were equivalent between the groups. Two patients in group PR required anesthesiologist intervention for arterial desaturation exceeding the primary safety end point.
CONCLUSIONS: PCS with propofol/remifentanil yields superior facility throughput compared with midazolam/fentanyl when used in an appropriate care setting.

Hypnosis Decreases Presurgical Distress in Excisional Breast Biopsy Patients.
Schnur, Julie, Bovbjerg, Dana, David, Daniel, Tatrow, Kristin, Goldfarb, Alisan, Silverstein, Jeffrey, Weltz, Christina, Montgomery, Guy
Anesthesia & Analgesia. 106(2):440-444, February 2008.

BACKGROUND: Excisional breast biopsy is associated with presurgical psychological distress. Such distress is emotionally taxing, and may have negative implications for postsurgical side effects and satisfaction with anesthesia. We investigated the ability of a brief hypnosis session to reduce presurgical psychological distress in excisional breast biopsy patients.
METHODS: Ninety patients presenting for excisional breast biopsy were randomly assigned to receive either a 15-minute presurgery hypnosis session (n = 49, mean age: 46.4 (95% CI: 42.3-50.4)) or a 15-minute presurgery attention control session (n = 41, mean age: 45.0 (95% CI: 40.8-49.2)). The hypnosis session involved suggestions for increased relaxation and decreased distress. The attention control session involved nondirective empathic listening. Presurgery distress was measured using visual analog scales (VAS) and the short version of the Profile of Mood States (SV-POMS). Data were analyzed using analysis of variance and [chi]2 procedures.
RESULTS: Groups did not differ in terms of the following: demographics (age, education, ethnicity, marital status, all P's > 0.28); medical variables (presurgery diagnosis, previous excisional biopsy, previous breast cancer, all P's > 0.11); or preintervention distress (SV-POMS P > 0.74) assessed on the day of surgery. Postintervention, and before surgery, patients in the hypnosis group had significantly lower mean values for presurgery VAS emotional upset (16.5 vs 38.2, P < 0.0001, d = .85), VAS depressed mood (6.6 vs 19.9, P < 0.02, d = .67), and SV-POMS anxiety (10.0 vs 5.0, P < 0.0001, d = 0.85); and significantly higher levels for VAS relaxation (75.7 vs 54.2, P < 0.001, d = -0.76) than attention controls.
CONCLUSIONS: The study results indicate that a brief presurgery hypnosis intervention can be an effective means of controlling presurgical distress in women awaiting diagnostic breast cancer surgery.

A Comparison of Seal in Seven Supraglottic Airway Devices Using a Cadaver Model of Elevated Esophageal Pressure.
Bercker, Sven, Schmidbauer, Willi, Volk, Thomas, Bogusch, Gottfried, Bubser, Hans, Hensel, Mario, Kerner, Thoralf
Anesthesia & Analgesia. 106(2):445-448, February 2008.

BACKGROUND: Supraglottic airway devices are increasingly important in clinical anesthesia and prehospital emergency medicine, but there are only few data to assess the risk for aspiration. We designed this study to compare the seal of seven supraglottic airway devices in a cadaver model of elevated esophageal pressure.
METHODS: The classic laryngeal mask airway, laryngeal mask airway ProSeal(TM), intubating laryngeal mask airway Fastrach(TM), laryngeal tube(TM), laryngeal tube LTS II(TM), Combitube(TM), and Easytube(TM) were inserted into unfixed human cadavers with an exposed esophagus that had been connected to a water column of 130 cm height. Slow and fast increases of esophageal pressure were performed and the water pressure at which leakage appeared was registered.
RESULTS: The Combitube, Easytube, and intubating laryngeal mask Fastrach withstood the water pressure up to more than 120 cm H₂O. The laryngeal mask airway ProSeal, laryngeal tube, and laryngeal tube LTS II were able to block the esophagus until 72-82 cm H₂O. The classic laryngeal mask airway showed leakage at 48 cm H₂O, but only minor leakage was found in the trachea. Devices with an additional esophageal drain tube drained fluid sufficiently without pulmonary aspiration.
CONCLUSIONS: Concerning the risk of aspiration, the use of devices with an additional esophageal drainage lumen might be superior for use in patients with an increased risk of aspiration. The Combitube, Easytube, and intubating laryngeal mask Fastrach showed the best capacity to withstand an increase of esophageal pressure.

Predicting Orthopedic Surgeons' Preferences for Peripheral Nerve Blocks for Their Patients.
Masursky, Danielle, Dexter, Franklin, MD, PhD, McCartney, Colin, MBChB, FRCA, FCARCSI, FRCPC, Isaacson, Sheldon, Nussmeier, Nancy
Anesthesia & Analgesia. 106(2):561-567, February 2008.

BACKGROUND: A 2002 survey of 468 Canadian orthopedic surgeons found that the "two principal reasons regional anesthesia is not favored" are "delays in operating rooms" and "unpredictable success." We reanalyzed the data from the study to evaluate whether these concerns were the best predictors of an individual surgeon's willingness to use peripheral nerve blocks for their patients.
METHODS: Of the five procedures included in the survey, three had relevant questions for our reanalysis of the results: arthroscopic shoulder surgery, arthroscopic anterior cruciate ligament reconstruction, and total knee replacement.
RESULTS: A surgeon's preference for peripheral nerve block for him or herself strongly predicted his or her anesthetic preference for patients (all P < 0.001). Concordance rates were 89% for arthroscopic shoulder surgery, 87% for anterior cruciate ligament reconstruction, and 93% for total knee replacement. There was almost no incremental predictive value for the surgeon's preference for patients from the surgeon's perception of the times to perform a block (P >= 0.27) or perception of block success rate (P >= 0.30). There was also almost no direct predictive value for the surgeon's preference for patients from the surgeon's perception of the times to perform a block (Kendall's [tau] <= 0.04, P >= 0.28) or perception of block success rate (Kendall's [tau] <= 0.02, P >= 0.24). An economically important percentage of surgeons (37%, 95% confidence interval: 32%-41%) would choose a peripheral nerve block for their own surgery for some, but not all, of the procedures (i.e., for 1 or 2 versus 0 or 3).
CONCLUSIONS: A surgeon's preference for peripheral nerve blocks for his or her own surgery predicted a surgeon's preference for his or her patients. Perceptions of delays and success rate did not add sufficient incremental information to the surgeon's preferences to be of economic importance. These results are important to better forecast the net economic impact on an anesthesia group of a regional block team.

Learning Curves and Mathematical Models for Interventional Ultrasound Basic Skills.
Filho, Getulio, Rodrigues de Oliveira MD, PhD, Helayel, Pablo, Conceicao, Diogo, Garzel, Ivo, Pavei, Patricia, Ceccon, Mauricio
Anesthesia & Analgesia. 106(2):568-573, February 2008.

BACKGROUND: We aimed to construct learning curves and mathematical learning models for ultrasound basic skills: optimizing needle-ultrasound beam alignment and reaching a target inside a phantom.
METHODS: Thirty subjects participated in the study. Each subject performed 25 trials. Linear ultrasound probes and a bovine muscular phantom were used. In Experiment 1, subjects tried to insert a needle parallel to the ultrasound beam with full imaging of the needle. For Experiment 2, a segment of tendon was inserted longitudinally into the phantom at a depth of 1 to 1.5 cm. Subjects tried to insert the needle until contacting the tendon. Learning curves were constructed using the cumulative sum (cusum) method. Bush and Mosteller's mathematical learning models were constructed for each skill.
RESULTS: Only 30% and 11% of subjects attained proficiency in Experiments 1 and 2, respectively. The predicted average numbers of trials to achieve 95% success rates as estimated from Bush and Mosteller's models were 37 and 109, respectively.
CONCLUSIONS: Learning interventional ultrasound basic skills may require a considerable number of trials. Cusum charts revealed that individuals acquire such abilities at variable rates. As skills were assessed in phantoms, our results do not apply to blocks given to real patients.

ANESTHESIOLOGY - TOP

None.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Anaesthesia and post-operative morbidity after elective groin hernia repair: a nation-wide study
M. BAY-NIELSEN, H. KEHLET
Acta Anaesthesiologica Scandinavica 2008; 52 (2), 169–174.

Background: Randomised studies suggest regional anaesthesia to have the highest morbidity and local infiltration anaesthesia to have the lowest morbidity after groin hernia repair. However, implications and results of this evidence for general practice are not known.
Methods: Prospective nation-wide data collection in a cohort of n=29,033 elective groin hernia repairs, registered in the Danish Hernia Database in three periods, namely July 1998–June 1999, July 2000–June 2001 and July 2002–June 2003. Retrospective analysis of complications in discharge abstracts, identified from re-admission within 30 days post-operatively, prolonged length of stay (>2 days post-operatively) or death.
Results: Complications after groin hernia repair were more frequent in patients 65+ years (4.5%), compared with younger patients (2.7%) (P<0.001). In patients 65+ years, medical complications were more frequent after regional anaesthesia (1.17%), compared with general anaesthesia (0.59%) (P=0.003) and urological complications were more frequent after regional anaesthesia (0.87%), compared with local infiltration anaesthesia (0.09%) (P=0.006). Seventeen prostatectomies occurred after post-operative urinary retention, but with no case after local anaesthesia. Mortality within 30 days after elective groin hernia repair was 0.12%. Regional anaesthesia was disproportionately more often used in patients dying within 1 week post-operatively.
Conclusion: Choice of the anaesthetic technique should be adjusted to available procedure-specific scientific evidence and the use of regional anaesthesia in elderly patients undergoing groin hernia repair is not supported by existing evidence.

Systematic follow-up increases incidence of anaphylaxis during adverse reactions in anesthetized patients
J.-M. MALINOVSKY, S. DECAGNY, F. WESSEl, L. GUILLOUX, P. M. MERTES
Acta Anaesthesiologica Scandinavica 2008; 52 (2), 175–181.

Background: The incidence of hypersensitivity reactions during anesthesia is underestimated because clinical symptoms may vary and diagnosis is not obvious. Our aim was to investigate the consequences of a systematic follow-up of patients on the estimated incidence of allergic reactions during anesthesia.
Methods: We conducted a prospective study over a 2-year period (70,000 anesthesias). When patients were suspected with hypersensitivity reactions or with unexplained adverse reactions during anesthesia, blood was sampled to measure histamine and tryptase, and then skin tests were performed 4–6 weeks later.
Results: During the studied period, 39 patients were enrolled in the database. Eight were excluded because of lack of skin tests. Twenty-two patients had clinical features compatible with immediate hypersensitivity reaction, and nine had reactions rated as ‘unexplained’ by the attending physician. Following systematic investigation, we found 22 hypersensitivity reactions (15 patients with obvious and seven with unexplained reactions) during anesthesia. This increases the estimated incidence of hypersensitivity reactions from 1 : 4667 to 1 : 3180 anesthesias. Tryptase concentrations were increased in only 50% of these patients. In our series, positive and negative predictive values of tryptase at T0 for the diagnosis of anaphylaxis were 100% and 60%, respectively. Latex was the major causative agent, followed by neuromuscular blocking agents and antibiotics.
Conclusions: Systematic follow-up of patients with unexplained reactions during anesthesia increases the estimated incidence of IgE-mediated hypersensitivity reactions during anesthesia by 50%.

Low-dose haloperidol prevents post-operative nausea and vomiting after ambulatory laparoscopic surgery
T. F. WANG, Y. H. LIU, C. C. CHU, J. P. SHIEH, J. I. TZENG, J. J. WANG
Acta Anaesthesiologica Scandinavica 2008; 52 (2), 280–284.

Background: We evaluated the prophylactic effect of low-dose haloperidol (1 mg) on post-operative nausea and vomiting (PONV) in women undergoing ambulatory laparoscopic surgery. Droperidol (0.625 mg) and saline were controls.
Methods: One hundred and fifty women undergoing ambulatory laparoscopic surgery under general anaesthesia were enrolled in this randomized, double-blind, and placebo-controlled study. After tracheal intubation, the haloperidol group (n=50) received intravenous haloperidol (1 mg), the droperidol group (n=50) received intravenous droperidol (0.625 mg), and the saline group (n=50) received intravenous saline.
Results: Haloperidol- and droperidol-group patients reported a lower incidence of PONV [24% and 23% vs. 49% (saline group); P<0.05] and requested fewer doses of rescue antiemetics [13% and 16% vs. 38% (saline group); P<0.05] during the first four post-operative hours. During the 24-h post-operative period, haloperidol- and droperidol-group patients also reported a lower incidence of PONV [31% and 32% vs. 62% (saline group); P<0.01]. No differences were found between the haloperidol and droperidol groups.
Conclusion: Like droperidol (0.625 mg), prophylactic intravenous haloperidol (1 mg) significantly reduced the incidence of PONV in women undergoing ambulatory laparoscopic surgery.

Dexmedetomidine blunts acute hyperdynamic responses to electroconvulsive therapy without altering seizure duration
Z. BEGEC, H. I. TOPRAK, S. DEMIRBILEK, F. ERDIL, D. ONAL, M. O. ERSOY
Acta Anaesthesiologica Scandinavica 2008; 52 (2), 302–306.

Background: This study was designed to evaluate the effect of dexmedetomidine on the acute hyperdynamic response, duration of seizure activity and recovery times in patients undergoing electroconvulsive therapy (ECT).
Methods: Fourteen patients underwent a total of 84 ECT sessions as a crossover design. Patients were randomly allocated to receive either dexmedetomidine (1 μg/kg IV over a period of 10 min) or saline (control). Anaesthesia was induced with propofol 1 mg/kg, and then succinylcholine 0.5 mg/kg IV was administered. Arterial blood pressure and heart rate (HR) were recorded during the study period.
Results: HR in the dexmedetomidine group was lower than that in the control group at 5 and 10 min after the start of study drug infusion, and at 1, 3 and 10 min after the seizure ended (P<0.05). Peak HR was lower in the dexmedetomidine group compared with that in the control group (P<0.05). The mean arterial pressure (MAP) values in the dexmedetomidine group were lower at 0, 1, 3 and 10 min after the seizure ended compared with the control group (P<0.05). Both motor and electroencephalography (EEG) seizure duration in the control group (35.65 ± 14.89 and 49.07 ± 9.94 s, respectively) were similar to that in the dexmedetomidine group (33.30 ± 12.01 and 45.15 ± 17.79 s, respectively) (P>0.05). Time to spontaneous breathing, eye opening and obeying commands were not different between the groups.
Conclusion: A dexmedetomidine dose of 1 μg/kg IV administered over 10 min before the induction of anaesthesia with propofol may be useful in preventing the acute hyperdynamic responses to ECT without altering the duration of seizure activity and recovery time.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Controlled comparison between betamethasone gel and lidocaine jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice
P. A. Sumathi, T. Shenoy, M. Ambareesha and H. M. Krishna
British Journal of Anaesthesia 2008 100(2):215-218

Background: Postoperative sore throat, cough, and hoarseness of voice though minor sequelae after general tracheal anaesthesia can be distressing to the patient.
Methods: This prospective, randomized, double blind, controlled study compares the incidence of postoperative sore throat, cough, and hoarseness of voice after general tracheal anaesthesia when applying betamethasone gel (betamethasone group) or lidocaine jelly (lidocaine group) on the tracheal tube. One hundred and fifty ASA class I and II patients undergoing elective surgeries under general orotracheal anaesthesia were randomized into three groups: betamethasone gel, lidocaine jelly, and control groups. In the post-anaesthesia care unit, a blinded anaesthesiologist interviewed all patients on postoperative sore throat, cough, and hoarseness of voice at 1, 6, 12, and 24 h after operation.
Results: In the first 24 h after surgery, the incidence of postoperative sore throat was 40, 100, and 100%; cough was 6, 40, and 28%; and hoarseness of voice was 4.1, 32.9, and 50%, for the betamethasone, lidocaine and control groups, respectively. The incidence of postoperative sore throat, cough, and hoarseness of voice was significantly lower in the betamethasone group compared with the other two groups (P<0.05).
Conclusions: A wide spread application of betamethasone gel on the tracheal tube decreases the incidence and severity of postoperative sore throat, cough, and hoarseness of voice.

Randomized controlled trial of duration of analgesia following intravenous or rectal acetaminophen after adenotonsillectomy in children
F. Capici, P. M. Ingelmo, A. Davidson, C. A. Sacchi, B. Milan, L. Rota Sperti, L. Lorini and R. Fumagalli
British Journal of Anaesthesia 2008 100(2):251-255

Background: Doses of acetaminophen 40 mg kg^-1 rectally and 15 mg kg^-1 i.v. produce similar effect-site concentrations. However, the clinical effectiveness of these routes has not been compared. The aim of this study was to compare duration and efficacy of analgesia in children following adenotonsillectomy after acetaminophen either 40 mg kg^-1 rectally or 15 mg kg^-1 i.v.
Methods: Fifty children aged between 2 and 5 yr were recruited. They received a standardized anaesthetic, including 2 µg kg^-1 of fentanyl. Children were randomized to receive either rectal or i.v. acetaminophen. Postoperative pain was assessed regularly with the Children and Infants Postoperative Pain Scale score and rescue analgesia provided if scores were 4 or greater. The primary outcome measure was time to first analgesia. Results were plotted with a Kaplan–Meier analysis and median time to rescue analgesia compared between the groups.
Results: The protocol was successfully completed in 46 children. Forty-five children required rescue medication. The time to first rescue analgesia was longer in children receiving rectal acetaminophen (median 10 h, inter-quartile range 9–11 h) compared with those receiving i.v. acetaminophen (7, 6–10 h) with a P-value of 0.01 by log-rank test for equality in survivor function. Few children in either group required rescue analgesia within the first 6 h with differences between the groups being most prominent in the period from 6 to 10 h.
Conclusions: Rectal acetaminophen 40 mg kg^-1 provides longer analgesia for moderately painful procedures when compared with 15 mg kg^-1 acetaminophen i.v.

Pathways through the nose for nasal intubation: a comparison of three endotracheal tubes
A. Ahmed-Nusrath, J. L. Tong and J. E. Smith
British Journal of Anaesthesia 2008 100(2):269-274

Background: In nasotracheal intubation, there are two main pathways in the nostril through which the endotracheal tube may pass. The lower pathway lies along the floor of the nose underneath the inferior turbinate. The upper pathway lies above the inferior turbinate, just below the middle turbinate. The lower pathway may be considered to be the safer route as it is located away from the middle turbinate and cribiform plate.
Methods: We conducted a randomized controlled trial comparing the frequency with which preformed, reinforced, and thermosoftened preformed tubes pass through upper and lower pathways. Ninety-two maxillofacial patients requiring nasotracheal intubation as part of their anaesthetic management were studied. Two patients were excluded from the study at endoscopy because of atypical nasal anatomy. After the induction of general anaesthesia, a standardized traditional nasal intubation was performed with a Macintosh laryngoscope, the operators endeavouring to direct the tube along the floor of the nose. Fibreoptic nasendoscopy was then performed by passing the tip of the fibrescope 2–3 cm into the nasal cavity above and below the tube, to identify the pathway taken.
Results: Data were analysed on 30 patients in each group. Five (16.7%) preformed tubes, 17 (56.7%) reinforced tubes, and 6 (20%) thermosoftened preformed tubes passed through the lower pathway. Significantly more reinforced tubes took the preferred pathway (P=0.001). Tubes passing through the upper pathway caused significantly more epistaxis than tubes passing through the lower pathway (P=0.003).
Conclusions: Endotracheal tubes, particularly preformed tubes, frequently take the less favourable pathway during nasotracheal intubation, in spite of specific attempts to avoid this.

CANADIAN JOURNAL OF ANESTHESIA - TOP

None.

PUB MED - TOP



Safety profile of parenteral ketamine and lignocaine infiltration in pediatric operations.
Osifo DO, Emeagui KN, Aghahowa SE.
Saudi Med J. 2008 Jan;29(1):60-4.

OBJECTIVE: To study the safety and benefits of parenteral ketamine and lignocaine infiltration among pediatric surgical patients with co-morbidities that would preclude the use of general anesthesia requiring endotracheal intubation/face mask in a developing country.
METHODS: This prospective study was undertaken at the Leadeks Medical Centre, Benin City Edo State, Nigeria between January 2002 and December 2006. Patients requiring surgery were safely operated even in the presence of co-morbidity.
RESULTS: A total of 416 children were recruited and they were aged 6 days to 16 years (mean 12 -/+ 2.04 years) with a male/female ratio of 1:1.1. Appendectomy (33.2%), herniotomy (20.2%) and suturing of laceration (15.9%) were the most common indications for surgery. Anemia, upper respiratory tract infections, malnutrition, malaria fever, typhoid fever, and retroviral infections were co-morbidities. Ambulatory surgery was carried out in 48.6% patients. Overall, only 23.3% experienced postoperative pain, which was statistically significant in those that had laparotomy and appendectomy (p<0.0001), and analgesics such as paracetamol were enough to relieve the pain. Complications recorded such as postoperative vomiting, emergence reaction, wound infection, post operative fever, and apnea occurring after ketamine injections were tolerated and no mortality was recorded.
CONCLUSION: The satisfactory anesthesia and analgesia recorded with this combination, and the low complications observed in the presence of co-morbidity showed that these agents have much to offer in a developing country.

Laser ablation of unwanted hand veins.
Shamma AR, Guy RJ.
Plast Reconstr Surg. 2007 Dec;120(7):2017-24.

BACKGROUND: Many patients express dissatisfaction with prominent and bulging hand veins. Abolishing these veins with sclerotherapy requires higher concentrations of sclerosing agents than are used for leg veins and often results in a tender, phlebitic cord. Phlebectomy is another treatment option. Endovenous occlusion and shrinkage techniques have been used successfully to treat varicose veins of the lower extremities. The authors demonstrate a new and unique endovenous laser technique to abolish unwanted hand veins.
METHODS: Fifty-four hands (28 patients) with prominent hand veins were treated using a 600-microm laser fiber. The Dornier MedTech 940-nm diode laser system was used. The laser fiber was introduced through a 4-French sheath, which tracked as a coaxial system over an 0.018-inch guidewire. Initial entry into the treated vein was accomplished with a 20-gauge angiocatheter percutaneously. On average, four veins were treated in each hand. Tumescent anesthesia was infiltrated around the laser fiber/sheath unit before activating the laser, and all procedures were performed in an office setting. A compressive dressing was used postoperatively.
RESULTS: All but one of the unwanted hand veins were cannulated successfully. The uncannulated vein was treated with sclerotherapy and eventually required phlebectomy. Hand swelling occurred in all treated hands and lasted 2 weeks or less. There was one skin burn of approximately 3 mm at a laser exit site. All 28 patients were satisfied with their results during follow-up, which ranged from 2 weeks to 31 months.
CONCLUSIONS: This is the first report of endovenous treatment of unwanted hand veins. Laser ablation of unwanted hand veins can be performed in an office setting. These cosmetically conscious patients were satisfied with their results.

Bispectral index monitoring of conscious sedation with the combination of meperidine and midazolam during endoscopy.
Qadeer MA, Vargo JJ, Patel S, Dumot JA, Lopez AR, Trolli PA, Conwell DL, Stevens T, Zuccaro G Jr.
Clin Gastroenterol Hepatol. 2008 Jan;6(1):102-8. Epub 2007 Dec 11.

BACKGROUND & AIMS: Current practice guidelines strongly recommend differentiation of deep from moderate sedation during endoscopy. Standard methods of sedation monitoring are labor-intense. Bispectral index monitoring (BIS) is widely used during anesthesia, but its benefits during conscious sedation are controversial. Thus, we performed a prospective observational study to assess its ability for detecting deep sedation during endoscopy.
METHODS: Patients presenting for elective outpatient endoscopy were monitored simultaneously with the Modified Observer's Assessment of Alertness and Sedation (MOAA/S) and BIS. A combination of a narcotic and benzodiazepine was used, with the target being moderate sedation and analgesia. Deep sedation was defined by MOAA/S score of 1-2 and BIS score of <or=75. With MOAA/S as the reference standard, the accuracy of BIS for detecting deep sedation was evaluated.
RESULTS: A total of 775 simultaneous observations of BIS and MOAA/S scores were recorded on 76 patients. Deep sedation, defined by MOAA/S and BIS, was seen in 204 (26%) and 92 (12%) observations, respectively. BIS correlated poorly with deep sedation (rho, -0.02; 95% confidence interval [CI], -0.16-0.12). The sensitivity, specificity, and positive and negative predictive values (95% CI) for detecting deep sedation were 29.6 (23.4-36.3), 94.9 (92.8-96.6), 68.2 (57.4-77.7), and 78.6 (75.3-81.7), respectively.
CONCLUSIONS: BIS has a low accuracy for detecting deep sedation as a result of a considerable overlap of scores across the sedation levels. Further refinements in BIS are needed to differentiate deep from moderate sedation for future studies on conscious sedation.

A survey of women's views of Thermachoice endometrial ablation in the outpatient versus day case setting.
Marsh F, Bekker H, Duffy S.
BJOG. 2008 Jan;115(1):31-7.

OBJECTIVE: To determine women's preference towards Thermachoice being performed either awake in the outpatient setting or under general anaesthetic (GA) as a day case.
DESIGN: Questionnaire. Setting Large teaching hospital.
POPULATION: One hundred women.
METHODS: The questionnaire was developed from prior research on factors associated with preference for procedures performed in the outpatient versus day case setting.
MAIN OUTCOME MEASURES: (1) Describe women's preference towards outpatient versus day case Thermachoice and other menorrhagia treatments. (2) Identify variations in preference by demographic characteristics and prior experience of anaesthesia. Results There was an exact split in preference with 50% preferring Thermachoice as an outpatient and 50% as a day case. The mean age of women preferring outpatient Thermachoice was significantly higher (41.5 years) than those preferring day case (33.5 years) (P < 0.005). Women with children and a higher qualification were more likely to opt for outpatient Thermachoice. A previous bad experience of GA was associated with preference for outpatient Thermachoice. Spending less time in hospital, attending for one visit, feeling well straight after treatment and choosing the treatment setting were important factors to the majority of women. Most women (70%) who opted for Thermachoice as a menorrhagia treatment would prefer to have it performed in the outpatient setting.
CONCLUSIONS: If the Department of Heath is to target services towards women's choice, there is a need to increase the provision of outpatient menorrhagia treatments, such as Thermachoice, to more women in the UK.

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