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PubMed1994

Critical respiratory events in the postanesthesia care unit. Patient, surgical, and anesthetic factors.

BACKGROUND: Previous studies have noted a high incidence of adverse outcomes in the postanesthesia care unit (PACU), but few have examined associated factors and patient outcomes. To determine the frequency of acute, unanticipated respiratory problems and to examine the associated patient, surgical, and anesthetic factors, we prospectively collected preoperative, intraoperative, and postoperative data on 24,157 consecutive PACU patients who received a general anesthetic during a 33-month period. METHODS: A PACU critical respiratory event (CRE), was defined as any unanticipated hypoxemia (hemoglobin oxygen saturation < 90%), hypoventilation (respiratory rate < 8 breaths/min or arterial carbon dioxide tension > 50 mmHg) or upper-airway obstruction (stridor or laryngospasm) requiring an active and specific intervention (ventilation, tracheal intubation, opioid or muscle relaxant antagonism, insertion of oral/nasal airway or airway manipulation). These problems were documented by PACU nurses whereas data on case-mix, surgical factors, and intraoperative management were retrieved from the anesthetic record. Significant patient, surgical, and anesthetic factors were identified by logistic regression analysis. Other morbidity experienced by patients with a CRE was also noted. RESULTS: For patients given general anesthesia the risk of a CRE was 1.3% (hypoxemia 0.9%, hypoventilation 0.2%, airway obstruction 0.2%). Preoperative factors that increase risk were age > 60 yr, male gender, diabetes, and obesity (P < 0.05). Patients who underwent operative procedures on an emergency basis and whose operation was longer than 4 h were also at increased risk, but those undergoing perineal procedures were at lower risk (P < 0.05). Anesthetic risk factors (P < 0.05) included opioid premedication (relative odds 1.8), sedatives preoperatively (2.0), fentanyl > 2.0 micrograms.kg-1.h-1 as the sole opioid (1.9), fentanyl used in combination with morphine (1.6) and atracurium > or = 0.25 mg.kg-1.h-1 (2.2). Patients in whom anesthesia was induced with thiopental (relative odds 2.5), compared with those who received propofol for induction, were also at increased risk of a CRE. Patients with a CRE stayed longer in PACU, had higher rates of unanticipated admissions to the intensive care unit and were more likely to have PACU cardiac problems (P < 0.01). CONCLUSIONS: A CRE is relatively rare. Multiple patient and surgical factors and specific aspects of anesthetic management are associated with the occurrence of a CRE in the PACU.

Airway Obstruction↗
PubMedDate not supplied

Children sedated for dental care: a pilot study of the 24-hour postsedation period.

PURPOSE: The purpose of this prospective, pilot study was to investigate postsedation events during the first 24 hours after discharge from the treatment facility in children sedated for dental treatment. METHODS: This prospective study involved a convenience sample of 30 healthy patients, ranging from 2 to 5 years of age, who were scheduled to undergo sedation in the dental clinic for operative procedures. Depending on the extent of dental need, child temperament, and other preoperative assessment variables, the children received either a triple combination of chloral hydrate, meperidine, and hydroxyzine ranging in dose from 20 to 30 mg/kg, 1 to 2 mg/kg, 1 to 2 mg/kg, respectively, or midazolam alone (0.5-0.75 mg/kg). Care was provided consistent with the American Academy of Pediatric Dentistry (AAPD) and hospital sedation guidelines. Parents were given a questionnaire concerning events that may occur during the 24 hours after the sedation and were told they would be interviewed via telephone regarding these events. The principal investigator called 24 hours after the sedation visit and interviewed the parents using the questionnaire given to the parents. Data analysis included descriptive statistics, frequency, and chi-square analysis. RESULTS: Data from 30 sedations were used. Differences were noted between a chloral hydrate, meperidine, and hydroxyzine regimen compared to midazolam alone for incidence of sleep on the way home or shortly after arriving at home, but not for postoperative pain, vomiting, eating, evening sleep, and memory. Those receiving the combination regimen were more likely to sleep on the way to and at home than those who received midazolam alone. CONCLUSIONS: It may be concluded that: (1) opportunities for the occurrence of an adverse event may occur on the way or at home following a sedation appointment; and (2) discharge criteria of the AAPD guidelines on elective use of minimal, moderate, or deep sedation and general anesthesia for pediatric dental patients should be met or exceeded as a precautionary measure to prevent adverse events once a child who has received sedative agents leaves a health care facility.

Anesthesia Recovery Period↗
PubMed1995

Brief wakeful response to command indicates wakefulness with suppression of memory formation during surgical anesthesia.

OBJECTIVE: In a previous study of patients emerging from anesthesia following surgery, we found that a brief wakeful response to command of an eye opening or single hand squeeze or count was not associated with memory formation, while the response of four hand squeezes or counts was associated with memory. We wanted to determine the anesthetic requirements for obtaining this brief wakeful response endpoint during surgery and to determine if memory occurred at this endpoint during surgical anesthesia. METHODS: Six different combinations of isoflurane, 70% N2O, and fentanyl were administered to 326 patients undergoing pelvic laparoscopy. After insertion of the trocar, anesthesia was reduced while patients were given verbal commands, and they were observed for movement responses to surgery and to command. Patients were classified as either not arousing, arousing with a movement response to surgery, or arousing with a wakeful response to command. For the patients who aroused, we calculated the percentage of arousal responses that were wakeful responses to command. The effect of fentanyl dosage upon the percentage of arousal responses that were wakeful responses to command was determined by using a Mann-Whitney test to compare a group of patients receiving fentanyl 2 micrograms/kg or less, with a group receiving fentanyl 4 micrograms/kg. In a subset of 39 patients, the potential for memory formation was evaluated by presenting a target sound to 29 patients during a period of either no arousal, movement response to surgery, or wakeful response to command; for a control group of 10 patients, no target sound was presented. All 39 patients were tested for memory of the target sound; the results from each group receiving a target sound were compared with the results of the control group, using a Mann-Whitney test. MAIN RESULTS: A total of 68 patients aroused with either a movement response or a wakeful response to command. Wakeful responses occurred with only 1 of 39 patients (3%) receiving fentanyl 2 micrograms/kg or less; but, wakeful responses occurred with 17 of 29 patients (59%) receiving fentanyl 4 micrograms/kg. The difference between the groups was significant at p = 0.01. None of the 68 patients had recall of intraoperative events or unpleasant dreams. None of these patients who were in the multiple-choice memory subset recalled the target sound. There were no statistically significant differences on the multiple-choice memory test between the groups presented with the target sound and the control group. Patient anecdotes suggested that some patients may have had memory of the target sound; but, memory was no more likely in patients with a brief wakeful response to command than in those who responded with a movement to surgical stimulation or those who did not have an arousal response. CONCLUSIONS: A brief wakeful response to a command of opening the eyes or squeezing the hand was not associated with increased memory formation during surgery. A brief wakeful response to command was found during surgery when patients received fentanyl 4 micrograms/kg; but it was rarely found at fentanyl dosages of 2 micrograms/kg or less.

Adolescent↗
PubMed2001

Remifentanil and fentanyl during anaesthesia for major abdominal and gynaecological surgery. An open, comparative study of safety and efficacy.

BACKGROUND: and objective This open, multicentre study compared the efficacy and safety of remifentanil with fentanyl during balanced anaesthesia with 0.8% isoflurane (end-tidal concentration) for major abdominal and gynaecological surgery, and the efficacy and safety of remifentanil for pain management in the immediate postoperative period. METHODS: Two-hundred and eighty-six patients were randomized to receive remifentanil 1 microg kg(-1) followed by 0.2 microg kg(-1) min-1 (n=98), remifentanil 2 microg kg(-1) followed by 0.4 microg kg(-1) min(-1) (n=91) or fentanyl 3 microg kg(-1) (n=97) at induction. Thereafter, the study opioids and isoflurane were titrated to effect during the operation. RESULTS: Compared with fentanyl, remifentanil 2 microg kg(-1) followed by 0.4 microg kg(-1) min(-1) reduced the incidence of response to tracheal intubation (30% vs. 13%, P < 0.01), skin incision (33% vs. 4%, P < 0.001) and skin closure (11% vs. 3%, P < 0.05), respectively. Patients receiving remifentanil 1 microg kg(-1) followed by 0.2 microg kg(-1) min(-1) had fewer responses to skin incision than the fentanyl group (12% vs. 33%, P < 0.001), but the incidences of response to tracheal intubation and skin closure were similar. Significantly fewer patients in both remifentanil groups had > or = 1 responses to surgical stress intraoperatively compared with fentanyl (68% and 48% vs. 87%, P < 0.003). The mean isoflurane concentrations required were less in both remifentanil groups compared with the fentanyl group (0.1%, P=0.05). In remifentanil-treated patients, continuation of the infusion at 0.1 microg kg(-1) min(-1) with titration increments of +/- 0.025 microg kg(-1) min(-1) was effective for the management of immediate postoperative pain prior to transfer to morphine analgesia. However, a high proportion of patients experienced at least moderate pain whilst the titration took place. CONCLUSIONS: Anaesthesia combining isoflurane with a continuous infusion of remifentanil was significantly more effective than fentanyl at blunting responses to surgical stimuli. Significantly fewer patients responded to tracheal intubation with remifentanil at 0.4 microg kg(-1) min(-1), supporting the use of a higher initial infusion rate before intubation. Both remifentanil and fentanyl were well-tolerated, with reported adverse events typical of mu-opioid agonists.

Abdomen↗
PubMed1994

Laryngeal mask airway vs face mask and Guedel airway during pediatric myringotomy.

OBJECTIVE: To compare perioperative conditions when a face mask and Guedel oral airway (FM-OA) or a laryngeal mask airway (LMA) are used to maintain airway patency during bilateral myringotomy with insertion of tympanostomy tubes (BMT). DESIGN: Randomized controlled trial in children's hospital tertiary-care operating rooms. PARTICIPANTS: Fifty healthy children undergoing BMT procedures during halothane--nitrous oxide (N2O) anesthesia. INTERVENTIONS: During BMT we managed the airway by inserting a Guedel oral airway or an LMA. MAIN OUTCOME MEASURES: We recorded the time taken to insert the airway device along with oxygen saturation during the operation and time from the end of surgery to eye opening, response to commands, and home readiness. In addition the surgeon assessed perioperative conditions on a 10-point scale (1, poor, through 10, excellent). RESULTS: Although insertion of the LMA took longer than the Guedel oral airway (mean +/- SD, 9 +/- 2 seconds vs 6 +/- 2 seconds; P < .05), no differences were noted in the actual operating, anesthesia, or recovery times. However, the frequency of hypoxemic episodes was decreased (8% vs 36%, P < .05) and the lowest recorded oxygen saturations were higher (mean +/- SD, 95% +/- 7% vs 88% +/- 12%; P < .05) in the LMA group than in the FM-OA group. Surgeons rated perioperative conditions better when the LMA was used (median score, 9 vs 8; P < .05). CONCLUSION: The LMA is an excellent alternative to the FM-OA technique for airway maintenance in children undergoing BMT procedures during halothane--N2O anesthesia.

Anesthesia Recovery Period↗
PubMedDate not supplied

Effects of general anesthesia on the human blink reflex.

The blink reflex was studied in 10 patients undergoing elective procedures under general anesthesia. Anesthetic agents were isoflurane, halothane, nitrous oxide, methohexital, and thiopental in various combinations. At induction, blink reflexes were diminished by low-dose thiopental (1-1.5 mg/kg) and abolished by high-dose thiopental (4-8 mg/kg) and methohexital (1.5 mg/kg). Blink reflexes were absent during halogenated volitile inhalational anesthesia and did not return until patients were in the recovery room, well after end-tidal anesthetic levels were zero by mass spectroscopy. Recovery of consciousness and the ability to blink on command often preceded return of any blink reflex activity, indicating that the blink reflex is not useful as a postoperative test of facial nerve function in the operating room after anesthesia. In six patients, blink reflexes were still diminished 2-3 hours after cessation of anesthesia, at a time when patients were fully oriented and corneal and eyelid reflexes were clinically normal. This finding suggests that the blink reflex might be a sensitive test of subtle CNS dysfunction after inhalational anesthesia and potentially could serve as a useful objective indicator of recovery from anesthesia for outpatient surgery.

Adult↗
PubMed1990

Ambulatory anesthesia.

Ambulatory surgical procedures are a large and increasing fraction of all surgery in the United States. A specialized health care team must be assembled to care for these patients and meet their special needs. Ambulatory surgery patients should be selected according to medical and psychosocial criteria. Patient preparation includes a history and physical examination, limited laboratory tests, empty stomach, and appropriate monitoring. Premedication should be supportive, and verbal as well as medicinal; drugs include ataractics and analgesics. All forms of general or regional anesthesia may be used. Recovery goals must be well defined, aiming for "home readiness." Ambulatory anesthesia care is concluded with postdischarge follow-up, for quality assurance and risk management.

Ambulatory Surgical Procedures↗
PubMed1993

Acceptable ranges for vital signs during general anesthesia.

OBJECTIVE: Define the ranges for normal vital signs during general anesthesia. METHODS: We studied 50 patients undergoing general anesthesia. We asked residents to state desirable ranges for each patient's systolic and diastolic blood pressure (BP), heart rate (HR), SpO2, and PETCO2 during induction, intubation, maintenance, and emergence from anesthesia. We called these ranges the clinical operating range (COR) and observed the frequency, duration, and magnitude of transgressions of these CORs. We also recorded whether the transgressions were treated or tolerated, or whether the COR values were changed. RESULTS: Upper COR values in the maintenance phase for systolic BP were 38% +/- 20% above the preoperative values and 30% +/- 20% above the values recorded just before induction of anesthesia. Lower COR values in the maintenance phase for systolic BP were 27% +/- 9% below preoperative, and 31% +/- 11% below preinduction values. For HR, upper and lower COR values in the maintenance phase were 53% +/- 44% above and 38% +/- 17% below preinduction values, respectively. Transgressions of COR values for BP and HR were common, treatment frequent, and redefinition of COR values rare. CONCLUSION: Clinicians recognize ranges for vital signs during uneventful anesthesia. These CORs may differ from one stage of anesthesia to the next. Transgressions of these ranges are common. Not all transgressions are treated.

Adolescent↗
PubMed1995

Wakeful response to command indicates memory potential during emergence from general anesthesia.

OBJECTIVE: An important aspect of assessing anesthetic depth is determining whether a patient will remember events during surgery. We looked for a clinical sign that would indicate a patient's potential for memory formation during emergence from anesthesia. A clinical sign indicating memory potential could be a useful endpoint for measuring the performance of anesthetic depth monitors and for titrating administration of anesthetic agents. METHODS: We evaluated patients' responses to commands to open the eyes, squeeze the hand four times, and count 20 numbers. These responses were correlated with results on recall, cued recall, and multiple-choice memory tests. MAIN RESULTS: Patients did not have evidence of memory formation until they sustained wakefulness sufficiently long to complete at least four hand squeezes or count four numbers. Of 28 patients, 13 (46%) with this sustained wakeful response had memory. Of 22 patients, 0 (0%) had evidence of memory formation when they demonstrated a brief wakeful response, defined as being responsive to command but unable to complete more than one hand squeeze or count, or an intermediate response, defined as two or three hand squeezes or counts. CONCLUSIONS: We conclude that a brief wakeful response to command indicates that a patient is unlikely to form memories, while a sustained wakeful response indicates that a patient may form memories. Thus, a patient's wakeful response to command could be a useful indicator of potential for memory.

Adult↗
PubMed1989

The use of pulse oximetry in post-operative hypoxaemia in patients after propofol induction of anaesthesia.

Pulse oximetry was used to measure changes in oxygen saturation in the early post-operative phase in three groups of 50 patients in whom anaesthesia was induced with propofol. One group breathed room air during induction and anaesthesia was maintained with halothane whereas the other two groups both breathed oxygen during induction and anaesthesia was maintained with either halothane inhalation or a propofol infusion. In 59 patients distributed fairly evenly between the three groups the oxygen saturation fell below 90%; the mean minimum oxygen saturation was 91.7 +/- 0.3 and the mean time at which it occurred was 3.9 +/- 0.4 min after the anaesthetic was withdrawn. Neither the inhalation of oxygen during induction nor the anaesthetic technique affected the decrease in postoperative oxygen saturation but the infusion group took significantly longer to recover consciousness.

Adolescent↗
PubMed1992

Neurological examination in patients recovering from general anesthesia.

We performed serial neurological evaluations on 86 patients who underwent surgery for herniated lumbar disk during the first 3 hours after the end of anesthesia (isoflurane-N20-02 for 25 patients, halothane-N20-02 for 38, fentanyl-droperidol-N20-02 for 23). At time 0, the idiomuscular response to percussion of the extensor carpi muscle was present in every patient, while tendon reflexes were always absent. Hyperreflexia was as frequent as shivering, but it took place earlier; we could determine no correlation between these two phenomena. There was no correlation between shivering and rectal temperature of the patients. Although almost all the patients were cooperative and could correctly calculate 100-7, the post-hyperventilation-apnea test was positive in 35 patients at time 120 minutes: this suggests that many patients considered "awake" still exhibit neurological abnormalities, such as inadequate respiratory drive.

Adolescent↗
PubMed1993

Clinical office anesthesia: the use of propofol for the induction and maintenance of general anesthesia.

Ambulatory surgery has become routine for many plastic surgery procedures. Anesthesia techniques including general anesthesia by inhalation and intravenous infusion and the dissociative technique have all been used successfully for outpatient anesthesia. Propofol (Diprivan), a relatively new agent, has proven to be a safe and effective general anesthesia agent for outpatient surgery. We report on our experience with propofol as an induction agent and continuous drip for general anesthesia maintenance in 100 consecutive outpatient, plastic surgery procedures performed in an office facility. Assessment factors were recovery-room time, nausea and vomiting in the recovery room and at home, hallucinations, patients' recollection of anesthesia experience, and overall patient satisfaction.

Ambulatory Surgical Procedures↗
PubMed2002

Functional magnetic resonance imaging of swine brain during change in thiopental anesthesia into EEG burst-suppression level--a preliminary study.

Deepening anesthesia produces well known changes in electroencephalogram (EEG) and evoked potentials, differing in pathological and normal brain. Yet, it is not known how the T2*-weighted signal changes in the healthy brain during deepening anesthesia. We studied the effect of thiopental bolus on functional magnetic resonance imaging (fMRI) in the healthy brain using porcine model. In five pigs (2-3 months, 20-25 kg), the control bolus prior to fMRI resulted in a change into burst-suppression. After the recovery of continuous EEG, fMRI (4 min) was performed with a single bolus of thiopental (11.4-17.1 mg/kg) administered 1 min after the onset of imaging. This was repeated in four of five pigs. Positive (6-8%) or negative (-3 to -8%) signal intensity changes correlated to the thiopental bolus injection were seen in the group average fMRI response. Positive response was 1.6% and negative response 2.3% of the total brain region of interest (ROI) voxels. Responding voxels were distributed more prominently in the thalamic ROI (4.5%) than in the cortical ROI (2.2%). The group average of unthresholded voxel time courses showed that the net effect of thiopental bolus was a small (0.5%) but a clear positive change in the thalamic region, while variance changed in the global level. In conclusion, this study is the first to show that significant signal intensity changes occur in fMRI response during the sudden deepening of thiopental anesthesia. However, these responses are neither anatomically constant nor global in the healthy swine brain.

Anesthesia Recovery Period↗
PubMed1988

Do evoked potentials measure depth of anaesthesia?

Somatosensory evoked potentials have been suggested as a possible neurophysiological in of anaesthetic depth. In order to test the usefulness of this technique of monitoring, 8 patients were monitored during balanced anaesthesia. Following induction with a sleep dose of thiopentone, a neuromuscular blocking agent was used and the patients' lungs ventilated with N2O/O2(F1O2 = 0.3). This was supplemented with halothane or fentanyl. Somatosensory evoked potentials were recorded every 10 minutes during surgery, blood pressure and heart rate being recorded at the end of each evoked potential measurement. Induction of anaesthesia was associated with the reduction in SEP amplitude from 4.2 +/- 1.04 micro volts to 1.6 +/- 0.9 micro volts. There was an increase in latency from 19.2 +/- 1.3 msec to 20.0 +/- 1.3 msec to 20.0 +/- 1.5 msec. Recovery from anaesthesia was accompanied by an increase in SEP amplitude pre-induction values. There were no apparent correlations between the changes in evoked potential measures and changes in heart rate or blood pressure. Consistent change in somatosensory evoked potentials (prolonged latency, decreased amplitude) occurred with both narcotic and volatile anaesthetics. There was a recovery of evoked potentials at the end of anaesthesia. This is a promising technique, worthy of further evaluation.

Anesthesia Recovery Period↗
PubMed1990

Comparative evaluation of propofol and thiopentone for total intravenous anaesthesia.

Sixty unpremedicated ASA physical status I or II patients scheduled for surgical procedures of intermediate duration (15 to 60 min) were studied to evaluate the safety and efficacy of propofol, to measure recovery times and to compare the return of psychomotor and cognitive function with thiopentone. Patients were randomly allocated into two groups. Anaesthesia was induced and maintained by either propofol (2.0-2.5 mg.kg-1 followed by a continuous infusion 0.1-0.2 mg.kg-1.min-1) or thiopentone (4.0-5.0 mg.kg-1, and infusion rate 0.16-0.32 mg.kg-1.min-1), titrated to patient response. Succinylcholine was administered to facilitate tracheal intubation and maintain neuromuscular blockade. Induction of anaesthesia was slightly longer with propofol than thiopentone (42.2 vs 29.8 sec) and was smooth with both drugs. Post-intubation increases in heart rate, and systolic and diastolic blood pressures were attenuated by propofol when compared with thiopentone. After the administration of propofol, times to eye opening (6.4 +/- 4.3 vs 13.9 +/- 15.9 min), response to verbal command (7.6 +/- 6.3 vs 15.4 +/- 16.6 min) and orientation (22.7 +/- 12.8 vs 36.2 +/- 23.1 min), were significantly shorter. Psychomotor and cognitive function returned earlier with propofol and fewer side effects were noted. At 24 hr there was no distinguishable difference between groups. Propofol is a safe anaesthetic agent with the potential for early patient discharge and street fitness after outpatient procedures.

Adult↗
PubMed1990

Changes in arterial oxygen saturation in cigarette smokers following general anaesthesia.

The effect of cigarette smoking on postoperative arterial oxygen saturation was evaluated in 45 adult patients using pulse oximetry. Patients were divided into a smoking group (n = 20) and a non-smoking group (n = 25) based on current smoking habits up until the time of surgery. The two groups were similar with respect to sex, ASA physical status, surgical procedure, duration of anaesthesia, narcotic and anaesthetic use and recovery characteristics. The non-smoking group was, however, significantly (P less than 0.05) older than the smoking group. Postoperative oxygen saturation (SaO2) decreased (P less than 0.001) during transport of both groups of patients from the Operating Room to the Recovery Room; a decrease which was significantly greater in the smoking group. The severity of hypoxaemia was also significantly greater in the smoking group than in the non-smoking group. This study suggests that cigarette smoking contributes to postoperative arterial oxygen desaturation following general anaesthesia and that supplemental oxygen should be administered to these patients during postoperative transport.

Adult↗
PubMed1990

Timing of caudal block placement in relation to surgery does not affect duration of postoperative analgesia in paediatric ambulatory patients.

The purpose of this study was to determine if the timing of caudal block placement in relation to surgery affected either the duration of postoperative pain relief or the discharge time in children undergoing brief ambulatory surgical procedures. Forty ASA physical status I or II children ages 18 mo to 11 yr were randomly assigned to one of two groups. Group 1 patients received a caudal block with 0.5 ml.kg-1 of bupivacaine 0.25 per cent following the induction of anaesthesia but before the onset of surgery. Group 2 patients received a similar block at the completion of surgery but before emergence from general anaesthesia. An experienced observer, who was not aware of the timing of block placement, observed all patients from arrival to the post-anaesthetic recovery room until discharge from the ambulatory surgery unit. Pain was assessed at five-minute intervals using an Objective Pain Scale. No statistically significant differences were noted between Group 1 and Group 2 patients with regard to their postoperative pain/discomfort scores, the need for postoperative narcotic analgesia, or the time required for either group to meet standard discharge criteria. It is concluded that the duration of postoperative analgesia is not impaired by placing the caudal block prior to the start of a brief surgical procedure.

Ambulatory Surgical Procedures↗