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[Surgery for children and adolescents. Post-operative phase].

The authors explain the third and last phase in the surgical process, the post-operative phase. The authors propose a standardized model of nursing care for children and adolescents. The third and last phase in the surgical process commences at the moment the child arrives in the recovery room and lasts until he/she is released from the hospital. This phase includes the treatment applied in the recovery room and later in a hospital ward or in the child's home. The authors use the Gordon Functional Health Patterns. Special emphasis is given to the perception-management health pattern, the nutritional-metabolic pattern, the elimination pattern, the exercise-activity pattern, and the cognitive-perception pattern. Of special importance is the vigilance during the first post-operative hours, as well as the child's parenteral nutrition or total parenteral nutrition, TPN, and the evaluation of pain according to the age of the child. The authors select the NANDA (North American Nursing Diagnosis Association) Nursing Diagnoses which appear most frequently in this post-operative phase.

Adolescent↗

The failure of negative pressure rewarming (Thermostat) to accelerate recovery from mild hypothermia in postoperative surgical patients.

UNLABELLED: The Thermostat device (Aquarius Medical Corp., Phoenix, AZ) is used in a new technique to accelerate recovery from hypothermia by mechanically distending blood vessels in the hand, thereby increasing transfer of exogenous heat to the body core. We evaluated the use of the Thermostat device in patients with mild postoperative hypothermia (< 36 degrees C). We studied adult patients undergoing elective surgery, general anesthesia, and neuromuscular blockade. Patients with an initial postoperative tympanic membrane temperature < 36 degrees C were randomized into two groups: 1) Thermostat, which consisted of a hypothermia warming mitt/seal and thermal exchange chamber for 60 min, and 2) conventional treatment, which consisted of warm blankets and/or radiant heat. Of the 191 patients enrolled, 60 (31%) developed hypothermia and were randomized to receive the Thermostat (n = 30) or conventional methods (n = 30). Fourteen patients in the Thermostat group and 17 patients in the conventional group rewarmed to 36 degrees C before discharge from the recovery room (P is not significant). There were no differences in vital signs, rewarming time, time to discharge from the recovery room, or postoperative temperature between groups. We conclude that patients with mild postoperative hypothermia rewarmed in a similar fashion, regardless of whether the Thermostat or conventional methods were used. IMPLICATIONS: We found that a commercially available negative pressure rewarming device (Thermostat; Aquarius Medical Corp., Phoenix, AZ) was not effective in accelerating rewarming in postoperative hypothermic surgical patients after general anesthesia.

Adult↗

Transdermal scopolamine for the reduction of postoperative nausea in outpatient ear surgery: a double-blind, randomized study.

We evaluated the effect of transdermal scopolamine on the incidence of postoperative nausea and vertigo after outpatient ear surgery (exploratory tympanotomy, mastoidectomy, or endolymphatic sac and oval and round window surgery) in a double-blind, placebo-controlled study. A transdermal patch containing either scopolamine (n = 19) or placebo (n = 20) was placed behind the nonsurgical ear 2 h before surgery. Anesthesia was induced with thiopental (4-6 mg/kg intravenously [i.v.]), sufentanil (0.5 microgram/kg i.v.), and vecuronium (0.1 mg/kg i.v.) and maintained with isoflurane (0.2%-2%) and nitrous oxide (70%) in oxygen. Patients were observed postoperatively in the recovery room and after discharge for 72 h. There was no significant difference between groups with respect to time in recovery room, time to discharge, incidence of in-house nausea, vomiting, amount of antiemetics required, or postoperative visual analog scale (VAS) scores while in the hospital. After discharge, there were lower VAS nausea scores (by repeat measures analysis, P < 0.05) and a lower reported incidence of nausea (31% vs 62%; P < 0.05) and vertigo (6.2% vs 25%; P < 0.05) in the active patch group versus the placebo group. There was a higher incidence of dry mouth in the active patch group (44% vs 25%). Seven patients did not complete the study due to failure to keep the patch in place or failure to return the diary from home; and one patient from the placebo patch group was admitted for uncontrolled nausea and vomiting. The authors concluded that transdermal scopolamine is effective in reducing, but not eliminating, postoperative nausea and vertigo after discharge in outpatient ear surgery.

Administration, Cutaneous↗

Comparison of laparoscopic vs open modified Shouldice technique in inguinal hernia repair.

Inguinal hernia repair has been a common procedure performed by general surgeons. Recently, a newly developed approach has been introduced using the pre-peritoneal laparoscopic repair. The laparoscopic approach allows patients to recover faster, with less pain, however, a disadvantage is the higher cost. We conducted a retrospective study of inguinal hernia repairs performed by one surgeon at the same institution, comparing the laparoscopic technique to the modified Shouldice procedure with regard to surgical time, postoperative recovery time, charge, and time to return to work and to activities. Patients undergoing laparoscopic hernia repairs were able to return to work and to activities sooner than patients undergoing the modified Shouldice procedure. The results obtained in this study showed a higher charge for the laparoscopic procedure, with longer surgical and recovery room time. The more rapid return to work and activities may outweigh the higher charge and longer surgical and recovery room time.

Adult↗

[Effects of surgical intervention on plasma levels of antidiuretic hormone and alpha-human atrial natriuretic polypeptide under sevoflurane anesthesia].

Effects of surgical intervention on plasma levels of antidiuretic hormone (ADH) and alpha-human atrial natriuretic polypeptide (alpha-hANP) under sevoflurane-nitrous oxide-oxygen anesthesia were evaluated in 24 patients, ranged in ages from 15 to 65, who underwent non-abdominal surgery (orthopedic surgery) or abdominal surgery (gastrointestinal or gynecological surgery). Anesthesia was induced and maintained with sevoflurane, nitrous oxide and oxygen. Succinylcholine was administered to facilitate tracheal intubation and pancuronium was given during abdominal surgery when needed. Lactated Ringer's solution was administered intravenously throughout the procedures. Neither plasma ADH nor alpha-hANP levels changed significantly during sevoflurane anesthesia alone for 20 min. Plasma ADH levels were unchanged during surgery in patients who underwent non-abdominal surgery, but they tended to increase although insignificantly after the recovery from anesthesia. On the contrary, plasma ADH levels increased significantly during surgery and in the recovery room in patients who underwent abdominal surgery. Plasma alpha-hANP levels were unchanged during surgery and in the recovery room in patients who underwent non-abdominal or abdominal surgery. The authors' findings suggest that ADH secretion was significantly stimulated with abdominal intervention but not with orthopedic one, furthermore neither anesthesia nor surgical stress induced any influence on plasma alpha-hANP levels.

Adolescent↗

Pain management in recovery.

I make no mistake in mixing anaesthetic care with recovery room nursing, as it is my belief that the two are linked. So this month we look at pain in the recovery room--or is this the only place to which this article is relevant? You decide. Pain is something which, quite rightly, occupies the minds of perioperative practitioners greatly. It is only human, and humane, to use our expertise to alleviate, control and understand it. In this piece, Trudi Starritt from St John's Hospital, Livingston, explores the concept of pain and pain relief from the recovery nurse's perspective.

Humans↗

Hypoxemia after general anesthesia in children.

Postoperative hypoxemia has been well documented in adults but not in infants and children, although they are potentially more susceptible to airway closure and to disturbances in pulmonary gas exchange. In a prospective study, we measured arterial oxygen saturation (SaO2) with a pulse oximeter in 97 ASA class I infants and children breathing room air before and after general anesthesia for superficial surgical procedures. Mean preoperative SaO2 was 97.6 +/- 0.15% (SEM). On arrival in the recovery room after anesthesia mean SaO2 in room air had decreased significantly (P less than 0.01) to 93.0 +/- 0.49% (range 100-71%), corresponding to calculated arterial oxygen tension (PaO2) of about 66 mm Hg. The second reading, 5-15 min later, also showed a statistically significant (P less than 0.01) decrease in SaO2 (94.1 +/- 0.35%). There was no statistical difference in SaO2 between patients who received inhalation anesthesia alone and those who were given narcotics. There was also no correlation between postoperative reduction in SaO2 and duration of anesthesia or patient age. Of 67 patients who were asleep on arrival in the recovery room, 47 who remained asleep at the second SaO2 reading had an average increase in SaO2 of less than 1%. In contrast, in those patients who awoke, average SaO2 increased more than 4% during a similar time period--a difference that was statistically significant (P less than 0.02).

Adolescent↗

[Lidocaine aerosol following tonsillectomy in children].

Post-tonsillectomy analgesia was compared using ten per cent aerosol lidocaine or 1.5 mg.kg-1 intramuscular codeine. Thirty ASA physical status I or II children between two and ten years of age were assigned, in a random fashion, to one of two groups: Group A received codeine 1.5 mg.kg-1 intramuscularly, Group B received a total dose of 4 mg.kg-1 of ten per cent aerosol lidocaine on the tonsillar beds. For both groups, the treatment was administered at the end of the surgical procedure. The postoperative comfort state was assessed on a global scale using the following statement: (1) comfortable = 1, (2) agitation = 2, (3) uncontrollable = 3. Assessment of postoperative comfort was recorded after 20 min in the post-anaesthetic recovery room. Blood samples for lidocaine concentration estimation were obtained at 5, 7.5, 10, and 15 min after administration. Finally, the time of recovery was recorded. The immediate post-anaesthetic comfort observed with ten per cent aerosol lidocaine was statistically superior to that obtained with 1.5 mg.kg-1 intramuscular codeine. The maximal systemic lidocaine concentration which was 2.1 +/- 0.2 micrograms.ml-1 was well below the accepted toxic level of 5.3 micrograms.ml-1. The recovery room times were not statistically different between the two groups. In conclusion, 4 mg.kg-1 of ten per cent aerosol lidocaine applied directly on the tonsillar beds was shown a superior immediate post-tonsillectomy analgesic technique.

Aerosols↗

Analgesic efficacy and safety of a caudal bupivacaine-fentanyl mixture in children.

The analgesic efficacy and safety of a single caudal injection of a bupivacaine-fentanyl mixture was investigated in this prospective, controlled, triple-blinded study of 34 children, aged 1-11 yr and of ASA physical status I-II undergoing urological surgery. After induction of anaesthesia and before surgery, the children were randomly assigned to receive a caudal injection of 1.0 ml.kg-1 bupivacaine 0.125% with epinephrine 1:400,000 and either fentanyl 1.0 microgram.kg-1 in 1.0 ml of normal saline or 1.0 ml of normal saline. After completion of surgery, patients were assessed in the recovery room for six hours from the time of the caudal injection and for a further 18 hr on the ward. While in the recovery room arterial oxygen saturation and respiratory rate were monitored continuously and recorded hourly together with end-tidal carbon dioxide, pain and sedation scores. Other complications were also recorded. While on the ward, pain and sedation scores, respiratory rate and side effects were recorded every two hours. Postoperative analgesia was provided by intravenous morphine. Analgesic requirements were recorded for the 24-hr study period. Pain and sedation scores did not differ between groups. Respiratory depression or hypoxia did not occur. The incidences of other side effects did not differ. There were no differences in the numbers of patients requiring morphine within eight hours, the time to first morphine administration or the total morphine requirements. We conclude that a single caudal injection of a bupivacaine-fentanyl mixture with epinephrine administered prior to surgery, while safe, offers no advantage over an injection of bupivacaine 0.125% with epinephrine for paediatric urological surgery.

Anesthesia, Caudal↗

Comparison of postoperative pain in patients receiving interscalene block or general anesthesia for shoulder surgery.

A retrospective review of 114 patients who underwent elective shoulder surgery from January 1, 1995 to December 31, 1996 was performed. Eighty-eight patients received general anesthesia and 26 patients received regional anesthesia (interscalene block). There were no differences in surgical and anesthesia time and time to hospital discharge between groups. Patients who received regional anesthesia had a shorter recovery room stay (63 +/- 25 minutes versus 85 +/- 33 minutes [P.002]) and required less intraoperative fentanyl (174 +/- 96 microg versus 379 +/- 193 microg [P<.0001) and morphine in the recovery room (2 +/- 3 mg versus 6 +/- 7 mg [P=.006]). A higher percentage of patients who received regional anesthesia had a lower pain rating at 4 hours. Regional anesthesia for shoulder surgery decreases pain and facilitates recovery in the immediate postoperative period.

Anesthesia, Conduction↗

Anesthetic recovery after ambulatory laparoscopy: a comparison of isoflurane and alfentanil infusion.

Women undergoing ambulatory laparoscopy are known to experience a variety of minor postoperative morbidity which prolongs recovery time and delays discharge. The purpose of this study was to investigate general anesthetic recovery of ambulatory laparoscopy patients receiving two rapid-acting, but disparate, anesthetic techniques. Thirty-one ASA I and II patients between 19 and 44 years of age were randomly divided into two groups. Group I received an isoflurane-based anesthetic, and Group II received an alfentanil continuous infusion. Through analysis of covariance (ANCOVA), Group II recovery scores were found to be significantly higher at T0 (p less than .0001), (p less than .0001), T15 (p less than .001), T30 (p less than .01) and T45 (p less than .02). There was no difference between groups at T60, at which time all patients received the maximum score of 10. No other factor besides anesthetic technique significantly affected recovery scores. Group II patients spent an average of 166 minutes (+/- 59 standard deviation) in the recovery room in comparison with 192 minutes (+/- 32 standard deviation) for Group I patients. Despite this finding, an ANCOVA determined that only presence of postoperative vomiting significantly affected recovery room time (p less than .03). Further research is indicated in the endeavor to reduce postoperative morbidity of this patient population.

Administration, Inhalation↗

[Propofol and sevoflurane--a comparison of anesthesia for laryngomicrosurgery].

Laryngomicrosurgery has some special characteristics. It is under much stress such as intubation and direct laryngoscopy during a short operation time. Therefore both adequate anesthesia and quick recovery are needed. Thirty three ASA physical status I patients for laryngomicrosurgery were randomly assigned to receive either anesthesia with propofol and small dose of fentanyl (Group P) or anesthesia with thiopental and sevoflurane (Group S). Group P was induced with propofol 2-3 mg.kg-1 and fentanyl 0.1 mg and maintained with propofol 6 mg.kg-1.h-1 (from 10 mg.kg-1.h-1 by 2 mg.kg-1.h-1 decrement in interval of 10 minutes). No intravenous analgesic was added. Group S was induced with thiopental 4 -5 mg.kg-1 and maintained with sevoflurane 2-3%. We compared emergence time and the state of recovery 5 minutes after extubation and 5 minutes after entering the recovery room. There was no episode of inadequate anesthetic state in both groups. The emergence time was significantly shorter in Group P than in Group S. The state of recovery was much better in Group P compared with Group S in both 5 minutes after extubation and 5 minutes after entering the recovery room. Therefore, anesthesia with propofol and small dose of fentanyl at induction is more adequate compared with anesthesia with sevoflurane in laryngomicrosurgery.

Adolescent↗

Pain relief using continuous bupivacaine infusion in the paravertebral space after loin incision.

OBJECTIVE: Continuous bupivacaine paravertebral nerve block after thoracotomy has been shown to reduce postoperative pain. This study was designed to determine whether paravertebral nerve block using bupivacaine infused through a catheter placed intraoperatively, can reduce postoperative pain, and analgesia requirements after loin incision. METHODS: Thirty-four patients undergoing renal surgery through loin incision at Jordan University Hospital, Amman, Jordan, from October 2001 to March 2003, were randomized either to receive bupivacaine 0.5% or normal saline through a catheter positioned intraoperatively against the costovertebral joints in the paravertebral space. The infusions were continued until the evening of the third postoperative day. Patients had access on request to intramuscular Morphine sulphate 5-15 mg, or Diclofenac sodium 50-100 mg, or both depending on body weight. Pain after operation was assessed at rest using linear visual analogue scale. Patient scores were recorded in the recovery room, at 4 hours, 8 hours, and at 9 am, and 5 pm. RESULTS: The analgesia requirements for each patient were recorded. Pain scores in the recovery room were significantly lower in the bupivacaine group (mean 4.5 versus 8.0, p=0.001). At 4 hours, the pain score was lower in the bupivacaine group though not significant (mean 3.5 versus 4.37, p=0.393). Thereafter, the pain scores were significantly lower in the bupivacaine group. Mean morphine requirement in the bupivacaine group was 13.3 mg (ranges 0-50), while in the saline group 40.13 mg (range 10-112.5), p<0.001. Morphine requirements in the first and second postoperative days were significantly less in the bupivacaine group (p=0.015 and p=0.03). CONCLUSION: Paravertebral blockade using bupivacaine is an effective and safe method for pain relief following renal surgery through loin incision.

Adolescent↗

Respiratory complications associated with tracheal intubation and extubation.

We conducted a prospective survey on the incidence of respiratory complications associated with tracheal intubation and extubation in 1005 patients who underwent elective general anaesthesia over a 4-month period. During induction of anaesthesia, respiratory complications occurred in 46 patients (4.6%; 95% confidence limits (CL): 3.3, 5.9%). The common complications were coughing (1.5%) and difficult ventilation through a facemask (1.4%). Tracheal intubation was difficult in eight patients (0.8%). Complications occurred immediately after tracheal extubation in 127 patients (12.6%; 95% CL: 10.6, 14.7) and in the recovery room in 95 patients (9.5%; 95% CL: 7.6, 11.3%). The common complications immediately after extubation were coughing (6.6%) and oxygen desaturation (SaO2 < 90%) (2.4%), and in the recovery room, airway obstruction (3.8%) and coughing (3.1%). The incidence of complications was significantly higher immediately after tracheal extubation than during induction of anaesthesia (P << 0.001). Even when all incidents of coughing that occurred after tracheal extubation were disregarded as a complication, the overall incidence was still higher immediately after extubation (7.4%) than during induction of anaesthesia (P < 0.01). We conclude that the incidence of respiratory complications associated with tracheal extubation may be higher than that during tracheal intubation.

Adolescent↗

Quality of recovery in children: sevoflurane versus propofol.

BACKGROUND: Sevoflurane, with its low pungency and low blood and tissue solubility, is an attractive anaesthetic in paediatric outpatient surgery. Propofol-anaesthesia is recognised for its rapid and clear-headed emergence. This study was designed to compare emergence and recovery characteristics of sevoflurane and propofol anaesthesia for tonsillectomy in children. METHODS: Children aged 3-10 years, undergoing elective tonsillectomy, were randomly assigned to receive propofol (n=25, induction with 3 mg x kg(-1), maintenance with 100-250 microg x kg(-1) min(-1)) or sevoflurane anaesthesia (n=25, induction 7 vol.%, maintenance 2-3 vol.%). Tracheal intubation was performed with alfentanil 20 microg x kg(-1) and atracurium 0.5 mg x kg(-1). Ventilation was controlled to maintain normocapnia and all patients received N2O/O2 (60:40 vol.%) for induction and maintenance of anaesthesia. At the end of surgery infiltration of the operative sites with bupivacaine 2 mg x kg(-1) was provided for postoperative analgesia. Emergence, recovery, discharge times, and incidence of side effects were compared between the two groups. RESULTS: Time to extubation (14 vs 15 min), time to response to simple verbal command (21 vs 21 min) and time to discharge from the recovery room (45 vs 50 min) were similar in the sevoflurane and propofol groups, respectively. There was a significantly greater incidence of postoperative agitation in the sevoflurane group (46%) compared with the propofol group (9%) (P=0.008). This did not, however, delay discharge from the recovery room. The incidence of nausea and vomiting was not significantly different (8% vs 0%; P=0.49). CONCLUSION: In children, recovery from anaesthesia with sevoflurane results in a higher incidence of agitation compared with propofol.

Anesthetics↗

Buprenorphine as premedication and as analgesic during and after light isoflurane-N2O-O2 anaesthesia. A comparison with oxycodone plus fentanyl.

Sixty patients undergoing gynaecological laparotomies under isoflurane anaesthesia received 0.4 mg of buprenorphine sublingually or 0.12 mg/kg of oxycodone intramuscularly in random order for preanaesthetic medication. Patients premedicated with buprenorphine were given buprenorphine before, during and after anaesthesia and patients premedicated with oxycodone received fentanyl before and during anaesthesia and oxycodone after anaesthesia. Buprenorphine premedication produced less drowsiness and sedation and alleviated patients' apprehension significantly (P less than 0.05) less than oxycodone. Systolic and diastolic blood pressure and heart rate were significantly (P less than 0.05 to P less than 0.01) higher after intubation in the buprenorphine group when compared with the oxycodone plus fentanyl group. After anaesthesia, spontaneous respiration started rapidly; the return of consciousness and immediate recovery occurred at the same rate in both groups. In the recovery room moderate to severe pain was more common (P less than 0.05) in the oxycodone plus fentanyl group than in the buprenorphine group. The respiratory rate in the recovery room was lower among patients given buprenorphine, and two patients given buprenorphine developed severe respiratory depression. In the ward (2 to 24 h after operation) sublingual buprenorphine provided pain relief as good as intramuscularly administered oxycodone. No differences were noted in the incidence or severity of emetic symptoms between the groups. It is concluded that buprenorphine can provide good postoperative pain relief for gynaecological laparotomies performed under light isoflurane anaesthesia, but patients need to be monitored carefully after operation because of the possibility of respiratory depression.

Adult↗

Effects of menstrual cycle on postoperative analgesic requirements, agitation, incidence of nausea and vomiting after gynecological laparoscopy.

BACKGROUND: Several studies have suggested that the menstrual cycle has an impact on postoperative nausea and vomiting (PONV). No previous study has evaluated the effect of the menstrual cycle on the incidence of postoperative agitation and analgesic/antiemetic requirements. METHODS: On the basis of the phase of the menstrual cycle [pre+/-menstrual (Pd 25-6), early follicular phase (Pd 8-12), ovulatory phase (Pd 13-15), and luteal phase (Pd 20-24)], 67 patients enrolled in this blinded, prospective study. Anesthesia was standardized. Fentanyl was given to the patients who had severe pain in the recovery room. The patients who had agitation were given midazolam. When pain intensity was >5 on the Visual Analog Scale, metamizol was administered in the Gynecology Department. A blinded anesthesiologist recorded episodes of PONV in the recovery room, and 2 and 24 h postoperatively. RESULTS: The opioid requirement and the frequency of agitation were similar in each group. Metamizol consumption was highest in the luteal phase (p < 0.05). The follicular and luteal phases were predictors for vomiting at recovery (p < 0.05 and p < 0.001, respectively). At the postoperative 2nd hour, nausea was higher in the follicular phase than in the other phases (p < 0.05) and the luteal phase was a predictor for retching (p < 0.001). At the postoperative 24th hour, nausea was the common symptom in the luteal phase (p < 0.05). The need for ondansetron was highest in the luteal phase (p < 0.01). CONCLUSIONS: In conclusion, we suggest that the scheduling of all surgical procedures according to the menstrual phase may serve to reduce the incidence of PONV and metamizol/ondansetron consumption and hospital costs.

Adult↗

Naloxone antagonism after narcotic-supplemented anesthesia.

Narcotic-supplemented balanced anesthesia is increasing in popularity; however, the narcotic must frequently be antagonized postoperatively. Authorities differ in their recommendations as to dose and as to mode and duration of administration of the narcotic antagonist. In the present study of 58 patients undergoing narcotic-supplemented anesthesia, 60 percent of 42 fentanyl patients and 81 percent of 16 morphine patients required postsurgical naloxone for respiratory inadequacy. Naloxone dosage was initially 1.5 mug/kg IV, with repeat IV doses of 1.5 mug/kg, when needed, at 3-minute intervals, until a regular respiratory rate greater than 15 breaths/min was attained. None of the fentanyl patients and only 25 percent (4/16) of the morphine patients required additional naloxone in the recovery room. For the latter, the dose of naloxone previously administered was given IM and proved satisfactory. Additional analgesia was needed by 12 percent (7/58) of the patients during the recovery room stay. Judicious naloxone titration permitted respiratory adequacy to coexist with analgesia after narcotic-supplemented anesthesia.

Adolescent↗