Volume 4, Issue 10 S A M B A T A L K S - PAGE 3 March, 2005

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

Optimal Timing of Acustimulation for Antiemetic Prophylaxis as an Adjunct to Ondansetron in Patients Undergoing Plastic Surgery
Paul F. White, MD, PhD, Mohamed A. Hamza, MD, Alejandro Recart, MD, Jayne E. Coleman, MD, Amy R. Macaluso, MD, Lyndsey Cox, MS, Omar Jaffer, MS, Dajun Song, MD, PhD, and Rod Rohrich, MD
Anesth Analg 2005;100:367-372

We designed this study to evaluate the antiemetic efficacy of transcutaneous electrical acupoint stimulation in combination with ondansetron when applied before, after, or both before and after plastic surgery. A randomized, double-blind, sham-controlled study design was used to compare three prophylactic acustimulation treatment schedules: preoperative—an active device was applied for 30 min before and a sham device for 72 h after surgery; postoperative—a sham device was applied for 30 min before and an active device for 72 h after surgery; and perioperative—an active device was applied for 30 min before and 72 h after surgery (n = 35 per group). All patients received a standardized general anesthetic, and ondansetron 4 mg IV was administered at the end of surgery. The incidence of vomiting/retching and the need for rescue antiemetics were determined at specific time intervals for up to 72 h after surgery. Nausea scores were recorded with an 11-point verbal rating scale. Other outcome variables assessed included discharge times (for outpatients), resumption of normal activities of daily living, complete antiemetic response rate, and patient satisfaction with antiemetic therapy and quality of recovery. Perioperative use of the ReliefBand^® significantly increased complete responses (68%) compared with use of the device before surgery only (43%). Median postoperative nausea scores were significantly reduced in the peri- and postoperative (versus preoperative) treatment groups. Finally, patient satisfaction with the quality of recovery (83 ± 16 and 85 ± 13 vs 72 ± 18) and antiemetic management (96 ± 9 and 94 ± 10 vs 86 ± 13) on an arbitrary scale from 0 = worst to 100 = best was significantly higher in the groups receiving peri- or postoperative (versus preoperative) acustimulation therapy. For patients discharged on the day of surgery, the time to home readiness was significantly reduced (114 ± 41 min versus 164 ± 50 min; P < 0.05) when acustimulation was administered perioperatively (versus preoperatively). In conclusion, acustimulation with the ReliefBand^® was most effective in reducing postoperative nausea and vomiting and improving patients’ satisfaction with their antiemetic therapy when it was administered after surgery.

Dolasetron Versus Ondansetron for the Treatment of Postoperative Nausea and Vomiting
Tricia A. Meyer, MS, FASHP, Charles R. Roberson, MD, Mohammed H. Rajab, PhD, Jad Davis, MD, and Charles H. McLeskey, MD
Anesth Analg 2005;100:373-377

The management of postoperative nausea and vomiting (PONV) remains a persistent problem. Despite the use of prophylactic antiemetics, breakthrough nausea and vomiting still frequently occur. There have been no published studies comparing dolasetron and ondansetron for the treatment of PONV. This was a prospective, randomized, double-blind, active-controlled study in adult outpatient surgery patients. We screened 559 consecutive adult surgery patients, with 92 patients randomized to either ondansetron or dolasetron. The objectives of the study were 1) to determine whether treatment of PONV with ondansetron 4 mg IV or dolasetron 12.5 mg IV would result in better outcomes in patients undergoing day surgery and 2) to compare the cost of drugs used for treating PONV. Thirty-three (70%) of 47 patients given ondansetron required rescue medication, compared with 18 (40%) of 45 patients given dolasetron (P < 0.004). Dolasetron was approximately 40% less expensive than ondansetron, and the costs of the study drug plus rescue antiemetics were 30% less in the dolasetron group than in the ondansetron group. Dolasetron provided greater efficacy for antiemetic treatment because of the need for less rescue therapy. Because of the decreased use of rescue antiemetics and acquisition cost at our hospital, costs in the dolasetron group were less than costs in the ondansetron group.

The Use of Nicardipine for Electroconvulsive Therapy: A Dose-Ranging Study
Yunan Zhang , MD , Paul F. White, MD, PhD, FANZCA, Larry Thornton, MD, Lisa Perdue, MD, and Michael Downing, MD
Anesth Analg 2005;100:378-381

A wide variety of vasoactive drugs have been used to treat the acute hypertensive response to electroconvulsive therapy (ECT). We designed this randomized, double-blind, saline-controlled, crossover study to compare three different doses of nicardipine when administered before the ECT stimulus. Twenty-five patients undergoing a series of 4 ECT treatments received bolus injections of either saline or nicardipine 20, 40, or 80 µg/kg IV in a random sequence during a standardized methohexital (1 mg/kg) and succinylcholine (1 mg/kg) anesthetic technique. The mean arterial blood pressure (MAP) and heart rate values were recorded at specific time intervals, as were the duration of seizure activity and the need for rescue labetalol. Both the 40 and 80 µg/kg doses of nicardipine reduced the percentage increase in MAP above the baseline value compared with the saline group (7% and 7% versus 30%, respectively). Nicardipine 40 and 80 µg/kg were also associated with a significant reduction in the need for labetalol (7 ± 3 mg and 5 ± 0 mg versus 22 ± 10 mg in the saline group). Compared with the 40 µg/kg dose, nicardipine 80 µg/kg was associated with a more rapid heart rate at the time the ECT stimulus was applied. The 80 µg/kg dose was also associated with a reduced MAP value on awakening compared with the baseline value (91 ± 12 mm Hg versus 102 ± 8 mm Hg). We conclude that a bolus injection of nicardipine 40 µg/kg IV immediately before the ECT stimulus was optimal for controlling the acute hemodynamic response to ECT treatments.

The Interaction Effect of Perioperative Cotreatment with Dextromethorphan and Intravenous Lidocaine on Pain Relief and Recovery of Bowel Function After Laparoscopic Cholecystectomy
Ching-Tang Wu, MD Cecil O Borel, MD, Meei-Shyuan Lee, MPH, Jyh-Cherng Yu, MD, Hang-Seng Liou, MD, Haun-De Yi, MD, and Chih-Ping Yang, MD
Anesth Analg 2005;100:448-453

Both dextromethorphan (DM) and IV lidocaine improve postoperative pain relief. In the present study, we evaluated the interaction of DM and IV lidocaine on pain management after laparoscopic cholecystectomy (LC). One-hundred ASA physical status I or II patients scheduled for LC were randomized into four equal groups to receive either: (a) chlorpheniramine maleate (CPM) intramuscular injection (IM) 20 mg and IV normal saline (N/S) (group C); (b) DM 40 mg IM and IV N/S (group DM); (c) CPM 20 mg IM and IV lidocaine 3 mg · kg^-1 · h^-1 (group L); or (d) DM 40 mg IM and IV lidocaine (group DM+L). All treatments were administered 30 min before skin incision. Analgesic effects were evaluated using visual analog scale pain scores at rest and during coughing, time to meperidine request, total meperidine consumption, and the time to first passage of flatus after surgery. Patients of the DM+L group exhibited the best pain relief and fastest recovery of bowel function among groups. Patients in the DM and L groups had significantly better pain relief than those in the C group. The results showed an additional effect on pain relief and a synergistic effect on recovery of bowel function when DM was combined with IV lidocaine after LC.

Spinal 2-Chloroprocaine for Surgery: An Initial 10-Month Experience (ACCOMPANIED BY THE BELOW EDITORIAL)
Jessica R. Yoos, MD, and Dan J. Kopacz, MD
Anesth Analg 2005;100:553-558

Spinal 2-chloroprocaine (2-CP) is currently being investigated as a short-acting alternative to lidocaine, which frequently causes transient neurologic symptoms (TNS) in surgical patients. TNS has not been reported with 2-CP in volunteers in doses ranging from 30 to 60 mg and appears to provide an excellent level of surgical anesthesia. In this retrospective study, we describe the experience with spinal 2-CP in surgical patients during its first 10 mo of clinical use at our institution. Most patients had ambulatory surgery, including 39 orthopedic, 30 general surgical, 18 gynecologic, and 34 genitourinary procedures. Chloroprocaine 30 or 40 mg, with or without fentanyl (10–20 µg), was the most common (92%) dose combination used. Mean peak block height averaged T6 to T8. The surgical procedure time was 32.3 ± 18.4 min. Time from placement of the block to the end of the surgical procedure was 53.1 ± 20.7 min. Times to ambulation and discharge were 155.1 ± 34.7 min and 207.9 ± 69.4 min, respectively. 2-CP spinal anesthesia has proven to be a safe and effective alternative to lidocaine and procaine for ambulatory surgical procedures of 1 h, with a predictable regression of block height. No patients reported TNS after surgery.

Spinal 2-Chloroprocaine: The Effect of Added Clonidine (ACCOMPANIED BY THE BELOW EDITORIAL)
Brad R. Davis, MD, and Dan J. Kopacz, MD
Anesth Analg 2005;100:559-565

Preservative-free 2-chloroprocaine (2-CP) is being investigated for short-acting spinal anesthesia. Clonidine improves the quality of spinal bupivacaine and ropivacaine, but in traditional doses (1–2 µg/kg) it produces systemic side effects. It has not been studied in combination with 2-CP. In this double-blind, randomized crossover study, we compared spinal 2-CP (30 mg) with and without clonidine (15 µg) in eight volunteers. Pinprick anesthesia, motor strength, tolerance to electrical stimulation and thigh tourniquet, and time to ambulation were assessed. Peak block height was similar between 2-CP (T8 [range, T6 to L2]) and 2-CP with clonidine (T8 [range, T4 to T11]) (P = 0.57). Sensory anesthesia was prolonged with clonidine at L1 (51 ± 23 min versus 76 ± 11 min; P = 0.002), as was complete block regression (99 ± 18 min versus 131 ± 15 min; P = 0.001). Lower extremity motor blockade was increased with clonidine (return to baseline Bromage score: 65 ± 13 min versus 79 ± 19 min, P = 0.004; return to 90% gastrocnemius strength: P = 0.003). Clonidine increased tourniquet tolerance from 33 to 45 min (P = 0.06) and increased time to ambulation, spontaneous voiding, and discharge (99 ± 18 min versus 131 ± 15 min for all; P = 0.001). There were no differences in hemodynamic measurements, and no subject reported transient neurologic symptoms. We conclude that small-dose clonidine increases the duration and improves the quality of 2-CP spinal anesthesia without systemic side effects.

Spinal 2-Chloroprocaine: A Comparison with Small-Dose Bupivacaine in Volunteers (ACCOMPANIED BY THE BELOW EDITORIAL)
Jessica R. Yoos, MD, and Dan J. Kopacz, MD
Anesth Analg 2005;100:566-572

Ambulatory surgery continues to increase nationwide. Because spinal lidocaine is associated with transient neurologic symptoms, many clinicians have switched to small-dose bupivacaine for outpatient spinal anesthesia. However, bupivacaine often produces inadequate surgical anesthesia and has an unpredictable duration. Preservative-free 2-chloroprocaine (2-CP) has reemerged as an alternative for outpatient spinal anesthesia. We designed this double-blind, randomized, crossover, volunteer study to compare 40 mg of 2-CP with small-dose (7.5 mg) bupivacaine with measures of pinprick anesthesia, motor strength, tolerance to tourniquet and electrical stimulation, and simulated discharge criteria. Peak block height (2-CP average T7 [range T3–10]; bupivacaine average T9 [range T4–L1]), regression to L1 (2-CP 64 ± 10 versus bupivacaine 87 ± 41 min), and tourniquet tolerance (2-CP 52 ± 11 versus bupivacaine 60 ± 27 min) did not differ between drugs (P = 0.15, 0.12, and 0.40, respectively). However, time to simulated discharge (including time to complete block regression, ambulation, and spontaneous voiding) was significantly longer with bupivacaine (2-CP 113 ± 14, bupivacaine 191 ± 30 min, P = 0.0009). No subjects reported transient neurologic symptoms or other side effects. We conclude that spinal 2-CP provides adequate duration and density of block for ambulatory surgical procedures, and has significantly faster resolution of block and return to ambulation compared with 7.5 mg of bupivacaine.

Spinal 2-Chloroprocaine: A Comparison with Procaine in Volunteers (ACCOMPANIED BY THE BELOW EDITORIAL)
Aaron F. Gonter, MD, and Dan J. Kopacz, MD
Anesth Analg 2005;100:573-579

Recent studies using preservative-free 2-chloroprocaine (2-CP) for spinal anesthesia have shown it to be a reliable short-acting drug that provides similar anesthesia to lidocaine. In this randomized, double-blind, crossover study, we compared the characteristics of spinal 2-CP (30 mg) with those of procaine (80 mg) in eight volunteers to determine whether either drug produces spinal anesthetic characteristics ideal for outpatient surgery. By using sensation to pinprick, transcutaneous electrical stimulation, tolerance to thigh tourniquet, and motor blockade as surrogates for surgical efficacy, 2-CP compared similarly to procaine. Peak block height (T9 [range, T6 to T12] versus T6 [T4 to T8]; P = 0.0796), time to two-segment regression (51 ± 17 min versus 53 ± 10 min; P = 0.7434), tourniquet time tolerance (37 ± 16 versus 49 min ± 17 min; P = 0.1755), and time to return of motor strength (Bromage scale: 54 ± 23 min versus 55 ± 44 min, P = 0.9366; return of 90% quadriceps strength: 78 ± 9 min versus 98 ± 30 min; P = 0.0721) were all similar. Procaine did produce overall longer sensory blockade (P = 0.0011) and motor blockade at the gastrocnemius (P = 0.0004) and quadriceps (P = 0.0146) muscles. Times until the resolution of sensory blockade (103 ± 12 min versus 151 ± 26 min; P = 0.0003), ambulation (103 ± 12 min versus 151 ± 26 min; P = 0.0003), and micturition (103 ± 12 min versus 156 ± 23 min; P < 0.0001) were all prolonged after procaine. In conclusion, at the doses tested, spinal 2-CP (30 mg) may be a better choice for short outpatient procedures because it provides anesthesia with similar efficacy as procaine (80 mg) but with more rapid fulfillment of discharge criteria.

Chloroprocaine Spinal Anesthesia: Back to the Future? (EDITORIAL)
Kenneth Drasner, MD
Anesth Analg 2005;100:549-552

No abstract available.

Positive End-Expiratory Pressure During Induction of General Anesthesia Increases Duration of Nonhypoxic Apnea in Morbidly Obese Patients
Sylvain Gander, MD, Philippe Frascarolo, PhD, Michel Suter, MD, Donat R. Spahn, MD, and Lennart Magnusson, MD, PhD
Anesth Analg 2005;100:580-584

Positive end-expiratory pressure (PEEP) applied during induction of anesthesia prevents atelectasis formation and increases the duration of nonhypoxic apnea in nonobese patients. PEEP also prevents atelectasis formation in morbidly obese patients. Because morbidly obese patients have difficult airway management more often and because arterial desaturation develops rapidly, we studied the clinical benefit of PEEP applied during anesthesia induction. Thirty morbidly obese patients were randomly allocated to one of two groups. In the PEEP group, patients breathed 100% O₂ through a continuous positive airway pressure device (10 cm H₂O) for 5 min. After induction of anesthesia, they were mechanically ventilated with PEEP (10 cm H₂O) for another 5 min until tracheal intubation. In the control group, the sequence was the same but without any continuous positive airway pressure or PEEP. We measured apnea duration until Spo 2 reached 90% and we performed arterial blood gases analyses just before apnea and at 92% SpO₂. Nonhypoxic apnea duration was longer in the PEEP group compared with the control group (188 ± 46 versus 127 ± 43 s; P = 0.002). PaO₂ was higher before apnea in the PEEP group (P = 0.038). Application of positive airway pressure during induction of general anesthesia in morbidly obese patients increases nonhypoxic apnea duration by 50%.

The ProSeal^TM Has a Shorter Life-Span than the Classic^TM Laryngeal Mask Airway
Sarah Doneley, MB BS, Joseph Brimacombe, MB ChB, FRCA, MD, Christian Keller, MD, and Achim von Goedecke, MD
Anesth Analg 2005;100:590-593

We tested the hypothesis that the life-span of the ProSeal^TM laryngeal mask airway (LMA) is shorter than the Classic^TM LMA. We also compared residual cuff volumes and changes in elastance and permeability with use. Six new size 4 ProSeal^TM LMAs and 6 new size 4 Classic^TM LMAs were tested. Each LMA underwent a simulated clinical use cycle until it failed the pre-use check tests. The simulated clinical use cycle comprised: i) inflating the cuff to the maximum recommended volume for 1 h; ii) immersion in an enzymatic solution for 3 min; iii) washing the external and internal surfaces; iv) automatic washing for 14 min (≤ 85°C); v) drying for 30 min (≤75°C); and vi) autoclaving at 134°C for 4 min at 206 kPa. Before the first cycle and every 10 subsequent cycles, the cuff was inflated with 40 mL air and the intracuff pressure was measured immediately and 3 h later. The initial intracuff pressure was taken to be an inverse measure of the elastance or resistance to deformation, and the intracuff pressure change were taken as a measure of the permeability. The residual cuff volume was determined for 10 Classic^TM and 10 ProSeal^TM size 4 LMAs using a gas dilution technique. The mean ± sd (range) longevity for the ProSeal^TM LMA and Classic^TM LMA was 82 ± 23 (45–109) uses and 133 ± 35 (76–176) uses, respectively. The ProSeal^TM LMA has a shorter life-span than the Classic^TM LMA (P = 0.01). For the ProSeal^TM LMA, there was no change in elastance or permeability with use. For the Classic TM LMA, there was a decrease in elastance (P < 0.0001) and an increase in permeability (P < 0.0001) with use. The residual cuff volume was higher for the ProSeal^TM LMA (2.6 ± 1.3 mL versus 1.5 ± 0.9, P = 0.04). We conclude that the life-span of the ProSeal^TM LMA is shorter than the Classic^TM LMA, but both exceed the manufacturer’s recommendations of 40 uses. We recommend that reusable LMA devices be discarded when they fail the pre-use check tests, rather than after a specific number of uses.

ANESTHESIOLOGY - TOP

Impact of Anesthesia Management Characteristics on Severe Morbidity and Mortality.
Arbous, M Sesmu M.D., Ph.D. ; Meursing, Anneke E. E. M.D., Ph.D. ; van Kleef, Jack W. M.D., Ph.D. ; de Lange, Jaap J. M.D., Ph.D. ; Spoormans, Huub H. A. J. M. M.D. ; Touw, Paul M.D., Ph.D.; Werner, Frans M. M.D., Ph.D. ; Grobbee, Diederick E. M.D., Ph.D.
Anesthesiology 2005;102(2):257-68.

Background: Quantitative estimates of how anesthesia management impacts perioperative morbidity and mortality are limited. The authors performed a study to identify risk factors related to anesthesia management for 24-h postoperative severe morbidity and mortality.
Methods: A case-control study was performed of all patients undergoing anesthesia (1995-1997). Cases were patients who either remained comatose or died during or within 24 h of undergoing anesthesia. Controls were patients who neither remained comatose nor died during or within 24 hours of undergoing anesthesia. Data were collected by means of a questionnaire, the anesthesia and recovery form. Odds ratios were calculated for risk factors, adjusted for confounders.
Results: The cohort comprised 869,483 patients; 807 cases and 883 controls were analyzed. The incidence of 24-h postoperative death was 8.8 (95% confidence interval, 8.2-9.5) per 10,000 anesthetics. The incidence of coma was 0.5 (95% confidence interval, 0.3-0.6). Anesthesia management factors that were statistically significantly associated with a decreased risk were: equipment check with protocol and checklist (odds ratio, 0.64), documentation of the equipment check (odds ratio, 0.61), a directly available anesthesiologist (odds ratio, 0.46), no change of anesthesiologist during anesthesia (odds ratio, 0.44), presence of a full-time working anesthetic nurse (odds ratio, 0.41), two persons present at emergence (odds ratio, 0.69), reversal of anesthesia (for muscle relaxants and the combination of muscle relaxants and opiates; odds ratios, 0.10 and 0.29, respectively), and postoperative pain medication as opposed to no pain medication, particularly if administered epidurally or intramuscularly as opposed to intravenously.
Conclusions: Mortality after surgery is substantial and an association was established between perioperative coma and death and anesthesia management factors like intraoperative presence of anesthesia personnel, administration of drugs intraoperatively and postoperatively, and characteristics of delivered intraoperative and postoperative anesthetic care.
 

Cricoid Pressure Does Not Increase the Rate of Failed Intubation by Direct Laryngoscopy in Adults.
Turgeon, Alexis F. M.D., M.Sc., F.R.C.P.C. ; Nicole, Pierre C. M.D., F.R.C.P.C. Trepanier, Claude A. M.D., F.R.C.P.C.; Marcoux, Sylvie M.D., Ph.D.; Lessard, Martin R. M.D., F.R.C.P.C.
Anesthesiology 2005;102(2):315-9

Background: Cricoid pressure (CP) is applied during induction of anesthesia to prevent regurgitation of gastric content and pulmonary aspiration. However, it has been suggested that CP makes tracheal intubation more difficult. This double-blind randomized study evaluated the effect of CP on orotracheal intubation by direct laryngoscopy in adults.
Methods: Seven hundred adult patients undergoing general anesthesia for elective surgery were randomly assigned to have a standardized CP (n = 344) or a sham CP (n = 356) during laryngoscopy and intubation. After anesthesia induction and complete muscle relaxation, a 30-s period was allowed to complete intubation with a Macintosh No. 3 laryngoscope blade. The primary endpoint was the rate of failed intubation at 30 s. The secondary endpoints included the intubation time, the Cormack and Lehane grade of laryngoscopic view, and the Intubation Difficulty Scale score.
Results: Groups were similar for demographic data and risk factors for difficult intubation. The rates of failed intubation at 30 s were comparable for the two groups: 15 of 344 (4.4%) and 13 of 356 (3.7%) in the CP and sham CP groups, respectively (P = 0.70). The grades of laryngoscopic view and the Intubation Difficulty Scale score were also comparable. Median intubation time was slightly longer in the CP group than in the sham CP group (11.3 and 10.4 s, respectively, P = 0.001).
Conclusions: CP applied by trained personnel does not increase the rate of failed intubation. Hence CP should not be avoided for fear of increasing the difficulty of intubation when its use is indicated.

Continuous Infusion of Ropivacaine for Pain Relief after Iliac Crest Bone Grafting for Shoulder Surgery.
Blumenthal, Stephan M.D. ; Dullenkopf, Alexander M.D. ; Rentsch, Katharina M.D. ; Borgeat, Alain M.D.
Anesthesiology 2005;102(2):392-7.

Background: The aim of the study was to compare the efficacy of either ropivacaine or placebo through an iliac crest (IC) catheter after Bankart repair with IC bone grafting.
Methods: With approval of the local ethics committee and after written informed consent was obtained, 36 patients had an interscalene catheter placed preoperatively. Intraoperatively, the surgeon placed a catheter at the IC donor site. At the end of surgery, 30 ml ropivacaine, 0.5% (ropivacaine group), or 30 ml NaCl, 0.9% (placebo group), was administered. Ropivacaine, 0.2%, was started 6 h after the initial block through the interscalene catheter for 48 h (t48) in all patients. At t0, the patient received either 5 ml/h ropivacaine, 0.2% (ropivacaine group), or 5 ml/h NaCl, 0.9% (placebo group), for 48 h through the IC catheter. All patients received an intravenous morphine patient-controlled analgesia device. Pain scores at the shoulder and at the IC donor site were assessed at rest and during motion every 8 h for 48 h and after 3 months. Plasma concentrations of total and unbound ropivacaine, morphine consumption, and patient satisfaction were assessed.
Results: At the IC donor site, pain was significantly lower in the ropivacaine group compared with the placebo group at rest and during motion at any time. Total and unbound plasma concentrations of ropivacaine were below the toxic threshold in both groups. Morphine consumption was significantly lower in the ropivacaine group after 24 and 48 h. Patient satisfaction was significantly higher in the ropivacaine group. At 3 months, pain at the IC during motion was significantly lower in the ropivacaine group.
Conclusions: Continuous application of 0.2% ropivacaine through an IC catheter after Bankart repair with IC bone grafting is an effective method for pain relief for the first 48 h, with few adverse effects and high patient satisfaction. The benefit of this technique is still present after 3 months.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Anaesthetic practice for groin hernia repair - A nation-wide study in Denmark 1998 - 2003
H. Kehlet and M. Bay Nielsen
Acta Anaesthesiologica Scandinavica 2005;49 : 143-6

Background:  Recent scientific data suggest that local infiltration anaesthesia for inguinal hernia surgery may be preferable compared to general anaesthesia and regional anaesthesia, since it is cheaper and with less urinary morbidity. Regional anaesthesia may have specific side-effects and is without documented advantages on morbidity in this small operation.
Methods: To describe the use of the three anaesthetic techniques for elective open groin hernia surgery in Denmark from January 1st 1998 to December 31st 2003, based on the Danish Hernia Database collaboration.
Results: In a total of 57,505 elective open operations 63.6% were performed in general anaesthesia, 18.3% in regional anaesthesia and 18.1% in local anaesthesia. Regional anaesthesia was utilized with an increased rate in elderly and hospitalized patients. Outpatient surgery was most common with local infiltration anaesthesia.
Conclusion:  Use/choice of anaesthesia for groin hernia repair is not in accordance with recent scientific data. Use of spinal anaesthesia should be reduced and increased use of local anaesthesia is recommended to enhance recovery and reduce costs.

Multimodal approach to rapid discharge after endoscopic thoracic sympathectomy
G. C. Cruvinel, J. B. V. Duarte, C. H. V. Castro, J. R. R. Costa and P. Kux
Acta Anaesthesiologica Scandinavica 2005;49:238-42

Background:  After a large experience (more than 10 years) with bilateral endoscopic thoracic sympathectomy (ETS) surgery on an outpatient basis, we studied prospectively a multimodal approach to rapid discharge patients undergoing this procedure.
Methods:  One hundred and seventeen consecutive patients, aged 1360 years, ASA physical status I or II, undergoing outpatient ETS under general anaesthesia were enrolled in this study. All patients were managed using a predefined multimodal clinical care protocol consisting of a general balanced anaesthesia. Basic demographic information was collected from each patient. Duration of surgery and anaesthesia and times to PACU and home discharge were recorded as well as intraoperative and postoperative complications like nausea and vomiting.
Results:  Surgery took 41.4 ± 22.1 min and anaesthesia lasted 63 ± 21.5 min. Time between induction of anaesthesia and beginning of surgery and end of surgery to extubation was 15.0 ± 2.0 and 7.2 ± 3.1 min, respectively. It took 4.9 ± 1.5 min from extubation to OR discharge. Time from PACU arrival to discharge was 12.8 ± 6.3 min. Time of hospital stay was 132 ± 18 min. No patient experienced vomiting and two had nausea, representing an incidence of 1.7%. The only anaesthetic cause for hospital admission was a severe allergic reaction.
Conclusion:  Multimodal management to rapid discharge after ETS surgery did result in a short time to patient discharge. We confirm that endoscopic thoracic sympathectomy can be performed safely on an outpatient basis with brief postoperative hospital care and a low rate of complications.

Comparison of recovery properties of desflurane and sevoflurane according to gender differences
E. Tercan, M. S. Kotanoglu, K. Yildiz, K. Dogru and A. Boyaci
Acta Anaesthesiologica Scandinavica 2005;49:243-7 

Background:  The aim of this study was to investigate the recovery properties of desflurane and sevoflurane in patients undergoing elective surgery, according to the gender differences.
Methods:  In the study, 160 ASA class III patients aged between 20 and 60 years were included. The patients were assigned into two groups according to their gender, and these groups were randomly divided into two groups according to a selected volatile anaesthetic agent. Intraoperative bispectral index, time of postoperative achievement for end-tidal concentrations of volatile agents to decline 50% (ET-AA_%50), time for extubation, time for eye opening and orientation, and time for bispectral index values to reach control values were recorded. Aldrete scores and error points of a delayed memory recall test were determined.
Results:  Desflurane groups had a shorter ET-AA_%50 time, extubation and eye-opening time in male and female patients compared to the sevoflurane groups, and these results were statistically significant (P < 0.05). In both the desflurane and sevoflurane groups, ET-AA_%50 time, extubation and eye-opening time were shorter in male patients than in female patients, and these results were also statistically significant (P < 0.05). There were no significant differences among the groups in terms of Aldrete scores and error points of delayed memory recall test (P > 0.05).
Conclusion:  In conclusion, early recovery time was shorter in male patients compared to female patients in both the desflurane and sevoflurane groups. Additionally, in the desflurane groups it was shorter in the sevoflurane groups for both genders.

Less local pain on intravenous infusion of a new propofol emulsion
E. Liljeroth and J. Åkeson
Acta Anaesthesiologica Scandinavica 2005;49:248-51

Background : Local pain at the site of intravenous (iv) injection of propofol remains a considerable problem in clinical anaesthesiology, and particularly so in infants. The aim of the present study was to compare the influence of two different emulsions of propofol on local pain following iv administration.
Methods:  Eighty adult patients (ASA I-II) scheduled for ear-nose-throat or plastic surgery were randomly allocated into two study groups: A and B. A 1.0-mm teflon cannula (BD, Helsingborg, Sweden) was inserted into a dorsal vein on each hand. Each patient was given two 3.0-ml iv bolus injections of two different propofol emulsions of 10 mg ml1 over 2 s, one in each cannula, at 5-min intervals. The first study drug administered was Diprivan^® (AstraZeneca, Södertälie, Sweden) in group A (n = 34) and Propofol-Lipuro (Braun, Melsungen, Germany) in group B (n = 39). Each patient was then asked by a blinded investigator to score maximal pain intensity on a visual analogue scale (VAS).
Results:  The maximal intensity of propofol-induced local pain was significantly (P < 0.0001) lower after Propofol-Lipuro than after Diprivan^® - median 1 (25th percentile: 0; 75th percentile: 2) range 0 - 6 vs. 3 (0; 5) 0 - 9 VAS units.
Conclusion:  The considerably lower intensity of local pain found to be associated with iv administration of the new drug formula Propofol-Lipuro indicates that emulsions of propofol based on medium- and long-chain triglycerides have a clinical advantage over traditional ones for induction of anaesthesia.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Evaluation of genitofemoral nerve block, in addition to ilioinguinal and iliohypogastric nerve block, during inguinal hernia repair in children
N. Sasaoka, M. Kawaguchi, K. Yoshitani, H. Kato, A. Suzuki and H. Furuya
British Journal of Anaesthesia 2005 94(2):243-246

Background. Ilioinguinal and iliohypogastric (IG-IH) nerve block has been widely used in children undergoing inguinal hernia repair. This technique may provide insufficient analgesia for intraoperative management as the inguinal region may receive sensory innervation from genitofemoral nerve. We proposed that addition of a genitofemoral nerve block might improve the quality of analgesia.
Methods. Ninety-eight children undergoing inguinal hernia repair were assigned randomly to receive either IG-IH nerve block (Group I) or IG-IH and genitofemoral nerve blocks (Group II). Systolic arterial pressure (SAP) and heart rate (HR) were recorded before surgery (control), after skin incision, at sac traction and at the end of surgery. Postoperative analgesic requirements and incidence of complications were recorded until discharge.
Results. At sac traction, SAP and HR were significantly higher in Group I (P<0.05), and the incidence of episodes of increased HR was also significantly higher in Group II (29 vs 12%, respectively, P<0.05). There were no significant differences in SAP and HR at other time points, postoperative analgesic requirements or incidence of complications between the groups.
Conclusions. The benefit of the additional genitofemoral nerve block to IG-IH nerve block was limited only to the time of sac traction without any postoperative effect. This suggests there is little clinical benefit in the addition of a genitofemoral nerve block.

Influence of working conditions on job satisfaction in anaesthetists
J. F. Kinzl, H. Knotzer, C. Traweger, W. Lederer, T. Heidegger and A. Benzer
British Journal of Anaesthesia 2005 94(2):211-215

Background. We studied job satisfaction, physical health, emotional well-being and working conditions in 125 Austrian and Swiss anaesthetists.
Methods. Responses to self-reporting questionnaires were evaluated. Dependent variables included job satisfaction, emotional well-being and physical health. Independent variables included age, sex, marital status, position and working conditions as assessed by the Instrument for Stress-related Job Analysis.
Results. Control over work shows a strong effect on job satisfaction in anaesthetists, for example influence on handling tasks (P=0.001), time control (P=0.002) and participation (P=0.001), whereas task demands and task-related problems did not have any effect. Anaesthetists in leading positions and specialists reported lower job satisfaction (P=0.012) than did anaesthetists in non-leading positions. Job satisfaction was associated with better physical health (P=0.001) and better emotional well-being (P=0.005).
Conclusions. Our results suggest that a high level of job satisfaction in anaesthetists correlates with interesting work demands and the opportunity to contribute skills and ideas. To improve job satisfaction, more attention should be paid to improving working conditions, including control over decision-making, and allowing anaesthetists to have more influence on their own work pace and work schedule.

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Increased incidence of postoperative cognitive dysfunction 24 hr after minor surgery in the elderly
Denise Rohan, FCARCSI, Donal J. Buggy, MD MSc DME FRCPI FCARCSI FRCA, Seamus Crowley, FCARCSI, Ferraby K. H. Ling, Helen Gallagher, PhD, Ciaran Regan and Denis C. Moriarty, FCARCSI FRCA
Canadian Journal of Anesthesia 52:137-142 (2005)

Purpose: Postoperative cognitive dysfunction (POCD) is evident in 26% of elderly patients seven days after major non-cardiac surgery. Despite the growing popularity of day surgery, the influence of anesthetic techniques on next day POCD has not been investigated. Therefore, we evaluated the incidence of POCD and changes in serum markers of neuronal damage (S-100ß protein and Neuron-Specific Enolase), 24 hr after single-agent propofol or sevoflurane anesthesia in elderly patients undergoing minor surgery.
Methods: Patients (n = 30, mean age 73, range 65–86 yr) coming for cystoscopy or hysteroscopy, were randomized, in an observer-blind design, to receive either single-agent propofol or sevoflurane anesthesia. Changes in neuropsychological tests (the Stroop test and the modified Word-Recall Test), 24 hr postoperatively were compared with age-matched control subjects (n = 15) using Z-score analysis. Changes in S-100ß protein and Neuron-Specific Enolase levels were also documented.
Results: POCD was present in 7/15 [47% (95% confidence interval (CI) 21 to 72%)] patients who received propofol and 7/15 [47% (95% CI 21 to 72%)] patients who received sevoflurane, compared with 1/15 [7% (95% CI 6 to 19%)] control patients, P = 0.03. S-100ß protein and Neuron-Specific Enolase levels were not significantly different in anesthetized patients postoperatively compared with preoperative values.
Conclusion: The incidence of POCD in elderly patients on the first day after minor surgery is higher than previously reported for seven days after major surgery, and is increased after both propofol and sevoflurane anesthesia, compared with age-matched controls. S-100ß protein and Neuron-Specific Enolase levels were unaffected by anesthetic technique.

Intravenous lidocaine 0.5 mg·kg^-1 effectively suppresses fentanyl-induced cough Chandra Kant Pandey, MD, Mehdi Raza, MD, Rajeev Ranjan, MD, Vinay Singhal, MD, Mukesh Kumar, MD, Archana Lakra, MD, Deepa Vishwas Navkar, MD, Anil Agarwal, MD, Ram Badan Singh, MD PDCC, Uttam Singh, PhD and Prabhat Kumar Singh, MD
Canadian Journal of Anesthesia 52:172-175 (2005) 

Purpose: To evaluate the minimal dose of lidocaine required for suppression of fentanyl-induced cough.
Methods: 320 ASA I and II patients, non-smokers of both sexes scheduled for elective surgery between the ages of 18 to 60 yr were randomly allocated into four equal groups. The patients were assigned to receive lidocaine 0.5 mg·kg^-1 (Group I), 1.0 mg·kg^-1(Group II), 1.5 mg·kg^-1 (Group III) or placebo (Group IV) over five seconds, one minute prior to the administration of fentanyl 3 µg·kg^-1 in a randomized and double-blind fashion. Any episode of cough was classified as coughing and graded as mild (1–2) moderate (3–4) or severe (5 or more). The data were analyzed by test of proportion.
Results: Eleven, 12, 11 and 28 patients (13.75%, 15%, 13.75% and 35%) had cough in Groups I, II, III and IV respectively (P < 0.05 Groups I, II, III vs IV). There was no significant difference in the incidence and severity of cough among the lidocaine pretreated groups (P > 0.05).
Conclusion: The results of our study suggest that iv lidocaine 0.5 mg·kg^-1 is the minimal dose required to suppress fentanyl-induced cough when administered one minute prior to fentanyl. Any further increase in the lidocaine dose does not reduce the incidence or severity of fentanyl-induced cough.

Early clinical experience with a new videolaryngoscope (GlideScope^®) in 728 patients
Richard M. Cooper, MSc MD, John A. Pacey, MD, Michael J. Bishop, MD and Stuart A. McCluskey, PhD MD
Canadian Journal of Anesthesia 52:191-198 (2005)

Purpose: To evaluate a new videolaryngoscope and assess its ability to provide laryngeal exposure and facilitate intubation.
Methods: Five centres, involving 133 operators and a total of 728 consecutive patients, participated in the evaluation of a new video-laryngoscope [GlideScope^® (GS)]. Many operators had limited or no previous GS experience. We collected information about patient demographics and airway characteristics, Cormack-Lehane (C/L) views and the ease of intubation using the GS. Failure was defined as abandonment of the technique.
Results: Data from six patients were incomplete and were excluded. Excellent (C/L 1) or good (C/L 2) laryngeal exposure was obtained in 92% and 7% of patients respectively. In all 133 patients in whom both GS and direct laryngoscopy (DL) were performed, GS resulted in a comparable or superior view. Among the 35 patients with C/L grade 3 or 4 views by DL, the view improved to a C/L 1 view in 24 and a C/L 2 view in three patients. Intubation with the GS was successful in 96.3% of patients. The majority of the failures occurred despite a good or excellent glottic view.
Conclusions: GS laryngoscopy consistently yielded a comparable or superior glottic view compared with DL despite the limited or lack of prior experience with the device. Successful intubation was generally achieved even when DL was predicted to be moderately or considerably difficult. GS was abandoned in 3.7% of patients. This may reflect the lack of a formal protocol defining failure, limited prior experience or difficulty manipulating the endotracheal tube while viewing a monitor.

Glottic insertion of the ProSeal^TM LMA occurs in 6% of cases: a review of 627 patients
Cornelius J. O’Connor, Jr, MD, Michael S. Stix, MD PhD and Dennis R. Valade, CRNA
Canadian Journal of Anesthesia 52:199-204 (2005)

Purpose: Glottic insertion of the ProSeal^TM Laryngeal Mask Airway (PLMA) has received little attention in the anesthesiology literature. We investigated the incidence and depth of insertion associated with this important cause for a failed insertion attempt with the PLMA.
Methods: With Institutional Review Board approval, we reviewed 15-months’ use of the PLMA. Diagnosis of glottic insertion involved a test with children’s bubble solution placed on the drain tube port, as well as a fibreoptic examination of the airway of patients experiencing airway obstruction. Patients were anesthetized and paralyzed and the PLMA was inserted deflated with the fingertip method (women size 4, men size 5). The cuff was inflated and a soap membrane established on the drain tube port. Glottic insertion was diagnosed by applying fingertip pressure to the patient’s chest wall and observing pulmonary exhalation via the drain tube and bubble formation. The PLMA was then removed and reinserted without further assessment. For all patients, we used a fibrescope to determine the cause of unexplained airway obstruction after the PLMA was considered successfully inserted.
Results: There were 627 patients (391 women, 236 men). We diagnosed glottic insertion in 38/627 (6.1%) patients, 37 by the soap membrane test and one with airway obstruction and direct fibreoptic visualization of malposition. Following glottic insertion, successful reinsertion of the PLMA behind the larynx was always associated with greater depth of insertion by an average 2.0 cm.
Conclusion: Glottic insertion can be easily and quickly diagnosed and our results suggest the incidence and importance of malposition are under-reported in the literature.  

Volatile anesthetics and liver injury: a clinical update or what every anesthesiologist should know (REVIEW ARTICLE)
Jackie L. Martin
Can J Anesth 2005 52: 125-129.

No abstract available.

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Landiolol attenuates acute hemodynamic responses but does not reduce seizure duration during maintenance electroconvulsive therapy.
Sakamoto A, Ogawa R, Suzuki H, Kimura M, Okubo Y, Fujiya T.
Psychiatry Clin Neurosci. 2004 Dec;58(6):630-5.

Maintenance electroconvulsive therapy (mECT) is an outpatient procedure that requires further consideration in terms of management of ambulatory anesthesia. Although many adjunctive drugs for stabilizing hemodynamic changes during ECT have been reported, side-effects of these drugs may delay recovery and discharge from hospital. The effects of landiolol, a novel ultra-short-acting beta-adrenergic blocker, have been measured on seizure duration, hemodynamic changes, recovery from anesthesia, and cognitive function during mECT under propofol anesthesia. A total of 10 patients with depression in the remission phase, were studied in a randomized, double-blind, placebo-controlled, crossover manner. Administration of 0.1 mg/kg of landiolol immediately before anesthesia significantly blunted the increase in heart rate and blood pressure during convulsions compared with placebo; landiolol was not associated with excessive hypotension or bradycardia. Landiolol did not affect seizure duration, recovery from anesthesia, or cognitive function before or after ECT. These results suggest that landiolol can be used effectively and safely during mECT.

Assessment of the recovery of dynamic balance after intravenous sedation with midazolam.
Fujisawa T, Takuma S, Koseki H, Kimura K, Fukushima K
J Anesth. 2005;19(1):26-30.

PURPOSE: To assess street fitness after sedation, computerized dynamic posturography (CDP) involving movement of the center of gravity may be more accurate than the conventional computerized static posturography (CSP). The purpose of this study was to evaluate the recovery of dynamic balance function after intravenous sedation by CDP in comparison with CSP, and to find a simple dynamic balance test that is well correlated with CDP.
METHODS: The subjects were 20 male volunteers aged 20-27 years. After intravenous injection of midazolam (0.07 mg kg^-1), four balance tests were performed. The recovery time and the percentage of subjects showing recovery (difference from the baseline value </=10%) were compared. As CDP, a test in which unexpected perturbation stimuli are given using an unstable platform was performed. As CSP, standing sway tests were performed. Maximum speed walking (MSW) and usual speed walking (USW) tests were performed as simple balance tests.
RESULTS: The recovery time in CDP (80 min) was longer than that in CSP (40-60 min). The percentage of subjects showing recovery in CDP (20%) was significantly lower than that in CSP (55%-70%) 60 min after the administration of midazolam. There was a significant positive correlation between the CDP test and the MSW test (r = 0.67).
CONCLUSION: CDP with perturbation stimuli detects the balance inhibitory effects of midazolam with greater sensitivity than CSP. The MSW test is well correlated with CDP with perturbation stimuli.

Spinal hyperbaric ropivacaine-fentanyl for day-surgery.
Kallio H, Snall EV, Suvanto SJ, Tuomas CA, Iivonen MK, Pokki JP, Rosenberg PH.
Reg Anesth Pain Med. 2005 Jan-Feb;30(1):48-54.

Background: Adequate intraoperative analgesia combined with faster mobilization might be achieved by replacing hyperbaric ropivacaine partly with fentanyl.
Methods: Sixty spinal anesthesia patients were randomized into 2 groups of either fentanyl 20 mug mixed with hyperbaric ropivacaine 10 mg (group FR10) or hyperbaric ropivacaine 15 mg (group R15). Forty-five patients underwent inguinal hernia repair and 15 patients had lower extremity surgery. Sensory block was tested by pinprick, and motor block was tested by use of a modified Bromage scale at 5-minute intervals for 30 minutes, 15-minute intervals for 60 minutes, and at 30-minute intervals until full recovery.
Results: The groups did not differ significantly regarding success (27 of 30 [group FR10] and 29 of 30 [group R15]), median onset time (10 [5 to 25] v 10 [5 to 20] minutes) or median duration of T10 sensory block (55 [20 to 115] v 80 [5 to 170] minutes), respectively. Recovery from spinal block was significantly quicker in group FR10 than in group R15, recorded in ability to walk (2.5 hours v 3 hours [ P = .017]), full motor recovery (1 hour v 1.5 hour [ P < .001]), and sensory recovery to S1 (2.5 hours v 3.3 hours [ P = .026]). Pruritus occurred in 18 (60%) of group FR10 v 0 of group R15 patients ( P < .001). This symptom was mild in all except 1 patient, who received ondansetron 8 mg IV. In the OR, the groups did not differ hemodynamically: 9 (30%) of the group FR10 and 10 (33%) of the group R15 patients, respectively, required medication for hypotension and/or bradycardia. Full motor block (Bromage 3) developed less frequently ( P < .001) in group FR10 patients than in group R15 patients (1 [3%] v 14 [47%]), and the group FR10 patients recovered faster in a median time of 60 v 90 minutes ( P < .001). In both groups, sensory and motor blocks were more extensive on the operative side compared with the nonoperative side ( P < .001).
Conclusion: Faster mobilization but equal onset and duration of analgesia were achieved with intrathecal hyperbaric ropivacaine 10 mg plus fentanyl 20 mug as compared with hyperbaric ropivacaine 15 mg.

Anesthetic techniques and postoperative emesis in pediatric strabismus surgery.
Chhabra A, Pandey R, Khandelwal M, Subramaniam R, Gupta S.
Reg Anesth Pain Med. 2005 Jan-Feb;30(1):43-7.

Background and objectives: Postoperative emesis after pediatric strabismus surgery continues to be a problem, despite the use of antiemetics. The purpose of this study was to identify an anesthetic technique associated with the lowest incidence of vomiting after pediatric strabismus surgery.
Methods: A prospective, randomized, double-blind study was conducted to evaluate the effect of intravenous fentanyl, meperidine, or peribulbar block with propofol infusion on emesis in 105 pediatric patients undergoing strabismus surgery. Anesthesia was maintained with nitrous oxide, oxygen, and propofol infusion. Ketorolac 1.0 mg/kg^-1 intramuscular was administered to all patients after induction. Patients were given either a peribulbar block, intravenous fentanyl 2 mug/kg^-1 , or intravenous meperidine 1mg/kg^-1 for perioperative analgesia. The emesis scores were observed for the first 24 hours postoperatively.
Results: The incidence of emesis was significantly lower (1 of 35; 2.9%) in the peribulbar group compared with the meperidine group (9 of 35; 25.6%) ( P < .01) in the first 24 hours. The fentanyl group had a higher incidence of postoperative vomiting (4 of 35; 11.4%) than did the peribulbar group; the difference, however, was not statistically significant.
Conclusion: Among the three techniques, peribulbar block with propofol-based anesthesia is the technique with the lowest incidence of postoperative emesis. Fentanyl-propofol is an equally acceptable alternative; however, meperidine-propofol is associated with a high incidence of postoperative emesis.

Recent advances in local anaesthetics for spinal anaesthesia.
Milligan KR.
Eur J Anaesthesiol. 2004 Nov;21(11):837-47

Although local anaesthesia is mentioned in historical manuscripts, it is only a hundred years since Bier first reported the intrathecal use of local anaesthetic agents. This has been followed by a rapid progression in the art and science of spinal anaesthesia. Isomerically pure agents with favorable clinical profiles, such as ropivacaine and levobupivacaine are now available. Spinal anaesthesia is commonly used in a variety of situations, including orthopaedic, abdominal, gynaecological surgery, Caesarean section and the relief of pain in childbirth. Hyperbaric solutions of local anaesthetics appear to produce more consistent results than plain solutions and the addition of other drugs, such as opioids and clonidine may improve analgesia. In addition to traditional spinal anaesthesia, local anaesthetics are now being evaluated in continuous spinal anaesthesia and combined epidural-spinal anaesthesia. This article reviews clinical experience with levobupivacaine and ropivacaine. Compared with levobupivacaine, ropivacaine generally produces a less intense motor block of shorter duration, which has advantages for earlier mobilization and discharge from hospital and may be particularly useful in obstetrics and ambulatory surgery. 

Comparison of regional nerve block to epidural anaesthesia in day care arthroscopic surgery of the knee.
Chakravarthy V, Arya VK, Dhillon MS, Chari P.
Acta Orthop Belg. 2004 Dec;70(6):551-9.

Day care minimally invasive surgery demands minimal complications with anaesthesia. Nerve blocks are increasingly being employed for surgical procedures on the lower limb, and we attempted to evaluate their benefits and drawbacks in a prospective randomised study in patients undergoing knee arthroscopy. We compared the effectiveness, onset time, duration of analgesia, patient acceptance, failure rate and post-operative comfort of epidural anaesthesia (with 20 ml of 2% lidocaine with adrenaline 1 in 200000) and peripheral nerve blocks (combined 3-in-1 and sciatic nerve block, with 50 ml of 1% lignocaine with adrenaline 1 in 200000, using nerve stimulator). Forty nine cases were randomised to receive either single shot epidural anaesthesia (Group-I, n = 23) or combined 3-in-1 and sciatic nerve block (Group-II, n = 26). The anaesthesia procedure and analgesia onset time was longer in Group-II (p < 0.001), with skin incision being significantly delayed as compared to group-I (45.2+/-6.2min vs 30.0+/-5.4 min respectively) (p < 0.001). Haemodynamic changes were comparable in both groups during the study period. All patients had complete analgesia at skin incision in group-I as compared to 89.1% in group-II (p < 0.05). However 52.2% of patients in group-I required rescue analgesia postoperatively, as compared to only 18.7% in group-II (p < 0.05). We concluded that even though combined 3-in-1 and sciatic nerve block technique has longer anaesthesia induction time, the lesser need for postoperative rescue analgesia, and lesser potential complications like inadvertent spinal puncture, retention of urine and late onset of back pain, make this an attractive option for day care arthroscopy. The use of a nerve stimulator ensures accuracy, patient counselling allows good cooperation, and advance planning can include potential skin incision delays.

Overnight hospital stay is not always necessary after uvulopalatopharyngoplasty.
Spiegel JH, Raval TH.
Laryngoscope. 2005 Jan;115(1):167-71.

OBJECTIVES: To determine whether patients with obstructive sleep apnea who undergo uvulopalatopharyngoplasty (UPPP) have a significant incidence of postoperative complications that would justify overnight postoperative observation in the hospital.
STUDY DESIGN: Part 1: review of published medical literature to determine incidence of postoperative complications. Part 2: retrospective review of 117 patients undergoing UPPP with or without additional procedures.
METHODS: A literature search for existing studies describing the postoperative complications after UPPP for obstructive sleep apnea was conducted. After this, the records of 117 patients who had undergone UPPP at a university-based medical center during a 5-year span were reviewed.
RESULTS: Respiratory events occur in 2% to 11% of cases. These include airway obstruction (e.g., laryngospasm), postobstructive pulmonary edema (POPE), and desaturation. Airway obstruction occurred in the immediate postoperative setting. POPE was rare and usually occurred within minutes after the conclusion of the surgical procedure. Desaturation could occur at any time, but the severity was usually equivalent to that found on preoperative sleep study. Hemorrhage occurred in 2% to 14% of cases and had a biphasic incidence, occurring either immediately postoperatively or several days after surgery. Depending on definition, hypertension was observed in between 2% and 70% of patients postoperatively. This was most commonly diagnosed and treated in the immediate postoperative setting. In most reports, arrhythmia and angina occurred in less than 1% of cases.
CONCLUSIONS: The majority of complications after UPPP with or without additional procedures occur within 1 to 2 hours after surgery. Postoperative oxygen desaturation is usually no worse than that that was observed on preoperative polysomnography findings. A 2 to 3 hour observation period may be suitable for patients after UPPP; if a patient experiences no complications and is maintaining adequate oxygenation and analgesia, same-day discharge from recovery room may be considered.

The effectiveness of rescue antiemetics after failure of prophylaxis with ondansetron or droperidol: a preliminary report.
Habib AS , Gan TJ.
J Clin Anesth. 2005 Feb;17(1):62-5.

STUDY OBJECTIVES: To compare the effectiveness of treating established postoperative nausea and vomiting (PONV) with an antiemetic acting at a different receptor with that of treating PONV with the antiemetic used for prophylaxis.
DESIGN: Analysis of data collected in a previously published randomized, double-blind, placebo-controlled study.
SETTING: Outpatient surgical procedures from 50 institutions in North America.
PATIENTS: Patients (N = 2061) undergoing outpatient surgical procedures planned to last no more than 2 hours.
INTERVENTIONS: Patients were randomized to receive ondansetron 4 mg, droperidol 1.25, droperidol 0.625 mg, or placebo. In the postoperative anesthesia care unit, patients who developed PONV received rescue antiemetics at the discretion of the attending anesthesiologist. The following antiemetics were used for rescue: ondansetron 4 mg, droperidol 0.625 to 1.25 mg, metoclopramide 10 mg, promethazine 6.25 to 25 mg, and dimenhydrinate 25 to 50 mg.
MEASUREMENTS: The complete response rate (no nausea, no emesis, and no need for further rescue) after administration of the rescue antiemetic in patients with established PONV was calculated. The complete response rate after administration of each of the different rescue antiemetics was compared with that after administration of the same antiemetic used for PONV prophylaxis.
MAIN RESULTS: In patients who failed prophylaxis with ondansetron 4 mg, the complete response rate was significantly higher (P = .02) after rescue with promethazine 6.25 to 25 mg (78%) than after rescue with ondansetron 4 mg (46%). In patients who failed prophylaxis with droperidol 0.625 and 1.25 mg, the complete response rate was significantly higher after rescue with promethazine 6.25 to 25 mg (77%; P = .02) and dimenhydrinate 25 to 50 mg (78%; P = .04) than after rescue with droperidol 0.625 to 1.25 mg (56%).
CONCLUSION: In patients who failed prophylaxis with ondansetron or droperidol, promethazine was significantly more effective than the agent used for prophylaxis for the treatment of PONV. In patients who failed prophylaxis with droperidol, dimenhydrinate was also more effective than droperidol for the treatment of established PONV in the postoperative anesthesia care unit .

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