Volume 3, Issue 5 S A M B A T A L K S - PAGE 3 October, 2003

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

Continuous Infraclavicular Perineural Infusion with Clonidine and Ropivacaine Compared with Ropivacaine Alone: A Randomized, Double-Blinded, Controlled Study
Brian M. Ilfeld, MD, Timothy E. Morey, MD, and F. Kayser Enneking, MD
Anesth Analg 2003;97:706-712

Although clonidine has been shown to increase the duration of local anesthetic action and prolong postoperative analgesia when included in single-injection nerve blocks, a controlled investigation of the efficacy of this practice to improve analgesia for continuous perineural local anesthetic infusion has not been reported. In this study, ambulatory patients (n = 34) undergoing moderately painful upper extremity orthopedic surgery received an infraclavicular brachial plexus block (mepivacaine 1.5%, epinephrine 2.5 µg/mL, and bicarbonate 0.1 mEq/mL) and a perineural catheter before surgery. After surgery, patients were discharged home with a portable infusion pump delivering either ropivacaine 0.2% or ropivacaine 0.2% plus clonidine 1 µg/mL via the catheter for 3 days (basal, 8 mL/h; patient-controlled bolus, 2 mL every 20 min). Investigators and patients were blinded to random group assignment. Daily end-points included pain scores, patient-controlled bolus doses, oral analgesic use, sleep quality, and symptoms of catheter- or infusion-related complications. Adding clonidine to ropivacaine resulted in a statistically significant decrease in the number of self-administered 2-mL bolus doses on postoperative Days 0 and 1 (P < 0.02), but this decreased actual local anesthetic consumption by an average of only 2–7 mL/d (P < 0.02). There were no statistically significant differences between the two groups for any of the other variables investigated, including sleep quality or oral analgesic requirements. We conclude that adding 1 µg/mL of clonidine to a ropivacaine infraclavicular perineural infusion does not provide clinically relevant improvements in analgesia, sleep quality, or oral analgesic requirements for ambulatory patients having moderately painful upper extremity surgery.
IMPLICATIONS: Clonidine is often added to long-acting local anesthetic perineural infusions in an effort to improve postoperative analgesia. This randomized, double-blinded, controlled study did not find evidence of clinically relevant benefits from adding clonidine to ropivacaine infraclavicular brachial plexus perineural infusions in ambulatory patients after moderately painful upper extremity surgery.

The Efficacy of 5% Lidocaine-Prilocaine (EMLA) Cream on Pain During Intravenous Injection of Propofol
A. McCluskey, B. A. Currer, and I. Sayeed
Anesth Analg 2003;97:713-714

Topical anesthesia using 60% lidocaine tape reduces the incidence of propofol injection pain. We conducted a randomized prospective double-blinded placebo-controlled study to assess the analgesic efficacy of pretreatment with topical 5% lidocaine-prilocaine (EMLA) cream in 90 ASA physical status I and II adult patients scheduled to undergo day-case gynecological surgery. Propofol injection pain was not reduced by pretreatment with EMLA cream, whereas the addition of lidocaine to propofol did significantly reduce propofol injection pain compared with the control group (P = 0.002). We conclude that topical anesthesia with EMLA cream applied for 60 min does not significantly reduce propofol injection pain.
IMPLICATIONS: Topical local anesthesia with 60% lidocaine tape reduces the incidence of propofol injection pain. However, we found no reduction after pretreatment with topical 5% lidocaine-prilocaine (EMLA) cream.

Continuous Paravertebral Catheter and Outpatient Infusion for Breast Surgery
Chester C. Buckenmaier, III, MD, Stephen M. Klein, MD, Karen C. Nielsen, MD, and Susan M. Steele, MD
Anesth Analg 2003;97:715-717

IMPLICATIONS: Paravertebral somatic nerve block is an alternative to general anesthesia for breast surgery. We describe a novel needle system for paravertebral catheter insertion linked to a disposable infusion pump for prolonged analgesia at home after breast surgery.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Nitrous oxide produces minimal hemodynamic changes in patients receiving a propofol-based anesthetic: an esophageal Doppler ultrasound study
Toshiya Shiga, MD PhD, Zen’ichiro Wajima, MD PhD, Tetsuo Inoue, MD PhD and Ryo Ogawa, MD PhD
Canadian Journal of Anesthesia 50:649-652 (2003)

Purpose: Nitrous oxide (N₂O) is a frequently used adjunct to propofol anesthesia. Although N₂O reduces the requirement of propofol for induction and maintenance, the effects of both drugs on overall hemodynamics remain controversial. We tested the hypothesis that the addition of N₂O to therapeutic doses of propofol alters hemodynamics and Doppler-derived variables evaluated with the esophageal Doppler monitor in a randomized, double-blinded, placebo-controlled design.
Methods: Thirty ASA I-II patients (aged 30–66 yr) were randomly assigned to receive propofol with oxygen-enriched air (FiO₂ = 0.3; air group) or propofol with 70% N₂O (N₂O group). Following intubation, a computerized target-controlled infusion technique was used to administer propofol from 0 mcg•mL^-1 (baseline) to 5 mcg•mL^-1 in 1 mcg•mL^-1 increments.
Results: Mean arterial pressure (MAP) decreased more in the N₂O group than in the air group only at 5 mcg•mL^-1. Aortic blood flow (ABF) showed a similar dose-dependent decrease in both groups. Peak aortic flow acceleration, as a myocardial contractility index, decreased significantly and similarly in both groups in a dose-dependent manner whereas peak velocity of ABF, as another measure of myocardial contractility, remained unchanged. Heart rate-corrected left ventricular ejection time, as a measure of preload, remained constant in both groups at any target plasma concentration.
Conclusion: Propofol causes dose-dependent decreases in ABF and MAP; however, 70% N₂O produces minimal hemodynamic and Doppler-derived variable changes under target-controlled propofol infusion at therapeutic concentrations.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Seizure duration with remifentanil/methohexital vs. methohexital alone in middle-aged patients undergoing electroconvulsive therapy
D. L. Smith, M. S. Angst, J. G. Brock-Utne, C. DeBattista
Acta Anaesthesiologica Scandinavica Volume: 47 Number: 9 Page: 1064 - 1066

Background: The object of this study was to test whether substituting part of the methohexital dose with the short-acting opioid remifentanil would prolong seizure duration in middle-aged patients while providing a similar depth of anesthesia as with methohexital alone. This has been reported for the combined use of methohexital and remifentanil in elderly patients, but has not been investigated in middle-aged patients likely to require a higher total dose of methohexital for inducing anesthesia.
Method: Seven patients (42±10 years; mean ±SD) receiving electroconvulsive therapy (ECT) were anesthetized with methohexital (1.25 mg kg^-1) or with methohexital (0.625 mg kg^-1) plus remifentanil (1 mcg kg^-1) in this randomized, double blind, crossover study. Additional methohexital was given as needed until loss of eyelash reflex was observed. Suxamethonium (1 mg kg^-1) was used for muscular paralysis.
Results: Motor and EEG seizure durations were significantly longer after induction with methohexital plus remifentanil (45±14 and 58±15 s) than with methohexital alone (31±11 and 42±18 s). A methohexital dose of 1.2±0.3 and 1.9±0.3 mg was necessary to achieve loss of eyelash reflex if methohexital was used with and without remifentanil. Peak heart rate after ECT was significantly higher if remifentanil was coadministered with methohexital (148±12 vs. 126±24 b.p.m).
Conclusion: Substituting part of the methohexital dose with remifentanil is a useful anesthetic technique to prolong seizure duration in middle-aged patients requiring a 1.5-fold higher induction dose of methohexital than elderly patients, the only population studied to date for the combined use of methohexital and remifentanil in ECT.

Which administration route of fentanyl better enhances the spread of spinal anaesthesia: intravenous, intrathecal or both?
A. Kararmaz, S. Kaya, S. Turhanoglu and M. A. Ozyilmaz
Acta Anaesthesiologica Scandinavica Volume 47 Issue 9 Page 1096

Background: To enhance the spread of spinal anaesthesia, fentanyl may be administered intrathecally (i.t.) or intravenously (i.v.). The purpose of this prospective study was to investigate the effects of fentanyl administered i.v., i.t. or concurrently by both i.v. and spinal routes on the spread of spinal anaesthesia.
Methods: Sixty patients were randomly assigned to one of three groups. In Groups I and II, spinal anaesthesia was performed with plain bupivacaine 10 mg plus 20 mcg fentanyl and in Group III with 10 mg of plain bupivacaine. The level of first peak sensory block was marked. In addition, fentanyl 50 mcg was administered i.v. in Groups II and III or by saline in Group I after the sensory blockade reached the highest dermatomal level. Ten minutes after i.v. administration, the level of the second peak sensory block was marked. The distance between the first- and second-highest levels of sensory block was measured.
Results: The distance between the first- and second-highest level of sensory block was significantly different for the three groups: Group II (5.8 ± 2.6 cm) > Group III (2.9 ± 2.1 cm) > Group I (-0.15 ± 1.7 cm). The peak dermatomal level of spinal block was significantly higher in Group II [T4 (T3-T7)] than in Group I [T6 (T4-T9)] and Group III [T6 (T4-T8)]. In Groups I and II the sensory block regressed to S2 for a longer period of time than it did in Group III.
Conclusion: Both the spinal and systemic administration of fentanyl enhanced the spread of spinal anaesthesia. The co-administration of spinal and i.v. fentanyl produced a greater increase in the cephalad spread of spinal block.

Intrathecal midazolam added to bupivacaine improves the duration and quality of spinal anaesthesia
N. Bharti, R. Madan, P. R. Mohanty and H. L. Kaul
Acta Anaesthesiologica Scandinavica Volume 47 Issue 9 Page 1101

Background: The antinociceptive action of intrathecal midazolam is well documented. In this prospective study, we investigated the addition of midazolam to intrathecal bupivacaine on the duration and quality of spinal blockade.
Methods: Forty ASA I or II adult patients undergoing lower abdominal surgery were selected for the study. The patients were randomly allocated to receive 3 ml of 0.5% hyperbaric bupivacaine intrathecally either alone or with 1 mg of midazolam using a combined spinal epidural technique. The duration and quality of sensory and motor block, perioperative analgesia, haemodynamic changes, and sedation levels were assessed.
Results: The duration of sensory block (i.e. time to regression to the S₂ segment) was significantly longer in the midazolam group than the control group (218 min vs. 165 min; P < 0.001). The duration of motor block was also prolonged in the midazolam group as compared with the control group (P < 0.01). In 90% of the patients in the midazolam group, the quality of block was adequate during the intra-operative period as compared with only 65% of the patients in the control group (P < 0.05). The duration of effective analgesia was longer in the midazolam group than in the control group (199 vs. 103 min; P < 0.001). Blood pressure, heart rate, oxygen saturation and sedation scores were comparable in both groups. No neurological deficit or other significant adverse effects were recorded.
Conclusion: The addition of intrathecal midazolam to bupivacaine significantly improves the duration and quality of spinal anaesthesia and provides prolonged perioperative analgesia without significant side-effects.

Does lidocaine provoke clinically significant vasospasm? Two cases with peripheral vascular constriction after topical application of lidocaine
T. Azma and M. Okida
Acta Anaesthesiologica Scandinavica Volume 47 Issue 9 Page 1174

Two cases with peripheral vasoconstriction possibly caused by topical application of lidocaine were reported. A potential risk of vasospasm provoked by lidocaine may be a pitfall for anesthesiologists because lidocaine is commonly considered a vasodilator.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Analgesic efficacy of rectal acetaminophen and ibuprofen alone or in combination for paediatric day-case adenoidectomy
H. Viitanen, N. Tuominen, H. Vääräniemi, E. Nikanne and P. Annila
Br J Anaesth 2003; 91: 363–7

Background: Acetaminophen and non-steroidal anti-inflammatory drugs have different mechanisms of action. We investigated if combining rectal acetaminophen with ibuprofen would provide better postoperative analgesia compared with either drug alone after adenoidectomy in children.
Methods: 160 children, aged 1–6 yr, undergoing day-case adenoidectomy, were randomized to receive either acetaminophen 40 mg kg^-1, ibuprofen 15 mg kg^-1, their combination, or placebo rectally immediately after anaesthetic induction. A standard anaesthetic method was used and all children received alfentanil 10 mcg kg^-1 i.v. during induction. Meperidine 5–10 mg i.v. was used for rescue analgesia for a pain score (Objective Pain Scale) over 3. Recovery times, sedation scores and the need for rescue analgesia and adverse events during the first 24 h after anaesthesia were recorded. Rescue analgesic at home was ibuprofen 10 mg kg^-1.
Results: Total meperidine requirements were significantly less in the groups receiving acetaminophen, ibuprofen, or their combination compared with the group receiving placebo indicating an opioid-sparing effect of 19–28% (P<0.05). Children given acetaminophen were more sedated than those given ibuprofen (P<0.05). Discharge criteria were fulfilled earlier in the ibuprofen group than in all the other groups (P<0.05). At home, less children (49%) needed rescue analgesia in the combination group compared with the other groups (74–77%) (P<0.02).
Conclusions: We conclude that prophylactically administered rectal acetaminophen combined with ibuprofen does not improve analgesia after adenoidectomy in the immediate postoperative period compared with either drug alone but does decrease the need for analgesia at home. Ibuprofen results in lesser sedation and faster discharge than when acetaminophen is used.

Comparison of remifentanil and alfentanil during anaesthesia for patients undergoing direct laryngoscopy without intubation
E. Wiel, M. Davette, L. Carpentier, P. Fayoux, C. Erb, D. Chevalier and B. Vallet
Br J Anaesth 2003; 91: 421–3

Background: Remifentanil and alfentanil are opioids often used during direct laryngoscopy (DL). This prospective, randomized study compared these agents with respect to haemodynamic and Bispectral Index (BIS) responses, glottic visualization, and rapidity of recovery (spontaneous ventilation, eye opening) in DL without intubation.
Methods: A total of 60 patients undergoing DL were randomized into two groups: remifentanil (R) and alfentanil (A). Anaesthesia was induced with propofol 2.5 mg kg^-1 and the opioid was administered 1 min later (R=2 mcg kg^-1 or A=30 mcg kg^-1 over 30 s). DL was commenced 1 min after (corresponding to 3 min after the beginning of induction). Glottic visualization, opioid and/or propofol re-injection, spontaneous ventilation recovery, and eye opening were recorded.
Results: During DL, mean arterial pressure (MAP) increased by 6% in the R group vs 20% in the A group (P<0.05) when compared with post-induction values without affecting heart rate or BIS. No significant difference was observed between groups with respect to glottic exposure, opioid and/or propofol re-injection, and spontaneous ventilation recovery (mean (SEM) 3.8 (0.6) min, R group vs 3.2 (0.7) min, A group, NS) or eye opening (7.1 (1.1) min, R group vs 7.4 (0.9) min, A group, NS). Thirty minutes after postanaesthesia care unit (PACU) admission, MAP returned to its pre-induction value in the R group (104 (3) vs 109 (3) at baseline, NS), whereas in the A group MAP remained significantly lower at this time point (96 (4) vs 106 (3) at baseline, P<0.05).
Conclusion: This study showed that only remifentanil prevented MAP increase without adverse effects such as bradycardia during DL, and prevented MAP decrease 30 min after PACU admission.

ANESTHESIOLOGY - TOP

Hand-cleansing during Postanesthesia Care
Didier Pittet, M.D., M.S.; François Stéphan, M.D., Ph.D.; Stéphane Hugonnet, M.D., M.Sc.; Christophe Akakpo, R.N.; Bertrand Souweine, M.D.; François Clergue, M.D.
Anesthesiology 2003; 99(3):530-535

Background: Transmission of microorganisms from the hands of healthcare workers is the main source of cross-infection and can be prevented by hand-cleansing. The authors assessed the compliance rate with hand-cleansing practices in the postanesthesia care unit and investigated factors associated with noncompliance.
Methods: Patient care activities, indications for and compliance of postanesthesia care unit staff with hand-cleansing, defined as either washing hands with soap and water or rubbing hands with alcohol, were monitored at the time of patient admission and during their stay. Multivariate analysis identified predictors of noncompliance with hand-cleansing on admission after adjustment for confounders.
Results: A total of 3,143 patient care activities, including 1,091 opportunities for hand-cleansing at high or medium risk for cross-transmission, were recorded among 187 patients. The higher the workload, the higher the number of indications for hand-cleansing and the lower the compliance. Average compliance with hand-cleansing at postanesthesia care unit admission was 19.6%. Independent predictors for noncompliance included caring for patients older than 65 yr (odds ratio, 2.23; 95% confidence interval, 1.40-3.57) and those recovering from clean/clean-contaminated surgery (odds ratio, 2.27; 95% confidence interval, 1.11-4.76), as well as high intensity of patient care (odds ratio, 1.01 per patient care activity; 95% confidence interval, 1.0-1.02). Compliance with hand-cleansing for patients already admitted to the postanesthesia care unit was 12.5%.
Conclusions: Failure to cleanse hands during patient care is common in the postanesthesia care unit and is associated with identifiable factors. The close relation between the intensity of patient care and noncompliance argues that hand-cleansing should not be viewed as a problematic individual behavior only, and system change must be considered in prevention strategies.

Awareness: Monitoring versus Remembering What Happened
Chantal Kerssens, Ph.D.; Jan Klein, M.D., Ph.D.; Benno Bonke, Ph.D.
Anesthesiology 2003; 99(3):570-575

Background: Awareness during anesthesia is foremost assessed with postoperative interviews, which may underestimate its incidence. On-line monitors such as the Bispectral Index® and patient response to verbal command are not necessarily commonly used. This study investigated response to command during deep sedation (Bispectral Index 60-70) and the ability of prevailing monitoring techniques to indicate awareness and predict recall.
Methods: The authors systematically assessed the response to command using the isolated forearm technique while monitoring electroencephalographic and hemodynamic variables. Fifty-six elective surgical patients were repeatedly given verbal instructions to squeeze the observer's hand during target-controlled infusion with propofol and alfentanil. After recovery, conscious recall was assessed with a short structured interview.
Results: Overall, 1,082 commands were given. No response was observed to 887 (82%) commands, an equivocal response was observed to 56 (5%) commands, and an unequivocal response was observed to 139 (13%) commands. Of the 37 patients (66%) with an unequivocal response to command ("awareness"), nine (25%) reported conscious recall after recovery. Their reports provided valuable insights as to how awareness may be adequately addressed. Hemodynamic variables poorly predicted awareness, whereas parameters derived from the encephalogram, especially the Bispectral Index, were highly significant predictors (P < 0.0001). Electroencephalographic parameters did not discriminate between patients with or without conscious recall, whereas heart rate and responsiveness to command did.
Conclusions: The incidence of awareness is underestimated when conscious recall is taken as evidence. Awareness can be monitored on-line with behavioral and modern neurophysiologic measures. Providing feedback during intra-anesthetic awareness helps patients to cope with a potentially stressful situation.

Urgent Adenotonsillectomy: An Analysis of Risk Factors Associated with Postoperative Respiratory Morbidity
Karen A. Brown, M.D.; Isabelle Morin, M.Sc.; Chantal Hickey, M.D.; John J. Manoukian, M.D., F.R.C.S.C., F.A.C.S.; Gillian M. Nixon, M.B.Ch.B., M.D., F.R.A.C.P.; Robert T. Brouillette, M.D.
Anesthesiology 2003; 99(3):586-595

Background: The aim of this study was to determine the frequency and type of respiratory complications after urgent adenotonsillectomy (study group) for comparison with a control group of children undergoing a sleep study and adenotonsillectomy for obstructive sleep apnea syndrome. A second aim was to assess risk factors predictive of respiratory complications after urgent adenotonsillectomy.
Methods: The perioperative course of children who underwent adenotonsillectomy between January 1, 1999, and March 31, 2001, was reviewed. Two groups of children were identified from two different databases: the hospital database for surgical procedures (the study group) and the sleep laboratory database (the control group). The retrospective chart review focused on the preoperative status (including an evaluation for obstructive sleep apnea), anesthetic management, and need for postoperative respiratory interventions.
Results: A total of 64 consecutive cases for urgent adenotonsillectomy were identified, and 54 children met the inclusion criteria. Thirty-three children (60%) had postoperative respiratory complications necessitating a medical intervention; 11 (20.3%) required a major intervention (reintubation, ventilation, and/or administration of racemic epinephrine or Ventolin), and 22 (40.7%) required a minor intervention (oxygen administration). Six children (11.1%) required reintubation in the recovery room for respiratory compromise. Risk factors for respiratory complications were an associated medical condition (odds ratio, 8.15; 95% confidence interval, 1.81-36.73) and a preoperative saturation nadir less than 80% (odds ratio, 5.54; 95% confidence interval, 1.15-26.72). Sixteen (49%) of the medical interventions were required within the first postoperative hour. Atropine administration, at induction, decreased the risk of postoperative respiratory complications (odds ratio, 0.18; 95% confidence interval, 0.11-1.050. Control group: Of 75 children who underwent a sleep study and adenotonsillectomy, 44 had sleep apnea and were admitted to hospital after elective adenotonsillectomy. Sixteen (36.4%) children had postoperative respiratory complications necessitating a medical intervention. Six percent of the children (n = 3) required a major medical intervention. No child required reintubation for respiratory compromise.
Conclusions: Severe obstructive sleep apnea syndrome and an associated medical condition are risk factors for postadenotonsillectomy respiratory complications. Risk reductions strategies should focus on their assessment.

Analgesic Efficacy of Inhaled Morphine in Patients after Bunionectomy Surgery
John B. Thipphawong, M.D.; Najib Babul, Pharm.D.; Richard J. Morishige, R.R.T.; Hugh K. Findlay, R.N. ; Keith R. Reber, D.P.M.; Gary J. Millward, D.P.M.; Babatunde A. Otulana, M.D.
Anesthesiology 2003; 99(3):693-700

Background: The AERx® Pain Management System (Aradigm Corporation, Hayward, CA) is a novel pulmonary delivery system for the systemic administration of morphine. The authors compared the relative analgesic efficacy and safety of the AERx® Pain Management System with those of placebo and intravenous morphine in an orthopedic postsurgical pain model.
Methods: Eighty-nine male and female PS-1 to PS-3 patients underwent standardized bunionectomy surgery and received multiple doses of inhaled or intravenous placebo, inhaled morphine (one inhalation [2.2 mg] or three inhalations [6.6 mg]), or intravenous morphine (4 mg) in a blinded fashion. Open-label rescue morphine (2 mg) was also available as needed. Pain intensity, pain relief, and time to pain relief were measured after the first dose. Global evaluation, morphine consumption, vital signs, and adverse events were monitored for 8 h after treatment. Blinded study personnel performed all treatment administrations and pain assessments.
Results: Three inhalations of morphine and 4 mg intravenous morphine provided comparable single- and multiple-dose analgesia. One inhalation of morphine was statistically indistinguishable from placebo. Three inhalations of morphine and 4 mg intravenous morphine both consistently demonstrated significantly greater analgesic efficacy than did placebo and one inhalation of morphine.
Conclusions: Comparable analgesic efficacy was demonstrated between a carefully matched dose of inhaled and intravenous morphine in a postsurgical pain model.

PUB MED - TOP

Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers.
Vila H Jr, Soto R, Cantor AB, Mackey D.
Arch Surg. 2003 Sep;138(9):991-5.

HYPOTHESIS: This study compared outcomes to determine whether patient safety is similar in Florida ambulatory surgery centers and offices.
DATA SOURCES: All adverse incident reports to the Florida Board of Medicine for procedure dates April 1, 2000, to April 1, 2002 were reviewed. The numbers of office procedures performed during a 4-month period were used to estimate the total number of procedures. Ambulatory surgery death summaries, adverse incident data, and volumes of procedures for 2000 were procured from the Florida Agency for Health Care Administration.
STUDY SELECTION/DATA EXTRACTION: Adverse incident reports were reviewed by multiple parties; only reports that involved an office surgical procedure and resulted in injury or death were included in the outcomes calculation. Reports were extracted independently by multiple reviewers.
DATA SYNTHESIS: Adverse incidents occurred at a rate of 66 and 5.3 per 100,000 procedures in offices and ambulatory surgery centers, respectively. The death rate per 100,000 procedures performed was 9.2 in offices and 0.78 in ambulatory surgery centers. The relative risks for injuries and deaths for office procedures vs ambulatory surgery centers were 12.4 (95% confidence interval, 9.5-16.2) and 11.8 (95% confidence interval, 5.8-24.1), respectively.
CONCLUSIONS: In this review of surgical procedures performed in offices and ambulatory surgery centers in Florida during a recent 2-year period, there was an approximately 10-fold increased risk of adverse incidents and death in the office setting. If all office procedures had been performed in ambulatory surgery centers, approximately 43 injuries and 6 deaths per year could have been prevented.

Indications for the use of propofol in electroconvulsive therapy.
Bailine SH, Petrides G, Doft M, Lui G.
J ECT. 2003 Sep;19(3):129-32.

BACKGROUND: Propofol is an anesthetic agent commonly used for ambulatory surgery because is associated with rapid recovery and a benign side effect profile. In electroconvulsive therapy (ECT), its use is limited because of its seizure-shortening effects, and is recommended only for patients with preexisting cardiac conditions requiring attenuated hemodynamic response during treatment. We have identified two additional significant indications for propofol: to induce shorter seizures in patients with prolonged seizures and to minimize post-ictal nausea and vomiting.
METHODS: We reviewed the records of 340 patients treated with ECT. We identified 28 patients who were switched from methohexital to propofol anesthesia due to adverse effects or to avoid prolonged seizures.
RESULTS: Twenty-two patients were switched from methohexital anesthesia to propofol because they had already experienced long seizures. Nine patients had seizures longer than 180 seconds requiring termination with a benzodiazepine. The switch resulted in an average shortening of the EEG recorded seizures by 38.7%. Eight of the 22 (36.4%) patients were adolescents. These 8 comprised 53% of the total of 15 adolescents treated with ECT in our service. Five of the 15 (33%) had seizures longer than 180 seconds. Finally, 7 of the 28 patients were switched to propofol because of nausea and vomiting, which was significantly reduced. No side effects were noted, and none of these patients needed to switch back to methohexital.
CONCLUSION: Propofol may be a useful alternative to methohexital for the treatment of patients who have excessively long seizures and/or severe nausea and vomiting after ECT. Such seizures are more common among adolescents.

Outpatient cleft lip repair.
Rosen H, Barrios LM, Reinisch JF, Macgill K, Meara JG.
Plast Reconstr Surg. 2003 Aug;112(2):381-7; discussion 388-9.

The emphasis on cost reduction and increased efficiency in health care delivery has prompted an increase in outpatient (ambulatory) surgical procedures. A retrospective review of the perioperative management of patients undergoing cleft lip repair at two urban tertiary pediatric hospitals was performed to assess the safety of outpatient cleft lip repair. The hospital database at Childrens Hospital Los Angeles was searched to find all patients who had been operated on for cleft lip repair during calendar years 1999 and 2000. Two groups were identified from Childrens Hospital Los Angeles: the outpatient cleft lip repair group (patients discharged the same day as the operation; n = 91) and the inpatient cleft lip repair group (n = 14). A data set was acquired from the Royal Children's Hospital in Melbourne, Australia, using the same criteria, for fiscal years 1998 to 2000 (n = 50). All patients from Royal Children's Hospital had operations as inpatients. Parameters considered for each group were age, sex, race, ethnicity, length of hospital stay, preexisting medical conditions or diagnoses, complications, and readmissions or presentation to the emergency department within 4 weeks of operation. The Childrens Hospital Los Angeles outpatient group had three readmissions that were considered to be complications of the operation. The Childrens Hospital Los Angeles inpatient group had one readmission attributable to a complication. The Royal Children's Hospital group also had one readmission for a complication. There was no significant difference in the complication rate of the Childrens Hospital Los Angeles outpatient group and the Royal Children's Hospital group (p > 0.05). There was also no significant difference in the complication rate of both of the Childrens Hospital Los Angeles groups compared with the Royal Children's Hospital group (p > 0.05). This study indicates that cleft lip repair performed in an outpatient setting may be a safe alternative to the inpatient operation. Certain preexisting medical conditions, however, may dictate the need for inpatient hospitalization after repair.