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PubMed1989

Anaesthesia for day case oral surgery.

A study was undertaken to evaluate the quality of recovery and the extent of morbidity following the extraction of wisdom teeth on an outpatient basis. Two anaesthetic techniques were compared, one based on spontaneous respiration and the other on mechanical ventilation, both were based on propofol and were in other respects tailored to the requirements of the short stay patient. Objective tests of recovery demonstrated no differences between the groups at 30 and 60 minutes postoperatively, and there was similarly no difference in the incidence of morbidity symptoms apart from a 16% incidence of severe muscle pain associated with the use of suxamethonium. The overall patient acceptability for the procedure was high; 80% in each group. It is argued that recent improvements in agents available for short stay anaesthesia should enable many patients hitherto treated as inpatients to be transferred to the outpatient setting with considerable economic benefit.

Adult↗
PubMed1993

Recovery from intravenous sedation with midazolam--the value of flumazenil.

A total of 40 patients receiving intravenous midazolam for surgical removal of impacted wisdom teeth were randomly assigned to recover either spontaneously or undergo reversal by the benzodiazepine antagonist flumazenil. Whilst initial postoperative recovery to a 'fully awake' state occurred more rapidly in the reversal group, objective psychomotor testing revealed significantly poorer performance postoperatively compared with spontaneously recovering patients; this emphasises the need to retain patients for at least 1 h prior to discharge home.

Adult↗
PubMed1990

Incidence of hypoxemia in the postanesthetic recovery room in patients having undergone intravenous sedation for outpatient oral surgery.

This study prospectively quantitated the incidence of hypoxia in outpatients in a postanesthetic recovery unit following intravenous (IV) sedation. After identifying the high incidence of hypoxia by the use of pulse oximetry, supplemental oxygen was given to another group of patients and the incidence of the hypoxia was again monitored. Twenty of 100 patients experienced hypoxic episodes in the postanesthetic recovery unit when no supplemental oxygen was administered; only 3 of an additional 100 patients who received supplemental oxygen had episodes of hypoxia. The difference between the groups receiving and not receiving supplemental oxygen was both clinically and statistically significant. As result of this study, the use of supplemental oxygen is recommended for all patients undergoing IV sedation for outpatient oral surgery.

Adolescent↗
PubMed1995

Propofol infusion technique for outpatient general anesthesia.

PURPOSE: The purpose was to evaluate the suitability of a continuous propofol infusion in combination with alfentanil for outpatient general anesthesia in an oral and maxillofacial surgery practice. MATERIALS AND METHODS: Twenty-seven ASA 1 patients were selected to undergo oral and maxillofacial surgery outpatient procedures of short duration. Induction of anesthesia was accomplished with 1 mg/kg intravenous (i.v.) propofol and 10 micrograms/kg i.v. alfentanil. Local anesthesia was administered. General anesthesia was maintained with a continuous infusion of 150 micrograms/kg/min of propofol. Various physical and psychomotor responses were recorded during induction, maintenance, emergence, and recovery. RESULTS: Anesthesia was successfully induced in all patients with single, slowly titrated, bolus doses of 1 mg/kg of propofol and 10 micrograms/kg of alfentanil. Induction of general anesthesia occurred in less than 1 minute in all cases and no excitatory phenomena, tremor, or hypertonus were observed. Maintenance of anesthesia was adequately accomplished and cardiovascular parameters remained within acceptable limits throughout the procedure. The average length of surgery was 22 minutes. Movement to surgical stimulus was minimal and easily managed with additional local anesthetic and/or a 10-mg bolus of propofol. Time to eye opening was approximately 5 minutes from the discontinuation of the propofol infusion. No emergence phenomena were observed. All patients were ready for discharge with baseline psychomotor activity within 30 minutes following the end of the procedure. The average total dose of propofol was 350 mg and the average dose of alfentanil was 750 micrograms. CONCLUSION: This anesthetic technique has numerous advantages with minimal side effects, and should be considered for routine use for outpatient general anesthesia in oral and maxillofacial surgery.

Adolescent↗
PubMed1995

Intramuscular ketamine, midazolam, and glycopyrrolate for pediatric sedation in the emergency department.

PURPOSE: The safety and efficacy of a new sedation technique for children with facial injuries in the emergency department were prospectively evaluated. MATERIALS AND METHODS: Thirty-seven children between the ages of 12 months and 7 years old who required sedation for minor surgical procedures were administered an intramuscular injection of ketamine (3 mg/kg), midazolam (0.05 mg/kg), and glycopyrrolate (0.005 mg/kg). A second 1-mg/kg intramuscular injection of ketamine alone was given if needed. Pulse rate, cardiac rhythm, respiratory rate, oxygen saturation, side effects, and behavior were recorded. RESULTS: Satisfactory sedation was achieved after a single injection in 32 children; five others required a second ketamine injection (1 mg/kg). Onset of anesthesia occurred within 6 minutes in 73% of the children who received one injection, and there were generally adequate working conditions for 30 minutes. The average time from initial injection to discharge was 76 minutes. Results of physiologic monitoring, behavioral ratings, and side effects are reported. Emergence delirium and hallucinations were not observed. Ketamine reliably produced dissociative anesthesia without loss of respiratory drive or protective airway tone. Midazolam reduced the incidence of ketamine-induced dysphoric reactions and muscular hypertonicity. CONCLUSION: The use of intramuscular ketamine, midazolam, and glycoyrrolate is a safe, effective, and practical approach to managing selected pediatric injuries in the emergency department. Advanced airway management proficiency is recommended for use of this technique.

Anesthesia Recovery Period↗
PubMed1990

Reversal of midazolam sedation with flumazenil following conservative dentistry.

The purpose of this double-blind randomized study was to assess recovery of mental function following reversal of midazolam-induced sedation with the specific antagonist flumazenil (R015-1788) or placebo following conservative dental procedures. Recovery was assessed using choice reaction time and critical flicker fusion threshold, both objective tests of psychomotor function; linear analogue sedation scores and simple memory tests. Assessments were repeated up to 3 h after administration of flumazenil or placebo to discover whether recovery was sustained or whether resedation occurred due to the short duration of action of flumazenil. Flumazenil in doses from 0.5 to 1.0 mg rapidly reversed the sedative and amnesic effects of a mean dose of 8.2 mg of midazolam without apparent evidence of subsequent resedation. Since recovery of mental function in the control group had ordinarily occurred 45 min after administration of placebo, routine reversal of midazolam sedation with flumazenil cannot be justified. Nevertheless, in cases of undue sedation persisting after dental treatment, flumazenil may be used with minimal risk of resedation occurring.

Adolescent↗
PubMed1989

Anesthetic management for surgical removal of renal carcinoma with caval or atrial tumor thrombus using deep hypothermic circulatory arrest.

Twenty cases of renal carcinoma with tumor thrombus extending into the vena cava or atrium, in which cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) were used, are reviewed. Arterial, central venous (n = 9), or pulmonary artery catheters (n = 11), ECG, and rectal or bladder and pharyngeal temperatures were used for monitoring. The anesthetic was a high-dose narcotic supplemented with a nondepolarizing relaxant and a volatile agent. The surgery consisted of mobilization of the kidney followed by CPB via atrial and aortic cannulae, cooling via CPB, exsanguination, and removal of thrombus during DHCA. Duration of cooling was 21 +/- 7 minutes to a pharyngeal temperature of 15.8 degrees +/- 2.6 degrees C with alpha-stat pH management; DHCA lasted 26 +/- 10 minutes, and rewarming was continued to a mean pelvic temperature of 36.2 degrees C. Duration of surgery was 8.1 +/- 1.6 hours. The mean initial hematocrit was 33.5%, mean lowest Hct during CPB was 16.9%, and mean Hct at the end of surgery was 30%. Intraoperatively, 9.0 +/- 6.4 units of blood were used, and most patients received component therapy. Average crystalloid use was 7 L, and albumin or hetastarch (1.3 +/- 0.9 L) was used in 13 patients. One patient with severe cardiac disease could not be weaned from CPB. In the 19 operative survivors, there were no neurological deficits. There was one late death from pulmonary complications. The use of thiopental (n = 13), dexamethasone (n = 11), or mannitol (n = 19) was not clearly related to outcome. Hypothermia, hemodilution, alpha-stat pH management, and normoglycemia are believed to be important aspects of perioperative care.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1990

Propofol anesthesia for major thoracic surgery.

One hundred patients undergoing elective thoracic surgery were anesthetized with propofol as a continuous intravenous infusion. In 60 patients, nitrous oxide was used for supplementation. The technique proved satisfactory, but induction of anesthesia was associated with significant decreases in blood pressure. The use of nitrous oxide markedly reduced the propofol requirements, and prolonged the time to the first spontaneous breath during recovery. The mean infusion rate of propofol was 7.2 +/- 2.72 mg/kg/h with air-oxygen, and 5.7 +/- 1.97 mg/kg/min with nitrous oxide-oxygen (P less than 0.01). This technique seems to be a satisfactory alternative for patients primarily requiring an intravenous anesthetic during thoracic surgery.

Anesthesia Recovery Period↗
PubMed1988

Postoperative gastric emptying in outpatient anesthesia: the effect of opioid supplementation.

Acetaminophen (paracetamol) 20 mg/kg was administered orally to 45 gynecological outpatients who had received either alfentanil 5 micrograms/kg, fentanyl 1 microgram/kg, or no analgesic supplement immediately prior to the induction of general anesthesia. Postoperative gastric emptying, assessed by acetaminophen absorption, was significantly inhibited in those given alfentanil. This inhibition is unlikely to be of great clinical importance and was much less than that found in previous studies using longer-acting opioids such as morphine.

Absorption↗
PubMed1989

A comparison of recovery in outpatients receiving fentanyl versus those receiving butorphanol.

The frequency of postanesthesia side effects and times to reach "benchmarks" in the recovery process for IV preinduction doses of 20 micrograms/kg butorphanol, 40 micrograms/kg butorphanol, or a 2 micrograms/kg dose of fentanyl were compared in a double-blinded study involving ambulatory surgical patients. The authors hypothesized that all drugs would perform equally well in all study areas. Sixty ASA physical status I and II women undergoing laparoscopic tubal sterilization were randomly assigned to one of three groups: Group I (n = 20) received 20 micrograms/kg butorphanol as a preinduction agent; Group II (n = 20) received 40 micrograms/kg butorphanol; Group III (n = 20) received 2 micrograms/kg fentanyl. Anesthesia management for all groups was the same. Statistically significant variance was found in time to discharge-ready status and duration of nausea (p less than 0.05) between 40 micrograms/kg butorphanol and 2 micrograms/kg fentanyl, but no significant difference was found between 20 micrograms/kg butorphanol and 2 micrograms/kg fentanyl in these areas. Statistically significant variance was found in duration of dizziness and time to obtain a 10 on the Aldrete Post Anesthesia Recovery Score (APARS) between 40 micrograms/kg butorphanol and 20 micrograms/kg butorphanol and 40 micrograms/kg butorphanol and 2 micrograms/kg fentanyl. From the study, 20 micrograms/kg butorphanol appears to be as suitable as 2 micrograms/kg fentanyl for use as a preinduction narcotic analgesic, whereas 40 micrograms/kg butorphanol appears to be unsuitable due to increased duration of nausea, dizziness, and time to score 10 on APARS and reach discharge-ready status.

Adult↗
PubMedDate not supplied

Intravenous droperidol decreases nausea and vomiting after alfentanil anesthesia without increasing recovery time.

The frequency rate of nausea and vomiting after an alfentanil-based anesthetic is high, with reported frequencies of 38% to 68%. This study was undertaken to evaluate the efficacy of low-dose and moderate-dose droperidol in decreasing the frequency of postoperative nausea and vomiting and to evaluate whether droperidol has any effect on slowing recovery after a standard alfentanil-based anesthetic. Sixty normal adults who were scheduled to undergo short surgical procedures requiring general anesthesia were assigned randomly in a double-blind manner to one of three groups of 20: (1) control--normal saline; (2) droperidol 10 micrograms/kg; or (3) droperidol 20 micrograms/kg. A standard alfentanil-based anesthetic was used, and the study drug was given immediately after induction of anesthesia. In the post-anesthesia recovery room, all patients were evaluated according to the Aldrete score, noting the time to achieve a score of 10. Presence or absence and severity of nausea and vomiting were noted. To assess psychomotor recovery, a Trieger dot test was performed by every patient preoperatively, at the time of an Aldrete score of 10, and upon discharge from the recovery room. There was no statistical difference between the groups in age, sex, type of procedure, weight, total dose of alfentanil, or duration of anesthetic. The frequency of nausea and vomiting was significantly less (p less than 0.05) for the 20 micrograms/kg group (5%) than for the 10 micrograms/kg group (25%) or the control group (40%). A dose-response relationship was evident for the antiemetic effect of droperidol. An analog scale for severity of nausea and vomiting also demonstrated a dose response effect.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

Perioperative arrhythmias with a propofol-based anesthetic.

Propofol was used for the induction and maintenance of anesthesia in a patient undergoing a laparoscopic tubal ligation. This new anesthetic has not been associated with postoperative ventricular arrhythmias. This report demonstrates the occurrence of supraventricular tachycardia deteriorating to ventricular tachycardia in a patient who received propofol. Included is a discussion of the possible causes of this event.

Adult↗
PubMedDate not supplied

Sedative infusions during local and regional anesthesia: a comparison of midazolam and propofol.

STUDY OBJECTIVE: To compare the intraoperative effects and recovery characteristics when either midazolam or propofol was used for sedation during local or regional anesthesia. DESIGN: Open-label, randomized study with blinded observer assessing recovery data. SETTING: Outpatients undergoing elective surgical procedures under local or regional anesthesia at Stanford University Hospital, Stanford, California. PATIENTS: Sixty-eight consenting, unpremedicated ASA physical status I, II, or III patients. INTERVENTIONS: After achieving adequate analgesia with local anesthetic solutions, patients were administered a loading dose of either midazolam (4.2 +/- 1.4 mg) or propofol (69 +/- 23 mg) followed by a variable-rate maintenance infusion equal to 8.6 +/- 5.4 mg/h or 265 +/- 185 mg/h, respectively, to maintain a stable level of sedation during the operation. MEASUREMENTS AND MAIN RESULTS: Intraoperative assessments included level of sedation, as well as cardiovascular and respiratory status, at 1- to 5-minute intervals during the operation. Postoperatively, recovery of cognitive and psychomotor function was assessed using analog scales and the digit-symbol substitution test. The overall quality of intraoperative sedation was similar in the two sedative treatment groups. Although midazolam produced less pain on injection and more effective intraoperative amnesia, use of propofol was associated with less postoperative sedation, drowsiness, confusion, clumsiness, and amnesia, as well as more rapid recovery of cognitive function. However, discharge times were similar in the two sedative treatment groups. CONCLUSIONS: Propofol infusion is a clinically useful alternative to midazolam for sedation during ambulatory surgery under local or regional anesthesia.

Adult↗
PubMedDate not supplied

Postanesthetic delirium: historical perspectives.

Postanesthetic delirium is a type of postoperative emotional response occurring immediately after emergence from general anesthesia. Associated with excitement and confusion, the alternative terms emergence delirium or postanesthetic excitement are frequently used. Historically, the more encompassing term postoperative psychosis is used interchangeably but more frequently refers to those conditions occurring after a lucid interval of 24 to 48 hours. Either phenomenon may arise from a variety of disturbances, with drug reactions, hypoxemia, or reaction to pain being common, or it may arise from psychological causes. Reported is a case of postanesthetic delirium in a healthy young man. An historical overview of this potentially harmful condition, with specific recommendations for diagnosis and treatment, also is presented.

Adult↗