Volume 7, Issue 8 S A M B A T A L K S - PAGE 3 January, 2008

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

Can Remifentanil Replace Nitrous Oxide During Anesthesia for Ambulatory Orthopedic Surgery with Desflurane and Fentanyl?
Donald M. Mathews, MD, Vijay Gaba, MD, Bledi Zaku, BS, and George G. Neuman, MD
Anesth Analg 2008; 106:101-108

Abstract
BACKGROUND: The administration of nitrous oxide (N2O) may be associated with side effects and toxicities. Remifentanil shares characteristics with N2O, including MAC-reducing and antinociceptive effects and a rapid decrease in clinical effect when discontinued. We compared the outcome after ambulatory orthopedic surgery with desflurane and fentanyl supplemented with clinically equivalent doses of either N2O or remifentanil.
METHODS: Seventy patients undergoing ambulatory orthopedic surgery were studied. Thirty-five received 66% N2O and 35 received remifentanil 0.085 µg · kg–1 · min–1 in addition to desflurane, titrated to a bispectral index (BIS) value of 50, and a fentanyl infusion. The principle outcome measure was time to awakening to verbal stimulation. Secondary outcome measures included neuropsychological testing, time to orientation, hemodynamic values, pain and nausea visual analog scores, discharge times, and satisfaction scores. The average end-tidal desflurane concentration and fentanyl effect-site concentration were determined.
RESULTS: The median time (interquartile range) to awakening to verbal stimulation, 3.0 min (3.0–5.0 min) in the remifentanil group and 4.6 min (3.0–8.1 min) in the N2O group was not significantly different. Median time to orientation was significantly faster in the remifentanil group: 6.0 min (5.0–8.5 min) compared with 8.0 min (5.0–12.8 min) for the N2O group. There was no difference between groups in desflurane or fentanyl administration, neuropsychological testing, or any other outcome measure.
CONCLUSIONS: This study demonstrates that a remifentanil infusion of 0.085 µg · kg–1 · min–1 may be substituted for 66% N2O during desflurane/fentanyl anesthesia without any clinically significant change in outcome.

Premedication with Mirtazapine Reduces Preoperative Anxiety and Postoperative Nausea and Vomiting
Chien-Chuan Chen, MD, Chia-Shiang Lin, MD, Yuan-Pi Ko, MD, Yu-Chun Hung, MD, Hsuan-Chih Lao, MD, and Yung-Wei Hsu, MD
Anesth Analg 2008; 106:109-113

Abstract
BACKGROUND: Mirtazapine is a new antidepressant that blocks 5-HT2 and 5-HT3 receptors. With this receptor profile, it is possible that mirtazapine could provide both anxiolysis and efficacy for postoperative nausea and vomiting (PONV). We therefore tested the hypothesis that premedication with mirtazapine can reduce preoperative anxiety and PONV.
METHODS: Eighty female patients with at least two PONV risk factors scheduled for gynecological surgery were enrolled. Dexamethasone 8 mg was given before induction of anesthesia and patients were randomly assigned to group M + D (mirtazapine plus dexamethasone) or group dexamethasone. An oral disintegrating mirtazapine 30 mg or placebo tablet was given 1 h before surgery. Preoperative anxiety level was assessed by a visual analog scale (VAS) before mirtazapine administration and 1 h thereafter. General anesthesia was induced with 1% propofol at the rate of 200 mL/h (until loss of consciousness) and was then maintained with sevoflurane in oxygen and air. An auditory evoked potentials index monitor was used to titrate sevoflurane. The incidence of PONV, the use of rescue antiemetic, complete response, postoperative Ramsay Sedation Scores, and VAS pain scores were assessed 1, 2, and 24 h after surgery and compared.
RESULTS: The VAS anxiety scale was lower in group M + D after mirtazapine administration. There were no differences in the induction dose of propofol, the concentrations of sevoflurane during anesthesia, and recovery times between the two groups. The incidence of complete response to PONV over 0–24 h was lower in group M + D (80% vs 50%, P < 0.01).
CONCLUSIONS: Premedication with mirtazapine 30 mg reduces the level of preoperative anxiety and the risk of PONV in moderate and high-risk female patients.

A Comparison of Sedation with Dexmedetomidine or Propofol During Shockwave Lithotripsy: A Randomized Controlled Trial
Kenan Kaygusuz, MD, Gokhan Gokce, MD, Sinan Gursoy, MD, Semih Ayan, MD, Caner Mimaroglu, MD, and Yener Gultekin, MD
Anesth Analg 2008; 106:114-119

Abstract
BACKGROUND: Dexmedetomidine, because it has both sedative and analgesic properties, may be suitable for conscious sedation during painful procedures. Extracorporeal shockwave lithotripsy (ESWL) is a minimal to mildly painful procedure that requires conscious sedation. We thus evaluated the utility of dexmedetomidine compared with propofol during an ESWL procedure.
METHODS: Forty-six patients were randomly allocated into two groups to receive either dexmedetomidine or propofol for elective ESWL. Dexmedetomidine was infused at 6 µg · kg–1 · h–1 for 10 min followed by an infusion rate of 0.2 µg · kg–1 · h–1. Propofol was infused at 6 mg · kg–1 · h–1 for 10 min followed by an infusion of 2.4 mg · kg–1 · h–1. Fentanyl 1 µg/kg IV was given to all patients 10 min before ESWL. Pain intensity was evaluated with a visual analog scale at 5-min intervals during ESWL (10–35 min). Sedation was determined using the Observer's Assessment of Alertness/Sedation. The Observer's Assessment of Alertness/ Sedation scores and hemodynamic and respiratory variables were recorded regularly during ESWL (35 min) and up to 85 min after.
RESULTS: Forty patients were evaluated. Visual analog scale values with dexmedetomidine were significantly lower than those with propofol only at the 25–35 min assessments (P < 0.05). During sedation, the respiratory rate with dexmedetomidine was significantly slower but Spo2 was significantly higher than with propofol (P < 0.05). Other clinical variables were similar (P > 0.05).
CONCLUSION: A combination of dexmedetomidine with fentanyl can be used safely and effectively for sedation and analgesia during ESWL.

Propofol Causes Less Postoperative Pharyngeal Morbidity Than Thiopental After the Use of a Laryngeal Mask Airway
Yuan-Yi Chia, MD, Shih-Wei Lee, MD, and Kan Liu, MD
Anesth Analg 2008; 106:123-126

Abstract

The insertion of a laryngeal mask airway (LMA) may result in postoperative sore throat. The choice of induction drug on airway morbidity after LMA insertion may be important. We performed this study to compare the incidence of postoperative pharyngeal morbidity after the insertion of a LMA in 340 patients administered either 2 mg/kg propofol (group P) or thiopental 5 mg/kg (group T) for induction of anesthesia. Patients were maintained at 1–2 minimum alveolar anesthetic concentration sevoflurane in 50% oxygen/air. Spontaneous or assisted spontaneous ventilation was maintained. An investigator blinded to group allocation visited patients at 2, 12, and 24 h postoperatively. Adverse responses were noted (yes/no) at each time point including sore throat, sore mouth, sore jaw, hoarseness, dysphonia, and dysphagia. At 2 h postoperatively, the incidence of sore throat, dysphagia, and postoperative nausea and vomiting in group T was higher than in group P (24% vs 13% for sore throat, 15% vs 3% for dysphagia, 20% vs 11% for nausea, 14% vs 6% for vomiting, P < 0.05). The number-needed-to-treat to prevent sore throat and dysphagia was 10 and 8, respectively (95% confidence intervals, 5–43). We concluded that, when propofol, rather than thiopental, is used for the induction of anesthesia, it results in a lower incidence of early pharyngeal morbidity and postoperative nausea and vomiting after the insertion of a LMA.

ANESTHESIOLOGY - TOP

Type and Severity of Cognitive Decline in Older Adults after Noncardiac Surgery.
Clinical Investigations
Price, Catherine C. Ph.D. ; Garvan, Cynthia W. Ph.D. ; Monk, Terri G. M.D., M.S. 
Anesthesiology. 108(1):8-17, January 2008.

Abstract:
Background: The authors investigated type and severity of cognitive decline in older adults immediately and 3 months after noncardiac surgery. Changes in instrumental activities of daily living were examined relative to type of cognitive decline.
Methods: Of the initial 417 older adults enrolled in the study, 337 surgery patients and 60 controls completed baseline, discharge, and/or 3-month postoperative cognitive and instrumental activities of daily living measures. Reliable change methods were used to examine three types of cognitive decline: memory, executive function, and combined executive function/memory. SD cutoffs were used to grade severity of change as mild, moderate or severe.
Results: At discharge, 186 (56%) patients experienced cognitive decline, with an equal distribution in type and severity. At 3 months after surgery, 231 patients (75.1%) experienced no cognitive decline, 42 (13.6%) showed only memory decline, 26 (8.4%) showed only executive function decline, and 9 (2.9%) showed decline in both executive and memory domains. Of those with cognitive decline, 36 (46.8%) had mild, 25 (32.5%) had moderate, and 16 (20.8%) had severe decline. The combined group had more severe impairment. Executive function or combined (memory and executive) deficits involved greater levels of functional (i.e., instrumental activities of daily living) impairment. The combined group was less educated than the unimpaired and memory groups.
Conclusion: Postsurgical cognitive presentation varies with time of testing. At 3 months after surgery, more older adults experienced memory decline, but only those with executive or combined cognitive decline had functional limitations. The findings have relevance for patients and caregivers. Future research should examine how perioperative factors influence neuronal systems.

Equipment-related Electrocardiographic Artifacts: Causes, Characteristics, Consequences, and Correction.
Review Article
Patel, Santosh I. M.D., F.R.C.A. ; Souter, Michael J. M.B., Ch.B., F.R.C.A. 
Anesthesiology. 108(1):138-148, January 2008.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Bispectral index monitoring: appreciated but does not affect drug dosing and hypnotic levels
M.-L. Lindholm, L. Budin, R. H. Sandin (2008)
Acta Anaesthesiologica Scandinavica 52 (1), 88–94.

Background: Bispectral index (BIS) has been associated with benefits from less-deep anesthesia as well as preventing awareness, albeit not at the same time. We investigated how increasing experience from BIS in clinical practice affect the hypnotic level, drug consumption, as well as subjective opinions on this monitoring.
Methods: Eight certified registered nurse anesthetists (CRNAs) with previous experience from 88 (46–121) BIS monitored cases anesthetized 80 cases with concealed BIS, followed by 80 cases with available BIS. Additional education and training was followed by yet another 160 patients randomized to open or blindly recorded BIS. BIS levels, anesthetic gas consumption, fentanyl use, and subjective opinions on utility and reliability were investigated.
Results: After gaining initial experience from BIS monitoring, the fraction of time with BIS levels of 40–60 did not deteriorate in cases with concealed monitoring and no further improvement was found in subsequent cases with available data from the BIS monitoring, not even after additional training and encouragement to adhere to the 40–60 interval. Compared with the first experience from BIS monitoring the subjective opinions on utility had increased from 33 to 78 mm (100 mm visual analog scales) (P<0.0001).
Conclusion: Although BIS became considerably appreciated, growing experience and repeated education had no impact on drug dosing and BIS levels.

The optimal bolus dose of alfentanil for tracheal intubation during sevoflurane induction without neuromuscular blockade in day-case anaesthesia
Y. Kim, Y. L. Kwak, K. C. Lee, Y. J. Chang, H. J. Kwak (2008)
Acta Anaesthesiologica Scandinavica 52 (1), 106–110.

Background: The purpose of this study was to determine the optimal bolus dose of alfentanil required to provide successful intubating conditions following inhalation induction of anaesthesia using 5% sevoflurane and 60% nitrous oxide without neuromuscular blockade in adult day-case anaesthesia.
Methods: Twenty-four adults, aged 18–60 years, undergoing general anaesthesia for short ambulatory surgery were enroled into the study. After vital capacity induction, with sevoflurane 5% and 60% nitrous oxide in oxygen, pre-determined dose of alfentanil was injected over 30 s. The dose of alfentanil was determined by modified Dixon's up-and-down method (2 μg/kg as a step size). Ninety seconds after the end of bolus administration of alfentanil, the trachea was intubated. Systolic blood pressure, heart rate and SpO2 were recorded at anaesthetic induction, before, 1 min and 3 min after intubation.
Results: The bolus dose of alfentanil for successful tracheal intubation was 10.7±2.1 μg/kg in 50% of patients during inhalation induction. From probit analysis, 50% effective dose (ED50) and ED95 values (95% confidence limits) of alfentanil were 10.7 μg/kg (8.0–12.9 μg/kg) and 14.9 μg/kg (12.9–31.1 μg/kg), respectively.
Conclusions: Using the modified Dixon's up-and-down method, the bolus dose of alfentanil for successful tracheal intubation was 10.7±2.1 μg/kg in 50% of adult patients during inhalation induction using 5% sevoflurane and 60% nitrous oxide in oxygen without neuromuscular blocking agent in day-case anaesthesia.

Administration of fentanyl before remifentanil-based anaesthesia has no influence on post-operative pain or analgesic consumption
H. Lenz, J. Raeder, S. C. Hoymork (2008)
Acta Anaesthesiologica Scandinavica 52 (1), 149–154.

Background: Remifentanil's short-acting analgesic effect and the potential of producing hyperalgesia is a challenge to post-operative pain control. This study investigated whether pre-treating the patients with fentanyl before remifentanil-based anaesthesia could reduce post-operative pain or analgesic consumption.
Methods: One-hundred patients admitted for anterior cruciate ligament repair were included in a double-blind study. Propofol and remifentanil were used for general anaesthesia. Group Pre received fentanyl 1.5 μg/kg intravenously (IV) and Group Post placebo before the remifentanil infusion. At the end of surgery, Group Pre received 1.5 μg/kg and Group Post received 3.0 μg/kg. Patient-controlled analgesia with fentanyl was used as analgesic rescue medication during the first 4 h post-operatively. Oxycodone 5 mg orally was taken as needed during the subsequent 4–24-h period.
Results: A mean dose of remifentanil 0.43 μg/kg/min was used for 90 min during surgery in both groups. There were no differences in the verbal rate scale (VRS) score or need of rescue analgesic medication between the groups during the first 4 h. Group Post had significantly less pain in the 4–24-h period after surgery, with a median VRS score of ‘slight pain’ vs. ‘moderate pain’ in Group Pre (P<0.05). The oxycodone consumption was similar in both groups.
Conclusion: Pre-treatment with fentanyl 1.5 μg/kg IV yielded no reduction in post-operative pain or analgesic consumption after 90 min of remifentanil-based anaesthesia with 0.43 μg/kg/min of remifentanil.

Clinical practice and routines for day surgery in Sweden: results from a nation-wide survey
M. Segerdahl, M. Warren-Stomberg, N. Rawal, M. Brattwall, J. Jakobsson (2008)
Acta Anaesthesiologica Scandinavica 52 (1), 117–124.

Background: Day surgery has expanded considerably during the last decades. Routines and standards have developed but differ between and within countries.
Methods: We studied the practice of day surgery in Sweden by an extensive questionnaire survey sent to all 92 hospitals.
Results: The proportion of day surgery vs. in-hospital procedures was overall 43%, with 43% in adults and 46% in children. Orthopaedic (33%), general (29%) and gynaecological (17%) surgery were the most common ambulatory procedures. Most patients (>90%) underwent pre-operative assessment by an anaesthesiologist. Patient self-assessment questionnaires were common (86%). Risk stratification for post-operative nausea and vomiting was used by 70% of the departments. Anxiolytic pre-medication was uncommon. Most anaesthesiologists (95%) used pre-operative oral analgesics to initiate post-operative analgesia, the most common being paracetamol (95%), NSAIDs (73%) and coxibs (15%). A balanced general anaesthesia technique was preferred. Post-operatively, 93% of the units routinely assessed patients' pain. Analgesic combinations of paracetamol, NSAIDs and weak opioids were used by 94% of the units. Most hospitals (80%) had standardised discharge criteria based on clinical assessment, and many required a patient escort at home for 24 h post-operatively. Assessments of unplanned admission, re-admission and post-operative complications were not performed routinely. Follow-up telephone calls within 1–2 days were performed regularly in about 40% of the units, or in selected patients only (37%). Pain was the most frequent complaint on follow-up.
Conclusions: In Sweden, a high degree of standardised regime for day surgical practice was found. Post-operative pain is the most common complaint after discharge.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Sedation and regional anaesthesia in the adult patient
D. Höhener, S. Blumenthal and A. Borgeat
British Journal of Anaesthesia 2008 100(1):8-16

This review discusses sedation for regional anaesthesia in the adult population. The first section deals with general aspects of sedation and shows that the majority of patients receiving sedation for regional anaesthesia are satisfied and would choose it again. Methods of assessing the level of sedation are discussed with emphasis on clinical measures. The pharmacology of the drugs involved in sedation is discussed, with propofol and remifentanil appearing to be the combination of choice for sedation in regional anaesthesia. The techniques for administering sedation are discussed and replacement of the traditional repeated boluses or continuous infusion with pharmacokinetic and patient-controlled systems is supported. Patient satisfaction studies suggest that patient-controlled systems are preferred.

Comparison of surgical conditions during propofol or sevoflurane anaesthesia for endoscopic sinus surgery
H. J. Ahn, S.-K. Chung, H.-J. Dhong, H. Y. Kim, J. H. Ahn, S. M. Lee, T. S. Hahm and J. K. Kim
British Journal of Anaesthesia 2008 100(1):50-54

Background: Endoscopic sinus surgery (ESS) is often affected by intra-nasal bleeding, which can be influenced by various anaesthetics and preoperative conditions. This study compared the surgical condition and the amount of intra-nasal bleeding between patients given sevoflurane/remifentanil (SR) and propofol/remifentanil (PR) anaesthesia.
Methods: ASA I or II patients undergoing ESS were randomly assigned to group SR (n=20) or group PR (n=20). The extent of the preoperative surgical lesion was classified as high (>12) and low Lund–Mackay (LM) (12) scores according to the computed tomography findings. The amount of intraoperative blood loss was calculated from the patients’ haemoglobin (Hb) and the amount of blood in the suction canister. The surgeons rated the visibility of the surgical field on a numeric rating scale (NRS).
Results: In the high-LM score patients, the median (1st/3rd quartiles) blood loss for the SR and PR groups was 135 (121/222) and 19 (8/71) ml h–1, respectively (P<0.01), and the mean (SD) of NRS was 5.8 (2.3) and 2.3 (1.0), respectively (P<0.05). However, in patients with low-LM score, both blood loss and NRS scores were not different between groups SR and PR.
Conclusions: In the high-LM score patients, PR anaesthesia results in less blood loss and a better surgical conditions for ESS than SR anaesthesia.

Efficacy of intravenous acetaminophen and lidocaine on propofol injection pain
O. Canbay, N. Celebi, O. Arun, A. H. Karagöz, F. Sarcaolu and S. Özgen
British Journal of Anaesthesia 2008 100(1):95-98

Background: Different methods and propofol formulations have been used to decrease propofol injection pain, but it remains an unresolved problem. We aimed to investigate the effect of i.v. acetaminophen pretreatment on the propofol injection pain.
Methods: One hundred and fifty ASA I–II patients undergoing general anaesthesia were randomly allocated into three groups. A 20-gauge catheter was inserted into a superficial radial vein of the left hand, and after the occlusion of venous drainage, Groups I, II, and III were pretreated with 40 mg of lidocaine in saline, 50 mg of i.v. acetaminophen, and 5 ml of saline, respectively. The occlusion was released after 2 min and one-fourth of the total propofol dose was injected into the vein over a period of 5 s. During the injection of both pretreatment solution and propofol, patients’ pain was assessed and recorded as 0–3, corresponding to no, mild, moderate or severe pain, respectively. 2 and Kruskal–Wallis tests were used for the statistical analysis. For all analyses, differences were considered to be significant at P<0.05.
Results: Patient characteristics were similar among the groups. Incidence of pain on injection of propofol in control, i.v. acetaminophen, and lidocaine groups was 64%, 22% and 8%, respectively (P<0.05).
Conclusions: Pretreatment with i.v. acetaminophen seems to be effective in attenuating pain during i.v. injection of propofol.

Spinal anaesthesia with articaine 5% vs bupivacaine 0.5% for day-case lower limb surgery: a double-blind randomized clinical trial
T. Dijkstra, J. A. Reesink, B. C. Verdouw, W. S. C. J. M. Van der Pol, T. Feberwee and A. G. Vulto
British Journal of Anaesthesia 2008 100(1):104-108

Background: A local anaesthetic with fast onset and short reliable duration of anaesthesia may be preferable for out-patient lower limb surgery. Articaine is believed to act faster and to have a shorter duration of action than bupivacaine, but there are no conclusive data available. The purpose of this study was to compare articaine and bupivacaine for day-case lower limb surgery.
Methods: Eighty patients planned for day-case lower limb surgery enrolled in this study. Patients were randomized to receive hyperbaric articaine 80 mg or plain bupivacaine 15 mg intrathecally. Primary outcome variable was recovery time from motor block. Secondary outcomes were: onset of sensory and motor block, maximum spread of sensory block, time to micturition, discharge from the hospital, and complications.
Results: The groups were comparable for the medians and the range of the maximum blocks after 30 min. Median time to complete regression of motor block was 101 min (range 80–129) for articaine compared with 307 min (range 225–350) for bupivacaine (P<0.0005). First spontaneous micturition occurred after 257 min (210–293) in the articaine group and after 350 min (304–370) in the bupivacaine group (P<0.0005). In the articaine and bupivacaine groups, patients were discharged after 300 min (273–347) and 380 min (332–431), respectively (P<0.0005). There was no significant difference in the occurrence of complications between the groups.
Conclusions: Spinal anaesthesia with 80 mg of hyperbaric articaine has a shorter duration than a spinal anaesthesia with 15 mg of plain bupivacaine in lower limb surgery of approximately 1 h duration.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Serotonin syndrome following methylene blue infusion during parathyroidectomy: a case report and literature review
Bradley K.W. Ng, MBChB, Andrew J.D. Cameron, FANZCA, Rhea Liang, MBChB and Habib Rahman, FRACS
Canadian Journal of Anesthesia 55:36-41 (2008)
 
Purpose: To report a case of autonomic, neurological and neuromuscular instability following methylene blue infusion for parathyroidectomy; to advance the argument for a diagnosis of serotonin syndrome; and to consider this diagnosis in previous, unexplained reports of adverse reactions amongst patients undergoing parathyroidectomy using methylene blue.
Clinical features: Methylene blue was administered to a 58-yr-old woman undergoing a parathyroidectomy under general anesthesia. The patient had a background of obsessive compulsive disorder treated with paroxetine. Postoperatively, she demonstrated symptoms and signs of serotonin syndrome; specifically tachycardia, agitation, dystonia and abnormal eye movements. These clinical findings spontaneously resolved themselves over the subsequent 48 hr.
Conclusion: An interaction between methylene blue and serotonergic agents may give rise to the serotonin syndrome. Consideration should be given to avoiding methylene blue in patients taking serotonergic agents. The diagnosis should be considered in patients with autonomic, neuromuscular or neurological changes and should be managed accordingly.

Comparison of laryngeal mask airway (LMA)- ProsealTM and the LMA-ClassicTM in ventilated children receiving neuromuscular blockade
David R. R. Lardner, MBChB FANZCA, Robin G. Cox, MBBS MRCP FRCA FRCPC, Alastair Ewen, MBChB FRCA FRCPC and Darren Dickinson, RRT
Canadian Journal of Anesthesia 55:29-35 (2008)
 
Purpose: To determine whether a functional difference exists between the size 2 laryngeal mask airway (LMA)-ClassicTM (CLMA) and LMA-ProsealTM (PLMA) in anesthetized children who have received neuromuscular blockade. Airway leak during intermittent positive pressure ventilation (IPPV) and adequacy of fibreoptic laryngeal view were the primary study outcomes.
Methods: A randomized, controlled, single-blinded study of 51 ASA I or II children weighing 10–20 kg was undertaken. The anesthetic technique was standardized. Following insertion of the LMA and cuff inflation to 60 cm H2O, we measured oropharyngeal leak pressure and gastric insufflation and leak fraction during IPPV, and evaluated the adequacy of fibreoptic view.
Results: Oropharyngeal leak pressure measured by neck auscultation was higher for the PLMA compared to the CLMA (23.7 vs 16.5 cm H2O, P = 0.009) but, when measured by the inspiratory hold maneuver was not significantly different (24.8 vs 20.3 cm H2O, respectively, P = 0.217). Leak fraction values were similar for the CLMA and the PLMA (21.2%. vs 13.3%, respectively, P = 0.473). A satisfactory view of the larynx was obtained more frequently in the PLMA group (21/25 vs 10/25, P = 0.003). Gastric insufflation during leak determination was more common with the CLMA (12/26 vs 2/25 CLMA vs PLMA, respectively, P = 0.006).
Conclusion: In children undergoing IPPV with neuromuscular blockade, the size 2 PLMA is associated with a higher leak pressure by auscultation and less gastric insufflation compared to the CLMA. Leak pressures assessed by manometric stability are similar with these two devices. The improved fibreoptic view of the larynx through the PLMA may be advantageous for bronchoscopy.

PUB MED - TOP



Fasting in paediatric ambulatory surgery.
Klemetti S, Suominen T.
Int J Nurs Pract. 2008 Feb;14(1):47-56.

University of Turku, Department of Nursing Science, Turku, Finland.

The purpose of this descriptive study was to examine how preoperative fasting and postoperative termination of the fast was experienced in ambulatory surgery by child patients and their mothers. The target group consisted of children (n = 12, age 2-10 years) who had undergone tonsillectomy/adenoidectomy, and their mothers. In the interviews, the mothers were asked to describe the problems connected with their child's preoperative fast and postoperative termination of the fast, as well as the things that went well in the process. Content analysis was carried out inductively. Preoperatively, the children were thirsty and anxious, but understood the fasting situation well. In some cases, there were conflicts between the child and his/her parent if fasting was prolonged. Parents also had doubts about their ability to implement the child's fast. Postoperatively, children had pains in their throats and stomachs, suffered from nausea, and had difficulty taking in nutrition and medication. Parents had worries about their child's home care, such as food intake and administration of pain medication. The possibility of postoperative bleeding and exacerbation of the child's condition was also worrying for the parents. The most evident result of the study was that parents need more information before their child's operation. Preparing the child for the operation by giving him/her nutrition as long as permitted enhances postoperative recovery and improves parents' control over the ambulatory surgical experience. Nurses should take a more active part in children's perioperative fasting and preoperative preparation of children and their parents. In further research, experimental studies should be designed in order to receive more evidence-based information for clinical practice.

PMID: 18190484 [PubMed - in process]

Office Surgery Incidents: What Seven Years of Florida Data Show Us.
Coldiron BM, Healy C, Bene NI.
Dermatol Surg. 2007 Dec 20 [Epub ahead of print]

Department of Dermatology, University of Cincinnati, Cincinnati, Ohio, USA.

BACKGROUND: In the wake of increased media attention focusing on human error in medicine, numerous state medical boards and legislatures have drafted, and are continuing to draft, regulations aimed at protecting patients undergoing procedures in the office setting. These regulations will have a considerable impact on patient access to medically necessary procedures, and any regulations should be based on good data. This report summarizes 7 years of prospective data from the state of Florida, the best data available on office surgery incidents.
OBJECTIVE: The objective was to determine the nature and incidence of hospital transfers and deaths resulting from office procedures. METHODS This study is a compilation of mandatory reporting by Florida physicians to a central agency of all in-office adverse incidents resulting in death, serious injury, or hospital transfer in the State of Florida from March 2000 to March 2007. Telephone and internet follow-up was conducted to determine reporting physician board certification, hospital privileges, and office accreditation.
RESULTS: In 7 years there were 31 deaths and 143 procedure-related complications and hospital transfers. Liposuction and liposuction with abdominoplasty or another cosmetic procedure resulted in 24 complications and 8 deaths. Of the offices reporting adverse incidents, 38.5% were accredited by an independent accrediting agency, 92.5% of the physicians were board-certified, and 96.6% had hospital privileges. A total of 58% (18/31) of the deaths and 61% (87/143) of the complications were associated with nonmedically necessary (cosmetic) procedures. A total of 78% (14/18) of these deaths were in ASA Class 1 patients. Plastic surgeons were responsible for 48% of all deaths (83% of cosmetic surgery deaths) and for 52% of all hospital transfers (83% of cosmetic surgery complications and hospital transfers).
CONCLUSION: Plastic surgeons were responsible for an inordinate number of deaths and hospital transfers. Requiring physician board certification and physician hospital privileges would not seem to increase safety, because most physicians already have these credentials, and physicians without these credentials were not responsible for a disproportionate share of incidents. These data do not show an emergent hazard to patients from medically necessary office surgery. Liposuction under general anesthesia deserves continued scrutiny because deaths due to this procedure continue to occur and this procedure can be performed with dilute local anesthesia, with which no deaths were reported. Mandatory reporting of office incidents should be strongly supported, as well as reporting of incidents that occur after surgery in the hospital outpatient department and ambulatory surgery center. These data should be available for analysis after protecting patient confidentiality. A national debate needs to occur to determine how many deaths and injuries are acceptable from cosmetic procedures performed under general and intravenous anesthesia.

PMID: 18177404 [PubMed - as supplied by publisher]

The use of ambulatory patient groups for regulation of hospital ambulatory surgery revenue in Maryland.
Atkinson G, Murray R.
J Ambul Care Manage. 2008 Jan-Mar;31(1):17-23.

From the Health Services Cost Review Commission, Baltimore, MD (Mr Murray). Dr Atkinson is a consultant in Washington, DC.

The Maryland Health Services Cost Review Commission (HSCRC or the commission) is a government agency with the authority to establish rates for both inpatient and outpatient services for all general acute care hospitals in the state. By law and consistent with the state's unique Medicare waiver, all payers (including Medicare and Medicaid) must pay hospitals on the basis of these rates. The HSCRC has used diagnosis related groups to set case-mix-adjusted limits on the revenue per discharge for inpatient services (similar to Medicare inpatient prospective payment nationally) yet, the Maryland rate-setting system for outpatient services has not embodied incentives to control utilization of services. Beginning in the state's fiscal year 2008, the HSCRC is implementing regulation of ambulatory surgery services using ambulatory patient groups to provide better incentives to control utilization, and to facilitate comparisons of the case-mix-adjusted charges per ambulatory surgery case across hospitals. Maryland has been an innovator in the design and successful implementation of payment systems and other incentive mechanisms to constrain hospital cost, maintain payment equity, and ensure access to needed hospital care. The HSCRC's adoption of all patient refined diagnosis related groups and the hospital-specific relative value method for establishing diagnosis related group weights in 2005 was relevant to the Centers for Medicare and Medicaid Services' decision to move to Medicare severity diagnosis related groups beginning in federal fiscal year 2008, and to consider the use of hospital-specific relative value weights. The HSCRC's decision to use ambulatory patient groups for ambulatory surgery is an attempt to apply the most effective features of inpatient payment systems, prospective payment, including incentives to control service volumes. As such, it represents a radical departure from prevailing payment arrangements in that it seeks to remove the traditional distinction between inpatient and outpatient surgical services, a distinction that has blocked the development of effective and well-integrated outpatient payment systems for decades. This article describes the policy rationale for this system, the analysis that was performed, and the methods that will be used to control the revenue per case and compare the relative charges of the hospitals.

PMID: 18162791 [PubMed - in process]

Outpatient laparoscopic cholecystectomy: a prospective study on 250 patients.
Bona S, Monzani R, Fumagalli Romario U, Zago M, Mariani D, Rosati R.
Department of General and Minimally Invasive Surgery, Istituto Clinico Humanitas, Rozzano, Milano, Italy.
Gastroenterol Clin Biol. 2007 Nov;31(11):1010-1015.

BACKGROUND: Patient selection, postoperative monitoring and discharge criteria after outpatient laparoscopic cholecystectomy (LC) are not clearly defined.
METHODS: Patients scheduled for elective LC who fulfilled socioeconomic requirements for ambulatory surgery were enrolled in an open prospective study. Choledocholithiasis, ASA IV and unstable ASA III patients were excluded. Discharge was allowed after at least 6 hours if patients were conscious, asymptomatic, ambulant, with normal vital signs, no evidence of bleeding, spontaneous micturition and tolerating soft diet.
RESULTS: Of the 250 patients included, 10.4% were admitted due to intraoperative causes. Of the remaining, 92% were discharged on the same day and 8.0% were admitted for pain control or postoperative anxiety/discomfort. Neither mortality or major complications were observed. Ninety-five percent of patients declared themselves satisfied. History of jaundice, common bile duct dilation on ultrasound, microlithiasis, abnormal preoperative alkaline phosphatase levels and surgeon's experience were independent predictors of admission due to intraoperative causes. No predictor of postoperative admission was identified. Cost analysis showed a benefit for ambulatory LC compared to overnight stay.
CONCLUSION: Outpatient LC is feasible and safe with high patient satisfaction even with broad selection criteria. Improvements may be achieved in postoperative pain management.

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