Jerome O'Hara

Anesthetic considerations for robotic prostatectomy: a review of the literature.

Since the first robotic prostatectomy in 2000, the number of prostatectomies performed using robot-assisted laparoscopy has been increasing. As of 2009, 90,000 robotic radical prostatectomies were performed worldwide, and 80% of all radical prostatectomies performed in the United States were performed robotically. Robotic prostatectomy is becoming more common globally because of the many advantages offered to patients, primarily due to the minimally invasive nature of the procedure. Several new perioperative concerns and challenges for anesthesiologists and are described.

Comparison of two preoperative medical management strategies for laparoscopic resection of pheochromocytoma

OBJECTIVES To compare the intraoperative and postoperative course of patients undergoing laparoscopic pheochromocytoma resection at 2 institutions (Mayo Clinic and Cleveland Clinic) with differing approaches to preoperative preparation. Patients undergoing adrenalectomy for pheochromocytoma typically undergo a preoperative preparation to normalize their blood pressure and intravascular volume. However, no consensus has been reached regarding the best preoperative preparation regimen. METHODS A retrospective chart review was performed of 50 Mayo Clinic patients and 37 Cleveland Clinic patients who had undergone laparoscopic pheochromocytoma resection. Mayo Clinic predominantly used the long-lasting nonselective alpha(1,2) antagonist phenoxybenzamine, and Cleveland Clinic predominately used selective alpha(1) blockade. Data regarding the intraoperative hemodynamics and postoperative complications were collected. RESULTS Almost all patients at Mayo Clinic received phenoxybenzamine (98%). At Cleveland Clinic, the predominant treatment (65%) was selective alpha(1) blockade (doxazosin, terazosin, or prazosin). Intraoperatively, patients at Cleveland Clinic had a greater maximal systolic blood pressure (209 +/- 44 mm Hg versus 187 +/- 30 mm Hg, P = .011) and had received a greater amount of intravenous crystalloid (median 5000, interquartile range 3400-6400, versus median 2977, interquartile range 2000-3139; P <.010) and colloid (median 1000, interquartile range 500-1000, versus median 0, interquartile range 0-0; P <.001). At Mayo Clinic, more patients had received phenylephrine (56.0% versus 27.0%, P = .009). No differences were found in the postoperative surgical outcomes, and the hospital stay was comparable between the 2 groups. CONCLUSIONS Differences in the preoperative preparation and intraoperative management were associated with differences in intraoperative hemodynamics but not with clinically significant outcomes in patients undergoing laparoscopic adrenalectomy for pheochromocytoma at 2 large tertiary care centers.

The impact of current antiemetic practices on patient outcomes: a prospective study on high-risk patients.

BACKGROUND: In this prospective, multicenter, observational study, we evaluated the incidence and time course of postoperative nausea and vomiting (PONV), assessed prophylactic and rescue antiemetic use in high-risk patients, and determined population-based effectiveness of antiemetics, including the impact of American Society of Anesthesiologists (ASA) and American Society of Perianesthesia Nurses (ASPAN) guideline compliance. METHODS: Eligible patients undergoing elective laparoscopic or major plastic surgery possessed two or more of the following Apfel PONV risk factors: female gender, history of PONV or motion sickness, and nonsmoking status. Antiemetic use, emetic episodes, severity of nausea, and functional interference due to PONV were documented during the first 72 h after surgery. Complete response (CR) was defined as no emesis or rescue medication use, and complete control was defined as CR and no moderate-severe nausea. The effect of compliance (versus noncompliance) with ASA and ASPAN guidelines on PONV outcomes was also analyzed. RESULTS: The proportion of patients experiencing postoperative emesis ranged from 18% to 40% depending on the number of antiemetics administered. The rate of rescue medication (45%) was similar to the reported incidences of moderate-to-severe nausea (47%) and functional interference due to emetic symptoms (44%). The administration of three or more antiemetics produced better patient outcomes overall compared to <1 prophylactic antiemetic. CR rates were <70% despite adherence to current organizational PONV management guidelines (ASA: 69%; ASPAN: 63%). The complete control rates were 10% lower than CR rates over the 3 day study period. CONCLUSIONS: Administration of three or more prophylactic antiemetics had the most positive impact on emetic outcomes over 72 hrs in patients at risk of developing PONV. Although compliance with organizational PONV management guidelines improved patient outcomes, postoperative emetic symptoms and interference with patient functioning still occurred in more than 30% of these high-risk patients.

Effects of topical nitroglycerin and intravenous lidocaine on propofol-induced pain on injection.

We performed a randomized, placebo-controlled, double-blind study to compare the efficacy of intravenous (IV) lidocaine and topical nitroglycerin ointment in preventing pain during propofol injection. Nitroglycerin or placebo ointments were applied to the back of the hand over the skin area overlying the IV catheter tip; lidocaine was or was not added to the propofol solution. One hundred twenty-four patients were randomly assigned to receive one of four treatments: placebo and plain propofol, propofol mixed with lidocaine, nitroglycerin ointment and plain propofol, and nitroglycerin ointment and propofol mixed with lidocaine. Hence, there were 31 patients in each treatment group. Patients receiving nitroglycerin ointment and plain propofol had the highest incidence of pain on propofol injection (23 of 31 patients, 74%), and the highest median pain score. Only when lidocaine was added to propofol did it effectively reduce the incidence and severity of pain. Patients aged 50 yr and older had a significantly lower incidence and less severe pain. We conclude that lidocaine and age, but not topical nitroglycerin ointment, are factors associated with a decreased incidence of propofol-induced pain. (Anesth Analg 1997;84:865-9)

Effectiveness of bupivacaine administered via femoral nerve catheter for pain control after anterior cruciate ligament repair

STUDY OBJECTIVE To evaluate the quality of pain control achieved with continuous local anesthetic infusion via a femoral nerve catheter, and to determine the optimum concentration of bupivacaine necessary to maintain pain control after full surgical anesthesia is established with 0.5% bupivacaine. DESIGN Randomized, prospective study. SETTING Tertiary care teaching center. PATIENTS 25 ASA physical status I and II patients scheduled to undergo arthroscopically-aided anterior cruciate ligament (ACL) reconstruction by one surgeon, and who were willing to accept a femoral nerve catheter for postoperative pain control. INTERVENTIONS All patients received general anesthesia with propofol/alfentanil (10 ml/1 ml) mixture and nitrous oxide/oxygen (60%/40%) mixture via endotracheal tube. After induction of general anesthesia, a femoral nerve catheter was inserted with the aid of a nerve stimulator, and 20 ml of 0.5% bupivacaine was administered. The surgery was completed in a standard manner and the patients were randomized into three groups for the concentration of local anesthetic to continue the pain relief into the recovery phase. On awakening, all patients were determined to have a functioning femoral nerve catheter. Group 1 received 0.0625% (n = 8) bupivacaine, Group 2 0.125% (n = 9) bupivacaine, and Group 3 0.25% (n = 8) bupivacaine; all doses were initiated in a blinded manner at 0.12 ml/kg/hr. Patients also received intravenous patient-controlled analgesia with morphine via demand mode only, with a 1.0 mg dose and a 6 minute lock-out interval. MEASUREMENTS AND MAIN RESULTS Pain was determined at defined intervals by visual analog scale (VAS). Data collected included demographics, VAS scores, and total morphine administered. All patients were pain-free on emergence from general anesthesia. No patient required parenteral opioid for pain control while in the postanesthesia care unit. There were no significant differences in pain scores among groups, and average pain scores (2.5 to 4.0) indicate good pain control throughout the entire hospitalization. There were no complications. CONCLUSIONS Low concentrations of bupivacaine delivered via femoral nerve catheter after an established femoral nerve block can provide excellent postoperative pain control after ACL reconstruction.

Alvimopan, a peripherally acting μ-opioid receptor antagonist, is associated with reduced costs after radical cystectomy: economic analysis of a phase 4 randomized, controlled trial.

PURPOSE We evaluated the effect of alvimopan treatment vs placebo on health care utilization and costs related to gastrointestinal recovery in patients treated with radical cystectomy in a randomized, phase 4 clinical trial. MATERIALS AND METHODS Resource utilization data were prospectively collected and evaluated by cost consequence analysis. Hospital costs were estimated from 2012 Medicare reimbursement rates and medication wholesale acquisition costs. Differences in base case mean costs between the study cohorts for total postoperative ileus related costs (hospital days, study drug, nasogastric tubes, postoperative ileus related concomitant medication and postoperative ileus related readmissions) and total combined costs (postoperative ileus related, laboratory, electrocardiograms, nonpostoperative ileus related concomitant medication and nonpostoperative ileus related readmission) were evaluated by probabilistic sensitivity analysis using a bootstrap approach. RESULTS Mean hospital stay was 2.63 days shorter for alvimopan than placebo (mean±SD 8.44±3.05 vs 11.07±8.23 days, p=0.005). Use of medications or interventions likely intended to diagnose or manage postoperative ileus was lower for alvimopan than for placebo, eg total parenteral nutrition 10% vs 25% (p=0.001). Postoperative ileus related health care costs were

Ischaemic optic neuropathy after spinal fusion.

2,340 lower for alvimopan and mean total combined costs were decreased by

The effect of epidural vs intravenous analgesia for posterior spinal fusion surgery

2,640 per patient for alvimopan vs placebo. Analysis using a 10,000-iteration bootstrap approach showed that the mean difference in postoperative ileus related costs (p=0.04) but not total combined costs (p=0.068) was significantly lower for alvimopan than for placebo. CONCLUSIONS In patients treated with radical cystectomy alvimopan decreased hospitalization cost by reducing the health care services associated with postoperative ileus and decreasing the hospital stay.

ANESTHESIA FOR KIDNEY TRANSPLANT SURGERY

PurposeWe report a case of ischaemic optic neuropathy which occurred after prolonged spine surgery in the prone position in an obese, diabetic patient.Clinical featuresThe patient was a 44-yr-old, 123 kg, 183 cm man for decompressive laminectomy and instrumented fusion of the lumbar spine. Anaesthesia was induced with thiopentone, fentanyl and succinylcholine and maintained with nitrous oxide, oxygen, isoflurane and a fentanyl infusion. He was positioned prone on the Relton-Hall frame and had an uneventful intraoperative course. Estimated blood loss was 3,000 ml. He was taken to the surgical intensive care unit (SICU) and the trachea was extubated 3.5 hr later. He had no pulmonary or haemodynamic problems and went to a regular nursing floor in the morning. He was discharged home on postoperative day #5. He telephoned his surgeon on postoperative day #7 to say that his vision had been blurry since surgery. His visual acuity was decreased, and on examination, he had a bilateral papillary defect, optic swelling and a splinter haemorrhage in the right eye. Magnetic resonance imaging (MRI) scan of the head and orbits detected no other abnormality. Based on this examination, he was felt to have bilateral ischaemic optic neuropathy and treated conservatively. By postoperative day #47, his visual acuity was greatly improved and near normal. Careful review of possible contributing factors suggests that the cause of the ischaemic optic neuropathy was venous engorgement.ConclusionThis patient developed ischaemic optic neuropathy from a prolonged interval in the prone position of the Relton-Hall frame, which may be related to venous engorgement.ObjectifNous rapportons un cas de neuropathie optique ischémique consécutive à une chirurgie rachidienne prolongée en décubitus ventral chez un obèse diabétique.Éléments cliniquesUn patient de 44 ans, pesant 123 kg et mesurant 183 cm était opéré pour une laminectomie décompressive avec ostéosynthèse instrumentale de la colonne lombaire. Le thiopental associé à du fentanyl et de la succinylcholine a servi à induire l’anesthésie, qui a été entretenue avec du protoxyde d’azote, de l’oxygène, de l’isoflurane et une perfusion de fentanyl. Il était immobilisé en décubitus ventral sur un cadre de Relton-Hall et l’opération s’est déroulée sans incident. On a estimé la perte sanguine à 3000 ml. Il a été transféré à l’unité des soins intensifs (USI) et extubé 3,5 h plus tard. Il ne présentait aucun problème respiratoire et hémodynamique et on l’a ramené dans son unité de soins le lendemain matin. Il était libéré le cinquième jour. Par téléphone, il avisait son chirurgien le septième jour que sa vision était embrouillée depuis l’intervention. Son acuité visuelle avait diminué et à l’examen, il présentait une lésion papillaire bilatérale, de l’oedème du nerf optique et une hémorragie linéaire de l’oeil droit. L’imagerie par résonance magnétique de la tête et des orbites ne montrait aucune autre anomalie. Cet examen suggérait une neuropathie optique ischémique bilatérale qui fut traitée de façon conservatrice. Le 47e jour postopératoire, son acuité visuelle s’était améliorée considérablement et était presque redevenue normale. Parmi les facteurs contributoires possibles cette neuropathie ischémique, il faut retenir l’engorgement veineux.ConclusionÀ la suite d’une immobilisation prolongée en décubitus ventral sur un cadre de Relton-Hall, ce patient a présenté une neuropathie optique par ischémie causée vraisemblablement par engorgement veineux.

Preoperative Autologous Donation Versus Cell Salvage in the Avoidance of Allogeneic Transfusion in Patients Undergoing Radical Retropubic Prostatectomy

Background : The study objective was to compare epidural vs intravenous postoperative analgesia in posterior spinal fusion surgery patients.