Dajun Song

Titration of volatile anesthetics using bispectral index facilitates recovery after ambulatory anesthesia.

Background: The bispectral (BIS) index has previously been shown to be a quantifiable measure of the sedative and hypnotic effects of anesthetic drugs. This study was designed to assess the effect of BIS monitoring on the utilization of volatile anesthetics and their recovery profiles after ambulatory surgery. Methods: Sixty consenting women undergoing outpatient laparoscopic tubal ligation procedures were randomly assigned to one of four treatment groups. After a standardized induction, anesthesia was maintained with either desflurane (Groups I and II) or sevoflurane (Groups III and IV) in combination with nitrous oxide, 65%, and fentanyl. In the control groups (Groups I and III), the anesthesiologists were blinded to the BIS value, and the volatile anesthetics were administered according to standard clinical practice. In Groups II and IV, the volatile anesthetics were titrated to maintain the BIS value at 60. The volatile anesthetic usage and the times from discontinuation of anesthesia to verbal response, orientation, and home‐readiness were recorded. Results: During the maintenance period, the BIS values were significantly lower in the control groups (mean, 42) compared with the BIS‐titrated groups (mean, 60). The volatile anesthetic usage in the BIS‐titrated groups was 30–38% lower (P < 0.05) compared with the control groups. Similarly, the times to verbal responsiveness were 30–55% shorter in the BIS‐titrated (vs. control) groups. Conclusions: Titrating desflurane and sevoflurane using the BIS monitor decreased their utilization and contributed to a faster emergence from anesthesia in outpatients undergoing laparoscopic tubal ligation procedures.

Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy

The use of an ilioinguinal-hypogastric nerve block (IHNB) as part of a monitored anesthesia care (MAC) technique has been associated with a rapid recovery profile for outpatients undergoing inguinal herniorrhaphy procedures. This study was designed to compare the cost-effectiveness of an IHNB-MAC technique with standardized general and spinal anesthetics techniques for inguinal herniorrhaphy in the ambulatory setting. We randomly assigned 81 consenting outpatients to receive IHNB-MAC, general anesthesia, or spinal anesthesia. We evaluated recovery times, 24-h postoperative side effects and associated incremental costs. 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 (

New Criteria for Fast-Tracking After Outpatient Anesthesia: A Comparison with the Modified Aldrete's Scoring System

132.73 ± 33.80 vs

Effect of low-dose droperidol on the QT interval during and after general anesthesia: a placebo-controlled study.

172.67 ± 29.82 and

Is the Bispectral Index Useful in Predicting Fast- Track Eligibility After Ambulatory Anesthesia with Propofol and Desflurane?

164.97 ± 31.03). We concluded that IHNB-MAC is the most cost-effective anesthetic technique for outpatients undergoing unilateral inguinal herniorrhaphy with respect to speed of recovery, patient comfort, and associated incremental costs. Implications Local anesthesia with propofol sedation for inguinal hernia repair was associated with a faster recovery, higher patient satisfaction, and lower costs compared with general and spinal anesthesia.

Remifentanil as an adjuvant during desflurane anesthesia facilitates early recovery after ambulatory surgery

T he modified Aldrete’s scoring system (1) is commonly used for determining when patients can be safely discharged from the postanesthesia care unit (PACU) to either the postsurgical ward or to the second stage (Phase II) recovery area. Recently, these discharge criteria have also been used in the operating room (OR) to determine the fast-track eligibility of outpatients undergoing ambulatory surgery (2,3). Because fast-tracking in the ambulatory setting implies taking a patient from the OR directly to the less extensively monitored Phase II step-down unit, this scoring system may not be adequate after ambulatory procedures requiring general anesthesia because it fails to consider common side effects that have traditionally been treated in the PACU (e.g., pain, nausea, and vomiting). Therefore, a new fasttrack scoring system that incorporates the essential elements of the modified Aldrete system, as well as an assessment of pain and emesis, has been proposed (4). We hypothesized that using this new scoring system to determine a patient’s fast-track eligibility would reduce the need for nursing interventions to administer parenteral medications in the Phase II recovery area. The times to fast-track eligibility were compared using the modified Aldrete and new fasttrack criteria in outpatients undergoing laparoscopic surgery with one of three standardized general anesthetic techniques. Methods

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

BACKGROUND Since the effects of antiemetic doses of droperidol on the QT interval have not been previously studied, the authors designed a randomized, double-blind, placebo-controlled study to evaluate the intraoperative and postoperative effects of small-dose droperidol (0.625 and 1.25 mg intravenous) on the QT interval when used for antiemetic prophylaxis during general anesthesia. METHODS One hundred twenty outpatients undergoing otolaryngologic procedures with a standardized general anesthetic technique were enrolled in this study. After anesthetic induction and before the surgical incision, 60 patients were given either saline or 0.625 or 1.25 mg intravenous droperidol in a total volume of 2 ml. A standard electrocardiographic lead II was recorded immediately before and every minute after the injection of the study medication during a 10-min observation period. The QTc (QT interval corrected for heart rate) was evaluated from the recorded electrocardiographic strips. In 60 additional patients, a 12-lead electrocardiogram was obtained before and at specific intervals up to 2 h after surgery to assess the effects of droperidol and general anesthesia on the QTc. Any abnormal heartbeats or arrhythmias during the operation or the subsequent 2-h monitoring interval were also noted. RESULTS Intravenous droperidol, 0.625 and 1.25 mg, prolonged the QT interval by an average of 15 +/- 40 and 22 +/- 41 ms, respectively, at 3-6 min after administration during general anesthesia, but these changes did not differ significantly from that seen with saline (12 +/- 35 ms) (all values mean +/- SD). There were no statistically significant differences among the three study groups in the number of patients with greater than 10% prolongation in QTc (vs. baseline). Although general anesthesia was associated with a 14- to 16-ms prolongation of the QTc interval in the early postoperative period, there was no evidence of droperidol-induced QTc prolongation after surgery. Finally, there were no ectopic heartbeats observed on any of the electrocardiographic rhythm strips or 12-lead recordings during the perioperative period. CONCLUSION Use of a small dose of droperidol (0.625-1.25 mg intravenous) for antiemetic prophylaxis during general anesthesia was not associated with a statistically significant increase in the QTc interval compared with saline. More importantly, there was no evidence of any droperidol-induced QTc prolongation immediately after surgery.

Remifentanil infusion facilitates early recovery for obese outpatients undergoing laparoscopic cholecystectomy

This study was designed to test the hypothesis that outpatients with higher electroencephalographic (EEG) Bispectral Index (BIS) values at the end of anesthesia achieve a modified Aldrete score of 10 and satisfy fast-track eligibility criteria more rapidly after ambulatory surgery. Sixty consenting women undergoing laparoscopic tubal ligation procedures were studied. After premedication with midazolam 2 mg IV, anesthesia was induced with propofol 2 mg/kg IV, fentanyl 1.5 [micro sign]g/kg IV, and succinylcholine 1 mg/kg IV and was initially maintained with either desflurane 4% (n = 31) or a propofol infusion 100 [micro sign]g [center dot] kg-1 [center dot] min-1 (n = 29), in combination with nitrous oxide 65% in oxygen. Subsequently, the inspired desflurane concentrations (2%-6%) and propofol infusion rates (50-150 [micro sign]g [center dot] kg-1 [center dot] min-1 were varied to maintain a clinically acceptable depth of anesthesia. The average BIS value during the 3-min interval immediately before the discontinuation of the maintenance anesthetics was recorded. Emergence times and modified Aldrete scores were assessed from the end of anesthesia until patients were considered fast-track-eligible. The BIS values at the end of anesthesia were significantly correlated with the time to reach fast-track eligibility in both the desflurane (r = -0.68) and propofol (r = -0.76) groups. We concluded that the EEG-BIS value at the end of anesthesia is useful in predicting fast-track eligibility after laparoscopic tubal ligation procedures with either a desflurane- or propofol-based anesthetic technique. Implications: In outpatients receiving either desflurane and propofol anesthesia for laparoscopic tubal ligation surgery, the times to achieve criteria for bypassing the recovery room (i.e., fast-tracking) correlated with the electroencephalo-graphic-Bispectral Index values at the end of anesthesia. (Anesth Analg 1998;87:1245-8)

Antiemetic Activity of Propofol after Sevoflurane and Desflurane Anesthesia for Outpatient Laparoscopic Cholecystectomy

STUDY OBJECTIVE To investigate the effect of using a remifentanil infusion during desflurane anesthesia on the early recovery profile and side effects. DESIGN Randomized, single-blind study. SETTING University-based ambulatory surgery unit. PATIENTS 46 healthy, ASA physical status I and II women undergoing outpatient laparoscopic tubal ligation procedures. INTERVENTIONS After premedication with midazolam 2 mg intravenously (IV), anesthesia was induced with propofol 2 mg.kg-1 i.v. and remifentanil 1 microgram.kg-1 i.v. Following tracheal intubation, anesthesia was maintained with desflurane 2% and nitrous oxide (N2O) 65% in both groups. During the maintenance period, hemodynamic stability was maintained using either a variable inspired concentration of desflurane, 2% to 8% (Control group), or a variable-rate infusion of remifentanil 0.05 to 0.2 microgram.kg-1.min-1 i.v. (Remi group). Ketorolac 30 mg i.v. and local anesthetic infiltration at the surgical portals were administered for preventive analgesia prior to skin closure. MEASUREMENTS AND MAIN RESULTS Emergence times and times to achieving an Aldrete score of 10 (i.e., fast-tracking eligibility) were determined. Postoperative nausea and vomiting (PONV), as well as the need for analgesic and antiemetic rescue medications, were noted during the 24-hour follow-up period. A structural questionnaire was used to assess intraoperative recall. Compared to the Control group, the Remi group had shorter emergence times and reduced times to achieving an Aldrete score of 10. There were no differences between the two groups with respect to the incidence of PONV and the requirements for postoperative analgesic and antiemetic drugs. None of the patients experienced intraoperative recall. CONCLUSIONS The adjunctive use of a remifentanil infusion (0.07 +/- 0.03 microgram.kg-1.min-1) during desflurane-N2O anesthesia facilitated early recovery without increasing PONV, pain, or the need for rescue medication after laparoscopic surgery.

Optimal Timing of Acustimulation for Antiemetic Prophylaxis as an Adjunct to Ondansetron in Patients Undergoing Plastic Surgery

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.