III. Preoperative Preparation and Premedication - TOP

A. NPO status - TOP

The traditional recommendation that patients undergoing surgery remain NPO after midnight is being challenged for a variety of reasons. Prolonged fasting leads to significant patient discomfort and can be particularly problematic in infants and treated diabetics who may be at risk for hypoglycemia. A growing body of literature suggests that much shorter fasting times are associated with low gastric fluid volume and acidity; consequently, more liberal guidelines for the consumption of fluids preoperatively are becoming the norm. The 1999 ASA Practice Guidelines are a good starting point.

American Society of Anesthesiologists: Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. A report by the American Society of Anesthesiologists Task Force on Preoperative Fasting. Anesthesiology 1999; 90:896-905.

As are all of the ASA Task Force Guidelines, these are rigorous, data-driven, recommendations based upon science, and “.by a synthesis of expert opinion, open forum commentary, and clinical feasibility data.” It’s only draw back is the need to write to ASA headquarters for the reference list.

Fennelly M, Galletly DC, Purdie GI: Is caffeine withdrawal the mechanism of postoperative headache? Anesth Analg 72:449, 1991

One advantage of allowing coffee drinkers their morning coffee is that the incidence of headaches after surgery is reduced.

Gilbert SS, Easy WR, Fitch WW: The effect of pre-operative oral fluids on morbidity following anesthesia for minor surgery. Anaesthesia 50:79-81, 1995

46 patients were allowed to drink water until 3 hours preoperatively, and 49 received the traditional fasting regimen. The patients who drank water complained less of thirst in the recovery room and subjectively recovered better than after prior anesthetics.

Maltby JR, Koehli N, Ewen A, Shaffer EA: Gastric fluid volume, pH, and emptying in elective inpatients: Influences of narcotic - atropine premedication, oral fluid and ranitidine. Can J Anaesth 35:562-566, 1988.

In healthy adult patients, 150 ml of oral fluid - water, coffee, tea, or fruit juice - was almost completely emptied from the stomach within 2 hours of ingestion, when followed one hour later by narcotic-atropine premedication.

Nygren J, Thorell A, Jacobsson H, Larsson S, Schnell PO, Hylen L, Ljungquist O: Preoperative gastric emptying. Effects of anxiety and oral carbohydrate administration. Annals of Surg 222:728-34, 1995

Twelve patients were studied before and after surgery to determine gastric emptying times following either water or a carbohydrate-rich drink. Neither anxiety nor the carbohydrate-rich drink increased the volume of gastric contents 90 minutes after ingestion of liquids.

Phillips S, Hutchinson S, Davidson T: Preoperative drinking does not affect gastric contents. Br J Anesth 70:6-9, 1993.

100 patients were randomly assigned to either drink liquids freely until 2 hours before surgery or remain NPO for 6 hours before surgery. The group allowed to drink was more comfortable with no increase in gastric volume or pH over the control group. No aspiration was seen in either group.

Schreiner MS, Triebwasser A, Keon TP: Ingestion of liquids compared with preoperative fasting in pediatric outpatients. Anesthesiology 72:593-597, 1990.

In this study evaluating the effects on gastric volume and pH of allowing pediatric outpatients to consume unlimited clear liquids up until 2 hours preoperatively, the authors found no significant differences in gastric volume, pH, or the number of patients with a gastric volume > 0.4 ml/kg and pH < 2.5 between the group allowed unlimited clear fluids and the control group. The parents of the patients receiving clear fluids rated the surgical experience as better tolerated and found their children to be less irritable. At the authors’ institution, the NPO guidelines were changed to allow patients unlimited intake of clear fluids until 2 hours preoperatively.

Sethi AK, Chatterji C, Bhargava SK, Narang P, Tyagi A: Safe pre-operative fasting times after milk or clear fluid in children. A preliminary study using real-time ultrasound. Anesthesia 54:51-85, 1999.

It is safe to give children a volume of 10 ml/kg (maximum volume of 100ml) of 3% fat milk 3 hour or 17.5% glucose 2 hour before anesthesia. However, more studies are required on breast milk to establish guidelines for its potential use as a pre-operative feed before anesthesia.

Simini B: Preoperative fasting. Lancet 353(9156):862, 1999 Mar 13.

Splinter WM, Schreiner MS: Preoperative fasting in children. Anesth Analg 1999; 89: 80-89.

A summary of the previous 5 years literature is discussed. Conclusions were drawn based upon the literature and expertise of these two authors. Guidelines suggest that clear liquids are acceptable until two hours prior to surgery in healthy children. Breast milk requires more than a two hours fast; however, the optimal fast thereafter may require anywhere from 3-5 hours. More investigations are needed for solid foods as well.

In addition to the traditional drugs used to reduce the risk from aspiration (antacids, H 2 -receptor antagonists, ands agents that increase gastric motility), newer agents such as proton pump inhibitors are becoming available to anesthesiologists and are being shown to be effective.

Bresnick WH, Rask-Madsen C, Hogan DL, Koss MA, Isenberg JI: The effect of acute emotional stress on gastric acid secretion in normal subjects and duodenal ulcer patients. J Clin Gastroenterol 17:117, 1993

Individuals experiencing emotional stress have increased gastric acid secretion, and if nervous, are also at an increased risk for aspiration.

Escolano F, Castano J, Lopez R, Bisbe E, Alcon A: Effects of Omeprazole, Ranitidine, Famotidine and placebo on gastric secretion in patients undergoing elective surgery. British Journal of Anaesthesia 69:404-406, 1992

Three hours before operation, the patients received orally, omeprazole 40 mg, ranitidine 150 mg, famotidine 40 mg, or placebo. Omeprazole, ranitidine and famotidine produced a significant increase in gastric pH and a significant decrease in gastric volume compared with placebo. Omeprazole was significantly less effective in increasing gastric pH, while there was no significant difference in gastric volume compared with ranitidine and famotidine. Thus omeprazole 40 mg given 2-4 h before surgery does not afford adequate prophylaxis for acid aspiration syndrome.

Escolano F, Sierra P, Ortiz JC, Cabrera JC, Castano J: The efficacy and optimum time of administration of ranitidine in the prevention of acid aspiration syndrome. Anaesthesia 51:182, 1996

In 138 surgical patients, 150 mg of oral ranitidine was effective in increasing gastric pH and decreasing fluid volume 60 minutes after administration.

Kluger MT, Owen H, Plummer JL, McLean C: The effect of oral Cisapride premedication on fasting gastric volume. Anaesth Intens Care 23:687-690, 1995

Cisapride administered as part of premedication for elective surgery significantly reduced mean gastric volume by 29% but there was no difference with respect to pH. Further work is needed to evaluate its role in reducing fasting gastric volumes in diabetic patients.

Levack ID, Bowie RA, Braid DP, Asbury AJ, Marshall RL, Slawson KB, Birrell H, Gillon KR: Comparison of the effect of two dose schedules of oral omeprazole with oral ranitidine on gastric aspirate pH and volume in patients undergoing elective surgery. Br J Anaesth 76:567, 1996

Omeprazole compares favorably with ranitidine for decreasing gastric volume and increasing gastric pH in elective surgery patients.

Manchikanti L, Grow JB, Colliver JA, et al: Bicitra (sodium citrate) and metoclopramide in outpatient anesthesia for prophylaxis against aspiration pneumonitis. Anesthesiology 63:378-384, 1985.

Patients received different doses of Bicitra or metoclopramide, alone or together. Bicitra, with or without metoclopramide, increased gastric pH to safe levels in the majority of patients. Gastric volume also increased. Bicitra, 30 ml, was more effective than 15 ml. H 2 receptor antagonists are better than Bicitra. However, Bicitra is useful when insufficient time is available for other drugs to be administered.

Mikawa K, Nishina K, Maekawa N, Asano M, Obara H: Lansoprazole reduces preoperative gastric fluid acidity and volume in children. Can J Anesth 42:467, 1995.

In this study of 100 patients aged 3-11 years, the proton pump inhibitor lansoprazole was found to be effective in reducing gastric pH and volume. The most effective regimen was 30 mg at bedtime and again on the morning of surgery.

Nishina K, Mikawa K, Maekawa N, Takao Y, Shiga M, Obara H: A comparison of Lansoprazole, Omeprazole, and Ranitidine for reducing preoperative gastric secretion in adult patients undergoing elective surgery. Anesth Analg 82:832-6, 1996

Two doses (bedtime and morning) of lansoprazole 30 mg or a morning dose of ranitidine 150 mg seemed to be the most effective preanesthetic medication for reducing gastric acidity and volume. The price of lansoprazole (60 mg) was approximately three times that of ranitidine (150 mg) for a similar effect.

Nishina K, Mikawa K, Maekawa N, Takao Y, Shiga M, Obara H: A comparison of Rabeprazole, Lansoprazole and Ranitidine for improving preoperative gastric fluid property in adults undergoing elective surgery. Anesth Analg 90:717-21, 2000

A single morning dose of ranitidine 150 mg rather than two doses (bedtime and morning) of rabeprazole 20 mg was the most effective premedication to control gastric fluid properties (pH and volume) and to minimize the risk of aspiration pneumonitis

Pandit SK , Kothary SP, Pandit UA, Mirakhur RK: Premedication with cimetidine and metoclopramide. Anaesthesia 41: 486-492, 1986.

Oral cimetidine given 2 hours preoperatively decreased gastric volume and increased pH in outpatients. The addition of metoclopramide, 10-20 mg IV 15 or 30 minutes prior to induction, reduced gastric volume but did not significantly change pH. Higher doses of metoclopramide were associated with more side effects.

C. Postoperative nausea treated preoperatively - TOP

1. Overview, including the problem with certain narcotics - TOP

Nausea and vomiting are significant postoperative problems, causing patient discomfort and delayed recovery. In addition, prolonged postoperative vomiting is a leading cause of admission to the hospital, both for pediatric and adult patients, after planned outpatient surgery. Additionally, preoperative anxiety has been long considered a contributing factor to postoperative nausea and vomiting; recent data, at least in children, suggest otherwise. See, in particular the following studies:

Beattie WS, Lindblad T, Buckley DN, Forrest JB: The incidence of postoperative nausea and vomiting in women undergoing laparoscopy is influenced by the day of the menstrual cycle. Can J Anaesth 38:298, 1991.

A higher incidence of postoperative nausea and vomiting was reported in women who were within the first eight days of their menstrual cycle (highest at day 5) compared to those who were in the last portion of their cycle. Droperidol did not appear to further reduce the incidence in the former group.

Carroll NV, Miederhoff P, Cox FM, Hirsch JD: Postoperative nausea and vomiting after discharge from outpatient surgery centers. Anesth & Analg 80:903-9, 1995

35% of patients surveyed experienced some degree of nausea after discharge from an outpatient surgery center. In these patients, nausea lasted an average of 1.7 days.

Carroll NV, Miederhoff PA, Cox FM, Hirsch JD: Costs incurred by outpatient surgery centers in managing postoperative nausea and vomiting. J Clin Anesth 6:364-9, 1994

In this prospective study, it was estimated that each patient who experienced postoperative nausea and vomiting cost the surgical center $415 in lost revenue. This figure varies from site to site depending on drug costs, nurse’s wages, and other variables.

Cepeda MS, Gonzalez F, Granados V, Cuervo R, Carr DB: Incidence of nausea and vomiting in outpatients undergoing general anesthesia in relation to selection of intraoperative opioid. J Clin Anesth 8:324-8, 1996 .

When used for induction, opioids had little effect on recovery in this group of 200 patients. The highest incidence of vomiting was 6 hours after surgery.

Friesen RH, Lockhart CH: Oral transmucosal fentanyl citrate for preanesthetic medication of pediatric day surgery patients with and without droperidol as a prophylactic anti-emetic. Anesthesiology 76:46-51, 1992.

Oral transmucosal fentanyl is an effective sedative, but is associated with a number of problems, including a higher incidence of postoperative nausea and vomiting that is not reduced by droperidol given preoperatively.

Ghoneim MM, Block RI, Sarasin DS et al: Tape-recorded hypnosis instructions as adjuvant in the care of patients scheduled for third molar surgery. Anesth Analg 2000; 90: 64-68.

Preoperative hypnotic suggestions for perioperative well-being are not helpful in the prevention of postoperative nausea and vomiting in this patient population.

Gold BS, Kitz DS, Lecky JH, Neuhaus JM: Unanticipated admission to the hospital following ambulatory surgery. JAMA 262:3008, 1989.

Gratz I, Allen E, Afshar M, Joslyn AF, Buxbaum J, Prilliman B: The effects of the menstrual cycle on the incidence of emesis and efficacy of ondansetron. Anesth & Analg 83:565-9, 1996

Although there is some evidence that the menstrual cycle influences the incidence of post-operative nausea and vomiting in women (see below), this study did not find such a difference.

Meeks GR, Waller GA, Meydrech EF, Flautt FH Jr: Unscheduled hospital admission following ambulatory gynecologic surgery. Obstet Gynecol 80:446-50, 1992.

In 2,470 patients during a four-year period, nausea and vomiting was the most common reason for unanticipated hospitalization, although previous abdominal surgery, significant medical illness, hemoglobin concentration, general anesthesia, procedure length, and blood loss were also predictive of admission using a multivariate step-wise regression analysis.

Patel RI, Hannallah RS: Anesthetic complications following pediatric ambulatory surgery: a 3-yr study. Anesthesiology 69:1009, 1988.

Wang SM, Kain ZN: Preoperative anxiety and postoperative nausea and vomiting in children: is there an association? Anesth Analg 2000; 90: 571-575.

In an important study performed by experts in the area of pediatric perioperative anxiety, they found no correlation with anxiety and postoperative nausea and vomiting. This study clearly, contradicts previous studies in this area.

Watcha MF, White PF: Postoperative nausea and vomiting: its etiology, treatment and prevention. Anesthesiology 77:162, 1992

Women, especially those who are pregnant, have a higher incidence of postoperative nausea and vomiting. Other risk factors include a previous history of motion sickness or postanesthetic emesis, surgery within 1-7 days of the menstrual cycle, and certain procedures, including laparoscopy; lithotripsy; and ear, nose, or throat surgery.

2. Treatment - TOP

Although treatment of nausea and vomiting can be difficult, new antiemetic agents developed for use with chemotherapy (specifically selective antagonists of 5-hydroxytryptamine type 3 receptors) are showing great promise in treating and preventing postoperative nausea and vomiting. They do have a higher cost, however, and it is not clear whether or not these new drugs are cost-effective compared to older treatments. Additional treatment modalities such as supplemental oxygen, acupressure, hypnosis, and older medications such as dimenhyramine may be rediscovered because of cost effectiveness and success of treatment.

Abramowitz MD, Oh TH, Epstein BS, Ruttimann UE, Friendly DS: The antiemetic effect of droperidol following outpatient strabismus surgery in children. Anesthesiology 59:579-583, 1983.

In this double-blind randomized trial the antiemetic efficacy of droperidol 75 µg/kg, administered 30 minutes before the end of surgery, was compared with saline. The study was performed as a follow-up to the authors' previous study, which found droperidol, 50 µg/kg, to be no more effective than saline. The results of the second study showed that the higher dose of droperidol significantly decreased the frequency and severity of postoperative vomiting without increasing the incidence of side effects or prolonging recovery. The timing of the dose relative to manipulation of the eye was not evaluated.

Ali-Melkkila T, Kanto J, Katevuo R: Tropisetron and Metoclopramide in the prevention of postoperative nausea and vomiting. A comparative, placebo controlled study in patients undergoing ophthalmic surgery. Anaesthesia 51:232-5, 1996.

In this double-blind study, tropisetron was effective in preventing nausea, but metoclopramide was effective at preventing both nausea and vomiting compared to placebo.

Alon E, Himmelseher S: Ondansetron in the treatment of postoperative vomiting: a randomized, double-blind comparison with droperidol and metoclopramide. Anesth Analg 75:561, 1992

An 8-mg dose of ondansetron was superior to droperidol, 1.25 mg, and metoclopramide, 10 mg.

Alon E, Kocian R, Nett PC, Koechli OR, Baettig U, Grimaudo V: Tropisetron for the prevention of postoperative nausea and vomiting in women undergoing gynecologic surgery. Anesth Analg 82:338-41, 1996.

In this group of 80 patients, tropisetron was more effective than placebo at preventing postoperative nausea and vomiting, with no reported adverse effects.

Bailey PL, Streisand JB, Pace NL, et al: Transdermal scopolamine reduces nausea and vomiting after outpatient laparoscopy. Anesthesiology 72:977, 1990

In patients undergoing outpatient laparoscopy; nausea, retching, and vomiting were less, and discharge was earlier after transdermal scopolamine.

Blanc, VF Ruest P, Milot J, Jacob JL, Tang A: Antiemetic prophylaxis with promethazine or droperidol in paediatric outpatient strabismus surgery. Can J Anaesth 38:54-60, 1991.

One hundred children, ages 2 to 10 years, who were scheduled for outpatient strabismus surgery received either droperidol IV or promethazine IV and IM preoperatively. After discharge from the recovery room, 54% of the patients given droperidol vomited compared to 10% of the patients who received promethazine. Thirty-six percent of the patients who received promethazine, however, were restless, compared to only 8% of the patients given droperidol. Acetaminophen was useful in preventing or relieving the restlessness. Otherwise, side effects were not different between the groups.

Bodner M, White PF: Antiemetic efficacy of ondansetron after outpatient laparoscopy. Anesth Analg 73:250 1991

In a study comparing ondansetron to placebo followed by a "rescue" antiemetic of 20 mg of iv metoclopramide and 25 mg of iv hydroxyzine, reduction of postoperative nausea in patients was similar.

Burmeister MA, Standl TG, Wintruff M, Brauer P, Blanc I, Schulte am Esch J: Dolasetron prophylaxis reduces nausea and postoperative recovery time after Remifentanil infusion during monitored anaesthesia care for extracorporeal shock wave lithotripsy. British J of Anaesth 90(2): 194-8, 2003

The potential benefit of remifentanil with respect to an earlier discharge from PACU in comparison to long-acting analgesics and sedatives is limited by its emetic side-effect when give as a sole agent. However, dolasetron (12.5 mg IV) prophylaxis directly improved postoperative recovery and decreased the time to readiness for discharge.

Coloma M, White PF, Markowitz SD, Whitten CW, Macaluso AR, Berrisford SB, Thornton KC: Dexamethasone in combination with Dolasetron for prophylaxis in the ambulatory setting. Effect on outcome after laparoscopic cholecystectomy. Anesthesiology 96: 1346-50, 2002

The adjunctive use of dexamethasone (4 mg) shortened the time to achieve discharge criteria and improved the quality of recovery and patient satisfaction scores after laparoscopic cholecystectomy procedures in outpatients receiving prophylaxis with dolasetron (12.5 mg)

Coloma M, White PF, Ogunnaike BO, Markowitz SD, Brown PM, Lee AQ, Berrisford SB, Wakefield CA, Issioui T, Jones SB, Jones D: Comparison of Acustimulation and Ondansetron for the treatment of established PONV. Anesthesiology 97:1387-92, 2002

Acustimulation with the ReliefBand can be used as an alternative to ondansetron for the treatment of established PONV. In addition, ondansetron (4 mg IV) enhances the efficacy of the ReliefBand in the management of PONV.

Davis PJ, McGowan FX Jr., Landsman I, Maloney K, Hoffmann P: Effect of antiemetic therapy on recovery and hospital discharge time. A double-blind assessment of ondansetron, droperidol, and placebo in pediatric patients undergoing ambulatory surgery. Anesthesiology 83:956-60, 1995

Ondansetron is an effective antiemetic in this setting. Patients treated with ondansetron and placebo had similar lengths of hospital stay, and patients treated with droperidol had significantly longer stays.

Dershwitz M, DiBiase PM, Rosow CE, Wilson RS, Sanderson PE, Joslyn AF: Ondansetron does not affect alfentanil-induced ventilatory depression or sedation. Anesthesiology 77:447-52, 1992

Ondansetron does not appear to interact significantly with alfentanil in this study of 29 healthy volunteers.

Eberhart LH, Seeling W, Ulrich B, Morin AM, Georgieff M: Dimenhydrinate and Metoclopramide alone or in combination for prophylaxis of PONV. Can J Anesth 47(8): 780-5, 2000

Neither metoclopramide nor dimenhydrinate alone reduced the incidence of PONV. However, the combination of both drugs revealed a moderate additive effect: PONV was reduced from 37.5% in the placebo group to 15%

Elhakim M, Nafie M, Mahmoud K, Atef A: Dexamethasone 8 mg in combination with Ondansetron 4 mg appears to be the optimal dose for the prevention of nausea and vomiting after laparoscopic cholecystectomy. Can J Anesth 49(9): 922-926, 2002

The optimal dose of dexamethasone 8 mg IV in combination with ondansetron 4 mg IV will effectively prevent PONV in patients undergoing laparoscopic cholecystectomy.

Fortney JT, Gan TJ, Graczyk S, et al: A comparison of the efficacy, safety, and patient satisfaction of ondansetron versus droperidol as antiemetics for elective outpatient surgical procedures. Anesth Analg 1998; 86:731-738.

In comparing a costly drug such as ondansetron versus an inexpensive one such as droperidol, these authors in a large multi-center trial, concluded that droperidol compared favorably with ondansetron. Interestingly, the incidence of postoperative headache was higher with ondansetron.

Fujii Y, Tanaka H, Ito M: Treatment of vomiting after pediatric strabismus surgery with Granisetron, Droperidol, and Metoclopramide. Ophthalmologica 216:359-362, 2002

Within 24 h post-op, emesis-free episodes were seen in patients who had received granisetron (40 µg/kg) 88% than in those who had received droperidol (50 µg/kg) 63% or metoclopramide (0.25 mg/kg) 58%

Gan TJ, Franiak R, Reeves J: Ondansetron orally disintegrating tablet vs. placebo for the prevention of post discharge nausea and vomiting after ambulatory surgery. Anesth Analg 94:1199-1200, 2002

All patients received GA with fentanyl, propofol and sevoflurane, and prophylactic ondansetron 4 mg at induction. Before discharge, patients received ondansetron orally disintegrating tablet (ODT) 8mg or placebo. Data shows that ondansetron ODT significantly reduces the incidence of post discharge N/V and improves patient satisfaction with PONV management.

Greif R, Laciny S, Rapf B et al: Supplemental oxygen reduces the incidence of postoperative nausea and vomiting. Anesthesiology 1999; 91: 1246-1252.

Although the study population was undergoing colorectal surgery, the results of this study are intriguing with the potential use in ambulatory procedures. Patients were given either FiO₂ 0.3 or 0.8 intraoperatively without nitrous oxide in a randomized manner such that only the administering anesthesiologist was aware of the FiO₂. Surgeons, patients, nurse investigators were all unaware of their inspired oxygen concentration. Rescue ondansetron was administered as needed. Patients who received the higher inspired oxygen concentration had significantly less postoperative nausea and vomiting than those who had the lower inspired oxygen concentration.

Harmon D, Gardiner J, Harrison R et al: Acupressure and the prevention of nausea and vomiting after laparoscopy. Brit J Anaesth 1999; 82: 387-390.

Using the P6 pressure point in the prevention of postoperative nausea and vomiting, this randomized, double-blind, controlled study suggests that acupressure is more effective than placebo in a high risk population. It a simple, economically sound, and worthy of further investigation.

Khalil SN, Berry JM, Howard G, Lawson K, Hanis C, Mazow ML, Stanley TH: The antiemetic effect of lorazepam after outpatient strabismus surgery in children. Anesthesiology 77:915-9, 1992

Lorazepam is an effective antiemetic in children undergoing strabismus surgery and is associated with less agitation than droperidol.

Knapp MR, Beecher HK: Postanesthetic nausea, vomiting, and retching: Evaluation of the antiemetic drugs dimenhydrinate (Dramamine), chlorpromazine, and pentobarbital sodium. JAMA 160:376-385, 1956.

A detailed article demonstrating a greater incidence of postoperative nausea in women than in men. However, women over 45 were better responders to the effects of antiemetics than men.

Lerman J, Eustis S, Smith DR: Effect of droperidol pretreatment on postanesthetic vomiting in children undergoing strabismus surgery. Anesthesiology 65:322-325, 1986.

The antiemetic efficacy of pretreatment with droperidol was compared to the postoperative administration of codeine IM or acetaminophen rectally. Droperidol, 0.075 mg/kg, given immediately after induction, was significantly more effective than the other agents in preventing vomiting in the postanesthesia care unit without prolonging postanesthesia recovery.

Loewen PS, Marra CA, Zed PJ: 5-HT₃; receptor antagonists vs. traditional agents for the prophylaxis of PONV. Can J Anesth 47(10): 1008-18

A systematic search of literature databases from 1966 to 1999. The 5-HT₃ receptor antagonists (ondansetron, dolasetron, granisetron, and tropisetron) are superior to traditional agents (metoclopramide, perphenazine, prochlorperazine, cyclizine, and droperidol) for the prevention of PONV and vomiting, especially in gynecological surgery. When compared with droperidol and metoclopramide, 5-HT₃ receptor antagonists would prevent 1 patient from developing PONV for every 14 and 6 patients treated, respectively.

Malins AF, Field JM, Nesling PM, Cooper GM: Nausea and vomiting after gynecological laparoscopy: comparison of premedication with oral ondansetron, metoclopramide and placebo. Br J Anaesth. 72:231-3, 1994.

The incidence of nausea and vomiting in women undergoing ambulatory gynecological procedures was reduced from 50% in patients receiving placebo, to 26% in patients receiving 4 mg of ondansetron. Metoclopramide 10 mg was not different from placebo.

Narchi P. Benhamou D. Elhaddoury M. Locatelli C. Fernandez H: Interactions of pre-operative erythromycin administration with general anaesthesia. Can J Anaesth 40:444-7, 1993.

Fifty patients scheduled for laparoscopy received either 250 ml dextrose 5%, or 500 mg of erythromycin in 250 ml dextrose 5%, 30 min before induction. The IV erythromycin decreased residual gastric volume and increased gastric pH without affecting recovery from anaesthesia.

Pandit SK , Kothary SP, Pandit UA, Levy L, Randel G: Dose-response study of droperidol and metoclopramide as antiemetics for outpatient anesthesia. Anesth Analg 68:798-802, 1989.

In this placebo-controlled, dose-response study of metoclopramide and droperidol, only doses of droperidol of 10 µ/kg or higher were effective in reducing postoperative nausea and vomiting. Metoclopramide given orally preoperatively was an ineffective antiemetic. The optimum dose of droperidol for preventing nausea and vomiting in the patient population studied was 20 µ/kg.

Pearman MH: Single dose intravenous ondansetron in the prevention of postoperative nausea and vomiting. Anaesthesia 49(suppl):11-5, 1994

One of several studies showing that ondansetron doses of 4 to 8 mg are very effective antiemetics, although 4 mg is not less effective than 8 mg.

Reinhart DJ, Klein KW, Schroff E: Transdermal scopolamine for the reduction of postoperative nausea in outpatient ear surgery: a double-blind, randomized study. Anesth Analg 79:281-4, 1994.

Transdermal scopolamine reduces, but does not eliminate postoperative nausea and vomiting in this group of patients. Other recovery parameters, such as time to discharge, were not significantly different in treatment and control groups.

Rothenberg DM, Parnass SM, Litwack K, McCarthy RJ, Newman LM: Efficacy of ephedrine in the prevention of postoperative nausea and vomiting. Anesth Analg 72:58-61, 1991.

This study is the only published controlled study in the current anesthesia literature that assessed the efficacy of ephedrine as an antiemetic. Ephedrine, 0.5 mg/kg IM, was as effective as droperidol, 0.04 mg/kg IM, in preventing postoperative nausea and vomiting. Detailed information is given in the report's introduction and discussion.

Sadhasivam S, Saxena A, Kathirvel S, et al: The safety and efficacy of prophylactic ondansetron in patients undergoing modified radical mastectomy. Anesth Analg 1999; 89: 1340-1345.

Mastectomy and reduction mammoplasty patients have a high incidence of postoperative nausea and vomiting. This study group, modified radical mastectomy patients, had increased satisfaction with the use of ondansetron prophylactically over placebo with no increased side affects versus the placebo group. The authors concluded its routine prophylactic use is justified. Since many patients with this surgical procedure are being performed on an ambulatory/office-based environment, prophylactic ondansetron may be justified.

Scuderi PE, James RL, Harris L, Mims GR: Antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic treatment. Anesthesiology 1999; 90: 360-371.

Routine antiemetic prophylaxis did not improve outcomes in this important study with respect to time to discharge, unanticipated admission, patient satisfaction, and return to activities of daily living as opposed to timely symptomatic treatment. The implication for economics and prevention of side effects are obvious.

Sukhani R, Pappas AL, Lurie J, Hotaling AJ, Park A, Fluder E: Ondansetron and Dolasetron provide equivalent postoperative vomiting control after ambulatory tonsillectomy in Dexamethasone-pretreated children. Anesth Analg 95:1230-5, 2002

Compared with dexamethasone alone (placebo), prophylactic antiemetic therapy consisting of a single dose of ondansetron (0.15 mg/kg; max 4 mg) or dolasetron (0.5 mg/kg; max 25 mg) given with dexamethasone (1 mg/kg; max 25 mg) at the induction of anesthesia, significantly reduces the incidence of PONV and the need for rescue antiemetics. The antiemetic efficacy of prophylactic ondansetron and dolasetron was comparable in dexamethasone-pretreated children.

Tang J, Chen X, White PF, Wender RH, Ma H, Sloninsky A, Naruse R, Kariger R, Webb T, Zaentz A: Antiemetic prophylaxis for office-based surgery. Are the 5-HT ₃ receptor antagonists beneficial? Anesthesiology 98:293-8, 2003

The addition of dolasetron (12.5 mg) or ondansetron (4 mg) failed to improve the antiemetic efficacy and the cost-effectiveness of droperidol (0.625 mg IV) in combination of dexamethasone (4 mg IV) when they were used for routine prophylaxis in the office-based surgery setting.

Trepanier CA , Isabel L: Perioperative gastric aspiration increases postoperative nausea and vomiting in outpatients. Can J Anaesth 40:325-8, 1993.

Intraoperative gastric aspiration did not reduce the incidence of nausea and vomiting in the recovery room, and was associated with a higher incidence of vomiting following discharge.

Wang JJ, Ho ST, Lee SC, et al: The prophylactic effect of dexamethasone on postoperative nausea and vomiting in women undergoing thyroidectomy: a comparison of droperidol with saline. Anesth Analg 1999; 89: 200-203.

In an interesting study, these authors concluded that dexamethasone compared favorably with droperidol and placebo in women undergoing thyroidectomy. They felt that the side affects of droperidol were sufficiently unpleasant that the choice of dexamethasone may be superior.

Watcha MF, Bras PJ, Cieslak GD, Pennant JH: The dose-response relationship of ondansetron in preventing postoperative emesis in pediatric patients undergoing ambulatory surgery. Anesthesiology 82:47-52, 1995

Intravenous ondansetron was effective in preventing nausea and vomiting at a dose of 50 mcg/kg.

Watcha MF, Smith I: Cost effectiveness analysis of antiemetic therapy for ambulatory surgery. J Clin Anesth 6:370-7, 1994

In a comparison of prophylactic treatments for nausea and vomiting, droperidol was more cost-effective than ondansetron, which in turn was more cost-effective than metoclopramide. Drug costs and expected frequency of nausea and vomiting can alter this analysis, however.

Welters ID, Menges T, Graf M, et al: Reduction of postoperative nausea and vomiting by dimenhydrinate supppositories after strabismus surgery in children. Anesth Analg 2000; 90: 311-314.

Intraoperative administration of dimenhyrinate suppositories was very effective in the reduction of postoperative nausea and vomiting in this study group. Dimenhyrinate is a very effective preventive and rescue drug. Due to its very low cost and generic status, this drug has not received the status of the higher cost mediciations.

White PF, Issioui T, Hu J, Jones SB, Coleman JE, Waddle JP, Markowitz SD, Coloma M, Macaluso AR: Comparative efficacy of Acustimulation (ReliefBand) versus Ondansetron (Zofran) in combination with Droperidol for preventing nausea and vomiting. Anesthesiology 97:1075-81, 2002

The ReliefBand compared favorably to ondansetron (4 mg IV) when used for prophylaxis against PONV. The Acustimulation device enhanced the antiemetic efficacy of ondansetron after plastic surgery. There were no significant differences between the ReliefBand and ondansetron when administered as adjuvant to droperidol for antiemetic prophylaxis.

3. Problems associated with treatment - TOP

Antiemetic drugs have a number of side effects, some of them potentially serious. While newer agents such as ondansetron have good side-effect profiles compared with older drugs, they are not free from problems.

Foster PN, Stickle BR, Laurence AS: Akasthesia following low-dose droperidol for antiemesis in day-case patients. Anaesthesia 51:491-4, 1996

Akasthesia is a complication of droperidol therapy that may be more common than is recognized and may make droperidol less attractive as an antiemetic.

Halperin JR, Murphy B: Extrapyramidal reaction to ondansetron. Cancer 69:1275, 1992.

A case report of an opisthotonic reaction apparently due to ondansetron.

Holesha W, Dziura-Murauski J: Extrapyramidal side effects of metoclopramide in outpatient surgery patients. J Post Anesth Nurs 9:107-10, 1994.

Three cases describe patients undergoing ambulatory surgery who experienced extra-pyramidal side effects after preoperative administration of intravenous metoclopramide. The scenarios illustrate the potential symptoms that may occur and their management.

Kataja V, de Bruijn KM: Hypersensitivity reactions associated with 5-hydroxytryptamine(3)-receptor antagonists: a class effect? Lancet 347:584-5, 1996

Although hypersensitivity reactions to ondansetron, granisetron, and tropisetron are rare, when they do occur, there may be some cross-reaction between these drugs.

Melnick BM: Extrapyramidal reactions to low-dose droperidol. Anesthesiology 69:424-426, 1988.

Two case reports demonstrate that extrapyramidal effects can occur following low-dose droperidol. In both cases, symptoms developed relatively late in the postanesthetic recovery.

Melnick B, Sawyer R, Karambelkar D, Phitayakorn P, Uy NT, Patel R: Delayed side effects of droperidol after ambulatory general anesthesia. Anesth Analg 69:748-51, 1989.

Anxiety and restlessness can occur after droperidol administration.

Palombaro JF, Klingelberger CE: Angioedema associated with droperidol administration. Annals Emerg Med 27:379-81, 1996

A case report of angioedema was following an intravenous dose of droperidol.

When scopolamine patches are used, anisocoria has occurred on occasion because of transfer of scopolamine to the eye by a finger that has touched the patch.

4. Prevention by the choice of anesthetic - TOP

Propofol, when administered for both induction and maintenance of anesthesia, is associated with a lower incidence of nausea and vomiting than most other anesthetic techniques, indeed, there is a growing body of evidence that propofol has direct antiemetic effects. But when propofol is used in conjunction with an inhalation agent, the incidence of nausea and vomiting may not differ from that with thiopental as an induction agent, nor from that with an inhalation anesthetic alone.

Borgeat A, Wilder-Smith OH, Saiah M, Rifat K: Subhypnotic doses of propofol possess direct antiemetic properties. Anesth Analg 74:539-41, 1992.

In this study of 52 outpatients, those treated with 10 mg propofol had a lower incidence of nausea and vomiting than those treated with placebo. Other recovery parameters were similar in both groups.

Chittleborough MC, Osborne GA, Rudkin GE, Vickers D, Leppard PI, Barlow J: Double-blind comparison of patient recovery after induction with propofol or thiopentone for day-case relaxant general anaesthesia. Anaesth Intensive Care 20:169-73, 1992.

Forty patients undergoing dental extractions received either propofol or thiopentone for induction of anesthesia. No differences were noted in the number of patients requiring treatment for nausea and vomiting, nor in the incidence of mild nausea not requiring treatment.

Dershwitz M, Michalowski P, Chang YC, Rosow CE, Conlay LA: PONV after Total Intravenous Anesthesia with Propofol and Remifentanil or Alfentanil: How important is the opioid? J Clin Anesth 14:275-278, 2002

When propofol-based TIVA is used for arthroscopic surgery, lasting about 45 min, short-acting opioids do not significantly affect the risk of PONV. Data suggested that propofol infusion, type of surgery, and gender are significantly more important in determining PONV risk.

Erb TO, Hall JM, Ing RJ, Kanter RJ, Kern FH, Schulman SR, Gan TJ: PONV in children and adolescents undergoing radiofrequency catheter ablation: A randomized comparison of Propofol- and Isoflurane-base anesthetics. Anesth Analg 95: 1577-81, 2002

Using Isoflurane has a high PONV risk and the prophylactic use of ondansetron, as well as antiemetic therapy with droperidol are ineffective. However, a Propofol-based anesthetic is highly effective in preventing PONV.

Eriksson H, Korttila K: Recovery profile after desflurane with or without ondansetron compared with propofol in patients undergoing outpatient gynecological laparoscopy. Anesth Analg 82:533-8, 1996.

Desflurane combined with ondansetron had a recovery profile similar to propofol.

FujiiY, Uemura A, Nakano M: Small dose of Propofol for preventing nausea and vomiting after third molar extraction. J Oral Maxillofac Surg 60:1246-49, 2002

Prophylactic therapy with a dose of Propofol (0.5 mg/kg) is effective for preventing PONV in female patients undergoing general anesthesia for third molar extractions.

Green G, Jonsson L: Nausea: the most important factor determining length of stay after ambulatory anaesthesia. A comparative study of isoflurane and/or propofol techniques. Acta Anaesthesiol Scand 37:742-6, 1993 .

When patients undergoing laparoscopy or arthroscopy received either propofol or isoflurane for maintenance, initial recovery was faster after isoflurane, although nausea was much less in the group who received propofol. Nausea was a significant factor contributing to recovery room time.

Grundmann U, Silomon M, Bach F, Becker S, Bauer M, Larsen B, Kleinschmidt S: Recovery profile and side effects of Remifentanil-based anaesthesia with Desflurane or Propofol for laparoscopic cholecystectomy. Acta Anaesth Scand 45:320-326, 2001

In remifentanil-based anesthetic regimens (free from N₂O) in conjunction with either propofol or desflurane, the use of propofol results in less postoperative analgesic consumption and PONV as compared to desflurane.

Karlsen KL, Persson E, Wennberg E, Stenqvist O: Anaesthesia, recovery and PONV after breast surgery. A comparison between Desflurane, Sevoflurane and Isoflurane anaesthesia. Acta Anaesthesiologica Scand 44:489-493, 2000

The quality of anesthesia, time to opening of eyes and influence on respiration were similar with all three anesthetics. Early PONV was significantly more common in Desflurane and Sevoflurane as compared to Isoflurane. The occurrence of PONV was 22% with isoflurane, 36% with sevoflurane and 67% with desflurane.

Kranke P, Morin AM, Roewer N, Wulf H, Eberhart LH: The efficacy and safety of transdermal Scopolamine for the prevention of PONV: A quantitative systematic review

Of 100 patients who received transdermal scopolamine, approximately 17 will not have PONV who would have done so had they all received a placebo. Time of application (night before vs. morning of surgery) seems not to be a factor. Common side effects are visual disturbances or dry mouth.

Langevin S, Lessard MR, Trepanier CA, Baribault JP: Alfentanil causes less PONV than equipotent doses of Fentanyl or Sufentanil in outpatients. Anesthesiology 91:1666-73, 1999

The incidence of PONV was significantly lower in patients who received alfentanil (12%) compared with approximately equipotent plasma concentration of fentanyl (34%) and sufentanil (35%). However, data does not support the hypothesis that the risk of POV is related to their pharmacokinetic characteristics.

Lebenbom-Mansour MH, Pandit SK, Kothary SP, Randel GI, Levy L: Desflurane versus propofol anesthesia: a comparative analysis in outpatients. Anesth Analg. 76:936-41, 1993.

Sixty outpatients received either a propofol induction/desflurane/N₂O; propofol/propofol N₂O; desflurane/N₂O induction and maintenance; or desflurane induction and maintenance. More patients receiving desflurane/N₂O vomited than in the other groups.

Martin TM, Nicolson SC, Bargas MS: Propofol anesthesia reduces emesis and airway obstruction in pediatric outpatients. Anesth Analg. 76:144-8, 1993.

In children, propofol infusion was associated with less nausea and vomiting than inhalation of volatile agents. Recovery room times were not different.

Moretti EW, Robertson KM, El-Moalem H, Gan T: Intraoperative Colloid administration reduces PONV and improves postoperative outcomes compared with Crystalloid administration. Anesth Analg 96:611-617, 2003

Intraoperative fluid resuscitation with colloid, when compared with crystalloid administration, is associated with less PONV, use of rescue antiemetics, severe pain, periorbital edema, and double vision; thus improvement in the quality of postoperative recovery.

Purhonen S, Turunen M, Ruohoaho UM, Niskanen M, Hynynen M: Supplemental Oxygen does not reduce the incidence of PONV after ambulatory gynecologic laparoscopy. Anesth Analg 96:91-96, 2003

Two groups: 30% oxygen, balance nitrogen (not nitrous oxide); and 80% oxygen, balance nitrogen. Oxygen was administered during surgery and up to 1 h after surgery. There was no difference between the two groups in PONV, the need for rescue antiemetics, recovery profiles and patient satisfaction. Thus, supplemental oxygen did not prevent PONV in patients undergoing ambulatory gynecologic laparoscopy.

Rapp SE, Conahan TJ, Pavlin DJ, et al: Comparison of desflurane with propofol in outpatients undergoing peripheral orthopedic surgery. Anesth Analg 75:572-9, 1992.

Ninety-one patients received propofol/desflurane N₂O, propofol N₂O; desflurane N₂O; or desflurane O₂ following the administration of fentanyl (2 ug/kg) and d-tubocurarine (3 mg) before induction. Patients receiving propofol/N₂O experienced less nausea. No difference was observed between the propofol/desflurane or desflurane/desflurane groups.

Reimer EJ, Montgomery CJ, Bevan JC, Merrick PM, Blackstock D, Popovic V: Propofol anaesthesia reduces early postoperative emesis after paediatric strabismus surgery. Can J Anaesth 40:927-33, 1993.

Seventy-five patients ages 2-12 yr received either thiopentone/halothane/ N₂O /O₂; propofol/ propofol/ O₂; or propofol/propofol/N₂O /O₂. The use of propofol anaesthesia with and without N₂O decreased only early emesis.

Sukhani R, Lurie J, Jabamoni R: Propofol for ambulatory gynecologic laparoscopy: does omission of nitrous oxide alter postoperative emetic sequelae and recovery? Anesth Analg 78:831-5, 1994.

The addition of N₂O to a propofol infusion technique did not increase the incidence of nausea and vomiting, and reduced recovery room time.

Tang J, White PF, Wender RH, Naruse R, Kariger R, Sloninsky A, Karlan MS, Uyeda RY, Karlan SR, Reichman C, Whetstone B: Fast-track office-based anesthesia: A comparison of Propofol versus Desflurane with antiemetic prophylaxis in spontaneously breathing patients. Anesth Analg 92:95-99, 2001

Desflurane provided significantly better intraoperative conditions, such as fewer movements and faster emergence, than Propofol. However, recovery end points and discharge were similar in the two groups. With triple antiemetic prophylaxis consisting of ondansetron (4 mg), droperidol (0.625 mg) and metoclopramide (10 mg) administered before the end of surgery, PONV after desflurane anesthesia was reduced to a level comparable to Propofol after office-based surgery.

Van Hemelrijck J, Smith I, White PF: Use of desflurane for outpatient anesthesia. A comparison with propofol and nitrous oxide. Anesthesiology. 75:197-203, 1991.

Ninety-two healthy patients received either: 1) propofol/propofol/ N₂O, 2) propofol/ desflurane/ N₂O, 3) desflurane/N₂O, or 4) desflurane O₂. Less nausea was observed in patients receiving propofol/propofol. The propofol/desflurane group did not differ from those receiving desflurane alone.

Watcha MF, Simeon RM, White PF, Stevens JL: Effect of propofol on the incidence of postop-erative vomiting after strabismus surgery in pediatric outpatients. Anesthesiology 75:204, 1991

In children, 50-75 µg/kg of propofol is useful to control postoperative nausea, although this dose is also associated with a delay in discharge. When propofol and droperidol were compared, postoperative nausea in patients was similar, but droperidol patients were fit for discharge one hour later.

Wennstrom B, Reinsfelt B: Rectally administered Diclofenac (Voltaren) reduces vomiting compared with opioid (Morphine) after strabismus surgery in children. Acta Anaesth Scand 46:430-434, 2002

5. Reversal of muscle relaxation may contribute to postoperative nausea and vomiting - TOP

One of the side effects of neuromuscular blockade that is not always recognized is that reversal agents can contribute to the incidence of postoperative nausea and vomiting. This should be a consideration when choosing a neuromuscular blocking agent. However, new data suggests that this may not be the case in all patients.

Boeke AJ, de Lange JJ, van Druenen B, Langemeijer JJ: Effect of antagonizing residual neuromuscular block by neostigmine and atropine on postoperative vomiting. Br J Anaesth 72:654-6, 1994.

Reversal of neuromuscular blockade with neostigmine was associated with a reduction in the need for antiemetic medication; no difference was observed in the incidence of nausea and vomiting when this group was compared to patients allowed to recover respiratory function spontaneously.

Ding Y, Fredman B, White PF: Use of mivacurium during laparoscopic surgery: effect of reversal drugs on postoperative recovery. Anesth Analg 78:450-4, 1994.

Sixty patients undergoing outpatient laparoscopic tubal ligation received either succinylcholine or mivacurium 0.2 mg/kg to facilitate tracheal intubation. Reversal of neuromuscular blockade increased the incidence of nausea and vomiting in the PACU. In addition, the succinylcholine group had more neck pain during the 24 hours after discharge.

Joshi GP, Garg SA, Hailey A, Yu SY: The effects of antagonizing residual neuromuscular blockage by neostigmine and glycopyrrolate on nausea and vomiting after ambulatory surgery. Anesth Analg 1999; 89: 628-631.

Patients who had reversal of two different intermediate acting neuromuscular blocking agents, had no statistical difference in the incidence of postoperative nausea and vomiting, discharge time or rescue antiemetics.

Lovstad RZ, Thagaard KS, Berner NS, Raeder JC: Neostigmine 50 m g/kg with Glycopyrrolate increases postoperative nausea in women after laparoscopic gynaecological surgery. Acta Anaesthesiologica Scand 45:495-500, 2001

Neostigmine reversal results in increased nausea and use of antiemetic rescue medication during the first 6 h after laparoscopic surgery in females, even when ondansetron prophylaxis is given.

Nelskyla K, Yli-Hanakala A, Soikkeli A, Korttila K: Neostigmine with glycopyrrolate does not increase the incidence or severity of postoperative nausea and vomiting in outpatients undergoing gynaecological laparoscopy. Br J Anaesth 81: 757-760, 1998.

In this study, using a double bind, placebo-controlled study, reversal of mivacurium with neostigmine-glycopyrrolate did not increase the risk of postoperative nausea and vomiting in ambulatory patients. Routine avoidance or use of reversal agents should be determined by clinical need and not by rote.

Tramer MR, Fuchs-Burder T: Omitting antagonism of neuromuscular block: effect on postop-erative nausea and vomiting and risk of residual paralysis. A systematic review. Brit J Anaesth 1999; 82: 379-386.

Omission of neostigmine in doses higher than 1.5 mg, the increase incidence of PONV should be weighed against the risk of postoperative weakness from unantagonized neuromuscular blockade. Omission of edrophonium had no effect upon the incidence of PONV.

6. The choice of anticholinergic drug in the reversal of neuromuscular block may increase the incidence of postoperative nausea and vomiting - TOP

Chibber AK, Lustik SJ, Thakur R, Francisco DR, Fickling KB: Effects of anticholinergics on postoperative vomiting, recovery, and hospital stay in children undergoing tonsillectomy with or without adenoidectomy. Anesthesiology 1999; 90: 697-700.

When evaluating the effect of atropine vs. glycopyrrolate on postoperative nausea and vomiting in children, atropine/neostigmine was associated with less postoperative nausea and vomiting than glycopyrrolate/neostigmine. Is now possible than choice of anticholinergic agent may increase the risk of postoperative nausea and vomiting.

Boker A, Brownell L, Donen N: The Amsterdam preoperative anxiety and information scale provides a simple and reliable measure of preoperative anxiety. Can J Anaesth 2002 Oct;49(8):792-8

In addition to VAS, the anxiety component of APAIS (sum C) is a promising new practical tool to assess preoperative patient anxiety levels.

Choi WY, Irwin MG, Hui TW, Lim HH, Chan KL: EMLA cream versus dorsal penile nerve block for postcircumcision analgesia in children. Anesth Analg 2003 Feb;96(2):396- 9

EMLA cream was found to have similar analgesia compared to a dorsal penile block. It is an effective and simple method to produce postcircumcision analgesia with a very small incidence of adverse effects.

De Witte JL, Alegret C, Sessler DI, Cammu G: Preoperative alprazolam reduces anxiety in ambulatory surgery patients: a comparison with oral midazolam. Anesth Analg 2002 Dec;95(6):1601-6

Because an oral formulation of midazolam is not approved in certain countries, the authors evaluated oral alprazolam as an alternative. Oral alprazolam 0.5 mg and midazolam 7.5 mg comparably reduce anxiety in ambulatory surgery patients. Despite early psychomotor impairment, neither drug delays postanesthetic extubation nor prolongs discharge from the postanesthesia care unit.

Duggan M, Dowd N, O'Mara D, Harmon D, Tormey W, Cunningham AJ: Benzodiazepine premedication may attenuate the stress response in daycase anesthesia: a pilot study. Can J Anaesth 2002 Nov;49(9):932-5

There is conflicting evidence in the literature regarding the benefit of benzodiazepine premedication in ambulatory surgery. The authors examined clinical evidence of stress response by analyzing urinary catecholamine and cortisol levels as well as subjective levels of anxiety in ambulatory surgical patients. Their finding of reduced stress hormones in the diazepam premedicated patients may support the role of preoperative benzodiazepines.

Kain ZN, Hofstadter MB, Mayes LC, Krivutza DM, Alexander G, Wang SM, Reznick JS.

Midazolam: effects on amnesia and anxiety in children. Anesthesiology 2000 Sep;93(3):676-84

The minimum time interval between administration of oral midazolam and separation of children from their parents that ensures good anterograde amnesia has not been previously determined. This is of particular importance in a busy operating room setting where schedule delays secondary to midazolam administration may not be tolerated. Midazolam administered orally produces significant anterograde amnesia when given as early as 10 min before a surgical procedure

Nilsson U, Rawal N, Enqvist B, Unosson M: Analgesia following music and therapeutic suggestions in the PACU in ambulatory surgery; a randomized controlled trial. Acta Anaesthesiol Scand 2003 Mar;47(3):278-283

Using music or music with therapeutic suggestions, the authors were able to demonstrate overall lower pain scores perioperatively. Although statistically significant, the improvement in analgesia was modest in a group of patients with low overall pain levels.

Reuben SS, Steinberg RB, Maciolek H, Joshi W: Preoperative administration of controlled-release oxycodone for the management of pain after ambulatory laparoscopic tubal ligation surgery. J Clin Anesth 2002 May;14(3):223- 7

The preoperative administration of Controlled Release oxycodone 10 mg is an effective analgesic technique in the management of pain following ambulatory laparoscopic tubal ligation surgery, and may facilitate earlier postoperative discharge.

Reuben SS, Sklar J, El-Mansouri M: The preemptive analgesic effect of intraarticular bupivacaine and morphine after ambulatory arthroscopic knee surgery. Anesth Analg 2001 Apr;92(4):923-6

The administration of intraarticular morphine 3 mg before arthroscopic knee surgery provides a longer duration of analgesia with less 24-h opioid use compared with the administration of the drug at the completion of surgery.

Turan A, Emet S, Karamanlioglu B, Memis D, Turan N, Pamukcu Z: Analgesic effects of rofecoxib in ear-nose-throat surgery. Anesth Analg 2002 Nov;95(5):1308-11

The authors evaluated the analgesic efficacy and opioid-sparing effect of rofecoxib, a new selective cyclooxygenase-2 inhibitor drug, in ear-nose-throat surgery patients. Preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the need for opioids in patients undergoing nasal septal and nasal sinus surgery.

Wang SM, Peloquin C, Kain ZN: Attitudes of patients undergoing surgery toward alternative medical treatment. J Altern Complement Med 2002 Jun;8(3):351-6

There has been an increased interest in complementary and alternative medical ( CAM) therapies in the scientific literature and the popular press for the last decade. The authors did a survey to find that alternative

medicine use is reported to be a common phenomenon prior to surgery and significant number of patients are willing to accept acupuncture as treatment for anxiety during the preoperative period.

Watson A, Srinivas J, Daniels L, Visram A: Preparation of parents by teaching of distraction techniques does not reduce child anxiety at anaesthetic induction. Paediatr Anaesth 2002 Nov;12(9):823 -4

The authors show that giving an active role for parents in the induction room, particularly by instructing them on distracting techniques for their child, does not reduce their child's anxiety compared to conventional parental presence. They felt that resources should not be directed at this type of parental preparation, however further work should examine the usefulness of distraction by nursing staff or play specialists during anaesthetic induction.

1. Existence of anxiety - TOP

Patients scheduled to undergo surgery tend to be anxious. This anxiety is present, particularly for adults, long before they come to the outpatient area. Children can be anxious, just like adults. Much of a child’s anxiety concerns separation from parent(s).

Aantaa R, Jaakola M-L, Kallio A, Kanto J, Scheinin M, Vuorinen J: A comparison of dexmedetomidine, an alpha 2 -adrenoceptor agonist, and midazolam as i.m. premedication for minor gynaecological surgery. Br J Anaesth 67:402, 1991

Some patients are not anxious preoperatively. A study of outpatients undergoing gynecologic surgery to examine the efficacy of drugs for relief of anxiety was unsucessful simply because of the low levels of preoperative anxiety present!

Arellano R, Cruise C, Chung F: Timing of the anesthetist’s preoperative outpatient interview. Anesth Analg 68:645-648, 1989.

Hospitalization arouses anxiety among patients admitted for day bed surgery. The optimal time of the preoperative anesthetic visit to reduce the anxiety of patients awaiting a therapeutic abortion is just before surgery, but even at this time, the level of anxiety in these patients may still be high. Thus, reassurance of patients should be done immediately before surgery.

Badner NH, Nielson WR, Munk S, Kwiotkowska C, Gelb AW: Preoperative anxiety: detection and contributing factors. Can J Anaesth 37:444, 1990

If in doubt about patient anxiety, ask: predictive accuracy in determining whether or not patients are anxious increases when they are asked.

Caumo W, Broenstrub JC, Fialho L, Petry SM, Brathwait O, et al: Risk factors for postoperative anxiety in children. Acta Anaesthesiologica Scandinavica 44(7):782-9, 2000 Aug.

BACKGROUND: Anxiety is defined as a set of behavioural manifestations that can be divided into state- and trait-anxiety. State-anxiety is a transitory emotional condition that varies in intensity and fluctuates over time. Trait-anxiety is a personality trait which remains relatively stable over time. The objective of this study was to identify and quantify perioperative risk factors for immediate postoperative anxiety in children.

METHODS : A prospective cohort study was performed with 90 schoolchildren, ages ranging from 7 to 13 years old, ASA physical status I-II, submitted to elective surgery. The measuring instruments were verbal scale of pain, visual analogue scale (VAS), Trait-State Anxiety Inventory for Children (STAIC), Trait-State Anxiety Inventory (STAI) for parents, and structured questionnaire.

RESULTS: Patients not submitted to analgesic block and patients with moderate and intense pain presented an estimated risk 5- and 13-fold greater for high levels of postoperative state-anxiety, respectively. High levels of preoperative state-anxiety and administration of doses of midazolam less than 0.056 mg x kg(-1) constituted an estimated risk for postoperative state-anxiety of 3- and 4-fold, respectively. A positive history of previous surgery was associated with lower risk for postoperative anxiety.

CONCLUSIONS: High levels of preoperative state-anxiety, administration of less than 0.056 mg x kg(-1) of midazolam, absence of analgesic block and presence of moderate and intense postoperative pain constituted risk factors for immediate postoperative state-anxiety inchildren. Previous surgery reduced the risk for postoperative anxiety.

Fredman B, Lahav M, Zohar E, Golod M, Paruta I, Jedeikin R: The effect of midazolam premedication on mental and psychomotor recovery in geriatric patients undergoing brief surgical procedures. Anesthesia & Analgesia 89(5):1161-6, 1999 Nov.

To assess the effect of IV midazolam premedication on recovery of cognitive function, 90 geriatric patients (aged 65-81 yr) undergoing brief transurethral procedures were enrolled into this prospective, placebo-controlled, double-blinded study. In all cases, a standard general anesthetic was administered. Thirty minutes before operating room transfer, patients in Group 0.5 mg, Group 2 mg, and Group S received 0.5 mg of midazolam, 2 mg of midazolam, or an equal volume of saline, respectively. Before study-drug administration (baseline), at 15 min thereafter, as well as on arrival in the postanesthesia care unit (PACU), and at 60 min and 120 min, postoperatively, we administered a digit-symbol substitution test, a mini-mental test, a shape-sorter test, and a patient-generated 100-mm visual analog score (0 = minimal and 100 = maximal) for anxiety, sleepiness, and coordination. A 4-point scale was used to assess the degree of patient sedation at 7, 15, and 30 min after study-drug administration. Using a modified Aldrete scoring system, PACU discharge was determined by the PACU staff. Patient anxiety, sleepiness, and coordination scores at baseline and at 15 min after study-drug administration were similar. When compared with saline, midazolam was associated with a significantly (P<0.05) higher incidence of "deep" sedation. In Group 2 mg, the incidence of a low preoperative SpO² (<94%) was significantly (P<0.05) higher when compared with Group S. Emergence, extubation, and orientation times, as well as time to follow commands were unaffected by midazolam premedication. Postoperatively, the digit-symbol substitution test, mini-mental test, and shape-sorter test were similar among the groups. However, time to PACU discharge was significantly (P = 0.03) longer in the two midazolam treatment groups (41 +/-25 min, 60 +/- 32 min, 53 +/- 39 min for Groups S, 0.5 mg, and 2 mg, respectively). Finally, patient satisfaction was unaffected by the randomization schedule. IMPLICATIONS: IV premedicant midazolam 0.5 mg or 2 mg does not adversely affect mental and psychomotor recovery in geriatric patients undergoing brief surgical procedures. However, midazolam administration significantly prolonged postanesthesia care unit discharge time. Finally, during the preoperative period, midazolam increases the incidence of a SpO² <94% in a dose-dependent manner.

Kain ZN, Mayes LC, Weisman SJ, Hofstadter MB: Social adaptability, cognitive abilities, and other predictors for children's reactions to surgery. Journal of Clinical Anesthesia 12(7):549-54, 2000 Nov.

STUDY OBJECTIVE: To examine the relationship between social adaptability, cognitive abilities, and other personality characteristics to perioperative anxiety.

STUDY DESIGN : Prospective cohort investigation.

PATIENTS: 60 children ASA physical status I and II, age 3 to 10 years.

SETTING: Tertiary care children's hospital.

MEASUREMENTS: Temperament (EASI), cognitive abilities (KABC), and adaptive behavior ( Vineland) were evaluated in a group of children undergoing surgery. Parental coping style (MBBS) and parental state (STAI-S) and trait (STAI-T) anxiety were assessed as well. On the day of surgery, anxiety of the child was measured at the preoperative holding area and during induction of anesthesia (m-YPAS).

MAIN RESULTS: Univariate correlational analysis demonstrated that young age (r = -0.27), poor social adaptability ( Vineland) (r = -0.38), shy and inhibited personality (EASI; temperament) (r = -0.33), higher intelligence (KABC) (r = 0.29), increased parental anxiety (r = 0.44), and parental high-monitoring coping style (r = -0.25) are all associated with higher levels of perioperative anxiety. Stepwise multivariate regression analysis has demonstrated that controlling for the variables above, parental anxiety (p = 0.004), child's social adaptive capabilities (p = 0.04), and child's temperament (sociability) (p = 0.04) are independent predictors for increased perioperative anxiety (R(2) = 0.38, F = 5.5, p = 0.003).

CONCLUSIONS: Anesthesiologists need to pay close attention to the families of pediatric surgical children who are socially maladjusted, shy and inhibited, and have anxious parents.

Kawana S, Uzuki M, Nakae Y, Namiki A: Preoperative anxiety and volume and acidity of gastric fluid in children. Paediatric Anaesthesia 10(1):17-21, 2000.

Forty-three patients aged 3-6 years, undergoing minor surgery were studied. Parents staying with their children were asked to evaluate the anxiety of their children and themselves by a visual-analogue scale the night before surgery (VAS-N) and just before premedication in the morning (VAS-M). After induction, gastric fluid was collected and the volume and pH were measured. Patients with a VAS-M lower than 5 were considered the low-anxiety group (L-group; n=24) and the remainder comprised the high-anxiety group (H-group; n=19). The gastric volume of the H-group was significantly lower than that of the L-group. No difference was found in pH. A significant overall correlation of VAS-N was found between patients and their parents. These results suggest that the low level anxiety of children and their parents could not reduce the volume and acidity of gastric fluid and consequently the risk of aspiration pneumonia.

Lichtor JL, Johanson CE, Mhoon D, et al: Preoperative anxiety: Does anxiety level the afternoon before surgery predict anxiety level just before surgery? Anesthesiology 67:595-599, 1987.

Patients completed a mood questionnaire on the afternoon before surgery and again 1 hour before surgery. Anxiety was virtually no different between the two times. Also, there was a good correlation between anxiety seen afternoon before surgery and 1 hour before surgery. The article questions the effectiveness of giving patients anxiolytics just before they go to the operating room. The anxiety is present for much longer preoperatively.

Miller KM, Wysocki T, Cassady JF Jr, Cancel D, Izenberg N: Validation of measures of parents' preoperative anxiety and anesthesia knowledge. Anesthesia & Analgesia 88(2):251-7, 1999 Feb. Parents' anxiety about their children's anesthesia may adversely affect the children's outcomes and compromise the quality of informed consent. Studies of these issues have been limited by the lack of validated measures of parental anxiety and knowledge surrounding anesthesia. In the present study, we evaluated psychometric properties of the Amsterdam Preoperative Anxiety and Information Scale (APAIS) and the Standard Anesthesia Learning Test (SALT) among 85 parents who participated in an evaluation of the effects of a videotape about pediatric anesthesia. The results supported the internal consistency, test-retest reliability, and concurrent validity of both instruments and documented the demonstrated factor structure of the APAIS, further confirming its construct validity. We conclude that the APAIS and SALT are reliable and valid measures of parental anxiety and knowledge of pediatric anesthesia that can be used for clinical and research purposes. Implications: This study verified the reliability and validity of two questionnaires for measuring parents' knowledge and anxiety about pediatric anesthesia. These questionnaires can be used in further research on factors affecting parental anxiety and knowledge before their children's surgery.

Mingus ML, Levitan SA, Bradford CN, Eisenkraft JB. Surgical patients’ attitude regarding participating in clinical anesthesia research. Anesth Analg 82:332-337, 1996.

A questionnaire was designed to identify the factors influencing both day of admission and ambulatory patients in their decision whether to participate in and give informed consent for clinical anesthesia research.

Vetter TR: The epidemiology and selective identification of children at risk for preoperative anxiety reactions. Anesth Analg 77:96, 1993

Children are more likely to demonstrate problematic behavior around the time of separation from parents for induction of anesthesia if they have not received information about a procedure preoperatively.

Wang SM, Kain SN: Preoperative anxiety and postoperative nausea and vomiting in children: is there an association? Anesthesia & Analgesia 90(3):571-5, 2000 Mar.

We performed a cross-sectional study to explore a potential association between preoperative anxiety and postoperative nausea and vomiting (PONV). The study enrolled 51 unpremedicated children 5-16 yr old undergoing outpatient surgery and standardized general anesthesia. Anxiety of children was assessed in the preoperative holding area and during the induction of anesthesia. The incidence of nausea and vomiting was documented in the postanesthesia care unit (PACU) and 24 h postoperatively (POD#1). In addition to univariate analysis, we used multivariate logistic regression models, wherein the dependent variable was the presence or absence of PONV and the independent variables included potential confounders such as age, sex, and perioperative opioid consumption. Univariate analysis showed that children who experienced nausea (32 +/- 5 vs 31 +/- 4, P = ns) or vomiting (32 +/- 4 vs 32 +/- 5, P = ns) in the PACU did not differ significantly in their anxiety before surgery. A multivariate model, in which the dependent variable was the presence or absence of vomiting at POD#1 and the independent variables included preoperative anxiety, age, sex, and opioid consumption, indicated that preoperative anxiety does not predict the occurrence of nausea and vomiting (P = ns). We conclude that children's anxiety in the preoperative holding area has no predictive value for the occurrence of PONV in the PACU or POD#1.

IMPLICATIONS: This study was performed to explore a possible association between children's anxiety before surgery and postoperative nausea and vomiting. We found that controlling for confounding variables, anxiety in the preoperative holding area has no predictive value for the occurrence of postoperative nausea and vomiting.

2. Treatment of anxiety, including the uncooperative child - TOP

Parental presence during induction of anesthesia is considered by some to be a necessary component of current pediatric anesthetic care. Others question the benefits of this practice and counter that it actually poses some risks.

Alderson PJ, Lerman J: Oral premedication for paediatric ambulatory anaesthesia: a comparison of midazolam and ketamine. Can J Anaesth 41:221, 1994

Oral midazolam in a dose of 0.5 mg/kg produces effective sedation and reduces anxiety.

Arrowsmith JB, Gerstman BB, Fleischer DE, Benjamin SB: Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc 37:421-427, 1991

At proper doses, midazolam places patients at no additional risk than does diazepam, in terms of cardiovascular and respiratory depression.

Ashburn MA, Streisand JB, Tarver SD, et al: Oral transmucosal fentanyl citrate for premedication in paediatric outpatients. Can J Anaesth 37:857, 1990

With fentanyl, PACU stay is not prolonged and postoperative analgesia requirements are less, although if children are required to drink fluids before they can be discharged, vomiting may delay their release.

Bevan JC, Johnston C, Haig MJ, et al: Preoperative parental anxiety predicts behavioural and emotional responses to induction of anaesthesia in children. Can J Anaesth 37:177-182, 1990.

Despite parental presence, children are upset during induction. Anxious parents make matters worse.

Bondy LR, Sims N, Schroeder DR, Offord KP, Narr BJ: The effect of anesthetic patient education on preoperative patient anxiety. Regional Anesthesia & Pain Medicine 24(2):158-64, 1999 Mar-Apr.

BACKGROUND AND OBJECTIVES: Preoperative time spent with patients has been abbreviated with the advent of same-day admission requirements and outpatient surgery. This study was conducted to evaluate the effects that materials mailed to the home relating to anesthetic-focused patient education may have on preoperative patient anxiety.

METHODS: Patients scheduled for a total hip arthroplasty or for a total knee arthroplasty were screened via telephone for inclusion in a prospective, randomized study. Patients were asked about their access to a video cassette recorder/player (VCR) and their limitations regarding hearing or vision. Subjects were randomly assigned to either the intervention group and received two pamphlets and a video describing general and regional anesthesia or to the usual care group. All subjects were mailed a preoperative demographic questionnaire and a State Trait Anxiety Inventory (STAI), as developed by CD Spielberger. Questionnaires were completed at least 96 hours prior to admission and again preoperative on the day of surgery.

RESULTS: Of 236 patients screened, 26 had no access to a VCR, 6 were hearing or visually impaired, and 4 declined participation. Of 200 subjects randomized, 134 completed both sets of questionnaires and thus form the basis of this report. A statistically significant difference between the subjects who received the video and pamphlets and the usual care subjects was detected with respect to change in STAI-assessed anxiety from baseline to immediately prior to surgery (P=.035). The intervention subjects experienced a smaller mean increase in anxiety. Forty-nine percent of the usual care subjects expressed interest in having additional information.

CONCLUSIONS: Increase in preoperative anxiety is diminished when additional anesthesia information in printed and video format is made available. Useful information can be provided to patients to view or read prior to surgery.

Cameron JA, Bond MJ, Pointer SC: Reducing the anxiety of children undergoing surgery: parental presence during anaesthetic induction. J Paediatr Child Health 32:51-6, 1996.

Parental presence can reduce a child’s anxiety, but parental anxiety is contagious.

Cassady JF Jr. Wysocki TT. Miller KM. Cancel DD. Izenberg N. Use of a preanesthetic video for facilitation of parental education and anxiolysis before pediatric ambulatory surgery. Anesthesia & Analgesia 88(2):246-50, 1999 Feb.

In this study, we evaluated the effects of viewing an educational videotape about pediatric anesthesia on measures of parental knowledge of anesthesia and preoperative anxiety using a randomized, controlled design. During their routine preoperative visit, 85 parents of children scheduled to undergo ambulatory surgical procedures under general anesthesia were randomized to view either the experimental videotape about pediatric anesthesia or a control videotape with no medical content. Before and immediately after viewing the assigned videotape, parents completed measures of situational anxiety (State-Trait Anxiety Inventory-State), preoperative anxiety and need for information (Amsterdam Preoperative Anxiety and Information Scale), and anesthesia knowledge (Standard Anesthesia Learning Test). Repeated-measures analyses of variance showed that parents who viewed the experimental videotape showed a significant increase in anesthesia knowledge (P < 0.022) and a significant reduction in their state of anxiety (P < 0.031), anesthesia-specific anxiety, and need for information (P < 0.0001) compared with the control group. These results demonstrated that viewing a preoperative educational videotape about pediatric anesthesia can provide immediate educational and anxiolytic benefits for parents of children undergoing ambulatory surgery. The duration of these benefits remains to be determined. Implications: In this study, we demonstrated the benefits of viewing an educational videotape about pediatric anesthesia on measures of parental knowledge of anesthesia and preoperative anxiety using a randomized, controlled design. We found that videotape viewing facilitated preoperative preparation and lessened preoperative anxiety.

Feld LH, Champeau MW, van Steennis CA, Scott JC: Preanesthetic medication in children: a comparison of oral transmucosal fentanyl citrate versus placebo. Anesthesiology 71:374, 1989

In children, given a lozenge form of fentanyl (oral transmucosal fentanyl citrate), anxiety was reduced, sedation was increased, and the quality of induction was improved.

Ferrari LR, Donlon JV: A comparison of propofol, midazolam, and methohexital for sedation during retrobulbar and peribulbar block. J Clin Anesth 4:93, 1992

Anxiety reduction and sedation were similar when propofol was compared to midazolam and methohexital for sedation for retrobulbar and peribulbar ocular block

Friesen RH, Lockhart CH: Oral transmucosal fentanyl citrate for preanesthetic medication of pediatric day surgery patients with and without droperidol as a prophylactic anti-emetic. Anesthesiology 76:46, 1992

Transmucosal fentanyl citrate (OTFC) or placebo was given to 100 children aged 2-8 yr undergoing general anesthesia for outpatient surgery. Children receiving OTFC had significantly greater sedation preoperatively, slower respiratory rates, lower SpO² , and less excitement during induction. Nausea and vomiting was more frequent after OTFC than after placebo. Prophylactic droperidol, 50µg/kg, did not significantly reduce the incidence of nausea and vomiting. Postooperative vomiting can be a problem after oral transmucosal fentanyl citrate.

Greenblatt DJ, Locniskar A, Ochs HR, Lauven PM: Automated gas chromatography for studies of midazolam pharmacokinetics. Anesthesiology 55:176-179, 1981.

The kinetic profile for midazolam is analyzed. The elimination half-life for midazolam is 2.5 hours.

Gross JB, Long WB: Nasal oxygen alleviates hypoxemia in colonoscopy patients sedated with midazolam and meperidine. Gastrointest Endosc 36:26-29, 1990

Routine administration of supplemental oxygen with or without continuous monitoring of arterial oxygenation is recommended whenever benzodiazepines are given.

Hannallah RS, Patel RI: Low-dose intramuscular ketamine for anesthesia pre-induction in young children undergoing brief outpatient procedures. Anesthesiology 70:598-600, 1989.

Describes the efficacy of ketamine for uncooperative children undergoing a short anesthetic for placement of tympanotomy tubes.

Hegarty JE, Dundee JW: Sequelae after the intravenous injection of three benzodiazepines -- diazepam, lorazepam and flunitrazepam. Br Med J 2:1384-1385, 1977.

Older patients have a higher incidence of venous thrombosis after diazepam injection.

Henderson MA, Baines DB, Overton JH: Parental attitudes to presence at induction of paediatric anaesthesia. Anaesth Intensive Care 21:324-327, 1993.

Ryder IG, Spargo PM: Parents in the anaesthetic room. A questionnaire survey of patents’ reactions. Anaesthesia 46:977-979, 1991.

Parents feel their presence is a definite help.

Kain ZN, Wang SM, Mayes LC, Krivutza DM, Teague BA: Sensory stimuli and anxiety in children undergoing surgery: a randomized, controlled trial. Anesthesia & Analgesia 92(4):897-903, 2001 Apr.

We assessed the effectiveness of a behavioral intervention aimed at reducing the anxiety of children undergoing anesthesia and surgery. The intervention consisted of dimmed operating room (OR) lights (200 Lx) and soft background music (Bach's "Air on a G String," 50-60 dB). Only one person, the attending anesthesiologist, interacted with the child during the induction of anesthesia. Children undergoing anesthesia and surgery were randomly assigned either to a low sensory stimulation group (LSSG, n = 33) or to control group (n = 37). By using validated behavioral measures of anxiety (mYPAS) and compliance (ICC), children were evaluated at the preoperative holding area and during the induction of anesthesia. On postoperative Days 1, 2, 3, 7, and 14, the behavioral recovery of the children was assessed by using the Post Hospitalization Behavior Questionnaire. We found that the LSSG was significantly less anxious compared with the control group on entrance to the OR (P = 0.03) and on the introduction of the anesthesia mask (P = 0.003). Also, the compliance during the induction of anesthesia was significantly better in children assigned to the LSSG (P = 0.02). The incidence of postoperative behavioral changes, however, did not differ significantly between the two groups (P = ns). We conclude that children who are exposed to low-level sensory stimuli during the induction of anesthesia and who are exposed to background music exhibit lower levels of anxiety and increased compliance.

IMPLICATIONS: Children are less anxious and show increased compliance during induction when exposed to a single care-provider in a dimmed, quiet operating room with background music.

Kain ZN, Hofstadter MB, Mayes LC, Krivutza DM: Midazolam: effects on amnesia and anxiety in children. Anesthesiology 93(3):676-84, 2000 Sep.

BACKGROUND: The minimum time interval between administration of oral midazolam and separation of children from their parents that ensures good anterograde amnesia has not been previously determined. This is of particular importance in a busy operating room setting where schedule delays secondary to midazolam administration may not be tolerated. METHODS: Children (n = 113) undergoing general anesthesia and surgery completed preoperative baseline memory testing using a validated series of picture cards and were randomly assigned to one of three midazolam groups or a control group. Exactly, 5, 10, or 20 min after receiving oral midazolam (0.5 mg/kg) or 15 min after receiving placebo, children were administered a second memory test that used pictures. Anxiety of children postintervention testing were assessed.

RESULTS: Postoperatively, recall and recognition of pictures presented to patients after drug administration (anterograde amnesia) showed significant group differences (P = 0.0001), with recall impaired in the 10- (P = 0.004) and 20-min groups (P = 0.0001). Similarly, recognition memory was impaired in the 5- (P = 0.0008), 10- (P =0.0001) and 20-min (P = 0.0001) groups. Significant anxiolytic effects of midazolam were observed as early as 15 +/- 4 min after midazolam administration (P = 0.02).

CONCLUSIONS: Midazolam administered orally produces significant anterograde amnesia when given as early as 10 min before a surgical procedure.

Kain ZN, Mayes LC, Wang SM, Caramico LA, Krivutza DM, Hofstadter MB. Parental presence and a sedative premedicant for children undergoing surgery: a hierarchial study. Anesthesiology 92(4):939-946, 2000 Apr.

The authors evaluated two groups of children, a sedative group which received 0.5 mg of oral midazolam or a group that received a sedative and parental presence during the induction of anesthesia. They found that parental presence in addition to 0.5 mg/kg of oral midazolam had no additive effect in terms of reducing a child’s anxiety. Parents who accompanied their children to the operating room were left less anxious and more satisfied.

Kain ZN, Mayes LC, Wang SM, Caramico LA, Hofstadter MB: Parental presence during induction of anaesthesia versus sedative premedication: which intervention is more effective?. Anesthesiology 89(5):1147-56, discussion 9A-10A, 1998 Nov..

BACKGROUND: Both midazolam and parental presence during induction of anesthesia are routinely used to treat preoperative anxiety in children. The purpose of this investigation was to determine which of these two interventions is more effective.

METHODS: Anxiety of the child during the perioperative period was the primary end point. Secondary end points included anxiety of the parent and compliance of the child during induction. Children (n = 88) were randomly assigned to one of three groups: (1) 0.5 mg/kg oral midazolam; (2) parental presence during induction of anesthesia; or (3) control (no parental presence or premedication). Using multiple behavioral measures of anxiety, the effect of the intervention on the children and their parents was assessed.

RESULTS: Observed anxiety in the holding area (T1), entrance to the operating room (T2), and introduction of the anesthesia mask (T3) differed significantly among the three groups (P = 0.032). Post hoc analysis indicated that children in the midazolam group exhibited significantly less anxiety compared with the children in the parental-presence group or control group (P = 0.0171). Similarly, parental anxiety scores after separation were significantly less in the midazolam group compared with the parental-presence or control groups (P = 0.048). The percentage of inductions in which compliance of the child was poor was significantly greater in the control group compared with the parental-presence and midazolam groups (25% vs. 17% vs. 0%, P = 0.013). CONCLUSIONS: Under the conditions of this study, oral midazolam is more effective than either parental presence or no intervention for managing a child's and parent's anxiety during the preoperative period.

Kain ZN, Ferris CA, Mayes LC, Rimar S: Parental presence during induction of anaesthesia: practice differences between the United States and Great Britain. Paediatr Anaesth 6:187-93, 1996.

In contrast to the U.S., parental presence is routinely accepted in Great Britain.

Kain ZN, Mayes LC, Caramico LA, et al: Parental presence during induction of anesthesia. A randomized controlled trial. Anesthesiology 84:1060-1067, 1996.

School-aged, calm children benefit the most from parental presence. This clinical trial showed no overall effect of parental presence on anxiety, however, children over 4 yr or those with a parent with low trait anxiety or who had a low baseline level of activity benefited from parental presence during induction.

Klopfenstein CE, Forster A, Van Gessel E: Anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety. Canadian Journal of Anaesthesia 47(6):511-5, 2000 Jun.

PURPOSE: Preoperative anxiety in relation to anesthesia remains for many patients a major subject of concern. The aim of the present study was to compare the level of preoperative anxiety in patients assessed in an outpatient consultation clinic with the anxiety level of those having been assessed by the anesthesiologist after entering the hospital.

METHOD: We studied two groups of 20 patients who underwent elective transurethral prostate or bladder resection: group A having the anesthetic assessment between one-two weeks before hospitalisation, group B having this assessment the evening before surgery, after entering the hospital. Two different methods to assess anxiety were used: the Multiple-Affect-Adjective-Check-List (MAACL) and the visual analogue scale of anxiety (VAS).

RESULTS: Both anxiety provided scores, assessed by two different methods, were lower in group A, than in group B(P<0.01).

CONCLUSION: The results of this study confirm that an anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety, when compared with an assessment on the evening before surgery.

Levine MF, Spahr-Schopfer IA, Hartley E, Lerman J, MacPherson B: Oral midazolam premedication in children: the minimum time interval for separation from parents. Can J Anaesth 40:726, 1993

With an oral dose of 0.5 mg/kg of midazolam, children can be effectively separated from their parents after 10 minutes.

Lichtor JL, Zacny JP, Coalson DW, et al: The interaction between alcohol and the residual effects of thiopental anesthesia. Anesthesiology. 79:28-35, 1993.

Twelve men received intravenous injections of either 5 mg/kg of 2.5% thiopental or an equal volume of saline for 30 s. Four hours after injection, the subjects consumed a beverage with or without 0.7 g/kg alcohol. Both thiopental and alcohol had strong independent effects on the dependent measures in this study. Body sway was greater, and lightheadedness more frequent after thiopental and alcohol than after alcohol alone.

Malviya S, Voepel-Lewis T, Huntington J, Siewert M, Green W: Effects of anesthetic technique on side effects associated with fentanyl Oralet premedication. Journal of Clinical Anesthesia 9(5):374-8, 1997 Aug.

STUDY OBJECTIVES: To evaluate the efficacy of 5 to 10 micrograms/kg of oral transmucosal fentanyl citrate (OTFC) as an anesthetic premedication, and to determine whether propofol induction reduces postoperative nausea and vomiting (PONV) in pediatric patients premedicated with OTFC undergoing outpatient surgery.

DESIGN : Prospective, randomized, double-blinded study.

SETTINGS: University of Michigan Health Care Systems and University of Arizona. PARTICIPANTS: 62 ASA physical status I and II children aged 4 to 14 years (8.9+/0.5 years). INTERVENTIONS: Subjects were randomly assigned to one of four groups: (1) OTFC premedication and halothane induction; (2) OTFC premedication and propofol induction; (3) placebo premedication and halothane induction; and (4) placebo premedication and propofol induction. OTFC or placebo was administered 30 minutes prior to induction, and activity (sedation), apprehension, and cooperation scores were recorded before, at 15 and 30 minutes after study drug, and on induction. All perioperative adverse events were recorded.

MEASUREMENTS AND MAIN RESULTS: Children who received OTFC became drowsier and had a significant change from baseline in combined activity, apprehension, and cooperation scores, whereas those who received placebo became less cooperative at induction. Patients who received OTFC experienced more adverse events overall (p < 0.001) than patients who received placebo. Additionally, OTFC patients experienced more vomiting (p < 0.001) and pruritus (p = 0.049) than controls. The incidence of PONV in patients who received OTFC and halothane induction was 50%, compared to 30% in patients receiving OTFC and a propofol induction (p = NS). CONCLUSIONS: OTFC in doses of 5 to 10 micrograms/kg was effective in producing sedation and facilitating cooperation with induction; however, it was associated with significant PONV in our study. Although propofol induction did not significantly reduce PONV in our study, further study with a larger sample, and with propofol as the sole anesthetic, may be warranted.

Maranets I, Kain ZN. Preoperative anxiety at intraoperative anesthetic requirements. Anesthesia & Analgesia 89(6):13246-1351, 1999 Dec.

This is a study done to determine whether anesthetic dose changes are required in the anxious patient. It was a study done in women undergoing bilateral laparoscopic tubal ligation. They found that a high baseline anxiety utilizing the Spielberger state/trait anxiety questionnaire increased intraoperative anesthetic requirements. The author suggested that the initial induction dose of anesthetic may need to be changed based on the anxiety level exhibited by the patient.

McGill WA, Hannallah RS: Parental presence during induction of anesthesia in children. Seminars in Anesthesia 11:259-264, 1992.

A good review.

McMillan CO, Spahr-Schopfer IA, Sikich N, Hartley E, Lerman J: Premedication of children with oral midazolam Can J Anaesth 39:545-550, 1992.

Eighty children received either midazolam 0.5, 0.75, 1.0 mg.kg^-1, or placebo 30 min before separation from parents. Sedation and anxiolysis did not differ among the three midazolam groups, and mean times to discharge from the hospital were similar for all four groups. Loss of balance and head control, blurred vision, and dysphoric reactions were observed only in the 0.75 and 1.0 mg. kg^-1 groups, and not in ch