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PubMed1990

Tryptophan-morphine interactions and postoperative pain.

Patients undergoing abdominal surgery were infused with saline or the 5-hydroxytryptamine (5-HT) precursor tryptophan starting in the operating room and continuing for three hours in the recovery room. There was a nonsignificant trend for patients who received tryptophan to have higher pain scores. In the saline-treated patients, plasma tryptophan was below the range for normal healthy subjects, and there was a strong positive relationship between plasma tryptophan and morphine requirements. These data, taken together with animal data obtained using the formalin pain test, suggest that a 5-HT system in the brain can antagonize the dissociative state produced by morphine, which helps patients to tolerate pain. When plasma tryptophan falls below normal levels, brain 5-HT falls and morphine requirements are reduced. While tryptophan may potentiate spinal 5-HT function to decrease nociceptive afference in some circumstances, there may be clinical conditions in which the use of tryptophan is contraindicated.

Double-Blind Method↗
PubMed1988

Flumazenil in total intravenous anaesthesia using midazolam and fentanyl.

Forty patients, scheduled for elective surgery in a thoracic and vascular surgical unit, were anaesthetized by a total intravenous anaesthesia technique using midazolam and fentanyl. Subsequent reversal of anaesthesia by the specific benzodiazepine antagonist flumazenil was evaluated in a double-blind trial. The patients were observed in the recovery room postoperatively until the next morning, and their recovery was repeatedly evaluated during the first 240 min after anaesthesia. Six patients in the placebo group required an oral airway or an endotracheal tube during the first hours of recovery, whereas none who received flumazenil did. The respiratory rate was significantly higher after flumazenil than placebo during the first 4 h postoperatively (Anova, P less than 0.01). Blood pressure and heart rate were not different between the two groups. The degree of sedation, orientation in time and space and the ability to cooperate were significantly superior after flumazenil than placebo (Anova, P less than 0.01). Some degree of resedation was observed in both groups, affecting 95% of the patients who received flumazenil against 30% after placebo (Mann-Whitney, P less than 0.05). No adverse reactions attributable to the use of flumazenil were encountered.

Adult↗
PubMed2006

Determining the impact of a surgical liaison nurse role in the paediatric operating room.

A two-group (N = 92) quasi-experimental pre-post test design was used to examine the effects of intra-operative communication by a surgical liaison nurse (SLN) on parental anxiety. Group I received in person progress reports from the SLN. Group II received routine perioperative care. The Speilberger's State-Trait Anxiety Inventory (STAI) Scale and investigator developed family rating scales were distributed to both groups and used as a quantitative as well as a qualitative approach to determine what was helpful for the family members during the operative period. Two hundred and eighty feedback forms were dispersed to various health care professionals including all anaesthetists, surgeons, nurses and other staff in the perioperative care team, including the operating room, day surgery unit and the post anaesthetic recovery room areas. Feedback forms were also circulated to staff from the intensive care unit and the surgical in-patient units. The results showed the anxiety levels were lower for the families who received in person progress reports but the difference by group was not statistically significant. Thematic written responses provided examples of improved care and effective time management behaviours on the part of the health care professionals. Written responses provided validation for the scale scores for both families and health care professionals and were an indication of the support for the role of the surgical liaison nurse. Qualitative findings implied that the surgical liaison nurse facilitated the transfer of necessary information between the perioperative care team and the family thus providing a support mechanism for families under stress.

Anxiety↗
PubMedDate not supplied

Criteria for early extubation after intracardiac surgery in adults.

Of 142 adult patients undergoing open-heart surgery, 123 were extubated either in the operating room or within 3 hours after admission to the recovery room, to avoid the discomfort and risks of prolonged mechanical ventilation. The remaining 19 patients, who had impaired cardiac function, were mechanically ventilated for 1 to 7 days postoperatively. The most important criteria for cardiopulmonary malfunction indicating the need for continued mechnical ventilation were a low mixed venous O2 saturation (SVO2) of less than 60% and a high left atrial pressure (greater than 20 torr). Of the 123 patients, 118, had an uneventful postoperative recovery and 5 needed reintubation, 2 because of low SVO2 and 3 because of complications unrelated to respiratory management. Most adult patients can spontaneously breathe adequately immediately after or within 3 hours of completed open-heart surgery, but a thorough physiologic and clinical evaluation should precede extubation, to identify those who need prolonged mechanical ventilation in the postoperative phase. Criteria for selection of patients for early extubation are presented.

Adolescent↗
PubMed1998

Minimally invasive approach for pneumonectomy culminating in an outpatient procedure.

STUDY OBJECTIVE: To establish the effects of the use of a clinical pathway that includes a minimally invasive access among patients undergoing pneumonectomy. DESIGN: Prospective study from February to December of 1997. SETTING: A community hospital. PATIENTS: Five consecutive patients with a mean age of 60 years (range 43 to 74 years) with lung malignancies who required pneumonectomy. INTERVENTIONS: Clinical pathway based on patient education, a meticulous minimally invasive operation (oblique muscle-sparing minithoracotomy), intercostal nerve cryoanalgesia, and a quick postoperative resumption of physical activity. RESULTS: All five patients were extubated in the operating room. They all had unrestricted shoulder mobility in the recovery room, and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation, and one patient was able to ambulate freely only a few hours after the procedure. Four patients were discharged the day after surgery, and one patient was discharged the same day of the operation. None required readmission related to the procedure. CONCLUSION: This initial experience seems to indicate that the application of this clinical pathway in patients undergoing pneumonectomy greatly accelerates their recovery and, for a select group of patients, converts it into an outpatient procedure.

Adult↗
PubMed1980

Comparison of flunitrazepam and thiopentone for induction of general anaesthesia.

Forty female out-patients undergoing therapeutic abortion participated in a double-blind study comparing flunitrazepam 0.05 mg . kg-1 with thiopentone 6.0 mg . kg-1 as induction agents for general anaesthesia. Induction time, as measured by the time to loss of lid reflex and voluntary speech, was not only significantly longer in patients receiving flunitrazepam, but also much more variable and imprecise than with thiopentone. The Steward recovery room scores and psychomotor drawing test results revealed that recovery was significantly slower in the flunitrazepam group. Anterograde amnesia was observed in all patients who had received flunitrazepam and in one patient who had received thiopentone. No retrograde amnesia was found in either group. Flunitrazepam produced postoperative drowsiness, sedation, ataxia and nausea while with thiopentone discomfort from surgery and discomfort at the intravenous injection site were the main complaints. Because of the slowness of induction with flunitrazepam and marked individual variation, we do not feel that this drug can be considered a suitable agent for routine induction of general anaesthesia.

Abortion, Therapeutic↗
PubMed1988

Effects of systemic morphine and epidural bupivacaine on postoperative oxygen consumption during rewarming.

The alterations in hemodynamics and oxygen consumption as a consequence of continuous epidural infusions of bupivacaine at room temperature and conventionally administered morphine were studied during recovery from general anesthesia for total hip replacement. Twenty-four patients were randomized to receive either bupivacaine or morphine in the recovery room. The bupivacaine group received from 6 to 12 ml per hour of 0.25% bupivacaine epidurally. Patients in the morphine group received 0.1 mg/kg of morphine intramuscularly no more frequently than every 4 hours. A pulmonary artery flotation catheter was inserted into each patient to determine hemodynamics and oxygen consumption at three instances: before analgesia, when pulmonary artery blood temperature reached 36 degrees C, and when it reached 37 degrees C. During the rewarming there was a decrease in mean arterial blood pressure and the systemic vascular resistance index and an increase in heart rate. The whole body oxygen consumption index increased in the bupivacaine group at the last measuring point but was stable in the morphine group. There was no effect on the arterial-venous oxygen content difference in either group. At 37 degrees C, the cardiac index and oxygen consumption index were significantly higher in the bupivacaine group than in the morphine group. In contrast to regional analgesia, systemic morphine administration can partially antagonize cardiovascular response to postoperative rewarming because it induces a stable oxygen demand.

Aged↗
PubMed1986

Alfentanil v. isoflurane for outpatient arthroscopy.

Alfentanil by continuous intravenous infusion and isoflurane have been compared as anaesthetic agents for outpatient arthroscopy. In 42 patients, divided at random into two groups, anaesthesia was induced with methohexitone and vecuronium bromide, and, after intubation, maintained with nitrous oxide 66% in oxygen combined with alfentanil or isoflurane. Alfentanil was given before intubation (1 mg), as a loading dose before starting surgery (50 micrograms kg-1) and by a continuous infusion at a rate of 1 microgram kg-1 min-1. Isoflurane was given in a concentration of 0.9% as a maintenance dose. Awakening from anaesthesia was more rapid with alfentanil than with isoflurane. Recovery tests were applied in the recovery room. Both anaesthetic techniques provided satisfactory anaesthesia and rapid recovery. All patients but one were content with the anaesthesia. The patients who received isoflurane scored better in the recovery tests in the first 3 h, but after 3 h there was no difference between the groups. The alfentanil group showed a higher incidence of nausea and/or vomiting: 45% compared to 14% in the isoflurane group.

Adult↗
PubMed1979

Experience with an alternative method of anesthesia for intracavitary therapy of pelvic carcinoma.

Placement of intracavitary applicators for treatment of gynecological cancer is usually done in the operating room under general anesthesia. This requires premedication, operating and recovery room time, and is time consuming and expensive. The authors have found that the implant can be performed in a radiation medicine department using intravenous Demerol and Valium. Analgesia has many advantages in comparison to general anesthesia for intracavitary implant therapy.

Analgesia↗
PubMed2004

[Anesthetic management of the surgical patients with complete left bundle branch block].

For last ten years twenty three cases of anesthesia were performed in twenty surgical patients with complete left bundle branch block (CLBBB) ranging in ages from 58 to 82 years. The CLBBB in these patients included 16 cases of permanent block, 6 cases of transient block and one case of alternative block. Two of these patients had no past history of heart disease, but the remaining patients had hypertension, ischemic heart disease, cardiomegaly, cardiac hypertrophy or others. Transient episodes of CLBBB were detected on the preoperative examination, on arrival at operating room or after the emergence from anesthesia at a recovery room, and some of which were provoked by elevated blood pressure or increased heart rate. A transient CLBBB in the patient changed to permanent CLBBB two years later. Complete atrioventricular (A-V) block appeared suddenly in the patient with alternative CLBBB four months after the surgery. Complete A-V block did not develop during anesthesia and surgery in our patients with CLBBB. Therefore we consider a routine prophylactic temporary pacemaker is not necessary during anesthesia and surgery in patients with asymptomatic CLBBB. However, a temporary pacemaker equipment should be at hand in case of complete A-V block. Appropriate perioperative management of circulatory system is important for the patients with CLBBB because most of these patients have underlying heart disease.

Aged↗
PubMed1990

[Alfentanil combination anesthesia in infants].

In the last few years new narcotic agents with more favourable pharmacokinetic properties have been introduced into clinical practice. Short half-lives and smaller distribution volumes facilitate control of anaesthetic depth and shorten the recovery period. One of these narcotics is alfentanil. This study was performed on the effects of alfentanil when used during anaesthesia in infants under the age of one year. After induction and relaxation alfentanil 20 mcg/kg were given i.v. initially. The same dose was repeated as needed until 15 min. before surgery ended. The patients were ventilated with N2O/O2 (2:1). Muscle relaxation was maintained at 90-95% with vecuronium, monitoring "train of four" twitch response. The effects of alfentanil on airway pressure, pulse and blood pressure were measured during and without muscle relaxation. The time from end of surgery until full recovery was recorded. Percutaneous CO2-tension was measured in the recovery room. There were no clinical problems with induction or recovery. The average time until the infants opened their eyes and started moving was 1.8 min. No significant changes in pulse and blood pressure occurred during surgery. Airway pressure showed minimal increases when muscle relaxation decreased. These data suggest that alfentanil/N2O anaesthesia can be considered as an alternative if halogenated hydrocarbons are rated unsuitable in paediatric anaesthesia.

Alfentanil↗
PubMed1994

"Simplified IVF": program for developing countries.

The aim of this study is to assess the results of the "Simplified IVF" program at Ramathibodi Hospital. Ramathibodi IVF program has been in operation since October, 1991. Some steps of the conventional IVF procedures have been modified due to the limitation of resources. The embryo laboratory is a simple, clean room situated in a different building from the oocyte recovery room. Short protocol of GnRHa/HMG is used for ovarian stimulation. Monitoring of the follicular development is performed by ultrasound alone with limited number of scans (2-3 times/cycle). Oocyte retrieval is carried out under transvaginal ultrasound guidance and the aspirate transported to the embryo laboratory in a simple insulated box. Luteal phase is supported by giving micronized progesterone. Eighty five couples have undergone 105 ovarian stimulation cycles. OR was done in 100 cycles from 80 couples. Total oocytes collected is 1091. The fertilization rate is 75 per cent. Embryos were transferred in 97 cycles. Clinical pregnancy occurred in 25 cycles. Pregnancy rate per OR and ET is 25 and 25.8 per cent respectively. Nineteen patients have delivered (6 twins, 13 singletons). Simplification of procedures has enabled the IVF service to be available in a center with limited resources without compromising the results. Other advantages are improvement of the patient's convenience, cost savings and less time consumed as well as being less stressful.

Adult↗
PubMed1993

Placement of central venous catheters by cut-down with electrocardiogram positioning.

A technique of placement of central venous catheters for hyperalimentation, long term antibiotic treatment or chemotherapy by cut-down and positioning of the catheter tip with intravascular electrocardiography is described. The method was used in 384 patients during a period of four years. The patients varied from premature newborns to adolescents. The external jugular vein was used in 218 patients, the internal jugular vein in 150, the cephalic vein in 11 and the axillary vein in five. Catheters were successfully positioned by electrocardiogram (ECG) control in 95 percent of the patients. In only 5 percent of the patients, the ECG was difficult to interpret because of interference, poor electrode contact or unsatisfactory ECG image or tracing. Roentgenograms to check catheter location did not have to be done in the operating room. Confirmation of catheter position was done in the recovery room or on return to the neonatal intensive care unit. Using the cut-down procedure described, there were no complications, such as bleeding or chest wall infections, along the course of the catheter.

Adolescent↗
PubMed1989

Oral transmucosal fentanyl citrate premedication in children.

The authors evaluated the safety and efficacy of four doses of oral transmucosal fentanyl citrate (OTFC) as a premedicant in 44 children about to undergo elective operations. The patients received 5-10, 10-15, 15-20, or 20-25 micrograms.kg-1 of OTFC in the holding area and had activity (sedation) scores, vital signs (including systolic and diastolic arterial blood pressures, heart, and respiratory rates), and pulse oximetry determined oxygen saturation measured before and at 15-min intervals after premedication until they were taken to the operating room. Cooperation during anesthetic induction, and quality and speed of recovery room emergence were measured and side effects noted. OTFC was readily accepted and provided significant (dose dependent) reductions in preoperative activity starting after 30 min. Onset of sedation was related to dose of OTFC but time to peak effect was not. Vital signs remained unchanged preoperatively in all groups but patients receiving 20-25 micrograms.kg-1 had oxygen saturations that were significantly lower than patients in the other groups 30 min after beginning OTFC consumption. Three of the 12 patients receiving the highest dose of OTFC experienced transient oxygen saturation less than 90% which, however, was easily treated by commands to take a breath. Anesthetic inductions were rated good or excellent in 80% of the patients and recovery times were similar irrespective of the OTFC dose. OTFC caused dose-independent preoperative pruritus in 90% or more of patients and pruritus (33%-70%), nausea (30%-58%), and vomiting (50%-83%) postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

Improved survival after intraoperative cardiac arrest in noncardiac surgical patients.

OBJECTIVE: To test the hypothesis that improvements in intraoperative and perioperative critical care are resulting in an improved outcome after intraoperative cardiac arrest. DESIGN: A retrospective consecutive series of patients who experienced an intraoperative cardiac arrest during noncardiothoracic surgical procedures between January 1986 and June 1994. SETTING: A tertiary care university-based hospital. PARTICIPANTS: Twenty-four consecutive patients who experienced an intraoperative arrest among 162,661 noncardiothoracic surgical procedures during the designated period. INTERVENTION: Advanced cardiac life support and advanced trauma life support methods were used appropriately. Postarrest pharmacologic and mechanical cardiopulmonary support were used as needed in the setting of a surgical intensive care unit. MAIN OUTCOME MEASURES: Survival out of the operating room and survival to discharge. RESULTS: Fifteen patients (62%) were resuscitated in the operating room and taken to the surgical intensive care unit or recovery room. Nine patients (38%) survived to discharge from the hospital. Twelve arrests (50%) were primarily cardiac in origin. Predictors of mortality included a need for pressor or inotropic support (P < .001) and duration of the arrest greater than 15 minutes (P < .001). CONCLUSION: Survival from an intraoperative cardiac arrest in a noncardiothoracic surgical patient is much improved over rates in historical controls who experienced in-hospital and out-of-hospital cardiac arrest. Rapid identification and aggressive correction of mechanical and metabolic derangements is warranted.

Adolescent↗
PubMedDate not supplied

Policies and practices for maternal support options during childbirth and breastfeeding initiation after cesarean in southeastern hospitals.

OBJECTIVE: To describe policies, practices, and associated rationales of hospital obstetric units regarding mothers' support person options during childbirth and to explore practices concerning support of breastfeeding initiation after cesarean delivery. DESIGN: Descriptive telephone survey. SETTING: Hospitals in the southeastern region of the United States. PARTICIPANTS: Convenience sample of 154 obstetric nurse manager and nurse representatives employed by the participating hospitals. MAIN OUTCOME MEASURES: Types of policies regarding mothers' support person options during childbirth and immediate postpartum stage, initiation of breastfeeding after cesarean birth, and attitudes about policies. RESULTS: All hospitals allowed two or more support persons during vaginal births, 89% permitted only one support person during nonemergent cesareans, and 58.0% of the nurse representatives believed that mothers should be allowed a second support person. Less than one third (31.2%) of the hospitals considered a mother's request to breastfeed in the operating room, and most (78.6%) allowed mothers to breastfeed in the recovery room. CONCLUSIONS: Overall, maternal support policies, practices, and nurse representatives' attitudes were mother and family friendly, particularly related to vaginal births. Though breastfeeding initiation after cesarean birth was encouraging, support person options during nonemergent cesarean births and related rationales warrant further examination.

Adult↗
PubMed1993

Evaluation of a clinical recovery score after general anesthesia.

A clinical recovery score (CRS) assessing recovery after general anesthesia was compared with the Digit-Symbol Substitution Test (DSST), Trieger Test (TT), a patient-completed visual analogue scale for alertness (VAS), and an independent observer's evaluation of recovery. The CRS included ratings of the following parameters: activity, respiration, circulation, consciousness, ambulation, color, and nausea and vomiting. Forty patients requiring the removal of three or four third molars participated in the study. All patients received the same general anesthetic technique. Each patient was evaluated by the five methods preoperatively, on admission to the recovery room, and at 15-min intervals until discharge. The four recovery tests (CRS, DSST, TT, VAS) were evaluated using chi 2 analysis to determine if there was any overall difference among the tests using the observer's determination of home readiness as the standard for discharge. The CRS was significantly more in agreement with the observer's determination than were the paper and pencil tests. The recovery tests were also evaluated with regard to instances of early dismissal or prolonged retention of the patient, again using the observer's determination as the "gold standard." The CRS was the only recovery test devoid of early dismissals. We conclude that the CRS provides a valid, simple measure of recovery that can be readily used in offices providing outpatient anesthesia and in studies measuring clinical recovery from anesthesia or sedation.

Ambulatory Surgical Procedures↗
PubMed1979

Pharmacy practice in an operating room complex.

The steps involved in establishing a comprehensive pharmaceutical service in an operating and recovery room complex is described. Objectives of the operating room pharmaceutical satellite were to: (1) improve control of distribution, storage and charging for all drugs, especially Schedule II controlled substances; (2) reduce inventory costs and loss of revenue; (3) improve compliance with the drug formulary; and (4) establish patient-oriented pharmaceutical services. The pharmacy satellite improved inventory control and patient charging, assured continual access to all drugs and appropriate security for controlled substances, and expanded the pharmacy department's clinical, drug information and research activities.

Alabama↗