Volume 7, Issue 12 S A M B A T A L K S - PAGE 3 May, 2008

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

The Prophylactic Effect of Haloperidol Plus Dexamethasone on Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopically Assisted Vaginal Hysterectomy.
Chu, Chin-Chen, Shieh, Ja-Ping, MD, MS, Tzeng, Jann-Inn, MD, MS, Chen, Jen-Yin, MD, MS, Lee, Yi, Ho, Shung-Tai, MD, MS, Wang, Jhi-Joung, MD, PhD
Anesthesia & Analgesia. 106(5):1402-1406, May 2008.

BACKGROUND: Haloperidol, a major tranquilizer, has been found to have a potent antiemetic effect on postoperative nausea and vomiting (PONV), but the prophylactic effect of haloperidol plus dexamethasone on PONV has not been evaluated. We evaluated the prophylactic effect of haloperidol plus dexamethasone to either given alone, placebo or droperidol on PONV in patients undergoing a laparoscopic-assisted vaginal hysterectomy.
METHODS: Four hundred adult women (n = 80 in each of five groups) scheduled for a laparoscopic-assisted vaginal hysterectomy were enrolled in a randomized, double-blind, placebo, and positive-control study. Fifteen minutes after the induction of anesthesia, patients received an IV injection of either saline (group S), droperidol 1.25 mg (group D), haloperidol 2 mg (group H), dexamethasone 5 mg (group Dx), or haloperidol 2 mg plus dexamethasone 5 mg (group H + Dx) to prevent PONV. The occurrence of PONV and medication-related side effects were recorded.
RESULTS: The incidences of PONV (0-24 h) in the D (36%), H (37%), Dx (38%), and H + Dx (19%) groups were significantly lower than in the S group (65%; P < 0.05 for each comparison). The H + Dx group had the lowest incidence of PONV (19%; P < 0.05 for each comparison) of the five study groups. No differences were found between the D, H, and Dx groups. Also, no differences were found among the five groups in the side effects of QT prolongation, intensity of postoperative pain, level of sedation, and occurrence of extra-pyramidal symptoms.
CONCLUSION: Prophylactic haloperidol 2 mg plus dexamethasone 5 mg produced a greater reduction in the incidence of PONV than did either drug used alone, placebo or droperidol without increasing perioperative adverse outcomes.

Haloperidol Versus Ondansetron for Prophylaxis of Postoperative Nausea and Vomiting.
Rosow, Carl, MD, PhD, Haspel, Kenneth, Smith, Sarah, Grecu, Loreta, Bittner, Edward, MD, PhD
Anesthesia & Analgesia. 106(5):1407-1409, May 2008.

BACKGROUND: Haloperidol is effective for postoperative nausea and vomiting prophylaxis, but there are almost no data comparing it to 5-HT3 antagonists.
METHODS: Two hundred forty-four adults were randomized to receive IV haloperidol 1 mg or ondansetron 4 mg, during general anesthesia. Nausea, vomiting, need for rescue, sedation, extrapyramidal effects, QTc intervals, and time to postanesthesia care unit discharge were evaluated with a third-party blind design.
RESULTS: There was no intergroup difference in any measure of efficacy or toxicity. Haloperidol and ondansetron subjects (78.2% and 76.8%) had complete response. Postoperatively, prolonged QTc occurred in 28.9% and 22.1% (N.S.).
CONCLUSIONS: In a mixed surgical population, the efficacy and toxicity of postoperative nausea and vomiting prophylaxis with haloperidol 1 mg was not significantly different from ondansetron 4 mg.

Haloperidol Plus Ondansetron Versus Ondansetron Alone for Prophylaxis of Postoperative Nausea and Vomiting.
Grecu, Loreta, Bittner, Edward, MD, PhD, Kher, Jay, Smith, Sarah, Rosow, Carl, MD, PhD
Anesthesia & Analgesia. 106(5):1410-1413, May 2008.

INTRODUCTION: Haloperidol 1 mg and ondansetron 4 mg are equally safe and effective for postoperative nausea and vomiting prophylaxis. We compared the combination to ondansetron alone in a mixed surgical population.
METHODS: Two-hundred and sixty-eight adults undergoing general anesthesia received 4 mg ondansetron plus 1 mg haloperidol or saline in this randomized, double-blind protocol. Efficacy and safety data were obtained until 480 min after postanesthesia care unit entry.
RESULTS: The combination had more complete responders (76.2% vs 59.2%), less nausea, less rescue, and longer time to rescue. Sedation, time to postanesthesia care unit discharge, and QTc prolongation were not different. No subject had dystonia, akathisia, or serious dysrhythmias.
CONCLUSIONS: Postoperative nausea and vomiting prophylaxis with both drugs is significantly more effective and longer lasting than ondansetron alone. There is no detectable increase in side effects.

Risk Factors Associated with Fast-Track Ineligibility After Monitored Anesthesia Care in Ambulatory Surgery Patients.
Twersky, Rebecca, MD, MPH, Sapozhnikova, Svetlana, Toure, Ben
Anesthesia & Analgesia. 106(5):1421-1426, May 2008.

BACKGROUND: Fast-tracking after ambulatory anesthesia has been advocated as a pathway to improve efficiency and maximize resources without compromising patient safety and satisfaction. Studies reporting successful fast-tracking focus primarily on anesthesia techniques and not on specific patient factors, surgical procedure, or process variables associated with unsuccessful fast-tracking. We performed this retrospective study to implement a process for improving fast-tracking, measure change over time, and identify variables associated with patients unable to fast-track successfully after monitored anesthesia care.
METHODS: A fast-track protocol for all patients receiving monitored anesthesia care based on the Modified Aldrete Score was instituted. It consisted of written policy changes and weekly review at physician and nursing department meetings for the first month, followed by monthly feedback during a 6-mo intervention period. Data collected for a 3-mo baseline and the consecutive 6-mo intervention period included fast-track status, surgical service and procedure, surgeon and anesthesiology provider, age, gender, ASA status, total time in operating room, and total postoperative time (end of surgery to actual discharge).
RESULTS: Three hundred and thirty-two cases were completed during the 3-mo baseline period, and 641 cases were completed during the 6-mo intervention period. Fast-track success rate improved from 23% to 56%, P < 0.001. Independent risk factors for fast-track ineligibility identified by multivariate regression analysis were significant for patients <60 yr-old, ASA III versus I, general surgery versus orthopedics and ophthalmology, month after implementation, and total postoperative time. Total postoperative time was significantly shorter by 64 min in the fast-track group, P < 0.001.
CONCLUSION: Fast-track success rate can be improved and sustained over time by education and personnel feedback. We identified risk factors that were significantly associated with fast-track ineligibility. If those factors are found to be associated with fast-track ineligibility in a prospective investigation, they should enable development of multidisciplinary patient and procedure-specific guidelines for fast-tracking.

Predictive Factors of Severe Postoperative Pain in the Postanesthesia Care Unit.
Aubrun, Frederic, MD, PhD, Valade, Nathalie, Coriat, Pierre, Riou, Bruno, MD, PhD
Anesthesia & Analgesia. 106(5):1535-1541, May 2008.

BACKGROUND: IV morphine titration (IMT) is widely used in the postanesthesia care unit to achieve pain relief. Numerous factors contribute to variability in postoperative pain or morphine consumption. We analyzed prospectively the pre- and intraoperative predictive factors of severe postoperative pain defined as a dose of IMT >0.15 mg/kg or a failure of IMT.
METHODS: We assessed the role of preoperative information about pain, medical treatments, and intraoperative events and their role on postoperative pain. After IMT, patients were divided into two groups: severe pain (SP) and nonsevere pain. Data are expressed as mean +/- sd.
RESULTS: Three hundred forty-two patients were included in the study: 200 (58%) in the nonsevere pain group and 142 (42%) in the SP group. Using a univariate analysis, there was no significant difference between groups related to medical or surgical history except for more frequent preoperative treatments in the SP group (P < 0.05). Duration of the surgical procedure and anesthesia were longer in the SP group (P < 0.001). The dose of sufentanil and visual analog scale scores before and at the end of IMT were higher in the SP group (P < 0.001). Using a multivariate analysis, a high dose of intraoperative opioid (sufentanil dose >0.6 [mu]g/kg) (Odds ratio = 2.68, P < 0.001), a general anesthetic procedure (Odd ratio = 3.96, P = 0.03), and the use of preoperative analgesic drugs (Odds ratio = 1.91, P < 0.01) were independent factors associated with severe postoperative pain.
CONCLUSION: A higher intraoperative dose of sufentanil, general anesthesia, and preoperative treatment with analgesics were significantly associated with severe postoperative pain.

Intraarticular Injection of Magnesium Sulphate and/or Bupivacaine for Postoperative Analgesia After Arthroscopic Knee Surgery.
Elsharnouby, Noha, Eid, Hala, Abou Elezz, Nahla, Moharram, Ashraf
Anesthesia & Analgesia. 106(5):1548-1552, May 2008.

BACKGROUND: Intraarticular bupivacaine is often used for prevention of pain after arthroscopic knee surgery. Intraarticular magnesium, a N-methyl-d-aspartate receptor blocker, would be of particular interest in either producing postoperative analgesia or enhancing the analgesic effect of intraarticular bupivacaine. We designed this study to determine whether intraarticular magnesium sulfate or bupivacaine results in a decrease in visual analog scale (VAS) score followed by a decrease in analgesic requirement and whether their combination would provide more reduction in VAS, and subsequently less analgesic requirement, than either drug alone.
METHODS: One-hundred and eight patients undergoing arthroscopic meniscectomy were randomized blindly into one of four parallel groups. The saline placebo group (group S) received 20 mL of isotonic saline, and the magnesium group (group M) received 20 mL of isotonic saline containing 1 g magnesium sulfate. The bupivacaine group (group B) received 0.25% (20 mL) bupivacaine, whereas the magnesium with bupivacaine group (group MB) received bupivacaine 0.25% and 1 g of magnesium sulfate in 20 mL. The postoperative analgesia was assessed using VAS recorded after surgery at 1, 2, 4, 6, 8, 12, and 24 h. Patients were evaluated at rest and with movement.
RESULTS: Group MB had a significantly reduced VAS both at rest and on movement, a significantly increased time to first postoperative analgesic request, as well as significantly reduced total analgesic requirement than other groups.
CONCLUSION: Magnesium combined with bupivacaine produces a reduction in postoperative pain when given intraarticularly in comparison to either bupivacaine or magnesium alone, or to saline placebo.

ANESTHESIOLOGY - TOP

STOP Questionnaire: A Tool to Screen Patients for Obstructive Sleep Apnea.
Chung, Frances F.R.C.P.C. ; Yegneswaran, Balaji M.B.B.S. ; Liao, Pu M.D. ; Chung, Sharon A. Ph.D. ; Vairavanathan, Santhira M.B.B.S. ; Islam, Sazzadul M.Sc. ; Khajehdehi, Ali M.D. ; Shapiro, Colin M. F.R.C.P.C. 
Anesthesiology. 108(5):812-821, May 2008.

Abstract:
Background: Obstructive sleep apnea (OSA) is a major risk factor for perioperative adverse events. However, no screening tool for OSA has been validated in surgical patients. This study was conducted to develop and validate a concise and easy-to-use questionnaire for OSA screening in surgical patients.
Methods: After hospital ethics approval, preoperative patients aged 18 yr or older and without previously diagnosed OSA were recruited. After a factor analysis, reliability check, and pilot study; four yes/no questions were used to develop this screening tool. The four questions were respectively related to snoring, tiredness during daytime, observed apnea, and high blood pressure (STOP). For validation, the score from the STOP questionnaire was evaluated versus the apnea-hypopnea index from monitored polysomnography.
Results: The STOP questionnaire was given to 2,467 patients, 27.5% classified as being at high risk of OSA. Two hundred eleven patients underwent polysomnography, 34 for the pilot test and 177 for validation. In the validation group, the apnea-hypopnea index was 20 +/- 6. The sensitivities of the STOP questionnaire with apnea-hypopnea index greater than 5, greater than 15, and greater than 30 as cutoffs were 65.6, 74.3, and 79.5%, respectively. When incorporating body mass index, age, neck circumference, and gender into the STOP questionnaire, sensitivities were increased to 83.6, 92.9, and 100% with the same apnea-hypopnea index cutoffs.
Conclusions: The STOP questionnaire is a concise and easy-to-use screening tool for OSA. It has been developed and validated in surgical patients at preoperative clinics. Combined with body mass index, age, neck size, and gender, it had a high sensitivity, especially for patients with moderate to severe OSA.

Validation of the Berlin Questionnaire and American Society of Anesthesiologists Checklist as Screening Tools for Obstructive Sleep Apnea in Surgical Patients.
Chung, Frances F.R.C.P.C. ; Yegneswaran, Balaji M.B.B.S. ; Liao, Pu M.D. ; Chung, Sharon A. Ph.D. ; Vairavanathan, Santhira M.B.B.S. ; Islam, Sazzadul M.Sc. ; Khajehdehi, Ali M.D. ; Shapiro, Colin M. F.R.C.P.C. 
Anesthesiology. 108(5):822-830, May 2008.

Abstract:
Background: Because of the high prevalence of obstructive sleep apnea (OSA) and its adverse impact on perioperative outcome, a practical screening tool for surgical patients is required. This study was conducted to validate the Berlin questionnaire and the American Society of Anesthesiologists (ASA) checklist in surgical patients and to compare them with the STOP questionnaire.
Methods: After hospital ethics approval, preoperative patients aged 18 yr or older and without previously diagnosed OSA were recruited. The scores from the Berlin questionnaire, ASA checklist, and STOP questionnaire were evaluated versus the apnea-hypopnea index from in-laboratory polysomnography. The perioperative data were collected through chart review.
Results: Of 2,467 screened patients, 33, 27, and 28% were respectively classified as being at high risk of OSA by the Berlin questionnaire, ASA checklist, and STOP questionnaire. The performance of the screening tools was evaluated in 177 patients who underwent polysomnography. The sensitivities of the Berlin questionnaire, ASA checklist, and STOP questionnaire were 68.9-87.2, 72.1-87.2, and 65.6-79.5% at different apnea-hypopnea index cutoffs. There was no significant difference between the three screening tools in the predictive parameters. The patients with an apnea-hypopnea index greater than 5 and the patients identified as being at high risk of OSA by the STOP questionnaire or ASA checklist had a significantly increased incidence of postoperative complications.
Conclusions: Similar to the STOP questionnaire, the Berlin questionnaire and ASA checklist demonstrated a moderately high level of sensitivity for OSA screening. The STOP questionnaire and the ASA checklist were able to identify the patients who were likely to develop postoperative complications.

Sevoflurane Concentrations Required to Block Autonomic Hyperreflexia during Transurethral Litholapaxy in Patients with Complete Spinal Cord Injury.
Yoo, Kyung Y. M.D., Ph.D. ; Jeong, Cheol W. M.D. ; Kim, Seok J. M.D. ; Chung, Sung T. M.D. ; Bae, Hong B. M.D. ; Oh, Kyung J. M.D. ; Lee, JongUn M.D., Ph.D. 
Anesthesiology. 108(5):858-863, May 2008.

Abstract:
Background: Autonomic hyperreflexia (AHR) is a potentially life-threatening hypertensive condition that occurs in patients with high spinal cord injury (SCI). The current study was aimed to determine sevoflurane concentrations that block AHR in SCI patients.
Methods: The study involved 28 patients with chronic, complete SCI scheduled to undergo transurethral litholapaxy during general anesthesia. Nine patients without SCI served as controls post hoc. Anesthesia was induced with thiopental, and sevoflurane concentrations in 50% nitrous oxide were adjusted to maintain a Bispectral Index of 40-50. When a patient developed AHR during bladder distension, the target sevoflurane concentration was maintained for at least 10 min, and then the procedure was resumed. Systolic blood pressure, heart rate, and Bispectral Index as well as plasma concentrations of catecholamines and arginine vasopressin were measured before and during the bladder distension. Each target concentration was determined by the up-and-down method based on changes (15% increase or more) of systolic blood pressure in response to bladder distension.
Results: In SCI, systolic pressure increased by 67 +/- 33 mmHg, whereas heart rate decreased by 13 +/- 8 beats/min during the first trial (P < 0.01). The hypertensive event was associated with increases of norepinephrine concentrations, but not of epinephrine or vasopressin concentrations. Systolic pressure, heart rate, and norepinephrine concentrations did not change significantly in the control patients. The end-tidal concentrations of sevoflurane to prevent AHR were EC50 of 3.12% and EC95 of 3.83%.
Conclusion: The EC95 for sevoflurane in 50% nitrous oxide to block AHR during transurethral litholapaxy in patients with SCI was 3.83%.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Spinal 2-chloroprocaine: effective dose for ambulatory surgery
A. SELL, T. TEIN, M. PITKÄNEN
Acta Anaesthesiologica Scandinavica 2008; 52 (5): 695–699

Background: There is an interest in finding a safe, short-acting spinal anaesthetic, suitable for ambulatory surgery. In this prospective study, we evaluated the effective dose of plain 2-chloroprocaine (2-CP) for lower limb surgery, including knee arthroscopy and saphenectomy.
Methods: Sixty-four ASA physical status I–III patients undergoing elective lower limb surgery were randomly allocated to one of the four local anaesthetic groups for spinal anaesthesia in a double-blind manner. The patients (n=16 patients in each group) received 35, 40, 45 or 50 mg of 10 mg/ml isobaric 2-CP.
Results: In all patients, anaesthesia was sufficient for the planned surgery. The median peak block height (T9) was similar in all four groups (P=0.66). Time to complete sensory block regression was faster in the 35 mg group (111 min, mean) and in the 40 mg group (108 min) than in the 50 mg group (134 min, P=0.005). No differences in time to complete motor block regression were observed (P=0.3). Home discharge time was faster in the 35 mg group (123 min) and in the 40 mg group (122 min) than in the 50 mg group (165 min, P=0.001). No complications related to spinal anaesthesia were observed and no transient neurologic symptoms (TNS) were reported at the 3-day follow-up.
Conclusion: Spinal 2-CP, 10 mg/ml 35, 40, 45 and 50 mg provide reliable sensory and motor block for ambulatory surgery, while reducing the dose of 2-CP to 35 and 40 mg resulted in a spinal block of faster ambulation.

Reversal of rocuronium-induced neuromuscular block with sugammadex is faster than reversal of cisatracurium-induced block with neostigmine
E. A. Flockton, P. Mastronardi, J. M. Hunter, C. Gomar, R. K. Mirakhur, L. Aguilera, F. G. Giunta, C. Meistelman and M. E. Prins
British Journal of Anaesthesia 2008 100(5):622-630

Background: Reversal of the residual effect of rocuronium or cisatracurium by neostigmine may be slow and associated with side-effects. This randomized, safety-assessor-blinded study compared the efficacy of sugammadex, a selective relaxant binding agent for reversal of rocuronium-induced neuromuscular block, with that of neostigmine for reversal of cisatracurium-induced neuromuscular block. The safety of sugammadex and neostigmine was also evaluated.
Methods: Adult surgical patients (ASA class I–III) were randomized to sugammadex 2.0 mg kg–1 for reversal of block induced by rocuronium 0.6 mg kg–1, or neostigmine 50 µg kg–1 for reversal of block induced by cisatracurium 0.15 mg kg–1. Anaesthesia was induced and maintained using i.v. propofol and remifentanil, fentanyl, or sufentanil. Neuromuscular function was monitored using acceleromyography (TOF-Watch® SX). Sugammadex or neostigmine was administered at reappearance of T2. The primary efficacy variable was time for recovery of the train-of-four (TOF) ratio to 0.9.
Results: Eighty-four patients were randomized, 73 of whom received sugammadex (n=34) or neostigmine (n=39). Time from start of administration of reversal agent to recovery of the TOF ratio to 0.9 was 4.7 times faster with sugammadex than with neostigmine (geometric mean=1.9 vs 9.0 min, P<0.0001). Reversal of block was sustained in all patients. There were no serious adverse effects from either reversal agent and no significant changes in any measure of safety, except for similar elevations in urinary N-acetyl glucosaminidase in both groups.
Conclusions: Sugammadex 2.0 mg kg–1 administered at reappearance of T2 was significantly faster in reversing rocuronium-induced blockade than neostigmine was in reversing cisatracurium-induced block.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Patient’s satisfaction with perioperative care: development, validation, and application of a questionnaire
M. A. A. Caljouw, M. van Beuzekom and F. Boer
British Journal of Anaesthesia 2008 100(5):637-644

Background: Measuring patient satisfaction after anaesthesia care is complex. The existing patient satisfaction questionnaires are limited and omit aspects of patient satisfaction, such as professional competence, information provision, service, and staff–patient relationship. The aim of our study was to develop a valid and reliable self-reported multidimensional questionnaire assessing patient satisfaction that included these issues.
Methods: The development of the Leiden Perioperative care Patient Satisfaction questionnaire (LPPSq) was as follows: expert consultation, construction of the pilot questionnaire, pilot study, statistical analysis of the results of the pilot study (validity, reliability, and factor analysis), compilation of the definitive questionnaire, main study, and repeated statistical analysis (validity, reliability, and factor analysis). The overall patient satisfaction is expressed by the mean satisfaction score.
Results: Three hundred and eighty-two patients consented to participate in the study; 80.4% of the patients (n=307) completed the questionnaire. The LPPSq isolated three dimensions: information (Cronbach’s =0.82), fear and concern (Cronbach’s =0.69), and staff–patient relationship (Cronbach’s =0.94). Patient satisfaction with perioperative care was not directly dependent on the outcomes of anaesthesia but how patients were approached and the amount of information they received. Age (P=0.001), gender (P=0.001), work situation (P=0.003), and specialty (P=0.017) were the characteristics most influencing patient satisfaction.
Conclusions: We developed the LPPSq questionnaire to measure patient satisfaction with perioperative care, of which anaesthesia care is an important element. In this study, information provision and the relationship between staff and patient were the major determinants of patient satisfaction.

Implementation of outpatient preoperative evaluation clinics: facilitating and limiting factors
L. C. Lemmens, H. E. Kerkkamp, W. A. van Klei, N. S. Klazinga, C. L. Rutten, R. H. van Linge and K. G. Moons
British Journal of Anaesthesia 2008 100(5):645-651

Background: Several studies have shown that outpatient preoperative evaluation by anaesthetists increases quality of care and is cost-effective. The aim of this study was to gain insight into the factors that positively or negatively influence the implementation of outpatient preoperative evaluation clinics (OPE clinics).
Methods: After an extensive literature study and pilot interviews, we constructed written questionnaires that were sent to all Dutch hospitals. The respondents were members of the board of directors, members of the medical staff, anaesthetists, internists, and surgeons.
Results: Cooperation of anaesthetists was most frequently mentioned as facilitating factor for implementation of an OPE clinic across all medical specialists interviewed. Lack of finance was most frequently reported as limiting factor in all categories of hospitals (with a complete, partial, or no OPE clinic), but it was significantly more often reported in hospitals without OPE clinic (P<0.01). Perceived benefits and disadvantages, financial rewarding system, and organizational structure played a clear role in the implementation of OPE clinics.
Conclusions: A variety of factors play a role in the implementation of an OPE clinic. Besides the more obvious ones, such as financing and cooperation of the professional groups involved, underlying factors, such as perceptions of the professionals involved, were found to be related to implementation of an OPE clinic. These underlying factors explain differences between different kinds of hospitals and between professional groups, regarding their resources and motivation to implement an OPE clinic.

CANADIAN JOURNAL OF ANESTHESIA - TOP

The timing of haloperidol administration does not affect its prophylactic antiemetic efficacy
Yao L. Yang, MD, Hsien Y. Lai, PhD, Jhi J. Wang, PhD, Po K. Wang, MD , Tsung Y. Chen, MD, Chin C. Chu, MD and Yi Lee, MD
Canadian Journal of Anesthesia 55:270-275 (2008)

Purpose: Postoperative nausea and vomiting (PONV) occurs frequently after general anesthesia. We evaluated the timing of 2 mg iv doses of haloperidol on the efficacy of this drug as a prophylactic antiemetic for PONV.
Methods: Ninety-four non-smoking female patients with a history of motion sickness and/or PONV (Apfel’s simplified risk score = 3; predicted incidence of PONV = 60%) were eligible to participate in this randomized, double-blind study. Patients were divided into two groups. Group 1 patients received haloperidol 2 mg iv during induction of anesthesia. Group 2 patients received haloperidol 2 mg iv approximately 30 min before the end of surgery. The occurrence of nausea and vomiting, nausea scores, pain scores, sedation levels, and adverse effects (cardiac arrhythmias, and extrapyramidal effects) were recorded by a trained, blinded investigator.
Results: The percentages of patients who experienced PONV in the first 24 hr were similar for the two groups (Group 1 = 30%; Group 2 = 26%, P = 0.645). The incidence of PONV was significantly smaller in both groups than that predicted (60%) according to the patients’ underlying risks (Group 1, P = 0.004; Group 2, P = 0.001). Nausea scores, pain scores, sedation scores, emergence times, and time to first rescue treatment were similar in the two groups. No adverse effects attributable to the study medication were observed.
Conclusion: The timing of administration of haloperidol 2 mg iv does not influence its antiemetic efficacy. The recovery profiles were also similar whether haloperidol was administered at the start, or at the end of surgery.

PUB MED - TOP

Paediatric day-case surgery: an audit of unplanned hospital admission Royal Hospital for Sick Children, Glasgow.
Blacoe DA, Cunning E, Bell G.
Anaesthesia. 2008 Jun;63(6):610-5.

Audit of unplanned hospital admission provides information to guide quality improvement measures and is a crude indicator of quality of care in ambulatory surgery. Our objectives were to re-audit factors relating to this outcome. Previous audit conducted in this unit revealed an unplanned admission rate of 3.7%. Data were collected between April 2000-March 2004. Of 13 592 day surgery patients, 238 (1.8%) unplanned admissions occurred. The admission rate displayed a falling trend and represented a significant improvement over the previous audit (p < 0.001). Unplanned admissions were most commonly caused by nausea/vomiting 23.5% (n = 56), postoperative bleeding 13.9% (n = 34), and unexpected extent/difficulty of procedure 11.8% (n = 28). Of all admissions, 18.5% (n = 44) were following orchidopexy, 16.4% (n = 39) following circumcision, and 12.6% (n = 30) following dental extraction. This audit shows that the unplanned admission rate is low and falling, and compares favourably with other units. Measures have been implemented targeting patients at high risk of admission.

Daycase laparoscopic cholecystectomy: a prospective study of post-discharge pain, analgesic and antiemetic requirements.
Kavanagh T, Hu P, Minogue S.
Ir J Med Sci. 2008 Jun;177(2):111-5. Epub 2008 Feb 13.

BACKGROUND: Laparoscopic cholecystectomy has been performed as a day-case procedure for over a decade. This procedure can be associated with a high incidence of pain and post-operative nausea and vomiting (PONV). There is a paucity of information regarding the post-discharge care of these patients. AIMS: To determine the effectiveness and adequacy of take-home analgesic packs given to patients undergoing ambulatory surgery.
METHODS: A prospective study of 40 patients undergoing laparoscopic cholecystectomy to evaluate post-operative pain, analgesia requirements and PONV following discharge. Data regarding unplanned admissions, patient satisfaction and GP attendance rates were also recorded.
RESULTS: At 24 h, 65% of patients reported moderate pain, 23% severe pain and 25% of patients reported PONV. The rate of GP attendance for further analgesia or antiemetics was 12.5%. Unexpected admission rate was 10%.
CONCLUSION: The incidence of PONV post-discharge suggests that adding an antiemetic to our take-home analgesic packs may improve patient comfort. The 2-day supply of diclofenac and co-codamol could also be extended as 65% of patients had moderate to severe pain. The information gathered shows the importance of post-discharge follow-up of ambulatory surgery patients.

Endometrial ablation in the office setting.
Fothergill RE.
Obstet Gynecol Clin North Am. 2008 Jun;35(2):317-30.

The introduction of global endometrial ablation technology during the past decade has revolutionized the treatment of abnormal uterine bleeding. These minimally invasive treatment options have fewer risks than traditional procedures, are faster, and have shorter recovery times for patients. As technology has advanced, so has the shift away from performing ablations in the operating room. With proper patient selection, equipment, and anesthesia techniques, endometrial ablation can be performed safely and effectively in the office setting.

Spinal 2-chloroprocaine: effective dose for ambulatory surgery.
Sell A, Tein T, Pitkänen M.
Acta Anaesthesiol Scand. 2008 May;52(5):695-9.

Background: There is an interest in finding a safe, short-acting spinal anaesthetic, suitable for ambulatory surgery. In this prospective study, we evaluated the effective dose of plain 2-chloroprocaine (2-CP) for lower limb surgery, including knee arthroscopy and saphenectomy.
Methods: Sixty-four ASA physical status I-III patients undergoing elective lower limb surgery were randomly allocated to one of the four local anaesthetic groups for spinal anaesthesia in a double-blind manner. The patients (n=16 patients in each group) received 35, 40, 45 or 50 mg of 10 mg/ml isobaric 2-CP.
Results: In all patients, anaesthesia was sufficient for the planned surgery. The median peak block height (T9) was similar in all four groups (P=0.66). Time to complete sensory block regression was faster in the 35 mg group (111 min, mean) and in the 40 mg group (108 min) than in the 50 mg group (134 min, P=0.005). No differences in time to complete motor block regression were observed (P=0.3). Home discharge time was faster in the 35 mg group (123 min) and in the 40 mg group (122 min) than in the 50 mg group (165 min, P=0.001). No complications related to spinal anaesthesia were observed and no transient neurologic symptoms (TNS) were reported at the 3-day follow-up.
Conclusion: Spinal 2-CP, 10 mg/ml 35, 40, 45 and 50 mg provide reliable sensory and motor block for ambulatory surgery, while reducing the dose of 2-CP to 35 and 40 mg resulted in a spinal block of faster ambulation.

Randomized clinical trial comparing day-care open haemorrhoidectomy under local versus general anaesthesia.
Kushwaha R, Hutchings W, Davies C, Rao NG.
Br J Surg. 2008 May;95(5):555-63.

BACKGROUND: Day-care open haemorrhoidectomy under local anaesthesia (LH) may be the most cost-effective approach to haemorrhoidectomy. This prospective randomized trial compared outcome after LH from patients' and clinical perspectives with that after day-care open haemorrhoidectomy under general anaesthesia (GH).
METHODS: Forty-one patients with third-degree haemorrhoids were randomized to LH (19) or GH (22). Patient demographics were comparable. A single haemorrhoid was excised in 15 patients, and two and three haemorrhoids in 13 each. Independent nurse-led assessment and clinical evaluation were carried out for 6 months. Outcome measures were mean and expected pain scores at 30, 60 and 90 min, then daily for 10 days, and satisfaction scores at 10 days, 6 weeks and 6 months. Secondary outcomes were journey time within the day-surgery unit and overall cost.
RESULTS: Pain was worse following LH than GH at 90 min after surgery (P = 0.028), but pain scores on reaching home were similar. Maximum pain was experienced on day 3 after LH and on day 6 after GH. From day 1 onwards, daily pain scores were lower in the LH group, and there was a significant difference on day 8 (mean (95 per cent confidence interval) 3.61 (2.74 to 4.48) for LH versus 5.29 (4.12 to 6.45) for GH; P = 0.027). Mean pain over 10 days, expectation and satisfaction scores were similar in the two groups. LH had a shorter journey time and was less expensive than GH.
CONCLUSION: LH has similar tolerance and clinical outcome to GH, and is associated with a shorter journey time and lower cost. Registration number: NCT00503269 (http://www.clinicaltrials.gov). 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Office-based ambulatory sedation--the use of the airway protector system during oral surgery: a prospective audit of the first 100 patients.
Klein M, Weksler N, Weksler D, Bodner L.
J Oral Maxillofac Surg. 2008 May;66(5):858-63.

PURPOSE: To evaluate the efficacy of the "Airway Protector System" (APS), a simple homemade device used for airway control during office-based dental sedation.
PATIENTS AND METHODS: A prospective audit was performed in 100 severely dental phobic patients submitted to dental treatment in a dentist office under propofol sedation. RESULTS: Sixty-eight females and 32 males were enrolled in this study. The mean age was 45 +/- 7 years (range, 18 to 67 years). A clear airway was obtained in 94 patients. Partial airway obstruction was observed in 4 patients but manual lifting of the jaw was enough to free the partial obstruction and dental treatment was uneventfully conducted. In 2 patients, the APS had to be converted to formal nasotracheal intubation because jaw-lifting maneuvers did not adequately relieve a partial airway obstruction. Sore throat was reported in 56 patients. In 27 cases, the patients rated the complaint as severe. No patient required a chest x-ray after sedation, as there was no clinical evidence of any pulmonary complication including dyspnea, cough, or fever.
CONCLUSION: We suggest that the concomitant use of a homemade cuffed nasopharyngeal airway with continuous suction facilitates airway control during deep levels of office-based sedation for dental treatment in severely dental phobic patients.

Anaesthetic choice in the colposcopy clinic: a retrospective analysis of routinely collected data.
Swancutt DR, Luesley DM, Eastaugh JL, Wilson S.
BJOG. 2008 Apr;115(5):646-52.

OBJECTIVES: Current guidelines recommend that less than 20% of treatments in colposcopy clinics should be under general anaesthetic. The objective of this study was to increase the evidence base for guidelines by establishing the proportion of women receiving general anaesthesia for treatment, determining the predictors of and reasons recorded for general anaesthetic use.
DESIGN: Retrospective analysis of routinely collected data.
SETTING: NHS Trust in the West Midlands. PARTICIPANTS: Colposcopy patients; January 2003 to March 2005.
METHODS: Logistic regression of factors associated with general anaesthetic choice.
MAIN OUTCOME MEASURES: Proportion of women treated under general anaesthesia, factors associated with anaesthetic choice and reasons recorded for general anaesthetic use.
RESULTS: About 5.4% (204/3777) of new appointments for colposcopy received treatment under general anaesthetic. Of women requiring treatment, 20% (204/1003) received general anaesthetic. General anaesthetic was more likely to be used when the woman required loop excision (OR = 3.63, 95% CI 2.11-6.24) and less likely when directed biopsy was performed (OR = 0.11, 95% CI 0.01-0.80), when the patient appointment date was after introduction of new guidelines (OR = 0.37, 95% CI 0.24-0.56) or when the assessment visit was with a nonconsultant status doctor rather than nurse or consultant (OR = 0.70, 95% CI 0.50-0.97). General anaesthetic use varied between colposcopists ranging from 0 to 16.5% of new patients seen. Woman's choice was the most commonly specified reason for the use of general anaesthetic.
CONCLUSIONS: The proportion of colposcopy patients treated under general anaesthetic is 20%, within guideline limits. Substantial variation in general anaesthetic rates between colposcopists was observed, and further investigation is required to discover the reason for this.

Efficacy of lidocaine spray as topical anesthesia for outpatient rigid cystoscopy in women: a prospective, randomized, double-blind trial.
Choe JH, Kwak KW, Hong JH, Lee HM.
Urology. 2008 Apr;71(4):561-6. Epub 2008 Feb 15.

OBJECTIVES: To determine the efficacy and feasibility of urethral lidocaine spray for rigid cystoscopy in female outpatients, compared with lidocaine gel for patient tolerance of pain.
METHODS: A total of 144 consecutive women scheduled to undergo rigid cystoscopy were randomized to receive either 10 mL of lidocaine gel (group 1, n = 48), five metered doses of 10% lidocaine spray (group 2, n = 48), or 10 mL of plain lubricating gel (group 3, n = 48). Patients recorded their level of pain perception during gel instillation or spray and immediately after the procedure using the visual analogue scale (VAS) and a 5-point verbal descriptor scale.
RESULTS: The perception of pain was significantly decreased when lidocaine spray was used (mean VAS scores 1.9 +/- 1.3 for group 2 versus 3.9 +/- 2.2 for group 3; P <0.001). There was no difference in pain perception when lidocaine spray or gel was used (P = 0.113). Four patients in group 1 and 1 in group 2 but 10 in group 3 requested post-cystoscopic analgesics. There was a slight increase in pain perception on the VAS during the intraurethral application with lidocaine spray (2.2 +/- 1.5) compared with lidocaine gel (0.7 +/- 1.1) or plain gel (1.0 +/- 1.4).
CONCLUSIONS: Lidocaine spray and lidocaine gel produce similar anesthetic effects in women undergoing rigid cystoscopy. However, concerns about the mild discomfort associated with delivery of the spray need to be resolved through future technical improvement before it gains widespread use.

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