Postoperative Cognitive Dysfunction in Older Patients with a History of Alcohol Abuse.
2006 Journal Symposium Postoperative Cognitive Dysfunction
Hudetz, Judith A. Ph.D.; Iqbal, Zafar M.D. ; Gandhi, Sweeta D. M.D. ; Patterson, Kathleen M. Ph.D. ; Hyde, Trevor F. Ph.D. ; Reddy, Diane M. Ph.D. ; Hudetz, Anthony G. B.M.D., Ph.D. ; Warltier, David C. M.D., Ph.D. 
Anesthesiology. 106(3):423-430, March 2007.

Abstract:
Background: Postoperative cognitive dysfunction (POCD) affects a significant number of patients and may have serious consequences for quality of life. Although POCD is most frequent after cardiac surgery, the prevalence of POCD after noncardiac surgery in older patients is also significant. The risk factors for POCD after noncardiac surgery include advanced age and preexisting cognitive impairment. Self-reported alcohol abuse is a risk factor for postoperative delirium, but its significance for long-term POCD has not been investigated. The goal of this study was to determine whether neurocognitive function is impaired after noncardiac surgery during general anesthesia in older patients with a history of alcohol abuse.
Methods: Subjects aged 55 yr and older with self-reported alcohol abuse (n = 28) and age-, sex-, education-matched nonalcoholic controls (n = 28) were tested using a neurocognitive battery before and 2 weeks after elective surgery (n = 28) or a corresponding time interval without surgery (n = 28). Verbal memory, visuospatial memory, and executive functions were assessed. A neurologic examination was performed to exclude subjects with potential cerebrovascular damage.
Results: Significant three-way interactions (analysis of variance) for Visual Immediate Recall, Visual Delayed Recall, Semantic Fluency, Phonemic Fluency, and the Color-Word Stroop Test implied that cognitive performance in the alcoholic group decreased after surgery more than it did in the other three groups.
Conclusions: The results suggest that a history of alcohol abuse in older patients presents a risk for postoperative cognitive impairment in the domains of visuospatial abilities and executive functions that may have important implications for quality of life and health risks.

Postoperative Cognitive Dysfunction in Patients with Preoperative Cognitive Impairment: Which Domains Are Most Vulnerable?
2006 Journal Symposium Postoperative Cognitive Dysfunction
Silverstein, Jeffrey H. M.D. ; Steinmetz, Jacob M.D. ; Reichenberg, Abraham Ph.D. ; Harvey, Philip D. Ph.D. ; Rasmussen, Lars S. M.D., Ph.D. 
Anesthesiology. 106(3):431-435, March 2007.

Abstract:
Background: The authors explored the database of the first International Study of Postoperative Cognitive Dysfunction study to specify the domains of cognitive function that were most vulnerable and to determine the pattern of deterioration in patients with preoperative cognitive impairment.
Methods: One thousand two hundred eighteen patients were included in the first International Study of Postoperative Cognitive Dysfunction, where neuropsychological testing was performed at entry to the study, at 1 week, and at 3 months after surgery. The authors' analyses determined the extent to which seven neuropsychological measures changed after surgery with focus on the relation with preoperative cognitive impairment, defined as a preoperative score 1.5 SD below healthy controls in the memory test.
Results: Preoperative cognitive impairment was found in 74 patients at baseline. At 1 week, cognitive deterioration was seen in all tests, but in particular in the Letter Digit Coding and the time of the Stroop interference test, with 14% and 16% of the total sample (n = 1,016) exceeding 2 SD, respectively. At 3 months, deterioration was more uniform. Significantly fewer in the preoperative cognitive impairment group had deterioration in the memory test, both at 1 week and at 3 months, with no patient displaying a deterioration exceeding 2 SD.
Conclusions: Postoperative cognitive deterioration was seen in all tests, although most commonly in attention and cognitive speed at 1 week. Deterioration in memory was difficult to detect after surgery in patients with preoperative cognitive impairment.

When Is a Bispectral Index of 60 Too Low?: Rational Processed Electroencephalographic Targets Are Dependent on the Sedative-Opioid Ratio.
Clinical Investigations
Manyam, Sandeep C. Ph.D. ; Gupta, Dhanesh K. M.D. ; Johnson, Ken B. M.D. ; White, Julia L. R.N., B.S., C.C.R.C. ; Pace, Nathan L. M.D., M.Stat. ; Westenskow, Dwayne R. Ph.D. ; Egan, Talmage D. M.D. 
Anesthesiology. 106(3):472-483, March 2007.

Abstract:
Background: Opioids are commonly used in conjunction with sedative drugs to provide anesthesia. Previous studies have shown that opioids reduce the clinical requirements of sedatives needed to provide adequate anesthesia. Processed electroencephalographic parameters, such as the Bispectral Index (BIS; Aspect Medical Systems, Newton, MA) and Auditory Evoked Potential Index (AAI; Alaris Medical Systems, San Diego, CA), can be used intraoperatively to assess the depth of sedation. The aim of this study was to characterize how the addition of opioids sufficient to change the clinical level of sedation influenced the BIS and AAI.
Methods: Twenty-four adult volunteers received a target-controlled infusion of remifentanil (0-15 ng/ml) and inhaled sevoflurane (0-6 vol%) at various target concentration pairs. After reaching pseudo-steady state drug levels, the modified Observer's Assessment of Alertness/Sedation score, BIS, and AAI were measured at each target concentration pair. Response surface pharmacodynamic interaction models were built using the pooled data for each pharmacodynamic endpoint.
Results: Response surface models adequately characterized all pharmacodynamic endpoints. Despite the fact that sevoflurane-remifentanil interactions were strongly synergistic for clinical sedation, BIS and AAI were minimally affected by the addition of remifentanil to sevoflurane anesthetics.
Conclusion: Although clinical sedation increases significantly even with the addition of a small to moderate dose of remifentanil to a sevoflurane anesthetic, the BIS and AAI are insensitive to this change in clinical state. Therefore, during "opioid-heavy" sevoflurane-remifentanil anesthetics, targeting a BIS less than 60 or an AAI less than 30 may result in an unnecessarily deep anesthetic state.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Analgesic and antiemetic effect of ketorolac vs. betamethasone or dexamethasone after ambulatory surgery
K. S. Thagaard, H. H. Jensen, J. Raeder
Acta Anaesthesiologica Scandinavica 2007; 51 (3), 271–277.

Background: Glucocorticoids are known to provide slower onset and more prolonged duration of analgesic effect than ketorolac. In the present study, we wanted to evaluate the effect over time from a single dose of either intravenous (i.v.) dexamethasone or an intramuscular (i.m.) depot formulation of betamethasone compared with i.v. ketorolac.
Materials and methods: One hundred and seventy-nine patients admitted for mixed ambulatory surgery were included in the study. After induction of general i.v. anaesthesia, the patients were randomized to receive double-blindly either dexamethasone 4 mg i.v. (Group D) or betamethasone depot formulation 12 mg i.m. (Group B) or ketorolac 30 mg i.v. (Group K). Fentanyl was used for rescue analgesic medication in the post-operative care unit (PACU) and codeine with paracetamol after discharge, for a study period of 3 days.
Results: There was significantly less post-operative pain in the ketorolac group during the stay in the unit (88% with minor or less pain in Group K vs. 74% and 67% in Groups D and B, respectively, P < 0.05), significantly less need for rescue medication (P < 0.05) and significantly less nausea or vomiting (12% in Group K vs. 30% in the other groups pooled, P < 0.05). The ketorolac patients were significantly faster for ready discharge, median 165 min vs. 192 min and 203 min in Groups D and B, respectively (P < 0.01). There were no differences between the groups in perceived pain, nausea, vomiting or rescue analgesic consumption in the 4- to 72-h period.
Conclusion: Dexamethasone 4 mg or bethamethasone 12 mg did not provide prolonged post-operative analgesic effect compared with ketorolac 30 mg, which was superior for analgesia and antiemesis in the PACU.

Do patients profit from physostigmine in recovery from desflurane anaesthesia?
K. D. Röhm, J. Riechmann, J. Boldt, T. Schöllhorn, S. N. Piper
Acta Anaesthesiologica Scandinavica 2007; 51 (3), 278–283.

Background: Physostigmine is the drug of choice in the central anticholinergic syndrome, but has also been used in post-operative mental derangement secondary to sedatives and volatile anaesthetics. The aim of this double-blind, randomized, prospective study was to determine whether physostigmine alters recovery after desflurane anaesthesia.
Methods: One hundred patients undergoing urologic or surgical procedures were enrolled to receive either NaCl 0.9% (n = 50) or 2 mg of physostigmine (n = 50) at the end of general anaesthesia with propofol, fentanyl, cisatracurium and desflurane. Times to extubation, stating name, birthday and place of residence, and obeying commands such as eye opening and hand squeezing were noted. Haemodynamics, Aldrete and pain scores, the analgesic requirements, and any adverse side-effects were documented until the 1st post-operative day.
Results: Demographic, peri-operative data including duration of anaesthesia, surgery and postanaesthetic care unit (PACU) stay, and consumption of anaesthetics were comparable in both groups. No significant difference between the groups was found for extubation time or other emergence parameters. Patients undergoing anaesthesia >150 min showed after receiving physostigmine significantly (P < 0.05) faster spontaneous breathing (2.6 ± 3.1 vs. placebo 5.0 ± 4.2 min) and extubation time (6.2 ± 3.7 vs. placebo 8.8 ± 5.0 min). Women showed significantly shorter extubation times (5.5 ± 3.4 min) and eye opening (5.5 ± 2.6 min) with physostigmine than placebo (7.7 ± 4.5 and 7.8 ± 4.0 min). The incidence of post-operative nausea and vomiting (PONV) was significantly higher after physostigmine than placebo, whereas shivering occurred more often after placebo.
Conclusion: Physostigmine does not alter desflurane-based anaesthesia compared with placebo. An option is to use physostigmine in patients with a duration of anaesthesia >150 min who profit in earlier return to spontaneous breathing and shorter extubation time.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis
M. Naguib, A. F. Kopman and J. E. Ensor
British Journal of Anaesthesia 2007 98(3):302-316

We conducted a meta-analysis to examine the effect of intraoperative monitoring of neuromuscular function on the incidence of postoperative residual curarisation (PORC). PORC has been considered present when a patient has a train-of-four (TOF) ratio of < 0.7 or < 0.9. We analysed data from 24 trials (3375 patients) that were published between 1979 and 2005. We excluded data on mivacurium from this meta-analysis because only three studies had examined the incidence of PORC associated with its use. Long- and intermediate-acting neuromuscular blocking drugs had been given to 662 and 2713 patients, respectively. Neuromuscular function was monitored in 823 patients (24.4%). A simple peripheral nerve stimulator was used in 543 patients, and an objective monitor was used in 280. The incidence of PORC was found to be significantly lower after the use of intermediate neuromuscular blocking drugs. We could not demonstrate that the use of an intraoperative neuromuscular function monitor decreased the incidence of PORC.

Trendelenburg position with hip flexion as a rescue strategy to increase spinal anaesthetic level after spinal block
J.-T. Kim, J.-K. Shim, S.-H. Kim, C.-W. Jung and J.-H. Bahk
British Journal of Anaesthesia 2007 98(3):396-400 

BACKGROUND: When the level achieved by a spinal anaesthetic is too low to perform surgery, patients are usually placed in the Trendelenburg position. However, cephalad spread of the hyperbaric spinal anaesthetics may be limited by the lumbar lordosis. The Trendelenburg position with the lumbar lordosis flattened by hip flexion was evaluated as a method to extend the analgesic level after the administration of hyperbaric local anaesthetic.
METHODS: When the pinprick block level was lower than T10 5 min after intrathecal injection of hyperbaric bupivacaine (13 mg), patients were recruited to the study and randomly allocated to one of the two positions: the Trendelenburg position with hip flexion (hip flexion group, n = 20) and the Trendelenburg position without hip flexion (control group, n = 20). Each assigned position was maintained for 5 min and then patients were returned to the horizontal supine position. Spinal block level was assessed by pinprick, cold sensation, and modified Bromage scale at intervals for the following 150 min.
RESULTS: The maximum level of pinprick and cold sensory block [median (range)] was higher in the hip flexion group [T4 (T8–C6) and T3 (T6–C2)] compared with the control group [T7 (T12–T4) and T5 (T11–T3)] (P < 0.001). The maximum motor blockade median (range) was not different between the two groups being 3 (3–3) in the hip flexion group vs 3 (0–3) in the control group.
CONCLUSIONS: When the level of spinal anaesthesia is lower than required, flexion of the hips in the Trendelenburg position may be useful as a strategy attempt to increase the level of the block.

CANADIAN JOURNAL OF ANESTHESIA - TOP

A heated humidifier does not reduce laryngo- pharyngeal complaints after brief laryngeal mask anesthesia
Duk-Kyung Kim, MD, Ka-Young Rhee, MD, Won-Kyoung Kwon, MD, Tae-Yop Kim, MD and Joo-Eun Kang, MD
Canadian Journal of Anesthesia 54:134-140 (2007)
 
Purpose: Warming and humidification of inspired gases is standard care for intubated patients whose lungs are ventilated mechanically for prolonged periods. We examined whether active humidification of inspired gases might reduce laryngo-pharyngeal discomfort in patients undergoing brief laryngeal mask airway (LMA) anesthesia.
Methods: In a prospective trial, 200 adult patients undergoing elective surgery under general anesthesia were randomly assigned to receive ventilation without airway warming and exogenous humidification (Group C - control), or active warming and humidification of inspired gases (Group HUM - humidified), using a humidifier with a heated wire circuit. Inhalational anesthesia was maintained via a circle system. The temperatures and relative humidities of inspired gases were monitored continuously throughout surgery. Postoperative sore throat, dysphonia, and dysphagia were assessed one and 24 hr after anesthesia. Whenever symptoms were present, their severities were graded using a 101-point numerical rating scale.
Results: The mean temperature and relative humidity of the inspired gases in Group HUM were greater compared to Group C (36.1 ± 0.4°C and 99.5 ± 0.5% vs 26.9 ± 0.8°C and 76.4 ± 10.9%, respectively). Postoperatively, the overall frequencies of laryngeal and pharyngeal discomfort were similar in the two groups (53.8% and 54.9% in Group C vs 51.6% and 41.9% in Group HUM at one and 24 hr respectively, P > 0.05). The groups were also similar with respect to the severity scores of laryngo-pharyngeal discomfort.
Conclusion: Active warming and humidification of inspired gases has no clinically appreciable effect in reducing the incidence and severity of laryngo-pharyngeal complaints after brief (< two hours) LMA anesthesia.

Protocol implementation in anesthesia: beta-blockade in non-cardiac surgery patients
Alan D. Baxter, MD FRCPC and Salmaan Kanji, PharmD
Canadian Journal of Anesthesia 54:114-123 (2007)

Purpose: An audit of intensive care unit (ICU) patients with perioperative myocardial ischemia and/or infarction (PMI/I) suggested under-use of prophylactic beta-adrenergic blocking drugs (ABDs). A multidisciplinary team developed an institutional protocol to identify at-risk patients, to standardize and facilitate prophylactic beta-adrenergic blockade, and to improve management of such patients. We report a retrospective assessment of the efficiency of program implementation.
Methods: Eligible preanesthesia assessment unit patients received metoprolol for one to four weeks prior to surgery, intraoperatively, and postoperatively. Patients with PMI/I requiring ICU admission were tracked from January 2002 to December 2004. The protocol was implemented in May 2003. The efficiency of program implementation was evaluated during two months of normal operating room activity (September 2003 and February 2004).
Results: The use of ABDs increased during the audit. Preoperative use increased from 31% in September 2003 to 39% of eligible patients in February 2004, with a stable surgical population. The incidence of patients with PMI/I admitted to ICU decreased from 2.6/1,000 surgical cases pre-implementation to 1.6/1,000 surgical cases post-implementation (P = 0.025). For the whole hospital, implementation was associated with a decrease in PMI/I incidence from 5.9 to 2.0/1,000 surgical cases (P < 0.001).
Conclusion: Heightened awareness and standardization of perioperative beta-blockade coincided with an increase in metoprolol use in at-risk patients and reduction in PMI/I. There was an increase in at-risk patients receiving prophylactic ABDs, a reduction in PMI/I diagnoses throughout the hospital, and reduced ICU patient admissions with PMI/I.

The sniffing position provides greater occipito-atlanto-axial angulation than simple head extension: a radiological study
Ichiro Takenaka, MD, Kazuyoshi Aoyama, MD, Tamao Iwagaki, MD, Hiroshi Ishimura, MD and Tatsuo Kadoya, MD
Canadian Journal of Anesthesia 54:129-133 (2007)

Purpose: While the anatomic sniffing position has traditionally been considered the standard head and neck position for laryngoscopy, recent evidence suggests that the sniffing position provides no significant advantage over simple head extension. To establish if the sniffing position provides an anatomic advantage, we compared the occipito-atlanto-axial extension angle, a key determinant for obtaining a good laryngeal view during laryngoscopy, in simple head extension and sniffing positions.
Methods: Thirty volunteers with normal cervical spines were studied. Radiological examinations of the lateral cervical spine were taken and compared in each of the following three positions for each subject: neutral position (flat on the table with no pillow and without head extension or flexion); simple head extension (head maximally extended without a pillow); and the sniffing position (head extension with cervical flexion obtained by 7 cm occipital elevation).
Results: Mean angles of the occipito-atlanto-axial extension in simple head extension and the sniffing position were 20.4°± 5.1° and 24.2°± 5.6°, respectively (P < 0.01).
Conclusion: The anatomic sniffing position provides greater occipito-atlanto-axial extension compared to simple head extension. These findings should be taken into consideration when optimizing patient positioning for laryngoscopy.

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A novel index of elevated risk of inpatient hospital admission immediately following outpatient surgery.
Fleisher LA, Pasternak LR, Lyles A.
Department of Anesthesia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA. fleishel@uphs.upenn.edu
Arch Surg. 2007 Mar;142(3):263-8. 

HYPOTHESIS: Patients with increasing comorbidities are at increased risk of admission to an inpatient facility after outpatient surgery. DESIGN AND SETTING: Data from operations performed in hospital-based and freestanding ambulatory surgery centers in New York during 1997 were obtained under the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.
PATIENTS: Of the 783 558 patients eligible for inclusion in this study, 4351 were discharged directly for short-term hospitalization (1:180), and 19 died (1:41 240). We performed a split-half analysis by randomly assigning the study sample to an analysis half for estimation or a holdout half for testing.
MAIN OUTCOME MEASURES: We developed an outpatient surgery admission index from independent predictors of immediate hospital admission using the following point values: 65 years or older (1), operating time longer than 120 minutes (1), cardiac diagnoses (1), peripheral vascular disease (1), cerebrovascular disease (1), malignancy (1), seropositive findings for human immunodeficiency virus (1), and regional (1) or general anesthesia (2).
RESULTS: Increasing scores were associated with higher odds of admission relative to scores of 0 or 1. For scores of 4 or higher, the odds ratio was 31.96 (95% confidence interval, 26.29-38.86), and 2.8% of these patients were discharged to the hospital. For the holdout half of the data set, scores of 4 or higher had an odds ratio of 34.62 (95% confidence interval, 28.55-41.97).
CONCLUSION: The proposed outpatient surgery admission index provides an evidence-based guide to assist clinicians and the health care systems in which they work in identifying patients at higher risk of immediate hospital admission.

Maximum cumulative doses of sedation medications for in-office use.
Donaldson M, Goodchild JH.
Kalispell Regional Medical Center, Montana, USA.
Gen Dent. 2007 Mar-Apr;55(2):143-8; quiz 149, 167-8.

The AGD acknowledges that dentists may need an additional permit to perform the procedure described in this article. Many states require dental practitioners to have additional or advanced training in order to perform enteral sedation. In some states, practitioners must have an i.v./conscious sedation permit before they are allowed to titrate (dose) oral medication. The ADA does not believe that oral medication can be titrated (dosed) without an i.v. sedation license. The AGD has adopted and published a white paper on sedation issues, which appeared in the September-October 2006 issue of General Dentistry. The AGD encourages continuing education in sedation modalities for general dentists. Oral conscious sedation (OCS) is an increasingly common practice in dentistry and is at the forefront of evolving state regulations. At the center of the OCS controversy is the oral titration of medications. Most medications available for OCS are used in an "off-label" manner and have no determined maximum recommended dosage for that purpose. This article proposes cumulative maximum dosing guidelines for in-office OCS, with an emphasis on triazolam.

A comparison of spinal anesthesia with small-dose lidocaine and general anesthesia with fentanyl and propofol for ambulatory prostate biopsy procedures in elderly patients.
Nishikawa K, Yoshida S, Shimodate Y, Igarashi M, Namiki A
Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, 060-8543 Hokkaido, Japan.
J Clin Anesth. 2007 Feb;19(1):25-9.  

STUDY OBJECTIVE: To compare operating conditions, intraoperative adverse events, recovery profiles, postoperative adverse effects, patient satisfaction, and costs of small-dose lidocaine spinal anesthesia with those of general anesthesia using fentanyl and propofol for elderly outpatient prostate biopsy. DESIGN: Prospective, randomized, blind study.
SETTING: Outpatient anesthesia unit at a municipal hospital. PATIENTS: 80 ASA physical status I and II patients, aged 65 to 80 years, scheduled for outpatient prostate biopsy.
INTERVENTIONS: Patients were assigned to receive either spinal anesthesia with 10 mg of hyperbaric 1% lidocaine (L group, n = 40) or anesthetic induction with fentanyl 1 mug . kg(-1) IV and 1.0 mg . kg(-1) propofol injected at 90 mg . kg(-1) . h(-1), followed by continuous infusion at 6 mg . kg(-1) . h(-1) (F/P group, n = 40).
MEASUREMENTS AND MAIN RESULTS: Both anesthetic techniques provided acceptable operating conditions for the surgeon. However, a significantly higher frequency of intraoperative hypotension was found in the F/P group than in the L group (P < 0.05). Time to home readiness was shorter in the F/P group (P < 0.05). Both techniques had no major postoperative adverse effects and resulted in a high rate of patient satisfaction. Total costs were significantly lower in the L group than in the F/P group (P < 0.01).
CONCLUSIONS: Spinal anesthesia with 10 mg of hyperbaric 1% lidocaine may be a more suitable alternative to general anesthesia with fentanyl and propofol for ambulatory elderly prostate biopsy in terms of safety and costs.

Cost savings of unsedated office-based laser surgery for laryngeal papillomas.
Rees CJ, Postma GN, Koufman JA.
Department of Otolaryngology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Ann Otol Rhinol Laryngol. 2007 Jan;116(1):45-8.

OBJECTIVES: Unsedated office-based laryngeal laser surgery (UOLS) is now an effective alternative to traditional operating room-based suspension microdirect laryngoscopy under general anesthesia. This procedure includes pulsed dye laser (PDL) treatment of recurrent respiratory papillomas, granulomas, leukoplakia, and polypoid degeneration. The objective of this study was to determine the magnitude of the cost savings derived by moving these types of procedures from the operating room to the office setting.
METHODS: Retrospective cost-identification analysis was performed by comparing the billing records of patients who underwent surgical laser treatment for recurrent respiratory papillomatosis in the operating room to the costs and charges for patients who underwent similar procedures with the in-office PDL.
RESULTS: In performing surgery with the PDL in the office, the average cost savings was more than $5,000 per case. Current reimbursement rates do not cover the cost of performing UOLS.
CONCLUSIONS: The potential cost savings of UOLS are tremendous; however, at present significant financial disincentives prevent proliferation of this technology.

Outpatient parathyroid surgery and the differences seen in the morbidly obese.
Norman J, Aronson K.
Norman Endocrine Surgery Clinic, Tampa, FL 33606, USA. jnorman@parathyroid.com
Otolaryngol Head Neck Surg. 2007 Feb;136(2):282-6.

OBJECTIVE: This prospective study examined rapid patient discharge after routine parathyroidectomy to identify differences between morbidly obese and non-morbidly obese patients. The efficacy of supplemental calcium in preventing postoperative hypocalcemia was also assessed.
METHODS: Between March 2003 and June 2004, 842 patients with primary hyperparathyroidism underwent outpatient parathyroid surgery. Morbid obesity was defined as 100 pounds above ideal body weight and/or body mass index greater than 39.
RESULTS: Fifty-one (6.1%) patients were morbidly obese (mean, 261 lbs; body mass index=45) compared with 791 non-morbidly obese patients (mean, 172 lbs; body mass index=28, P<.001). Morbidly obese patients were more likely to require conversion of laryngeal masked airway to endotracheal intubation (P<.05). Incision length, total operative times, and the total time spent in the post-anesthesia care unit were longer for morbidly obese patients (all, P<.05). Of the 842 patients, only four, all non-morbidly obese, spent the night after their operation. No postoperative untoward events occurred in either group.
CONCLUSIONS: Immediate discharge after routine parathyroid surgery is extremely safe for nearly all patients although morbid obesity is associated with a longer operation, a more difficult airway, and a longer stay in the recovery room.

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