Robert Naruse

The Effect of Location of Transcutaneous Electrical Nerve Stimulation on Postoperative Opioid Analgesic Requirement: Acupoint Versus Nonacupoint Stimulation

Transcutaneous electrical nerve stimulation (TENS) has been used as a complementary (supplemental) therapy to opioid analgesics for pain relief after surgery.Simultaneous stimulation at a classical Chinese acupoint site and periincisional dermatomes significantly decreases the postoperative analgesic requirement. This sham-controlled study was designed to assess the relative effectiveness of acupoint versus nonacupoint stimulation on the postoperative hydromorphone (HM) requirement, the incidence of opioid-related side effects, and the overall recovery profile. One hundred women undergoing total abdominal hysterectomy or myomectomy procedures with a standardized general anesthesia were randomly assigned to one of four postoperative analgesic treatment regimens (n = 25 each): Group I = sham-TENS (no electrical current) at the Zusanli (ST36) acupoints, Group II = nonacupoint-TENS at the shoulders, Group III = dermatomal-TENS at the level of the surgical incision, and Group IV = acupoint-TENS at the Zusanli acupoints. The frequency of TENS was set in the standard dense-and-disperse mode of 2/100 Hz. The intensity of stimulation was set at 0 mA for patients in Group I and at 9-12 mA for patients in Groups II, III, and IV. A patient-controlled analgesia (PCA) device programmed to deliver bolus doses of HM 0.2-0.4 mg IV on demand with a minimal lockout interval of 10 min was used to quantify the postoperative opioid analgesic requirement. Standard 100-mm visual analog scales were used to assess pain, as well as sedation, fatigue, and nausea, at specific intervals after surgery. The numbers of PCA demands and delivered bolus doses, requirements for supplemental medication, and any opioid-related side effects were recorded. In the first 24 h postoperatively, the opioid requirements in Groups III and IV were decreased by 37% and 39%, respectively, compared with the control (sham) group and 35% and 38%, respectively, compared with Group II. The duration of PCA usage and the incidences of nausea and dizziness were also significantly decreased in Groups III and IV compared with Groups I and II. We conclude that periincisional dermatomal and Zusanli acupoint stimulation were equally effective in decreasing the postoperative opioid analgesic requirement and in reducing opioid-related side effects. Both of these positions were more effective than the nonacupoint (shoulder) location. Implications: The location of the stimulating electrodes seems to be an important determinant of the efficacy of transcutaneous electrical nerve stimulation in decreasing the need for opioid analgesics in the postoperative period. This study demonstrates that transcutaneous electrical nerve stimulation applied at the dermatomal level of the skin incision is as effective as Zusanli acupoint stimulation, and both were more effective than stimulation at a nonacupoint (shoulder) location. (Anesth Analg 1998;87:1129-34)

The recovery of cognitive function after general anesthesia in elderly patients: a comparison of desflurane and sevoflurane.

We evaluated the cognitive recovery profiles in elderly patients after general anesthesia with desflurane or sevoflurane. After IRB approval, 70 ASA physical status I–III consenting elderly patients (≥65 yr old) undergoing total knee or hip replacement procedures were randomly assigned to one of two general anesthetic groups. Propofol and fentanyl were administered for induction of anesthesia, followed by either desflurane 2%–4% or sevoflurane 1%–1.5% with nitrous oxide 65% in oxygen. The desflurane (2.5 ± 0.6 MAC · h) and sevoflurane (2.7 ± 0.5 MAC · h) concentrations were adjusted to maintain comparable depths of hypnosis using the electroencephalogram bispectral index monitor. The Mini-Mental State (MMS) test was used to assess cognitive function preoperatively and postoperatively at 1, 3, 6, and 24-h intervals. The use of desflurane was associated with a more rapid emergence from anesthesia (6.3 ± 2.4 min versus 8.0 ± 2.8 min) and a shorter length of stay in the postanesthesia care unit (213 ± 66 min versus 241 ± 87 min). However, there were no significant differences between the Desflurane and the Sevoflurane groups when the MMS scores were compared preoperatively, and postoperatively at 1, 3, 6, and 24 h. Compared with the preoperative (baseline) MMS scores, the values were significantly decreased at 1 h postoperatively (27.8 ± 1.7 versus 29.5 ± 0.5 in the Desflurane group, and 27.4 ± 1.7 versus 29.2 ± 1.0 in the Sevoflurane group, respectively). However, the MMS scores returned to preoperative baseline levels within 6 h after surgery. At 1 h and 3 h after surgery, 51% and 11% (versus 57% and 9%) of patients in the Desflurane (versus Sevoflurane) Group experienced cognitive impairment. In conclusion, desflurane is associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar after desflurane and sevoflurane-based anesthesia.

Effect of Parecoxib, A Novel Intravenous Cyclooxygenase Type-2 Inhibitor, on the Postoperative Opioid Requirement and Quality of Pain Control

Background The analgesic efficacy and side effect profile of intravenous parecoxib, a novel cyclooxygenase type-2 (COX-2) inhibitor, was assessed in a double-blinded, placebo-controlled study involving patients undergoing major gynecologic surgical procedures. Methods After Institutional Review Board approval, 60 consenting women, American Society of Anesthesiologists (ASA) physical status I–III, undergoing lower abdominal surgery with a standardized general anesthetic technique were randomly assigned to receive one of three study medications: group 1 (control) received normal saline; group 2 received intravenous parecoxib, 20 mg; and group 3 received intravenous parecoxib, 40 mg. The initial dose of study medication was administered when the patient first requested pain medication after surgery. All patients had access to patient-controlled analgesia (PCA) with intravenous morphine, 1 or 2 mg, with a 6-min lockout period. Subsequent doses of the same study medication were administered at 12-h and 24-h intervals after the initial dose. The postoperative opioid analgesic requirement (PCA morphine usage), pain scores, pain relief scores, side effects, and need for supplemental medications (e.g., antiemetics, antipruritics, laxatives) were recorded. Results Compared with saline, intravenous parecoxib, 20 mg and 40 mg every 12 h, significantly decreased the PCA morphine usage during the first 6 h postoperatively (group 1, 25 ± 13 mg; group 2, 16 ± 11 mg; group 3, 17 ± 10 mg) and at 12 h (group 1, 34 ± 18 mg; group 2, 24 ± 14 mg; group 3, 23 ± 13 mg) and 24 h (group 1, 51 ± 27 mg; group 2, 34 ± 20 mg; group 3, 33 ± 21 mg) after surgery. However, there were no significant differences in the patients’ global evaluation of the study medications at 12 h and 24 h between those who received intravenous parecoxib (20 or 40 mg) and saline. Moreover, the postoperative pain scores and side effect profiles were similar in the three treatment groups. Conclusion Intravenous parecoxib (20 or 40 mg) was effective in decreasing the PCA opioid requirement after lower abdominal surgical procedures. However, it failed to improve pain management or reduce opioid-related side effects in the early postoperative period.

The effect of intraoperative use of esmolol and nicardipine on recovery after ambulatory surgery

There is controversy regarding the optimal technique for maintaining hemodynamic stability during anesthesia. We designed this prospective, randomized, double-blinded study to test the hypothesis that the technique used for maintaining hemodynamic stability during general anesthesia can influence recovery after ambulatory surgery. Forty-five healthy consenting women undergoing gynecologic laparoscopy procedures were randomly assigned to 1 of 3 treatment groups: Group 1 (control, n = 15) received normal saline 5 mL and 1 mL, followed by a saline infusion at a rate of 0.005 mL · kg−1 · min−1; Group 2 (n = 15) received esmolol 50 mg and saline 1 mL, followed by an esmolol infusion 5 &mgr;g · kg−1 · min−1; and Group 3 (n = 15) received esmolol 50 mg and nicardipine 1 mg, followed by an esmolol infusion 5 &mgr;g · kg−1 · min−1. The study drugs were administered after the induction of anesthesia with fentanyl 1.5 &mgr;g/kg, and propofol 2 mg/kg IV. Tracheal intubation was facilitated with vecuronium 0.12 mg/kg IV. Anesthesia was initially maintained with desflurane 2% end-tidal and N2O 67% in oxygen in all 3 groups. During surgery, the mean arterial blood pressure (MAP) was maintained within ±15% of the baseline value by varying the study drug infusion rate and the inspired concentration of desflurane. In addition to MAP and heart rate values, electroencephalogram bispectral index values were recorded throughout the perioperative period. Recovery times and postoperative side effects were assessed. Compared with the control group, adjunctive use of esmolol and nicardipine attenuated the increase in heart rate (in Group 2) and MAP (in Group 3) after tracheal intubation. Furthermore, the use of an esmolol infusion as an adjunct to desflurane to control the acute autonomic responses during the maintenance period significantly decreased emergence times (4 ± 2 versus 7 ± 4 min), decreased the need for postoperative opioid analgesics (43% versus 80%), and reduced the time to discharge (209 ± 89 versus 269 ± 100 min). We conclude that the adjunctive use of esmolol alone or in combination with nicardipine during the induction of anesthesia reduced the hemodynamic response to tracheal intubation. Furthermore, use of an esmolol infusion as an adjuvant to desflurane-N2O anesthesia for controlling the acute hemodynamic responses during the maintenance period improved the recovery profile after outpatient laparoscopic surgery.

Desflurane versus sevoflurane for maintenance of outpatient anesthesia: the effect on early versus late recovery and perioperative coughing.

BACKGROUND: There is controversy regarding the relative perioperative benefits of desflurane versus sevoflurane when used for maintenance of anesthesia in the ambulatory setting. Although studies have consistently demonstrated a faster emergence with desflurane (versus sevoflurane), the impact of this difference on the later recovery end points has not been definitively established. Furthermore, the effect of desflurane (versus sevoflurane) on the incidence of coughing is also controversial. METHODS: We randomized 130 outpatients undergoing superficial surgical procedures requiring general anesthesia to one of two maintenance anesthetic treatment groups. All patients were induced with propofol, 2 mg/kg IV, and after placement of a laryngeal mask airway, anesthesia was maintained with either sevoflurane 1%–3% or desflurane 3%–8% in an air/oxygen mixture. The inspired concentration of the volatile anesthetic was varied to maintain hemodynamic stability and a Bispectral Index value of 50–60. Analgesia was provided with local anesthetic infiltration and ketorolac (30 mg IV). Antiemetic prophylaxis consisted of a combination of ondansetron (4 mg), dexamethasone (4 mg), and metoclopramide (10 mg) at the end of surgery. Assessments included recovery times to eye opening, response to commands, orientation, fast-track score of 14, first oral intake, sitting, standing, ambulating unassisted, and actual discharge. Patient satisfaction with anesthesia, the ability to resume normal activities on the first postoperative day, adverse side effects (e.g., coughing, purposeful movement, oxygen desaturation <90%, sore throat, postoperative nausea, and vomiting), and the requirement for postoperative analgesic and antiemetic drugs were recorded in the early postoperative period and during the initial 24-h period after discharge. RESULTS: The two study groups had comparable demographic characteristics. Although the overall incidence of coughing during the perioperative period was higher in the desflurane group (60% versus 32% in the sevoflurane group, P < 0.05), the incidences of coughing during the actual administration of the volatile anesthetics (i.e., the maintenance period) did not differ between the two groups. Emergence from anesthesia was more rapid after desflurane; however, all patients achieved fast-track recovery criteria (fast-track score ≥12) before leaving the operating room. Finally, the time to discharge home (90 ± 31 min in sevoflurane and 98 ± 35 min in desflurane, respectively) and the percentage of patients able to resume normal activities on the first postoperative day (sevoflurane 48% and desflurane 60%) did not differ significantly between the two anesthetic groups. CONCLUSIONS: Use of desflurane for maintenance of anesthesia was associated with a faster emergence and a higher incidence of coughing. Despite the faster initial recovery with desflurane, no significant differences were found between the two volatile anesthetics in the later recovery period. Both volatile anesthetics should be available for ambulatory anesthesia.

Fast-Track office based anesthesia : a comparison of propofol versus desflurane with antiemetic prophylaxis in spontaneously breathing patients

IMPLICATIONS Compared to propofol, maintenance of anesthesia with desflurane provided significantly better intraoperative conditions during office-based surgery. In addition, desflurane with routine antiemetic prophylaxis was associated with a faster early recovery and similar incidence of postoperative side effects.

Perioperative rofecoxib improves early recovery after outpatient herniorrhaphy.

Non-opioid analgesics have become increasingly popular as part of a multimodal regimen for pain management in the ambulatory setting. We designed this randomized, double-blind, placebo-controlled study to evaluate the effect of perioperative administration of the cyclooxygenase-2 inhibitor rofecoxib on patient outcome after inguinal herniorrhaphy procedures. Sixty consenting outpatients undergoing elective hernia repair surgery were randomly assigned to one of two treatment groups: control (vitamin C, 500 mg) or rofecoxib (rofecoxib, 50 mg). The first oral dose of the study medication was administered 30–40 min before entering the operating room, and a second dose of the same medication was given on the morning of the first postoperative day. Recovery times, postoperative pain scores, the need for “rescue” analgesics, and side effects were recorded at 1- to 10-min intervals before discharge from the recovery room. Follow-up evaluations were performed at 36 h, 7 days, and 14 days after surgery to assess postdischarge pain, analgesic requirements, resumption of normal activities, as well as patient satisfaction with their postoperative pain management. Rofecoxib significantly decreased the early recovery times, leading to an earlier discharge home after surgery (88 ± 30 vs 126 ± 44 min, P < 0.05). When compared with the control group, the patients’ median [range] quality of recovery score was also significantly higher in the rofecoxib group (18 [14–18] vs 16 [13–18], P < 0.05). In the predischarge period, a significantly larger percentage of patients required rescue pain medications in the control group (67% vs 37% in the rofecoxib group, P < 0.05). At the 36-h follow-up assessment, rofecoxib-treated patients reported significantly reduced oral analgesic requirements (0 [0–20] vs 9 [1–33] pills, P < 0.05) and lower maximal pain scores, resulting in improved patient satisfaction with their postoperative pain management (3 [1–4] vs 2 [0–3], P < 0.05). However, there were no differences in the times required to resume their activities of daily living. In conclusion, perioperative rofecoxib, 50 mg per os, significantly decreased postoperative pain and the need for analgesic rescue medication, leading to a faster and improved quality of recovery after outpatient hernia surgery. However, perioperative use of rofecoxib failed to improve recovery end points in the postdischarge period.

A comparison of state and response entropy versus bispectral index values during the perioperative period

Cerebral monitoring indices are associated with a large degree of inter-patient variability and electrical signal interference during surgery. We designed this clinical study to test the hypothesis that use of the spectral entropy (Entropy) module is associated with less frequent intraoperative interference with the displayed indices than the bispectral index (BIS) monitor when used during general anesthesia with propofol and desflurane. Thirty consenting patients scheduled for major laparoscopic surgery procedures were enrolled in this prospective study. The elapsed time to obtain a baseline index value was recorded, as well as the simultaneous state entropy (SE), response entropy (RE), and BIS values at specific time intervals during the induction, maintenance, and emergence periods in patients administered a standardized general anesthetic technique. During the maintenance period, the changes in these indices were evaluated after a bolus dose of propofol (20 mg IV) and a 2% increase or decrease in the inspired concentration of desflurane. As expected, the baseline SE values were less than the RE and BIS values (88 ± 2 versus 96 ± 3 and 96 ± 4, respectively). However, the SE and RE values correlated with the BIS value during the induction (r = 0.77 and 0.78, respectively) and emergence (r = 0.86 and 0.91, respectively) periods. The area under the receiver operating characteristic curve for detection of consciousness also indicated a similar performance of the SE (0.93 ± 0.04) relative to the RE (0.98 ± 0.04) and BIS (0.97 ± 0.04). During the maintenance period, the responses to changes in propofol and desflurane concentrations were consistent with all three indices. Finally, the entropy indices were less interfered with by the electrocautery unit during the operation (12% versus 62% for the BIS monitor). Because the average selling prices of the Entropy and BIS disposable electrode strips (

Antiemetic prophylaxis for office-based surgery: are the 5-HT3 receptor antagonists beneficial?

14.25 versus

The effect of timing of dolasetron administration on its efficacy as a prophylactic antiemetic in the ambulatory setting

14.95 USD, respectively) are comparable, we conclude that the Entropy module is a cost-equivalent alternative to the BIS monitor.