Volume 4, Issue 2 S A M B A T A L K S - PAGE 3 July, 2004

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

Prophylaxis of Postoperative Nausea and Vomiting with Oral, Long-Acting Dimenhydrinate in Gynecologic Outpatient Laparoscopy
Kim E. Turner, MD, Joel L. Parlow, MD, Nicole D. Avery, MSc, Deborah A. Tod, RN, and Andrew G. Day, MSc
Anesth Analg 2004;98:1660-1664

Dimenhydrinate is an inexpensive antiemetic with few side effects available as an oral, long-acting (LA) formulation (Gravol L/A) containing 25 mg of immediate and 50 mg of sustained release drug. We designed this double-blind comparison trial to assess the efficacy of dimenhydrinate LA versus droperidol alone and the combination for prophylaxis of nausea, vomiting, and retching in outpatient gynecologic laparoscopy. One-hundred-forty-one women were randomized into 3 groups: 1) droperidol (placebo capsule preoperatively and IV droperidol 0.625 mg before induction), 2) dimenhydrinate LA preoperatively and IV placebo before induction, or 3) combination. Information regarding nausea, vomiting, retching, pain, and sedation was recorded in the postanesthesia care unit (PACU) and collected by telephone for the presence of symptoms: on arrival home; at bedtime; upon arising, and at lunchtime the following day. The overall incidence of complete treatment failure (rescue medication in PACU or nausea, vomiting, or retching at any time point) was 28 of 46 (61%), 28 of 48 (58%), and 22 of 47 (47%); and for treatment failure vomiting (rescue medication in PACU or vomiting or retching at any time point) was 16 of 46 (35%), 11 of 48 (23%), and 5 of 47 (11%), for the droperidol, dimenhydrinate, and combination groups, respectively (P = 0.007 for droperidol versus combination). There were no differences in sedation or pain. Preoperative administration of an oral dose of LA dimenhydrinate in combination with droperidol when compared with droperidol alone effectively reduced the incidence of vomiting but not nausea in women undergoing elective outpatient gynecologic laparoscopy.
IMPLICATIONS: Dimenhydrinate is an inexpensive antiemetic with few side effects available as a long-acting oral formulation. Women undergoing outpatient gynecologic laparoscopy were given droperidol, an effective antiemetic, dimenhydrinate alone, or the combination of the two drugs. Dimenhydrinate plus droperidol significantly reduced the overall incidence of vomiting, but not nausea, when compared with droperidol alone.

Preoperative Parenteral Parecoxib and Follow-Up Oral Valdecoxib Reduce Length of Stay and Improve Quality of Patient Recovery After Laparoscopic Cholecystectomy Surgery
Tong J. Gan, MD, Girish P. Joshi, MD, Eugene Viscusi, MD, Raymond Y. Cheung, BPharm, PhD, William Dodge, MSc, John G. Fort, MD, and Connie Chen, PharmD
Anesth Analg 2004;98:1665-1673

In this randomized, double-blinded, placebo-controlled study, we evaluated the effects of preoperative IV parecoxib sodium (parecoxib) followed by postoperative oral valdecoxib on length of stay, resource utilization, opioid-related side effects, and patient recovery after elective laparoscopic cholecystectomy. Patients were randomized to receive a single IV dose of parecoxib 40 mg (n = 134) or placebo (n = 129) 30–45 min before the induction of anesthesia. Six to 12 h after the IV dose, the parecoxib group received a single oral dose of valdecoxib 40 mg, followed by valdecoxib 40 mg once daily on postoperative Days 1–4 and then 40 mg once daily as needed on Days 5–7. Patients in the parecoxib/valdecoxib group had a shorter length of stay in the postanesthesia care unit (78 ± 47 min) compared with those taking placebo (90 ± 49 min; P < 0.05). Patients in the parecoxib/valdecoxib group also had reduced pain intensity and, after discharge, experienced a significant reduction in vomiting in the first 24 h, slept better, returned to normal activity earlier, and expressed greater satisfaction than placebo patients (P < 0.05). Preoperative parecoxib followed by postoperative valdecoxib is a valuable adjunct for treating pain and improving patient outcome after laparoscopic cholecystectomy.
IMPLICATIONS: The administration of preoperative IV parecoxib followed by oral valdecoxib after surgery resulted in a shorter length of stay in the postoperative anesthesia care unit, a better quality of postoperative recovery, and a faster return to normal activity, with greater patient satisfaction, after laparoscopic cholecystectomy.

Anterior Approach to the Sciatic Nerve Block: Adaptation to the Patient’s Height
Carole Barbero, MD, Régis Fuzier, MD, and Kamran Samii, MD
Anesth Analg 2004;98:1785-1788

To improve the incidence of block of the posterior femoral cutaneous nerve (PFCN) when using an anterior approach as described recently, we hypothesized that the distance between the inguinal line and the puncture site depends on the patient’s height. A preliminary radiological study performed in 13 patients established a formula describing the relationships between the patient’s height and the puncture site "S." A line was drawn between the anterior iliac spine and the superior angle of the pubic tubercle (inguinal line) and another line from the midpoint of the inguinal line to the puncture site "S." "S" was calculated from the midpoint of the inguinal line as "S" = (height in cm – 100)/10. A prospective study was conducted in 53 patients. Results are presented as median (range, 0.25–0.75). Two minutes were required to locate the sciatic nerve at a depth of 12 cm (10.5–13.0 cm). Complete sciatic and PFCN blocks were observed in 92% of the patients. We conclude that consideration should be given to the patient’s height when the sciatic nerve is blocked using an anterior approach. This technique seems to improve the success of block of the PFCN, essential to tolerate a thigh tourniquet.
IMPLICATIONS: This prospective but noncomparative work was performed to evaluate a new anterior technique of sciatic block, an adaptation of the anatomic landmarks described by Chelly and Delaunay, to patient height.

0.5% Versus 1.0% 2-Chloroprocaine for Intravenous Regional Anesthesia: A Prospective, Randomized, Double-Blind Trial
Stephan C. Marsch, MD, DPhil, Mathias Sluga, MD, Wolfgang Studer, MD, Jonas Barandun, MD, Domenic Scharplatz, MD, and Wolfgang Ummenhofer, MD
Anesth Analg 2004;98:1789-1793

In this randomized prospective double-blind study we tested the hypothesis that compared with 40 mL chloroprocaine 0.5%, 40 mL chloroprocaine 1% results in an earlier onset to analgesia duration and improves distal tourniquet tolerance in 150 patients undergoing forearm surgery under IV regional anesthesia using a double-cuff technique, switching from the proximal to the distal cuff was performed if pain scores increased above 4 of 10. Switching to the distal cuff resulted in pain scores below 4 in 69% of patients in the 0.5% group and in 88% of patients in the 1% group (P = 0.047). In addition, both groups differed in the sustained effect on distal tourniquet pain (P = 0.020). Time between injection and onset to analgesia duration was 13 ± 1 min in the 0.5% group and 11 ± 1 min in the 1% group (P = 0.0006). On release of the tourniquet, signs of systemic local anesthetic toxicity occurred in 6 patients of the 0.5% group and 28 of the 1% group (P < 0.0001). We conclude that chloroprocaine 1% resulted in an earlier onset of analgesia and improved distal tourniquet tolerance. However, these beneficial effects must be weighed against a fourfold increase in side effects.
IMPLICATIONS: Compared to a standard dose of 40 mL 0.5% chloroprocaine, 40 mL 1% chloroprocaine resulted in an earlier onset of analgesia duration and improved distal tourniquet tolerance during IV regional anesthesia. These beneficial effects must be weighed against a fourfold increase in signs of systemic local anesthetic toxicity.

Muscular Injury After Succinylcholine and Electroconvulsive Therapy
Thewarug Werawatganon, MD, Oranuch Kyokong, MD, MSc, Somrat Charuluxananan, MD, MSc, and Sahadol Punyatavorn, MD
Anesth Analg 2004;98:1676-1679

Both succinylcholine and seizures cause muscular injury during electroconvulsive therapy. We compared the muscular damage in two groups of patients. The psychiatric patient group received succinylcholine for electroconvulsive therapy. The surgical patient group received succinylcholine for endotracheal intubation. Serum myoglobin was measured as a marker for muscular injury and myalgic symptoms were also recorded. Serum myoglobin increased from baseline in both groups at 5 and 20 min. The surgical patients, however, had a higher myoglobin level than the psychiatric patients at 5 and 20 min after the administration of succinylcholine (P < 0.001). The median (range) of myoglobin concentration at 20 min in psychiatric patients was 32.6 (23.1–60.1) ng/mL, compared with 61.2 (31.6–1687.0) ng/mL in surgical patients. The incidence of myalgia was not different between the two groups. In conclusion, we unexpectedly conclude that the psychiatric patients who received electroconvulsive therapy had less effect of muscular damage associated with succinylcholine than the surgical patients did.
IMPLICATIONS: Both succinylcholine and electroconvulsive therapy cause muscular injury. However, we unexpectedly found that psychiatric patients who received succinylcholine and electroconvulsive therapy had less muscular damage than surgical patients who received succinylcholine for intubation. Therefore, appropriate use of succinylcholine can attenuate the muscular damaging effect from the therapy.

Moderate-to-Severe Pain After Knee Arthroscopy Is Relieved by Intraarticular Saline: A Randomized Controlled Trial
Leiv A. Rosseland, MD, Knut G. Helgesen, MD DMSc, Harald Breivik, MD DMSc FRCA, and Audun Stubhaug, MD DMSc
Anesth Analg 2004;98:1546-1551

We have previously studied intraarticular (IA) analgesics compared with saline 10 mL in 2 randomized clinical trials. The patients who were given IA saline experienced rapid pain relief. Hypothetically, saline may produce a local analgesic effect by cooling or by diluting IA algogenic substances. This randomized double-blind study compared the analgesic effect of IA saline 10 mL with saline 1 mL, which should be a pure placebo. A soft catheter was left IA in 79 patients. We included 60 patients who developed moderate-to-severe pain within 1 h after knee arthroscopy under general anesthesia. A randomized, double-blind controlled comparison of IA saline 10 mL with saline 1 mL followed. Outcome measures were pain intensity, pain relief, and analgesic consumption. Within 1 h pain intensity decreased in both groups from approximately 50 to approximately 27 on a 0–100 mm visual analog scale. Pain intensity remained low and other pain outcome measures were similar during the 36-h observation period. The patients experienced equally good pain relief after IA injection of saline 10 mL and 1 mL. Our finding of a major placebo effect may have implications for the interpretation of previously published placebo-controlled IA analgesia studies.
IMPLICATIONS: In a randomized controlled trial we showed that pain after knee arthroscopy is modest and short-lived and can successfully be treated with intraarticular saline as placebo.

ANESTHESIOLOGY - TOP

Parental Auricular Acupuncture as an Adjunct for Parental Presence during Induction of Anesthesia
Wang, Shu-Ming M.D.; Maranets, Inna M.D. ; Weinberg, Megan E. M.A. ; Caldwell-Andrews, Alison A. Ph.D. [S]; Kain, Zeev N. M.D.
Anesthesiology. 100(6):1399-1404, June 2004

Background: The purpose of this study was to determine whether parental auricular acupuncture reduces parental preoperative anxiety and thus allows children to benefit from parental presence during induction of anesthesia.
Methods: Mothers of children who were scheduled to undergo surgery were randomly assigned to an acupuncture intervention group (auricular press needles at relaxation, tranquilizer point, and master cerebral point) or a sham acupuncture control group (auricular press needles at the shoulder, wrist, and extraneous auricular point). The intervention was performed at least 30 min before the child's induction of anesthesia. All mothers were present during induction of anesthesia. The behavioral and physiologic anxiety of mothers and children were rated during the perioperative process.
Results: Multivariable analysis examining maternal anxiety as a function of group found a group-by-time interaction (F1,65 = 4.1, P = 0.04). That is, after induction, maternal anxiety in the acupuncture group was significantly lower (42.9 +/- 10 vs. 49.5 +/- 11; P = 0.014). A multivariate model (F1,65 = 4.8, P =0.031) also showed that children whose mothers received the acupuncture intervention were significantly less anxious on entrance to the operating room (34.9 +/- 20 vs. 47.4 +/- 26; P = 0.03) and during introduction of the anesthesia mask (38.6 +/- 25 vs. 55.6 +/- 31; P = 0.016). There were no significant differences in maternal blood pressure and heart rate between the two groups.
Conclusions: Auricular acupuncture significantly decreased maternal anxiety during the preoperative period. Children of mothers who underwent acupuncture intervention benefitted from the reduction of maternal anxiety during the induction of anesthesia.

Electrical Nerve Localization: Effects of Cutaneous Electrode Placement and Duration of the Stimulus on Motor Response.
Hadzic, Admir M.D., Ph.D. ; Vloka, Jerry D. M.D., Ph.D. ; Claudio, Richard E. B.S. ; Hadzic, Nihad M.C.E. ; Thys, Daniel M. M.D. ; Santos, Alan C. M.D., M.P.H.
Anesthesiology. 100(6):1526-1530, June 2004.

Background: Recommendations regarding the technical aspects of nerve stimulator-assisted nerve localization are conflicting. The objectives of this study were to determine whether the placement of the cutaneous electrode affects nerve stimulation and to determine the duration and intensity of an electrical stimulus that allows nerve stimulation with minimal discomfort.
Methods: Ten healthy volunteers underwent an interscalene and a femoral nerve block. After obtaining a clearly visible motor response of the biceps (interscalene) and quadriceps (femoral) muscles at the minimal current (0.1 ms, 2 Hz), the position of the cutaneous electrode was varied. Next, the duration of the stimulating current was set at 0.05, 0.1, 0.3, 0.5, or 1.0 ms, in random order. Intensity of the motor response and discomfort on stimulation were recorded.
Results: The minimal current at which a visible motor response was obtained was 0.32 +/- 0.1 mA (0.23-0.38 mA) for the inter-scalene block and 0.29 +/- 0.1 mA (0.15-0.4 mA) for the femoral block. Changing the position of the return electrodes did not result in any change in the grade of the motor response or in the current required to maintain it. Currents of longer duration caused discomfort and more forceful contraction at a lower current intensity as compared with currents of shorter duration (P < 0.01). When the current was adjusted to maintain the same visible motor response, there was no significant discomfort among studied current durations.
Conclusion: Site of placement of the cutaneous electrode is not important when constant current nerve stimulators are used during nerve localization in regional anesthesia. There is an inverse relation between the current required to obtain a visible motor response and current duration. Selecting a current duration between 0.05 and 1.0 ms to specifically stimulate sensory or motor components of a mixed nerve does not seem to be important in clinical practice.

Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management.
Anesthesiology. 100(6):1573-1581, June 2004

The American Society of Anesthesiologists Task Force on Acute Pain Management presents an updated set of recommendations based on the analysis of the current literature and a synthesis of expert opinion.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Ketamine does not decrease postoperative pain after remifentanil-based anaesthesia for tonsillectomy in adults
A. C. Van Elstraete, T. Lebrun, I. Sandefo and B. Polin
Acta Anaesthesiologica Scandinavica 2004; 48(6); 756 - 760

Background:  There are conflicting results concerning the pre-emptive effect of ketamine on central sensitization following surgery. The aim of this prospective, randomized, double-blind, placebo-controlled study was to assess the effect of the N-methyl-D-aspartate receptor antagonist ketamine on postoperative morphine consumption and pain score after remifentanil-based anaesthesia in adult patients scheduled for tonsillectomy.
Methods: We studied 40 adult patients undergoing elective tonsillectomy. Total intravenous anaesthesia was induced and maintained with remifentanil (0.125-1.0 µg kg^-1 min^-1) and propofol target-controlled infusion. Patients in group K received a bolus dose of ketamine 0.5 mg kg^-1 immediately after anaesthetic induction, followed by a continuous infusion of 2 µg kg^-1 min^-1. Saline was administered in the same sequence in group S. Propofol, remifentanil, and the study drug infusions were discontinued at the end of surgery.
Results: Intraoperative remifentanil consumption (0.57 ± 0.18 in group K vs. 0.55 ± 0.14 µg kg^-1 min^-1 in group S), morphine requirement in the PACU (11 ± 3 in group K vs. 9 ± 4 mg in group S) and in the ward (22 ± 11 in group K vs. 25 ± 14 mg in group S), median time to first analgesia in the ward (338 ± 126 in group K vs. 328 ± 144 min in group S), and VAS pain scores were comparable in both groups.
Conclusion: Small-dose of ketamine does not seem to be a useful adjunct to remifentanil-based anaesthesia during short, painful surgical procedures.

Disturbing post-operative symptoms are not reduced by prophylactic antiemetic treatment in patients at high risk of post-operative nausea and vomiting
A. Alkaissi, H. Gunnarsson, V. Johnsson, K. Evertsson, L. Ofenbartl and S. Kalman
Acta Anaesthesiologica Scandinavica 2004; 48(6); 761-771

Background:  To give prophylactics or timely treatment for post-operative nausea and vomiting (PONV) is the question. We compared the intensity and number of disturbing post-operative symptoms (i.e. pain, PONV, headache, fatigue, etc.) after prophylactic antiemetic treatment in a group of patients with >30% risk for post-operative vomiting.
Methods:  Four hundred and ninety-five patients, from three hospitals, planned for gynaecological surgery were randomized double blind. They were given granisetron 3 mg, droperidol 1.25 mg or no prophylactic antiemetic. Post-operative symptoms were followed for 24 h using a questionnaire. Symptoms were analyzed both according to their intensity and in a dichotomous fashion.
Results:  The intensity of different symptoms differed depending on whether droperidol, granisetron or no antiemetic had been given (P = 0.005) but the overall incidence of moderate to very severe symptoms was similar in all groups. No group fared better in general. The total number of symptoms was higher in the groups given prophylactic treatment (P < 0.05). The relative risk reduction for PONV with granisetron or droperidol prophylaxis was 27% [95% confidence interval (CI) 8-43] and 22% (2-38), respectively. The NNT (number needed to treat) for granisetron (0-24 h) was 7 and for droperidol 8. The NNH (number needed to harm) (0-24 h) for headache and visual disturbances was 6 and 13 (NS) for granisteron and 50 (NS) and 6 for droperidol.
Conclusion:  The intensity of symptoms or the total number of disturbing symptoms did not decrease after prophylactic antiemetic treatment in a group of patients, but the profile of disturbing symptoms changed. The relevance of post-operative symptoms in terms of patients' well-being needs to be addressed

The effects of etomidate, thiopental, and propofol in induction on hypoperfusion-reperfusion phenomenon during laparoscopic cholecystectomy
H. Yagmurdur, T. Cakan, A. Bayrak, M. Arslan, B. Baltaci, N. Inan and K. Kilinc
Acta Anaesthesiologica Scandinavica 2004; 48(6); 772 - 777

Background:  A hypoperfusion-reperfusion human model is observed during and soon after laparoscopic surgery. The aim of the study was to research the preventive effects of etomidate, thiopental, and propofol in induction on hypoperfusion- reperfusion phenomenon during laparoscopic cholecystectomy.
Methods:  Thirty-six consecutive ASA I-II patients were randomized into three groups of 12 patients each. Anaesthesia was induced with etomidate in group 1, thiopental in group 2, and propofol in group 3. Venous blood samples were obtained at different time points for measurement of plasma malondialdehyde (MDA) levels. Arterial blood and gastric juice samples were obtained for the calculation of gastric intramucosal pH (pHi). Also changes in aminotransferases, alkaline phosphatase and total bilirubin levels were assessed.
Results:  There was a significant decrease in pHi at 1 min before desufflation (BD) and 20 min after desufflation (AD) compared with before insufflation (BI) in all groups. Plasma level of MDA was significantly increased in group 1 at 1 min BD and 20 min AD compared with before induction of anaesthesia (baseline). Malondialdehyde levels were decreased significantly in group 3 and increased non-significantly in group 2 at the same time points. Also AST and ALT levels were significantly increased in both groups 1 and 2 at 24 h postoperatively.
Conclusion:  Propofol with antioxidant activity may offer many advantages by scavenging reactive oxygen species and their metabolites in case of anticipated hypoperfusion-reperfusion phenomenon, such as would occur in laparoscopic surgery.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Early analgesic effects of parecoxib versus ketorolac following laparoscopic sterilization: a randomized controlled trial
A. Ng, A. Temple, G. Smith and J. Emembolu
Br J Anaesth 2004; 92: 846–9

 Background. The aim of this prospective double blind randomized controlled trial was to compare the effects of ketorolac and parecoxib on early postoperative pain.
Method. We studied 36 ASA I/II patients who received a standardized general anaesthetic for laparoscopic sterilization. Patients were allocated randomly to receive either parecoxib 40 mg i.v. or ketorolac 30 mg i.v., at induction. After surgery, patients were assessed on awakening and then at 1, 2, and 3 h. Abdominal pain at rest and on inspiration, in addition to nausea and sedation were assessed on a 100 mm visual analogue scale.
Results. Of 36 patients, one was excluded from analysis. In the remaining patients, pain scores at rest and on inspiration were significantly lower in patients given ketorolac compared with those given parecoxib. This difference was attributable to the higher pain scores on awakening and at 1 h postoperatively in the parecoxib group compared with the ketorolac group. Despite this initial difference, there was no significant difference between the two groups in the number of patients receiving rescue analgesia. The median (interquartile range) time to consumption of rescue cocodamol of 60 (46–74) min in the parecoxib group was not significantly shorter than that of 100 (70–130) min in the ketorolac group. The amount of cyclizine given, nausea and sedation did not differ significantly between the groups.
Conclusion. We found that parecoxib 40 mg i.v. given at induction of anaesthesia was less effective than or ketorolac 30 mg i.v., in the first hour after laparoscopic sterilization.

Drug patient information leaflets in anaesthesia: effect on anxiety and patient satisfaction
M. Oldman, D. Moore and S. Collins
Br J Anaesth 2004; 92: 854–8

Background. Patient information leaflets are produced for all new drugs, including anaesthetic drugs that are licensed solely for physician administration. The effect of this information on patients’ satisfaction and anxiety has not been investigated previously.
Methods. Eighty-five patients were allocated randomly to receive a standard information leaflet about anaesthesia (Group 1) or the standard leaflet plus the manufacturers’ patient information leaflets for propofol and remifentanil (Group 2). Anxiety was assessed using the state trait anxiety index (STAI) and a visual analogue scale (VAS) for anxiety before and after this information had been read. Patients’ attitudes to this information were assessed by a short questionnaire.
Results. There was no significant difference in STAI or VAS scores for anxiety between the two groups before or after the information leaflets. Significantly more patients who received drug patient information leaflets felt that they had received too much information (0% Group 1 vs 18% Group 2, P=0.003). More than 64% of patients in both groups said that they would not wish to receive detailed anaesthetic drug information. There was a correlation between the STAI and the VAS scores for anxiety (R=0.8).
Conclusions. A minority of patients (up to 36%) wish to receive detailed anaesthetic drug information before anaesthesia. Manufacturers’ drug patient information leaflets do not alter preoperative anxiety and may be safely issued to patients requesting such information.

Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions
T. Asai and K. Shingu
Br J Anaesth 2004; 92: 870–81

No abstract available.

 

CANADIAN JOURNAL OF ANESTHESIA - TOP

Sedation after spinal anesthesia in elderly patients: a preliminary observational study with the PSA-4000
Viji Kurup , MD, Ramachandran Ramani, MD and Peter G. Atanassoff, MD
Canadian Journal of Anesthesia 51:562-565 (2004)

Purpose: Neuraxial blockade is known to have a sedative effect, decreasing the need for inhalational and iv anesthetic agents. The purpose of the present study was to quantify the sedative effect of spinal anesthesia and to determine the time of maximum sedation.
Methods: This is an observational study in which 20 unsedated patients were scheduled to undergo urologic and orthopedic surgeries under spinal anesthesia. Patients with pre-existing neurological conditions or receiving psychotropic medications were excluded from the study. All received 1.5 mL (11.25 mg) of hyperbaric bupivacaine 0.75% intrathecally. No sedative or narcotic was administered intravenously or intrathecally. The Patient State Analyzer, (PSA-4000) was used to monitor sedation along with Observer’s Assessment of Alertness and Sedation (OAA/S) scores every five minutes. Differences in patient state index (PSI) and OAA/S scores are expressed as median and range and were evaluated by Wilcoxon’s signed rank test for non-parametric data; P < 0.05 was considered significant. PSI, OAA/S and time at lowest score are expressed as median (range).
Results: PSI scores decreased from baseline 99 (96–99) to 78 (56–87) at 35 (14.5–54) min into the spinal anesthetic (P < 0.05). OAA/S scores decreased from baseline 5 to 4 (range 3–5) at the time of the lowest PSI scores (P < 0.05).
Conclusions: In this elderly patient population, spinal anesthesia induced changes in the processed electroencephalogram with reduction in PSI and OAA/S scores. The reduction in afferent input to the reticular activating system could possibly explain the sedation that has been observed and the reduction in the PSA scores.

PUB MED - TOP

Comparison of ropivacaine with bupivacaine and lidocaine for ilioinguinal block after ambulatory inguinal hernia repair in children.
Tsuchiya N, Ichizawa M, Yoshikawa Y, Shinomura T.
Paediatr Anaesth. 2004 Jun;14(6):468-70

Summary Background : We have compared ropivacaine with bupivacaine and lidocaine for ilioinguinal block in thirty children undergoing ambulatory inguinal hernia repair.
Methods : Patients were assigned randomly to receive 0.5 ml.kg^-1 of 0.2% ropivacaine (Group R, n = 10), 0.25% bupivacaine (Group B, n = 10) or 1% lidocaine (Group L, n = 10). The patients' parents, who were not informed of the type of local anaesthetic employed, evaluated the postoperative pain at 2 h and 6 h after operation using the Wong-Baker FACES Pain Rating Scale.
Results : There was a significant difference in the face scale score between Group R and Group L, and Group B and Group L. There was no difference in the face scale score between Group R and Group B. There were no complications or clinical evidence of local anaesthetic toxicity.
Conclusions : We have confirmed that bupivacaine and ropivacaine are more effective than lidocaine in the prevention of postoperative pain after children's inguinal hernia repair. We suggest that ropivacaine 0.2% is an alternative to bupivacaine 0.25% for ilioinguinal block in ambulatory paediatric surgery.  

Analgesic effect of clonidine added to bupivacaine 0.125% in paediatric caudal blockade.
Joshi W, Connelly NR, Freeman K, Reuben SS.
Paediatr Anaesth. 2004 Jun;14(6):483-6

Summary Background : Caudals are a common method of providing pain relief in children undergoing surgery. Clonidine, an alpha₂ agonist, exhibits significant analgesic properties. The current investigation sought to determine whether caudal clonidine added to caudal bupivacaine would decrease pain in paediatric patients undergoing surgery.
Methods : Thirty-six children undergoing elective surgery were studied. Following anaesthetic induction, a caudal was placed (1 mg.kg^-1 bupivacaine 0.125%) with an equal volume of either clonidine (2 microg.kg^-1) or saline. Perioperative analgesic requirements in the postanaesthesia care unit (PACU) and at home following hospital discharge, and parental pain scores were evaluated.
Results : There were no significant demographic, haemodynamic, or pain score differences between the groups. There was no difference in analgesic duration between groups. There were significantly more children who vomited during the first 24 postoperative hours in the clonidine group than in the saline group (eight in clonidine, two in saline; P < 0.05).
Conclusion : We do not recommend adding clonidine (2 microg.kg^-1) to a bupivacaine (0.125%) caudal block in children undergoing surgery.

Oral ketamine premedication can prevent emergence agitation in children after desflurane anaesthesia.
Kararmaz A, Kaya S, Turhanoglu S, Ozyilmaz MA.
Paediatr Anaesth. 2004 Jun;14(6):477-82

Summary Background : The purpose of the present study was to determine whether oral ketamine premedication affected the incidence of emergence agitation in children.
Methods : Thirty minutes before induction of anaesthesia, 80 children who were undergoing adenotonsillectomy with or without bilateral myringotomy and insertion of tubes received either ketamine 6 mg.kg^-1 per oral in group K or sour cherry juice alone in group C. Anaesthesia was maintained with desflurane. Emergence and recovery times were recorded. Tramadol was used for postoperative analgesia. Fentanyl (1 microg.kg^-1) was administered for the treatment of emergence agitation or severe pain that still continued after tramadol administration. Postoperative behaviour was evaluated using a 5-point agitation scale.
Results : The incidence of emergence agitation was 56% in group C, and 18% in group K (P = 0.001). There was no significant difference with respect to emergence times except from time to eye opening that was significantly longer in group K (P < 0.0001).
Conclusion : Oral ketamine premedication reduced the incidence of postanaesthesia emergence agitation in children without delaying recovery.

Systematic review of the analgesic efficacy and tolerability of COX-2 inhibitors in post-operative pain control.
Chen LC, Elliott RA, Ashcroft DM
J Clin Pharm Ther. 2004 Jun;29(3):215-29

Summary Objective: To evaluate the relative analgesic efficacy and tolerability of single-dose COX-2 inhibitors in post-operative pain management.
Method: Systematic review of randomized controlled trials (RCTs). Outcome measures: The area under the pain relief vs. time curve was used to evaluate the proportion of patient achieving at least 50% pain relief using validated equations. The proportions of patients experiencing any adverse event or specific adverse events were also examined.
Results: In all, 18 RCTs were included which contained 2783 patients. The results of the effects of single-dose analgesics on the basis of 50% of patients achieving pain relief over 6 h from dental pain models suggested that oral rofecoxib 50 mg was more effective than codeine/paracetamol 60/600 mg, and the rate ratio (RR) was 2.11 (95% CI 1.6-2.75). Valdecoxib 40 mg was also more effective than oxycodone/paracetamol 10/1000 mg (RR 1.34; 95% CI 1.11-1.62). There was no significant differences between other oral COX-2 inhibitors and non-selective non-steroidal anti-inflammatory drugs (NSAIDs), except that celecoxib 200 mg was less effective than ibuprofen 400 mg (RR 0.66; 95% CI 0.48-0.90) and rofecoxib 50 mg (RR 0.65; 95% CI 0.49-0.87). The results from orthopaedic pain model showed no significant difference between rofecoxib 50 mg and naproxen sodium 550 mg (RR 1.04; 95% CI 0.73-1.49). The adverse effects of single-dose COX-2 inhibitor used in short-term post-operative pain management were generally mild and less than non-selective NSAIDs, although there was no significant difference.
Conclusions: The analgesic efficacy and tolerability of single-dose COX-2 inhibitors were more effective than opioid-containing analgesics and similar to non-selective NSAIDs in post-operative pain management. Further studies are needed to examine the efficacy and tolerability of COX-2 inhibitors compared against active comparators over a longer duration to assess whether these short-term effects are mirrored by longer-term outcomes and to determine their ultimate risk-benefit profile.

Effect of topical bupivacaine on postoperative pain after laparoscopic tubal sterilization with Filshie clips.
Brennan MC, Ogburn T, Hernandez CJ, Qualls C.
Am J Obstet Gynecol. 2004 May;190(5):1411-3

OBJECTIVE: The purpose of this study was to evaluate postoperative pain after the administration of topical bupivacaine during laparoscopic sterilization with Filshie clips.
STUDY DESIGN : Sixty-three women who underwent laparoscopic tubal sterilization with Filshie clips were assigned randomly to receive topical bupivacaine or placebo. Presence of pain, pain intensity, nausea, vomiting, timing of request for pain medication, and pain medication requirements were assessed postoperatively.
RESULTS: Patient demographics were similar between the 2 groups. Topical bupivacaine decreased the incidence (P=.005) and intensity (P=.028) of postoperative pain at 30 minutes. No differences in incidence or severity of pain were seen at hospital discharge or on postoperative day 1.
CONCLUSION: Topical bupivacaine that is applied to the fallopian tubes at the time of laparoscopic tubal sterilization with the Filshie clip decreases immediate postoperative pain.  

Perioperative treatment of patients with diabetes having eye surgery with local anesthesia in an ambulatory facility.
Kollarits CR, Kendrick RM, Guess M.
Ophthalmic Surg Lasers Imaging. 2004 May-Jun;35(3):185-8

BACKGROUND AND OBJECTIVE: To evaluate the incidence of hyperglycemia and hypoglycemia in diabetic patients on the morning of eye surgery scheduled under local anesthesia in an ambulatory surgery facility.
PATIENTS AND METHODS: A retrospective analysis of fasting blood glucose levels in 216 diabetic patients on 326 admissions.
RESULTS: The fasting blood glucose level was 80 mg/dL or lower in 10 patient admissions (3%). Hyperglycemia (fasting blood glucose level of greater than 300 mg/dL) was present on 8 admissions (2.4%).
CONCLUSIONS: Blood glucose levels need to be monitored in diabetic patients undergoing even short surgical procedures. The dosage of long-acting insulins or oral hypoglycemics given the night prior to surgery may have to be reduced to prevent hypoglycemia on the morning of surgery.

The efficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery.
Dal, D., O. Tetik, et al.
Arthroscopy 2004; 20(3): 300-5

PURPOSE: The purpose of this study was to compare the postoperative analgesic effects of intra-articularly administered ketamine, neostigmine, and bupivacaine after outpatient arthroscopic surgery.
TYPE OF STUDY : Prospective, randomized, double-blind, clinical study.
METHODS: In this study, 60 patients undergoing arthroscopic surgery other than ligament reconstruction were evaluated for postoperative pain. Ketamine, neostigmine, and bupivacaine were administered intra-articularly. The period of effective analgesia, recorded in minutes, was measured between time 0 and first usage of patient-controlled anesthesia (PCA) by the patients. The visual analog scale (VAS) was used to describe the pain level of the patient.
RESULTS: VAS values were lower for the 3 medication groups compared with the placebo at rest and 90 degrees knee flexion. Intra-articular administration of 0.5 mg/kg ketamine provided longer duration of analgesia as defined by the first PCA use time (P <.05). The total amount of pethidine and analgesia time were longer for the 3 medication groups.
CONCLUSIONS: Our basic finding was reduction in postoperative pain and consumption of adequate analgesic drugs with intra-articular ketamine, bupivacaine, or neostigmine use. We have not seen any psychomimetic side effects, particularly as seen with higher doses or systemic use. This study may conclude that intra-articular administration of ketamine provides long-lasting and effective analgesia, similar to neostigmine but less effective than bupivacaine after knee arthroscopy without any adverse effects.

Effects of droperidol dosage on postoperative emetic symptoms following pediatric strabismus surgery
Stead, S. W., C. D. Beatie, et al.
J Clin Anesth 2004; 16(1): 34-9

STUDY OBJECTIVE: To compare the frequency of postoperative emetic symptoms and side effects in pediatric strabismus surgery using four doses of droperidol.
DESIGN: Randomized, blinded study.
SETTING: University eye institute.
PATIENTS: 82 ASA physical status I and II pediatric patients, aged 1 to 16 years, undergoing outpatient strabismus surgery.
INTERVENTIONS: Patients were assigned to one of four doses of droperidol (10, 20, 40, or 80 microg.kg^-1) (Groups 1, 2, 3, and 4, respectively). All patients received the same anesthetic management, with droperidol administered intravenously immediately after induction of anesthesia.
MEASUREMENTS AND MAIN RESULTS : Postoperatively, patients were evaluated for emetic symptoms (nausea, retching, and/or vomiting) and side effects (postoperative sedation or extrapyramidal symptoms). There was a dose-dependent reduction of emetic symptoms seen with increasing droperidol dose. Predischarge emetic symptoms were 50%, 15%, 15%, and 5% in Groups 1, 2, 3, and 4, respectively (p < 0.009). Peak emetic symptoms were observed after discharge: 75%, 40%, 35%, and 15% in Groups 1, 2, 3, and 4, respectively (p < 0.003). Convalescence times, including awakening, extubation, recovery, and hospitalization, were unaffected by increasing droperidol dose. Sedation was similar in all groups and no patient exhibited any side effects. However, when patients exhibited emetic symptoms, discharge time increased from 207 +/- 57 minutes to 283 +/- 128 minutes (p < 0.001).
CONCLUSIONS: Prophylactic administration of droperidol 80 microg.kg^-1 is most effective in reducing postoperative emetic symptoms without increasing time to discharge. In those patients with emetic symptoms who also received prophylactic droperidol, time to discharge was significantly delayed.

Nitrous oxide analgesia for minor pediatric surgical procedures: an effective alternative to conscious sedation?
Burnweit, C., J. A. Diana-Zerpa, et al.
J Pediatr Surg 39(3): 495-9

BACKGROUND/PURPOSE: Minor surgical procedures in children, while usually not requiring general anesthesia, need effective control of pain, anxiety, and motion. Certain techniques of conscious sedation may result in loss of protective airway reflexes. Nitrous oxide, however, when inhaled at levels below 50% maintains protective reflexes and does not require fasting or postprocedure monitoring. This study prospectively examines the efficacy of nitrous oxide analgesia in children undergoing outpatient surgical procedures.
METHODS: Over a 2-year period (2000 to 2002), 150 consecutive children were given nitrous oxide analgesia as an alternative to a general anesthetic, sedation, or local anesthetic alone. Nitrous oxide (<50%) was administered by our practice's sedation-certified nurse practitioner without an anesthesiologist present. The children used the Wong-Baker Faces Scale (0-5) to score pain at different intervals (preprocedure, at injection, during procedure, and postprocedure) and event memories were tabulated.
RESULTS: Of 150 children, 5 were uncooperative and could not participate. One hundred forty-five children, ages 1 to 20 years (Mean, 9.83 +/- 4.92 years) successfully underwent procedures (58 cyst/nevus excisions, 49 abscess drainages, 38 other) using nitrous. Two patients were too young to score pain. Pre- and postprocedure pain scores were significantly higher in the abscess group (P <.0001); during the procedures, however, all groups reported pain scores less than 1, with parents citing 100% satisfaction with the technique. Of 128 children receiving local anesthesia, 107 (84%) had no recall of the injection. Complications were limited to 4 patients; 2 experienced nausea, and 2 vomited. All resolved without interrupting the procedure.
CONCLUSIONS: Nitrous oxide analgesia is a cost-effective and efficacious alternative to conscious sedation or general anesthesia for minor pediatric surgical procedures. In the office or outpatient setting, the technique provides for almost pain/anxiety-free surgery, no postoperative monitoring, and a high degree of satisfaction for patients, parents, and staff.

Assessment of risk factors for emergence distress and postoperative behavioural changes in children following general anaesthesia
Tripi, P. A., T. M. Palermo, et al.
Paediatr Anaesth 2004; 14(3): 235-40

BACKGROUND: Emergence distress commonly occurs in children recovering from the immediate effects of general anaesthesia. This study was performed to (1) examine whether parental presence in the operating room during emergence from anaesthesia reduces the incidence or severity of emergence distress behaviour, and (2) assess psychosocial risk factors, including child temperament and sleep behaviour, for development of emergence distress.
METHODS : A randomized and controlled trial of parental presence at emergence was conducted in 100 ASA class I and II children having general anaesthesia for inguinal or penile surgery. Children in the study group had a parent present at induction and emergence of anaesthesia, while children in the control group had a parent present only at induction. Emergence and postanaesthesia care unit (PACU) behaviour was monitored using both the Operating Room Behaviour Rating Scale (ORBRS) and a 7-point Likert type cooperation scale.
RESULTS: One-way ANOVA showed no significant differences between the control group and the study group on emergence distress behaviour. The frequency of negative postoperative behavioural changes at 1 and 4 weeks postsurgery was low in both groups. Children described as clingy/dependent (chi² = 5.57, P < 0.06) and children with frequent temper tantrums (chi² = 7.44, P < 0.02) were more likely to have emergence distress behaviour.
CONCLUSIONS: Parental presence during emergence from anesthesia did not decrease the incidence or severity of emergence distress behaviour in children. Young children and children with a history of temper tantrums or separation anxiety may be more likely to develop such behaviour.

A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting  (ACCOMPANIED BY EDITORIAL SHOWN BELOW)
Christian C. Apfel, M.D., Kari Korttila, F.R.C.A., Ph.D., Mona Abdalla, Ph.D., Heinz Kerger, M.D., Alparslan Turan, M.D., Ina Vedder, M.D., Carmen Zernak, M.D., Klaus Danner, M.D., Ritva Jokela, M.D., Ph.D., Stuart J. Pocock, Ph.D., Stefan Trenkler, M.D., Markus Kredel, M.D., Andreas Biedler, M.D., Daniel I. Sessler, M.D., Norbert Roewer, M.D., for the IMPACT Investigators
NEJM 2004; 350 (24): 2441-2451

Background : Untreated, one third of patients who undergo surgery will have postoperative nausea and vomiting. Although many trials have been conducted, the relative benefits of prophylactic antiemetic interventions given alone or in combination remain unknown.
Methods: We enrolled 5199 patients at high risk for postoperative nausea and vomiting in a randomized, controlled trial of factorial design that was powered to evaluate interactions among as many as three antiemetic interventions. Of these patients, 4123 were randomly assigned to 1 of 64 possible combinations of six prophylactic interventions: 4 mg of ondansetron or no ondansetron; 4 mg of dexamethasone or no dexamethasone; 1.25 mg of droperidol or no droperidol; propofol or a volatile anesthetic; nitrogen or nitrous oxide; and remifentanil or fentanyl. The remaining patients were randomly assigned with respect to the first four interventions. The primary outcome was nausea and vomiting within 24 hours after surgery, which was evaluated blindly.
Results : Ondansetron, dexamethasone, and droperidol each reduced the risk of postoperative nausea and vomiting by about 26 percent. Propofol reduced the risk by 19 percent, and nitrogen by 12 percent; the risk reduction with both of these agents (i.e., total intravenous anesthesia) was thus similar to that observed with each of the antiemetics. All the interventions acted independently of one another and independently of the patients' baseline risk. Consequently, the relative risks associated with the combined interventions could be estimated by multiplying the relative risks associated with each intervention. Absolute risk reduction, though, was a critical function of patients' baseline risk.
Conclusions : Because antiemetic interventions are similarly effective and act independently, the safest or least expensive should be used first. Prophylaxis is rarely warranted in low-risk patients, moderate-risk patients may benefit from a single intervention, and multiple interventions should be reserved for high-risk patients.

Prevention of Postoperative Nausea and Vomiting &#8212; A Multimodal Solution to a Persistent Problem (EDITORIAL)
Paul F. White, Ph.D., M.D.
NEJM 2004; 350 (24): 2511-2512

No abstract available.

Ambulatory surgery centers--current legal issues 2004 (Part 2).
Becker S, Szabad M, Foltushansky S
Health Care Law Mon 2004 May;:3-10

This article covers several of the emerging issues related to ASCs, the anti-kickback statute and safe harbors, other regulations and relevant court decisions. The ASC Safe Harbors raise several concerns either because they are vague, silent, or provide little guidance as to their requirements. Perhaps the most challenging question under the ASC safe harbor relates to the handling of physicians who do not comply with the various safe harbor tests. As discussed, an ASC should address early on whether physicians who fail to meet or comply with the safe harbor will be redeemed from the venture. In redeeming such physicians, it is important to consider whether the company's operating agreement or shareholder agreement provides for redemption upon such event and whether the redemption will lead to litigation or compliance risks. Along the same lines, since it is illegal to provide any form of value in exchange for referrals under the anti-kickback statute, share sales at below fair market value may be viewed as an illegal kickback in exchange for referrals. Thus, in terms of adding physician owners, a number of guidelines should be followed. An ASC should also carefully consider situations in which it waives or discounts co-payments or deductibles. The safest course for a provider remains to collect the entire co-payment and deductible amounts from patients. Moreover, in the case of Medicare and Medicaid patients, an ASC should never waive or discount co-payments and deductibles unless the patient demonstrates financial hardship. Either way, such a waiver or discount should only be in accord with an applicable charity care or discount policy. A new issue involving the anti-kickback statue, state and federal self referral laws, and Medicare regulations, has gained attention as ASCs are increasingly finding themselves approached by third party vendors to enter into an arrangement, where the vendor owns the equipment and bills a third-party payor for the technical component of the procedure performed with the equipment, and the vendor then pays the ASC a fee for its lease of ASC space to house the equipment. These types of relationships can raise several legal compliance concerns. An ASC should understand that the arrangement could jeopardize its state ASC license and its Medicare certification even though the arrangement does not involve Medicare certified procedures or Medicare patients. Furthermore, this type of business venture might not comply with state and federal self referral laws. ASCs are also increasingly facing situations where a provider performs a procedure for which there is no facility charge for the ASC, but the physician is receiving a professional fee from Medicare. In this situation, ASCs should implement a policy, similar to the example provided in this article, to avoid even the appearance of providing an inducement or reward for referrals of Medicare or Medicaid business by requiring physicians to pay the Center a fee, consistent with fair market value, for the use of the Center for non-Covered Procedures or for performing multiple procedures within the same operative session. Lastly, as touched upon by this article, in the joint venture context, ASCs must take into account several guidelines in order to steer clear from risks associated with tax-exempt entities as an investor and antitrust price fixing issues. Whether a joint venture, of which a tax exempt entity is an investor, is deemed organized and operated in furtherance of the charitable purposes of a tax-exempt partner as set forth in Section 501(c)(3) of the Code depends on the facts and circumstances of each case. Generally, a joint venture will satisfy the guidelines if the tax-exempt investor in the joint venture retains sufficient control over the joint venture to ensure that the joint venture furthers the charitable purposes of the tax-exempt investor and adequately serves the community. In the ASC physician hospital joint venture arena, the principal antitrust concern relates to potential claims of price fixing. Where a hospital is a partner in a joint venture, the hospital and joint venture must take action to assure that the pricing and negotiations of the hospital and the ASC are handled separately. In all of these situations, ASCs and their investors must pay close attention and stay current of the safe harbor concepts, as well as the other regulations, guidelines, and court decisions discussed in this article in order to avoid potential regulatory and litigation risks.

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