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PubMed2005

Recovery and cognitive function after fentanyl or remifentanil administration for carotid endarterectomy.

STUDY OBJECTIVE: To compare recovery and restoration of cognitive function after fentanyl-propofol or remifentanil-propofol anesthesia administration in patients undergoing carotid endarterectomy. DESIGN: Randomized, double-blind, prospective study. SETTING: Department of Anesthesiology, University hospital. PATIENTS: Seventy patients with ASA physical statuses II and III (53 men and 17 women) undergoing elective carotid endarterectomy. INTERVENTIONS: Anesthetic technique and drugs were identical in the 2 groups, with the exception of remifentanil and fentanyl administration. Induction of anesthesia was obtained with a bolus dose of propofol (1-2 mg/kg), maintenance was achieved with a propofol infusion according to hemodynamics and nitrous oxide/oxygen (FIO(2), 0.50). Muscle relaxation was achieved with rocuronium. The remifentanil group received 1 microg/kg of remifentanil as a single dose during the induction of anesthesia and 0.5 microg/kg per minute as an infusion throughout the procedure. The fentanyl group received 2 microg/kg of fentanyl as a single dose during the induction of anesthesia. MEASUREMENTS: Intraoperative hemodynamic adverse events were recorded. All patients were also evaluated with regard to their recovery and the restoration of their cognitive function, recording the immediate recovery times and using the Aldrete score 15 and 60 minutes after surgery and the Hasegawa scale 6 hours after surgery. For evaluation of postoperative pain, the Numeric Pain Scale (0-10) was used. MAIN RESULTS: Patients receiving remifentanil had significantly (P < .05) fewer episodes of intraoperative hypertension and needed nitroglycerine administration less frequently (P < .05) than those receiving fentanyl. Immediate recovery was significantly earlier (P < .05) with remifentanil (eye opening, 5.1 +/- 1.3 [remifentanil] and 7.2 +/- 3.7 [fentanyl] minutes; extubation time, 5.4 +/- 1.9 [remifentanil] and 7.8 +/- 4.1 [fentanyl] minutes). The Hasegawa Dementia Scale scores 6 hours after surgery and Aldrete scores 15 and 60 minutes after surgery did not differ significantly between the 2 groups. Pain levels were also similar for patients taking remifentanil and fentanyl. CONCLUSIONS: Although intraoperative hemodynamics were better preserved and immediate recovery was more rapid with remifentanil, overall postoperative recovery and restoration of cognitive functions as well as postoperative pain intensity seem to be similar for patients receiving remifentanil and for those receiving fentanyl combined with propofol for carotid endarterectomy operations.

Aged↗
PubMed2005

Antagonism of profound cisatracurium and rocuronium block: the role of objective assessment of neuromuscular function.

STUDY OBJECTIVE: The purpose of this study is to determine the incidence of significant (train-of-four [TOF] ratio <0.70), but clinically undetectable (TOF ratio >0.40), residual neuromuscular block after neostigmine antagonism of profound cisatracurium (CIS) or rocuronium (ROC) block. DESIGN: Prospective, randomized, open-label study. SETTING: University hospital. PATIENTS: Forty ASA physical status I and II undergoing elective surgical procedures. INTERVENTIONS: Anesthesia was induced with propofol 1.5 to 2.5 mg/kg IV plus fentanyl 2 to 4 mug/kg and maintained with N(2)O/desflurane plus narcotic supplementation. The electromyographic response of the adductor pollicis was recorded. Train-of-four stimulation was given every 20 seconds. Twitch height (T1) and TOF fade ratio were continuously recorded. In group 1 (n = 20), neuromuscular block was induced with CIS 0.10 mg/kg, and T1 was maintained at 5% of control by a constant infusion of CIS until the end of surgery. One minute after the termination of the infusion, neostigmine 0.05 mg/kg was administered. T1 and TOF values were monitored continuously for the next 20 minutes. Group 2 (n = 20) is identical to group 1 except that the initial drug was ROC 0.60 mg/kg, and paralysis was maintained with an infusion of ROC. MEASUREMENTS AND MAIN RESULTS: There were no significant differences in the recovery patterns of CIS vs ROC. The duration (bolus to end of infusion) in both groups averaged 2.7 hours, and the mean cumulative dose of relaxant approximated 4 x the ED(95). T1 at the time of reversal was 6% (4%-10%) of control. Mean TOF ratios at 10, 15, and 20 minutes were 0.55, 0.71, and 0.0.81, respectively. Return to a TOF ratio >0.40 was always achieved in 15 minutes or less. However, at 20 minutes postreversal, 5 of 40 subjects had TOF ratios <0.70 and only 11 individuals had recovered to a TOF ratio of 0.90 or greater. CONCLUSIONS: Most clinicians cannot detect tactile fade once the TOF ratio exceeds 0.40. When reversing profound block, an objective monitor of neuromuscular function is required if the extent of residual block is to be assessed with any confidence.

Adult↗
PubMed2006

Similar recovery from bispectral index-titrated isoflurane and sevoflurane anesthesia after outpatient gynecological surgery.

STUDY OBJECTIVE: To test the hypothesis that the recovery of gynecological day-case patients is equally fast after isoflurane and sevoflurane anesthesia, when administration of the inhaled agent is adjusted by monitoring the bispectral index (BIS). DESIGN: Prospective, randomized, controlled, single-blinded clinical study. SETTING: University-affiliated women's hospital. PATIENTS: 120 adult female patients, ASA physical status I or II, scheduled for ambulatory surgery under general anesthesia. INTERVENTIONS: Patients were randomized to receive either isoflurane or sevoflurane as the maintenance anesthetic. BIS values were titrated to remain between 50 and 60 during the maintenance of anesthesia by adjusting the inspired concentration of the inhaled agent. Administration of the inhaled agent was discontinued abruptly at the end of the procedure. MEASUREMENTS: The times to achieving several recovery end points were recorded. The main outcome parameter was the time to home-readiness. In the postoperative care unit, sedation was evaluated with the digit-symbol substitution test. The degree of pain and nausea was evaluated on the visual analog scale. MAIN RESULTS: There were no statistically significant differences in the times to home-readiness, or in any other parameters of early or intermediate recovery between the 2 groups. The degrees of sedation, pain, and nausea in the postoperative care unit were similar in the 2 groups. CONCLUSIONS: Isoflurane and sevoflurane are equally acceptable maintenance anesthetics in terms of the speed and quality of recovery in gynecological ambulatory surgery patients when the dose of the inhaled agent is adjusted to achieve a BIS between 50 and 60.

Adult↗
PubMed2005

Postoperative morbidities following dental care under day-stay general anesthesia in intellectually disabled children.

PURPOSE: The objective of this study was to compare the postoperative morbidities for 24 hours following dental care under day-stay general anesthesia using sevoflurane or halothane in intellectually disabled children. MATERIALS AND METHODS: Eighty-six premedicated patients with intellectual disabilities underwent general anesthesia for their dental treatment. They were randomly given anesthesia maintained with sevoflurane (2% to 3%) or halothane (1% to 1.5%) after receiving inhalation induction either with sevoflurane (8%) or halothane (5%) and nitrous oxide in oxygen (50:50). The patients' age, gender, weight, ASA Class, type of dental treatment, and duration of anesthesia and operation were recorded as well as the time required for recovery (Aldrete Scale) and the length of time taken before they were discharged (postanesthetic discharge scoring system) from the hospital. Pain and agitation were recorded using a visual analog scale (0 to 10). Other postoperative morbidities, which include crying, nausea and vomiting, bleeding, and drowsiness, were also noted for 24 hours after the operation. RESULTS: The most common morbidities during the postoperative 24 hours were agitation and pain, and their occurrence was significantly more common in the sevoflurane group than in the halothane group (P < .05). The recovery time was shorter in the sevoflurane group, but it was not statistically significant. There was no difference between the groups in the discharge time. CONCLUSIONS: Apart from more postoperative agitation and pain after awakening from sevoflurane, the quality of recovery was similar for both sevoflurane and halothane.

Ambulatory Surgical Procedures↗
PubMed2007

Hemodynamic stability in medically treated hypothyroid patients undergoing intravenous sedation.

PURPOSE: To evaluate the hemodynamic stability of medically treated hypothyroid patients undergoing intravenous sedation for dentoalveolar surgery. PATIENTS AND METHODS: A retrospective chart analysis of 20 consecutive white male patients actively being treated for hypothyroidism undergoing intravenous sedation for dentoalveolar surgery. Twenty consecutive normothyroid white male patients undergoing intravenous sedation for dentoalveolar surgery were used as controls. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), pulse pressure (PP), peripheral oxygen saturation (S(p)O(2)) and pulse were recorded at 5-minute intervals during intravenous sedation. RESULTS: Statistically significant lower average hemodynamic values were seen in hypothyroid patients compared to normothyroid patients in SBP (P = .05) and PP (P = .003). There were highly significant baseline changes for hypothyroid patients in DBP (P < .001) and MAP (P < .001) and significant baseline changes for normothyroid patients in DBP (P = .03), PP (P = .02) and pulse (P = .03). All changes were maintained within +/- 10% of baseline (range, -8.9% to +9.6%). CONCLUSIONS: Intravenous sedation for dentoalveolar surgery in medically treated hypothyroid patients maintains hemodynamic stability.

Adult↗
PubMed2005

Anesthetic choices in surgery.

Advances in technology and pharmacology continue to change techniques for anesthesia. So-called "fast-track" anesthesia has led to the development of new anesthetic agents and changes in anesthetic practice, including the increased use of regional anesthesia, techniques involving continuous plexus catheters to improve postoperative analgesia, and total intravenous anesthesia. Technological advances now provide additional options for airway management when a difficult airway is encountered. Advances have also produced additional intraoperative monitoring through the use of depth-of-anesthesia monitors and transesophageal echocardiography. Future areas of development are likely to include target-controlled infusion pumps as well as techniques and medi-cations that improve fast-track anesthesia safely.

Anesthesia↗
PubMed2004

General versus spinal anesthesia in patients undergoing radical retropubic prostatectomy: results of a prospective, randomized study.

OBJECTIVES: To evaluate the impact of general anesthesia (GA) versus spinal anesthesia (SpA) on intraoperative and postoperative outcome in patients undergoing radical retropubic prostatectomy. METHODS: Seventy-two consecutive patients with clinically localized prostate cancer were randomized into group 1 (GA: 34 patients) or group 2 (L2-L3 or L3-L4 SpA: 38 patients) and underwent radical retropubic prostatectomy. The intraoperative and postoperative anesthetic and surgical variables were evaluated. RESULTS: The mean +/- SEM operative time was not significantly different between the two groups (P = 0.43). The overall blood loss was less in group 2 (P = 0.04). The mean +/- SEM postoperative time in the postoperative holding area was significantly shorter after SpA than after GA (P <0.0001). The perioperative pain outcome in the postoperative holding area was significantly better for group 2 than for group 1 (P = 0.0017), but postoperative pain on day 1 was not significantly different between the two groups. The postoperative sedation score was significantly less in group 2 than in group 1 (P <0.0001). On day 1, first flatus passed in a significantly larger number of patients in group 2 (P <0.0001), and the overall gait was greater for group 2 patients (P = 0.02). CONCLUSIONS: These results suggest that SpA allows good muscle relaxation and a successful surgical outcome in patients undergoing radical retropubic prostatectomy with pelvic lymphadenectomy for clinically localized prostate cancer. Moreover, SpA results in less intraoperative blood loss, less postoperative pain, and a faster postoperative recovery than GA.

Adenocarcinoma↗
PubMed1999

Routine immediate extubation after cardiac operation: a review of our first 100 patients.

BACKGROUND: Early extubation after cardiac operation is an important aspect of fast-track cardiac anesthesia. Immediate extubation is an extension of this concept. We describe a technique that allows immediate extubation in the majority of patients. METHODS: To allow rapid emergence, anesthesia was modified from a high-dose opioid technique to intravenous propofol anesthesia supplemented with sevoflurane. Normothermic cardiopulmonary bypass was used with routine intermittent antegrade and retrograde tepid blood cardioplegia. High thoracic epidural analgesia was used to facilitate immediate extubation in the majority of patients. Contraindications to immediate extubation were prolonged cardiopulmonary bypass (CPB) (>2.5 hours), hemodynamic instability, uncontrolled bleeding, morbid obesity, severe pulmonary hypertension, congestive cardiac failure, or if the operation was emergent. RESULTS: Of 109 consecutive patients, 100 were immediately extubated (92%). No patient required reintubation within the first 24 hours after operation. One patient required reintubation 3 days after operation for sputum retention, and 2 patients required reoperation. There was no mortality and the incidence of perioperative morbidity was low. CONCLUSIONS: Immediate extubation after cardiac operation can be safely achieved and is possible in a majority of patients.

Aged↗
PubMed2002

Inhalational and enteral conscious sedation for the adult dental patient.

There are clearly many safe and effective sedatives available to the dental practitioner for reducing patient fear and improving their level of comfort. Careful consideration needs to be given to the objectives of the sedation when deciding which pharmacologic agents to use because they all possess slightly different clinical characteristics and various degrees of risk. Patient selection also is critical when making decisions about sedation because the patient's expectations and general health status factor into keeping the procedure safe. N2O/O2 sedation is an excellent choice for managing the mildly fearful dental patient or when minimal sedation is desirable. Among the sedatives administered enterally, the benzodiazepines are the most commonly used, and for good reason. These drugs are safe, effective, and offer a host of different personalities from which the dentist can choose. If used wisely and thoughtfully, the dentist can tailor the effects and duration of onset and recovery to the needs of the patient and the expected parameters of the appointment. When N2O/O2 sedation is combined with a single enteral sedative, a more profound level of CNS depression is achieved that can be modestly altered by changing the concentration of inhaled nitrous oxide. With these many pharmacologic alternatives, many different dental patient populations can be sedated in a safe, effective manner, thus allowing the delivery of most dental treatments in a setting of reduced psychologic and physiologic stress. These pharmacologic sedatives have truly opened up a wonderful world of possibilities for the comfortable delivery of dental care, and should be integrated into every office's repertoire for delivery of care.

Administration, Inhalation↗
PubMed1985

Halothane anesthesia in infancy: identification and correlation of preoperative risk factors with intraoperative arterial hypotension and postoperative recovery.

Infants are well known to be sensitive to the myocardial depressant effects of halothane. In this study of more than 300 infants, 0 to 24 weeks of age, who received halothane anesthesia, preoperative risk factors were correlated with intraoperative outcome and postoperative recovery. Possible risk factors considered were age, history of respiratory distress syndrome (RDS), preoperative fasting time, and anemia. Intraoperative morbidity was evaluated by occurrence of significant hypotension, slow heart rates, or serious bradycardias. Parameters of postoperative recovery included postanesthetic recovery room admission score, duration of recovery room stay, and time to first feeding. Arterial hypotension occurred with an unexpectedly high frequency of 49.2%. Infants younger than 8 weeks of age (particularly newborns), infants 9-16 weeks of age (fasting eight or more hours), and RDS survivors 0-16 weeks of age were found to be most susceptible to hypotension. Only age and history of RDS, however, proved to be statistically significant risk factors in predicting the probability of intraoperative circulatory depression. Though circulatory depression during halothane inhalation was common, it was not associated with significant intraoperative or postoperative morbidity in terms of cardiorespiratory arrests, serious dysrhythmias, prolonged postanesthetic recovery, or delayed feeding times.

Age Factors↗
PubMed1990

Transurethral resection of the prostate in the outpatient setting.

Transurethral resection of the bladder neck (8 patients) or prostate (142) was performed in the outpatient setting. Of the patients 5 required hospitalization for post-prostatectomy hemorrhage. This method has proved to be safe and cost-effective in the treatment of patients with outlet obstruction.

Adenocarcinoma↗
PubMed2004

Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trial.

BACKGROUND: Awareness is an uncommon complication of anaesthesia, affecting 0.1-0.2% of all surgical patients. Bispectral index (BIS) monitoring measures the depth of anaesthesia and facilitates anaesthetic titration. In this trial we determined whether BIS-guided anaesthesia reduced the incidence of awareness during surgery in adults. METHODS: We did a prospective, randomised, double-blind, multicentre trial. Adult patients at high risk of awareness were randomly allocated to BIS-guided anaesthesia or routine care. Patients were assessed by a blinded observer for awareness at 2-6 h, 24-36 h, and 30 days after surgery. An independent committee, blinded to group identity, assessed every report of awareness. The primary outcome measure was confirmed awareness under anaesthesia at any time. FINDINGS: Of 2463 eligible and consenting patients, 1225 were assigned to the BIS group and 1238 to the routine care group. There were two reports of awareness in the BIS-guided group and 11 reports in the routine care group (p=0.022). BIS-guided anaesthesia reduced the risk of awareness by 82% (95% CI 17-98%). INTERPRETATION: BIS-guided anaesthesia reduces the risk of awareness in at-risk adult surgical patients undergoing relaxant general anaesthesia. With a cost of routine BIS monitoring at US16 dollars per use in Australia and a number needed to treat of 138, the cost of preventing one case of awareness in high-risk patients is about 2200 dollars.

Anesthesia Recovery Period↗
PubMed1995

Propofol-based anesthesia as compared with standard anesthetic techniques for middle ear surgery.

OBJECTIVE: To determine whether a totally intravenous technique with propofol and fentanyl is superior to isoflurane anesthesia in patients undergoing middle ear surgery. DESIGN: Prospective randomized study. SETTING: Inpatient otolaryngology service at a university medical center. PATIENTS: Physical status 1 and 2 nonobese patients with no significant history of diabetes, chronic cholecystitis, neuropathy, or neuromuscular disorders that could produce delayed gastric emptying. One hundred two patients were admitted to the study and randomly divided into three equal groups. INTERVENTIONS: Intravenous thiopental, 5 mg/kg, was administered for induction of anesthesia followed by 60% air/O2 with isoflurane, 1% to 2% end tidal, for maintenance anesthesia (group 1). The same anesthetic with the addition of droperidol, 25 micrograms/kg, was given after induction (group 2). Propofol, 2 mg/kg, was administered intravenously for induction of anesthesia and followed by propofol, 50 to 250 micrograms/kg/min, for maintenance anesthesia. All groups received fentanyl, 3 micrograms/kg intravenously, after induction. MEASUREMENTS AND MAIN RESULTS: Surgical duration, induction, maintenance, and total anesthesia times were recorded together with eye opening and extubation. Intergroup comparisons of postoperative nausea, vomiting, and pain, and recovery scores, we made by use of the Steward system. Patients receiving propofol, compared with the isoflurane-only group, had significantly less nausea (4/34 vs 12/34 patients, respectively; p < 0.05) and as vomiting (2/34 vs 8/34 patients, respectively; p < 0.05). Immediate recovery scores were significantly better for propofol compared with the isoflurane-droperidol group. Recovery scores at 30 minutes were also faster with propofol compared with isoflurane or isoflurane-droperidol (5.7 +/- 0.1 vs 5.1 +/- 0.2 and 5.2 +/- 0.2; p < 0.05).

Adult↗
PubMed1993

Outcomes after same-day oral surgery: a review of 1,180 cases at a major teaching hospital.

Outcome was measured from data collected on 1,180 consecutive ambulatory oral surgery patients, two thirds of whom were treated under general anesthesia and the remainder who were treated under local anesthesia supplemented with intravenous sedation. Three patients (0.25%) required admission on the day of surgery; all had undergone general anesthesia. The surgery-related complication rate in the general anesthesia group (1:132) was similar to that for local anesthesia and sedation (1:128). However, anesthesia-related complications had an incidence of 1:99 in the general anesthesia group, but were absent in those receiving local anesthesia and sedation. Eight patients (0.7%) required hospital readmission after being discharged, mostly because of complications of surgery. The incidence of postoperative nausea and vomiting in the recovery room after local anesthesia and sedation (6%) was less than after general anesthesia (14%) (P < .01) Average recovery times to sitting out of bed and being ready for discharge were less after local anesthesia and sedation (38 +/- 15 minutes and 120 +/- 39 minutes, respectively) than after general anesthesia (61 +/- 50 minutes and 141 +/- 62 minutes). At the time of follow-up during the first few postoperative days, 7% of patients had gone to a family doctor and 4% to hospital accident and emergency departments, usually for minor problems. Paracetamol 500 mg plus codeine phosphate 30 mg was effective in 97% of cases when provided as a take-home analgesic. Ninety-nine percent of patients were satisfied with their management.

Adult↗
PubMed1993

A comparison of propofol with methohexital and isoflurane in two general anesthetic techniques.

The purpose of this study was to compare two general anesthetic techniques involving oral intubation for use in outpatient third molar surgery. Fifty American Society of Anesthesiologists I or II patients were randomly allocated to two groups. Group 1 received methohexital, isoflurane, nitrous oxide, and alfentanil, while group 2 received propofol, alfentanil, and nitrous oxide. An analysis of the results showed that although the technique used in group 2 cost more, had a slightly longer induction time, and produced a similar duration of apnea, it did not cause significant hypotension (as previously reported), and had a significantly better overall recovery. It was concluded that the use of propofol in the outpatient surgery setting may be a valuable addition to the oral and maxillofacial surgeon's anesthetic armamentarium.

Adolescent↗