IV. Anesthetic Management - TOP

A. What type of anesthetic is appropriate: general, regional, sedation or local? - TOP

Many considerations are involved in the choice among anesthetic methods: general anesthetic, block, or a block with sedation. Certainly, some procedures are possible only with a general anesthetic. For others the preference of patients, surgeons, or anesthesiologists may determine selection. Cost may be a factor: the cost of sedation is usually less than the cost of a general anesthetic.

Buckley N: Regional vs general anaesthesia in orthopaedics. Can J Anaesth 40:R104-R112, 1993

This is a review of regional and general anesthesia in the orthopedic patient population.

Chye EP, Young IG, Osborne GA, Rudkin GE: Outcomes after same-day oral surgery: a review of 1180 cases at a major teaching hospital. J Oral Maxillofac Surg 51:846, 1993

Of 1,180 ambulatory oral surgery patients, two-thirds of whom were treated with general anesthesia and the remainder with local anesthesia supplemented by intravenous sedation, the three patients who required admission on the day of surgery had undergone general anesthesia. The incidence of postoperative nausea and vomiting in the recovery room after local anesthesia and sedation was`6% compared to 14% after general anesthesia. Recovery times were also shorter after local anesthesia and sedation.

D'Alessio JG. Rosenblum M. Shea KP. Freitas DG: A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy. Regional Anesthesia. 20(1):62-8, 1995 Jan-Feb.

Repair of shoulder pathology to as outpatients: this study was designed to ascertain whether interscalene block is reliable and efficient compared with general anesthesia for shoulder arthroscopy. The authors retrospectively reviewed patients treated at the University of Connecticut over a 42-month period in the same-day surgery unit. Of 263 patients, 160 had a general anesthetic and 103 had an interscalene block. Compared to general anesthesia, regional anesthesia required significantly less total nonsurgical intraoperative time use (53 +/- 12 vs. 62 +/- 13 minutes, P = .0001) and also decreased postanesthesia care unit stay (72 +/- 24 vs. 102 +/- 40, P = .0001). Interscalene block anesthesia resulted in significantly fewer unplanned admissions for therapy of severe pain, sedation, or nausea/vomiting than general anesthesia (0 vs. 13, P = .004) and an acceptable failure rate (8.7%). Interscalene block should be considered as a viable alternative to general anesthesia for shoulder arthroscopy in ambulatory surgery patients.

Dahl JB, Schultz P, Anker-Møller E, Christensen EF, Staunstrup HG, Carlsson P: Spinal anaesthesia in young patients using a 29-gauge needle: technical considerations and an evaluation of postoperative complaints compared with general anaesthesia. Br J Anaesth 64:178, 1990

Backache was higher (26% ) after spinal anesthesia than general anesthesia (4%). However, incidence of sore throat (24%) and nausea (22%) was higher after general anesthesia than spinal anesthesia (6% for both).

Dexter F, Tinker JH: Analysis of strategies to decrease postanesthesia care unit costs. Anesthesiology 82:94, 1995.

Review of PACU times and charges for outpatient surgery implied that anesthetic choices had little effect on total PACU costs if staffing and admission times were not altered. Local and regional anesthetic techniques were associated with sooner discharges, and nausea and vomiting were significant factors in prolonging discharge after general anesthesia.

Fairclough JA, Graham GP, Pemberton D: Local or general anaesthetic in day case arthroscopy? Ann R Coll Surg Engl 72:104, 1990

In this study of 136 patients undergoing arthroscopy, intraarticular bleeding and onset time was less, and the success rate was much higher after general anesthesia than local anesthesia: 16/66 patients receiving local anesthesia had procedures that were either partially successful or unsatisfactory, whereas all procedures under general anesthesia were successful.

Fredman B, Zohar E, Philipov A, Olsfanger D, Shalev M, Jedeikin R: The induction, maintenance, and recovery characteristics of spinal versus general anesthesia in elderly patients. Journal of Clinical Anesthesia 10(8):623-30, 1998 Dec.

100 [ASA physical status I, II, and III] patients over 60 years of age undergoing brief transurethral surgery. In Groups Propofol-Propofol (P-P), Propofol-Isoflurane (P-I), and Propofol-Desflurane (P-D), anesthesia was induced with fentanyl (1 to 2 micrograms/kg i.v.) and propofol (1.0 to 2.0 mg/kg i.v.) and maintained with 70% nitrous oxide in oxygen and either a propofol infusion (75 to 150 micrograms/kg/min) or isoflurane (end-tidal 0.7% to 1.2%) or desflurane (end-tidal 1% to 4%), respectively. After induction, a laryngeal mask airway was placed and spontaneous ventilation was maintained. In Group Spinal (S), 1.5 ml 4% lidocaine (60 mg), in an equal volume of 10% dextrose, was administered intrathecally. Induction and recovery characteristics were compared. Induction with propofol was technically easier and significantly (medp < 0.0001) faster (4.6 +/- 1.7 min, 4.7 +/- 2.2 min, and 3.8 +/- 1.4 min for Groups P-P, P-I, and P-D, respectively) than induction of spinal anesthesia (9.3 +/- 3.4 min). During the induction period, mean arterial blood pressure and heart rate were significantly higher in Group S. Emergence, extubation, and orientation times were similar among the general anesthesia treatment groups. In Group S, patient-generated pain scores were lower (p < 0.05) and recovery room admission longer (p < 0.001). Time to return to baseline digit symbol substitution test (DSST) scores was marginally improved in Groups P-P and P-D when compared to Group P-I. Postoperative nausea, sleepiness, anxiety, and coordination were unaffected by the treatment modality. General anesthesia with propofol and desflurane facilitates shorter induction and recovery times without adversely affecting patient comfort. Therefore, this technique may be preferable to spinal anesthesia for elderly patients undergoing short transurethral surgical procedures.

Lintner S. Shawen S. Lohnes J. Levy A. Garrett W.Local anesthesia in outpatient knee arthroscopy: a comparison of efficacy and cost. Arthroscopy. 12(4):482-8, 1996 Aug.

Study compared the efficacy, cost-effectiveness, and safety of general, regional, and local anesthesia when performing outpatient knee arthroscopy. The study consisted of two portions. A retrospective review of 256 outpatient knee arthroscopies was performed. The types of anesthesia used were general endotracheal, regional (epidural or spinal), and local. Comparisons were made between operative procedure, anesthesia procedure time, need for supplemental anesthesia, recovery room time and cost, pharmaceutical cost, and complications. A prospective study consisted of 100 consecutive outpatient knee arthroscopies performed using local anesthesia. Data identical to the retrospective portion were obtained. Visual analog scales were used in a patient questionnaire completed at the first postoperative visit to assess patient satisfaction with local anesthesia. The retrospective data showed similar demographics and operative procedures performed in the three study groups. The difference between operative time and total anesthetic time for the local group was 35 minutes less than for regional, and 23 minutes less than for the general group. These differences were statistically significant (P < or = .05). Total pharmaceutical cost was significantly less for the local group (P < or = .05). Recovery room cost for the local anesthesia group averaged $134 compared with $450 for regional and $527 for general. This difference was significant (P < or = .05). There were 19 complications with general anesthesia, 16 with regional anesthesia, and 2 with local. There were two regional and two local cases that needed subsequent general anesthesia. The prospective data showed nearly identical time and cost data. The patient questionnaire showed nearly universal acceptance and satisfaction with the use of local anesthesia. The use of local anesthesia for outpatient knee arthroscopy is safe, effective, and well accepted. The use of local anesthesia was shown to save a minimum of $400 per case compared with the other anesthetic methods studied.

Meursing AE: Anaesthesia for day care surgery, patient selection, evaluation, preoperative preparation and selection of drugs. Acta Anaesthesiologica Belgica. 50(1):29-34, 1999.

Paediatric patients are a challenge to the anaesthetist because of their specific differences in behaviour, physiology, pharmacology, congenital anomalies and pathology. The number of day care paediatric patients show a steady increase. It is important that anticipated anaesthetic problems are solved or prevented by a good preoperative evaluation and preparation. Adequate psychological preparation and parental presence on induction and recovery have been shown to be a very good, if not the best premedication especially for toddlers. Relaxation of fluid restriction has led to more cooperation of the paediatric patient. Provided physicians, anaesthetists, surgeons and nurses share the same positive view on day care surgery, the facility will be greatly appreciated by both children and their parents.

Raeder JC: Propofol anaesthesia versus paracervical blockade with alfentanil and midazolam sedation for outpatient abortion. Acta Anaesthesiol Scand 36:31, 1992

In this study comparing regional anesthesia with sedation and general anesthesia, patients’ blood pressure and pulse rate tended to be higher with the former. During local block with sedation, patients had more perioperative complaints, although few recalled any discomfort, presumably because of amnesia caused by benzodiazepines. Time spent in the operating room was longer because more time was needed to institute the block than the general anesthetic; however time in the postanesthesia care unit was shorter, because patients were more alert and in less pain.

Richardson MG, Dooley J: The effects of general versus epidural anesthesia for outpatient extracorporeal shockwave lithotripsy. Anesthesia & Analgesia 86(6):1214-8, 1998 Jun.

Although many anesthetic techniques are described for immersion extracorporeal shockwave lithotripsy (ESWL), regional and i.v. techniques are the most commonly reported. This randomized, prospective study compared general anesthesia (GA) and epidural anesthesia (EPID) with regard to effectiveness, side effects, induction time, and recovery in patients undergoing ESWL using an unmodified Dornier HM-3 lithotriptor. Twenty-six healthy outpatients were randomized to GA (propofol, N₂O, laryngeal mask airway) or EPID (lidocaine 1.5% with epinephrine). Intraoperative and postoperative supplemental medications, side effects, and complications were noted. Induction times and times required to meet standard recovery criteria were compared between groups. Patients were surveyed regarding their satisfaction with anesthesia. All patients in the EPID group had effective blocks with a single catheter insertion and local anesthetic injection. In the GA group, the LMA was inserted successfully in all patients. Time from room entry to procedure start was significantly less in the GA group (23 +/- 11 vs 34 +/- 9 min; P < 0.05). Patients in the GA group were ready for discharge home earlier (127 +/- 59 vs 178 +/- 49 min; P < 0.05). Only three patients experienced nausea (one in the GA group, two in the EPID group). There were no differences in patient or urologist satisfaction with anesthesia. We conclude that GA is associated with a rapid recovery compared with EPID. Implications: General anesthesia with propofol, nitrous oxide, and a laryngeal mask airway is comparable to epidural anesthesia with lidocaine for outpatient extracorporeal shock wave lithotripsy procedures. However, early recovery is more rapid after general anesthesia compared with epidural anesthesia.

Tetzlaff JE, Yoon HJ, Brems J: Patient acceptance of interscalene block for shoulder surgery. Reg Anesth 18:30-33, 1993

Intrascalene block (ISB) for shoulder surgery was found to yield better recovery room pain scores, less nausea, and less vomiting than general anesthesia. Overall, the patients preferred ISB.

Van Sickels JE, Tiner BD: Cost of a genioplasty under deep intravenous sedation in a private office versus general anesthesia in an outpatient surgical center. J Oral Maxillofac Surg 50:687, 1992

Genioplasty under deep intravenous sedation in a private office was twice as expensive as general anesthesia in an outpatient surgical center.

Williams BA. Kentor ML. Williams JP. Vogt MT. DaPos SV. Harner CD:PACU bypass after outpatient knee surgery is associated with fewer unplanned hospital admissions but more phase II nursing interventions. Anesthesiology. 97(4):981-8, 2002 Oct.

Study reports recovery scoring system for outpatients receiving regional anesthesia (RA) or general anesthesia (GA). It was designed to allow qualifying patients to be directly routed to the phase II (step-down) recovery unit instead of the regular unit (PACU). Day-of-surgery outcomes were studied for 894 outpatients undergoing outpatient sports medicine surgery on the lower extremity. Eighty-seven percent (778/894) of all patients bypassed PACU. Of PACU-bypass patients, 241/778 (31%) required step-down nursing interventions. Of patients requiring PACU, only 19/116 (16%) required additional interventions in step-down (P < 0.001). PACU-bypass patients were almost three times more likely (odds ratio 2.9,P < 0.001) to require at least one nursing intervention in the step-down unit, when compared with patients requiring PACU. Fewer unplanned admissions were required by patients who bypassed PACU (odds ratio = 0.3,P = 0.007).

Williams BA . Kentor ML. Williams JP. Figallo CM. Sigl JC. Anders JW. Bear TC. Tullock WC. Bennett CH. Harner CD. Fu FH: Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology. 93(2):529-38, 2000 Aug. The performance of anesthetic procedures before operating room entry (e.g., with either general or regional anesthesia [RA] induction rooms) should decrease anesthesia-controlled time in the operating room. The authors retrospectively studied the associations between anesthesia techniques and anesthesia-controlled time, evaluating one surgeon performing a single procedure over a 3-yr period.: The authors queried an institutional database for 369 consecutive patients undergoing the same procedure (anterior cruciate ligament reconstruction) performed by one surgeon over a 3-yr period (July 1995 through June 1998). Throughout the period of study, anesthesia staffing consisted of an attending anesthesiologist medically directing two nurse anesthetists in two operating rooms. Anesthesia-controlled time values were compared based on anesthesia techniques (GA, RA, or GA-RA) using one-way analysis of variance, general linear modeling using time-series and seasonal adjustments, and chi-square tests when appropriate. P < 0. 05 was considered significant. RA was associated with the lowest anesthesia-controlled time (11.4 +/- 1.3 min, mean +/- 2 SEM). GA-RA (15.7 +/- 1.0 min) was associated with lower anesthesia-controlled time than GA used alone (20.3 +/- 1.2 min). When compared with GA without an induction room for outpatients undergoing anterior cruciate ligament reconstruction, RA with an induction room was associated with the lowest anesthesia-controlled time. Managers must weigh the costs and time required for anesthesiologists and additional personnel to place nerve blocks or induce GA preoperatively in such a staffing model.

Yeo SW, Tay D, Chong JL, Tan TK: General anaesthesia vs sedation for minor gynaecological procedures--a comparative study. Singapore Med J 34:395, 1993

The advantage of general anesthesia is shown for patients undergoing minor gynecological procedures. Oxygen saturation was normal in all of the patients receiving general anesthesia, whereas sedated patients had significant oxygen desaturation. Some of the sedated patients made excessive movements that interfered with surgery, and 6% of sedated patients were switched to a general anesthetic.

1. Pain - TOP

Control of pain before it is inflicted is useful for controlling pain in the early postoperative period. Non-steroidal antiinflamatory drugs, in particular, represent one of the most interesting additions to the anesthesiologist's armamentarium in recent years. Although ketorolac is popular, and is clearly superior to placebo, it seems to offer little advantage over opiates and is associated with a similar incidence of nausea and vomiting.

Aho M, Erkola O, Kallio A, Scheinin H, Korttila K: Comparison of dexmedetomidine and midazolam sedation and antagonism of dexmedetomidine with atipamezole. J Clin Anesth. 5:194-203, 1993.

Seventy-two healthy women scheduled for termination of pregnancy received either dexmedetomidine 2 µg/kg and atipamezole 50 µg/kg; dexmetomidine 2 µg/kg and saline; or midazolam 0.15 mg/kg and saline in addition to paracervical block. The mean time to regain consciousness was shorter in both the dexmedetomidine groups compared with the midazolam group. Postoperative sedation decreased more quickly in the dexmedetomidine-atipamezole group than in the other two groups.

Aho MS, Erkola OA, Scheinin H, et al: Effect of intravenously administered dexmedetomidine on pain after laparoscopic tubal ligation. Anesth Analg 73:112-118, 1991.

Dexmedetomidine, 0.2 or 0.4 mg/kg IV, relieved pain and reduced opioid drug requirement but was accompanied by sedation and a high incidence of bradycardia.

Alexander CD, Wetchler BV, Thompson RE: Bupivacaine infiltration of the mesosalpinx in ambulatory surgical laparoscopic tubal sterilization. Can J Anaesth 34:362-365, 1987.

One hundred women who underwent elective laparoscopic tubal ligation were randomly assigned to receive infiltration of the mesosalpinx with either lidocaine 1%, bupivacaine 0.5%, normal saline, or no injection. The group that received bupivacaine required significantly less fentanyl in the recovery room. Therefore, intraoperative infiltration with local anesthetics significantly reduces of postoperative pain.

Arain SR. Ebert TJ. The efficacy, side effects, and recovery characteristics of dexmedetomidine versus propofol when used for intraoperative sedation. Anesthesia & Analgesia. 95(2):461-6, 2002 Aug.

Forty patients scheduled for elective surgery provided informed consent and were randomized equally to receive either dexmedetomidine (1 microg/kg initial loading dose for 10 min; maintenance, 0.4-0.7 microg. kg(-1). h(-1)) or propofol (75 microg. kg(-1). min(-1) x 10 min; maintenance, 12.5-75 microg. kg(-1). min(-1)). Intraoperative sedation levels were targeted to achieve a bispectral index score of 70-80. Patient demographics, ASA class, surgical procedure, and baseline cardio-respiratory variables were similar between groups. Sedation was achieved more rapidly with propofol but was similar between groups 25 min after initiating infusions. The average infusion rate for dexmedetomidine was 0.7 microg. kg(-1). h(-1) and 38 microg. kg(-1). min(-1) for propofol. There were no differences between groups in psychomotor performance and respiratory rate during recovery. The previous use of dexmedetomidine resulted in more sedation, lower blood pressure, and improved analgesia (less morphine use) in recovery. Dexmedetomidine may be useful for perioperative sedation. It has a slower onset and offset of sedation compared with propofol. Dexmedetomidine was associated with improved analgesia and less morphine use in the postoperative period.

Bone ME, Dowson S, Smith G: A comparison of nalbuphine with fentanyl for postoperative pain relief following termination of pregnancy under day care anaesthesia. Anaesthesia 43:194-197, 1988.

Forty patients received either nalbuphine, 0.25 mg/kg, or fentanyl, 1.5 mg/kg, immediately before induction of anesthesia. Patients who received nalbuphine had lower pain scores and required significantly less postoperative analgesia. Nausea and observer assessment of appearance were similar. There was some evidence of psychomotor impairment at 2 hours in the nalbuphine group. Nalbuphine, unlike fentanyl, is not a controlled substance and thus, from a regulatory sense, may be easier to use.

Code WE, Yip RW, Rooney ME, Browne PM, Hertz T: Preoperative naproxen sodium reduces postoperative pain following arthroscopic knee surgery. Can J Anaesth 41:98-101, 1994.

A randomized, double-blind clinical trial of 66 patients scheduled for arthroscopic knee surgery compared patients treated with 550 mg of naproxen sodium, or placebo. Post-operative pain, both in hospital and after discharge, was reduced in the naproxen group, as was the use of analgesics after discharge (naproxen group 30.4% vs placebo 71.4%).

Comfort VK, Code WE, Rooney ME, Yip RW: Naproxen premedication reduces postoperative tubal ligation pain. Can J Anaesth 39(4):349-52, 1992.

Forty-four patients undergoing outpatient laparoscopic tubal ligations were treated with 550 mg of naproxen sodium or placebo. Pain scores were significantly lower in patients receiving naproxen, as were the requirement for postoperative opioids and time in the day surgery unit. There was no difference in the incidence of nausea and vomiting.

Ding Y, Fredman B, White PF: Use of ketorolac and fentanyl during outpatient gynecologic surgery. Anesth Analg 77:205-10, 1993.

One hundred nine patients received either fentanyl 50-100 ug, ketorolac 30-60 mg, or a combination of fentanyl 50-100 ug and ketorolac 30-60 mg IV. Anesthesia was induced with midazolam and propofol and maintained with propofol and N 20. Recovery times, postoperative side effects, pain scores, and postoperative analgesic and antiemetic requirements were similar in all treatment groups. However, the ketorolac group reported higher pain scores in the early postoperative period.

Ding Y, White PF: Comparative effects of ketorolac, dezocine, and fentanyl as adjuvants during outpatient anesthesia. Anesth Analg 75:566-71, 1992.

Ketorolac, dezocine, and fentanyl were compared in 136 patients undergoing outpatient laparoscopy. Less postoperative fentanyl was required in the ketorolac and dezocine groups. Of the patients receiving dezocine, 52% required anti-nausea therapy in the postanesthesia care unit, compared with 20% and 18% in the fentanyl and ketorolac groups, respectively. Recovery times were shorter in the ketorolac (vs dezocine) group; however, incidence of nausea and vomiting was similar in the ketorolac and fentanyl groups.

Iannarone C. Tellan G. Fegiz A. Levato C. Baumgartner I. Maselli AM. Fantera A. Analgesia and sedation with propofol-NSAIDs for day-hospital extracorporeal shock wave lithotripsy. European Review for Medical & Pharmacological Sciences. 1(6):203-6, 1997 Nov-Dec.

The authors report the results obtained with a technique of analgesia and sedation. The drugs employed are two NSAIDs, keto-prophene and ketorolac tromethamine associated with propofol. The main advantages consist in the limited cardiovascular and respiratory depression, typical of the first minutes of administration of propofol and the rapid return of a complete functional autonomy in relative brief time intervals, with possibility of dismissing the patient after 4 hours from the end of treatment.

Jaakola ML: Dexmedetomidine premedication before intravenous regional anesthesia in minor outpatient hand surgery. J Clin Anesth 6:204-11, 1994.

Thirty healthy outpatients scheduled for minor hand surgery with i.v. regional anesthesia received either dexmedetomidine 1 ug/kg i.v. or saline 10 min before inflation of a tourniquet. Pain during tourniquet inflation was similar in both groups, but fewer intraoperative analgesics were needed in the dexmedetomidine group. Dexmedetomidine also reduced sympathoadrenal responses.

Klein SM. Buckenmaier CC. Ambulatory surgery with long acting regional anesthesia. Minerva Anestesiologica. 68(11):833-41; 841-7, 2002 Nov

Ambulatory surgery has grown dramatically in the past 3 decades; however, advances in postoperative pain treatment have not kept pace with the proliferation of outpatient procedures. Two techniques that may offer a solution to part of this problem are long acting peripheral nerve blocks (PNB) and outpatient continuous peripheral nerve blocks (CPNB), but the safety of sending patients home with blocked extremities has also remained controversial. Prospectively studied 2,382 long-acting PNB with ropivacaine in both the upper and lower extremity noting a low incidence of block failure, rare use of opioids in the recovery unit and high patient satisfaction. This study also demonstrated a low incidence of accidental injury to the blocked extremity and a rare block complication rate after discharge (0.2%). Only 1 patient in this data set fell while exiting a car. Patients in our study appeared to uniformly protect themselves from further injury despite having a blocked extremity.

Langer JC, Shandling B, Rosenberg M: Intraoperative bupivacaine during outpatient hernia repair in children: A randomized double blind trial. J Pediatr Surg 22:267-270, 1987.

The efficacy of intraoperative infiltration of the ilioinguinal and iliohypogastric nerves with bupivacaine 0.5% containing epinephrine 1:200,000 was compared with saline. Bupivacaine infiltration decreased postoperative analgesic requirements (both for narcotics and for acetaminophen). In addition, the level of activity of children in the bupivacaine treatment group was higher at all but one time interval. The authors concluded that this or a similar technique should be used routinely in children undergoing herniorrhaphy.

Londergan TA, Hochman HI, Goldberger N: Postoperative pain following outpatient pediatric urologic surgery: a comparison of anesthetic techniques. Urology 44:572-6, 1994.

Seventy-seven boys undergoing outpatient urologic surgery received either general anesthesia alone, general anesthesia + caudal nerve block, or general anesthesia + local nerve block. Both caudal and local groups had lower pain scores and medication requirements than controls in the immediate postoperative period. The caudal group also had lower pain scores than the local group at 24 hours and than control at 1 week postoperatively. This article supports the use of caudal block and the efficacy of preemptive analgesia.

Lysak SZ, Anderson PT, Carithers RA, DeVane GG, Smith ML, Bates GW: Postoperative effects of fentanyl, ketorolac, and piroxicam as analgesics for outpatient laparoscopic procedures. Obstet Gynecol 83(2):270-5, 1994.

Intramuscular ketorolac was associated with shorter recovery room stays while providing analgesia equal to intravenous fentanyl or the oral nonsteroidal anti-inflammatory drug piroxicam. The incidence of side effects did not differ between groups.

McHugh GA. Thoms GM. The management of pain following day-case surgery. Anaesthesia. 57(3):270-5, 2002 Mar.

Study assessed patients' experience of pain management following day surgery. One hundred and two patients agreed to take part in a telephone survey, 2 and 4 days following day surgery. The majority of patients (73%) were broadly satisfied with the quality of pain management they received, however, there was room for improvement. Despite modern anaesthesia and surgery, 17% of patients surveyed reported having severe pain immediately following day-case surgery. The majority (82%) of patients left the day-case ward in pain and an even higher proportion (88%) had pain at some time between 2 and 4 days postoperatively. Severe levels of pain following discharge from hospital were a concern for 21% of patients. It was reported that day-case staff did not always ask patients whether they were in pain. Communication with patients is vital in the delivery of optimal care.

McLoughlin C, McKinney MS, Fee JP, Boules Z: Diclofenac for day-care arthroscopy surgery: Comparison with a standard opioid therapy. Br J Anaesth 65:620-623, 1990.

Diclofenac is a nonsteroidal anti-inflammatory drug. Patients undergoing arthroscopy received diclofenac, fentanyl, or no analgesic during the course of anesthesia. Diclofenac was effective in reducing postoperative pain, and it also was not accompanied by as much drowsiness as was fentanyl.

Michaloliakou C. Chung F. Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesthesia & Analgesia. 82(1):44-51, 1996 Jan. Patients were randomized to a treatment (n = 24) or control (n = 25) group and studied using a prospective, double-blind design. Preoperatively, at 45 min before induction of anesthesia, the treatment group received an intramuscular (IM) bolus injection of meperidine 0.6 mg/kg and ketorolac 0.5 mg/kg. The control group received two bolus IM injections of placebo (normal saline). Ten minutes before incision, local anesthesia (treatment group) or saline (control group) was infiltrated into the skin of each patient. Anesthetic management, postoperative pain, and nausea treatment were standardized. Pain and nausea assessment were done 1 h preoperatively, 0, 0.5, 1, 2, 3, and 4 h postoperatively, at discharge, and 10, 24, and 48 h postoperatively. Patients were discharged by scoring criteria. Postoperatively, significantly more patients in the treatment group were without pain on arrival in the postanesthesia care unit (PACU), 12/21 (57.1%) vs 1/24 (4.2%) in the control group (P < 0.001). Similarly, the severity of pain was sixfold less in the treatment group than in the control group. The incidence of nausea in the PACU was significantly less in the treatment group; 4.7% vs 29.5% in the control group (P < 0.05). Patients from the treatment group satisfied Postanesthesia Discharge Score significantly earlier than those in the control group (281 +/- 12 min vs 375 +/- 19 min; P < 005). The concomitant use of local anesthetic and nonsteroidal antiinflammatory and opioid drugs proved to be highly effective in patients, resulting in faster recovery and discharge.

Monagle J, Wongprasartsuk P, Shearer W: Ketorolac versus fentanyl for gynecological day-case surgery. Aust N Z J Obstet Gynaecol 33:430-2, 1993.

The incidence of nausea and vomiting was similar in patients receiving ketorolac 30 mg or fentanyl 1 µg/kg.

Morley-Forster P, Newton PT, Cook MJ: Ketorolac and indomethacin are equally efficacious for the relief of minor postoperative pain. Can J Anaesth 40:1126-30, 1993.

Ninety women undergoing outpatient gynecological or breast surgery received either 30 mg IM ketorolac, 100 mg indomethacin per rectum, or placebo. The placebo group required more fentanyl in the PACU and had less pain relief than either of the NSAID-treated groups. However, no differences were observed between the two NSAIDs.

Munro HM. Malviya S. Lauder GR. Voepel-Lewis T. Tait AR. Pain relief in children following outpatient surgery.Journal of Clinical Anesthesia. 11(3):187-91, 1999 May.

To evaluate perioperative analgesia, prescription patterns, pain relief, and parental care of children undergoing outpatient surgery. Prospective data collection and parental interview. 471 children aged between 10 months and 18 years who underwent an outpatient surgical procedure expected to be associated with pain. Parents were telephoned 24 hours following surgery, and data concerning their child's pain relief, analgesic and antiemetic usage, and their ability to care for their child were obtained. Of the 460 patients questioned, 97% were described by their parents as having adequate, good, or very good pain relief (acceptable) during the first 24 hours postoperatively, whereas only 15 (3%) had poor pain relief (unacceptable). All patients received some form of analgesia intraoperatively. The children with poor pain relief were more likely to have experienced postoperative nausea and vomiting (p = 0.01) and were more difficult to care for at home (p < 0.0001). In a subset of 185 patients who had genitourinary procedures, those who received regional analgesia reported better pain relief (p = 0.05).

O'Hanlon JJ, Muldoon T, Lowry D: Improved postoperative analgesia with preoperative piroxicam. Can J Anaesth 43:102-5, 1996.

Patients in this study received either 20 mg piroxicam, a non-steroidal anti-inflammatory drug or a placebo 2 hrs preoperatively, immediately before induction or one hour postoperatively. The group receiving the treatment drug 2 hours preoperatively had lower pain scores on admission to PACU, requested pain medication later than the other two treatment groups and requested less pain medication later. The true value of this study relates to the timing of pre-emptive analgesia.

Peden CJ. Cloote AH. Stratford N. Prys-Roberts C. The effect of intravenous dexmedetomidine premedication on the dose requirement of propofol to induce loss of consciousness in patients receiving alfentanil. Anaesthesia. 56(5):408-13, 2001 May.

Dexmedetomidine reduces the dose requirements for opioids and anaesthetic agents. Study-single-centre, open-label, noncomparative phase II study of the effect of intravenous dexmedetomidine on the dose requirement of propofol to induce loss of consciousness in 49 ASA I and II patients. The initial dexmedetomidine infusion scheme was reduced twice because of adverse events. Forty patients who received the final infusion scheme were randomly allocated to receive one of five stepped propofol infusions; loss of consciousness was assessed after 21 min. The ED50 for the final infusion rate of propofol to suppress consciousness was 3.45 mg x kg(-1) x h(-1) (95% CL 2.7-4.2): ED95 was 6.68 mg x kg(-1) x h(-1) (95% CL 5.1-19.1), EC50 was 1.69 microg x ml(-1) (95% CL 0.95-2.5) and EC95 was 5.7 microg x ml(-1) (95% CL 3.2 to > 10). Our final dose of dexmedetomidine of 0.63 microg x kg(-1) caused a reduction in the overall concentration and dose of propofol required to produce loss of consciousness, but no significant shift in the dose-response curve compared with other studies.

Rosenblum M, Weller RS, Conard PL, Falvey EA, Gross JB: Ibuprofen provides longer lasting analgesia than fentanyl after laparoscopic surgery. Anesth Analg 73:255-259, 1991.

In this randomized, double-blind study, the analgesic efficacy of fentanyl, 75 µg IV given 30 minutes before the end of surgery was compared with ibuprofen 800 mg given PO 1 hour preoperatively. Although the postoperative narcotic requirement was the same in both groups, pain scores were lower in the same-day surgery unit and at home for the patients who received ibuprofen. In addition, patients in the ibuprofen group had lower nausea scores in the same-day surgery unit. The authors concluded that preoperative oral ibuprofen produced longer lasting analgesia than fentanyl.

Sinclair R, Cassuto J, Hogstrom S, et al: Topical anesthesia with lidocaine aerosol in the control of postoperative pain. Anesthesiology 68:895-901, 1988.

This study compared the postoperative analgesic effects of lidocaine spray, a non-lidocaine-containing spray, and a no treatment control in patients undergoing elective inguinal herniorrhaphy. The spray was applied before the wound was closed. The lidocaine spray was very effective in reducing postoperative pain as well as in preventing postoperative elevations in beta-endorphin levels. In addition, no effects on wound healing were demonstrated. The study nicely demonstrated the effectiveness of a noninvasive analgesic technique that produces what appears to be a similar effect on the beta-endorphin system as regional anesthesia.

Singelyn FJ. Gouverneur JM. Robert A. A minimum dose of clonidine added to mepivacaine prolongs the duration of anesthesia and analgesia after axillary brachial plexus block. Anesthesia & Analgesia. 83(5):1046-50, 1996 Nov.

This study assessed the minimum dose of clonidine required to prolong the duration of both anesthesia and analgesia after axillary brachial plexus blockade. Eighty patients scheduled for elective hand surgery were divided into eight groups in a randomized, double-blind fashion. An axillary brachial plexus block was performed with 40 mL 1% mepivacaine plus 1:200,000 epinephrine. The control group received no clonidine. In the other groups, increasing doses of clonidine (0.1, 0.2, 0.3, 0.4, 0.5, 1, and 1.5 micrograms/kg) were added to the local anesthetic solution. The eight groups were comparable in terms of onset time, postoperative pain score, and analgesic requirement. The minimum dose of clonidine required to significantly prolong the duration of analgesia and anesthesia was, respectively, 0.1 and 0.5 microgram/kg. No side effects (sedation, drowsiness, bradycardia, arterial hypotension) were reported.

Smith I, Van Hemelrijck J, White PF, Shively R: Effects of local anesthesia on recovery after outpatient arthroscopy. Anesth Analg 73:536-539, 1991.

Previous studies of the use of intra-articular bupivacaine were unable to demonstrate any clear benefit from this technique for the control of postoperative pain. In this double-blind, randomized trial the authors showed narcotic requirement decreased in patients who received intra-articular bupivacaine 0.5% (30 ml), as compared to a control group that received 30 ml of intra-articular saline. In addition, patients receiving bupivacaine were ambulatory, home-ready, and discharged sooner than patients who received saline. However, visual analogue pain scores were not different between the groups.

Suzuki M. Tsueda K. Lansing PS. Tolan MM. Fuhrman TM. Ignacio CI. Sh eppard RA. Small-dose ketamine enhances morphine-induced analgesia after outpatient surgery. Anesthesia & Analgesia. 89(1):98-103, 1999 Jul.

Studied the effect of IV coadministration of small-dose ketamine 50-100 microg/kg with morphine 50 microg/kg on postoperative morphine requirements and pain in 140 patients undergoing outpatient surgery. Midazolam 1-2 mg was administered in the holding area. Anesthesia was induced with propofol 2-2.5 mg/kg and was maintained with desflurane in a nitrous oxide/oxygen mixture. Patients received morphine 50 microg/kg with placebo (Group 1, n = 35) or ketamine 50 microg/kg IV (Group 2, n = 35), 75 microg/kg IV (Group 3, n = 35), or 100 microg/kg IV (Group 4, n = 35) 15 min before the end of the operation. Pain and drowsiness were assessed using visual analog scales on arrival in the recovery room, then every 15 min until the time of discharge to phase 2 recovery (phase 1 recovery). Morphine consumption in Groups 3 and 4 was approximately 40% less than that in the control group (91+/-9 and 89+/-8 microg/kg vs. 145+/-9 microg/kg; P<0.05 for both). Pain scores in Groups 3 and 4 were approximately 35% less than those in the control group at all time periods (P<0.0001 for all). There was no significant group difference in drowsiness scores. Small-dose ketamine 75-100 microg/kg IV, enhanced morphine-induced analgesia after outpatient surgery. Simultaneous use of small doses of ketamine with morphine enhances the pain relief produced by morphine. IMPLICATIONS: Simultaneous use of small doses of ketamine with morphine enhances the pain relief produced by morphine.

Tobias JD. Berkenbosch JW. Initial experience with dexmedetomidine in paediatric-aged patients. Paediatric Anaesthesia. 12(2):171-5, 2002 Feb.

Dexmedetomidine in paediatric-aged patients. Dexmedetomidine provided effective sedation during mechanical ventilation and was an effective agent for controlled hypotension during anterior spinal fusion. When considering the preliminary data combined with adult trials, recommend doses of 0.25-0.75 g·kg 1·h 1. The higher end of the dosing regimen may be required to achieve controlled hypotension. In one patient, authors found dexmedetomidine to be ineffective as the sole agent for sedation during an invasive procedure. Larger clinical trials in various scenarios are needed to delineate its role in paediatric anaesthesia and critical care. The information from adult trials and authors preliminary data suggest that its adverse effect profile includes a limited incidence of bradycardia and hypotension which is easily corrected with discontinuation of the infusion. An issue that must be considered when evaluating the potential role of dexmedetomidine is its cost. In our area, current acquisition costs vary from $100 to $200 for the 2 ml (200 g) vial.

van EE R, Hemrika DJ, van der Linden CT: Pain relief following day-case diagnostic hysteroscopy-laparoscopy for infertility: a double-blind randomized trial with preoperative naproxen versus placebo. Obstet Gynecol 82:951-4, 1993.

Sixty healthy women scheduled for day-case hysteroscopy and laparoscopy received either 500 mg naproxen suppositories or placebo preoperatively. Patients premedicated with naproxen had significantly less postoperative pain, showed more rapid ambulation, could be discharged earlier, and had less post-discharge pain.

Wood GJ, Lloyd JW, Bullingham RES, Britton BJ, Finch DRA. Postoperative analgesia for day-case herniorrhaphy patients: A comparison of cryoanalgesia, paravertebral blockade and oral analgesia. Anaesthesia 36:603-610, 1981.

This study is interesting for a number of reasons. First, from a reading of the article it is clear that at the time of its publication outpatient surgery was not widely accepted in the United Kingdom. Second, this study evaluates the efficacy of cryoanalgesia and compares itwith the efficacy of paravertebral block and oral analgesia for the relief of postoperative pain. The authors found cryoanalgesia to be very effective, reducing the postoperative analgesic requirement and improving patient well-being (increased appetite, increased activity). A paravertebral block did many of the same things, but was not as effective as cryoanalgesia. The positive effects of both cryoanalgesia and paravertebral block lasted throughout the study period (up to postoperative day 4). The authors concluded that cryoanalgesia should be considered a safe, effective technique for postoperative analgesia.

a. Arthroscopy - TOP

Both intra-articular bupivacaine and opiates reduce postoperative pain following arthroscopy. Bupivacaine seems superior to morphine, and the addition of morphine to bupivicaine offers little advantage.

Brandsson S. Karlsson J. Morberg P. Rydgren B. Eriksson BI. Hedner T. Intraarticular morphine after arthroscopic ACL reconstruction: a double-blind placebo-controlled study of 40 patients. Acta Orthopaedica Scandinavica. 71(3):280-5, 2000 Jun.

In a double-blind placebo-controlled study, 40 patients were randomly allocated to one of four treatment groups. Group I received 1 mg morphine intraarticularly and saline intravenously; group II received 5 mg morphine intraarticularly and saline intravenously; group III received 5 mg saline intraarticularly and morphine intravenously and group IV, the control group, received saline both intraarticularly and intravenously. The pain scores were significantly lower in groups I and II at 24 hours postoperatively than in group IV, and in group II during the rest of the postoperative period, as compared to groups III and IV. After intraarticular injection of 1 mg and 5 mg morphine, respectively, low concentrations of morphine-6-glucuronide (M6G) were found in the circulation, while morphine-3-glucuronide (M3G) appeared late after the injection in concentrations that considerably exceeded those of morphine in groups I and II. The analgesic effect of intraarticular morphine together with the low levels of morphine and morphine-6-glucuronide in plasma further strengthens the view that opioids have a peripheral mechanism of action.

Laurent SC, Nolan JP, Pozo JL, Jones CJ: Addition of morphine to intra-articular bupivacaine does not improve analgesia after day-case arthroscopy. Br J Anaesth 72:170-3, 1994.

Patients undergoing arthroscopy received either 2 mg or 5 mg of morphine added to 40 ml of 0.25% bupivacaine administered by intra-articular injection at the end of the operation. Preoperative and postoperative pain scores, consumption of additional analgesia, and time to first analgesia were similar between the groups.

McLoughlin C, McKinney MS, Fee JP, Boules Z: Diclofenac for day-care arthroscopy surgery: Comparison with a standard opioid therapy. Br J Anaesth 65:620-623, 1990.

Diclofenac is a nonsteroidal anti-inflammatory drug. Patients under-going arthroscopy received diclofenac, fentanyl, or no analgesic during the course of anesthesia. Diclofenac was effective in reducing postoperative pain, and it also was not accompanied by as much drowsiness as was fentanyl.

Mulroy MF. Larkin KL. Batra MS. Hodgson PS. Owens BD. Femoral nerve block with 0.25% or 0.5% bupivacaine improves postoperative analgesia following outpatient arthroscopic anterior cruciate ligament repair. Regional Anesthesia & Pain Medicine. 26(1):24-9, 2001 Jan-Feb. Prospectively randomized patients to receive, in a blinded fashion, either a sham block, a femoral nerve block with 25 mL 0.25% bupivacaine, or with 25 mL 0.5% bupivacaine after anterior cruciate ligament repair under epidural anesthesia. In the sham block group, 6 of 12 patients reported inadequate analgesia in the postanesthesia care unit (4 at 20 minutes, 2 at 40 minutes; greater than other groups, P <.003) and were excluded from further study. Patients with sham blocks had higher pain scores 20 minutes after the block, and requested intravenous analgesia more often. Bupivacaine 0.25% and 0.5% provided 23.2 +/- 7 and 25.7 +/- 11 hours of analgesia, respectively.

Peng P. Claxton A. Chung F. Chan V. Miniaci A. Krishnathas A. Femoral nerve block and ketorolac in patients undergoing anterior cruciate ligament reconstruction. Canadian Journal of Anaesthesia. 46(10):919-24, 1999 Oct.

Prior to standard general anesthesia, 90 patients were randomized into three groups of preoperative treatment: 1) femoral nerve block (15 mL bupivacaine 0.5%) and 1 mL normal saline i.v. (FNB group); 2) placebo femoral nerve block (15 mL normal saline) and 30 mg (1 mL) ketorolac i.v. (KT group); 3) placebo femoral nerve block (15 mL normal saline) and 1 mL normal saline i.v. (PL group). Morphine consumption within one hour, three hours and until POD 1 in the FNB group was lower than the PL group (7 +/- 6, 11 +/- 9, 27 +/- 23 mg vs 13 +/- 5, 20 +/- 9, 49 +/- 28 mg respectively), whereas only that within one hour in the KT group was lower than the PL group. Pain score was lower in FNB and KT groups in the first postoperative hour than in the PL group (P < 0.05). There were no differences among the three groups in the times to meet recovery milestone and discharge criteria.

Raja SN, Dickstein RE, Johnson CA: Comparison of postoperative analgesic effects of intra-articular bupivacaine and morphine following arthroscopic knee surgery. Anesthesiology. 77:1143-7, 1992.

Postoperative pain scores and opioid requirements were compared among 47 patients receiving 20 ml of intra-articular normal saline with epinephrine; 0.25% bupivacaine with epinephrine; or 3 mg morphine sulfate in normal saline with epinephrine. Intra-articular bupivacaine provided significantly better analgesia than did saline or morphine in the first 2 hrs postoperatively.

Rautoma P. Santanen U. Avela R. Luurila H. Perhoniemi V. Erkola O. Diclofenac premedication but not intra-articular ropivacaine alleviates pain following day-case knee arthroscopy. Canadian Journal of Anaesthesia. 47(3):220-4, 2000 Mar.

In a randomized, double-blind investigation, 200 ASA physical status 1-2 outpatients, age 18-60 yr,had arthroscopy with spinal anesthesia and received either 50 mg diclofenac p.o. or placebo one hour before operation (100 patients per group), and intraarticular injections of either 20 ml of ropivacaine 0.5% or 20 ml of saline 0.9% (50 patients in each premedication groups). Patients received 50 mg diclofenac p.o. prn and, if needed, 0.1 mg x kg(-1) oxycodone im for postoperative pain relief. Patients were discharged home with a supply of 50 mg diclofenac tablets and were given a sheet of paper with knee pain VAS scales and a questionnaire of analgesics taken. Patients rated their VAS scores eight hours after surgery and in the morning and at the end of the first and the second postoperative days, respectively. The only statistically significant difference was found when the diclofenac groups were combined and compared with the combined placebo premedication groups. The VAS scores of knee pain at eight hours after the operation were 19+/-22 in the two diclofenac premedication groups and 32+/-28 in the two placebo groups (P = 0.001). CONCLUSIONS: Diclofenac premedication p.o. reduced the VAS scores at eight hours postoperatively while intra-articular ropivacaine did not.

Reuben SS. Connelly NR. Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular clonidine. Anesthesia & Analgesia. 88(4):729-33, 1999 Apr.

Intraarticular (i.a.) local anesthetics are often used for the management and prevention of pain after arthroscopic knee surgery. Clonidine prolongs the duration of local anesthetics. Fifty patients were randomly assigned to one of five groups that received clonidine (either via the subcutaneous or i.a. route) or saline placebo with or without i.a. bupivacaine, as follows: Group 1 received 30 mL of 0.25% bupivacaine i.a.; Group 2 received 30 mL of 0.25% bupivacaine with clonidine (1 microg/kg) i.a.; Group 3 received 30 mL of 0.25% bupivacaine i.a. and subcutaneous clonidine (1 microg/kg); Group 4 received 30 mL of 0.25% bupivacaine with epinephrine (5 microg/mL) i.a.; and Group 5 received clonidine (1 microg/kg) in 30 mL of saline i.a.. The results of this study revealed a significant difference in analgesia from the i.a. administration of clonidine. The group who received a combination of i.a. bupivacaine and clonidine had a significantly decreased need for oral postoperative analgesics and an increased analgesic duration (P < 0.0001). We conclude that i.a. clonidine improved comfort in patients undergoing knee arthroscopy. Implications: The intraarticular administration of clonidine along with bupivacaine results in a significant improvement in analgesia compared with either drug alone. There was an increased time to first analgesic request and a decreased need for postoperative analgesics.

Smith I, Shively RA, White PF: Effects of ketorolac and bupivacaine on recovery after outpatient arthroscopy. Anesth Analg 75:208-12, 1992.

Sixty patients undergoing knee arthroscopy received 2 ml of either ketorolac (60 mg) or saline. On completion of surgery, the patient's knee joint was injected with 30 ml of either 0.5% bupivicaine or saline. No differences were observed among the three treatment groups in postoperative pain, nausea, or sedation. Ketorolac alone or with bupivicaine offered no advantage over bupivicaine alone with respect to recovery time.

Smith I, Van Hemelrijck J, White PF, Shively R: Effects of local anesthesia on recovery after outpatient arthroscopy. Anesth Analg 73:536-539, 1991.

Intra-articular bupivacaine 0.5% (30 ml) reduced narcotic usage more than did control, 30 ml of intra-articular saline. Patients receiving bupivacaine were also ambulatory, home-ready, and discharged sooner than patients who received saline. However, visual analogue pain scores were not different between the groups.

Wong HY, Carpenter RL, Kopacz DJ, Fragen RJ: A randomized, double-blind evaluation of ketorolac tromethamine for postoperative analgesia in ambulatory surgery patients. Anesthesiology 78:6-14, 1993.

A group of 221 patients received either 30 mg ketorolac iv twice followed by 10 mg every 10 min as needed for pain and 10 mg oral ketorolac every 4-6 h; or 50 ug of IV fentanyl according to the same regimen followed by 60 mg codeine plus 600 mg oral acetaminophen every 4-6 h; or 10 µg of fentanyl per dose instead of 50 µg/as above. Ketorolac 30 mg iv provided delayed but equivalent analgesia when compared with 50 µg fentanyl IV, and side effects were similar. Thus, ketorolac offered little benefit over fentanyl.

b. Laparoscopy - TOP

Alexander CD, Wetchler BV, Thompson RE: Bupivacaine infiltration of the mesosalpinx in ambulatory surgical laparoscopic tubal sterilization. Can J Anaesth 34:362-365, 1987.

One hundred women who underwent elective laparoscopic tubal ligation were randomly assigned to receive infiltration of the mesosalpinx with either lidocaine 1%, bupivacaine 0.5%, normal saline, or no injection. The group that received bupivacaine required significantly less fentanyl in the recovery room.

Michaloliakou C, Chung F, Sharma S: Pre-operative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 82:44-51, 1996.

In this study the treatment patients received IM meperidine and ketoralac 45 minutes before induction of anesthesia for laparoscopic cholecystectomy. The treatment group also received skin infiltration with local anesthesia 10 minutes before incision. The control group received saline both IM and infiltration. Anesthetic management and postoperative treatment was the same for both groups. The treatment group had less pain on arrival to the PACU, less severe pain and less nausea. Discharge criteria was met much earlier by the treatment group.

Putland AJ. McCluskey A. The analgesic efficacy of tramadol versus ketorolac in day-case laparoscopic sterilisation. Anaesthesia. 54(4):382-5, 1999 Apr.

Prospective, randomised, double-blind study to compare the analgesic efficacy of intravenous tramadol 1.5 mg.kg-1 and ketorolac 10 mg in 60 ASA grade 1 and 2 patients scheduled to undergo day-case laparoscopic sterilisation by application of Filshie clips. Patients who received tramadol had significantly less postoperative pain in the recovery room (p = 0.007) and at discharge from the day-surgery unit (p = 0.03), and they required rescue analgesia with morphine less often (p = 0.02) than patients who received ketorolac. No difference in either the incidence or severity of nausea and vomiting was observed between the two groups. Both analgesic drugs were well tolerated at the doses given in the study, although dry mouth was significantly more common after the administration of tramadol (p = 0.009). Three patients in the tramadol group and five in the ketorolac group required overnight admission due to pain or nausea and vomiting.

Rosenblum M, Weller RS, Conard PL, Falvey EA, Gross JB: Ibuprofen provides longer lasting analgesia than fentanyl after laparoscopic surgery. Anesth Analg 73:255-259, 1991.

This randomized, double-blind study compared the analgesic efficacy of fentanyl, 75 µg IV given 30 minutes before the end of surgery, with ibuprofen 800 mg given orally 1 hour preoperatively. Although the postoperative narcotic requirement was the same in both groups, patient who received ibuprofen had lower pain scores and less nausea in the same-day surgery unit and lower pain scores and lower pain scores at home. The authors concluded that preoperative oral ibuprofen produced longer lasting analgesia than fentanyl.

Salman MA. Yucebas ME. Coskun F. Aypar U. Day-case laparoscopy: a comparison of prophylactic opioid, NSAID or local anesthesia for postoperative analgesia. Acta Anaesthesiologica Scandinavica. 44(5):536-42, 2000 May.

Study evaluated the analgesic efficacy, postoperative comfort, recovery characteristics and side effects of three different analgesic agents administered prophylactically.Eighty patients undergoing day-case minor operative laparoscopy were randomly allocated into four groups to receive tenoxicam 20 mg i.v. (Group T), fentanyl 100 microg i.v. (Group F), 5 ml of bupivacaine 2.5 mg/ml for infiltration of trocar sites (Group B), 30, 10 and 5 min before incision respectively. Bupivacaine, 35 ml, 2.5 mg/ml was also administered into the pelvic cavity in Group B. Group P received only placebo. Postoperative pain scores were lower and time to requirement of rescue analgesics was longer in groups F and B compared to Group P. In the PACU, analgesic requirements were lower in Group B, compared to Group P. Nausea and vomiting were increased in Group F.CONCLUSION: Tenoxicam 20 mg i.v. was found to be ineffective whereas bupivacaine was superior to other groups in reducing pain and analgesic requirements. Bupivacaine also increased time to first analgesics and obtained better recovery characteristics, underlining its value in prophylactic pain management compared to the other two agents.

Wheatley SA, Millar JM, Jadad AR: Reduction of pain after laparoscopic sterilization with local bupivacaine: a randomized, parallel, double-blind trial. Br J Obstet Gynaecol 101:443-6, 1994.

Sixty women presenting for day-case laparoscopic sterilization were treated with 10 ml of bupivacaine 0.5% or normal saline applied to the fallopian tubes under direct vision. In the bupivacaine group, time to first analgesia was significantly longer, and fewer patients requested escape analgesia before the 1 h assessment. By the time of discharge, no differences were observed between the groups.

c. Herniorrhaphy - TOP

Klein SM. Greengrass RA. Weltz, C. Warner DS. Paravertebral somatic nerve block for outpatient inguinal herniorrhaphy: an expanded case report of 22 patients. Regional Anesthesia & Pain Medicine. 23(3):306-10, 1998 May-Jun.

Twenty-two patients received a PSNB at T10 to L2 using 5 mL of 0.5% bupivacaine with epinephrine 1:400,000 at each of the five levels. Surgical anesthesia occurred 15-30 minutes after injection. Two patients had a failed block. The mean +/- SD time to onset of discomfort was 14 +/- 11 hours. Time until first narcotic requirement was 22 +/- 18 hours. Thirteen patients (n = 20) had no incisional discomfort 10 hours or longer after their blocks. Three patients had epidural spread. Most patients were very satisfied with their anesthetic technique.

Langer JC, Shandling B, Rosenberg M: Intraoperative bupivacaine during outpatient hernia repair in children: A randomized double blind trial. J Pediatr Surg 22:267-270, 1987.

Intraoperative infiltration of the ilioinguinal and iliohypogastric nerves with bupivacaine 0.5%, containing epinephrine 1:200,000 was compared with saline. Bupivacaine infiltration decreased postoperative analgesic requirements (both for narcotics and for acetaminophen). In addition, the level of activity of children in the bupivacaine treatment group was higher at all but one time interval. Thus, this technique could be used routinely in children undergoing herniorrhaphy.

Sinclair R, Cassuto J , Högström S, et al: Topical anesthesia with lidocaine aerosol in the control of postoperative pain. Anesthesiology 68:895-901, 1988.

This study compared the postoperative analgesic effects of lidocaine spray, a non-lidocaine-containing spray and a no treatment control in patients undergoing elective inguinal herniorrhaphy. The lidocaine spray was very effective in reducing postoperative pain as well as in preventing postoperative elevations in beta-endorphin levels. There were no effects on wound healing. The study demonstrated the effectiveness of a non-invasive analgesic technique similar to regional anesthesia.

Song D. Greilich NB. White PF. Watcha MF. Tongier WK. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesthesia & Analgesia. 91(4):876-81, 2000 Oct.

This study was designed to compare the cost-effectiveness of an ilioinguinal-hypogastric nerve block (IHNB)-MAC technique with standardized general and spinal anesthetics techniques for inguinal herniorrhaphy in the ambulatory setting. 81 consenting outpatients received IHNB-MAC, general anesthesia, or spinal anesthesia. Compared with general and spinal anesthesia, patients receiving IHNB-MAC had the shortest time-to-home readiness (133+/-68 min vs. 171+/-40 and 280+/-83 min), lowest pain score at discharge (15+/-14 mm vs. 39+/-28 and 34+/-32 mm), and highest satisfaction at 24-h follow-up (75% vs. 36% and 64%). The total anesthetic costs were also the least in the IHNB-MAC group ($132.73+/-33.80 vs. $172.67+/-29.82 and $164.97+/-31.03).

Tobias J, Holcomb GW, Brock JW, Morgan WM, O'Dell N, Lowe S, Rasmussen GE: Analgesia after inguinal herniorrhapby with laparoscopic inspection of the peritoneum in children. Am J Anesthesiol 22:193-197, 1995.

Pediatric patients scheduled for inguinal herniorrhaphy received either caudal block or local infiltration combined with ilioinguinal/iliohypogastric block for analgesia. The caudal group required less general anesthesia, were extubated sooner and discharge from PACU quicker. Also the caudal group had lower pain scores and needed less IV analgesia.

d. Breast Surgery - TOP

Greengrass R. O'Brien F. Lyerly K. Hardman D. Gleason D. D'Ercole F. Steele S. Paravertebral block for breast cancer surgery. [Journal Article] Canadian Journal of Anaesthesia. 43(8):858-61, 1996 Aug .

Twenty-five patients agreeing to have surgery performed under paravertebral blocks were studied. Procedures performed varied from simple lumpectomy with axillary dissection to modified radical mastectomy with axillary dissection. During monitored sedation, blocks opposite spinous processes of C7-T6 were performed using bupivacaine 0.5% with epinephrine, 3-4 ml per segment. Twenty patients had blocks that required no supplementation. Five patients had blocks that were incomplete. No complications were attributed to the blocks. Post-operatively, patients with successful blocks had minimal nausea, vomiting and pain. No patients found the procedure unsatisfactory. Patients with successful blocks were all very satisfied.

Greengrass R. Buckenmaier CC 3rd.Paravertebral anaesthesia/analgesia for ambulatory surgery.Best Practice & Research. Clinical Anaesthesiology. 16(2):271-83, 2002 Jun. Paravertebral nerve blockade has been an established technique for providing analgesia to the chest and abdomen. The current emphasis on containment of health care costs has resulted in a rediscovery of paravertebral blocks facilitating outpatient surgical management and promoting early discharge. Paravertebral nerve blocks (PVB) produce excellent surgical conditions for many procedures of the chest and abdomen while providing profound long-lasting analgesia with few undesirable side-effects allowing early discharge of the patient from the ambulatory setting. This chapter reviews the pertinent anatomy and techniques involved in the successful placement of PVB. Continuous paravertebral catheters, pharmacological agents used in PVB, and single versus multiple injection paravertebral block techniques are also covered. Specific clinical situations that are particularly well suited to the application of PVB as the primary anaesthetic in the ambulatory setting and other clinical situations where analgesia from PVB is efficacious are discussed.

O'Hanlon DM. Colbert ST. Keane PW. Given FH. Preemptive bupivacaine offers no advantages to postoperative wound infiltration in analgesia for outpatient breast biopsy. American Journal of Surgery. 180(1):29-32, 2000 Jul.

Preemptive administration of analgesics, ie, prior to commencing surgery, has many theoretical advantages. In this prospective randomized study, the use of preincisional bupivacaine was compared with a postincision dose for the relief of postoperative pain, in 74 patients undergoing day-case breast biopsy. Demographic criteria were similar in both groups. There were no differences in pain scores postoperatively on the visual analog scale (VAS): VAS at 30 minutes 4.5 ([SD] 2.4) versus 4.7 (1.9); P = not significant (NS); VAS at 60 minutes 3.3 (2. 3) versus 3.6 (2.2); P = NS; VAS at 120 minutes 1.9 (1.7) versus 2.5 (2.0); P = NS; VAS at 240 minutes 0.9 (1.0) versus 1.3 (1.4); P = NS. There was no difference in the number of patients requiring additional analgesia: 13 (36%) versus 18 (47%); P = NS. Nor was there a difference in the time to additional analgesia: 55.0 (37.8) versus 55.3 (39.2) minutes; P = NS.

2. Time spent in the PACU - TOP

Recovery profiles of anesthetic regimens have become increasingly important because the quality of recovery often influences the amount of time spent in the recovery room. The time for recovery from drug effect is dependent on the concentration of the drug required during anesthesia, the concentration of the drug that will allow awakening and full recovery, and the disposition of the drug that allows drug concentration to decrease from that required during anesthesia to that required for awakening. The concentration required for anesthesia is dependent on the drug used and the sensitivity of the individual as well as concomitant drugs that are administered during the anesthetic.

The pharmacokinetic principles that govern the rate of decrease of drug concentration are well illustrated by the articles by Shafer SL, Varvel JR, Pharinacokinetics, pharinacodynamics, and rational opioid selection. Anesthesiology 74: 5363, 1991, and Hughes M.A., Glass P.S.A., Jacobs J.R., Context-sensitive half-time in multicompartment pharinacokinetic modelsfor intravenous anesthetic drugs. Anesthesiology 76: 334-341, 1992.

Opioids markedly reduce the concentration of volatile anesthetic or amount of propofol required for adequate anesthesia. Thus, the time for recovery from the volatile anesthetic is affected by the amount of opioid used. The effects of these drug interactions on recovery are discussed by Vuyk J., Lim T., Engbers F.H.M., Burm A. G.L., Vletter A.A., and Bovill J. G. The pharmaco-dynamic interaction of propofol and alfentanil during lower abdominal surgery in female patients. Anesthesiology 83: 8-22, 1995 and Lang E, Kapila A, Shlugman D, Hoke JF, Sebel PS, Glass PSA. Reduction of isoflurane minimal alveolar concentration by remifentanil. Anesthesiology 85:721-728, 1996. It is also important to note that the principles that apply to intravenous drugs described in these articles also applies for the volatile anesthetics. The amount of time spent in the recovery room may determine staffing requirements. Thus, recovery time often plays an important role in the agents “pharmacoeconomics”.

Pavlin DJ, Rapp SE, Polissar NL, Malmgren JA, Koerschgen M, Keyes H: Factors affecting discharge time in adult outpatients. Anesthesia & Analgesia. 87(4):816-26, 1998 Oct.

Discharge time (total recovery time) is one determinant of the overall cost of outpatient surgery. We performed this study to determine what factors affect discharge time. Details regarding patients, anesthesia, surgery, and recovery were recorded prospectively for 1088 adult patients undergoing ambulatory surgery over an 8-mo period. The contribution of factors to variability in the discharge time was assessed by using multivariate linear regression analysis. In the last 4 mo of the study, nurses indicated the causes of discharge delays > or =50 min in Phase 1 or > or =70 min in Phase 2 recovery. When all anesthetic techniques were included, anesthetic technique was the most important determinant of discharge time (R2 = 0.10-0.15; P = 0.001), followed by the Phase 2 nurse. After general anesthesia, the Phase 2 nurse was the most important factor (R2 = 0.13; P = 0.01-0.001). In women, the choice of general anesthetic drugs was significant (R2 = 0.04; P = 0.002). The three most common medical causes of delay were pain, drowsiness, and nausea/vomiting. System factors were the foremost cause of Phase 2 delays (41%), with lack of immediate availability of an escort accounting for 53% of system-related delays. We conclude t