Volume 5, Issue 4 S A M B A T A L K S - PAGE 3 September, 2005

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

The Incidence of Transient Neurologic Symptoms After Spinal Anesthesia with Mepivacaine
Jacques T. YaDeau, MD, PhD, Gregory A. Liguori, MD, and Victor M. Zayas, MD
Anesth Analg 2005;101:661-665

We prospectively evaluated 1273 patients who received spinal (or combined spinal-epidural [CSE]) anesthesia with 1.5% mepivacaine (plain, no glucose) for ambulatory surgery. We hypothesized that analysis of a large series of patients would confirm previous findings that isobaric 1.5% mepivacaine is not frequently associated with transient neurologic symptoms (TNS). Patients were contacted twice after the anesthetic, at days 1–4 and days 6–9. One-thousand-two-hundred-ten patients were successfully contacted postoperatively (95% follow-up rate). None of the patients had permanent neurologic sequelae from the anesthetic. None of the 372 CSE anesthetics was inadequate for surgery. Fourteen of 838 (1.7%) of the spinal anesthetics were inadequate. TNS, defined as the new onset of back pain that radiated bilaterally to buttocks or distally, occurred in 78 patients (6.4%; 95% confidence intervals 5.1%–8%). The mean age of patients who developed TNS (48 ± 14 yr) was older than that of patients without TNS (41 ± 16 yr) (P < 0.001). TNS was not influenced by gender or intraoperative position. The frequent success rate and infrequent rates of complications such as TNS and postdural puncture headache suggest that spinal anesthesia with mepivacaine is likely to be a safe and effective anesthetic for ambulatory patients.

Acupressure and Preoperative Parental Anxiety: A Pilot Study
Shu-Ming Wang, MD, Dorothy Gaal, MD, Inna Maranets, MD, Alison Caldwell-Andrews, PhD, and Zeev N. Kain, MD
Anesth Analg 2005;101:666-669

In this randomized sham-controlled study we examined the anxiolytic and sedative effects of acupressure on parents in the preoperative holding area before their children’s surgery. Sixty-one parents received acupressure either at the Yintang point (midpoint between the two eyebrows) or at a sham point. Anxiety (as measured by the Stait-Trait Anxiety Inventory), arterial blood pressure, and heart rate were assessed before and after the intervention and a Bispectral Index monitor was used to continuously monitor hypnotic sedation levels. Repeated-measures analysis of variance showed that parents in the acupressure group reported significantly less anxiety at 20 min postintervention as compared with parents in the sham group (37 ± 10 versus 45 ± 13, P = 0.03). Bispectral Index values, heart rate, and arterial blood pressure, however, did not differ between the two study groups (P = not significant). We conclude that acupressure at the Yintang point may be used as a treatment for parental preoperative anxiety. Future studies are needed to quantify the magnitude and duration of the anxiolytic effect.

ANESTHESIOLOGY - TOP

Sole Use of Dexmedetomidine Has Limited Utility for Conscious Sedation during Outpatient Colonoscopy.
Jalowiecki, Przemyslaw M.D., Ph.D. ; Rudner, Robert M.D., Ph.D. ; Gonciarz, Maciej M.D., Ph.D. ; Kawecki, Piotr M.D., Ph.D. ; Petelenz, Michal M.D., Ph.D. ; Dziurdzik, Piotr M.D., Ph.D.
Anesthesiology. 103(2):269-273, August 2005.

Background: This study evaluated the ability of dexmedetomidine to provide analgesia and sedation for outpatient colonoscopy, examining outcomes including cardiorespiratory variables, side effects, and discharge readiness.
Methods: Sixty-four patients were randomly assigned to one of three treatment regimens. In group D, patients received 1 [mu]g/kg dexmedetomidine over 15 min followed by an infusion of 0.2 [mu]g [middle dot] kg^-1 [middle dot] h^-1. Group P received meperidine (1 mg/kg) with midazolam (0.05 mg/kg), and group F received fentanyl (0.1-0.2 mg intravenous) on demand. The assessment included measurements of heart rate, blood pressure, oxygen saturation, respiratory rate, quality of sedation/analgesia, and an evaluation of the recovery time.
Results: The study was terminated before the planned 90 patients had been recruited because of adverse events in group D. In all groups, negligible hemoglobin oxygen saturation and respiratory rate variations were observed. In group D, there was a significantly larger decrease in heart rate (to approximately 40 beats/min in 2 of 19 cases) and blood pressure (to less than 50% of the initial value in 4 of 19 patients). Supplemental fentanyl was required in 47% of patients receiving dexmedetomidine to achieve a satisfactory level of analgesia (vs. 42.8% of patients in group P and 79.2% of patients in group F). Vertigo (5 patients), nausea/vomiting (5 patients), and ventricular bigeminy (1 patient) were observed only in group D. Time to home readiness was longest in group D (85 +/- 74, 39 +/- 21, and 32 +/- 13 min in groups D, P and F, respectively; P = 0.007).
Conclusions: The use of dexmedetomidine to provide analgesia/sedation for colonoscopy is limited by distressing side effects, pronounced hemodynamic instability, prolonged recovery, and a complicated administration regimen.

Spectral Entropy Monitoring Is Associated with Reduced Propofol Use and Faster Emergence in Propofol-Nitrous Oxide-Alfentanil Anesthesia.
Vakkuri, Anne M.D., Ph.D.; Yli-Hankala, Arvi M.D., Ph.D. ; Sandin, Rolf M.D., Ph.D.; Mustola, Seppo M.D., Ph.D.; Hoymork, Siv M.D.; Nyblom, Stina M.D., Ph.D.; Talja, Pia M.Sc.; Sampson, Timothy M.Sc.; van Gils, Mark Ph.D.; Viertio-Oja, Hanna Ph.D.
Anesthesiology. 103(2):274-279, August 2005.

Background: This multicenter study evaluated the effect of a new depth of anesthesia-monitoring device based on time-frequency-balanced spectral entropy of electroencephalogram monitoring (GE Healthcare Finland, Helsinki, Finland) on consumption of anesthetic drugs and recovery times after anesthesia.
Methods: The study was a prospective, randomized, single-blind study performed in six hospitals in Finland, Sweden, and Norway. After institutional review board approval and written informed consent from each patient, the patients were randomly allocated to anesthesia with entropy values either shown (entropy group) or not shown (control group). Anesthesia was maintained with propofol, nitrous oxide, and alfentanil. In the entropy group, propofol was given to keep the state entropy value between 45 and 65, and alfentanil was given to keep the state entropy-response entropy difference below 10 units and heart rate and blood pressure within +/-20% of the baseline values. The control group patients were anesthetized to keep heart rate and blood pressure within +/-20% of the baseline values. Statistical methods included Mann-Whitney U test and unpaired t tests.
Results: A total of 368 patients were studied. In the entropy group, entropy values were higher during the whole operation and especially during the last 15 min (P < 0.001). Consequently, propofol consumption was smaller in the entropy group during the whole anesthesia period (P < 0.001) and especially during the last 15 min (P < 0.001). This shortened the time delay in the early recovery parameters in the entropy group.
Conclusion: Entropy monitoring assisted titration of propofol, especially during the last part of the procedures, as indicated by higher entropy values, decreased consumption of propofol, and shorter recovery times in the entropy group.

Overlapping Induction of Anesthesia: An Analysis of Benefits and Costs.
Hanss, Robert M.D. ; Buttgereit, Bjorn M.D. ; Tonner, Peter H. M.D. ; Bein, Berthold M.D. ; Schleppers, Andreas M.D. ; Steinfath, Markus M.D. ; Scholz, Jens M.D.; Bauer, Martin M.D., M.P.H.
Anesthesiology. 103(2):391-400, August 2005.

Background: Overlapping induction (OI), i.e., induction of anesthesia with an additional team while the previous patient is still in the operating room (OR), was investigated.
Methods: The study period was 60 days in two followed by three ORs during surgical Block Time (7:30 am until 3:00 pm). Patients were admitted the day before surgery and were thus available and did not have surgery that day unless there was a time reduction. Facilities were already constructed. Number of cases, Nonsurgical Time (Skin Suture Finish until next Procedure Start Time), Turnover Time, and Anesthesia Control Time plus Turnover Time were studied. In addition, economic benefit was calculated.
Results: Three hundred thirty-five cases were studied. Using OI, the time of care of regularly scheduled cases was shortened, and the number of cases performed within OR Block Time increased (151 to 184 cases; P < 0.05). Nonsurgical Time (in h:min) decreased (1:08 +/- 0:26 to 0:57 +/- 0:18; P < 0.001), Turnover Time decreased (0:38 +/- 0:24 to 0:25 +/- 0:15; P < 0.05), and Anesthesia Control Time plus Turnover Time decreased (0:43 +/- 0:23 to 0:28 +/- 0:18; P < 0.001). Subgroup analysis showed a significant benefit of OI only in three ORs. In three ORs, economic benefit can be gained at a case mix index greater than 0.3 besides additional costs.
Conclusions: Overlapping induction increased productivity and profit despite the expense of additional staff. Subgroup analysis emphasizes the importance of the number of ORs involved in OI.

Use of Anesthesia Induction Rooms Can Increase the Number of Urgent Orthopedic Cases Completed within 7 Hours.
Torkki, Paulus M. M.Sc. ; Marjamaa, Riitta A. M.D ; Torkki, Markus I. M.D., Ph.D.; Kallio, Pentti E. M.D.,Ph.D.; Kirvela, Olli A. M.D., Ph.D.
Anesthesiology. 103(2):401-405, August 2005.

Background: Mean turnover times and the time spent in the operating room (OR) can be reduced by concurrent induction of anesthesia. Previous studies of anesthesia induction outside the OR have concentrated either on anesthesia-controlled time or turnover time. The goal of this study was to investigate the impact of an induction room model on the whole surgical process, its phases and delays between the phases, and the number of cases performed during the 7-h working day.
Methods: A prospective analysis of OR times was conducted for 5 weeks with the traditional induction-in-the-OR model followed by 4 weeks with a new model: A team of two nurses and one anesthesiologist was added to one OR to perform parallel anesthesia induction in a separate induction room. The durations of phases of surgical process, number of completed cases between 7:45 am and 3:00 pm, and daily raw utilization of the OR were assessed. Results were compared to those measured before the intervention.
Results: The mean nonoperative time was reduced by 45.6%, whereas surgery time remained unchanged. The time savings contributed to the concurrent anesthesia induction and the cut down in delays between the phases. The new model allowed one additional case to be performed during the 7-h working day.
Conclusions: Anesthesia induction outside the OR can increase the number of surgical cases performed during a regular workday.

Deliberate Perioperative Systems Design Improves Operating Room Throughput.
Sandberg, Warren S. M.D., Ph.D.; Daily, Bethany M.H.A. ; Egan, Marie R.N., M.S.; Stahl, James E. M.D., C.M., M.P.H.; Goldman, Julian M. M.D.; Wiklund, Richard A. M.D. ; Rattner, David M.D.
Anesthesiology. 103(2):406-418, August 2005.

Background: New operating room (OR) design focuses more on the surgical environment than on the process of care. The authors sought to improve OR throughput and reduce time per case by goal-directed design of a demonstration OR and the perioperative processes occurring within and around it.
Methods: The authors constructed a three-room suite including an OR, an induction room, and an early recovery area. Traditionally sequential activities were run in parallel, and nonsurgical activities were moved from the OR to the supporting spaces. The new workflow was supported by additional anesthesia and nursing personnel. The authors used a retrospective, case- and surgeon-matched design to compare the throughput, cost, and revenue performance of the new OR to traditional ORs.
Results: For surgeons performing the same case mix in both environments, the new OR processed more cases per day than traditional ORs and used less time per case. Throughput improvement came from superior nonoperative performance. Nonoperative Time was reduced from 67 min (95% confidence interval, 64-70 min) to 38 min (95% confidence interval, 35-40 min) in the new OR. All components of Nonoperative Time were meaningfully reduced. Operative Time decreased by approximately 5%. Hospital and anesthesia costs per case increased, but the increased throughput offset costs and the global net margin was unchanged.
Conclusions: Deliberate OR and perioperative process redesign improved throughput. Performance improvement derived from relocating and reorganizing nonoperative activities. Better OR throughput entailed additional costs but allowed additional patients to be accommodated in the OR while generating revenue that balanced these additional costs.

Predicting Difficult Intubation in Apparently Normal Patients: A Meta-analysis of Bedside Screening Test Performance.
Shiga, Toshiya M.D., Ph.D. ; Wajima, Zen'ichiro M.D., Ph.D. ; Inoue, Tetsuo M.D., Ph.D. ; Sakamoto, Atsuhiro M.D., Ph.D. 
Anesthesiology. 103(2):429-437, August 2005.

Abstract:
The objective of this study was to systematically determine the diagnostic accuracy of bedside tests for predicting difficult intubation in patients with no airway pathology. Thirty-five studies (50,760 patients) were selected from electronic databases. The overall incidence of difficult intubation was 5.8% (95% confidence interval, 4.5-7.5%). Screening tests included the Mallampati oropharyngeal classification, thyromental distance, sternomental distance, mouth opening, and Wilson risk score. Each test yielded poor to moderate sensitivity (20-62%) and moderate to fair specificity (82-97%). The most useful bedside test for prediction was found to be a combination of the Mallampati classification and thyromental distance (positive likelihood ratio, 9.9; 95% confidence interval, 3.1-31.9). Currently available screening tests for difficult intubation have only poor to moderate discriminative power when used alone. Combinations of tests add some incremental diagnostic value in comparison to the value of each test alone. The clinical value of bedside screening tests for predicting difficult intubation remains limited.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Pre-operative fasting guidelines: an update
E. Søreide, L. I. Eriksson, G. Hirlekar, H. Eriksson, S. W. Henneberg, R. Sandin, J. Raeder, (Task Force on Scandinavian Pre-operative Fasting Guidelines, Clinical Practice Committee Scandinavian Society of Anaesthesiology and Intensive Care Medicine)
Volume 49 Issue 8 Page 1041 - September 2005

Liberal pre-operative fasting routines have been implemented in most countries. In general, clear fluids are allowed up to 2 h before anaesthesia, and light meals up to 6 h. The same recommendations apply for children and pregnant women not in labour. In children <6 months, most recommendations now allow breast- or formula milk feeding up to 4 h before anaesthesia. Recently, the concept of pre-operative oral nutrition using a special carbohydrate-rich beverage has also gained support and been shown not to increase gastric fluid volume or acidity. Based on the available literature, our Task Force has produced new consensus-based Scandinavian guidelines for pre-operative fasting. What is still not clear is to what extent the new liberal fasting routines should apply to patients with functional dyspepsia or systematic diseases such as diabetes mellitus. Other still controversial areas include the need for and effect of fasting in emergency patients, women in labour and in association with procedures done under 'deep sedation'. We think more research on the effect of various fasting regimes in subpopulations of patients is needed before we can move one step further towards completely evidence-based pre-operative fasting guidelines.

Continuous peripheral nerve blockade in lower extremity surgery
Á. M. Navas, T. V. Gutiérrez and M. E. Moreno
Volume 49 Issue 8 Page 1048 - September 2005

Peripheral nerve blocks afford numerous benefits for lower extremity surgery. There is growing interest in continuous peripheral nerve blocks, mainly for treatment of postoperative pain, a field that represents a challenge to the anaesthesiologist. This paper seeks to review the efficacy of continuous lower limb blocks for postoperative pain relief. Not only do continuous peripheral nerve blocks afford specificity of analgesic area but current research has shown that they enhance postoperative analgesia and patient satisfaction. New techniques and devices are increasingly appearing, and catheters are constantly being developed and improved; an example being the stimulating catheter, which represents one of the newest advances in this area.

The above techniques show that continuous postoperative analgesia with catheters in the lower extremities is not only possible, but indeed provides sustained effective postoperative analgesia, reduces use of opioids, and improves rehabilitation and patient well-being with minimal side-effects. These techniques could prove an alternative to postoperative pain treatment following ambulatory surgery.

Bispectral Index values are higher during halothane vs. sevoflurane anesthesia in children, but not in infants
J. J. Edwards, R. G. Soto and R. F. Bedford
Volume 49 Issue 8 Page 1084 - September 2005

Background: Previously, we have shown in adult patients that bispectral index score (BIS) values are significantly higher during halothane anesthesia (5361 units) as compared with those observed during equipotent concentrations of sevoflurane (3943 units). Because halothane is frequently used in the pediatric setting, we tested the hypothesis that BIS values observed in children might also be higher during general anesthesia with halothane than with sevoflurane.
Methods: Forty-one healthy, unpremedicated pediatric patients scheduled for elective operations received either halothane or sevoflurane titrated as appropriate for surgical stimulation.
Results: During maintenance sevoflurane anesthesia (n = 20), the mean BIS values and percent end-tidal concentrations were 44 ± 14 and 2.1 ± 0.6, respectively, whereas for the halothane group (n = 21) the corresponding values were 61 ± 7 and 1.1 ± 0.4, respectively.
Conclusion: These findings suggest that BIS values are higher during halothane vs. sevoflurane anesthesia in children, but not in infants.

Bradycardia and hypertension in anticipation of, and exacerbated by, peribulbar block: a prospective audit
A. A. van den Berg
Volume 49 Issue 8 Page 1207 - September 2005

Background: Changes in heart rate (HR), systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) occur in anticipation of, and following, injection of a peribulbar local analgesic agent. We examined these changes in two groups of awake patients given a pre-medication of either hydroxyzine 1.0 mg/kg alone (control) or hydroxyzine 1.0 mg/kg with morphine 0.05 mg/kg.
Methods: HR, SAP and DAP of 100 patients per group were monitored the day before surgery (baseline), every 5 min in the anesthesia holding room before peribulbar injection, every minute for the first 5 min after peribulbar injection and then every 5 min until transfer to the operating room. Within and between pre-medication group values of HR, SAP and DAP before and after peribulbar injection were compared with baseline.
Results: The two groups of patients were similar. Before peribulbar injection, HR was unchanged in the hydroxyzine group, but 6% slower in those given morphine (P < 0.01). After injection, HR slowed in both groups, by 5% and 7% (P < 0.01, both comparisons), respectively. In anticipation of injection, SAP increased in both groups to 20% and 16% above baseline, respectively, and increased further after injection to 26% and 24% above baseline, respectively (P < 0.001, all comparisons). In both groups, maximum SAP following injection exceeded maximum SAP before injection (P < 0.02, both comparisons). DAP increased by 4% (P < 0.05) in the hydroxyzine group before injection, and by 5% and 4%, respectively (P < 0.005 and P < 0.05, respectively) after peribulbar injection.
Conclusion: The audit reveals pronounced increases in SAP accompanied by lesser increases in DAP and a tendency to slowing of HR in awake patients in anticipation of peribulbar injections. Peribulbar injections cause further increases in blood pressure and mild bradycardia. These changes occur similarly in patients pre-medicated with hydroxyzine or hydroxyzine plus morphine. A mix of neuro-humoral influences (anxiety/catecholamine/baroreceptor/trigemino-vagal) are postulated as etiological.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Correlation of bispectral index with end-tidal sevoflurane concentration and age in infants and children
H. S. Kim, A. Y. Oh, C. S. Kim, S. D. Kim, K. S. Seo and J. H. Kim
British Journal of Anaesthesia 2005 95(3):362-366

Background. The bispectral index (BIS) has been evaluated as a tool for measuring depth of anaesthesia, but the use of BIS in a paediatric population is still controversial. This study was designed to evaluate the correlation of BIS with end-tidal sevoflurane concentration and age in infants and children.
Methods. Eighty-one patients undergoing elective urology surgery were allocated into three age groups; 6 months to 2 yr (n=28), 3–7 yr (n=33), and 8–12 yr (n=20). Sevoflurane was administered to achieve steady-state end-tidal sevoflurane concentrations (ETsevo) of 2.0, 3.0, and 4.0%; these were achieved consecutively either from the lowest or from the highest concentration. The BIS (version XP) was monitored continuously.
Results. In all three groups, BIS decreased significantly when ETsevo increased from 2.0 to 3.0% but there was a paradoxical increase in BIS values when ETsevo increased from 3.0 to 4.0%. The non-linear regression analysis showed a significant correlation between BIS and age at each ETsevo. The younger patients showed the higher BIS values.
Conclusions. In children aged 6 months to 12 yr, the BIS increased paradoxically as ETsevo increased from 3.0 to 4.0%. BIS values showed a wide variation in the same ETsevo and the age itself was considered to be a factor affecting the BIS values.

Assessment of the cough reflex after propofol anaesthesia for colonoscopy
J. Guglielminotti, T. Rackelboom, A. Tesniere, X. Panhard, F. Mentre, M. Bonay, J. Mantz and J. M. Desmonts
British Journal of Anaesthesia 2005 95(3):406-409

Background. Dysfunction of the cough reflex as a result of the lingering effects of anaesthetics may lead to aspiration pneumonia or retained secretions after general anaesthesia. It is unknown whether low concentrations of propofol alter the cough reflex in the early period after anaesthesia. The objective of this study was to investigate the effect of low concentrations of propofol on the cough reflex sensitivity as assessed by the cough reflex threshold to an inhaled irritant.
Methods. Fifteen, ASA I–II, non-smoking patients undergoing elective colonoscopy were studied. Anaesthesia was induced and maintained with a blood target-controlled propofol infusion. Cough reflex threshold was measured with citric acid. Increasing concentrations of nebulized citric acid (2.5, 5, 10, 20, 40, 80, 160, 320, and 640 mg ml^-1) were delivered during inspiration until a cough was evoked. The citric acid concentration eliciting one cough (C1) was defined as the cough reflex threshold. C1 was log transformed for statistical analysis (Log C1). Log C1 was measured before anaesthesia and during the recovery period with estimated decreasing propofol concentrations of 1.2, 0.9, 0.6, and 0.3 µg ml^-1.
Results. Log C1 (median; interquartile range) measured with propofol concentrations of 1.2, 0.9, 0.6, 0.3, and 0 µg ml^-1 were 1.9 (0.6), 1.9 (1.0), 1.9 (1.1), 1.9 (0.6), and 1.9 (0.7) mg ml–1 (NS), respectively. However, light sedation was observed with propofol concentrations of 1.2 and 0.9 µg ml^-1.
Conclusion. This study indicates that residual sedation after propofol anaesthesia for colonoscopy does not adversely affect the cough reflex.

Lingual nerve injury associated with the ProSeal laryngeal mask airway: a case report and review of the literature
J. Brimacombe, G. Clarke and C. Keller
British Journal of Anaesthesia 2005 95(3):420-423

We present a case of lingual nerve injury that was associated with use of the ProSeal laryngeal mask airway during shoulder replacement in a 61-yr-old male. We also review other cases of cranial nerve injury, most of which were associated with use of the classic laryngeal mask airway. In principle, the frequency of cranial nerve injuries can be reduced by avoiding insertion trauma, using appropriate sizes, minimizing cuff volume, and early identification and correction of malposition.

Postoperative NSAIDs and COX-2 inhibitors: cardiovascular risks and benefits (Editorial)
S. F. Jones, I. Power
British Journal of Anaesthesia 2005 95(3):281-284

No abstract available.

CANADIAN JOURNAL OF ANESTHESIA - TOP

Current preoperative testing practices in ambulatory surgery are widely disparate: a survey of CAS members
Hongbo Yuan, MD PhD, Frances Chung, MD FRCPC, David Wong, MD FRCPC and Reginald Edward, FFARCSI FRCA
Canadian Journal of Anesthesia 52:675-679 (2005)

Purpose: Routine preoperative testing has been criticized as having little impact on perioperative outcomes. The purpose of this study is to identify the current practice of preoperative testing in ambulatory surgery.
Methods: A standard questionnaire was sent to all active members of the Canadian Anesthesiologists’ Society (CAS). The study inquired into the anesthesiologist’s preoperative testing practice in healthy patients and patients with stable medical conditions undergoing ambulatory surgery.
Results: Of 1,335 mailed questionnaires, a total 617 respondents who reported their participation in ambulatory surgical care were received. Eighty percent [95% confidence interval (CI) 76.5–83.2] of the respondents indicated that, if testing had to be ordered in asymptomatic patients undergoing low-risk ambulatory surgery, it would be due to the patient’s clinical indications while others indicated it would be the result of following institutional guidelines (15.1%, 95% CI 12.2–17.9), and even fewer attributed it to a ‘routine’ testing practice (0.5%, 95% CI 0–1.14). Forty-four percent (95% CI 39.8–47.8) of the anesthesiologists indicated that age alone is not a criterion when they required a preoperative electrocardiogram (ECG) while others reported various cut-points (> 65; > 55; > 45; > 40 yr) for ECG ordering for asymptomatic patients undergoing the low-risk ambulatory surgery. About 40% (95% CI 35.7–43.5) of the anesthesiologists had no specific concern about eliminating preoperative testing in ambulatory surgery.
Conclusion: Our survey has documented marked disparities in the practices of preoperative testing. A large proportion of the anesthesiologists indicated that age alone is not a criterion for preoperative ordering of ECG. Many anesthesiologists had no concern about eliminating preoperative testing in low-risk ambulatory surgery.

Preoperative medical consultations: impact on perioperative management and surgical outcome
Robert I. Katz, MD, Linda Cimino, MS RN CPNP ANP and Stephen A. Vitkun, MD MBA PhD
Canadian Journal of Anesthesia 52:697-702 (2005)

Purpose: This study was designed to assess the effect of preoperative medical consults on both perioperative management and surgical outcome.
Methods: The charts of 387 consecutive patients over the age of 50 undergoing non-cardiac, elective surgery during a six-week period were retrospectively examined. Patient factors including age, ASA status, gender, type of surgery, outcome (death, unexpected intensive care unit admission or uncomplicated discharge), presence of medical consult, and, in those cases where a medical consult was present, stated reason for the consult, the ordering physician, and recommendations of the consultant, were recorded.
Results: 138 patients receiving medical consults (35.7%) were identified (a total of 146 consults). The most common stated purpose of the consults examined was "preoperative evaluation." In only five consults (3.4%) did the consultant identify a new finding. Sixty-two consults (42.5%) contained no recommendations. There was no statistically significant difference in outcome between those patients who received a medical consult and those who did not.
Conclusion: A review of 146 medical consults suggests that the majority of such consults give little advice that truly impacts either perioperative management or outcome of surgery.

P6 acupressure increases tolerance to nauseogenic motion stimulation in women at high risk for PONV
Aidah Alkaissi, RN PhD, Torbjörn Ledin, MD PhD, Lars M. Odkvist, MD PhD and Sigga Kalman, MD PhD
Canadian Journal of Anesthesia 52:703-709 (2005)

Purpose: In a previous study we noticed that P6 acupressure decreased postoperative nausea and vomiting (PONV) more markedly after discharge. As motion sickness susceptibility is increased by, for example, opioids we hypothesized that P6 acu-pressure decreased PONV by decreasing motion sickness susceptibility. We studied time to nausea by a laboratory motion challenge in a group of volunteers, during P6 and placebo acupressure.
Methods: 60 women with high and low susceptibilities for motion sickness participated in a randomized and double-blind study with an active P6 acupressure, placebo acupressure, and a control group (n = 20 in each group). The risk score for PONV was over 50%. The motion challenge was by eccentric rotation in a chair, blindfolded and with chin to chest movements of the head. The challenge was stopped when women reported moderate nausea. Symptoms were recorded.
Results: Mean time to moderate nausea was longer in the P6 acu-pressure group compared to the control group. P6 acupressure = 352 (259–445), mean (95% confidence interval) in seconds, control = 151 (121–181) and placebo acupressure = 280 (161–340); (P = 0.006). No difference was found between P6 and placebo acupressure or placebo acupressure and control groups. Previous severity of motion sickness did not influence time to nausea (P = 0.107). The cumulative number of symptoms differed between the three groups (P < 0.05). Fewer symptoms were reported in the P6 acupressure compared to the control group P < 0.009. Overall, P6 acupressure was only marginally more effective than placebo acupressure on the forearms.
Conclusion: In females with a history of motion sickness P6 acu-pressure increased tolerance to experimental nauseogenic stimuli, and reduced the total number of symptoms reported.

PUB MED - TOP

Unanticipated hospital admission after ambulatory surgery.
Khan M, Ahmed A, Abdullah L, Nizar A, Fareed A, Khan FA. J Pak Med Assoc.
2005 Jun;55(6):251-2.

The unplanned admission rate is considered to be an important measure of the quality of ambulatory surgical units. The objective of our study was to evaluate the unanticipated hospital admission rate from the Surgical Day Care (SDC) unit of our university affiliated teaching hospital and to analyze the reasons for admission. A review of all unanticipated admissions over a one-year period was done. The admission rate was calculated and the reasons for admission were analysed. The overall admission rate was 4.93%. Most of the admissions were ordered by the surgeons (97%). The main reasons for admission were patient observation indicated for various reasons (72%) and patient request (18%). Eighty percent of the admitted patients had received general anaesthesia. Admissions were also related to the male gender (69%), age over 65 years (27%) and surgeries ending in the afternoon (69%). On analyzing the reasons for admission, a large number of admissions were found to be due to preventable causes. We conclude that proper selection of patients, careful scheduling of lists and education of patients and clinical professionals can help to avoid many unanticipated admissions after day care surgical procedures.

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