Volume 3, Issue 8 S A M B A T A L K S - PAGE 3 January, 2004

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

The effect of intraoperative use of esmolol and nicardipine on recovery after ambulatory surgery
White PF, Wang B, Tang J, Wender RH, Naruse R, Sloninsky A.
Anesth Analg. 2003 Dec;97(6):1633-8

There is controversy regarding the optimal technique for maintaining hemodynamic stability during anesthesia. We designed this prospective, randomized, double-blinded study to test the hypothesis that the technique used for maintaining hemodynamic stability during general anesthesia can influence recovery after ambulatory surgery. Forty-five healthy consenting women undergoing gynecologic laparoscopy procedures were randomly assigned to 1 of 3 treatment groups: Group 1 (control, n = 15) received normal saline 5 mL and 1 mL, followed by a saline infusion at a rate of 0.005 mL. kg^-1. min^-1; Group 2 (n = 15) received esmolol 50 mg and saline 1 mL, followed by an esmolol infusion 5 micro g. kg^-1.min^-1; and Group 3 (n = 15) received esmolol 50 mg and nicardipine 1 mg, followed by an esmolol infusion 5 micro g. kg^-1. min^-1. The study drugs were administered after the induction of anesthesia with fentanyl 1.5 micro g/kg, and propofol 2 mg/kg IV. Tracheal intubation was facilitated with vecuronium 0.12 mg/kg IV. Anesthesia was initially maintained with desflurane 2% end-tidal and N2O 67% in oxygen in all 3 groups. During surgery, the mean arterial blood pressure (MAP) was maintained within +/-15% of the baseline value by varying the study drug infusion rate and the inspired concentration of desflurane. In addition to MAP and heart rate values, electroencephalogram bispectral index values were recorded throughout the perioperative period. Recovery times and postoperative side effects were assessed. Compared with the control group, adjunctive use of esmolol and nicardipine attenuated the increase in heart rate (in Group 2) and MAP (in Group 3) after tracheal intubation. Furthermore, the use of an esmolol infusion as an adjunct to desflurane to control the acute autonomic responses during the maintenance period significantly decreased emergence times (4 +/- 2 versus 7 +/- 4 min), decreased the need for postoperative opioid analgesics (43% versus 80%), and reduced the time to discharge (209 +/- 89 versus 269 +/- 100 min). We conclude that the adjunctive use of esmolol alone or in combination with nicardipine during the induction of anesthesia reduced the hemodynamic response to tracheal intubation. Furthermore, use of an esmolol infusion as an adjuvant to desflurane-N2O anesthesia for controlling the acute hemodynamic responses during the maintenance period improved the recovery profile after outpatient laparoscopic surgery.
IMPLICATIONS: The adjunctive use of the beta-adrenergic blocker esmolol to control the acute sympathetic responses during desflurane-based anesthesia provided a more rapid awakening from anesthesia, reduced the postoperative opioid analgesic requirement, and decreased the time to discharge home after ambulatory laparoscopic surgery.

Preincisional treatment to prevent pain after ambulatory hernia surgery.
Pavlin DJ, Horvath KD, Pavlin EG, Sima K.
Anesth Analg. 2003 Dec;97(6):1627-32

We designed this study as a randomized comparison of postoperative pain after inguinal hernia repair in patients treated with triple preincisional analgesic therapy versus standard care. Triple therapy consisted of a nonsteroidal antiinflammatory, a local anesthetic field block, and an N-methyl-D-aspartate inhibitor before incision. The treatment group (n = 17) received rofecoxib, 50 mg PO, a field block with 0.25% bupivacaine/0.5% lidocaine, and ketamine 0.2 mg/kg IV before incision; controls (n = 17) received a placebo PO before surgery. The anesthetic protocol was standardized. Postoperative pain was treated by fentanyl IV and oxycodone 5 mg/acetaminophen 325 mg PO as required for pain. Pain scores (0-10) and analgesic were recorded for the first 7 days after surgery. Pain scores were 47% lower in the treatment group before discharge (3.1 +/- 0.6 versus 5.9 +/- 0.6, P = 0.0026) (mean +/- SE) and 18% less in the first 24 h after discharge (5.6 +/- 0.4 versus 6.8 +/- 0.5, P = 0.05); oral analgesic use was 34% less in the treatment group (4.6 +/- 0.8 doses versus 7.1 +/- 0.7 doses, P = 0.02) in the first 24 h after surgery. We conclude that triple preincisional therapy diminishes pain and analgesic use after outpatient hernia repair, and encourage further evaluation of this technique.
IMPLICATIONS: Outpatients undergoing inguinal hernia repair under general anesthesia report moderate-to-severe pain after surgery. Triple preincisional therapy that included rofecoxib, 50 mg PO, ketamine, 0.2 mg/kg IV, and local anesthetic field block reduced pain scores and analgesic use in the first 24 h after discharge.

Preoperative Interscalene Block for Elective Shoulder Surgery: Loss of Benefit over Early Postoperative Block After Patient Discharge to Home
W. Heinrich Wurm, MD, Mercedes Concepcion, MD, Andrew Sternlicht, MD, Jean Marie Carabuena, MD, Gary Robelen, MD, Leonidas C. Goudas, MD PhD, Scott A. Strassels, Pharm D, and Daniel B. Carr, MD
Anesth Analg 2003;97:1620-1626

We performed a randomized, prospective, parallel-group, open-label, multicenter trial to compare the effects of pre- versus postoperative interscalene block using levobupivacaine on postoperative pain and analgesic requirements. One-hundred-two outpatients scheduled for elective shoulder surgery were randomized to receive 30 mL of 0.5% levobupivacaine either preoperatively (PRE group) or postoperatively (POST group). Analgesic outcome measures during the postoperative period were: (a) time to first request for analgesic medication after surgery, (b) pain intensity using the visual analog scale at rest and during arm movement, and (c) total analgesic consumption of nonsteroidal antiinflammatory drugs and opioids. The time to first analgesic request did not differ between treatment groups. However, mean maximum pain intensity scores during the day of surgery were significantly less for the PRE group than the POST group, both at rest (P = 0.001) and after movement (P = 0.004). The mean opioid administered during surgery was lower in the PRE than the POST group (P < 0.001). Levobupivacaine was well tolerated in both treatment groups, and no adverse reactions were related to this local anesthetic. In conclusion, preoperative interscalene block with levobupivacaine provided superior pain control for the first 12 h after surgery, but this benefit was not maintained during the week after discharge because the subjects assumed control of their own pain relief as outpatients.
IMPLICATIONS: Preoperative interscalene block with levobupivacaine provides safe and effective analgesia for same-day elective shoulder surgery, but the benefit of this one-time intervention does not persist.

Endotracheal Tube Cuff Pressure Is Unpredictable in Children
Marie-Louise Felten, MD, Emmanuelle Schmautz, MD, Sonia Delaporte-Cerceau, MD, Gilles A. Orliaguet, MD PhD, and Pierre A. Carli, MD
Anesth Analg 2003;97:1612-1616

The use of cuffed tracheal tubes in children younger than 8 yr of age has recently increased, although cuff hyperinflation may cause tracheal mucosal damage. In this study, we sought to measure the cuff pressure (Pcuff) after initial free air inflation (iPcuff) and to follow its evolution throughout the duration of 50% nitrous oxide (N₂O) anesthesia. One-hundred-seventy-four children, aged 0 to 9 yr, fulfilling the following criteria, were studied: 1) weight of 3–35 kg; 2) ASA physical status I or II; 3) elective surgery; 4) anesthesia with tracheal intubation using a cuffed tube and lasting at least 45 min; and 5) gas mixture containing 50% N₂O. Free air inflation results in variable iPcuff, with hyperinflation in 39% of cases. Numerous gas removals were required to maintain Pcuff less than 25 cm H₂O in 85% of the patients. The number of deflations decreased with the duration of mechanical ventilation and was small after 105 min. No difference was observed among the different cuffed tube sizes. We conclude that iPcuff is unpredictable after free air inflation and that numerous gas removals are required to maintain Pcuff less than 25 cm H₂O during N₂O anesthesia in children.
IMPLICATIONS: Free inflation of the tracheal tube cuff, controlled only by the palpation of the pilot balloon, is not reliable and results in extremely variable (and sometimes very high) initial cuff pressures in children. In addition, nitrous oxide anesthesia may result in cuff hyperinflation requiring numerous gas removals.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Infection control and anesthesia: lessons learned from the Toronto SARS outbreak
Philip W.H. Peng, MBBS FRCPC, David T. Wong, MD, David Bevan, MB MRCP FRCA FRCPC and Michael Gardam, MD CM MSC FRCPC
Canadian Journal of Anesthesia 50:989-997 (2003)

Purpose: To describe the outbreak of severe acute respiratory syndrome (SARS) in Toronto, its impact on anesthesia practice and the infection control guidelines adopted to manage patients in the operating room (OR) and to provide emergency intubation outside the OR.
Clinical features: The SARS outbreak in Toronto was the result of a single index patient. The causative virus, SARS-CoV, is moderately contagious, and is spread by droplets and contact. The virus gains access to host through the mucosa of the respiratory tract and the eyes. It can affect both healthy and compromised patients. The use of several precautionary measures such as goggles, gloves, gowns and facemasks and the application of various infection control strategies designed to minimize the spread of the virus are discussed.
Conclusion: In containing the spread of SARS, vigilance and strict infection control are important. This results in the rediscovery of standards of infection control measures in daily anesthesia practice.

Rofecoxib does not compromise platelet aggregation during anesthesia and surgery
David G. Silverman, MD, Thomas Halaszynski, MD, Raymond Sinatra, MD PhD, Martha Luther, MPH and Christine S. Rinder, MD
Canadian Journal of Anesthesia 50:1004-1008 (2003)

Purpose: This study was undertaken because, although there is evidence that cyclooxygenase type 2 (COX)-2 inhibitors do not compromise platelets in healthy volunteers, many clinicians remain hesitant to administer them perioperatively without definitive evidence of intact platelet function during anesthesia and surgery.
Methods: In 20 patients scheduled for lower abdominal and pelvic surgery, 5 mL of blood were obtained for baseline platelet aggregometry. One hour prior to surgery, patients received an oral solution of either rofecoxib (ROF) 50 mg or placebo (PLAC) by randomized, double-blinded assignment. Approximately one hour after onset of anesthesia, an intraoperative blood sample was obtained.
Baseline and postdrug samples were centrifuged to generate platelet-rich plasma, which was challenged with adenosine diphosphate (ADP) and arachidonic acid (AA). Aggregometry was performed with and without incubation with aspirin. The data in each subject were normalized to baseline aggregation in response to AA alone and ADP alone. Intergroup differences were assessed using paired t test; P < 0.05 was considered significant.
Results: Consistent with known effects of anesthesia on platelet function, both groups had approximately 25% intraoperative declines in aggregation in response to ADP (P = NS for PLAC vs ROF) and even greater declines in response to AA (P = NS for PLAC vs ROF). Aspirin eliminated aggregation in response to AA in both groups (P = NS), and it caused similar declines in PLAC and ROF groups during exposure to ADP (P = NS).
Conclusion: This study provides strong evidence that ROF does not compromise platelet aggregation during anesthesia and surgery; nor does it interfere with the platelet inhibitory effect of aspirin.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Reduction in the incidence of awareness using BIS monitoring
A. Ekman, M-L. Lindholm, C. Lennmarken and R. Sandin
Acta Anaesthesiologica Scandinavica Volume: 48 Number: 1 Page: 20 -- 26

Background: Explicit recall (ER) is evident in approximately 0.2% of patients given general anaesthesia including muscle relaxants. This prospective study was performed to evaluate if cerebral monitoring using BIS to guide the conduction of anaesthesia could reduce this incidence significantly.
Patients and methods: A prospective cohort of 4945 consecutive surgical patients requiring muscle relaxants and/or intubation were monitored with BIS and subsequently interviewed for ER on three occasions. BIS values between 40 and 60 were recommended. The results from the BIS-monitored group of patients was compared with a historical group of 7826 similar cases in a previous study when no cerebral monitoring was used.
Results: Two patients in the BIS-monitored group, 0.04%, had ER as compared with 0.18% in the control group (P < 0.038). Both BIS-monitored patients with ER were aware during intubation when they had high BIS values (>60) for 4 min and more than 10 min, respectively. However, periods with high BIS = 4 min were also evident in other patients with no ER. Episodes with high BIS, 4 min or more, were found in 19% of the monitored patients during induction, and in 8% of cases during maintenance.
Conclusions: The use of BIS monitoring during general anaesthesia requiring endotracheal intubation and/or muscle relaxants was associated with a significantly reduced incidence of awareness as compared with a historical control population.

Propofol and remifentanil for intubation without muscle relaxant: the effect of the order of injection
F. Trabold, M. Casetta, J. Duranteau, P. Albaladejo, J. X. Mazoit, K. Samii, D. Benhamou and P. Sitbon
Acta Anaesthesiologica Scandinavica Volume 48 Issue 1 Page 35-39

Background: Common practice in intubation without muscle relaxant is to inject the opioid drug prior to the hypnotic drug. Because remifentanil reaches adequate cerebral concentration more rapidly than does propofol, we tested the hypothesis that injection of remifentanil after propofol might lead to better intubating conditions.
Methods: Thirty ASA I-II patients scheduled for elective surgery and with no anticipated difficult intubation were enrolled in the study. Five minutes after midazolam 30 µg kg ^-1, patients were randomized into two groups: group PR received propofol 2.5 mg kg^-1 followed by remifentanil 1 µg kg^-1, and group RP received remifentanil 1 µg kg^-1 followed by propofol 2.5 mg kg^-1. Intubating conditions were compared using a well-validated score, and continuous arterial pressure was recorded non-invasively.
Results: Compared with group RP, intubating conditions were significantly better in group PR. The mean arterial pressure decrease was more pronounced in group RP.
Conclusions: We therefore conclude that in premedicated healthy patients with no anticipated risk of difficult intubation, intubating and haemodynamic conditions are better when remifentanil is injected after propofol.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Bispectral index, serum drug concentrations and emergence associated with individually adjusted target-controlled infusions of remifentanil and propofol for laparoscopic surgery
S. C. Hoymork, J. Raeder, B. Grimsmo and P. A. Steen
Br J Anaesth 2003; 91: 773–80

Background: Target-controlled infusions (TCI) are used to simplify administration and increase precision of i.v. drugs during general anaesthesia. However, there is a limited relationship between preset targets and measured concentrations of drugs and between measured concentrations and measures of brain function, such as the bispectral index (BIS).
Methods: We set out to evaluate the performance of TCI devices for propofol (Diprifusor^®) and remifentanil (Remifusor, prototype), during laparoscopic cholecystectomy in 21 patients. We also checked if there was any correlation between serum concentrations of propofol and BIS during individually adjusted anaesthesia.
Results: The Diprifusor and Remifusor had a median absolute performance error of 60% and 25% respectively. Propofol concentrations were underpredicted by a median of 60%, and remifentanil concentrations were slightly overpredicted by a median of 7%. When anaesthesia was adjusted to keep BIS values between 45 and 60, no correlation existed between measured concentrations of propofol and the corresponding BIS values, although both BIS and serum propofol concentration discriminated well between the awake and asleep states. Emergence was rapid and uneventful in all patients. Female patients had a more rapid emergence than male patients (6.6 and 11.6 min respectively).
Conclusions: TCI devices for remifentanil and propofol result in large variation in measured serum concentrations. The lack of correlation between BIS and serum concentrations of propofol adds to the debate about whether BIS measures hypnosis as a graded state during surgery. This study confirms that women wake up faster than men, but provides no explanation for this repeatedly shown difference.

Randomized, controlled, cross-over clinical trial comparing intravenous midazolam sedation with nitrous oxide sedation in children undergoing dental extractions
K. E. Wilson, N. M. Girdler and R. R. Welbury
Br J Anaesth 2003; 91: 850–6

Background: The use of benzodiazepines for paediatric dental sedation has received limited attention with regard to research into clinical effectiveness. A study was therefore designed to investigate the use of midazolam, for i.v. sedation in paediatric dental patients.
Method: The aim of the study was to assess the effectiveness of i.v. midazolam in a randomized, controlled, cross-over trial. Children aged 12–16 yr (ASA I and II), requiring two appointments for equivalent but contralateral dental extractions for orthodontic purposes, were recruited. Conscious sedation with either i.v. midazolam titrated at 0.5 mg min^–1, to a maximum of 5 mg, or nitrous oxide/oxygen titrated to 30%/70% inhalation sedation was used at the first visit, the alternative being used at the second visit. Vital signs including blood pressure, arterial oxygen saturation and ventilatory frequency, as well as sedation levels and behavioural scores, were recorded every 2 min.
Results: Forty patients, mean age 13.2 yr (range 12–16 yr), participated in the trial. A mean dose of midazolam 2.8 mg was administered in the test group. The median time to the maximum level of sedation was 8 min for midazolam compared with 6 min for nitrous oxide (P<0.001). Vital signs for both treatments were comparable and within acceptable clinical limits and communication with the patient was maintained at all times. The median (range) lowest arterial oxygen saturation level recorded for midazolam was 97 (91–99)% compared with 97 (92–100)% for nitrous oxide. The mean (range) recovery time for midazolam was 51.6 (39–65) min and 23.3 (20–34) min for nitrous oxide (P<0.0001). Fifty-one per cent said they preferred i.v. midazolam, 38% preferred nitrous oxide, and 11% had no preference.
Conclusion: I.V. midazolam sedation (0.5 mg min^–1 to a maximum of 5 mg) appears to be as effective as nitrous oxide sedation in 12–16-yr-old healthy paediatric dental patients.

Supplemental oxygen does not reduce postoperative nausea and vomiting after thyroidectomy
J. L. Joris, N. J. Poth, A. M. Djamadar, D. I. Sessler, E. E. Hamoir, T. R. Defêchereux, M. R. Meurisse and M. L. Lamy
Br J Anaesth 2003; 91: 857–61

Background: Supplemental intra-operative oxygen 80% halves the incidence of nausea and vomiting after open and laparoscopic abdominal surgery, perhaps by ameliorating intestinal ischaemia associated with abdominal surgery. It is unlikely that thyroid surgery compromises intestinal perfusion. We therefore tested the hypothesis that supplemental perioperative oxygen does not reduce the risk of postoperative nausea and vomiting (PONV) after thyroidectomy.
Methods: One hundred and fifty patients undergoing thyroidectomy were given sevoflurane anaesthesia. After induction, patients were randomly assigned to the following treatments: (i) 30% oxygen, (ii) 80% oxygen, or (iii) 30% oxygen with droperidol 0.625 mg.
Results: The overall incidence of nausea during the first 24 h after surgery was 48% in the patients given oxygen 30%, 46% in those given oxygen 80%, and 22% in those given droperidol (P=0.004). There were no significant differences between the oxygen 30% and 80% groups in incidence or severity of PONV, the need for rescue antiemetics, or patient satisfaction. Droperidol significantly shortened the time to first meal.
Conclusions: Supplemental oxygen was ineffective in preventing nausea and vomiting after thyroidectomy, but droperidol reduced the incidence.

ANESTHESIOLOGY - TOP

Ropivacaine-induced Cardiac Arrest after Peripheral Nerve Block: Successful Resuscitation (Case Report)
Pascal Chazalon, M.D.; Jean P. Tourtier, M.D.; Thierry Villevielle, M.D.; Didier Giraud, M.D.; Jean M. Saïssy, M.D.; Georges Mion, M.D.; Dan Benhamou, M.D.
Anesthesiology 2003;99(6);1449-50

No abstract available

Cardiac Arrest after Injection of Ropivacaine for Posterior Lumbar Plexus Blockade (Case Report)
Olivier Huet, M.D.; Luc J. Eyrolle, M.D.; Jean X. Mazoit, Ph.D., M.D.; Yves M. Ozier, M.D.
Anesthesiology 2003;99(6):1451-2

No abstract available

Severe Airway Obstruction during Arthroscopic Shoulder Surgery (Case Report)
Stephan Blumenthal, M.D.; Marco Nadig, M.D.; Christian Gerber, M.D.; Alain Borgeat, M.D.
Anesthesiology 2003;99(6):1455

No abstract available

Life-threatening Airway Edema Resulting from Prolonged Shoulder Arthroscopy (Case Report)
Steven L. Orebaugh, M.D.
Anesthesiology 2003;99(6):1456-8

No abstract available

PUB MED - TOP

A comparison of deep vs. awake removal of the laryngeal mask airway in paediatric dental daycase surgery. A randomised controlled trial
S. Dolling, N. R. K. Anders, S. E. Rolfe
Anaesthesia Volume 58: Issue 12: 1224-1228

Dental anaesthesia provides a potential conflict between anaesthetist and surgeon because of the shared airway. The laryngeal mask airway (LMA) has helped to improve airway control for these procedures, but there is little evidence for best practice on the timing of their removal after airway surgery in the paediatric population. We compared ‘awake’ and ‘deep’ removal of the LMA in 196 patients aged from 2 to 15 years in a randomised, controlled study. We found that average peripheral oxygen saturation (SpO₂) was lower in the deep group and this was statistically significant (96.2% vs. 94.9%, p = 0.04). It was also found that the deep group had a higher incidence of patients with SpO₂< 95% (p = 0.003) and of patients who coughed (p = 0.003). We conclude that the LMA should be taken out awake in these patients.

The effect of preincisional periportal infiltration with ropivacaine in pain relief after laparoscopic procedures: a prospective, randomized controlled trial.
Pavlidis TE, Atmatzidis KS, Papaziogas BT, Makris JG, Lazaridis CN, Papaziogas TB.
JSLS. 2003 Oct-Dec;7(4):305-10

BACKGROUND AND OBJECTIVES: It is essential to minimize pain after laparoscopic surgery. This study examined the effect of wound infiltration by a long-acting local anesthetic.
METHODS: This prospective, randomized study includes 190 laparoscopic procedures carried out by the same surgeon. The patients were randomly allocated into 2 groups. The control group comprised 75 cases of laparoscopic cholecystectomy (LC) and 20 cases of laparoscopic inguinal hernia repair (LIHR) without the use of a local anesthetic; only saline was used. The study group comprised 75 cases of LC and 20 cases of LIHR with preincisional periportal infiltration with 20 mL of ropivacaine (10 mg/mL). The postoperative pain scores at 3, 6, 12, and 24 hours determined with a visual analogue scale (VAS), nausea, and the kind and amount of analgesic drugs were assessed.
RESULTS: In the study group in 41% of LC cases and 85% of LIHR cases, no analgesia was required at all; likewise, in the control group in 20% of LC cases and 44% of LIHR cases, no analgesia was required. The difference was statistically significant (P<0.05). In the remainder, pain at 3 and 6 hours and total analgesic requirements in the study group were less than that in the control group (P<0.05). The postoperative nausea and shoulder pain remained statistically unchanged (P>0.05).
CONCLUSIONS: It seems that wound infiltration with ropivacaine in laparoscopy provides satisfactory postoperative analgesia, diminishing or reducing the need for opioids.

Benefits of the laryngeal mask for airway management during electroconvulsive therapy
Nishihara F, Ohkawa M, Hiraoka H, Yuki N, Saito S.
J ECT. 2003 Dec;19(4):211-6

SUMMARY: Accumulation of carbon dioxide (CO₂) can disturb systemic hemodynamics and increase the seizure threshold in patients receiving electroconvulsive therapy (ECT). The purpose of this study was to investigate the effects of the laryngeal mask on blood gas, hemodynamics, and seizure duration during ECT under propofol anesthesia. Ventilation was assisted using either a face mask (n = 23) or laryngeal mask (n = 23) and 100% oxygen.There was no significant difference in PaO₂ between the two groups. PaCO₂ was greater in the face mask group than the laryngeal mask group at 3 minutes (54 +/- 11 mm Hg, 41 +/- 8 mm Hg, respectively) and 5 minutes (52 +/- 11 mm Hg, 43 +/- 15 mm Hg, respectively) after electrical stimulation (p < 0.01). Mean blood pressure was higher than the corresponding preanesthesia value at 1 to 5 minutes after electrical stimulation in the face mask group and at 1 to 3 minutes after electrical stimulation in the laryngeal mask group. Mean seizure duration in the face mask group was significantly shorter than that in the laryngeal mask group (33 +/- 11 seconds, 42 +/- 10 seconds, respectively p < 0.01). The change in PaCO₂ was minor in the laryngeal mask group compared with the face mask group and seizure duration was longer in the laryngeal mask group. Laryngeal mask may be suitable for airway management during ECT anesthesia, especially when fitting a face mask is difficult.

The comparative effects of sevoflurane and methohexital for electroconvulsive therapy
Calarge CA, Crowe RR, Gergis SD, Arndt S, From RP.
J ECT. 2003 Dec;19(4):221-5

SUMMARY: The standard anesthetic agent for electroconvulsive therapy (ECT) has been methohexital. We compared sevoflurane, a short-acting halogenated anesthetic, to methohexital for induction in ECT. Twelve subjects received sevoflurane or methohexital on alternating treatment days. Seizure duration, time to administering ECT, emergence and recovery, as well as several hemodynamic measures were recorded. A total of 69 treatments were analyzed. When sevoflurane was used, seizure durations recorded by observation and by EEG, were shorter by 10 and 23 seconds, respectively. With sevoflurane, seizure duration remained, however, within a clinically acceptable range. Methohexital allowed faster administration of ECT and discharge from the recovery room (3.8 vs. 6.2 minutes and 40.8 vs. 47.0 minutes, respectively). No difference in the post-ECT hemodynamic changes was found between the two treatments. We conclude that, when indicated, sevoflurane could provide a suitable alternative treatment option to methohexital, but some limitations, including shortened seizure duration and potential side effects, should be kept in mind.

Lumbar discectomy: developing and implementing a day surgery protocol
Doerksen K, Dusik-Sharpe J.
Axone. 2003 Sep;25(1):18-21

In some centres, patients who require a lumbar discectomy are successfully discharged the day of surgery. With the ongoing pressure to provide safe care for patients within certain bed limitations, this option was considered. Using a continuous quality improvement method, a prospective review of patients undergoing a single-level lumbar discectomy was monitored. Based on pre-set criteria, patients were included or excluded in the day surgery protocol and both groups were monitored. A large component of nursing education was provided for all patients, and will be highlighted. Data retrieved for both groups included demographics, length of operation, length in recovery room, length of hospital stay required, and the re-admission rate. There were 47 patients monitored over 11 months. Of the 34 patients entered in the protocol, seven required an overnight length of stay. The reasons for the extended length admission will be described. Of the 13 patients excluded from the protocol, one did not require an overnight stay. Following review of the data, the criteria for inclusion of patients into the protocol has been altered and patients can safely proceed with day surgery for lumbar discectomy.

Sevoflurane general anesthesia: an alternative technique in the pediatric oral and maxillofacial surgery patient
Lee M, Bennett HE, Gordon N.
J Oral Maxillofac Surg. 2003 Nov;61(11):1249-52

PURPOSE: The objective of this prospective descriptive study was to report our experience with an alternative general anesthetic technique, using sevoflurane for the pediatric patient, in an ambulatory setting.
PATIENTS AND METHODS: Twenty consecutive pediatric patients participated over a 4-month period. A general anesthetic technique, using mask induction with sevoflurane and maintenance with a nasal trumpet as airway, was used throughout the surgical procedure. A standard anesthesia and recovery record was made for each patient; this included observations for untoward effects and complications.
RESULTS: The average time for induction of anesthesia was 95 seconds, time from termination of sevoflurane to eye opening was 8 minutes, and duration of recovery was 30 minutes. Procedure time for each case did not exceed 10 minutes. Two patients had transient tachycardia.
CONCLUSIONS: The results of this prospective descriptive study indicate that this technique is an effective and acceptable alternative to other modalities for the control of apprehension and fear in the pediatric patient in an ambulatory oral and maxillofacial facility.

Parent's management of their child's pain in the home following day surgery
Jonas DA.
J Child Health Care. 2003 Sep;7(3):150-62

When a child returns home following day case surgery, the parent becomes responsible for the assessment and treatment of their child's pain. Pain is documented as being the most common complication following day case surgery. The study investigated parental management of their child's pain at home following day surgery. A purposive sample of 100 parents of children undergoing day case surgery at a regional paediatric hospital was obtained. Parents were contacted by telephone in their own home 24 hours after day surgery and, through a structured interview schedule, were asked a series of questions relating to their child's pain management and discharge information. The results indicated that parents managed their child's pain in the home if provided with information and suitable analgesia on discharge. Instigation of telephone follow-up for parents was upheld as a measure to provide support to parents, as 79 percent of parents found the telephone call useful.

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