Trends in Anesthesia-related Death and Brain Damage: A Closed Claims Analysis. Clinical Investigations
Cheney, Frederick W. M.D. ; Posner, Karen L. Ph.D. ; Lee, Lorri A. M.D. ; Caplan, Robert A. M.D. ; Domino, Karen B. M.D., M.P.H. 
Anesthesiology. 105(6):1081-1086, December 2006.

Abstract:
Background: The authors used the American Society of Anesthesiologists Closed Claims Project database to determine changes in the proportion of claims for death or permanent brain damage over a 26-yr period and to identify factors associated with the observed changes.
Methods: The Closed Claims Project is a structured evaluation of adverse outcomes from 6,894 closed anesthesia malpractice claims. Trends in the proportion of claims for death or permanent brain damage between 1975 and 2000 were analyzed.
Results: Claims for death or brain damage decreased between 1975 and 2000 (odds ratio, 0.95 per year; 95% confidence interval, 0.94-0.96; P < 0.01). The overall downward trend did not seem to be affected by the use of pulse oximetry and end-tidal carbon dioxide monitoring, which began in 1986. The use of these monitors increased from 6% in 1985 to 70% in 1989, and thereafter varied from 63% to 83% through the year 2000. During 1986-2000, respiratory damaging events decreased while cardiovascular damaging events increased, so that by 1992, respiratory and cardiovascular damaging events occurred in approximately the same proportion (28%), a trend that continued through 2000.
Conclusion: The significant decrease in the proportion of claims for death or permanent brain damage from 1975 through 2000 seems to be unrelated to a marked increase in the proportion of claims where pulse oximetry and end-tidal carbon dioxide monitoring were used. After the introduction and use of these monitors, there was a significant reduction in the proportion of respiratory and an increase in the proportion of cardiovascular damaging events responsible for death or permanent brain damage.

Estimation of Mean Body Temperature from Mean Skin and Core Temperature.
Clinical Investigations
Lenhardt, Rainer M.D., Sessler, Daniel I. M.D. 
Anesthesiology. 105(6):1117-1121, December 2006.

Abstract:
Background: Mean body temperature (MBT) is the mass-weighted average temperature of body tissues. Core temperature is easy to measure, but direct measurement of peripheral tissue temperature is painful and risky and requires complex calculations. Alternatively MBT can be estimated from core and mean skin temperatures with a formula proposed by Burton in 1935: MBT = 0.64 [middle dot] TCore + 0.36 [middle dot] TSkin. This formula remains widely used, but has not been validated in the perioperative period and seems unlikely to remain accurate in dynamic perioperative conditions such as cardiopulmonary bypass. Therefore, the authors tested the hypothesis that MBT, as estimated with Burton's formula, poorly estimates measured MBT at a temperature range between 18[degrees] and 36.5[degrees]C.
Methods: The authors reevaluated four of their previously published studies in which core and mass-weighted mean peripheral tissue temperatures were measured in patients undergoing substantial thermal perturbations. Peripheral compartment temperatures were estimated using fourth-order regression and integration over volume from 18 intramuscular needle thermocouples, 9 skin temperatures, and "deep" hand and foot temperature. MBT was determined from mass-weighted average of core and peripheral tissue temperatures and estimated from core temperature and mean skin temperature (15 area-weighted sites) using Burton's formula.
Results: Nine hundred thirteen data pairs from 44 study subjects were included in the analysis. Measured MBT ranged from 18[degrees] to 36.5[degrees]C. There was a remarkably good relation between measured and estimated MBT: MBTmeasured = 0.94 [middle dot] MBTestimated + 2.15, r2 = 0.98. Differences between the estimated and measured values averaged -0.09[degrees] +/- 0.42[degrees]C.
Conclusions: The authors concluded that estimation of MBT from mean skin and core temperatures is generally accurate and precise.

The Effects of Ketamine and Rocuronium on the A-Line(R) Auditory Evoked Potential Index, Bispectral Index, and Spectral Entropy Monitor during Steady State Propofol and Remifentanil Anesthesia.
Clinical Investigations
Vereecke, Hugo E. M. M.D. ; Vanluchene, Ann L. M.D. ; Mortier, Eric P. M.D., D.Sc. ; Everaert, Karel M.D., Ph.D. ; Struys, Michel M. R. F. M.D., Ph.D. 
Anesthesiology. 105(6):1122-1134, December 2006.

Abstract:
Background: The authors studied the effects of ketamine and rocuronium on the Bispectral Index, A-Line(R) auditory evoked potential index, state entropy, and response entropy during a calculated steady state anesthesia with propofol and remifentanil.
Methods: After ethics committee approval, 42 patients were allocated to four groups. Baseline measurements were performed after implementing a calculated steady state anesthesia with propofol and remifentanil. The control group received no additional medication. The ketamine group received a bolus and continuous infusion of ketamine. The rocuronium group received a bolus of rocuronium. The rocuronium-ketamine group received both. All data were stored during 15 min after baseline. After inspection of the raw data, the authors conducted an explorative statistical analysis.
Results: No significant changes were found in the control group for any of the monitors. Mean values decreased in the rocuronium group for the A-Line(R) auditory evoked potential index, Bispectral Index, and response entropy, but not for state entropy. In the ketamine group, the A-Line(R) auditory evoked potential index and Bispectral Index did not change significantly, but state and response entropy increased. In the rocuronium-ketamine group, the A-Line(R) auditory evoked potential index and Bispectral Index did not decrease as found in the rocuronium group. Response and state entropy increased significantly.
Conclusions: The response of all monitors after ketamine administration is not affected by simultaneous administration of rocuronium. Interpretation of all studied indices must be done cautiously while taking into account the clinical setting during measurement.

Extent and Localization of Changes in Upper Airway Caliber with Varying Concentrations of Sevoflurane in Children. Clinical Investigations
Crawford, Mark W. M.B.B.S., F.R.C.P.C. ; Arrica, Mauro M.D. ; Macgowan, Christopher K. Ph.D. ; Yoo, Shi-Joon M.D., F.R.C.P.C. 
Anesthesiology. 105(6):1147-1152, December 2006.

Abstract:
Background: Previous studies in humans suggest that inhibition of upper airway muscle activity is independent of the dose of inhalational anesthesia. Whether a dose-independent relation applies to changes in airway caliber is unknown. The authors sought to evaluate the configurational changes that lead to upper airway narrowing during inhalational anesthesia with sevoflurane and to determine whether these changes are dose dependent within a clinically relevant dose range.
Methods: Fifteen children undergoing elective magnetic resonance imaging of the brain were studied. Magnetic resonance images of the upper airway were acquired at sevoflurane concentrations of 0.5, 1.0, and 1.5 minimum alveolar concentration (MAC), administered in random sequence. At least 15 min was allowed for equilibration of inspired and alveolar partial pressures of sevoflurane. Images were acquired in early expiration at the level of the soft palate, base of the tongue, and tip of the epiglottis. Airway cross-sectional area (CSA), anteroposterior, and transverse dimension were determined using image-analysis software.
Results: At each anatomical level, pharyngeal CSA decreased progressively with increasing depth of sevoflurane anesthesia (P < 0.001). Increasing the sevoflurane concentration from 0.5 to 1.0 MAC reduced airway CSA by 13-18%, and a further increase to 1.5 MAC resulted in an overall 28-34% reduction in CSA. The reduction in CSA was predominantly due to a decrease in anteroposterior dimension.
Conclusions: Increasing the depth of sevoflurane anesthesia resulted in a relatively uniform reduction in pharyngeal caliber at each anatomical level studied. The effect of sevoflurane on upper airway caliber is dose dependent.

Value of Preoperative Clinic Visits in Identifying Issues with Potential Impact on Operating Room Efficiency.
Economics
Correll, Darin J. M.D. ; Bader, Angela M. M.D. ; Hull, Melissa W. M.D. ; Hsu, Cindy M.D. ; Tsen, Lawrence C. M.D. ; Hepner, David L. M.D. 
Anesthesiology. 105(6):1254-1259, December 2006.

Abstract:
Background: Preoperative clinics have been shown to decrease operating room delays and cancellations. One mechanism for this positive economic impact is that medical issues are appropriately identified and necessary information is obtained, so that knowledge of the patients' status is complete before the day of surgery. In this study, the authors describe the identification and management of medical issues in the preoperative clinic.
Methods: All patients coming to the Preoperative Clinic during a 3-month period from November 1, 2003, through January 31, 2004, at the Brigham and Women's Hospital, Boston, Massachusetts, were studied. Data were collected as to the type of issue, information needed to resolve the issue, time to retrieve the information, cancellation and delay rates, and the effect on management.
Results: A total of 5,083 patients were seen in the preoperative clinic over the three-month period. A total of 647 patients had a total of 680 medical issues requiring further information or management. Of these issues, 565 were thought to require further information regarding known medical problems, and 115 were new medical problems first identified in the clinic. Most of the new problems required that a new test or consultation be done, whereas most of the old problems required retrieval of information existing from outside medical centers. New problems had a far greater probability of delay (10.7%) or cancellation (6.8%) than old problems (0.6% and 1.8%, respectively).
Conclusions: The preoperative evaluation can identify and resolve a number of medical issues that can impact efficient operating room resource use.

Improved Postoperative Outcomes Associated with Preoperative Statin Therapy.
Review Article
Hindler, Katja M.D. ; Shaw, Andrew D. M.B.B.S., F.R.C.A. ; Samuels, Joshua M.D., M.P.H. ; Fulton, Stephanie M.S. ; Collard, Charles D. M.D. ; Riedel, Bernhard M.B., Ch.B., F.C.A., M.Med., F.A.H.A., Ph.D. 
Anesthesiology. 105(6):1260-1272, December 2006.

Abstract:
Statin therapy is well established for prevention of cardiovascular disease. Statins may also reduce postoperative mortality and morbidity via a pleiotropic (non-lipid-lowering) effect. The authors conducted a meta-analysis to determine the influence of statin treatment on adverse postoperative outcomes in patients undergoing cardiac, vascular, or noncardiovascular surgery. Two independent authors abstracted data from 12 retrospective and 3 prospective trials (n = 223,010 patients). A meta-analysis was performed to evaluate the overall effect of preoperative statin therapy on postoperative outcomes. Preoperative statin therapy was associated with 38% and 59% reduction in the risk of mortality after cardiac (1.9% vs. 3.1%; P = 0.0001) and vascular (1.7% vs. 6.1%; P = 0.0001) surgery, respectively. When including noncardiac surgery, a 44% reduction in mortality (2.2% vs. 3.2%; P = 0.0001) was observed. Preoperative statin therapy may reduce postoperative mortality in patients undergoing surgical procedures. However, the statin associated effects on postoperative cardiovascular morbidity are too variable to draw any conclusion.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Amnesia for electric dental pulp stimulation and picture recall test under different levels of propofol or midazolam sedation
Y. Matsuki, T. Ichinohe  and Y. Kaneko
Acta Anaesthesiologica Scandinavica Volume 51 Issue 1 Page 16 - January 2007

Aim: To compare the amnesic effect of propofol and midazolam to electric dental pulp stimulation (invasive) and picture recall test (non-invasive) at two sedation levels with the aid of bispectral index (BIS) monitoring.
Methods: The subjects were 10 male volunteers (24–34 years) classified as ASA physical status I. Propofol was administered to achieve a sedation score of three with a target-controlled infusion technique; it was then regulated to give a sedation score of two (P group). Midazolam was administered by a titration dosage to achieve a sedation score of three (M group). It then gradually decreased to give a sedation score of two. The BIS score, sedation score, plasma/serum concentration of propofol and midazolam, blood pressure, pulse rate, respiratory rate, end-tidal CO2 tension and arterial oxygen saturation were observed at each sedation level in both groups. Amnesic effects were evaluated using a picture recall test and electric dental pulp stimulation.
Result: No difference was observed in the amnesic effect evaluated by picture recall test at the two sedation levels. Likewise, there was no difference at a sedation score of three when the amnesic effect was evaluated by electric dental pulp stimulation. In contrast, a significant difference was observed at a sedation score of two; midazolam produced amnesia in more subjects than did propofol.
Conclusion: Propofol and midazolam did not show any significant difference in amnesic effects to non-invasive stimuli. For invasive stimuli, midazolam showed a stronger amnesic effect at the moderate sedation level, but not at the deeper sedation level.

Control of shivering during regional anaesthesia: prophylactic ketamine and granisetron
O. Sagir, N. Gulhas, H. Toprak, A. Yucel, Z. Begec  and O. Ersoy
Acta Anaesthesiologica Scandinavica Volume 51 Issue 1 Page 44 - January 2007

Background: The aim of the present study was to compare placebo, ketamine, granisetron and a combination of ketamine and granisetron in the prevention of shivering caused by regional anaesthesia.
Methods: In this prospective, randomized, double-blind study, 160 ASA I and II patients undergoing urological surgery were included. Subarachnoid anaesthesia was performed in all patients with bupivacaine 15 mg. The patients were randomly allocated to receive saline (group P, n = 40), ketamine 0.5 mg (group K, n = 40), granisetron 3 mg (group G, n = 40) or ketamine 0.25 mg + granisetron 1.5 mg (group KG, n = 40). Shivering was graded as 0 = no shivering, 1 = piloerection or peripheral vasoconstriction but no visible shivering, 2 = muscular activity in only one muscle group, 3 = muscular activity in more than one muscle group but not generalized, and 4 = shivering involving the whole body. If 15 min after spinal anaesthesia and concomitant administration of a prophylactic dose of one of the study drugs, the patients shivered according to at least grade 3, the prophylaxis was regarded as ineffective and intravenous (i.v.) pethidine 25 mg was administered.
Results: After 15 min, the number of patients with observed shivering was 22 in group P, 6 in group G, 7 in group GK and 0 in group K. The difference between group K and all the other groups was statistically significant (P < 0.0001). The number of patients with a shivering score of 3 was statistically significantly higher in group P compared with the other groups.
Conclusion: The prophylactic use of 0.5 mg/kg i.v. ketamine was effective in preventing shivering developed during regional anaesthesia.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Pretreatment with remifentanil to prevent withdrawal after rocuronium in children
J. Y. Kim, J. Y. Kim, Y. B. Kim and H. J. Kwak
British Journal of Anaesthesia 2007 98(1):120-123
 
Background. Pain from rocuronium injection is a common side-effect reported to occur in 50–80% of the patients. This randomized, double-blind, placebo-controlled study was designed to evaluate the efficacy of pretreatment with i.v. remifentanil on prevention of withdrawal response during rocuronium injection in paediatric patients.
Methods. After obtaining parental consents, 70 paediatric patients were randomly allocated into two groups to receive either i.v. remifentanil 1 µg kg^-1 (remifentanil group, n=35) or i.v. saline 5 ml (saline group, n=35). Anaesthesia was induced with thiopental sodium 2.5% (5 mg kg^-1) and the test drug was injected over 30 s. One minute after the test drug injection, rocuronium 1% (0.6 mg kg^-1) was injected over 5 s and the response was recorded. Mean arterial pressure (MAP) and heart rate were recorded on arrival in the operating theatre, before and 1 min after the tracheal intubation.
Results. The overall incidence of withdrawal movements was significantly higher in the saline group (33 patients; 94%) than that in the remifentanil group (8 patients; 23%) (P<0.001). No patient in the remifentanil group showed generalized movement, whereas 51% of patients in the saline group did. Remifentanil prevented significant increase in MAP after intubation.
Conclusion. This study demonstrated that pretreatment with remifentanil 1 µg kg^-1 provided a safe and simple method for reducing the incidence of rocuronium-associated withdrawal movement with haemodynamic stability in children.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Evidence-based clinical update: Does premedication with oral midazolam lead to improved behavioural outcomes in children?
Robin G. Cox, MB BS MRCP(UK) FRCA FRCPC, Ulyana Nemish, BSc MSc, Alastair Ewen, MB ChB FRCA FRCPC and Marie-Josée Crowe, MD FRCPC
Canadian Journal of Anesthesia 53:1213-1219 (2006)

Purpose: The purpose of this evidence-based clinical update was to identify the best evidence to determine if behavioural outcomes are improved in children after oral midazolam premedication.
Methods: A literature search was conducted using both PubMed and OVID programs, utilizing the terms "midazolam", and either "premedication" or "preoperative treatment". Search limits that were employed included randomized controlled trials (RCTs), English language, human studies, children aged 0–18 yr, and publication dates 1990 – present (January 2006). A review of the 171 abstracts obtained was undertaken and, of these, 30 papers were identified that concerned oral midazolam in children prior to general anesthesia, and that involved a RCT with a placebo or control arm. These studies were assigned levels of evidence, and grades of recommendation were made according to Centre for Evidence-Based Medicine criteria.
Results: Oral midazolam premedication in children was found to reduce the anxiety associated with separation from parents/guardians, and with induction of anesthesia. Recovery times are not significantly delayed. There is no consistent evidence to suggest a reduction in the phenomenon of emergence agitation. Evidence suggesting an improvement in behavioural outcomes at home is also inconsistent.
Conclusion: Premedication with midazolam 0.5 mg·kg^-1 po administered 20–30 min preoperatively, is effective in reducing both separation and induction anxiety in children (grade A recommendation), with minimal effect on recovery times. However improved postoperative behavioural outcomes in the postanesthesia care unit, or at home cannot be predicted on a consistent basis.

PUB MED - TOP

      
Patients push for price data. Lawsuits, regulations could cause consumers nationwide to start seeking more transparency from hospitals on outpatient fees.
Becker C
Mod Healthc. 2006 Nov 20;36(46):6-7

Lawsuits over hospital outpatient fees, including a case at Virginia Mason Medical Center, could prompt consumers nationwide to seek more information about their bills. The issue highlights the turf battle between physician- or corporate-owned clinics and competing hospital facilities, and how they're marketed. "We absolutely agree that patients need full information", says Virginia Mason's Sarah Patterson, left.

Competition keeps getting hotter for ambulatory surgery.
Haugh R.
Gastrointest Endosc Clin N Am. 2006 Oct;16(4):801-15.
Hosp Health Netw. 2006 Oct;80(10):68-70, 72, 2.

With fast-paced advances in medicine and technology, certain types of surgery that could once only be performed on an inpatient basis are now moving to ambulatory surgery centers. Hospitals are exploring a variety of strategies to hold on to--and even expand--their share of the few profitable areas of health care today.

Medication safety within the perioperative environment.
Wanzer LJ, Hicks RW.
United States Army Nurse Corps, USA.
Annu Rev Nurs Res. 2006;24:127-55.

With the widespread patient safety movement comes an increased public awareness of the risks inherent within the health care setting. More specifically, the highly publicized medication error cases that hit the media demonstrate the effect mediation errors have on patient safety within the perioperative environment. This awareness, however, has triggered limited research across the continuum of care within this complex environment. A current review of the state of the science related to medication safety within this setting reveals research primarily focused on the anesthesia domain of practice. Although application to the perioperative environment can be extrapolated from this research, there is a notable lack of nursing-initiated research that focuses on improved systems or processes related to medication safety within the perioperative continuum of care. This knowledge gap in the literature presents an excellent opportunity for nursing to grow a research program to improve medication safety within the perioperative environment in support of evidence-based practice.

Factors affecting unanticipated hospital admission following otolaryngologic day surgery.
Tewfik MA, Frenkiel S, Gasparrini R, Zeitouni A, Daniel SJ, Dolev Y, Kost K, Samaha M, Sweet R, Tewfik TL.
Department of Otolaryngology-Head and Neck Surgery, Royal Victoria Hospital, McGill University, Montreal, Quebec. marc.tewfik@mail.mcgill.ca
J Otolaryngol. 2006 Aug;35(4):235-41.

BACKGROUND: Day surgery constitutes an important part of modern otolaryngology practice. However, high rates of unplanned admissions remain an issue.
OBJECTIVE: To determine the incidence, reasons, and predictive factors for unanticipated admission after ambulatory otolaryngologic surgery. METHODS: A retrospective review of all cases of unplanned admission following otolaryngology day surgery at a tertiary care centre over a 4-year period from 2000 to 2004. Data relating to patient demographics, physical status, surgical procedure, perioperative complications, and reasons for hospital admission were recorded. A case-control analysis of these parameters with nonadmitted day surgery patients was used for comparison.
RESULTS: During the above period, 1106 patients underwent otolaryngologic day surgery, of whom 74 (6.7%) required admission. Fifty-seven percent of the patients were male, and the average age was 48.9 years. The three most common procedures with unplanned admission were open neck biopsy (27%), functional endoscopic sinus surgery (20.3%), and panendoscopy (16.2%). The reasons for admission could be divided into airway monitoring (37.7%), postoperative bleeding (28.6%), the need for supportive or pain management (19.5%), anesthetic complication (5.2%), cardiovascular complication (3.9%), clerical error (3.9%), and suspicion of a cerebrospinal fluid leak (1.3%). Risk factors for admission were determined to be an American Society of Anesthesiologists' class of 3 or greater, open neck surgical procedures, and a length of surgery of 60 minutes or greater. Minor factors included the use of general anesthesia, male gender, advanced age, and living far from a hospital.
CONCLUSIONS: This study suggests strategies to reduce the rate of unplanned admission by means of careful preoperative assessment and planning, patient selection, careful scheduling of higher-risk patients, and appropriate postoperative observation and management.

Nitrous oxide as an adjunct in tumescent liposuction.
Bird G, Albert C.
Mc Gill University, Montreal, Quebec, Canada.
J Cosmet Dermatol. 2005 Dec;4(4):267-71

Background: Nitrous oxide (N(2)O) has been used as an anesthetic for over 300 years. It is safe, easy to use, and effective. In this article we will document N(2)O use as an adjunct to tumescent liposuction. The history, mechanism of action, use, and safety in ambulatory surgery of N(2)O are reviewed.
Objective: The authors intend to review the history of both tumescent liposuction and N(2)O in surgery, discuss the possible adverse reactions, and present guidelines for the use of N(2)O during tumescent liposuction.
Methods: A Medline review of articles, 1966-2004, related to N(2)O was performed, using the search terms nitrous, oxide, safety, toxicity, mechanism, anesthetic, surgery, risks, and delivery. Articles that were cited by the authors of this subset of original articles were also used when appropriate. Articles were rated and included based on date of publication, level of evidence, and applicability to tumescent liposuction.
Conclusion: Nitrous oxide is safe, easily administered, inexpensive, and is an effective adjunct to tumescent liposuction. It provides a high level of pain control, and is patient controlled, while not putting the patient at risk of full anesthesia. When used correctly, with proper equipment, it poses little risk to either patients or healthcare workers.

Day-care surgery for pilonidal sinus.
Abdul-Ghani AK, Abdul-Ghani AN, Ingham Clark CL.
Department of Surgery, Whittington Hospital, London, UK.
Ann R Coll Surg Engl. 2006 Nov;88(7):656-8.

INTRODUCTION: The surgical approach to symptomatic pilonidal sinus is open to debate. Many techniques have been described and no single technique fulfils all the requirements of an ideal treatment. Ambulatory treatment with minimal morbidity and rapid return to activity is desirable. The aim of this work was to study the feasibility of day-care surgery for excision and primary asymmetric closure of symptomatic pilonidal sinus.
PATIENTS AND METHODS: All patients referred electively over 2 years were assessed in a single-consultant, colorectal clinic and booked for day-care surgery. All patients had excision and primary asymmetric closure under general anesthesia in the left lateral position. Whenever possible, they were discharged on the same day according to the day-surgery protocol. Patients were subsequently seen in the out-patient clinic for removal of stitches and were followed up further if there was any wound breakdown.
RESULTS: Fifty-one patients were operated on electively for pilonidal sinus over the 2 years. Two patients were excluded as the final diagnosis was not pilonidal sinus. At 4 weeks following operation, 43 (88%) had complete healing and 6 (12%) had dehiscence of the wound. Recurrence rate was 8% (4 patients) for follow-up of 12-38 months. There was no admission from the day-surgery unit and no unplanned re-admissions. The cost for day-care pilonidal sinus surgery was estimated to be 672.00 pounds per patient compared with in-patient cost of 2405.00 pounds. CONCLUSIONS: Excision and primary asymmetric closure for pilonidal sinus is safe and feasible as day-care surgery and is associated with potential cost saving.

Ambulatory proctology surgery--an Indian experience.
Gupta PJ.
Gupta Nursing Home, Laxminagar, NAGPUR, India. drpjg@yahoo.co.in
Eur Rev Med Pharmacol Sci. 2006 Sep-Oct;10(5):257-62.

OBJECTIVE: To evaluate the results of proctological surgeries carried out by us on an outpatient basis. Design: Retrospective study. Subject: 3256 patients with benign ano-rectal pathologies needing surgical intervention.
MATERIALS AND METHODS: Patient demographics, type of anesthesia used, the type of operation and postoperative complications are described. Patient satisfaction was assessed independently after surgical procedure.
RESULTS: Mean age of the patients was 37.5 years. 61% patients were male. There was no mortality. The mean duration of hospital stay was 8.4 hours (range 3-22 hours). Complication rate was 2.9%. 81.4% patients were highly satisfied with the procedure.
CONCLUSION: Day care proctological procedures are a safe and effective way of reducing costs without increasing morbidity, mortality, and is acceptable to majority of patients.

Simple harmonic scalpel hemorrhoidectomy utilizing local anesthesia combined with intravenous sedation: a safe and rapid alternative to conventional hemorrhoidectomy.
Haveran LA, Sturrock PR, Sun MY, McDade J, Singla S, Paterson CA,Counihan TC.
Section of Colon and Rectal Surgery, University of Massachusetts Medical Center,Worcester, MA, USA.
Int J Colorectal Dis. 2006 Nov 22; [Epub ahead of print]

BACKGROUND: Harmonic Scalpel(R) hemorrhoidectomy (HSH) is an established surgical therapy for the treatment of symptomatic grade III and IV hemorrhoids. Hemorrhoid surgery is still being performed as an inpatient procedure with general or regional anesthesia in many centers today. There was a trend toward performing hemorrhoid surgery as an ambulatory procedure using local anesthesia supplemented with intravenous sedation. The aim of the current study was to evaluate the safety and efficacy of HSH performed with combination local anesthesia and intravenous sedation in an ambulatory surgical center.
MATERIALS AND METHODS: A retrospective review was performed on the clinical charts of all patients undergoing HSH in an ambulatory surgical center from 2001 to 2005. All hemorrhoidectomies were attempted under propofol/ketamine intravenous sedation and local anesthesia in the prone position. A simple, open technique without routine suture was used.
RESULTS: During the study period, 180 patients (70 females) underwent HSM. Mean procedure and total operating room time were 12 and 28 min, respectively. One patient (0.6%) was converted to general endotracheal anesthesia. Ten patients (5.6%) required post anesthesia care unit (PACU) observation. All patients were discharged home after the procedure. Postoperative complications occurred in 19 patients (10.6%). There were no re-operations and the total readmission rate was 3.7%.
CONCLUSION: HSH performed with a combination of intravenous sedation and local anesthesia is safe and effective in the ambulatory surgery setting. The combined technique was associated with a rate of complications comparable to published series utilizing conventional hemorrhoidectomy techniques. Added benefits include shorter hospital stay and a potential for cost savings.

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