Herbal Medicines and Perioperative Care [Editorial View]
Moss, Jonathan M.D., Ph.D.; Yuan, Chun-Su M.D., Ph.D.
Anesthesiology: Volume 105(3) September 2006 pp 441-442

This Editorial View accompanies the following article.

Incidence and Risk of Adverse Perioperative Events among Surgical Patients Taking Traditional Chinese Herbal Medicines.
Lee, Anna Ph.D., M.P.H.;  Chui, Po Tong F.A.N.Z.C.A.; Aun, Cindy S. T. M.D. ; Lau, Angel S. C. B.S.N.(Hons); Gin, Tony M.D. 
Anesthesiology. 105(3):454-461, September 2006.

Background: The use of traditional Chinese herbal medicines (TCHMs) among the presurgical population is widespread, but their impact on perioperative patient care is unclear. The authors estimated the incidence and risk of TCHM-related perioperative events.
Methods: In a Hong Kong cohort study, 601 patients undergoing major elective surgery were asked about their Western medicine and TCHM use in the 2 weeks before surgery. Unanticipated perioperative events were noted by attending anesthesiologists, blinded to patients' use of specific TCHMs. Modified Poisson regression models were used to obtain the relative risk of combined endpoints of perioperative events associated with TCHM use.
Results: Of the 601 patients, 483 patients (80%) took self-prescribed TCHM, and 47 (8%) took TCHM by prescription (with or without self-prescribed TCHM) in the 2 weeks before surgery. The crude incidences of any combined endpoints of preoperative, intraoperative, and postoperative events were 23% (95% confidence interval, 19-26%), 74% (95% confidence interval, 71-78%), and 63% (95% confidence interval, 59-66%), respectively. Compared with nonusers, patients who took TCHM by prescription were more likely to have a preoperative event (adjusted relative risk, 2.21; 95% confidence interval, 1.14-4.29). The authors present four case reports to highlight the effect of TCHM by prescription on prolonged activated partial thromboplastin time and hypokalemia in the preoperative period. In contrast, there was no significant association between the use of any type of TCHM and the occurrence of either intraoperative or postoperative events.
Conclusions: The use of TCHM by prescription near the time of surgery should be discouraged because of the increased risk of adverse events in the preoperative period.

The Sheath of the Brachial Plexus: Fact or Fiction?
Cornish, Philip B. M.B.,Ch.B., F.A.N.Z.C.A.; Leaper, Christopher F.R.A.N.Z.C.R. 
Anesthesiology. 105(3):563-565, September 2006.

Background: The concept of the axillary "sheath" has been a central tenet of brachial plexus regional anesthesia for many years. Recent investigations have cast doubt on its nature and existence. This study further examines the issue.
Methods: Computerized axial tomographic dye studies were performed using continuous catheter systems for the sciatic nerve and the brachial plexus. The resultant images were compared and contrasted.
Results: The images of the two catheter systems were the same, with the exception that one was of the upper extremity and the other was of the lower extremity.
Conclusions: The sciatic nerve is not surrounded or enveloped by a "sheath"- it lies in the tissue plane between rigid anatomical structures. Similarly, the brachial plexus lies in the tissue plane between the rigid anatomy of the chest wall, scapula, humerus, and pectoral fascia. This finding is inconsistent with the concept of the axillary sheath.

Effect of Patient-controlled Perineural Analgesia on Rehabilitation and Pain after Ambulatory Orthopedic Surgery: A Multicenter Randomized Trial.
Capdevila, Xavier M.D., Ph.D. ; Dadure, Christophe M.D. ; Bringuier, Sophie Pharm.D., M.Sc. ; Bernard, Nathalie M.D. ; Biboulet, Philippe M.D. ; Gaertner, Elisabeth M.D. ; Macaire, Philippe M.D. 
Anesthesiology. 105(3):566-573, September 2006.

Background: Efficacy of continuous perineural and patient-controlled ropivacaine infusion at home after orthopedic surgery was compared with patient-controlled intravenous morphine for functional recovery and postoperative analgesia in a multicenter randomized trial.
Methods: Eighty-three patients scheduled to undergo acromioplasty or hallux valgus surgery received an interscalene (n = 40) or popliteal (n = 43) peripheral nerve block with 30 ml ropivacaine, 0.5%. After randomization, patients were discharged home 24 h after surgery with a disposable infusion pump delivering either patient-controlled intravenous morphine (n = 23) or perineural 0.2% ropivacaine infusion, either continuous infusion without bolus (n = 30) or basal infusion plus bolus (n = 30). The patients recorded pain scores on movement and/or walking and were directed to take paracetamol and rescue analgesics if necessary. The time necessary to be able to walk for 10 min; daily activities on days 1, 2, and 3; adverse events; and overall satisfaction scores were noted and graded by the patient.
Results: Basal-bolus ropivacaine decreased the time to 10 minutes' walk, optimized daily activities (P < 0.01), and decreased the amount of ropivacaine used. The morphine group had greater pain scores and consumption of morphine and ketoprofen compared with both ropivacaine groups (P < 0.05). The incidence of nausea/vomiting, sleep disturbance, and dizziness increased, and the patient satisfaction score decreased in the morphine group (P < 0.05).
Conclusions: After ambulatory orthopedic surgery, 0.2% ropivacaine delivered as a perineural infusion using a disposable elastomeric pump with patient-controlled anesthesia bolus doses optimizes functional recovery and pain relief while decreasing the consumption of rescue analgesics and ropivacaine, and the number of adverse events.

Gender and Post-Dural Puncture Headache. [Review]
Wu, Christopher L. M.D. ; Rowlingson, Andrew J. B.A. ; Cohen, Seth R. B.S. ; Michaels, Robert K. M.D., M.P.H. ; Courpas, Genevieve E. B.A. ; Joe, Emily M. M.D. ; Liu, Spencer S. M.D. 
Anesthesiology. 105(3):613-618, September 2006.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Return hospital visits and morbidity within 60 days after day surgery: a retrospective study of 18,736 day surgical procedures
J. Engbæk, J. Bartholdy and N.-C. Hjortsø
Acta Anaesthesiologica Scandinavica Volume 50 Page 911  September 2006

Background: As day surgery includes more extensive procedures focus should be put on late outcome. The frequency of day surgery-related return visits and the associated morbidity were examined to identify suitable indicators of quality.
Methods: From two centres, 16,048 patients underwent 18,736 day surgery operations including 4,829 surgical abortions. Patients were retrospectively analysed for contacts to Danish hospitals within 60 post-operative days and the associated morbidity and mortality. Data were obtained from the Danish National Patient Registry and the National Causes of Death Registry. Patient records were studied to validate contacts as being definite, likely, possible or not related.
Results: Altogether 113 patients (not including the surgical abortions) were readmitted to hospitals with 117 complications definitely or likely related to day surgery. The most common complications were haematomas or haemorrhage (0.40%) and infections (0.29%). Morbidity after the two most common procedures, hernia repair and knee arthroscopy, was observed in 1 : 39 patients and 1 : 220 patients, respectively. More serious complications included four patients with septic arthritis of the knee and six patients with venous thromboembolism. After surgical abortion, pelvic inflammation and bleeding were observed in 3.1% and 2.2%, respectively, with centre differences. Altogether no myocardial infarctions, central nervous system deficits, pneumonias or deaths were recorded that could definitely or likely be related to day surgery.
Conclusion: Day surgery in Denmark is a safe practice. Readmission rates, haematomas and wound infections are likely future indicators of outcome quality after day surgery.

The effects on the lower esophageal sphincter of sevoflurane induction and increased intra-abdominal pressure during laparoscopy
K. Thörn, S.-E. Thörn and M. Wattwil
Acta Anaesthesiologica Scandinavica Volume 50 Page 978  September 2006

Background: Today sevoflurane is one of the most frequently used volatile anesthetics. The speed of induction can approach that of intravenous anesthetics, and case reports using sevoflurane induction for emergency anesthesia have been published. The purpose of this study in laparoscopic cholecystectomy patients was to investigate the effects of sevoflurane during inhalation induction on the lower esophageal sphincter pressure (LESP) and barrier pressure (BrP). The effects on lower esophageal sphincter (LES) and BrP of increased intra-abdominal pressure during laparoscopy were also evaluated.
Methods: We recorded LESP and BrP in nine patients using a Dent sleeve device. Recordings were made before and after inhalation induction of anesthesia with 8% sevoflurane, as well as before and after insufflation of CO2 into the abdomen.
Results: After induction with sevoflurane, LESP (P = 0.039) and BrP (P = 0.020) decreased. Nevertheless, BrP was kept positive in all patients. Insufflation of CO2 into the abdomen during laparoscopy induced a significant increase in LESP (P = 0.02) and gastric pressure (P = 0.004). However, there was no significant change in BrP (P = 0.66); it increased in four patients and decreased in five.
Conclusion: BrP was kept positive in all patients after induction of anesthesia. Therefore, we believe that in combination with cricoid pressure, inhalation induction with sevoflurane might be a safe choice. As the adaptive increase in LESP during laparoscopy was not enough to retain a barrier pressure in all patients, it is important to be aware of the risk of regurgitation throughout the anesthesia.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Alzheimer's disease and anaesthesia: implications for the central cholinergic system (REVIEW)
V. Fodale, D. Quattrone, C. Trecroci, V. Caminiti and L. B. Santamaria
British Journal of Anaesthesia 2006 97(4):445-452

Alzheimer's disease (AD) is associated with a loss of cholinergic neurons resulting in profound memory disturbances and irreversible impairment of cognitive function. The central cholinergic system is involved in the action of general anaesthetic agents. Anaesthetic modulation of cholinergic transmission has profound effects on brain function via a cascade of synaptic and postsynaptic events by binding both nicotinic and muscarinic receptors. During general anaesthesia, decrease in acetylcholine release and depression of cholinergic transmission facilitates the desirable effects of general anaesthetics, such as loss of consciousness, pain, voluntary movements and memory. From this point of view, patients with AD, characterized by a compromised neuronal transmission, represent particular cases in which the choice of anaesthesia drugs may have a negative effect on the postoperative outcome. A future challenge may be the identification of brain targets of general anaesthetics which do not expose patients to postoperative cognitive dysfunction, nor interfere with prognosis of brain degenerative disease.

Etomidate-®Lipuro is associated with considerably less injection pain in children compared with propofol with added lidocaine
Y. Nyman, K. Von Hofsten, C. Palm, S. Eksborg and P. A. Lönnqvist
British Journal of Anaesthesia 2006 97(4):536-539
 
Background. Propofol is associated with a high incidence of injection pain in children, even if given together with lidocaine. A new lipid formulation of etomidate (Etomidate-®Lipuro) has been found in adults to cause very little discomfort during i.v. injection. The aim of the present prospective, double-blind, randomized trial was to compare the incidence of injection pain during i.v. induction of anaesthesia between propofol with added lidocaine (previous standard) and this new etomidate formulation in paediatric patients.
Methods. A total of 110 paediatric patients, aged 2–16 years, scheduled for outpatient surgery were planned to be included in the study. The primary end point of the study was the incidence of injection pain during induction of anaesthesia as assessed by a four-point scale as described previously. The occurrence of myoclonic muscular activity was registered as a secondary end point (four-point scale). An interim analysis after 80 patients was requested by the Ethics' Committee.
Results. The study was stopped after the inclusion of 80 patients. A significantly lower incidence of injection pain was found in the Etomidate-®Lipuro group as compared with the propofol–lidocaine group (5.0% vs 47.5%, P<0.001). The use of etomidate was associated with a significantly higher incidence of myoclonic activity compared with propofol–lidocaine (85.0% vs 15%, P<0.001).
Conclusions. The use of a new lipid formulation of etomidate is associated with significantly less injection pain than propofol with added lidocaine in children. This finding may warrant a change in clinical practice in order to avoid unnecessary pain in children.

Factors affecting recovery and discharge following ambulatory surgery.
Awad IT, Chung F.
Can J Anaesth. 2006 Sep;53(9):858-72

Purpose: Recovery and discharge following ambulatory surgery are important components of the ambulatory surgery experience. This review provides contemporary perspectives on the issues of discharge criteria, fast-tracking, patient escort requirements, and driving after ambulatory anesthesia.
Source: A search was performed in the Cochrane Central Register for Controlled Trials, MEDLINE(R), EMBASE(R), CINAHL, and PsycINFO, to review factors delaying discharge following ambulatory surgery. The following subject headings were used: "ambulatory surgery, discharge, recovery, car driving, escort, transport, fast tracking, patient discharge, recovery, transportation of patients, hospital discharge, recovery room, patient transport, hospital discharge, recovery room, anesthetic recovery, patient transport, ambulatory surgical procedures, patient discharge, recovery of function, automobile driving, patient escort service, recovery room". Using the same search engines, the following keywords were used: "fast tracking, recovery, and discharge". PRINCIPAL FINDINGS: The current literature supports that discharge scoring systems may be useful to guide discharge following ambulatory surgery. While fast-tracking has become common in some centres, further studies are required to justify more routine implementation of this practice in the management of patients undergoing ambulatory surgery. Patients at low risk for urinary retention can be discharged home without voiding. Patients should not drive until at least 24 hr postoperatively.Conclusions: Ensuring rapid postoperative recovery and safe discharge following ambulatory surgery are important components of the ambulatory surgical program. A clearly defined process should be established for each ambulatory surgical unit to ensure the safe and timely discharge of patients after anesthesia, in accordance with current best evidence.

Epidural dexamethasone reduces postoperative pain and analgesic requirements
Siji Thomas, MD and Suhara Beevi, MD
Canadian Journal of Anesthesia 53:899-905 (2006)
 
Purpose: Epidural steroids may have potential advantages for providing postoperative analgesia. We therefore undertook a study to evaluate the efficacy of epidurally administered dexamethasone in reducing postoperative morphine requirements, as a measure of analgesia following laparoscopic cholecystectomy.
Methods: In a randomized, double-blind study, 94 patients undergoing laparoscopic cholecystectomy were randomly assigned to one of three groups. Group 1 (Control) patients received dexamethasone 5 mg iv with epidural injection of 0.25% bupivacaine 8 mL and normal saline 2 mL, Group 2 (D1) patients received normal saline 2 mL iv with epidural injection of 0.25% bupivacaine 8 mL and dexamethasone 5 mg in normal saline 2 mL, and Group 3 (D2) patients received normal saline 2 mL iv with epidural injection of dexamethasone 5 mg in normal saline 10 mL. After surgery, morphine 2–4 mg iv was administered as needed for analgesia. Postoperative morphine requirements, visual analogue scale (VAS) pain scores at rest and with effort, and time to first analgesic administration were recorded by a blinded observer.
Results: Total morphine consumption for the first 24 hr following surgery was lower in both epidural dexamethasone groups (D1, D2) compared to the control group (P < 0.05). The percentage reduction in morphine consumption in Group D1 was 53.9% and in Group D2 was 52.9% in the first 24 hr. Postoperatively at 12 hr, 18 hr and 24 hr, the VAS scores at rest and during effort were also lower in the epidural dexamethasone groups (D1, D2) compared to the control group (P < 0.05). The percentage reductions in VAS scores with effort at 12 hr, 18 hr and 24 hr in Group D1 were 50%, 52.9% and 50% respectively, and in Group D2 percentage reductions in pain scores with effort were 54.8%, 58.8% and 55.5% at corresponding sampling intervals.
Conclusion: Preoperative epidural administration of dexamethasone 5 mg, with or without bupivacaine, reduces postoperative pain and morphine consumption following laparoscopic cholecystectomy.

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Regional anaesthesia versus general anaesthesia, morbidity and mortality.
Gulur P, Nishimori M, Ballantyne JC.
Best Pract Res Clin Anaesthesiol. 2006 Jun;20(2):249-63.

The regional versus general anaesthesia debate is an age-old debate that has brought about few clear answers. Most concur that multiple factors including the patient, the surgery, the method of regional and general anaesthesia, and the quality of perioperative care, all influence surgical outcome. In this age of evidence-based medicine, the heterogenous data available need to be reconciled with the advances in perioperative care and the significant decline in complications associated with the surgical process as a whole. This review considers general issues such as the type of available evidence, and its limitations, particularly with regard to the relatively broad question of neuraxial versus general anaesthesia. It then assesses current evidence on regional versus general anaesthesia for specific scenarios such as hip fracture surgery, carotid endarterectomy, Caesarean section, ambulatory orthopaedic surgery, and postoperative cognitive dysfunction in elderly patients after non-cardiac surgery.

Do race, gender, and source of payment impact on anesthetic technique for inguinal hernia repair?
Memtsoudis SG, Besculides MC, Swamidoss CP.
J Clin Anesth. 2006 Aug;18(5):328-33.

STUDY OBJECTIVE: To evaluate the potential differences in the type of anesthesia provided to patients of different race, gender, and source of payment undergoing inguinal hernia repair (IHR).
DESIGN: Retrospective cohort study.
SETTING: Ambulatory surgical centers/National Survey of Ambulatory Surgery.
PATIENTS: 5810 patients older than 14 years who underwent IHR in an ambulatory surgical center.
INTERVENTIONS: Inguinal hernia repair under different types of anesthesia. MEASUREMENTS: The association of race, gender, and source of payment with different types of anesthesia for IHR as determined by multivariate regression analysis.
RESULTS: Significant discrepancies in the use of various anesthetics between patients of different race, gender, and source of payment were found. Patients identified as black and those of other minority groups were significantly more likely to receive general anesthesia compared with those identified as white (odds ratio [OR] 2.76, confidence interval [CI] 1.96-3.88 and OR 1.66, CI 1.14-2.42, respectively). Those identified as black were less likely to receive epidural anesthesia compared with their white counterparts (OR 0.36, CI 0.14-0.95). Women were less likely than men to undergo IHR with epidural anesthesia (OR 0.5, 95% CI 0.3-0.85).
CONCLUSION: Significant discrepancies in the use of various anesthetics for IHR between patients of different race, gender, and insurance status were found. Despite limitations inherent to secondary data analysis, the findings raise the possibility that nonmedical factors may influence anesthetic management.

Ambulatory anesthesia for children undergoing laser treatment.
Isago T, Kono T, Nozaki M, Kikuchi Y, Honda T, Nakazawa H.
Surg Today. 2006;36(9):765-8.

PURPOSE: Since 1993, we have performed laser surgery for cutaneous lesions, such as simple hemangioma and nevus of Ota, in children under ambulatory anesthesia. Although we anticipate that the numbers of patients treated under ambulatory anesthesia will increase, few reports detail the procedures involved and their perioperative management. We describe this method of anesthesia and discuss its limitations, and future issues. METHODS: To date, we have performed laser treatment on 633 pediatric patients under ambulatory anesthesia. The mean age of the children was 3.6 +/- 1.9 years and their mean weight was 16.4 +/- 4.7 kg. The lesions treated included simple hemangioma, nevus of Ota, nevus pigmentosus, nevus spilus, and ectopic Mongolian spots. Anesthesia is induced with oxygen, nitrous oxide, and sevoflurane; then an intravenous cannula is inserted under spontaneous respiration. Anesthesia is maintained with assisted ventilation using a mask. Children are not intubated unless a mask cannot be used because the lesion is on the face or back.
RESULTS: No serious peri- or postoperative complications were encountered and there were no serious adverse reactions to anesthesia. With the exception of one child who was admitted overnight for a low-grade fever, all were released from hospital within a few hours.
CONCLUSION: Ambulatory anesthesia can be performed safely using oxygen, nitrous oxide, and sevoflurane for the laser treatment of cutaneous lesions in pediatric patients.

Anesthesia systems for ambulatory surgery settings.
[No authors listed]
Health Devices. 2006 Aug;35(8):316-29.

This Evaluation presents ECRI's detailed findings for two anesthesia systems designed for the ambulatory surgery market-the Datex-Ohmeda S/5 Aespire 7100 and the Draeger Medical Fabius Tiro. The study examines whether and how well the systems can meet the needs of the typical patient population for this application, and it considers factors such as the adequacy of the systems' safety features, the comprehensiveness of their pre-use checks, and ease of use. We subjected the two systems to the same test protocol that is detailed in our July 2006 Evaluation of anesthesia systems designed for inpatient surgical applications. While the six systems evaluated in that issue could also be used in outpatient clinics and other ambulatory surgery centers, such systems are not the most economical choices for these facilities. The two systems we evaluate in the current study offer performance similar to that of the inpatient units, without many of the (often expensive) features that would likely go unused in an ambulatory surgery setting.

Interscalene block anesthesia at an ambulatory surgery center performing predominantly regional anesthesia: A prospective study of one hundred thirty-three patients undergoing shoulder surgery.
Faryniarz D, Morelli C, Coleman S, Holmes T, Allen A, Altchek D, Cordasco F, Warren RF, Urban MK, Gordon MA.
J Shoulder Elbow Surg. 2006 Aug 30;

Interscalene block (ISB) of the brachial plexus is frequently used for patients undergoing ambulatory shoulder surgery. We previously reported that the incidence of postoperative complaints (neurapraxia) after an ISB was low (3% at 2 weeks), but objective neurologic assessment was not included in the study. The present study combines subjective findings with both preoperative and postoperative objective sensory and motor assessments after an ISB. We prospectively evaluated 133 patients undergoing elective ambulatory shoulder surgery. ISB anesthesia was accomplished by use of 1.5% mepivacaine alone or in combination with bupivacaine (0.5%-0.75%) via a paresthesia technique and a 23-gauge needle. All of the blocks were performed by experienced anesthesiologists. The number of passes with the needle, site of paresthesia, ease of performing the block, and success of the ISB were recorded for each patient. Neurologic assessment was performed preoperatively and up to 2 weeks postoperatively by 1 of 4 health care professionals but not by the anesthesiologists who performed the ISB and included diminished sensation, localized nerve pain, Semmes-Weinstein monofilament pressure threshold sensibility, Weber static 2-point discrimination, and grip strength changes. Patients with postoperative changes were followed up until resolution of symptoms occurred. Successful surgical anesthesia was achieved in 98% of the patients. There was 1 major perioperative complication (0.7%), a seizure that occurred within 5 minutes of the ISB. Two (1.4%) complained of transient postoperative neurapraxias. Neither patient had any changes in objective sensory and motor measurements. Hence, there was no correlation between subjective complaints and objective findings in this study. This study demonstrates that, in the hands of anesthesiologists doing predominantly regional anesthesia, there is a 1.4% incidence of neurologic complications after an ISB. ISB is a safe and effective technique for patients undergoing ambulatory shoulder surgery when an anesthesiologist experienced with regional anesthesia is involved.

Safe Total Corporal Contouring with Large-Volume Liposuction for the Obese Patient.
Dhami LD, Agarwal M.
Aesthetic Plast Surg. 2006 Sep 14;

The advent of the tumescent technique in 1987 allowed for safe total corporal contouring as an ambulatory, single-session megaliposuction with the patient under regional anesthesia supplemented by local anesthetic only in selected areas. Safety and aesthetic issues define large-volume liposuction as having a 5,000-ml aspirate, mega-volume liposuction as having an 8,000-ml aspirate, and giganto-volume liposuction as having an aspirate of 12,000 ml or more. Clinically, a total volume comprising 5,000 ml of fat and wetting solution aspirated during the procedure qualifies for megaliposuction/large-volume liposuction. Between September 2000 and August 2005, 470 cases of liposuction were managed. In 296 (63%) of the 470 cases, the total volume of aspirate exceeded 5 l (range, 5,000-22,000 ml). Concurrent limited or total-block lipectomy was performed in 70 of 296 cases (23.6%). Regional anesthesia with conscious sedation was preferred, except where liposuction targeted areas above the subcostal region (the upper trunk, lateral chest, gynecomastia, breast, arms, and face), or when the patient so desired. Tumescent infiltration was achieved with hypotonic lactated Ringer's solution, adrenalin, triamcinalone, and hyalase in all cases during the last one year of the series. This approach has clinically shown less tissue edema in the postoperative period than with conventional physiologic saline used in place of the Ringer's lactate solution. The amount injected varied from 1,000 to 8,000 ml depending on the size, site, and area. Local anesthetic was included only for the terminal portion of the tumescent mixture, wherever the subcostal regions were infiltrated. The aspirate was restricted to the unstained white/yellow fat, and the amount of fat aspirated did not have any bearing on the amount of solution infiltrated. There were no major complications, and no blood transfusions were administered. The hospital stay ranged from 8 to 24 h for both liposuction and liposuction with a lipectomy. Serous discharge from access sites and serosanguinous fluid accumulation requiring drainage were necessitated in 32 of 296 cases (10.8%). Minor recontouring touch-ups were requested in 17 of 296 cases (5.7%). Early ambulation was encouraged for mobilization of third-space fluid shifts to expedite recovery and to prevent deep vein thrombosis. Follow-up evaluation ranged from 6 to 52 months, with 38 (12.8%) of 296 patients requesting further sessions for other new areas. Average weight reduction observed was 7 to 11.6 kg (approx. 4 to 10% of pre-operative body weight). Meticulous perioperative monitoring of systemic functions ensures safety in tumescent megaliposuction for the obese, and rewarding results are achieved in a single sitting.

Patients' understanding of pre-operative fasting.
Walker H, Thorn C, Omundsen M.
Anaesth Intensive Care. 2006 Jun;34(3):358-61.

We aimed to assess elective day surgery patients' understanding of the reason for pre-operative fasting. One hundred adult patients presenting to the peri-operative unit for day procedures requiring general anaesthesia were surveyed before discharge. All day-stay, adult patients able to complete a questionnaire in English were included. Only 22% (95%CI [14,31]) of patients correctly understood why fasting was necessary. Patients who did not understand were nearly five times more likely to underrate the importance of compliance (risk ratio 4.65, 95%CI [1.2,18]). Two per cent (95%CI [0.2,7]) of patients reported actual non-compliance, and 4% (95%CI [1,10]) stated they would consider misrepresenting their fasting status if it was inconvenient for them to have their surgery postponed. The results of this study suggest a need to better inform day surgery patients about the reason for pre-operative fasting. A better understanding of the need for pre-operative fasting may lead to improved compliance and patient safety.

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