[Use of an opioid antagonist naloxone and the agonist-antagonist nalbuphine during the awakening period to eliminate depressive effects of fentanyl].
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Adolescent↗
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A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit.
UNLABELLED: Emergence agitation (EA) is a postanesthetic problem that interferes with a child's recovery and presents a challenge in terms of assessment and management. In this prospective cohort study, we sought to determine the incidence of EA, evaluate factors associated with and predictive of EA, and describe associated outcomes in healthy children. Children aged 3-7 yr who were undergoing general anesthesia for elective outpatient procedures were included. All perioperative care was documented, and postoperative behaviors in the postanesthesia care unit were recorded. Parents completed the Behavioral Style Questionnaire for 3- to 7-yr-olds. Five-hundred-twenty-one children were studied, of whom 96 (18%) had EA. Agitation lasted up to 45 min in some cases (range, 3-45 min; mean, 14 +/- 11 min), required pharmacologic intervention in 52% of children, and was associated with a prolonged postanesthesia care unit stay (117 +/- 66 min versus 101 +/- 61 min for nonagitated children; P = 0.02). Ten factors were found to be associated with EA, including age, previous surgery, adaptability, ophthalmology and otorhinolaryngology procedures, sevoflurane, isoflurane, sevoflurane/isoflurane, analgesics, and time to awakening. Of these, otorhinolaryngology procedures, time to awakening, and isoflurane were shown to be independent risk factors. IMPLICATIONS: Children may become agitated after general anesthesia. This study describes several factors that may increase the risk for agitation. These data are important in planning anesthesia care for young children.
Anesthesia Recovery Period↗
Patient flow in the Post Anesthesia Care Unit: an observational study.
PURPOSE: Anesthesiologists are constantly striving for improvement in health care delivery. We assessed the patient flow in the Post Anesthesia Care Unit (PACU) to determine if patients are being transported out of the PACU when ready. METHODS: A University student recorded the flow of 336 patients who recovered in our Post Anesthesia Care Unit. The corresponding nursing and orderly complements were recorded. If a delay arose between the time the patient was deemed fit for discharge by the PACU nurse and the time the patient was transported from the PACU, the student determined the duration and cause(s) of the delay. RESULTS: The number of patients, nurses, and orderlies increased from three to twelve, three to seven, and one to two respectively throughout the elective working day. Seventy-six per cent of patients studied were delayed in transport from the PACU, with 26% of patients waiting 30 min. The average delay in discharge for patients increased during the day from 0 to 65 +/- 54 min from the time of fit for discharge, as determined by the PACU nurse, until transport. Five causes were identified as contributing to the delay: orderly too busy (41%), awaiting Anesthesia assessment (36%), Post Anesthesia Care Unit nurse too busy (15%), receiving floor not ready (6%), and patient awaiting radiographic interpretation (2%). CONCLUSION: Our study has shown that system errors unnecessarily prolongs the stay of patients in the PACU.
Anesthesia Recovery Period↗
Comparison of tracheal extubation in patients deeply anesthetized with desflurane or isoflurane.
A randomized, single-blind study design was used to compare desflurane with isoflurane in 31 adults undergoing intraocular surgery to determine whether the lower blood:gas partition coefficient of desflurane would result in a more rapid emergence after endotracheal extubation of deeply anesthetized patients. A standardized general anesthetic technique was used, consisting of sufentanil, 0.25 microgram/kg, and propofol, 1.5 mg/kg, followed by either isoflurane (n = 15) or desflurane (n = 16) in an air/oxygen mixture. After the operation and reversal of residual neuromuscular block, spontaneous ventilation was reestablished and the patients' tracheas were extubated at equianesthetic concentrations of desflurane and isoflurane (i.e., approximately 1.4 times the minimum alveolar anesthetic concentration [MAC]). Spontaneous movements occurred 5.7 (+/- 2.4) and 8.7 min (+/- 3.1; P = 0.005) after extubation in the desflurane and isoflurane groups, respectively. Eye opening and orientation also occurred significantly earlier after desflurane compared to isoflurane. Patients receiving desflurane (versus isoflurane) were also able to be transferred from the operating room significantly earlier (10.4 +/- 3.7 vs 14.5 +/- 4.3 min, P = 0.01). Use of desflurane (versus isoflurane) was not associated with an increased incidence of coughing or airway irritation during the emergence period. However, use of desflurane did not significantly reduce the duration of the postanesthesia care unit (PACU) stay or alter later recovery events compared to isoflurane. In conclusion, the more rapid emergence would favor the use of desflurane when tracheal extubation during deep anesthesia is required.
Adult↗
Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors.
Based on previous studies, we hypothesized that the clinical phenomena of preoperative anxiety, emergence delirium, and postoperative maladaptive behavioral changes were closely related. We examined this issue using data obtained by our laboratory over the past 6 years. Only children who underwent surgery and general anesthesia using sevoflurane/O(2)/N(2)O and who did not receive midazolam were recruited. Children's anxiety was assessed preoperatively with the modified Yale Preoperative Anxiety Scale (mYPAS), emergence delirium was assessed in the postanesthesia care unit, and behavioral changes were assessed with the Post Hospital Behavior Questionnaire (PHBQ) on postoperative days 1, 2, 3, 7, and 14. Regression analysis showed that the odds of having marked symptoms of emergence delirium increased by 10% for each increment of 10 points in the child's state anxiety score (mYPAS). The odds ratio of having new-onset postoperative maladaptive behavior changes was 1.43 for children with marked emergence status as compared with children with no symptoms of emergence delirium. A 10-point increase in state anxiety scores led to a 12.5% increase in the odds that the child would have a new-onset maladaptive behavioral change after the surgery. This finding is highly significant to practicing clinicians, who can now predict the development of adverse postoperative phenomena, such as emergence delirium and postoperative behavioral changes, based on levels of preoperative anxiety.
Adaptation, Psychological↗
CYP2C19 genotype affects diazepam pharmacokinetics and emergence from general anesthesia.
OBJECTIVES: Diazepam is widely used to relieve preoperative anxiety in patients. The objective of this study was to investigate the effects of polymorphism in CYP2C19 and the effects of CYP3A4 messenger ribonucleic acid (mRNA) content in blood on recovery from general anesthesia and on diazepam pharmacokinetics. METHODS: Sixty-three Japanese patients were classified into the following 3 genotype (phenotype) groups on the basis of polymerase chain reaction-restriction fragment length polymorphism analysis of CYP2C19 polymorphism: no variants, *1/*1 (extensive metabolizer [EM]); 1 variant, *1/*2 or *1/*3 (intermediate metabolizer [IM]); and 2 variants, *2/*2, *2/*3, or *3/*3 (poor metabolizer [PM]). We assessed the effects of these polymorphisms and of CYP3A4 mRNA content in the lymphocytes on the patients' recovery from general anesthesia. RESULTS: CYP2C19 genotyping analysis in the 63 subjects showed that 32%, 46%, and 22% of subjects were classified into the EM, IM, and PM groups, respectively. The PM subjects showed a larger area under the curve representing the concentration of diazepam over a 24-hour period (AUC(0-24)) (2088 +/- 378 ng/mL.h(-1), P = .0259), lower clearance of diazepam (0.049 +/- 0.009 L.h(-1).kg(-1), P = .0287), and longer emergence time (median, 18 minutes; 25th-75th percentile range, 13-21 minutes; P < .001) in comparison with subjects in the EM group (AUC(0-24), 1412 +/- 312 ng/mL; clearance, 0.074 +/- 0.018 L.h(-1).kg(-1); and emergence time, 10 minutes, 8-12 minutes [median and 25th-75th percentile range]). The IM group also showed a longer emergence time (median, 13 minutes; 25th-75th percentile range, 9-20 minutes; P < .001) and a larger variation in this parameter in comparison with the EM group. The distributions of the CYP2C19 genotype were significantly different between the 2 groups (rapid emergence <20 minutes, slow emergence >20 minutes) (P = .0148). The mean value of the CYP3A4 mRNA level in the slow-emergence group (mean +/- SD, 4.80 +/- 3.99 x10(-10)) was significantly lower than that of the rapid-emergence group (mean +/- SD, 12.50 +/- 11.90 x10(-10)) (P = .0315). However, there was no significant correlation between emergence time and CYP3A4 mRNA levels (r = 0.239, P = .0601). CONCLUSION: We found that the CYP2C19 genotype affects diazepam pharmacokinetics and emergence from general anesthesia and that the slow-emergence group possesses lower levels of CYP3A4 mRNA than are found in the rapid-emergence group.
Actins↗
A multicenter evaluation of remifentanil for early postoperative analgesia.
We evaluated the use of an infusion of remifentanil to provide postoperative analgesia during recovery from total intravenous anesthesia (TIVA) with remifentanil and propofol. One hundred fifty-seven patients from seven medical centers underwent abdominal, spine, joint replacement, or thoracic surgery. Remifentanil was titrated in an effort to limit pain to 0 or 1 on a 0-3 scale. At the end of the 30-min titration period, 78% of infusion rates were in the range of 0.05 to < or = 0.15 microgram.kg-1.min-1, 5% were < 0.05 microgram.kg-1.min-1, and 17% were > 0.15 microgram.kg-1.min-1. Pain scores were 0 or 1 in 64% of patients. Nausea occurred in 35% and emesis in 8% of patients; the peak incidence of nausea followed discontinuation of the remifentanil infusion at the time of administering morphine. Respiratory adverse events (oxygen saturation by pulse oximetry [Spo2] < 90% or respiratory rate < 12) affected 29% of patients. Apnea occurred in 11 patients (7.0%). There was a large variation in the incidence of respiratory depression between the centers, ranging from 0 to 75%. The explanation for the large variability in respiratory outcome was not evident.
Abdomen↗
Care of obstetric patients during the immediate postanesthesia period.
STUDY OBJECTIVE: To determine the level of care available to obstetric patients during the immediate postanesthesia period. DESIGN: Mail and telephone survey of members of anesthesia departments in Michigan. SETTING: All Michigan hospitals with licensed obstetric beds. PATIENTS: Patients recovering from general or major regional anesthesia following an operative delivery. INTERVENTIONS: The factors determining patient care were the physical suitability of the recovery site, skills and experience of personnel providing care in postanesthesia care units (PACUs), and adjustments in care patterns by anesthesia personnel. MEASUREMENTS AND MAIN RESULTS: Most obstetric PACUs are staffed by labor and delivery nurses whose assignment to the unit is only part of their overall patient care responsibilities within the labor and delivery area (88.2% of hospitals with more than 2,000 annual births and performing cesarean deliveries in the obstetric suite; 92.3% of hospitals with 500 to 1,999 annual births and performing cesarean deliveries in the obstetric suite). Obstetric PACUs in the remaining hospitals in either group are staffed by dedicated nurses who are permanently assigned to these units. Preparation of labor and delivery nurses for PACU duties varies greatly, but 60.0% of hospitals with more than 2,000 annual births and 30.8% of hospitals with 500 to 1,999 annual births provide no special training. Concern about the level of expertise available in obstetric PACUs staffed by labor and delivery nurses was expressed by almost every respondent and has led to a practice pattern followed by most anesthesia personnel of transferring patient care responsibility only after patients have regained consciousness, cardiovascular stability, and ventilatory adequacy. Several institutions also allow anesthesia personnel to summon nurses from the surgical PACU or to transfer patients to alternate recovery sites, such as the surgical PACU or the intensive care unit (ICU). CONCLUSIONS: In many obstetric PACUs, the level of expertise of personnel needs to be upgraded to ensure the safety of patients recovering from general or major regional anesthesia and to comply with existing care standards.
Adult↗
Noise in the postanaesthesia care unit.
BACKGROUND: Although the postanaesthesia care unit (PACU) can be noisy, the effect of noise on patients recovering from anaesthesia is unknown. We studied the sources and intensity of noise in the PACU and assessed its effect on patients' comfort. METHODS: We measured noise in a five-bed PACU with a sound level meter. Noise levels were obtained using an A-weighted setting (dBA) and peak sound using a linear scale (dBL). Leq (average noise level at 5-s intervals), maximum Leq (LeqMax), minimum Leq (LeqMin) and noise peaks (Lpc) were calculated. During recording, an independent observer noted the origin of sounds from alarms and noise above 65 dB intensity (P65dB). Two hours after leaving the PACU, patients were asked about their experience and to rank their complaints on a visual analogue scale (VAS) using unstructured and structured questionnaires. RESULTS: We made 20,187 measurements over 1678 min. The mean Leq, LeqMax and LeqMin were 67.1 (SD 5.0), 75.7 (4.8) and 48.6 (4.1) dBA respectively. The mean Lpc was 126.2 (4.3) dBL. Five per cent of the noise was at a level above 65 dBA. Staff conversation caused 56% of sounds greater than 65 dB and other noise sources (alarm, telephone, nursing care) were each less than 10% of these sounds. Five patients reported disturbance from noise. There was no significant difference in Leq measured for patients who found the PACU noisy and those who did not [59.5 (3.1) and 59.4 (2.4) dBA respectively]. Stepwise multiple logistic regression indicated that only pain was associated with discomfort. CONCLUSIONS: Even though sound in the PACU exceeded the internationally recommended intensity (40 dBA), it did not cause discomfort. Conversation was the most common cause of excess noise.
Adult↗
Loss of consciousness after emergence from anaesthesia. A case of suspected micturition syncope.
A case of postanaesthesia micturition syncope with respiratory arrest is described. If syncope occurs, the temporary myocardial ischaemia and cerebral hypoperfusion may increase anaesthetic risk in the marginally compensated patient. The loss of airway protection during the syncopal period is also a cause of concern. We recommend the use of an indwelling bladder catheter during any prolonged surgical procedure.
Anesthesia Recovery Period↗
[Sevoflurane anesthesia for magnetic resonance procedures in pediatrics].
OBJECTIVE: To assess the efficacy and safety of sevoflurane anesthesia in children during magnetic resonance imaging procedures. MATERIAL AND METHODS: The patients were 105 ASA-I-II children, mean weight 13 +/- 10 Kg and mean age 2.9 years (range 1 day-10 years), twenty (20%) of whom were under 3 months old. Induction was gradual with 6% sevoflurane in a mixture of nitrous oxide and oxygen, followed by maintenance with 1-2% sevoflurane in the same mixture through a face mask or nasal tubes while the patient breathed spontaneously. All procedures were performed satisfactorily. Ten minutes after anesthesia, 88% of the patients were fully awake. None suffered prolonged sedation and no serious complications occurred during the study period. The most common side effects were transient decreases in oxygen saturation in 15 patients (14%), although none reached the critical level (SpO2 < 90%). Six of those patients were under 3 months old. After recovering from sedation, 13 patients (12%) suffered transient episodes of excessive agitation, usually 5 minutes after awakening. Five patients (4.8%) vomited in the recovery room. CONCLUSIONS: This study indicates that sevoflurane is safe and effective for sedating children, including newborn infants, who must undergo magnetic resonance imaging.
Anesthesia Recovery Period↗
The impact of choice of muscle relaxant on postoperative recovery time: a retrospective study.
UNLABELLED: To test the hypothesis that the use of long-acting muscle relaxants is associated with prolonged postoperative recovery when compared with the use of shorter-acting relaxants, we undertook a retrospective study of 270 patients with induced paralysis recovering from general anesthesia. We calculated the mean recovery time associated with each muscle relaxant used. Regression analyses were performed to control for potential confounding of the results by length and type of surgery, as well as age and sex. Taking these into account, the adjusted difference in mean recovery time between patients receiving short- and intermediate-acting relaxants (mivacurium, atracurium, and vecuronium) versus those receiving long-acting relaxants (d-tubocurarine, pancuronium, and pancuronium and d-tubocurarine combination) was 30 min (95% confidence interval [CI] 8-53). The adjusted difference in mean recovery time between patients receiving vecuronium and those receiving pancuronium (i.e., the single most frequently used drug in each category) was 33 min (95% CI 1-66). Shortened recovery time accounted for an estimated average $37.95 decrease in recovery room charge per patient when vecuronium was used instead of pancuronium, versus a $22.84 increase in drug cost. Our data and analyses support the hypothesis that the use of long-acting muscle relaxants is associated with prolonged recovery after surgery and provide preliminary evidence that restricting the use of the more expensive, shorter-acting muscle relaxants may represent a false economy. IMPLICATIONS: In this retrospective study, the use of old-fashioned, inexpensive, long-acting paralyzing drugs was found to be associated with prolonged postoperative recovery. This has implications when deciding whether, as an economic measure, to restrict the use of the more expensive, shorter-acting paralyzing drugs, because prolonged recovery also has a price.
Adolescent↗
Outcomes in day surgery.
PURPOSE OF REVIEW: To summarize and examine the updated published results on the outcome measures that can be used to assess the quality of ambulatory surgery and anesthesia. RECENT FINDINGS: Major morbidity and mortality following ambulatory surgery is exceedingly low. Cancellations and delays may have a negative impact on the patients, healthcare personnel and the organizations. Minor cardiovascular adverse events are the most common intraoperatively and are associated with preexisting cardiovascular diseases and elderly patients. Respiratory events postoperatively are associated with obesity, smoking and asthma. Also, pain is a common cause for longer postoperative stay, unanticipated admission and readmission. Postoperative nausea and vomiting occurs in 30% of patients and strongly affects patient satisfaction. Furthermore, prolonged stays are mainly caused by surgical factors, or minor symptoms like pain or nausea. Surgical factors are also the main causes of unanticipated hospital admission. The type of surgery and the 24 h postoperative symptoms may affect the degree of return to daily living function. Also, patient satisfaction affects the outcome of healthcare and the use of healthcare services. SUMMARY: Ambulatory surgery, as currently practiced, provides quality care that is cost-effective. Minor adverse events such as pain and postoperative nausea and vomiting are still common, and improvement could be targeted in these areas.
Ambulatory Surgical Procedures↗
Alkalinization of intracuff lidocaine improves endotracheal tube-induced emergence phenomena.
UNLABELLED: We sought to evaluate the effect of filling an endotracheal tube cuff with 40 mg lidocaine alone (Group L) or alkalinized lidocaine (Group LB) in comparison to an Air Control group (Group C) on adverse emergence phenomena in a randomized controlled study (n = 25 in each group). The incidence of sore throat was decreased for Group LB in comparison to Group L during the 24 postextubation hours. The difference between Group L and Group C remained significant in the two postextubation hours only. Plasma lidocaine levels increased when lidocaine was alkalinized (C(max) were 62.5 +/- 34.0 ng/mL and 3.2 +/- 1.0 ng/mL for Groups LB and L, respectively). Cough and restlessness before tracheal extubation were decreased in Group LB compared with Group L and in Group L compared with Group C. Nausea, postoperative vomiting, dysphonia, and hoarseness were increased after extubation in Group C compared with the liquid groups, and a better tolerance was recorded with Group LB compared with Group L. The increase of arterial blood pressure and cardiac frequencies during the extubation period was less in the liquid groups than in the control group and less in Group LB compared with Group L. We concluded that use of intracuff alkalinized lidocaine is an effective adjunct to endotracheal intubation. IMPLICATIONS: Use of 40 mg of alkalinized lidocaine, rather than lidocaine or air, to fill the endotracheal tube cuff reduces the incidence of sore throat in the postoperative period. This approach also decreases hemodynamic effects, restlessness, dysphonia, and hoarseness.
Anesthesia Recovery Period↗
Oxygen saturation during intravenous sedation using midazolam.
Intravenous sedation with midazolam was given to young, fit, adult patients undergoing third molar surgery; oxygen saturation (SpO2) was continuously measured during the surgery and for 30 minutes after the surgery. There were some instances of a brief fall in the oxygen saturation, during the surgery and in the immediate period following surgery. It is suggested that it may be necessary to observe and selectively monitor some patients in the immediate post-surgical period as well as during the period of operation. Although not addressed by this investigation, this would be particularly true of medically compromised patients and the elderly.
Adult↗
Quantitative EEG analysis during anaesthesia with isoflurane in nitrous oxide at 1.3 and 1.5 MAC.
In 14 patients undergoing elective surgery the EEG was studied during anaesthesia with isoflurane and nitrous oxide (in oxygen) at 1.3 and 1.5 MAC. The distribution of spectral EEG indices of the baseline EEG, during the intraoperative and recovery periods were established and compared. Median frequency exhibited the most clear separation between the distributions during recovery and the intraoperative period. During anaesthesia, the median values were found to be lower than 5 Hz; when the patient was conscious, the EEG median frequency values were greater than 6 Hz. Time to recovery was 13.4 +/- 2.9 min and 30.0 +/- 8.5 min for the groups treated with 1.3 and 1.5 MAC, respectively. Burst suppression was observed during the loading period in all patients treated with 1.5 MAC and in five patients out of seven receiving 1.3 MAC. The average duration of the period of burst suppression was markedly greater in the group receiving 1.5 MAC than in the group receiving 1.3 MAC. It is concluded that devices designed for EEG trend monitoring during anaesthesia should preferably depict a frequency measure, and allow for burst suppression recognition before spectral analysis.
Adult↗
Endotracheal lidocaine instillation in pediatric anesthesia.
The purpose of this study is to evaluate the effectiveness of lidocaine administered via the endotracheal tube in suppressing cough reflex during anesthetic recovery in children. Fifty ASA class I-II children, aged from 1-5 years old undergoing elective abdominal or urogenital surgery were randomly assigned into two groups. 2% lidocaine 1.5 mg/kg (1ml = 20mg) was administered in group B while normal saline (N/S) 0.1 ml/kg was used in group A (control group). Either one of the agents was instilled into the endotracheal tube right before the end of operation. Airway responses and other associated phenomena were recorded during the recovery period. Recovery condition was categorized into a two-grade categories, namely "good", and "poor" to denote the quality of recovery. Recovery conditions differ significantly between the control group and the experimental group. In group A, 3 patients were classified as the "good" grade but 22 patients were categorized in the "poor" grade. Group B (lidocaine 1.5 mg/kg) has a much better recovery condition than the control group, there were 19 in the "good" grade and only 6 in the "poor" grade. The experimental group treated with 2% lidocaine presented a significantly better recovery than the control group. This effective suppression of the cough reflex might be due to the local anesthetic effect exerted by lidocaine. For the sake of safety all patients were closely followed up at the post anesthesia room until the return of consciousness and laryngeal reflexes. In conclusion, we found that 2% lidocaine 1.5 mg/kg given intratracheally via the endotracheal tube could attenuate cough response during recovery in pediatric anesthesia.
Abdomen↗
[The incidence of hypoxia in the immediate postoperative period].
Arterial oxygen saturation (SaO2) was continuously measured using a pulse oximeter in 214 spontaneously breathing adult patients in a recovery room. Hypoxaemia was defined as an SaO2 of 90% or below. The patients were divided into three groups: in group I (n = 83) monitoring was started immediately after arrival in the recovery room, just before oxygen therapy was begun. The patients in group II (n = 106) were observed during and after oxygen therapy. Patients in group III (n = 25), most of whom had regional anaesthesia, were not treated with oxygen in the recovery room. RESULTS. Clinically unexpected hypoxaemia occurred in all three groups: hypoxaemia was observed in 32.6% of patients before oxygen administration (group I). Under oxygen therapy SaO2 was normal in 99.4% of the patients; however, in 30.2% of patients hypoxaemia recurred after oxygen had been discontinued (group II). Hypoxaemic periods were seen in 24% of patients in group III. CONCLUSION. The results indicate the necessity of oxygen administration during transport and in the early postoperative period to all patients. Even during and after regional anaesthesia or brief general anaesthesia, oxygen administration appears to be indicated. Monitoring of SaO2 with a pulse oximeter has become an increasingly standard procedure in modern anaesthesia and should be mandatory.
Adult↗