Elaine Fluder

Intrathecal morphine for coronary artery bypass grafting and early extubation.

Aggressive control of pain during the immediate postoperative period after cardiac surgery with early tracheal extubation may decrease morbidity and mortality.This prospective, randomized, double-blinded, placebo-controlled clinical study examined the use of intrathecal morphine in patients undergoing cardiac surgery and its influence on early tracheal extubation and postoperative analgesic requirements. Patients were randomized to receive either 10 micro g/kg of intrathecal morphine (n = 19) or intrathecal placebo (n = 21). Perioperative anesthetic management was standardized (intravenous (IV) fentanyl, 20 micro g/kg, and IV midazolam, 10 mg) and included postoperative patient-controlled morphine analgesia. Of the patients who were tracheally extubated during the immediate postoperative period, the mean time from intensive care unit arrival to extubation was significantly prolonged in patients who received intrathecal morphine (10.9 h) when compared to patients who received intrathecal placebo (7.6 h). Three patients who received intrathecal morphine had extubation substantially delayed because of prolonged ventilatory depression. Although mean postoperative IV morphine use for 48 h was less in patients who received intrathecal morphine (42.8 mg) when compared to patients who received intrathecal placebo (55.0 mg), the difference between groups was not statistically significant. In conclusion, intrathecal morphine offers promise as a useful adjunct in controlling postoperative pain in patients after cardiac surgery. However, the optimal dose of intrathecal morphine in this setting, along with the optimal intraoperative baseline anesthetic that will provide significant analgesia, yet not delay extubation in the immediate postoperative period, remains to be elucidated. (Anesth Analg 1997;84:241-8)

Effect of metoclopramide on gastric fluid volumes in diabetic patients who have fasted before elective surgery

Background: Diabetes-induced gastroparesis is believed to increase fasting gastric fluid volume before elective surgery. Metoclopramide is routinely administered preoperatively to reduce gastric fluid volume in these patients. This study compared nondiabetic controls to non–insulin-dependent and insulin-dependent diabetics to determine the effect of metoclopramide, administered before surgery, on gastric volumes in patients who fasted before surgery. Methods: Control and diabetic patients fasted preoperatively before receiving either placebo or 10 mg intravenous metoclopramide 20 min before induction of anesthesia. After intubation, a gastric tube was placed, and stomach contents were aspirated with volumes compared among the groups. Results: Both groups of diabetic patients were older than the control group, and insulin-dependent patients had a higher incidence of comorbidities compared with the non–insulin-dependent group. Fasting blood sugar and hemoglobin A1C values were higher in both insulin-dependent and non–insulin-dependent patients. Gastric fluid volumes were similar in control, non–insulin-dependent, and insulin-dependent patients (8.0 ± 2.6 vs. 9.6 ± 4.1 vs. 17.7 ± 2.5 ml, respectively). In insulin-dependent diabetic patients, metoclopramide decreased gastric volume compared with placebo treatment (17.7 ± 2.5 vs. 7.8 ± 2.9 ml; P = 0.027). After stratification, a subpopulation of patients with poorly controlled diabetes, regardless of type, were identified to have increased gastric residual volumes. Conclusion: In elective surgical patients who have fasted before surgery, gastric volumes are minimal, even in diabetics with severe neuropathic symptoms. Metoclopramide prophylaxis to reduce gastric volumes seems to be unnecessary unless the patient has a prolonged history of poor blood glucose control.

Port-access minimally invasive cardiac surgery increases surgical complexity, increases operating room time, and facilitates early postoperative hospital discharge

Background Proposed advantages of port-access cardiac surgery have yet to be substantiated. The authors retrospectively compared patients undergoing port-access cardiac surgery with a matched group undergoing conventional cardiac surgery. Methods Forty-six patients who underwent port-access cardiac surgery were matched with 46 who underwent conventional cardiac surgery. Absolute criteria for matching included morning-of-surgery admission, procedure undergone, and care being delivered by one of two surgeons. If possible, matching included care delivered by one of two anesthesiologists. Patients were matched as closely as possible for preoperative demographic and clinical characteristics. Results All 46 pairs of patients were matched for procedure and admitted the morning of surgery. All 92 operations were performed by one of two surgeons, and 89% were performed by one of two anesthesiologists. Preoperative demographic and clinical characteristics were equivalent between groups. Compared with conventional cardiac surgery, port-access cardiac surgery increased surgical complexity (it almost tripled cardiopulmonary bypass time during coronary artery bypass grafting and increased it almost 40% during mitral valve procedures) and increased total operating room time (P < 0.0001). Port-access cardiac surgery had no beneficial effect on earlier postoperative extubation, decreased incidence of atrial fibrillation, or intensive care unit time, yet it decreased postoperative duration of stay (P = 0.029, all patients), a benefit observed primarily in patients undergoing coronary artery bypass grafting (P = 0.002). Conclusions This retrospective analysis revealed that port-access cardiac surgery increases surgical complexity, increases operating room time, has no effect on earlier postoperative extubation or decreased incidence of atrial fibrillation or intensive care unit time, and may facilitate postoperative hospital discharge (primarily in patients undergoing coronary artery bypass grafting). Properly designed prospective investigation is necessary to ascertain whether port-access cardiac surgery truly offers any benefits over conventional cardiac surgery.

Use of postanesthesia discharge criteria to reduce discharge delays for inpatients in the postanesthesia care unit

STUDY OBJECTIVE To determine whether a set of predetermined discharge criteria, used by nurses, shortens the length of patient stay in the postanesthesia care unit (PACU) without compromising safety. STUDY DESIGN Prospective clinical study. SETTING Postoperative recovery area of a large, tertiary-care, academic hospital. PATIENTS 1,198 adult, ASA physical status I, II, and III patients, 18 years or older, requiring general anesthesia. INTERVENTIONS Two groups of inpatients were followed. In the first group, over a 90 day period, all inpatients meeting study inclusion criteria were discharged by a physician (traditional discharge group [TDG]). This period was followed by a subsequent 90 day period in which a second group of patients were discharged by a PACU nurse using predetermined discharge criteria (discharge criteria group [DCG]). MEASUREMENTS Demographic and discharge variables, including the time when the physician was called for an order, the time a discharge order was written, and the actual discharge time, were recorded. Other comparisons of various discharge variables included the time that discharge criteria were met, the actual discharge time, and the difference between these times. The frequency of PACU stays longer than 60 minutes, PACU discharge delays, and the time discharge criteria were met longer than 60 minutes were also compared between groups. Floor nurse satisfaction with patient status and any related morbidities noted were also measured. MAIN RESULTS Length of PACU stay was significantly shorter (133.1 +/- 91.4 vs 101.7 +/- 53.7 min; P < 0.05) for inpatients in the DCG group. Discharge delays were higher with physician discharge. The DCG had a lower number of patients with multiple delays. There was no significant difference in the occurrence of adverse events between the two groups. CONCLUSIONS Predetermined discharge criteria resulted in a 24% decrease in PACU time.

Remifentanil-based anesthesia versus a propofol technique for otologic surgical procedures

Otologic procedures require a still surgical field and are associated with a 50% incidence of emetic symptoms. Propofol reduces nausea and vomiting but not intraoperative movement. This study compares a remifentanil/propofol anesthetic to a propofol/fentanyl combination to determine which provides the best perioperative conditions for otologic microsurgery. Eighty healthy patients were randomly assigned to receive one of the anesthetic combinations. Demographic data, hemodynamic variables, movement, and bispectral index monitoring values in addition to anesthetic emergence, nausea, vomiting, pain, and other recovery variables were compared between groups with appropriate statistical methods. Both groups were similar. Times to eye opening (7.7 ± 0.7 vs 12.4 ±1.2 minutes) and extubation (9.8 ± 0.9 vs 12.4 ±1.0 minutes) were shorter with remifentanil. This group also had lower hemodynamic variables and movement (23% vs 65%) under anesthesia. Postoperative pain was mild in both groups, but remifentanil patients had more than the propofol group. All other postoperative parameters were similar. Remifentanil-based anesthesia produces better hemodynamic stability, less movement, and faster emergence after otologic surgery, with propofols antiemetic effect, for the same cost.

Perioperative and long-term operative outcomes after surgery for trigeminal neuralgia: microvascular decompression vs percutaneous balloon ablation

ObjectivesNumerous medical and surgical therapies have been utilized to treat the symptoms of trigeminal neuralgia (TN). This retrospective study compares patients undergoing either microvascular decompression or balloon ablation of the trigeminal ganglion and determines which produces the best long-term outcomes.MethodsA 10-year retrospective chart review was performed on patients who underwent microvascular decompression (MVD) or percutaneous balloon ablation (BA) surgery for TN. Demographic data, intraoperative variables, length of hospitalization and symptom improvement were assessed along with complications and recurrences of symptoms after surgery. Appropriate statistical comparisons were utilized to assess differences between the two surgical techniques.ResultsMVD patients were younger but were otherwise similar to BA patients. Intraoperatively, twice as many BA patients developed bradycardia compared to MVD patients. 75% of BA patients with bradycardia had an improvement of symptoms. Hospital stay was shorter in BA patients but overall improvement of symptoms was better with MVD. Postoperative complication rates were similar (21% vs 26%) between the BA and MVD groups.DiscussionMVD produced better overall outcomes compared to BA and may be the procedure of choice for surgery to treat TN.

Is succinylcholine after pretreatment with d-tubocurarine and lidocaine contraindicated for outpatient anesthesia?

Because succinylcholine has obvious advantages for facilitating endotracheal intubation in the ambulatory setting (e.g., low cost, fast onset, and no need for reversal of neuromuscular block), it is important to determine whether this muscle relaxant is indeed associated with an increased incidence of postoperative myalgias, compared with alternative but more expensive nondepolarizing muscle relaxants. We studied 119 outpatients undergoing endoscopic nasal sinus surgery or septoplasty. The anesthetic technique consisted of propofol/lidocaine for induction, followed by isoflurane/nitrous oxide/oxygen for maintenance. Oral tracheal intubation was performed by using a fiberscope. Patients were randomly assigned to one of two muscle relaxant groups. Group 1 patients received d-tubocurarine 3 mg followed by succinylcholine 1.5 mg/kg. Group 2 patients received mivacurium 0.2 mg/kg. After recovery from anesthesia, patients were asked whether they had any muscle pain and/or stiffness. Pain was categorized by location and quantified by using a verbal scale (from 0 to 10). Analgesic usage and myalgias limiting ambulation were recorded. After discharge from the ambulatory surgery unit, patients were contacted by telephone on Postoperative Day 1. If patients complained of myalgias, they were contacted by telephone on Days 2 and 3. Only one patient (in the mivacurium-treated group) reported myalgia as a limiting factor in ambulation or resumption of normal activity. There were no differences between groups with respect to the incidence (21% in the succinylcholine-treated group and 18% in the mivacurium-treated group), location, or severity of myalgia. In conclusion, succinylcholine (preceded by pretreatment with d-tubocurarine and lidocaine) is not associated with an increased incidence of myalgias, compared with mivacurium, when used to facilitate tracheal intubation in patients undergoing ambulatory nasal surgery. Implications The results of this study show that the frequency of muscle pains after surgery in outpatients is approximately 20%, regardless of whether succinylcholine (after precurarization) or mivacurium is used to assist in insertion of the breathing tube.

Standard Anesthetic Technique for Middle Ear Surgical Procedures: A Comparison of Desflurane and Sevoflurane

Objective: This study was designed to compare desflurane and sevoflurane anesthesia for middle ear microsurgery. Study Design: One hundred healthy adults undergoing middle ear surgery were assigned to receive either desflurane or sevoflurane as their anesthetic. Intraoperative hemodynamics and BIS numbers were recorded. Hemodynamics, pain, nausea/vomiting, discharge readiness, and other parameters were compared postoperatively and 24 hours later. Results: No intraoperative differences were noted except in BIS scores which trended lower with desflurane. PACU blood pressures were higher after desflurane but pain scores, nausea/vomiting, rescue anti-emetics, recovery scores, and discharge times were similar. A significant difference was noted in anesthetic costs (desflurane > sevoflurane), and in patients with the lowest BIS scores associated with more nausea/vomiting. Conclusions: Both anesthetics may be used for ototic surgery but propofol anesthesia should still be considered in patients with a history of emetic sequelae. Significance: Short-acting inhalational anesthetics produce excellent operating conditions and reduce costs for otologic surgery.

Ondansetron Versus Droperidol or Placebo to Prevent Nausea and Vomiting after Otologic Surgery

This study compares the preoperative administration of ondansetron with that of droperidol or saline solution for the prevention of nausea and vomiting in otologic surgery patients. A total of 120 otherwise healthy individuals were randomly assigned to receive either saline solution, ondansetron (4 mg intravenously), or droperidol (25 μg/kg intravenously) before anesthetic induction. Intraoperative and postanesthesia care unit times were recorded along with incidence of nausea, vomiting, pain, nausea and recovery scores, and the administration of rescue antiemetics. Similar assessments were made during the next 24 hours. Demographics were similar, but more males received ondansetron. Anesthetic recovery scores were lower after administration of droperidol than after ondansetron. Incidence of nausea was similar between groups, but severity was greater with placebo and droperidol than with ondansetron. More vomiting occurred with placebo than with ondansetron or droperidol. No intergroup differences in rescue antiemetic administration were noted, however. Twenty-four hours later, more patients receiving placebo had nausea or vomited than patients receiving droperidol or ondansetron. Fewer women in the ondansetron group vomited than in the other two groups. Ondansetron 4 mg intravenously is as effective as droperidol and better than saline solution in preventing nausea and vomiting in patients undergoing otologic surgery. No cost advantage as determined by lower use of rescue antiemetics or shorter postanesthesia care unit times was noted after ondansetron therapy. (Otolaryngol Head Neck Surg 1998;118:785–9.)

Patient-controlled analgesia combined with either ondansetron or ondansetron plus prochlorperazine for control of pain and nausea and vomiting in patients undergoing abdominal surgery

STUDY OBJECTIVE To compare ondansetron with ondansetron plus prochlorperazine, added to a patient-controlled analgesia (PCA) solution for control of postoperative nausea and vomiting (PONV). DESIGN Prospective, randomized, double-blinded study. SETTING University hospital. PATIENTS 150 ASA physical status I, II, and III patients undergoing abdominal surgery. INTERVENTIONS Patients were given a PCA morphine solution containing either 30 mg of ondansetron (Group O), 30 mg of ondansetron plus 20 mg of prochlorperazine (Group OP), or no antiemetic (Group C; control group). MEASUREMENTS Demographic data were recorded, along with anesthetic and surgical time, total fluid intake, frequency of Postanesthesia Care Unit (PACU) PONV, discharge time and length of stay, frequency of PONV while on the hospital floor, highest nausea scores, total PCA morphine use, and PCA utilization times. MAIN RESULTS Demographic and intraoperative variables were similar in all groups. In the first 24 hours after surgery, nausea was higher in Group C than Group OP. Emesis in Group C was twice that of either Group O or Group OP. No differences were noted between groups in PACU PONV. Patients receiving ondansetron plus prochlorperazine when on the hospital floor had a lower frequency of nausea, while patients receiving ondansetron alone had a lower frequency of vomiting than did the control group. The adjusted odds of vomiting doubled for every 12 hours for Group C patients when receiving PCA. CONCLUSIONS Combination antiemetics added to PCA reduced emetic symptoms after abdominal surgery.