Julie Golembiewski

Intrathecal sufentanil for extracorporeal shock wave lithotripsy provides earlier discharge of the outpatient than intrathecal lidocaine.

Many anesthetic techniques are currently used for extracorporeal shock wave lithotripsy (ESWL).This randomized, prospective, double-blind study was designed to examine postoperative recovery with two anesthetic techniques for unilateral ESWL; i.e., intrathecal sufentanil versus intrathecal 5% lidocaine. The incidence of adverse effects was also assessed. Twenty-two ASA physical status I-III patients, 18-70 yr of age who were scheduled for unilateral ESWL under spinal anesthesia were studied. Patients were randomized to receive either intrathecal sufentanil 20 micro g + saline (n = 11) or intrathecal 5% lidocaine (n = 11) based on their height. Both patients and observers were blinded to the treatment groups. Patients were assessed for intraoperative and postoperative pain via a 10-cm verbal analog pain scale (VAPS) (0 = no pain, 10 = extreme pain). Stone sizes, number of shock waves, and voltages were also compared. The recovery profile-time to ambulate, void, oral intake, and home discharge-was documented. Antiemetic requirements in the postanesthesia care unit (PACU) and incidence of postoperative nausea and vomiting (PONV), pruritus, and sedation were also recorded. This study showed no differences in VAPS between groups at any time in the perioperative period. Patients who received intrathecal sufentanil ambulated (79 +/- 16 vs 146 +/- 57 min mean +/- SD; P < 0.05), voided (80 +/- 18 vs 152 +/- 54 min, P < 0.05), and were discharged home (98 +/- 17 vs 166 +/- 50 min, P < 0.005) significantly sooner than the patients who received intrathecal lidocaine. Although 27% (3 of 11) of the patients who received sufentanil reported pruritus, respiratory depression was not found. There were no differences in PONV between the two groups. Intrathecal sufentanil provided an enhanced recovery profile with significantly earlier home discharge when compared with intrathecal lidocaine. In conclusion, intrathecal sufentanil is a safe and effective method of anesthesia for outpatient unilateral ESWL. (Anesth Analg 1997;84:1227-31)

Determination of the effective therapeutic dose of intrathecal sufentanil for extracorporeal shock wave lithotripsy

UNLABELLED Intrathecal (IT) sufentanil provides effective analgesia for extracorporeal shock wave lithotripsy. However, the optimal dose of sufentanil has not been established. We designed a prospective, randomized, double-blinded study to determine the optimal dose of IT sufentanil. Sixty men were randomized to receive 12.5,15,17.5, or 20 microg of IT sufentanil (n = 15 for each group) via a combined spinal epidural technique. Inadequate analgesia was treated with IV propofol, and the epidural was activated for a pain score greater than 6 on a 10-point verbal analog pain scale. Intraoperative and postoperative visual analog pain scale scores were significantly higher in the 12.5-microg group compared with 20-microg group (3.2 +/- 1.6 vs 1.6 +/- 1.2, P < 0.05, and 1.1 +/- 0.5 vs. 0.5 +/- 0.4, P < 0.05, respectively). The smaller-dosage groups of IT sufentanil required significantly more supplemental boluses of propofol compared with the 20-microg group (67%, 53%, and 40% vs 6%, respectively, P < 0.05). However, pruritus was significantly diminished in the smaller-dosage groups compared with the 20-microg group (55%, 60%, and 67% vs 100%, P < 0.05). The time to discharge was significantly shorter in the 15-microg group compared with the 20-microg group (84 +/- 40 min vs 126 +/- 48 min, P < 0.05). These results suggest that 15 microg of IT sufentanil may be the optimal IT dose for patients undergoing extracorporeal shock wave lithotripsy. IMPLICATIONS Many anesthetic techniques are used for extracorporeal shock wave lithotripsy (ESWL). We have previously shown that intrathecal sufentanil was effective for ESWL, but was associated with a high incidence of itching. We tested 60 patients in four spinal sufentanil dose groups and found that doses of 15 and 17.5 microg provided the most effective analgesia with the fewest side effects for ESWL, with only mild itching.

Low-dose ketamine infusion for postoperative pain management.

THE MANAGEMENT OF postoperative pain continues to be a challenge of perianesthesia care. Opioids remain the mainstay of pharmacologic therapy. Although they are effective, their use is fraught with problems. Many patients present for surgery already receiving high-dose opioid therapy or with a history of intravenous (IV) drug abuse. In these patients, even large doses of opioids are often inadequate to control pain and, in some cases, may even worsen the problem. 1 Issues of surgical site location and the use of anticoagulation limit the use of regional techniques (ie, epidural infusions) for all patients. Evidence exists to support the claim that poor pain control is associated with a range of comorbidities including deep venous thrombosis, infection, ischemic events, pneumonia, and skin ulcers. 2 Research exists that has investigated the relationship between perioperative pain management and the development of chronic pain. This growing body of literature suggests that perioperative pain management can impact long-term outcomes with regard to the development of chronic pain states. 3-5 Moreover, opioid-induced hyperalgesia (OIH) is gaining acceptance as a contributing factor to both postoperative and chronic pain states. 1,6,7 The aim of this article is to discuss OIH in the perioperative/perianesthesia period and explain the rationale for the use of low (subanesthetic)doseketamineinfusionstoassistinmanagingthisproblem. Ketamine is auniquedrugthat interactswith manycell receptors to produce effects different from other anesthetic and analgesic agents. It isan extraordinarilypotentanalgesic agent with rapid onset. Ketamine has been used throughout its history in nearly all surgical arenas, as well as for procedural sedation in obstetrics, pediatrics, burn wards, and emergency department settings. As an anesthetic agent, ketamine is noted for its ability to produce a state of anesthesia while preserving respiratory drive and protective airway reflexes. When used as a general anesthetic, ketamine acts as a cardiovascular stimulant with bronchodilatory properties. Despite these useful properties, ketamine fell out of favor because of its association with postoperative delirium and hallucinations. For a time, it was regarded as an anesthetic most appropriateforhemodynamicshockand other frailorbrittle patients, but not well regarded for general or routine use. In addition, ketamine has become a popular drug of abuse, contributing to increased reluctance of many clinicians to administer it. However, recent data have led to a renewed interest in this unique drug for the treatment

Contrast Media Use in the Operating Room

Iodinated contrast media is frequently used in the OR, but often is not well understood by health care providers who are administering it. Although used for diagnosis rather than treatment, contrast media is classified as a drug by the FDA, and has indications, contraindications, adverse effects, drug interactions, disease interactions, and laboratory interference issues related to its use. Iodinated contrast media is classified according to osmolarity and ionicity, and these characteristics contribute to potential for adverse effects and choice of agent. Financial and safety concerns are factors to be considered when selecting an appropriate agent. Adverse effects can range from mild and self-limited to severe and life threatening; potentially the most serious of these are anaphylactoid reactions and contrast-induced acute renal failure. Knowledge of risk factors and preventive strategies is vital, as are issues related to substitution of gadolinium-based contrast, an off-label use. It is important for the perianesthesia nurse to become familiar with these commonly used imaging medications.

Drug Shortages in the Perioperative Setting: Causes, Impact, and Strategies

A DRUG SHORTAGE is defined as ‘‘a situation in which the total supply of all clinically interchangeable versions of an FDA-regulated drug is inadequate to meet the current or projected demand at the user level.’’ An inadequate supply of a drug alters how the pharmacy prepares or dispenses a drug product, and/or it can more directly affect patient care if an alternate drugmust be used because of unavailability of the preferred drug. From 2003 to 2006, the number of drug shortages was fairly low (about 70 shortages each year), with little variability from year to year. From 2007 to 2010, however, the number of drug shortages increased dramatically each year (from 129 in 2007 to 211 in 2010). In 2011, a record high of 267 drug shortages was reported.

Dabigatran: A New Oral Anticoagulant

Warfarin exerts its effect by inhibiting the production of vitamin K–dependent coagulation factors (factors II, VII, IX, and X) and regulatory anticoagulant proteins (proteins C and S). The anticoagulant effect of warfarin may be influenced by genetic factors, drug interactions that affect its absorption or hepatic metabolism, comorbidities (such as cancer and congestive heart failure), and dietary factors (such as changes in vitamin K levels from food). As a result, the dose response to warfarin is highly variable. There is an increased risk of thromboembolism if its anticoagulant effect is less than that required for the indication. On the other hand, there is an increased risk for significant bleeding if its

Altering meperidine prescribing patterns in a university teaching hospital.

Education and operational changes and restrictions led to a sustained reduction in meperidine use.

The changing landscape of perioperative pain management.

AN INCREASED UNDERSTANDING of the transmission and perception of pain is leading to new, more effective, but unfortunately more complex, management strategies for postoperative pain. With increased complexity comes the potential for unanticipated errors and complications. It is imperative that the perianesthesia clinician understands the therapeutic and toxic effects associated with these new modalities of pain management. Patients will increasingly be exposed to multiple boluses and infusions of medications, delivered through intravenous (IV), perineural, and wound infusion catheters.Opioid analgesics are increasingly supplemented and even supplanted by nonopioid analgesic medications, antihyperalgesic regimens, and continuous peripheral nerve blockade.

Rescheduling of Hydrocodone Combination Products: Potential Impact and Alternatives for Postoperative Pain Management

IN A RECENT survey of 300 patients who underwent an inpatient or outpatient surgical procedure, 65% reported experiencing moderate, severe, or extreme acute postoperative pain. Although effective postoperative pain control is the goal, it must be done safely in all patients particularly when opioids are used. A multimodal analgesic approach, where two or more drugs that act by different mechanisms are used, strives to achieve superior analgesia at the lowest effective opioid dose (‘‘opioid-sparing’’) or in some cases, avoiding opioids altogether. The hydrocodone and acetaminophen combination product (Vicodin, AbbVie Inc.; Norco, Watson Laboratories, Inc.) was developed to provide superior analgesia to either drug alone.

Antiemetics: Focus on Pharmacology

THE ACT OF VOMITING is controlled by the vomiting center, located in the medulla oblongata in close proximity to the nucleus of the solitary tract in the brainstem. The vomiting reflex can be activated by one or more sources: 1) the chemoreceptor trigger zone (CTZ), 2) the vestibular system (via cranial nerve VIII), 3) vagal and spinal afferent nerves from the gastrointestinal (GI) tract, and 4) the central nervous system (eg, stress, anticipatory nausea/vomiting before chemotherapy). The area postrema/CTZ/nucleus of the solitary tract is rich in many ‘‘emetogenic’’ receptors: serotonin type-3 (5-HT3), histamine type-1 (H1), muscarinic cholinergic type-1 (M1), dopamine type-2 (D2), neurokinin type-1 (NK1), and opioid receptors. Stimulation of M1 and H1 receptors in the vestibular system, via the CTZ, also activate the vomiting center. Vagal and afferent nerves from the GI tract are rich in 5-HT3 receptors, that when stimulated, can also trigger the vomiting reflex.