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PubMed1990

Phlebotomy via the pulmonary artery catheter introducer for intraoperative autotransfusion.

Fear of the acquired immune deficiency syndrome and other blood-transmitted diseases has created a revival of autologous transfusion during cardiac surgery. The present report is of 200 patients undergoing cardiopulmonary bypass during cardiac surgery in whom phlebotomy was performed via the sideport of the introducer for the pulmonary artery catheter for later reinfusion. Each unit of phlebotomized blood was replaced with 500 mL of normal saline. Cardiac output and mean arterial blood pressure decreased significantly after phlebotomy (P less than 0.05) and returned toward control values after administration of the sodium chloride. The autologous blood was replaced after cardiopulmonary bypass. Fresh frozen plasma and platelets were not administered to the patients in the operating room. Eleven patients undergoing coronary artery bypass grafting received fresh frozen plasma in the recovery room because they were receiving aspirin and dipyridamole up to the day of surgery. Prolonged duration of cardiopulmonary bypass in two double-valve replacements, and one coronary artery bypass graft patient who required insertion of an intra-aortic balloon, accounted for the administration of fresh frozen plasma and platelets in three patients. The average volume of phlebotomized blood was 875 mL, which resulted in a decrease of the hematocrit from 40.5% +/- 0.5% (P less than 0.05) to 29.75% +/- 0.5% and 30.5% +/- 0.5% at the end of surgery and at discharge from the hospital, respectively. Phlebotomy via the Y port of the introducer of the pulmonary artery catheter is an easy, simple, and cost-effective way to remove autologous blood in patients undergoing cardiac surgery.

Adult↗
PubMedDate not supplied

An update on pulse oximetry. Part II: limitations and future applications.

The pulse oximeter can be used in all clinical situations in which the patient is at risk for hypoxemia. Now standard in the operating room, pulse oximetry is beginning to be used in prehospital transport, emergency department, postanesthesia recovery room, intensive care unit, endoscopy and catheterization suites, and delivery room, as well as for ambulatory monitoring and preoperative screening. The pulse oximeter is an invaluable monitor for the anesthesiologist and may allow better health care delivery to the patient, especially when combined with capnography and mixed venous oximetry. This article presents an update on its limitations and future applications.

Carbon Dioxide↗
PubMed2002

Comparison of fentanyl and nalbuphine in total intravenous anaesthesia (TIVA).

OBJECTIVE: To compare Nalbuphine and fentanyl as total intravenous anaesthesia with propofol infusion in laproscopic cholecystectomy cases. STUDY DESIGN: Double blind randomised. METHODS: Changes in haemodynamic variables greater than twenty percent above or below the baseline and recovery profile were observed. RESULTS: Blood pressure remained within 20% of baseline in either group. Nine patients in fentanyl and fifteen in nalbuphine group required an additional bolus of propofol intraoperatively. Heart rate response after tracheal intubation was significantly higher in the nalbuphine group (25%). No difference was observed in the incidence of nausea and vomiting in the recovery room. Twenty-seven percent patients in the nalbuphine group required analgesia in the recovery in comparison to 87% in the fentanyl group. Patients in the fentanyl group required analgesia earlier (37 minutes vs. 62 minutes). CONCLUSION: Fentanyl provided better intraoperative haemodynamic stability in comparison to nalbuphine when used as the analgesic component in total intravenous anaesthesia with propofol. The recovery profile with both drugs was similar. Lesser number of patients required analgesia in the recovery in the nalbuphine group.

Adult↗
PubMed2000

Recovery characteristics of sevoflurane or halothane for day-case anaesthesia in children aged 1-3 years.

BACKGROUND: Our objective was to compare the recovery characteristics of sevoflurane and halothane for short day-case anaesthesia in a specifically limited age group of children 1-3 yr. METHODS: Eighty unpremedicated children undergoing day-case adenoidectomy were randomly assigned to receive inhalational induction with either sevoflurane 8% or halothane 5% and nitrous oxide in oxygen (70/30) via a face mask. Tracheal intubation was performed without a muscle relaxant. Anaesthesia was continued with the volatile anaesthetic, adjusted to maintain heart rate and blood pressure within +/-20% of initial values. Recovery was evaluated using a modified Aldrete score, a Pain/Discomfort scale and by measuring recovery end-points. A postoperative questionnaire was used to determine the well-being of the child at home until 24 h after discharge. RESULTS: Emergence and interaction occurred significantly earlier after sevoflurane than halothane but discharge times were similar. More children in the sevoflurane group achieved full Aldrete scores within the first 30 min after anaesthesia, although this group suffered more discomfort during the first 10 min. The amount of postoperative analgesic administered was higher and the first dose given earlier in the sevoflurane group. Postoperative vomiting was more common with halothane, but side-effects in the two groups were otherwise similar in the recovery room and at home. CONCLUSIONS: In children 1-3 yr, sevoflurane provided more rapid early recovery but not discharge after anaesthesia of <30-min duration. Apart from more vomiting with halothane and more discomfort during the first 10 min after awakening with sevoflurane, the quality of recovery was similar with the two anaesthestics.

Ambulatory Surgical Procedures↗
PubMed1995

Femoral and lateral femoral cutaneous nerve block for muscle biopsies in children.

Retrospective chart review (1978-1993) of 179 children less than age 18 (10.0 +/- 3.8 SD yrs) undergoing muscle biopsy for determination of susceptibility to malignant hyperthermia provided data. One hundred and forty-six patients received femoral and lateral femoral cutaneous nerve blocks as their primary anaesthetic. We examined age, weight, duration of surgery, time to discharge from hospital, choice and dosage of local anaesthetics, choice and dosage of sedation, postoperative pain medications, and complications. All children receiving this form of anaesthesia remained outpatients. Between 1978 and 1985 procaine (10 mg.kg-1) with hyaluronidase or 2-chloroprocaine (12 mg.kg-1) provided nerve blockade; after 1985, lignocaine (6.8 mg.kg-1), or a combination of lignocaine or mepivacaine and 2-chloroprocaine, were the preferred agents. More recently the combination of 2-chloroprocaine and bupivacaine has been popular. Three patients required admission to the recovery room postoperatively, due to heavy sedation. Forty-three children (29%) received pain medication during recovery. Femoral and lateral femoral cutaneous block anaesthesia with light to moderate sedation is well tolerated in children undergoing anterior thigh procedures.

Anesthetics, Local↗
PubMed1980

A comparative study on the clinical effects of rectal diazepam and pentobarbital on small children. Relationship between plasma level and effect.

In order to test the possible differences in the clinical effects between benzodiazepines and barbiturates, 5 mg of diazepam and 60 mg of pentobarbital were used in a double-blind study as rectal premedication in 75 small children before major surgery. There were no significant differences between the two groups in the six parameters tested (demeanour in the anaesthetic room, preoperative emetic effect, response to venepuncture, degree of salivary suppression, postoperative state in the recovery room, postoperative emetic effect). The concentrations of pentobarbital and diazepam (and its 3 active metabolites) in the plasma were determined by gas chromatography and correlated with the clinical effects. No significant correlation was found between the total active benzodiazepine concentrations and the clinical effects of rectal diazepam. In contrast to diazepam, a weak but significantly positive correlation between the plasma concentrations of pentobarbital and the total score was found. Similarly, the plasma level of pentobarbital and the response to venepuncture and the degree of salivary secretion were in correlation with each other. In the plasma concentrations of both pentobarbital and total benzodiazepines, a wide interindividual variation was observed, indicating irregular rectal drug absorption.

Child, Preschool↗
PubMed1998

A comparison of transnasal and transoral oesophagogastroduodenoscopy.

Transnasal oesophagogastroduodenoscopy (OGD) with a narrow-bore endoscope has been demonstrated to be feasible in unsedated volunteers. The aim of the study was to compare efficacy, safety, patient tolerance and costs between this novel approach to OGD and standard sedated OGD. Sixty day patients were enrolled for either sedated transoral endoscopy with a standard calibre endoscope or for unsedated transnasal endoscopy with a narrow-bore (5.3 mm diameter) endoscope. Visualization was unsatisfactory in one examination in each group. The only complications were minor epistaxis in four of the transnasal group and oxygen desaturation below 90% in two of the sedated transoral group. On a 1 (very uncomfortable) to 5 (very comfortable) visual analogue scale, the mean transnasal group score was 3.09, compared with 3.86 in the transoral group (P = 0.013). In the transnasal group, mean procedure room time was 15 min compared with 20 min in the transoral group (P < 0.0003), and mean recovery room time was 7 min compared with 37 min (P < 0.0001). Consumable and pharmaceutical costs were reduced by 65 and 92%, respectively. This study demonstrates that unsedated transnasal OGD is a safe and effective route for OGD and has acceptable patient tolerance. The safety and decreased recovery times offer major cost savings and the potential for this method of OGD to become an office procedure for the investigation of the upper gastrointestinal tract.

Adult↗
PubMed1998

Comparative effects of desflurane and isoflurane on recovery after long lasting anaesthesia.

PURPOSE: Increasing the duration of exposure could lead to amplification of the pharmacokinetic differences between halogenated anaesthetic agents. The aim of our study was to compare anaesthesia recovery after desflurane and isoflurane, administered for more than three hours. METHODS: After informed consent, patients were randomly assigned to either desflurane (n = 15) or isoflurane (n = 15) groups. At the end of surgery, halogenated agents were discontinued and fresh gas flow was increased to 6 l.min-1 oxygen 100%. RESULTS: Mean anaesthesia duration was 292 +/- 63 and 304 +/- 91 min in the desflurane and isoflurane groups respectively. After desflurane and isoflurane discontinuation, the time to opening eyes was 12 +/- 7 and 24 +/- 11 min respectively (P < 0.001); to squeeze fingers at command was 17 +/- 11 and 35 +/- 19 min (P < 0.001); to extubation was 16 +/- 6 and 33 +/- 13 min (P < 0.001); to give their name was 22 +/- 12 and 43 +/- 21 min (P < 0.001); to achieve a Steward score of 6 was 28 +/- 16 and 57 +/- 33 min (P < 0.001), to be fit for discharge from the recovery room was 46 +/- 19 and 81 +/- 37 min (P < 0.003). Ranges of times to reappearance of recovery variables in the desflurane group were less than those after isoflurane (P < 0.05). CONCLUSION: After long duration anaesthesia lasting up to three hours, desflurane allowed recovery and extubation in approximately half the time required by isoflurane. Less variability in results suggests better predictability of recovery with desflurane.

Adolescent↗
PubMed1989

Establishing an endoscopy unit for surgical training.

Gastrointestinal endoscopy is slowly returning to the core of surgical resident training. The intent is to integrate endoscopy into the mainstream of surgical education such that it will be approached and used the same as any of the many diagnostic and therapeutic tools at the surgeon's disposal. The current feeling is that although endoscopy should be intimately incorporated into training, there is a level of technical expertise required such that a dedicated teaching experience must be provided. This education must be directed by a surgeon experienced in endoscopy; we should not abdicate this responsibility to others. The training program should be founded on education, clinical practice, and research, with technical skills to begin in PGY 2 or PGY 3 and be incorporated throughout the remainder of training. Quality assurance should be monitored closely but not separately from that of the surgical service. Certification of the resident should not depend on numbers, nor be specifically singled out from the body of surgery. There is adequate patient demand to establish the endoscopy unit under the supervision of a surgeon, either as a separate unit or as part of the surgical clinic. However, as the number of endoscopic procedures performed approaches 600 per year, a fully dedicated endoscopy room and full-time gastrointestinal assistant technician are required. The most efficient method of postsedation recovery is through coordination with an ambulatory surgery unit or postoperative recovery room. The current standard for equipment is video endoscopy in order to provide the most efficient method for surgical training.

Digestive System Surgical Procedures↗
PubMed2000

Litigation of laparoscopic major vessel injuries in Canada.

This study is a review of conditions and circumstances associated with 15 injuries to great vessels during laparoscopic surgery. Thirteen cases were litigated in Canada and two occurred in the author's operating room. Body habitus may have been an underlying factor in the injuries. Most injuries were entry related and independent on complexity of surgery. One was caused by the Veress needle and one by a secondary trocar, and three occurred during dissection of adhesions. Ten were primary trocar injuries, 9 after pneumoperitoneum and 1 at direct trocar insertion. Of these, five were caused by reusable and five by disposable trocars with so-called safety shields. In 6 of 15 cases recognition of the injury was delayed; 5 in the recovery room. Eleven women had uncomplicated recovery. Of 13 litigated cases, 8 (62%) resulted in settlement.

Adult↗
PubMed2003

Effects of different doses of oral ketamine for premedication of children.

BACKGROUND AND OBJECTIVE: A need exists for a safe and effective oral preanaesthetic medication for use in children undergoing elective surgery. The study sought to define the dose of oral ketamine that would facilitate induction of anaesthesia without causing significant side-effects. METHODS: We studied 80 children undergoing elective surgery under general anaesthesia who received oral ketamine 4, 6 or 8 mg kg(-1) in a prospective, randomized, double-blind placebo controlled study. We compared the reaction to separation from parents, transport to the operating room, the response to intravenous cannula insertion and application of an anaesthetic facemask, the induction of anaesthesia and recovery from anaesthesia. RESULTS: In the group receiving ketamine 8 mg kg(-1), the children were significantly calmer than those of the other groups, and anaesthesia induction was more comfortable. Recovery from anaesthesia was longer in the group receiving ketamine 8 mg kg(-1) compared with the other groups, but no differences between the groups were observed after 2 h in the recovery room. CONCLUSIONS: It is concluded that oral ketamine 8 mg kg(-1) is an effective oral premedication in inpatient children undergoing elective surgery.

Administration, Oral↗
PubMed1981

Pre-anaesthetic medication in paediatric day-care surgery.

Pre-anaesthetic medication has the primary aim of making the whole process of anaesthesia smooth and agreeable. This prospective blind study was planned to compare the efficacy of three active drugs and a placebo as premedication in a paediatric population undergoing operation on a day care basis. One hundred and fifty-nine patients between one and 12 years of age were assigned randomly to one of four groups who received either hydroxyzine 0.5 mg . kg-1 (n - 43) promethazine 0.5 mg . kg-1 (n 40) diazepam 0.1 mg . kg (n - 378) or placebo (n - 36) by mouth, 60 minutes before operation. Observations in the operating room included the emotional state of the patient on arrival, quality of induction and complications. In the recovery room time for emergence from anaesthesia, complications and requirements for analgesia were recorded. The parents were asked for return a questionnaire detailing psychological and physical complications during three postoperative days. There was no difference between the groups in any of the factors examined. From this study we conclude that children undergoing surgical operations and anaesthesia on a day care basis should not receive pharmacological premedication, not because of overwhelming risk from its use, but because of the absence of any benefit.

Ambulatory Surgical Procedures↗
PubMed1993

Outcomes after same-day oral surgery: a review of 1,180 cases at a major teaching hospital.

Outcome was measured from data collected on 1,180 consecutive ambulatory oral surgery patients, two thirds of whom were treated under general anesthesia and the remainder who were treated under local anesthesia supplemented with intravenous sedation. Three patients (0.25%) required admission on the day of surgery; all had undergone general anesthesia. The surgery-related complication rate in the general anesthesia group (1:132) was similar to that for local anesthesia and sedation (1:128). However, anesthesia-related complications had an incidence of 1:99 in the general anesthesia group, but were absent in those receiving local anesthesia and sedation. Eight patients (0.7%) required hospital readmission after being discharged, mostly because of complications of surgery. The incidence of postoperative nausea and vomiting in the recovery room after local anesthesia and sedation (6%) was less than after general anesthesia (14%) (P < .01) Average recovery times to sitting out of bed and being ready for discharge were less after local anesthesia and sedation (38 +/- 15 minutes and 120 +/- 39 minutes, respectively) than after general anesthesia (61 +/- 50 minutes and 141 +/- 62 minutes). At the time of follow-up during the first few postoperative days, 7% of patients had gone to a family doctor and 4% to hospital accident and emergency departments, usually for minor problems. Paracetamol 500 mg plus codeine phosphate 30 mg was effective in 97% of cases when provided as a take-home analgesic. Ninety-nine percent of patients were satisfied with their management.

Adult↗
PubMedDate not supplied

Evaluation of an anesthetic pump for postoperative care after shoulder surgery.

In theory, a prolonged, local infusion of anesthetic into a surgical field should reduce postoperative pain. Recently, disposable products have become available to implement this, but the balance between cost and benefit is controversial. This study evaluated such a device in two specific types of arthroscopic surgery of the shoulder: decompression of the subacromial space and repair of a torn labrum in the glenohumeral joint. Placement of the catheter into the glenohumeral joint resulted in problems in removing the device from some cases so that application is not recommended. When the catheter was placed in the subacromial space, the infusion pump was associated with significantly shorter stays in the recovery room, but there was no benefit over placebo with regard to pain, demand for rescue narcotic, or recovery of motion. Furthermore, use of the device presented some inconveniences to the surgical staff and the patient. It was concluded that use of this particular device in these particular applications is not justified.

Adolescent↗
PubMed1993

Clonidine premedication for craniotomy: effects on blood pressure and thiopentone dosage.

The purpose of this study was to determine whether oral clonidine premedication improves cardiovascular stability and/or reduces the requirements for drugs used to control systolic blood pressure (SBP) during elective craniotomies. We performed a double blind randomized trial involving 77 normotensive, ASA physical status I or II adults. Clonidine 4 micrograms/kg or placebo was given as oral premedication. The patient's mean SBP on the day before surgery was used as the baseline. SBP was controlled between the baseline and 30% below it (but not < 90 mm Hg). Anesthesia was induced with thiopentone, N2O, and fentanyl; maintenance was with N2O. Further doses of thiopentone were administered to control rises in SBP until skin incision. After skin incision trimethaphan (TMP) was used to control the SBP and isoflurane only added if TMP was insufficient. Isoflurane was discontinued as soon as SBP control allowed. The induction dose of thiopentone was the same in both groups but subsequent usage for blood pressure control was significantly lower in the clonidine group. There were no differences in trimethaphan dose, or the incidence and duration of isoflurane use. The clonidine group had lower SBP on arrival in the operating room, preinduction, and postintubation. There were no differences in mean "intraoperative" SBP, their coefficients of variation, or recovery room values. Two subgroups were analyzed, based on the study groups mean age and baseline SBP. Three-way analysis of variance revealed that the blood pressure effects of clonidine were almost entirely confined to patients older than 45 years. Baseline SBP had no independent effect.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed1991

Observations on the postpartum shivering phenomenon.

Fifty healthy, nonmedicated, laboring women who had normal spontaneous vaginal deliveries were studied to determine the incidence, time of onset, severity, duration, temperature patterns and relationship of various perinatal factors to the postpartum shivering phenomenon. Axillary temperature was recorded on admission, before delivery, at delivery and every 15 minutes postpartum for 75 minutes. The degree and duration of shivering were quantified visually. The environmental temperature was recorded. Of the 50 women, 22 (44%) commenced shivering during delivery or up to 30 minutes postpartum. Shiverers and nonshiverers exhibited a reduction in the mean axillary temperature during labor, with a rise post-partum (P less than .002). The median axillary temperature of the shiverers at all time points was higher than that of the nonshiverers and was statistically significant 30 (P less than .01), 45 (P less than .003), 60 (P less than .004) and 75 minutes (P less than .001) after delivery. The shiverers tended to raise their postdelivery temperature somewhat later than did the nonshiverers. The temperature pattern of both shiverers and nonshiverers fell during labor, and the temperature pattern of the shiverers differed from that of the nonshiverers postpartum. The mean delivery room temperature for shiverers was lower than for nonshiverers (P less than .009), as was the mean recovery room temperature (P less than .03). Environmental temperature may play a heretofore unsuspected role in the postpartum shivering phenomenon.

Adult↗
PubMed1994

Postoperative sore throat in children and the laryngeal mask airway.

Postoperative sore throat is a minor complaint after general anaesthesia of multifactorial aetiology. The purpose of this study was to compare the effect of the laryngeal mask airway (LMA) and endotracheal tube (ETT) on postoperative sore throat in children. We hypothesized that the incidence of sore throat would be less after the use of the LMA. This was a randomized, single-blind study of 112 patients of age 3 to 12 yr undergoing minor peripheral surgery. The groups were similar, except that airway maintenance was either with an LMA or ETT. After induction of anaesthesia with O2, N2O and halothane, an LMA or ETT was inserted. Anaesthesia was maintained with O2, N2O and halothane. At the end of surgery, the ETT was removed in the operating room before airway reflexes had returned. The LMA was removed after the patient's airway reflexes had returned in the recovery room. On the first postoperative day, the parents were contacted and asked whether or not their child had had a sore throat. If a sore throat had been present, the parents rated the discomfort as mild, moderate or severe. The groups were similar with respect to age, weight, sex and duration of procedure. The overall incidence of sore throat was 9%. The difference between the groups (LMA 13% vs ETT 5%) was not statistically significant. All of the reported sore throats were rated as mild. In conclusion, postoperative sore throats after minor paediatric surgery is uncommon. If it does occur, it is mild and the incidence is unaffected by the choice of an LMA or ETT.

Analgesia↗
PubMed1995

Comparison of intravenous ketorolac and alfentanil as supplements to propofol anesthesia for diagnostic panendoscopy.

STUDY OBJECTIVE: To determine if ketorolac tromethamine is an acceptable alternative to alfentanil as a supplement to propofol for diagnostic panendoscopy. DESIGN: Randomized, double-blind study. SETTING: University medical center. PATIENTS: 40 patients scheduled for panendoscopy and laryngeal tissue biopsy. INTERVENTIONS: Patients were randomly assigned to receive either alfentanil 14.5 micrograms/kg or ketorolac 1.0 mg/kg in a double-blind fashion, 5 to 10 minutes before induction of general anesthesia. MEASUREMENTS AND MAIN RESULTS: Heart rate (HR) and noninvasive blood pressure (BP) were measured and recorded before and immediately after injection of the study drug, after laryngoscopy for the endotracheal tube placement, and after initiation of diagnostic panendoscopy. Bleeding in the operative field was rated by the endoscopist. Observation from discontinuation of the propofol infusion and nitrous oxide inhalation to eye opening, head lifting, and orientation to time and place was observed and recorded. The presence of stridor after extubation, and pulse oximeter-determined arterial blood oxyhemoglobin saturation immediately after extubation and 5 minutes later, were noted. In the recovery room, the ability to tolerate oral fluids, sit, stand, and walk were recorded. Supplementation with ketorolac provides faster recovery from anesthesia as evidenced by shorter time to eye opening, head lifting, and orientation to time and place. However, no intergroup differences were found in measured intraoperative variables (BP and HR following laryngoscopy, tracheal intubation, diagnostic panendoscopy, and tissue biopsy). Operative site bleeding was comparable in both groups. The variables reflecting street readiness and the incidence of nausea and vomiting were statistically comparable. CONCLUSION: Supplementation of propofol anesthesia with ketorolac is an efficacious alternative to supplementation with alfentanil. The faster recovery in the ketorolac group is explained by the mostly peripheral effect of this drug, whereas the slow decline in the alfentanil concentration at the effective site may be responsible for slower emergence from anesthesia.

Alfentanil↗