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Biomedical subjects

Frances Chung

Publications and source records attributed to Frances Chung.

At least 37 records · Page 2Linked to original sources
PubMed2004

Pain management following discharge after ambulatory same-day surgery.

AIM AND BACKGROUND: Same-day surgeries are becoming routine for many surgical procedures. However, the degree to which patients need help with pain management at home following laparoscopic cholecystectomy (LC), shoulder, or hand ambulatory day surgery has received minimal examination. This study examined pain and related interference, analgesic use and adverse events, complications and resources utilized, and adequacy of postdischarge information at four time periods. METHODS: Data were collected from 180 patients by telephone interviews at 24, 48 and 72 hours, and 7 days after discharge. Patients (n = 78 hand, 48 shoulder, 54 LC surgery) were on average 41 years old. RESULTS: For all patients, worst 24-hour pain was reported as moderate to severe at all time periods. Using repeated measures anova demonstrated that shoulder patients had significantly more pain and overall pain-related interference, particularly in sleep and work, from 24 hours to day 7 than did hand or LC patients. The main analgesic taken was acetaminophen (paracetamol) with codeine 30 mg; 50% took no analgesia from 72 hours. About 20% experienced analgesic adverse events within 72 hours, mainly constipation and nausea. Only </=6% used non-pharmacological strategies. Bleeding (4%) and sore throat (11%) at 24-48 hours were identified as complications; six patients (4%) called their physician. Most patients received no information about analgesic use with inadequate pain relief and/or adverse events. CONCLUSIONS: Despite the considerable pain reported across all time periods, analgesic use and other interventions were minimal. Adverse events, which were problematic for some, may explain why patients stopped analgesics despite pain. These data support further research on more effective pain interventions and related education for day-surgery patients after discharge.

Adult↗
PubMed2004

Are patients comfortable consenting to clinical anesthesia research trials on the day of surgery?

UNLABELLED: Consent for clinical anesthesia research trials is often sought on the day of surgery when patients are most anxious and have little privacy or time for reflection. We conducted a retrospective survey of patients' perceptions and concerns regarding consent for clinical anesthesia trials on the day of surgery. Questionnaires were mailed to 175 patients who had participated in 1 of 6 negligible- or minimal-risk clinical anesthesia trials within the preceding year. Seventy-six patients responded (43%). Most patients (80%) reported that they understood the purpose of their trial, did not feel obligated (61%) or pressured (67%) to participate, and were satisfied (mean visual analog scale: 71 mm) with the recruitment and consent process on the day of surgery. Few patients (7%) believed that their well-being was put at risk because of their participation in the trial. IMPLICATIONS: This retrospective survey suggests that patient recruitment and consent for negligible- or minimal-risk clinical anesthesia research trials is appropriate when performed on the day of surgery.

Adult↗
PubMed2003

General anesthesia does not impair simulator driving skills in volunteers in the immediate recovery period - a pilot study.

PURPOSE: The current recommendations to refrain from driving for 24 hr after general anesthesia (GA) lack evidence. Our objective was to measure impairment of driving performance at various time intervals after anesthesia using driving impairment at different blood alcohol concentrations (BAC) as a gold standard for comparison. METHODS: Institutional Review Board approval was obtained. A cross-over design, within subject comparison was used. Twelve volunteers were randomized to three treatments: GA, alcohol, and no drug. Psychomotor recovery was assessed by Digit Symbol Substitution Test (DSST) and Trieger Dot Test (TDT). On the anesthetic day, GA was induced with propofol 2.5 mg x kg(-1) and fentanyl l micro g x kg(-1) and maintained with N(2)O-O(2) 50:50 and approximately one minimum alveolar concentration of desflurane by spontaneous ventilation for 30 min. Driving simulator test runs occurred at two, three, four, and 24 hr postanesthesia. On the alcohol treatment day, a vodka and orange juice beverage was administered to reach the legal limit for BAC in the province of Ontario, Canada (BAC 0.08%). On the control day, no drug was given. Driving simulator test runs corresponded to the same time of day as the postanesthetic test runs. Two-way analysis of variance for dependent samples (ANOVA) was performed using the SAS program. P values of less than 0.05 were considered significant. RESULTS: There was no significant difference in postanesthetic driving skills at two, three, and four hours postanesthesia, and the corresponding control sessions. There was no significant difference among the three sessions with respect to pen and paper tests of psychomotor performance. Performance during the alcohol session differed significantly from that during the control and postanesthetic sessions. CONCLUSION: Certain driving skills return by two hours after one half hour of GA of propofol, desflurane, and fentanyl in a group of young volunteers.

Adult↗
PubMed2003

Elimination of routine testing in patients undergoing cataract surgery allows substantial savings in laboratory costs. A brief report.

PURPOSE: To evaluate the possible cost savings when routine preoperative testing is discontinued in ambulatory cataract surgery patients. METHODS: A policy was introduced at our hospital to stop routine testing in ambulatory cataract patients. Consecutive patients' medical records were analyzed in a four-month period pre- and a four-month period post-discontinuation of routine laboratory tests. Ambulatory cataract surgery is performed under topical (and sometimes retrobulbar block) anesthesia with iv sedation. Co-morbidities, perioperative events, frequency and cost of tests ordered were compared for the two groups. Average costs per patient pre- and post-discontinuation of routine tests, and total possible cost savings were calculated. RESULTS: One thousand two hundred and thirty-one patients were studied; 636 had routine laboratory tests and 595 had no routine laboratory tests. The ratios of gender, co-morbidities and perioperative events were similar in the two groups. There was a significant reduction in the number of tests ordered after the new policy was introduced, from 5.8 tests per patient to 0.4 tests per patient. The cost of tests per patient was reduced from Can $39.67 to $4.01. CONCLUSION: In ambulatory cataract surgery, over 90% savings in laboratory costs is possible after elimination of routine tests.

Ambulatory Surgical Procedures↗
PubMed2003

Successful implementation of perioperative beta-blockade utilizing a multidisciplinary approach.

PURPOSE: To describe how we implemented a protocol for perioperative beta-blockade in patients with or at risk of coronary artery disease (CAD) undergoing major non-cardiac surgery and to present our results. METHODS: After institutional approval, from May 1999 to April 2001, patients with surgical and medical indications (CAD as indicated by previous myocardial infarction, typical angina or atypical angina with a positive stress test or at least two risk factors for CAD: age 65 yr, hypertension, smoking, high cholesterol, diabetes mellitus) for perioperative beta-blockade were identified preoperatively by anesthesiology and referred to the General Internal Medicine Service (MED). MED initiated patients on outpatient beta-blockers. The intraoperative anesthetic management was left to the discretion of the anesthesiologist. In the postanesthesia care unit (PACU), patients received iv metoprolol according to hemodynamic criteria. Postoperatively, patients were followed by MED for adverse cardiac events. RESULTS: Sixty-nine patients received perioperative beta-blockade. Preoperatively, 60% were started on metoprolol, 39% on atenolol and 1% on propranolol. In PACU, 42%, 9% and 38% of patients were given iv metoprolol 0, 5 and 10 mg respectively. One patient was given glycopyrrolate in the PACU for bradycardia and none received vasoactive or inotropic agents. Three patients (4.3%) had postoperative cardiac events. CONCLUSIONS: With close collaboration between anesthesiologists, internists, PACU nurses and family physicians, a strategy for perioperative beta-blockade was implemented successfully in patients with cardiac risks. Beta-blockade was associated with few side effects and morbidities.

Adrenergic beta-Antagonists↗
PubMed2003

Remifentanil with morphine transitional analgesia shortens neurological recovery compared to fentanyl for supratentorial craniotomy.

PURPOSE: To compare the recovery profiles, efficacy and safety of remifentanil and morphine for transitional analgesia with fentanyl in patients undergoing elective craniotomy for supratentorial mass lesions. METHODS: Ninety-one patients were enrolled in this prospective, randomized, multicentre study. Anesthesia was induced with thiopental and remifentanil (1.0 micro g x kg(-1) bolus and a 1 micro g x kg(-1) x min(-1) infusion) or fentanyl (1 micro g x kg(-1) bolus and a 1.0 micro g x kg(-1) x min(-1) infusion). The opioid infusion continued until the level of anesthesia was deemed appropriate for intubation. Anesthesia was maintained with N(2)O/O(2), isoflurane 0.5 MAC and remifentanil 0.2 micro g x kg(-1) x min(-1) or fentanyl 0.04 micro g x kg(-1) x min(-1). At bone flap replacement, either morphine 0.08 mg x kg(-1) (remifentanil group) or saline (fentanyl group) was given. RESULTS: Systolic blood pressure was greater in those receiving fentanyl during induction (145.6 +/-17.5 mmHg vs 128.8 +/-18.3 mmHg; P = 0.006) and intubation (126.9 +/-17.1 vs 110.9 +/-16.5 mmHg; P < 0.001). Median time to tracheal extubation was similar but less variable in the remifentanil group (remifentanil = 8 min: range = 2-44 min; fentanyl = 8 min: range = 1-732 min). The fentanyl patients required a longer time to achieve the first normal neurological score (fentanyl = 38.0 min; remifentanil = 26.0 min; P = 0.035). Both the anesthesiologists and the recovery room nurses rated remifentanil better with respect to level of consciousness. Analgesics were required earlier in patients receiving remifentanil; median time 0.5 vs 1.08 hr, P < 0.001. CONCLUSIONS: Remifentanil is a suitable alternative to fentanyl in supratentorial craniotomy. Time to preoperative neurological recovery is faster and morphine provides some transitional analgesia without compromising the quality of recovery.

Adult↗
PubMed2003

Pain, nausea, vomiting and ocular complications delay discharge following ambulatory microdiscectomy.

OBJECTIVE: Nowadays, microsurgical discectomy is being performed as an outpatient procedure. A retrospective chart review was done to document factors that delayed discharge or led to unanticipated admission. METHODS: After Institutional Review Board approval, the hospital medical records of 106 patients who underwent microsurgical discectomy on an ambulatory basis were reviewed. All patients were operated upon by a single surgeon at the Toronto Western Hospital. Perioperative data were collected on specifically designed data sheets. All anesthetic and surgical factors that affected discharge were noted. RESULTS: Of the 106 patients reviewed, only six required unanticipated admission. Two patients were admitted due to nausea and vomiting, one due to severe pain, one due to urinary retention and two were surgical causes (dural tear). Eight patients had delayed discharge. Anesthesia causes were severe nausea, severe pain, low oxygen saturation, sore throat and dry eyes. Two patients had surgical causes. The incidence of postoperative nausea was 61% and postoperative vomiting was 9.4%. Eighty patients (75.4%) complained of pain in the postanesthesia care unit. Of these, 33.9% had visual analogue pain scale scores more than 6. CONCLUSION: Ambulatory lumbar microdiscectomy can be carried out as an ambulatory procedure with an acceptably low unanticipated admission rate (5.7%). The percentage of patients with severe nausea (16%) and pain (33.9%) is high. Adequate perioperative pain management and effective control of nausea and vomiting may further improve the patients' experience after anesthesia for ambulatory microdiscectomy.

Adult↗
PubMed2003

Postoperative recovery and discharge.

Ambulatory surgery provides quality care that is cost-effective. The use of innovative surgical and anesthetic techniques will allow larger numbers of patients to take advantage of the benefits of undergoing an elective operation on an ambulatory basis. Anesthesiologists will be faced with more complex surgery, which will require careful selection and assessment of patients to ensure continuity of the excellent safety record of ambulatory anesthesia. Minor adverse events, such as pain and PONV, are still common. The occurrence of these minor adverse advents is now the major area of quality assessment and an area where improvement could be targeted. Fast tracking facilitates earlier discharge, but we must ensure this has benefit to the patient as speedy discharge may mask the true incidence of adverse minor symptoms. This can lead to patient dissatisfaction and a poor impression of ambulatory surgery.

Ambulatory Surgical Procedures↗
PubMed2003

Prospective study on incidence and functional impact of transient neurologic symptoms associated with 1% versus 5% hyperbaric lidocaine in short urologic procedures.

BACKGROUND: The objectives of this study were to compare the incidence, onset, duration and pain scores of transient neurologic symptoms (TNS) with 1% versus 5% hyperbaric lidocaine in spinal anesthesia for short urological procedures in a large prospective study. This study would also evaluate patient satisfaction, and impact of TNS on functional recovery to assess the clinical significance of TNS. METHODS: This was a multicenter, double-blind, randomized controlled trial. Four hundred fifty-three patients undergoing short transurethral procedures were randomized to receive 1% or 5% hyperbaric lidocaine. Eighty milligrams of 1% or 5% hyperbaric lidocaine was administered. During the first 3 days after surgery, the presence of TNS, its intensity and duration, and patient functional level were recorded. An intention-to-treat analysis was used. RESULTS: There was no difference in the incidence of TNS (21% vs. 18%) between 1% versus 5% lidocaine. Patients with TNS had significantly higher pain scores (5.3 +/- 3 vs. 2.3 +/- 3) than patients without TNS during the first 24 h. This difference in pain scores persisted until 72 h postoperatively. There was a significant difference in the daily activities functional scores (2.2 +/- 1 vs. 1.4 +/- 0.8) of TNS non-TNS patients during the first 24 h postoperatively. CONCLUSIONS: There was no difference in the incidence of TNS between the 1% versus 5% spinal lidocaine groups. Pain scores were higher in patients with TNS than those who did not have TNS. During the first 48 h postop, a small proportion of patients who had TNS experienced functional impairment of walking, sitting, and sleeping.

Acetaminophen↗
PubMed2003

Spinal anesthesia: functional balance is impaired after clinical recovery.

BACKGROUND: The ability of patients to walk without assistance after spinal anesthesia is a determining factor in the time to discharge following ambulatory surgery. The authors compared clinical markers of gross motor recovery with objective data of functional balance after spinal anesthesia. METHODS: Twenty-two male patients with American Society of Anesthesiology physical status I or II who were scheduled for perineal surgery were studied during recovery from spinal anesthesia to compare the predictive accuracy of clinical markers of ambulatory readiness (e.g., full knee flexion and extension) with that of an objective method of measurement focused on functional balance. Lumbar puncture was performed at the L2-L3 or L3-L4 interspace using a 25-gauge Whitacre needle, with patients in the sitting position. A 3-ml mixture of 5 mg bupivacaine (heavy) and 10 microg fentanyl was injected. Block regression and restoration of motor function were assessed and recorded. Functional balance was measured using a computerized force platform method. RESULTS: The majority of patients maintained motor function and proprioception sensation at the onset of surgical anesthesia, as indicated by performance on clinical tests of function: 96% were able to perform the straight leg increase; 82, 77, and 91%, respectively, were able to perform full knee flexion and extension, perform heel-to-shin maneuvers, and identify joint position in the supine position. Postoperatively, clinical return of motor function occurred much earlier than recovery of functional balance. At 60 min after onset of spinal anesthesia, 22 patients (100%) had recovered sensory and gross motor function, but only 36% could stand, and 8% could walk without assistance (P < 0.01). At 150-180 min after onset, 96-100% of patients achieved the levels of functional balance that permitted adequate ambulation. CONCLUSIONS: The results suggest that the recovery time to unassisted ambulation is longer than has been assumed, and that the standard clinical markers of gross motor function are poor predictors of functional balance following ambulatory surgery.

Adolescent↗
PubMed2002

Probable gas embolism during operative hysteroscopy caused by products of combustion.

PURPOSE: Gas embolism is a rare but well documented entity during operative hysteroscopy, with an incidence of 10-50%. Catastrophic outcomes occur at a rate of three in 17,000 procedures. The purpose of this report is to present a non-fatal case of gas embolism probably caused by the gaseous products of combustion. CLINICAL FEATURES: A 50-yr-old woman with a history of menorrhagia was scheduled for hysteroscopy and endometrial ablation and polypectomy. Fifteen minutes into the procedure, with the patient in lithotomy position, 20 degree head down tilt, and breathing spontaneously, a sudden oxygen desaturation occurred from 97% to 87%. The patient's end-tidal carbon dioxide dropped from 46 mmHg to 27 mmHg. The patient's breathing pattern remained normal, respiratory rate remained 11-12 breaths x min(-1) but amplitude of the reservoir bag movement was increased. Cardiovascular variables remained stable. She responded rapidly to 100% oxygen and made an uneventful recovery. Having ruled out other possible causes, we concluded gas embolism was responsible for the fall in oxygen saturation and end-tidal CO(2). CONCLUSION: With all the precautions in place to minimize the likelihood of fluid overload and ambient air embolism occurring, we surmised that products of combustion were the cause of the gas embolism. During endometrial ablation, gaseous products of combustion, mainly carbon dioxide, accumulate. The gases may then contribute to the rise in uterine pressure that occurs as irrigation fluid enters the uterus and this rise in pressure in turn encourages passage of gas into the open venous sinuses.

Carbon Dioxide↗
PubMed2002

Canadian survey of postsurgical pain and pain medication experiences.

PURPOSE: To assess the postoperative pain and pain medication experiences of Canadians. METHODS: Three hundred and five general population subjects from across Canada who had surgery in the previous three years were retrospectively questioned regarding pain experiences in the surgical facility and at home, pain medication efficacy and pain medication satisfaction. RESULTS: While in the surgical facility, pain was experienced by 68% of patients who expected overnight admission ("inpatients") and 49% of patients who expected same-day discharge ("outpatients"). Overall, 47% of inpatients and 15% of outpatients reported that their highest experience of pain was severe or extreme; 25% of inpatients and 9% of outpatients reported that their average pain was severe or extreme. In the two weeks post-discharge, 79% and 74% respectively of inpatients and outpatients experienced pain. Severe or extreme pain occurred at home in 25% of inpatients and 28% of outpatients; average pain was severe or extreme for 9% of inpatients and 12% of outpatients. Complete or a lot of pain relief was experienced by 54% to 72% patients who received pain medication; higher rates of pain medication satisfaction were reported than rates of pain relief from pain medication. CONCLUSION: Severe or extreme pain was experienced by many surgical patients. Improvements could be made to patients' postsurgical pain experience in Canada, both in the surgical facility and subsequent to discharge.

Adolescent↗
PubMed2002

Titration of isoflurane using BIS index improves early recovery of elderly patients undergoing orthopedic surgeries.

PURPOSE: This study was designed to investigate the effect of bispectral index (BIS) monitoring on the recovery profiles, level of postoperative cognitive dysfunction, and anesthetic drug requirements of elderly patients undergoing elective orthopedic surgery with general anesthesia. METHODS: Sixty-eight patients over the age of 60 were randomized into one of two groups. In the standard practice (SP) group, the anesthesiologists were blinded to the BIS value, and isoflurane was titrated according to standard clinical practice. In the BIS group, isoflurane was titrated to maintain a BIS value between 50-60. RESULTS: The total isoflurane usage was 30% lower in the BIS group compared to the SP group (5.6 +/- 3 vs 7.7 +/- 3 mL, P <0.05). The time to orientation was faster in the BIS group compared to the SP group (9.5 +/- 3 vs 13.1 +/- 4 min, P <0.001). There were no differences in the postoperative psychometric tests between the two groups. CONCLUSIONS: There was no difference in the level of postoperative cognitive dysfunction between the two groups. However, titration of isoflurane using the BIS index decreased utilization of isoflurane and contributed to faster emergence of elderly patients undergoing elective knee or hip replacement surgery.

Aged↗
PubMed2002

Fat embolism syndrome and elective knee arthroplasty.

PURPOSE: To report a case of fat embolism syndrome (FES) following elective left knee arthroplasty and review the diagnosis, investigation, prevention and perioperative management of this condition. CLINICAL FEATURES: A 76-yr-old lady presented for left total knee arthroplasty under general anesthesia. After an uneventful anesthetic and initial recovery, she developed respiratory and neurological complications six hours postoperatively necessitating supportive care in the intensive care unit. Following extensive investigation, a clinical diagnosis of FES was made 48 hr postoperatively supported by the development of diffuse encephalopathy, thrombocytopenia, hypoxemia, chest petechiae and chest x-ray changes. A magnetic resonance imaging scan five days postoperatively confirmed this diagnosis. Her postoperative course showed gradual improvement consistent with a slowly resolving encephalopathy. Previous published cases of FES associated with knee arthroplasty present either with intraoperative cardiorespiratory collapse or, as with this patient, in the postoperative period with respiratory, cardiovascular and/or cerebral dysfunction. CONCLUSIONS: The clinical diagnosis of FES is essentially one of exclusion, supported by laboratory and radiological investigations. Preoperative identification of at-risk patients, use of appropriate invasive perioperative monitoring and modified surgical techniques may minimize the development of the syndrome. Treatment is supportive.

Aged↗
PubMed2002

The assessment of postural stability after ambulatory anesthesia: a comparison of desflurane with propofol.

UNLABELLED: We designed this study to evaluate postural stability in outpatients after either desflurane or propofol anesthesia. After IRB approval, 120 consenting women undergoing gynecological laparoscopic procedures were randomly assigned to receive either desflurane or propofol-based general anesthesia. After surgery, patients' postural stability was measured as body sway velocity by using a computerized force platform in the following conditions: 1) standing on a firm surface with eyes open versus closed and 2) standing on a foam surface with eyes open versus closed. These measurements were made before anesthesia, immediately after the patient achieved a Post-Anesthesia Discharge Score of 9, and at actual discharge home. At the time patients first achieved a Post-Anesthesia Discharge Score of 9, the body sway in the Propofol group was significantly more than in the Desflurane group when patients were asked to stand on a foam surface with eyes closed (testing the ability of using vestibular information for balance control). We concluded that the desflurane-based anesthetic was associated with better postural control than the propofol-based anesthetic in the early recovery period after outpatient gynecological laparoscopic procedures. IMPLICATIONS: The residual effects of the short-acting general anesthetics desflurane and propofol on patient's balance function during recovery after surgery were assessed with a computerized force platform. The results showed that desflurane seemed to be associated with better postural control than propofol in the early recovery period.

Adult↗