Margarita Coloma

What is the minimum training required for successful cricothyroidotomy?: a study in mannequins.

Background A correctly performed cricothyroidotomy may be lifesaving in a cannot-ventilate, cannot-intubate situation. However, many practicing anesthesiologists do not have experience with cricothyroidotomy. The purpose of this study was to determine the minimum training required to perform cricothyroidotomy in 40 s or less in mannequins. Methods After informed consent, participants were shown a demonstration video and asked to perform 10 consecutive cricothyroidotomy procedures on a mannequin using a preassembled percutaneous dilational cricothyroidotomy set. Each attempt was timed from skin palpation to lung insufflation. Cricothyroidotomy was considered successful if it was performed in 40 s or less, and the cricothyroidotomy time was considered to have plateaued when there were no significant reductions in cricothyroidotomy times in three consecutive attempts. Results One hundred two anesthesiologists participated in the study. There was a significant reduction of cricothyroidotomy times over the 10 attempts (P < 0.0001) and between three consecutive attempts until the fourth attempt (P < 0.03). The cricothyroidotomy times plateaued by the fourth attempt, while the success rate plateaued at the fifth attempt (94, 96, 96, and 96% at the fourth, fifth, sixth, and seventh attempts, respectively). Conclusion Practice on mannequins leads to reductions in cricothyroidotomy times and improvement in success rates. By the fifth attempt, 96% of participants were able to successfully perform the cricothyroidotomy in 40 s or less. While clinical correlates are not known, the authors recommend that providers of emergency airway management be trained on mannequins for at least five attempts or until their cricothyroidotomy time is 40 s or less. The most appropriate retraining intervals have yet to be determined for optimal cricothyroidotomy skill retention.

Comparison of the Costs and Recovery Profiles of Three Anesthetic Techniques for Ambulatory Anorectal Surgery

BackgroundGiven the current practice environment, it is important to determine the anesthetic technique with the highest patient acceptance and lowest associated costs. The authors compared three commonly used anesthetic techniques for anorectal procedures in the ambulatory setting. MethodsNinety-three consenting adult outpatients undergoing anorectal surgery were randomly assigned to one of three anesthetic treatment groups: group 1 received local infiltration with a 30-ml mixture containing 15 ml lidocaine, 2%, and 15 ml bupivacaine, 0.5%, with epinephrine (1:200,000) in combination with intravenous sedation using a propofol infusion, 25–100 &mgr;g · kg−1 · min−1; group 2 received a spinal subarachnoid block with a combination of 30 mg lidocaine and 20 &mgr;g fentanyl with midazolam, 1–2-mg intravenous bolus doses; and group 3 received general anesthesia with 2.5 mg/kg propofol administered intravenously and 0.5–2% sevoflurane in combination with 65% nitrous oxide. In groups 2 and 3, the surgeon also administered 10 ml of the previously described local anesthetic mixture at the surgical site before the skin incision. ResultsThe mean costs were significantly decreased in group 1 (

The Use of Esmolol as an Alternative to Remifentanil During Desflurane Anesthesia for Fast-track Outpatient Gynecologic Laparoscopic Surgery

69 ± 20 compared with

Dexamethasone facilitates discharge after outpatient anorectal surgery.

104 ± 18 and

Comparative Efficacy of Acustimulation (ReliefBand®) versus Ondansetron (Zofran®) in Combination with Droperidol for Preventing Nausea and Vomiting

145 ± 25 in groups 2 and 3, respectively) because both intraoperative and recovery costs were lowest (P < 0.05). Although the surgical time did not differ among the three groups, the anesthesia time and times to oral intake and home-readiness were significantly shorter in group 1 (vs. groups 2 and 3). There was no significant difference among the three groups with respect to the postoperative side effects or unanticipated hospitalizations. However, the need for pain medication was less in groups 1 and 2 (19% and 19%vs. 45% for group 3;P < 0.05). Patients in group 1 had no complaints of nausea (vs. 3% and 26% in groups 2 and 3, respectively). More patients in group 1 (68%) were highly satisfied with the care they received than in groups 2 (58%) and 3 (39%). ConclusionsThe use of local anesthesia with sedation is the most cost-effective technique for anorectal surgery in the ambulatory setting.

Dexamethasone in combination with dolasetron for prophylaxis in the ambulatory setting: effect on outcome after laparoscopic cholecystectomy.

We compared esmolol and remifentanil infusions with respect to their effect on intraoperative hemodynamic stability and early recovery after outpatient laparoscopic surgery when administered as IV adjuvants during desflurane anesthesia. After premedication with midazolam 2 mg IV, anesthesia was induced with propofol 2 mg · kg−1 IV in combination with either esmolol 1 mg · kg−1 IV (n = 27) or remifentanil 1 &mgr;g · kg−1 IV (n = 26) and succinylcholine 1 mg · kg−1 IV according to a randomized, double-blinded protocol. Anesthesia was initially maintained with des- flurane 2.5% (subsequently titrated to maintain an electroencephalogram-bispectral index value of 60) and nitrous oxide 65% in oxygen. Before skin incision, an infusion of either esmolol (5 &mgr;g · kg−1 · min−1) or remifentanil (0.05 &mgr;g · kg−1 · min−1) was started and titrated to maintain the heart rate within 25% of the baseline value. Mivacurium, 0.04 mg/kg IV, bolus doses were administered to maintain a stable peak inspiratory pressure. Esmolol (12.8 ± 13.1 &mgr;g · kg−1 · min−1) and remifentanil (0.04 ± 0.02 &mgr;g · kg−1 · min−1) infusions were equally effective in maintaining a stable heart rate during these laparoscopic procedures. Although the mivacurium requirement was larger in the Esmolol group (7 ± 5 vs 3 ± 4 mg), the Esmolol group reported a smaller incidence of postoperative nausea and vomiting (4% vs 35%). Both drugs were associated with frequent “postanesthesia care unit bypass” rates (78–81%), short times to “home readiness” (119–120 min), excellent patient satisfaction (81–85%), and rapid resumption of normal activities (2.6–3.2 d). Fast-tracked patients were ready for discharge home significantly earlier (112 ± 46 vs 151 ± 50 min). We concluded that esmolol infusion is an acceptable alternative to remifentanil infusion for maintaining hemodynamic stability during desflurane-based fast-track anesthesia for outpatient gynecologic laparoscopic surgery. Implications Adjunctive use of a variable-rate infusion of esmolol during outpatient anesthesia with desflurane-nitrous oxide was associated with less postoperative nausea and vomiting than a remifentanil infusion. However, both adjuvants facilitated fast-tracking and lead to early discharge after laparoscopic tubal ligation surgery.

Fast-tracking after outpatient laparoscopy: Reasons for failure after propofol, sevoflurane, and desflurane anesthesia

Corticosteroids can decrease pain and postoperative nausea and vomiting after ambulatory surgery. Therefore, we designed a study to evaluate if the routine use of dexamethasone would facilitate the early recovery process after anorectal surgery. A secondary aim of the study was to determine if dexamethasone would increase the incidence of postoperative wound complications. Eighty adult outpatients undergoing anorectal surgery with a standardized monitored anesthesia care technique were randomly assigned to receive either dexamethasone 4 mg IV or an equal volume of saline before the start of surgery. All patients were premedicated with midazolam 2 mg IV and received ketorolac 30 mg IV as a preemptive analgesic. A propofol infusion, 50 &mgr;g · kg−1 · min−1 IV, was initiated and subsequently titrated to maintain an observer’s assessment of alertness/sedation score of 2 or 3 (with 5 = awake/alert to 1 = asleep). Fentanyl 25 &mgr;g IV was administered 3–5 min before infiltrating the surgical field with a 30-mL local anesthetic mixture containing 15 mL of lidocaine 1% and 15 mL of bupivacaine 0.25% (with epinephrine 1:200,000 and sodium bicarbonate 3 mL). All patients were fast-tracked directly from the operating room to the step-down recovery area. Even though the incidences of postoperative pain and postoperative nausea and vomiting were small in both treatment groups, the time to “home readiness” was significantly shorter in the dexamethasone group. Importantly, there was no increase in the incidence of wound infections (8% vs 12%) or hematoma formation (3% vs 5%) in the dexamethasone (versus saline) group. We conclude that the administration of dexamethasone, 4 mg IV, shortened the time to home readiness without increasing the incidence of postoperative wound infections in a high-risk outpatient population undergoing anorectal surgery. IMPLICATIONS A single dose of dexamethasone (4 mg IV) decreased the time to “home readiness” without increasing the incidence of postoperative wound complications in an outpatient population undergoing anorectal surgery.

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

Background Antiemetic drugs are costly, are associated with variable efficacy, and can produce unwanted side effects when used for prophylaxis against postoperative nausea and vomiting. This clinical study was designed to compare the efficacy of transcutaneous electrical acupoint stimulation using a ReliefBand® to ondansetron (Zofran®) when utilized alone or in combination for preventing postoperative nausea and vomiting after plastic surgery. Methods A single-center, randomized, double-blind, placebo- and sham-controlled study design was conducted to compare three prophylactic antiemetic treatment regimens in 120 outpatients undergoing plastic surgery procedures with routine low-dose droperidol prophylaxis: (1) ondansetron (n = 40), 4 mg intravenous ondansetron and a sham ReliefBand®; (2) acustimulation (n = 40), 2 ml intravenous saline and an active ReliefBand®; and (3) combination (n = 40), 4 mg intravenous ondansetron and an active ReliefBand®. The incidences of postoperative nausea and vomiting, as well as the need for “rescue” antiemetics, were determined at specific time intervals for up to 72 h after surgery. The outcome variables assessed included recovery times, quality of recovery score, time to resumption of normal diet, and patient satisfaction with the prophylactic antiemetic therapy. Results Use of the ReliefBand® in combination with ondansetron significantly reduced nausea (20 vs. 50%), vomiting (0 vs. 20%), and the need for rescue antiemetics (10 vs. 37%) compared with ondansetron alone at 24 h after surgery. Furthermore, the ability to resume a normal diet (74 vs. 35%) within 24 h after surgery was significantly improved when the ReliefBand® was used to supplement ondansetron (vs. ondansetron alone). Finally, the quality of recovery (90 ± 10 vs. 70 ± 20) and patient satisfaction (94 ± 10 vs. 75 ± 22) scores were significantly higher in the combination group versus the ondansetron group. There were no significant differences between the ReliefBand® and ondansetron when administered as adjuvants to droperidol for antiemetic prophylaxis. Conclusions The ReliefBand® compared favorably to ondansetron (4 mg intravenously) when used for prophylaxis against postoperative nausea and vomiting. Furthermore, the acustimulation device enhanced the antiemetic efficacy of ondansetron after plastic surgery.

Ketorolac improves recovery after outpatient anorectal surgery.

Background Postoperative nausea and vomiting after laparoscopic cholecystectomy remains a common problem despite routine antiemetic prophylaxis. Therefore, the authors investigated the effect of administering 4 mg intravenous dexamethasone as an adjunct to a 5-HT3 antagonist (12.5 mg intravenous dolasetron) with respect to patient outcome. Methods Outpatients (N = 140) were enrolled in this prospective, randomized, placebo-controlled, double-blind, institutional review board–approved protocol involving two antiemetic treatment groups. After induction of anesthesia, the control group received 1 ml intravenous saline, whereas the dexamethasone group received 4 mg intravenous dexamethasone. Both groups received 12.5 mg intravenous dolasetron at the time of gallbladder removal. A blinded observer recorded the recovery times, emetic episodes, rescue antiemetics, maximum nausea score, and time to achieve discharge criteria. Postdischarge side effects, as well as patient satisfaction and quality of recovery scores were assessed at 24 h after surgery. Results Although there was no difference in the incidence of postoperative nausea and vomiting in the early recovery period, the dexamethasone group had a shorter stay in the day-surgery unit (136 ± 57 vs. 179 ± 62 min) and more rapidly achieved discharge criteria (161 ± 32 vs. 209 ± 39 min). In addition, fewer patients in the dexamethasone group experienced nausea at home within 24 h after discharge (13 vs. 28%, P < 0.05). Finally, the dexamethasone group reported higher quality of recovery and patient satisfaction scores (P < 0.05). Conclusions The authors conclude that the adjunctive use of 4 mg intravenous dexamethasone shortened the time to achieve discharge criteria and improved the quality of recovery and patient satisfaction scores after laparoscopic cholecystectomy procedures in outpatients receiving prophylaxis with 12.5 mg intravenous dolasetron.

Use of the Intubating Laryngeal Mask Airway: Are Muscle Relaxants Necessary?

IMPLICATIONS In this study, although 41%-94% of the patients were fast-track eligible after laparoscopic surgery, only 35%-53% of the patients actually bypassed the postanesthesia care unit (PACU) because of anesthetic-related factors and surgical complications. Residual sedation was the most common anesthetic-related cause of failure to bypass thePACU.