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PubMed1995

Comparison of sevoflurane and halothane anesthesia in children undergoing outpatient ear, nose, and throat surgery.

STUDY OBJECTIVE: To compare the induction, maintenance, and recovery characteristics of sevoflurane and halothane in pediatric ambulatory patients undergoing adenoidectomy with or without myringotomies (BMTs). To compare the hemodynamic effects of the two drugs. DESIGN: Open, randomized study. SETTING: University-affiliated pediatric hospital. PATIENTS: 39 ASA physical status I children aged 12 months to 12 years undergoing adenoidectomies with or without BMTs. INTERVENTIONS: Patients were randomized to receive sevoflurane or halothane in 60% nitrous oxide (N2O) for induction and maintenance of anesthesia. All patients received midazolam 0.5 mg/kg orally as premedication, as well as fentanyl 1 mcg/kg intravenously (i.v.) immediately following induction. Tracheal intubation was facilitated with mivacurium 0.2 mg/kg i.v. Anesthesia was maintained with an end-tidal concentration corresponding to 1 minimum alveolar concentration (MAC) of each drug until the end of surgery, at which time all anesthetic gases were discontinued simultaneously. Emergence (extubation), recovery (Steward score = 6), and discharge times were compared among patients in both groups. Heart rate (HR) and mean arterial pressure were compared at predetermined intervals. Additional fentanyl was administered after full recovery was documented for an objective pain score of at least 6. MEASUREMENTS AND MAIN RESULTS: Emergence from anesthesia was significantly faster (7.11 +/- 3.05 minutes vs. 9.58 +/- 5.12 minutes) and recovery (19.89 +/- 10.07 minutes vs. 31.08 +/- 9.81 minutes) more rapid in the sevoflurane group. However, there was no difference in the time to meet home discharge criteria (184 +/- 49 minutes vs. 189 +/- 48 minutes). HR was consistently maintained at or above baseline in the sevoflurane group. Blood pressure was significantly more depressed after fentanyl administration in the halothane group. There were no significant differences in the incidence of postoperative vomiting between the two groups. CONCLUSION: Sevoflurane provides a faster anesthetic emergence and recovery than halothane in premedicated patients but it does not expedite meeting current home discharge criteria.

Adenoidectomy↗
PubMed1995

Pediatric ambulatory anesthesia: role of parents.

Preschool children depend on their parents for support and guidance in dealing with new or stressful situations. When requested, the parents should be allowed to support their children during ambulatory surgical procedures, especially during the induction of anesthesia. With proper understanding on our part, and with proper preparation and counseling, the parents can become our allies and help to smooth the experience for the child, for the staff, and for themselves. Future efforts should be directed at studying the effects of different methods of preoperative preparation and counselling on the parents' attitude and cooperation during induction.

Ambulatory Surgical Procedures↗
PubMed1995

Recovery advantages of regional anesthesia compared with general anesthesia: adult patients.

The data support but do not conclusively prove, that RA results in a superior recovery compared with GA. However, several questions need to be answered. Even though the patient may leave the hospital or surgicenter sooner after RA, how does the patient treat pain at home once the block has "worn off"? Since short-acting sedatives and opioids are so commonly used with RA, to what extent is recovery due to them and to what extent is recovery due to the RA alone? Many of the studies examining beneficial effects of RA have been poorly conducted, combining RA with GA and producing inconclusive results. Anesthetic techniques need to be carefully compared to determine whether they are equal in quality, efficiency, and cost. Finally, to determine whether RA is cost-effective, future studies involving ambulatory patients with a focus on outcome and well-being need to be conducted.

Adult↗
PubMed1995

Practical cost-effective choices: ambulatory general anesthesia.

To determine cost-effectiveness, we need to determine the value obtained for the price paid. Several points emerge. We need to identify specific recovery goals as our benefits, looking at early, intermediate, and late phases of recovery. Benefits such as effects on nausea may be specific to the procedure, duration, and site of practice. Time savings in the OR or recovery areas do not generate cost savings unless utilization actually increases or staffing actually decreases. Recovery care protocols that mandate a specific duration of stay in the PACU can negate any intraoperative or postoperative benefit differences generated by an anesthetic agent. Most of all, it is difficult to assign a dollar value to a very important benefit: patient satisfaction. Each of us, in our practices, must identify cost-effective choices for ambulatory anesthesia. Determining prices is simple. This we can and should do. Determining value, however, is more complicated and it is in this direction our work must lie.

Ambulatory Surgical Procedures↗
PubMed1996

Propofol infusion for induction and maintenance of anesthesia in elderly patients: recovery and hemodynamic profiles.

STUDY OBJECTIVE: To evaluate the effect of propofol infusion for both induction and maintenance of anesthesia on hemodynamics and recovery in elderly patients compared with conventional thiopental-isoflurane anesthesia. DESIGN: Randomized, prospective, study. SETTING: Teaching hospital. PATIENTS: 60 nonpremedicated ASA physical status I, II, and III adult elderly patients scheduled to undergo total hip replacement surgery. INTERVENTIONS: Patients received either intravenous propofol infusion at 0.75 mg/kg/min or thiopental bolus 2 to 4 mg/kg for induction, followed by variable-rate propofol infusion up to 0.15 mg/kg/min or isoflurane 0.5% to 1.5% for maintenance of anesthesia. Nitrous oxide and fentanyl supplements were given in all patients. MEASUREMENTS AND MAIN RESULTS: Perioperative hemodynamic changes, patient recovery profile, and myocardial ischemia incidents were assessed in both anesthetic groups. Induction of anesthesia by propofol infusion (1.6 mg/kg) did not produce significant hypotension (-8.3% +/- 5.5%) or bradycardia; these changes were similar to induction by thiopental bolus injection (3.3 mg/kg). Furthermore, increases in blood pressure and heart rate (HR) during endotracheal intubation were limited to 6% following propofol induction compared with 22% for thiopental induction. During maintenance of anesthesia, the decrease in MAP and HR was comparable in both anesthetic groups. Postanesthetic recovery times for patient to achieve wakefulness, mental orientation, and a maximum Aldrete score (10) were significantly faster in the propofol group, by 4 minutes, 6 minutes, and 20 minutes, respectively; however, the time to discharge from the postanesthesia care unit was not different. Holter-monitored perioperative myocardial ischemic events detected in 23% of the patients occurred independent of hemodynamic changes or the type of anesthetic administered. CONCLUSION: Induction of anesthesia by propofol infusion in elderly patients produces greater attenuation of cardiovascular sympathetic response than thiopental bolus induction. Induction and maintenance of anesthesia by propofol infusion results in more rapid recovery in our elderly patients than thiopental isoflurane anesthesia.

Aged↗
PubMed1991

Postoperative course after sufentanil or fentanyl anesthesia for coronary artery surgery.

Postoperative hemodynamic effects were compared in 50 patients randomly selected to receive either sufentanil, 25 micrograms/kg, or fentanyl, 100 micrograms/kg, anesthesia for coronary artery bypass grafting. The two groups exhibited similar patient demographics; dose of premedicants and muscle relaxants; and use of inhalation agents. Values for 15 hemodynamic variables were recorded at baseline and at six postoperative times. The times to awakening, response to verbal commands, and extubation were also noted. Patients who received sufentanil had a more stable course, with higher cardiac outputs, lower systemic vascular resistances, and a lower incidence of hypertension. Postoperatively, the two groups had similar values for time to awakening, response to verbal commands, and extubation. Elimination half-lives differed significantly: 554 +/- 91 minutes (fentanyl) versus 277 +/- 60 minutes (sufentanil). Serum concentrations of both decreased linearly. The added advantages of postoperative hemodynamic stability could be important in the choice of anesthetic.

Anesthesia Recovery Period↗
PubMed1991

Noncardiac surgery in heart transplant recipients in the cyclosporine era.

As survival and quality of life continue to improve for cardiac transplant recipients, there is an ever-increasing possibility that these patients will present for elective and/or emergency surgery outside of a transplantation center. Cyclosporine therapy has been a major factor in extending homograft survival, but recent studies have suggested that cyclosporine administration increases the duration of action of some anesthetics. The authors evaluated the influence on anesthetic management of cardiac transplantation and chronic cyclosporine therapy in a retrospective review of all postcardiac transplant patients who presented for noncardiac surgery at the study institution. The data suggest that a number of commonly used anesthetic techniques can be administered safely to these patients when no evidence of graft rejection is present. No clinically significant prolongation of anesthetic effect was encountered following the doses of anesthetics described.

Anesthesia Recovery Period↗
PubMed2004

Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment.

BACKGROUND: It is known that smokers and patients with chronic obstructive pulmonary disease (COPD) experience a higher rate of pulmonary-related complications following abdominal surgery. The impact of anesthetic technique (regional [RA] versus general [GA] versus combination of both) on the complication rate has not been established. This study examined the outcomes of abdominal surgery performed using RA (epidural or continuous spinal) as the sole anesthetic technique in patients with severe pulmonary impairment (SPI). METHODS: We reviewed a series of 8 general surgery cases performed using RA alone (T4-T6 sensory level) in patients with SPI, as evidenced by an forced expiratory volume in 1 second (FEV(1)) less than 50% predicted and/or home oxygen requirement. One patient also received postoperative epidural analgesia. FEV(1) ranged from 0.3 to 1.84 L; 3 patients required home oxygen therapy, and 5 of the 8 were American Society of Anesthesiology (ASA) class 4. Operations included segmental colectomy (n = 2), open cholecystectomy (n = 1), incisional herniorrhaphy (n = 1), and laparoscopic herniorrhaphy (n = 4). RESULTS: Intraoperative conditions were adequate with RA alone for successful completion of the procedure in all cases. All patients recovered uneventfully except for 1 who developed postoperative pneumonia that resolved with standard therapy. Length of stay was less than 24 hours for 5 of 8 patients. Mortality was 0%. CONCLUSIONS: Abdominal surgery can be safely performed using RA alone in selected high-risk patients, making this option an attractive alternative to GA for those with severe pulmonary impairment.

Abdomen↗
PubMed2004

[Uncommon cause of respiratory distress in the post-anaesthesia care unit].

We report a case of respiratory distress in the post anesthesia care unit following general anaesthesia for a dilatation and curettage related to miscarriage in a 32-year-old woman. The preoperative physical examination showed no abnormalities except for the presence of dry cough during the preceding two or three days. A few minutes after her arrival in the PACU, the patient developed hyperthermia till 40.6 degrees C, cough, polypnea and oxygen desaturation (SpO(2): 82% on FiO(2): 40%). A thoraco-abdominal angioscanner showed pulmonary basal condensations and a thrombosis of the right ovarian vein. The patient had to be transferred to the intensive care unit where she remained intubated and ventilated during 13 days because of a Haemophilus influenzae pneumonia.

Adult↗
PubMed2005

[Postobstructif pulmonary oedema after endotracheal extubation at the recovery of general anaesthesia].

We report two cases of postobstructif pulmonary oedema occurring after extubation at the recovery of general anaesthesia and presenting some similarities. The young age of the patient and the occurrence of upper airway obstruction after extubation, as well as the radiologic nondependent distribution of alveolar pattern are typical. The underlying pathophysiology seems to be the mechanical disruption of the alveolar-capillary membrane.

Adult↗
PubMed2006

A prospective randomized comparison of spinal versus local anesthesia with propofol infusion for knee arthroscopy.

PURPOSE: Knee arthroscopy is the most common orthopaedic procedure performed in the United States, and there are few randomized studies comparing local anesthesia, in conjunction with propofol, with regional anesthesia for knee arthroscopy. The purpose of the study was to test the hypothesis that patients receiving local anesthesia combined with propofol infusion (LAP) will recover from anesthesia faster and experience less postoperative headache and back pain compared with spinal anesthesia (SA). TYPE OF STUDY: Randomized trial. METHODS: A randomized trial was used to compare SA and LAP in adults undergoing knee arthroscopy. A simple randomization scheme in sealed envelopes was used. An independent observer collected data the day of surgery and contacted patients by telephone on the first postoperative day to inquire about back pain or headaches, and to have them rate their anesthesia (excellent, good, fair, or poor). RESULTS: Eighteen patients (average age, 53 years) received LAP and 14 received SA. Baseline assessment of the 2 groups was similar. The mean time spent in the postoperative anesthesia care unit (PACU) was 2.8 hours for the LAP group and 4.0 hours for the SA group (P < .0001). Spinal anesthesia was associated with back pain in 5 of 14 patients in the SA group compared with none in the LAP group (P = .004). There were no statistically significant differences between the 2 groups with respect to headache (P = .5) or overall patient satisfaction (P = .3). The amount of time required to administer anesthesia was similar between the 2 groups (P = .2). The number of patients requiring additional sedation intraoperatively was higher in the LAP group compared with the SA group, 9 of 18 and 1 of 14, respectively (P = .02). CONCLUSIONS: Although subjects receiving LAP were more likely to require additional sedation intraoperatively compared with the SA group, LAP was associated with significantly less time to home readiness as measured by time in the PACU. LEVEL OF EVIDENCE: Level I.

Anesthesia Recovery Period↗
PubMed2004

Effects of low-dose midazolam with propofol in patient-controlled sedation (PCS) for apicectomy.

We studied the effects of low-dose midazolam with propofol for patient control sedation (PCS) in 30 healthy (ASA grade I) patients who were randomly allocated into two equal groups (n = 15 in each). They were given a propofol infusion of 2mg/kg/h after a bolus dose of 0.7 mg/kg. The second group was given the 2mg/kg/h propofol infusion after a dose of midazolam 0.03 mg/kg and a bolus dose of propofol 0.7 mg/kg. The standard dose for PCS was propofol 0.2mg/kg in both groups. Clinical data were taken and haemodynamic variables, and oxygen saturation were recorded before and on the 5th, 10th, 20th, and 30th minutes during the operations. The level of sedation, amnesia and conditions of each patient were evaluated during the study. Patients' satisfaction was recorded using a modified visual analogue scale (VAS). All results were evaluated statistically. We conclude that low-dose midazolam with propofol during PCS neither reduced oxygen saturation nor prolonged the time of discharge. Low-dose midazolam with propofol also improved the acceptability and comfort for patients and made the operation easier, which makes it preferable to propofol alone.

Adolescent↗
PubMed2006

Use of cerebral monitoring during anaesthesia: effect on recovery profile.

This review article examines the effect of cerebral monitoring using an EEG-based device [i.e. bispectral index (BIS), patient state analyzer (PSA), auditory evoked potential (AEP), cerebral state index (CSI), or entropy] on titration of anaesthetic, analgesic and cardiovascular drugs during surgery. In addition, articles discussing the effects of these cerebral monitoring devices on recovery profiles following general anaesthesia, postoperative side effects, and anaesthetic costs are reviewed.

Anesthesia Recovery Period↗
PubMed2006

Improved sedation for oral surgery by combining nitrous oxide and intravenous Midazolam: a randomized, controlled trial.

The objective is to investigate whether sedation techniques for oral surgery can be improved by combining the use of inhalation of nitrous oxide/oxygen with intravenous Midazolam. Prospective, randomized controlled clinical trial: Patients requiring extractions or surgery were randomly allocated to subgroups receiving either intravenous Midazolam or nitrous oxide/oxygen or a combined technique using nitrous oxide/oxygen and intravenous Midazolam. Safety parameters, amount of sedative agents administered, recovery time and co-operation scores were recorded. Patients receiving the combined sedation technique were initially titrated with 10% nitrous oxide, increasing by increments of 10% up to a maximum of 40% nitrous oxide and 60% oxygen. Midazolam was then titrated (initially 2 mg wait 2 min with increments of 1mg every minute until appropriately sedated) whilst still administering 40% nitrous oxide. When a combined technique of N(2)O/O(2) and Midazolam was used there was a statistically significant reduction in the amount of Midazolam required to achieve effective sedation (P<0.001), an overall significant reduction in recovery time (P<0.001) and a significant improvement in co-operation (P<0.01) and arterial oxygen saturation (P<0.001). This combined technique was found to be safe and reliable, requiring reduced doses of Midazolam and demonstrable improvement in patient recovery and co-operation.

Adolescent↗
PubMed2003

Criteria for immediate postoperative extubation in adult recipients following living-related liver transplantation with total intravenous anesthesia.

STUDY OBJECTIVE: To evaluate whether our criteria for immediate postoperative extubation predicts successful extubation in living-related liver transplantation of the right lobe, and to test the effects of our standardized anesthetic technique on the success of immediate postoperative extubation. DESIGN: Open-label, descriptive study. SETTING: University hospital. PATIENTS: 6 ASA physical status III and IV patients with end-stage liver disease undergoing living-related liver transplantation of the right lobe. INTERVENTIONS: Patients received a standardized anesthetic technique with propofol, remifentanil, and cisatracurium. They were extubated when they met our criteria for immediate postoperative extubation: good donor liver function, <10 U packed red blood cells administered, hemodynamic stability, and alveolar-arterial oxygen gradient <200 mmHg. MEASUREMENTS AND MAIN RESULTS: At the end of surgery, four of the six patients fulfilled our criteria for immediate postoperative extubation. They were uneventfully extubated rapidly after surgery and soon arrived in the intensive care unit. Their postoperative stay in the operating room was only 36 minutes (range: 30 to 42 min). No patient required reintubation in the operating room or the intensive care unit. They had no recorded hemodynamic or respiratory problems postoperatively. CONCLUSIONS: Immediate extubation of selected living-related liver transplant recipients can be a safe procedure. Anesthetic management to immediate extubation seems appropriate and the derived guidelines appear acceptable.

Adolescent↗
PubMed2004

Laryngeal mask airway versus endotracheal tube for outpatient surgery: analysis of anesthesia-controlled time.

STUDY OBJECTIVE: To show that efficiency of operating room times can be improved significantly using rapid changes between operative procedures. DESIGN: Randomized, prospective clinical study. SETTING: Tertiary care university hospital, elective peripheral trauma-related orthopedic surgery. PATIENTS: 72 adult, ASA physical status I, II, and III patients scheduled for elective peripheral trauma-related orthopedic surgery requiring general anesthesia. INTERVENTIONS: Patient airways were managed using either a Laryngeal Mask Airway (LMA) or an endotracheal tube (ETT) in the hands of anesthesiologists experienced in both. They were not informed as to the primary intention of the study. All perioperative data, including the preoperative and postoperative outpatient stay at the outpatient surgical ward, were recorded with an anesthesia information management system. MEASUREMENTS: The primary outcome measures were: time needed for anesthesia induction and emergence from anesthesia. All manual recording into the anesthesia information management system during anesthesia was accomplished by nurses who were uninformed as to the aim of the study. MAIN RESULTS: Anesthesia induction was significantly (p < 0.01) shorter using LMAs (means +/- SD, medians, [interquartile ranges]) (LMA: 5.8 +/- 1.5, 5, [5;7] vs. ETT: 7.4 +/- 1.8, 7, [7;8] min), whereas emergence from anesthesia was not different (LMA: 11.8 +/- 3.3, 11, [9;14] vs. ETT: 13.2 +/- 4.8; 12, [10;16] min). CONCLUSION: The clinical relevance of reduced anesthesia induction time using LMA is questionable. The lack of difference in emergence time could be a result of the use of total intravenous anesthesia.

Adult↗
PubMed2004

A comparison of anesthetic quality in propofol-spinal anesthesia and propofol-fentanyl anesthesia for total knee arthroplasty in elderly patients.

STUDY OBJECTIVE: To compare propofol plus spinal anesthesia during spontaneous ventilation using the Laryngeal Mask Airway and propofol plus fentanyl anesthesia during mechanical ventilation with an endotracheal tube on quality of recovery after anesthesia. DESIGN: Prospective, randomized study. SETTING: Hirosaki National Hospital. PATIENTS: 150 patients (aged > 70 years) undergoing total knee arthroplasty. INTERVENTIONS: Patients were divided randomly into two groups, to receive spontaneous ventilation with a Laryngeal Mask Airway during propofol-spinal anesthesia, or to receive propofol-fentanyl anesthesia with mechanical ventilation via endotracheal tube. MEASUREMENTS: Quality of anesthesia recovery such as nausea, vomiting, headache, pain throat, hoarse voice, back pain, dizziness, feeling comfortable, dreaming, recovery times in recovery of anesthesia, recovery times, postoperative pain, confusion, was assessed. MAIN RESULTS: The frequency of postoperative pain throat, hoarse voice, and nausea was significantly lower in the propofol-spinal anesthesia group than the propofol-fentanyl anesthesia group. The time to extubation, emergence, response to commands, and orientation were significantly faster (p < 0.001) in the propofol-spinal anesthesia group than the propofol-fentanyl anesthesia group. The frequency of postoperative confusion occurring in the propofol-spinal anesthesia group during the first 24 hours was significantly lower than that of the propofol-fentanyl anesthesia group (p = 0.03). CONCLUSIONS: Propofol-spinal anesthesia provided better and faster recovery than did propofol-fentanyl anesthesia for elderly patients undergoing total knee arthroplasty.

Aged↗