Babatunde Ogunnaike

Anesthetic considerations for bariatric surgery.

According to the National Institutes of Health, obesity is a major health problem with clearly established health implications, including an increased risk for coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, gallbladder disease, degenerative joint disease, obstructive sleep apnea, and socioeconomic and psychosocial impairment (1). The risk of developing one or more of these obesityrelated conditions is based on body mass index (BMI), with 25–30 kg/m 2 being low risk and 40 kg/m 2 being very high risk (2). The prevalence of obesity in the 18- to 29-yr-old group increased from 12% in 1991 to 18.9% in 1999 (3). Bariatric surgery encompasses a variety of surgical weight loss procedures used to treat morbid obesity. Obesity is clinically expressed in terms of BMI or Quetelet’s index (4), which is derived by dividing weight by the square of height to estimate the degree of obesity. Thus, BMI body weight (kg)/height 2 (m 2 ). Morbid obesity is a BMI more than 35 kg/m 2 , and super morbid obesity is BMI more than 55 kg/m 2 . The indications for surgical treatment of severe obesity, as outlined in the 1991 National Institutes of Health Consensus Development Conference Panel, include an absolute BMI more than 40 kg/m 2 or BMI more than 35 kg/m 2 in combination with lifethreatening cardiopulmonary problems or severe diabetes mellitus (1). Patients seeking surgical weight loss must have proven attempts at medically supervised weight loss. Documentation of loss of 5% to 10% excess body weight or weight gain after at least 6 mo of diet modification, exercise, and medical therapy or nonimprovement in comorbid conditions during this period indicates failure. Studies have shown that weight loss of 5%–10% of initial body weight improves glucose intolerance and Type II diabetes, hypertension, and dyslipidemia (5–7). The average expenditure is approximately

Effect of Short-Term Postoperative Celecoxib Administration on Patient Outcome After Outpatient Laparoscopic Surgery

7000 per year per patient on weight loss programs and equipment. Unfortunately, long-term weight loss is the exception, and most patients regain weight, sometimes more than they initially lost.

Comparison of Acustimulation and Ondansetron for the Treatment of Established Postoperative Nausea and Vomiting

PurposeNon-opioid analgesics are increasingly used as part of a multimodal regimen for pain management. This prospective, randomized, double-blinded, placebo-controlled study was designed to evaluate the effect of short-term postoperative administration of celecoxib on pain management and recovery outcomes following laparoscopic surgery.MethodsEighty consenting ASA I-III outpatients undergoing laparoscopic surgery were randomly assigned to one of two treatment groups: Control (placebo) or Celecoxib (celecoxib, 400 mg·day-1). The initial dose (celecoxib 400 mg or placebopo) was administered in the recovery room, and celecoxib 200 mg (or a placebo)po bid was continued for three additional days after surgery. Postoperative pain scores and the need for opi-oid-containing analgesics were recorded at specific intervals in the recovery room. Follow-up evaluations were performed at 24 hr, 48 hr, 72 hr and seven days and one month after surgery to assess post-discharge pain, analgesic requirements, complications, quality of recovery, and resumption of normal activities, as well as patient satisfaction with their pain management.ResultsCelecoxib reduced mean pain scores and the need for analgesics at 24 hr and 48 hr postoperatively. Patient satisfaction with their postoperative pain management was also higher in the Celecoxib group (94 ± 8 vs 80 ± 25,P < 0.05). Quality of recovery scores were significantly higher in the Celecoxib group on the first and second postoperative days (17 ± 1 vs 15 ± 2, and 18 ± 1 vs 16 ± 2, respectively). Finally, bowel function recovered an average of one day earlier and patients resumed activities of daily living two days earlier in the Celecoxib group (P < 0.05).ConclusionShort-term administration of celecoxib, 400 mg·day−1po, decreased postoperative pain and the need for opioid-containing analgesic medication, leading to an improved quality of recovery after outpatient laparoscopic surgery.RésuméObjectifLes analgésiques non-opiacés sont de plus en plus utilisés dans le cadre d’un régime multimodal pour le traitement de la douleur. Cette étude prospective, randomisée, à double insu et contrôlée par placebo a été effectuée afin de déterminer l’effet de l’administration postopératoire à court terme de célécoxib sur le traitement de la douleur et la convalescence suite à une chirurgie laparoscopique.MéthodeQuatre-vingt patients ASA I-III non hospitalisés subissant une chirurgie laparoscopique ont été randomisés en deux groupes de traitement : Témoin (placebo) ou Célécoxib (célécoxib, 400 mg·jour−1). La dose initiale (célécoxib 400 mg ou placebo po) a été administrée à la salle de réveil, et l’administration de célécoxib 200 mg (ou un placebo) po a été continuée deux fois par jour pendant trois jours suivant l’opération. La douleur postopératoire et les besoins en analgésiques à base d’opiacés ont été mesurés à des intervalles spécifiques à la salle de réveil. Des examens de contrôle ont été effectués 24 h, 48 h, 72 h, sept jours et un mois après la chirurgie afin d’évaluer la douleur suite au congé de l’hôpital, les besoins analgésiques, les complications, la qualité du rétablissement et la reprise des activités normales, ainsi que la satisfaction des patients quant au traitement de la douleur.RésultatsLe célécoxib a réduit les scores moyens de douleur ainsi que le besoin d’analgésiques à 24h et 48h après l’opération. La satisfaction des patients quant au traitement postopératoire de la douleur qu’ils ont reçu était également plus élevée dans le groupe célécoxib (94 ±8 vs 80 ± 25,P< 0,05). Les résultats de la qualité du rétablissement étaient significativement plus élevés dans le groupe célécoxib le premier et le deuxième jour après l’opération (17±1vs15±2,et18 ± 1 vs 16 ± 2, respectivement). Finalement, la fonction intestinale a été rétablie en moyenne un jour plus tôt et les patients ont repris leurs activités quotidiennes deux jours plus tôt dans le groupe célécoxib (P < 0,05).ConclusionL’administration à court terme de célécoxib 400 mg·jour−1 po a diminué la douleur postopératoire et le besoin de médication analgésique à base d’opiacés, ce qui a engendré une qualité de rétablissement améliorée après la chirurgie laparoscopi-que sans hospitalisation.

Transdermal scopolamine: an alternative to ondansetron and droperidol for the prevention of postoperative and postdischarge emetic symptoms.

Background This study was designed to evaluate transcutaneous electrical acupoint stimulation (acustimulation) using the ReliefBand® compared with ondansetron for the treatment of established postoperative nausea and vomiting (PONV) after outpatient laparoscopic surgery. Methods After the authors obtained institutional review board approval and written informed consent, 268 outpatients were enrolled in this randomized, double-blind, placebo- and sham-controlled study. All patients received antiemetic prophylaxis with metoclopramide, 10 mg intravenously, or droperidol, 0.625 mg intravenously, after induction of anesthesia. A total of 90 patients developed PONV in the recovery units and were randomized to one of three treatment groups: (1) the ondansetron group received 4 mg intravenous ondansetron and a sham ReliefBand®; (2) the acustimulation group received 2 ml intravenous saline and a ReliefBand®; and (3) the combination group received 4 mg intravenous ondansetron and a ReliefBand®. A rescue antiemetic (10 mg intravenous metoclopramide) was administered only if the PONV symptoms persisted for 15 min or longer after initiating the treatment. A blinded observer recorded the recovery times, emetic symptoms, rescue antiemetics, maximum nausea scores, complete response to study treatment, and time to achieve discharge criteria. Postdischarge side effects, as well as patient satisfaction and quality of recovery scores, were assessed at 24 and 72 h after surgery. Results The combination group had a significantly higher complete response rate than the acustimulation group (73%vs. 40%, P < 0.01). In addition, fewer patients (8 vs. 18) in the combination (vs. acustimulation) group experienced subsequent emetic events (P < 0.03). However, there were no significant differences between the three groups with respect to patient satisfaction and quality of recovery scores. Conclusions Acustimulation with the ReliefBand® can be used as an alternative to ondansetron for the treatment of established PONV. However, the use of ondansetron (4 mg intravenously) in combination with the ReliefBand® device improved the complete response rate to the acustimulation therapy.

Sedation and anesthesia care for ophthalmologic surgery during local/regional anesthesia

BACKGROUND:Given the controversy regarding the use of droperidol and the high cost of the 5-HT3 antagonists, a cost-effective alternative for routine use as a prophylactic antiemetic would be desirable. We designed two parallel, randomized, double-blind sham and placebo-controlled studies to compare the early and late antiemetic efficacy and adverse event profile of transdermal scopolamine (TDS) 1.5 mg, to ondansetron 4 mg IV, and droperidol 1.25 mg IV for antiemetic prophylaxis as part of a multimodal regimen in “at risk” surgical populations. METHODS:A total of 150 patients undergoing major laparoscopic (n = 80) or plastic (n = 70) surgery procedures received either an active TDS patch (containing scopolamine 1.5 mg) or a similar appearing sham patch 60 min before entering the operating room. All patients received a standardized general anesthetic technique. A second study medication was administered in a 2-mL numbered syringe containing either saline (for the two active TDS groups), droperidol, 1.25 mg, or ondansetron, 4 mg (for the sham patch groups), and was administered IV near the end of the procedure. The occurrence of postoperative nausea and vomiting/retching, need for rescue antiemetics, and the complete response rates (i.e., absence of protracted nausea or repeated episodes of emesis requiring antiemetic rescue medication) was reported. In addition, complaints of visual disturbances, dry mouth, drowsiness, and restlessness were noted up to 72 h after surgery. RESULTS:There were no significant differences in any of the emetic outcomes or need for rescue antiemetics among the TDS, droperidol, and ondansetron groups in the first 72 h after surgery. The complete response rates varied from 41% to 51%, and did not significantly differ among the treatment groups. The overall incidence of dry mouth was significantly more frequent in the TDS groups than in the droperidol and ondansetron groups (21% vs 3%). CONCLUSIONS:Premedication with TDS was as effective as droperidol (1.25 mg) or ondansetron (4 mg) in preventing nausea and vomiting in the early and late postoperative periods. However, the use of a TDS patch is more likely to produce a dry mouth.

The use of oral granisetron versus intravenous ondansetron for antiemetic prophylaxis in patients undergoing laparoscopic surgery: the effect on emetic symptoms and quality of recovery.

Anesthesia care for the patients undergoing ophthalmologic surgical procedures during local/regional anesthesia balances goals of patient comfort with safety and an optimal outcome in a highly cost-conscious environment. This article discusses current practices and trends in anesthesia care with respect to sedation for eye surgery during local/regional anesthesia. Although there is no evidence that one local/regional anesthesia technique or sedation analgesia regimen is superior to the others, this review highlights important differences between these varied approaches. The type of block used for the ophthalmologic surgery alters the sedation requirements. Changes in surgical techniques have increased the popularity of topical anesthesia, which reduces the need for sedation analgesia and may lessen the need for an anesthesia practitioner. The involvement of an anesthesia practitioner in eye surgery varies from facility to facility based on costs, anesthesiologist availability, and local standards. Anesthesia care choices are often made based on surgeon skill and anesthesiologist comfort, as well as the expectations and needs of the patient.

Transversus Abdominis Plane Block Versus Surgical Site Infiltration for Pain Management After Open Total Abdominal Hysterectomy.

Based on comparative studies in patients receiving emetogenic chemotherapy, it has been suggested that granisetron would be more effective than ondansetron for the prevention of postdischarge nausea and vomiting (PDNV). However, there have been no direct comparisons of these two popular 5-HT3 antagonists with respect to PDNV and quality of recovery. We designed this randomized, double-blind study to compare the antiemetic efficacy of oral granisetron (1 mg) to a standard IV dose of ondansetron (4 mg) when administered for antiemetic prophylaxis as part of a multimodal regimen in a laparoscopic surgical population. A total of 220 patients undergoing laparoscopic surgery with a standardized general anesthetic technique were enrolled in this prospective study at two major medical centers. Patients were randomly assigned to one of two prophylactic treatment groups: the control (ondansetron) group received an oral placebo 1 h before surgery and ondansetron, 4 mg IV, at the end of the surgery, and the granisetron group received granisetron, 1 mg per os, 1 h before surgery, and normal saline, 2 mL IV, at the end of the surgery. The early recovery profiles, requirement for rescue antiemetics, incidence of PDNV, and the side effects were recorded over the 48 h study period. In addition, nausea scores were assessed using an 11-point verbal rating scale at specific intervals in the postoperative period. The quality of recovery and patient satisfaction scores were recorded at 48 h after surgery. The demographic characteristics were similar in the two prophylaxis treatment groups, as well as the recovery times to patient orientation, oral intake, and hospital discharge. The incidences of PDNV, requirements for rescue antiemetics, and quality of recovery did not differ between the two study groups. The antiemetic drug acquisition costs to achieve comparable patient satisfaction with ondansetron and granisetron were US

Phase 2, double-blind, placebo-controlled, dose-response trial of intravenous adenosine for perioperative analgesia.

25.65 and

Patients Presenting with Acute Toxin Ingestion

47.05, respectively. Therefore, ondansetron (4 mg IV) was more cost-effective than granisetron (1 mg per os) for routine antiemetic prophylaxis as part of a multimodal regimen in patients undergoing either outpatient or inpatient laparoscopic surgery.

Body mass index and outcomes of in-hospital ventricular tachycardia and ventricular fibrillation arrest

BACKGROUND:Surgical site infiltration and transversus abdominis plane (TAP) blocks are commonly used to improve pain relief after lower abdominal surgery. This randomized, observer-blinded study was designed to compare the analgesic efficacy of TAP blocks with surgical site infiltration in patients undergoing open total abdominal hysterectomy via a Pfannenstiel incision. METHODS:Patients were randomized to receive either bilateral ultrasound-guided TAP blocks using bupivacaine 0.5% 20 mL on each side (n = 30) or surgical site infiltration with liposomal bupivacaine 266 mg diluted to 60 mL injected in the preperitoneal, subfascial, and subcutaneous planes (n = 30). The remaining aspects of the perioperative care were standardized. An investigator blinded to the group allocation documented pain scores at rest and with coughing, opioid requirements, nausea, vomiting, and rescue antiemetics in the postanesthesia care unit and at 2, 6, 12, 24, and 48 hours postoperatively. The primary outcome measure was pain scores on coughing at 6 hours postoperatively. RESULTS:One patient in each group was excluded from the analysis because of reoperation within 24 hours in the TAP block group and change of incision type in the infiltration group. The pain scores at rest and with coughing were significantly lower in the surgical site infiltration group at all postoperative time points (P < 0.0001) except at rest in the postanesthesia care unit. The opioid requirements between 24 and 48 hours were significantly lower in the infiltration group (P = 0.009). The nausea scores, occurrence of vomiting, and need for rescue antiemetics were similar. CONCLUSIONS:Surgical site infiltration provided superior pain relief at rest and on coughing, as well as reduced opioid consumption for up to 48 hours. Future studies need to compare TAP blocks with liposomal bupivacaine with surgical site infiltration with liposomal bupivacaine.