Volume 3, Issue 12 S A M B A T A L K S - PAGE 3 May, 2004

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

Perioperative Rofecoxib Improves Early Recovery After Outpatient Herniorrhaphy
Hong Ma, MD, PhD, Jun Tang, MD, Paul F. White, PhD, MD, FANZCA, Alan Zaentz, MD, Ronald H. Wender, MD, Alexander Sloninsky, MD, Robert Naruse, MD, Robert Kariger, MD, Raymond Quon, Dennis Wood, MD, and Brendan J. Carroll, MD Section Editor
Anesth Analg 2004;98:970-975

Non-opioid analgesics have become increasingly popular as part of a multimodal regimen for pain management in the ambulatory setting. We designed this randomized, double-blind, placebo-controlled study to evaluate the effect of perioperative administration of the cyclooxygenase-2 inhibitor rofecoxib on patient outcome after inguinal herniorrhaphy procedures. Sixty consenting outpatients undergoing elective hernia repair surgery were randomly assigned to one of two treatment groups: control (vitamin C, 500 mg) or rofecoxib (rofecoxib, 50 mg). The first oral dose of the study medication was administered 30–40 min before entering the operating room, and a second dose of the same medication was given on the morning of the first postoperative day. Recovery times, postoperative pain scores, the need for "rescue" analgesics, and side effects were recorded at 1- to 10-min intervals before discharge from the recovery room. Follow-up evaluations were performed at 36 h, 7 days, and 14 days after surgery to assess postdischarge pain, analgesic requirements, resumption of normal activities, as well as patient satisfaction with their postoperative pain management. Rofecoxib significantly decreased the early recovery times, leading to an earlier discharge home after surgery (88 ± 30 vs 126 ± 44 min, P < 0.05). When compared with the control group, the patients’ median [range] quality of recovery score was also significantly higher in the rofecoxib group (18 [14–18] vs 16 [13–18], P < 0.05). In the predischarge period, a significantly larger percentage of patients required rescue pain medications in the control group (67% vs 37% in the rofecoxib group, P < 0.05). At the 36-h follow-up assessment, rofecoxib-treated patients reported significantly reduced oral analgesic requirements (0 [0–20] vs 9 [1–33] pills, P < 0.05) and lower maximal pain scores, resulting in improved patient satisfaction with their postoperative pain management (3 [1–4] vs 2 [0–3], P < 0.05). However, there were no differences in the times required to resume their activities of daily living. In conclusion, perioperative rofecoxib, 50 mg per os, significantly decreased postoperative pain and the need for analgesic rescue medication, leading to a faster and improved quality of recovery after outpatient hernia surgery. However, perioperative use of rofecoxib failed to improve recovery end points in the postdischarge period.
IMPLICATIONS: Rofecoxib (50 mg per os), given before and after surgery, was effective in improving postoperative pain management, as well as the speed and quality of recovery after outpatient inguinal herniorrhaphy. However, it failed to accelerate the postdischarge resumption of normal activities of daily living.

Modafinil Improves Recovery After General Anesthesia
Ghassem E. Larijani, PharmD, Michael E. Goldberg, MD, Mohammadreza Hojat, PhD, Behnam Khaleghi, MD, Jeffrey B. Dunn, MD, and Alex T. Marr, CRNA
Anesth Analg 2004;98:976-981

Recovery from general anesthesia often involves residual sedation, drowsiness, fatigue, and lack of energy that may last hours to days. Modafinil is a wakefulness-promoting drug approved for patients with excessive daytime sleepiness associated with narcolepsy. We evaluated the effect of single doses of modafinil (200 mg) and placebo in patients recovering from general anesthesia. Thirty-four subjects participated in this prospective, randomized, double-blind study approved by our IRB. Preoperatively, patients were asked to rate various symptoms they had experienced over the previous 24-h using a verbal analog scale (VAS) of 0 to 10 as well as discrete scale when indicated. Postoperatively, once the patient was able to tolerate oral intake and met our institutional discharge criteria, the study drug (modafinil 200 mg or placebo) was administered with a sip of water. Patients were contacted 24 (1) hours after dosing to evaluate postdischarge symptoms. Patients in the placebo group reported significantly more postoperative fatigue (4.8 [3.3] versus 1.4 [1.8]), exhaustion (4.3 [3.3] versus 2.4 [3.1]), or degree of feeling worn out (4.7 [3.6] versus 2.9 [2.4]). Significantly more patients reported moderate to severe fatigue in the placebo group (65% versus 12%). Two major themes of "alertness" and "energy" were expressed by 71% of the patients receiving modafinil versus 18% of those receiving placebo. Patients recovering from general anesthesia can significantly benefit from modafinil.
IMPLICATIONS: Modafinil significantly reduces fatigue and improves feelings of alertness and energy in postoperative patients. Patients recovering from general anesthesia can significantly benefit from modafinil administration.

Warm Steaming Enhances the Topical Anesthetic Effect of Lidocaine
Young-Chang P. Arai, MD, and Wasa Ueda, MD
Anesth Analg 2004;98:982-985

Warm steaming has been used for hydrating the skin, thereby increasing its permeability. We studied whether skin pretreatment with a steamed towel (at 45°C) for 5 min could enhance the anesthetic effect of a topical lidocaine tape in 14 female volunteers. After each volunteer received the skin pretreatment on one of the forearms, lidocaine tape was applied for 30 min on both the treated and the untreated forearms. Superficial anesthesia was scored by recording the number of painful experience during 5 pinpricks delivered with a 27-gauge needle. To assess anesthesia of the deeper layer, single insertion of a 27-gauge needle to a depth of 3 mm was made and pain was scored by a visual analog scale (VAS). There were significant reductions in the scores of superficial anesthesia (median [range]: treated arm, 2 [0–5], versus untreated arm, 4 [1–5]; P < 0.01) and the VAS scores of deeper insertion (median [range]: treated arm, 4.5 [0–8], versus untreated arm, 8 [2–10]; P < 0.01). In conclusion, the application of a warm steamed towel enhanced the anesthetic effect of a topical lidocaine tape.
IMPLICATIONS: We showed that the skin pretreatment with a steamed towel (at 45°C) enhanced the anesthetic effect of a topical lidocaine tape in female volunteers.

Patient Satisfaction with Preoperative Assessment in a Preoperative Assessment Testing Clinic
David L. Hepner, MD, Angela M. Bader, MD, Shelley Hurwitz, PhD, MS, MA, Michael Gustafson, MD, MBA, and Lawrence C. Tsen, MD Section Editor
Anesth Analg 2004;98:1099-1105

Preoperative Assessment Testing Clinics (PATCs) coordinate preoperative surgical, anesthesia, nursing, and laboratory care. Although such clinics have been noted to lead to efficiencies in perioperative care, patient experience and satisfaction with PATCs has not been evaluated. We distributed a one-page questionnaire consisting of satisfaction with clinical and nonclinical providers to patients presenting to our PATC over three different time periods. Eighteen different questions had five Likert scale options that ranged from excellent (5) to poor (1). We achieved a 71.4% collection rate. The average for the subscale that indicated overall satisfaction was 4.48 ± 0.67 and the average for the total instrument was 4.46 ± 0.55. Although the highest scores were given for subscales describing the anesthesia, nurse, and lab, only the anesthesia subscale improved with time (P = 0.007). The subscale that involved information and communication had the highest correlation with the overall satisfaction subscale (r = 0.76; P < 0.0001). The satisfaction with the total duration of the clinic visit (3.71 ± 1.26) was significantly less (P < 0.0001) than the satisfaction to the other items. The authors conclude that the practitioner and functional aspects of the preoperative visit have a significant impact on patient satisfaction, with information and communication versus the total amount of time spent being the most positive and negative components, respectively.
IMPLICATIONS: Patient satisfaction can serve as an important indicator of the quality of preoperative care delivered in Preoperative Assessment Testing Clinics (PATC). Information and communication, both from clinical and nonclinical service providers, remain the most important positive components, and the total duration of the clinic visit represents the most negative component, of patient satisfaction in a PATC.

Preoperative Ketamine Improves Postoperative Analgesia After Gynecologic Laparoscopic Surgery
Rebecca F. K. Kwok, FANZCA, Jean Lim, FHKCA, Matthew T.V Chan, FANZCA, Tony Gin, MD, FRCA, FANZCA, and Wallace K.Y. Chiu, FRCA
Anesth Analg 2004;98:1044-1049

In this study, we evaluated the preemptive effect of a small dose of ketamine on postoperative wound pain. In a randomized, double-blinded, controlled trial, we compared the analgesic requirement in patients receiving preincision ketamine with ketamine after skin closure or placebo after gynecologic laparoscopic surgery. One-hundred-thirty-five patients were randomly assigned to receive preincision or postoperative ketamine 0.15 mg/kg or saline IV. Anesthetic technique was standardized. Patients were interviewed regularly up to 4 wk after surgery. Pain score, morphine consumption, side effects, and quality of recovery score were recorded. Patients receiving preincision ketamine had a lower pain score in the first 6 h after operation compared with the postoperative (P = 0.001) or placebo groups (P < 0.001). The mean (95% confidence intervals) time to first request for analgesia in the preincision group, 1.8 h (1.4–2.1), was longer than the postoperative group, 1.2 h (0.9–1.5; P < 0.001), or the placebo group, 0.7 h (0.4–0.9; P < 0.001). The mean ± SD morphine consumption in the preincision group, 1.5 ± 2.0 mg, was less than that in the postoperative group, 2.9 ± 3.1 mg (P = 0.04) and the placebo group, 3.4 ± 2.7 mg (P = 0.003). There was no significant difference among groups with respect to hemodynamic variables or side effects. No patient complained of hallucinations or nightmares. We conclude that a small dose of ketamine is not only safe, but it also provides preemptive analgesia in patients undergoing gynecologic laparoscopic surgery.
IMPLICATIONS: In women undergoing laparoscopic gynecologic surgery, a small preoperative dose of ketamine (0.15 mg/kg) produced preemptive analgesia. There were no significant hemodynamic and psychological side effects with this dose.

ANESTHESIOLOGY - TOP

Recurrent Hypoxemia in Young Children with Obstructive Sleep Apnea Is Associated with Reduced Opioid Requirement for Analgesia
Brown, Karen A. M.D.; Laferrière, André B.A.; Moss, Immanuela Ravé M.D., Ph.D.
Anesthesiology : Volume 100(4) April 2004 pp 806-810

Background: Obstructive sleep apnea (OSA) in children is often associated with recurrent hypoxemia during sleep. In developing animals, central opioid neuropeptide content is high, and opioid receptors are up-regulated after recurrent hypoxia. The authors hypothesized that children with recurrent hypoxemia due to OSA might have altered central opioid functionality that could affect their responsiveness to opioid drugs. Using a retrospective database, we assessed the relation of age and preoperative oxygen saturation to the cumulative postoperative morphine dose administered for analgesia in children with OSA undergoing adenotonsillectomy.
Methods: Inclusion criteria were (1) adenotonsillectomy for OSA; (2) no concomitant pathology; (3) intraoperative administration of short-acting opioid drugs; (4) endotracheal extubation on awakening in the operating room; and (5) morphine as the parenteral, postoperative analgesic.
Results: Forty-six children (16 girls) fulfilled the inclusion criteria. Age and preoperative arterial oxygen saturation (SaO₂) nadir, either individually ( P = 0.023, P = 0.0003, respectively) or in combination ( P = 0.00009), exhibited a significant correlation to the morphine dose required for analgesia. Four of these children, aged 26.5 ± 13.2 months, with a preoperative SaO₂ nadir of 70.3 ± 12.9%, did not require any postoperative morphine for analgesia at all.
Conclusions: The authors speculate that the reduced morphine requirement for analgesia in children displaying oxygen desaturation associated with severe OSA may be related to their young age and to an up-regulation of central opioid receptors consequent to recurrent hypoxemia. In evaluating OSA in children, preoperative determination of the SaO₂ nadir is important for predicting the postoperative opioid dosage required for analgesia.

Does the Use of Electroencephalographic Bispectral Index or Auditory Evoked Potential Index Monitoring Facilitate Recovery after Desflurane Anesthesia in the Ambulatory Setting?
White, Paul F. Ph.D., M.D., F.A.N.Z.C.A.; Ma, Hong M.D., Ph.D.; Tang, Jun M.D.; Wender, Ronald H. M.D.; Sloninsky, Alexander M.D.; Kariger, Robert M.D.
Anesthesiology : Volume 100(4) April 2004 pp 811-817

Background: Analogous to the Bispectral Index® (BIS®) monitor, the auditory evoked potential monitor provides an electroencephalographic-derived index (AAI), which is alleged to correlate with the central nervous system depressant effects of anesthetic drugs. This clinical study was designed to test the hypothesis that intraoperative cerebral monitoring guided by either the BIS or the AAI value would facilitate recovery from general anesthesia compared with standard clinical monitoring practices alone in the ambulatory setting. Methods: Sixty consenting outpatients undergoing gynecologic laparoscopic surgery were randomly assigned to one of three study groups: (1) control (standard practice), (2) BIS guided, or (3) AAI guided. Anesthesia was induced with 1.5-2.5 mg/kg propofol and 1-1.5 μg/kg fentanyl given intravenously. Desflurane, 3%, in combination with 60% nitrous oxide in oxygen was administered for maintenance of general anesthesia. In the control group, the inspired desflurane concentration was varied based on standard clinical signs. In the BIS- and AAI-guided groups, the inspired desflurane concentrations were titrated to maintain BIS and AAI values in targeted ranges of 50-60 and 15-25, respectively. BIS and AAI values, hemodynamic variables, and the end-tidal desflurane concentration were recorded at 5-min intervals during the maintenance period. The emergence times and recovery times to achieve specific clinical endpoints were recorded at 1- to 10-min intervals. The White fast-track and modified Aldrete recovery scores were assessed on arrival in the PACU, and the quality of recovery score was evaluated at the time of discharge home.
Results: A positive correlation was found between the AAI and BIS values during the maintenance period. The average BIS and AAI values (mean ± SD) during the maintenance period were significantly lower in the control group (BIS, 41 ± 10; AAI, 11 ± 6) compared with the BIS-guided (BIS, 57 ± 14; AAI, 18 ± 11) and AAI-guided (BIS, 55 ± 12; AAI, 20 ± 10) groups. The end-tidal desflurane concentration was significantly reduced in the BIS-guided (2.7 ± 0.9%) and AAI-guided (2.6 ± 0.9%) groups compared with the control group (3.6 ± 1.5%). The awakening (eye-opening) and discharge times were significantly shorter in the BIS-guided (7 ± 3 and 132 ± 39 min, respectively) and AAI-guided (6 ± 2 and 128 ± 39 min, respectively) groups compared with the control group (9 ± 4 and 195 ± 57 min, respectively). More importantly, the median [range] quality of recovery scores was significantly higher in the BIS-guided (18 [17-18]) and AAI-guided (18 [17-18]) groups when compared with the control group (16 [10-18]).
Conclusion: Compared with standard anesthesia monitoring practice, adjunctive use of auditory evoked potential and BIS monitoring can improve titration of desflurane during general anesthesia, leading to an improved recovery profile after ambulatory surgery.

Can Ropivacaine and Levobupivacaine Be Used as Test Doses during Regional Anesthesia?
Owen, Medge D. M.D.; Gautier, Philippe M.D.; Hood, David D. M.D.
Anesthesiology : Volume 100(4) April 2004 pp 922-925

Background: Lower systemic toxicity reported with ropivacaine and levobupivacaine may produce less reliable recognition of inadvertent intravenous injection during regional anesthesia. This study was undertaken to determine whether ropivacaine and levobupivacaine are suitable for use as intravenous test doses by evaluating central nervous system (CNS) symptoms after intravenous bolus injection.
Methods: Institutional approval and informed consent were granted for the study. One hundred twenty patients scheduled to undergo elective surgery were randomly assigned to receive 5 ml intravenous saline, 100 mg lidocaine, 25 mg ropivacaine, or 25 mg levobupivacaine before anesthesia. Patients reported CNS symptoms after injection and were monitored for hemodynamic change.
Results: Intravenous ropivacaine or levobupivacaine produced CNS symptoms in only 52% and 57% of patients, respectively, compared with 87% of patients after lidocaine ( P < 0.02). Despite preparatory instruction, many patients receiving ropivacaine or levobupivacaine did not spontaneously volunteer symptoms because they were subtle and admitted symptoms only after in-depth questioning by the investigator.
Conclusions: Plain ropivacaine and levobupivacaine (25 mg) solutions are unsuitable for use as intravenous test doses during regional anesthesia because CNS symptoms are insufficient. When using ropivacaine or levobupivacaine for regional anesthesia, for test dose purposes, the authors recommend the addition of epinephrine to the local anesthetic solution or the use of a separate agent with more predictable CNS characteristics.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Spinal anesthesia for arthroscopic knee surgery
Y. Gürkan, H. Canatay, D. Özdamar, M. Solak and K. Toker
Acta Anaesthesiologica Scandinavica 2004; 48(4): 513 -7

Background and objective:  The purpose of the study was to compare the effects of adding 50 µg of morphine, 25 µg of fentanyl or saline to 6 mg of hyperbaric bupivacaine on postoperative analgesia and time to urination in patients undergoing arthroscopic knee surgery under spinal anesthesia.
Methods:  The study was designed in a prospective, randomized, double-blinded and placebo-controlled manner. Sixty ASA I-II patients were randomized into the following three groups: Group BM: 6 mg of bupivacaine and 50 µg of morphine, Group BF: 6 mg of bupivacaine and 25 µg of fentanyl, and Group BS: 6 mg of bupivacaine and saline. Selective spinal anesthesia was performed in a lateral decubitus position, with the operative knee dependent for 10 min.
Results:  In all groups satisfactory anesthesia was provided during the operation. There was a statistically significant difference between all the groups in times to voiding [Group BM 422 ± 161 min; Group BF 244 ± 163 min; Group BS 183 ± 54 min (mean ± SD)]. The incidence of pruritus was significantly greater in Group BM (80%) and BF (65%) in comparison with Group BS (no pruritus) (P < 0.05). The incidence of nausea was significantly increased in Group BM (35%) in comparison with Group BF (10%) and Group BS (P < 0.05). Analgesic consumption was significantly greater in Group BS in comparison with Groups BM and BF (P < 0.01).
Conclusions: We conclude that during spinal anesthesia even mini-dose intrathecal morphine is not acceptable for outpatient surgery due to side-effects, especially severely prolonged time to urination.

Convulsions on anaesthetic induction with sevoflurane in young children.
Akeson J, Didriksson I.
Acta Anaesthesiol Scand. 2004 Apr;48(4):405-7

Increased worldwide use for paediatric anaesthesia of the volatile anaesthetic agent sevoflurane has mainly resulted from its low blood-gas partition coefficient and low airway irritability, providing smooth conditions for rapid induction of anaesthesia. Nevertheless, there are several clinical and experimental reports suggesting a correlation between exposure to sevoflurane and generalized clonic or tonic seizure activity. We report two clinical episodes of convulsions associated with the induction of sevoflurane anaesthesia in young children. Case 1: during induction of anaesthesia with sevoflurane by facemask in a 3-year-old healthy boy, there were symmetrical clonic seizure-like movements of the upper extremities for 60 s. Case 2: on re-induction of anaesthesia with sevoflurane because of profuse bleeding following nasal adenoidectomy in a 4-year-old healthy girl with a family history of epilepsy, there were symmetrical tonic and clonic seizure-like movements for 30-40 s in the upper and lower extremities. Both episodes ceased spontaneously. Although no EEG was recorded, it cannot be excluded that both episodes resulted from seizure activity within the CNS. Based on our observations and reports by others we suggest that, until further notice, sevoflurane should be avoided or at least used cautiously in patients where clinical epileptic activity has been verified or is strongly suspected.

Improved application of Lidocaine/Prilocaine cream in children. A randomized and prospectively controlled study of two application regimes.
Gad LN , Olsen KS , Lysgaard AB, Culmsee M.
Acta Anaesthesiol Scand. 2004 Apr;48(4):491-7

Summary: Intravenous cannulation in children aged 6-12 years is less painful after a 90-min application of a Lidocaine/ Prilocaine cream followed by a 30-min interval without cream, than cannulation immediately after a 60-min application.
Background: Sixty-min application of an eutectic mixture of 25 mg g^-1 Lidocaine and 25 mg g^-1 Prilocaine cream is widely used in both adults and children to alleviate pain related to intravenous cannulation. However, studies have shown that this is not the optimal procedure in adults. Inspired by the results from these studies, the aim of the present study was to find an improved application regime for children.
Methods: In this prospective, randomized, and single-blind study 60 Caucasian children, aged 6-12 years, presenting for an i.v. cannulation were included. The children were allocated to either a 60-min application of anaesthetic cream followed by i.v. cannulation (Group A) or to a 90-min application followed by an interval of 30 min before cannulation (Group B). No sedatives or analgesics were given. The children scored their pain by a faces scale with four faces.
Results : The i.v. cannulations in Group B were less painful than the cannulations in Group A (Mann-Whitney test, P = 0.01). There was no difference between the two groups as regards problems when performing the cannulations.
Conclusion: I.v. cannulation after application of anaesthetic cream for 90 min followed by a 30-min interval is less painful than the widely used 60-min application directly followed by cannulation.

Effect of aminophylline on bispectral index.
Turan A, Memis D, Karamanlyoethlu B, PamukCu Z, Sut N.
Acta Anaesthesiol Scand. 2004 Apr;48(4):408-11

Background: The aim of the present study was to investigate the effects of aminophylline on BIS as well as clinical recovery in patients anesthetized with sevoflurane.
Methods : Sixty patients with status of ASA I-II scheduled for elective surgery were enrolled in this study. Anesthesia was induced by 2 mg kg^-1 of propofol and 0.5 mg kg^-1 of atracurium, maintained with 1:1 ratio of oxygen and nitrous oxide and 2-2.5% sevoflurane, keeping BIS values at 50 +/- 5. During the last 30 min of the operation no muscle relaxant was given and anesthesia was continued without decreasing anesthetic concentration. After sevoflurane discontinuation, saline was given to Group P, and 5 mg kg^-1 of aminophylline was given to Group A. Bispectral index values, heart rate, blood pressure and oxygen saturation were determined in all the patients before and every min after injection of the test drug for 15 min. The following variables were measured in both groups: eye opening, extubation time, response to command, Aldrete scores, and performing three simple arithmetic calculations.
Results: Between groups there was no statistically significant difference in mean arterial blood pressure, SpO₂ and anesthesia time. Heart rate was found to be statistically higher (P < 0.001) at 2 to 6 min in Group A when compared with group P. Eye opening, verbal response, extubation and arithmetic calculation times were significantly shorter (P < 0.001) in Group A. Bispectral index scores were significantly higher in Group A at 1 to 12 min after aminophylline injection when compared with placebo (P < 0.001).
Conclusion: Recovery from sevoflurane anesthesia and BIS scores are improved in early period when aminophylline is given at emerging from anesthesia.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Sore throat and hoarseness after total intravenous anaesthesia
K. Maruyama, H. Sakai H. Miyazawa, N. Toda, Y. Iinuma, N. Mochizuki, K. Hara and T. Otagiri
Br J Anaesth 2004; 92: 541–3

Background. Sore throat and hoarseness are common complications, but these have not been studied after total i.v. anaesthesia.
Methods. We prospectively studied 418 surgical patients, aged 15–92 yr, after total i.v. anaesthesia with propofol, fentanyl and ketamine to assess possible factors associated with sore throat and hoarseness.
Result. We found sore throat in 50% and hoarseness in 55% of patients immediately after surgery. This decreased to 25% for sore throat and 24% for hoarseness on the day after surgery. Both sore throat and hoarseness were more common in females and when lidocaine spray had been used. Cricoid pressure during laryngoscopy was inversely associated with the risk of sore throat.
Conclusion. Knowledge of these factors may reduce postoperative throat complications, and improve patient satisfaction.

CANADIAN JOURNAL OF ANESTHESIA - TOP

The efficacy of the 5-HT 3 receptor antagonists combined with droperidol for PONV prophylaxis is similar to their combination with dexamethasone. A meta-analysis of randomized controlled trials
Ashraf S. Habib, MBBCH MSC FRCA, Habib E. El-Moalem, PhD and Tong J. Gan, MBBS FRCA FFARCS (I)
Canadian Journal of Anesthesia 51:311-319 (2004)

Purpose: The aim of this quantitative systematic review is to compare the efficacy and side effects of combining one of the 5-HT₃ receptor antagonists (5-HT) with droperidol or dexamethasone for postoperative nausea and vomiting (PONV) prophylaxis.
Methods: We performed a systematic search (Medline, Embase, and the Cochrane Library) for randomized controlled trials that compared the antiemetic efficacy of combining one of the 5-HT with droperidol or dexamethasone vs 5-HT alone. Relevant endpoints were prevention of early (0 to 6 hr), and overall (0 to 24 hr) PONV, and side effects. The articles that could meet the inclusion criteria were scored for inclusion and methodological validity using the three-item, five-point, Oxford-scale. Relative risk and numbers needed-to-treat with 95% confidence intervals were calculated for each combination vs 5-HT alone. The two combinations were then indirectly compared. A random effects model was used.
Results: We considered 41 trials for analysis but subsequently excluded eight. Thirty-three trials with data from 3,447 patients were analyzed. Except for early nausea with the 5-HT plus droperidol, both combinations were significantly more effective than 5-HT in preventing early and overall PONV. There was no difference in antiemetic efficacy between the two combinations. The incidence of commonly reported side effects was also similar in the two combination groups.
Conclusion: We conclude that there is no statistically significant difference in antiemetic efficacy or side effects profile when one of the 5-HT is combined with either droperidol or dexamethasone and that both combination regimens are significantly more effective than 5-HT alone.

Evidence-based management of postoperative nausea and vomiting: a review
Ashraf S. Habib, MBBCH MSc FRCA and Tong J. Gan, MB FRCA
Canadian Journal of Anesthesia 51:326-341 (2004)

Purpose: To provide evidence-based guidelines for the prophylaxis and treatment of postoperative nausea and vomiting (PONV).
Source: Literature from randomized controlled trials, systematic reviews, logistic regression analyses and expert opinion in the management of PONV.
Principal findings: The etiology of PONV is multifactorial. Patient, anesthesia, and surgery related risk factors have been identified. Universal PONV prophylaxis is not cost-effective. Identification of patients at high-risk of PONV allows targeting prophylaxis to those who will benefit most from it. No prophylaxis is needed for patients at low risk for PONV. For patients at moderate risk for PONV, prophylaxis using a single antiemetic or a combination of two agents should be considered. Double and triple antiemetic combinations should be considered for patients at high risk for PONV. Furthermore, a multimodal approach should be adopted incorporating steps to keep the baseline risk of PONV low. The optimum cost-effective approach to the management of PONV will differ between an ambulatory centre and an inpatient hospital setting. For the treatment of established PONV in patients who failed prophylaxis, patients should not receive a repeat dose of the prophylactic antiemetic. Rather, a drug acting at a different receptor should be used. Beyond six hours after surgery, patients can be treated with any of the agents used for prophylaxis, except dexamethasone and transdermal scopolamine.
Conclusion: PONV are common after anesthesia and surgery. We provided evidence-based guidelines for the management of this problem based on the available literature.

PUB MED - TOP

Anaesthesia in elderly patients with neurodegenerative disorders: special considerations.
Burton DA, Nicholson G, Hall GM.
Drugs Aging. 2004;21(4):229-42

Neurodegenerative diseases are increasingly common in elderly patients, who present a particular anaesthetic challenge. The majority of people over the age of 70 years have some degree of cerebral atrophy. The pathogenesis of neurodegenerative diseases is due to alterations in the transport, degradation and aggregation of proteins. Alterations in physiology that occur with advancing age affect both the pharmacokinetics and pharmacodynamics of drugs used in the elderly. Changes in pharmacokinetics result in either increased or reduced drug concentrations depending on the variable contributions of absorption, metabolism and elimination. The distribution of a drug depends on its protein binding, cardiac output and blood volume, which are all altered in the elderly. Metabolism and excretion of drugs are also affected due to changes in hepatic and renal mass and blood flow in the elderly. A number of drugs are used in neurodegenerative disorders including antidepressants, benzodiazepines, antipsychotics, acetylcholinesterase inhibitors and levodopa. Polypharmacy is a common problem, which can lead to adverse drug interactions and an exacerbation of dementia. Levodopa, bromocriptine and tricyclic antidepressants are known to cause orthostatic hypotension in patients with neurodegenerative disease. Elderly patients are liable to excessive sedation from benzodiazepines in both the pre- and postoperative period; therefore these drugs should be prescribed in low doses. For induction of general anaesthesia propofol is a suitable agent in patients with neurodegenerative disease due to its rapid metabolism, but may not be suitable in patients with Parkinson's disease as it can induce spontaneous involuntary movements. Volatile inhalational agents should be administered carefully in the elderly, as they are more sensitive to the depressant cerebral and cardiovascular effects. Levodopa should be avoided in conjunction with halothane, which sensitises the heart to catecholamines. Co-administration of monoamine oxidase inhibitors and opioids should be avoided as it can cause agitation, muscular rigidity, sweating and hyperpyrexia. If an anticholinergic agent is required, then glycopyrronium bromide is the drug of choice in this group of patients, as it does not cross the blood brain barrier. Patients should continue to take their usual medications in hospital and do not let the change in routine alter the times at which treatments are administered. This is particularly relevant to the timing of levodopa in Parkinson's disease, as missed treatment can be detrimental. Regional anaesthesia may, however, have significant advantages in patients with Parkinson's disease, who can continue to take oral levodopa preoperatively, during surgery, if required, and early in the postoperative period. Anti-emetic drugs such as phenothiazines, butyrophenones and metoclopramide should be used carefully in the postoperative period in these patients as their antidopaminergic effects may induce or exacerbate parkinsonian effects.
 

Same-day discharge for selected patients undergoing combined nasal and palatal surgery for obstructive sleep apnea.
Kieff DA, Busaba NY.
Ann Otol Rhinol Laryngol. 2004 Feb;113(2):128-31

To determine the safety of same-day discharge for patients who undergo combined nasal and palatal surgery for obstructive sleep apnea syndrome, we undertook a retrospective review and analysis of 2 groups of patients (total, 86 patients) who underwent such surgery. The patients with obstructive sleep apnea syndrome who underwent combined nasal and palatal surgery were considered for same-day discharge if they fulfilled the following postoperative criteria: sustained O 2 saturation of 94% or greater on room air while asleep, no history of cardiopulmonary disease or diabetes mellitus, adequate oral analgesia and oral intake, hemostasis, and normal vital signs. Twenty-three patients met these criteria and were assigned to group 1. The remaining 63 patients were admitted overnight for monitoring and were assigned to group 2. The data collected included patient demographics, respiratory disturbance index, lowest O₂ saturation, body mass index, and postoperative complications. The mean age, respiratory disturbance index, lowest O₂ saturation, and body mass index for group 1 were 45.9 years, 36 events per hour, 84.9%, and 28.7 kg/m², respectively. For group 2, the results were 48 years, 36.5 events per hour, 82%, and 32.5 kg/m². There were no postoperative complications in group 1, and 3 in group 2. There were no incidents of airway compromise or cardiopulmonary events in the immediate postoperative period in either group. There were no readmissions for either group. We conclude that same-day discharge for patients who have undergone combined nasal and palatal surgery for obstructive sleep apnea syndrome is relatively safe in selected cases in which significant comorbid diseases are not present. These selected cases would have constituted a minority of the patients studied.
 

Same-evening discharge after carotid endarterectomy: our initial experience.
Sheehan MK, Greisler HP, Littooy FN, Baker WH.
J Vasc Surg. 2004 Mar;39(3):575-7

PURPOSE: The purpose of this study was to review the initial implementation of a same-evening discharge algorithm for patients undergoing carotid endarterectomy (CEA).
METHOD: We conducted a retrospective review of a prospective database of patients undergoing CEA over 3 years.
RESULTS: From January 2000 to December 2002, 207 patients underwent CEA, of which 186 qualified for same-evening discharge. Fifty-nine patients (32%) who qualified were discharged to home the same evening; none had an adverse event after discharge. The most common reason for patients not to be discharged the same evening was exiting the operating room too late (n = 63, 34%). Thirteen patients chose to stay overnight, and 11 patients did not go home secondary to physician choice. None of these patients experienced any adverse sequelae during the overnight stay.
CONCLUSION : Same-evening discharge after CEA is safe and feasible in selected patients. Currently, nearly one third of our patients are discharged within 8 hours of CEA. With appropriate scheduling, patient education, and increasing physician awareness, most patients can be discharged to home the same evening after CEA.

The addition of sufentanil, tramadol or clonidine to lignocaine for intravenous regional anaesthesia.
Alayurt S, Memis D, Pamukcu Z.
Anaesth Intensive Care. 2004 Feb;32(1):22-7

This study was designed to evaluate the effect of sufentanil, tramadol or clonidine added to lignocaine for intravenous regional anaesthesia. We investigated the onset and duration of sensory and motor block, the quality of the anaesthesia, intraoperative and postoperative haemodynamics, intraoperative and postoperative pain and sedation. Sixty patients undergoing ambulatory hand surgery received intravenous regional anaesthesia using 35 ml of 0.5% lignocaine and either 5 ml saline (Group L, n = 15); sufentanil 25 micrograms (Group LS, n = 15); tramadol 100 mg (Group LT, n = 15) or clonidine 1 microgram.kg^-1 (Group LC, n = 15). Before and after the tourniquet application, haemodynamic data, tourniquet pain, sedation scores and analgesic use were recorded. After tourniquet deflation, haemodynamic data, pain and sedation, time to first analgesic requirement and analgesic use were noted. There were no differences among groups in intraoperative haemodynamic data, the time to recovery of sensory block, the onset and the recovery of motor block, sedation scores or postoperative pain. Compared to the other groups, in Group L the onset of sensory block was longer, the time to initial tourniquet pain was shorter and the intraoperative tourniquet pain scores and use of the opioid were higher (P < 0.05). The quality of anaesthesia in Groups LS, LT and LC was better than in Group L (P < 0.05). In conclusion, the addition of sulfentanil, tramadol or clonidine to lignocaine shortened the onset of the sensory block, delayed the onset time of the tourniquet pain and reduced the intraoperative consumption of opioid, but did not affect postoperative pain.

Ureteroscopy: anesthetic considerations.
Cybulski PA, Joo H, Honey RJ.
Urol Clin North Am. 2004 Feb;31(1):43-7, viii

Ureterorenoscopy (URS) is a vital procedure in the armamentarium of the modern-day urologist for the management of ureteral and renal pathology. With advances in ureteroscopic design and the introduction of short-acting anesthetics, URS can now be performed efficiently with high patient satisfaction and minimal posteroperative recovery time. Recently, URS under local anesthesia, with or without sedation, has become a viable option for a high percentage of correctly selected patients. For those patients who then require deeper sedation or general anesthesia, anesthesia can be induced quickly with the new agents such as remifentanil, propofol, and desflurane, without a prolonged postoperative recovery period.

Practice advisory on liposuction.
Iverson RE, Lynch DJ; American Society of Plastic Surgeons Committee on Patient Safety.
Plast Reconstr Surg. 2004 Apr 15;113(5):1478-90; discussion 1491-5

COMMITTEE STATEMENT: At the 69th annual meeting of the American Society of Plastic Surgeons (ASPS) in October of 2000, the ASPS Board of Directors convened the Task Force on Patient Safety in Office-Based Surgery Facilities. The task force was assembled in the wake of several highly publicized patient deaths involving plastic surgery and increasing state legislative and regulatory activity of office-based surgery facilities. In response to the increased scrutiny of the office-based surgery setting, the task force produced two practice advisories: "Procedures in the Office-Based Surgery Setting" and "Patient Selection in the Office-Based Surgery Setting." Since the task force's inception, professional and public awareness of patient safety issues has continued to grow. This heightened interest resulted in an increased need for plastic surgeons to communicate their views on the topic. To meet this challenge, the task force evolved into the Committee on Patient Safety, allowing the committee to address topics affecting the safety and welfare of plastic surgery patients, regardless of the facility setting. The "Practice Advisory on Liposuction" is the first advisory developed since the committee was formed. It was a lengthy and painstaking process for the committee, which included representatives from related plastic surgery organizations as well as the American Society of Anesthesiologists (ASA). Committee members included Ronald E. Iverson, M.D., chair; Jeffery L. Apfelbaum, M.D., ASA representative; Bruce L. Cunningham, M.D., ASPS/Plastic Surgery Educational Foundation (PSEF) Joint Outcomes Task Force representative; Richard A. D'Amico, M.D., ASPS representative; Victor L. Lewis, Jr., M.D., ASPS Health Policy Analysis Committee representative; Dennis J. Lynch, M.D., ASPS representative; Noel B. McDevitt, M.D., ASPS Deep Vein Thrombosis Task Force representative; Michael F. McGuire, M.D., The American Society for Aesthetic Plastic Surgery (ASAPS) representative; Louis Morales, Jr., M.D., American Society of Maxillofacial Surgeons representative; Calvin R. Peters, M.D., Florida Ad Hoc Commission on Patient Safety representative; Robert Singer, M.D., American Association for Accreditation of Ambulatory Surgery Facilities representative; Thomas Ray Stevenson, M.D., American College of Surgeons representative; Rebecca S. Twersky, M.D., ASA representative; Ronald H. Wender, M.D., ASA representative; and James A. Yates, ASAPS representative. The authors thank members of the committee for the insights they brought to this process. The final document represents their significant contributions to these efforts. They would also like to recognize DeLaine Schmitz and Pat Farrell of the ASPS staff for their work on and support of this project.

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