Preoperative dexamethasone enhances quality of recovery after laparoscopic cholecystectomy: effect on in-hospital and postdischarge recovery outcomes.

BACKGROUND: The effect of dexamethasone on quality of recovery after discharge from the hospital after laparoscopic surgery has not been examined rigorously in previous investigations. We hypothesized that preoperative dexamethasone would enhance patient-perceived quality of recovery on postoperative day 1 in subjects undergoing laparoscopic cholecystectomy. METHODS: One hundred twenty patients undergoing outpatient laparoscopic cholecystectomy were randomized to receive either dexamethasone (8 mg) or placebo-saline. A 40-item quality-of-recovery scoring system (QoR-40) was administered preoperatively and on postoperative day 1 to all subjects. Nausea, vomiting, fatigue, and pain scores were recorded at the time of discharge from the postanesthesia care unit and ambulatory surgical unit. Hospital length of stay was also assessed. RESULTS: Global QoR-40 scores on postoperative day 1 were higher in the dexamethasone group (median [range], 178 [130-195]) compared with the control group (161 [113-194]) (median difference [99% CI], -18 [-26 to -8]; P < 0.0001). Postoperative QoR-40 scores in the dimensions of emotional state, physical comfort, and pain were all improved in the dexamethasone group compared with the control group (P < 0.001). Nausea, fatigue, and pain scores were all reduced in the dexamethasone group during the hospitalization, as were postoperative analgesic requirements (P < 0.05). Total hospital length of stay was also reduced in subjects administered steroids (P = 0.003). CONCLUSIONS: Among patients undergoing outpatient laparoscopic cholecystectomy surgery, the use of preoperative dexamethasone enhanced postdischarge quality of recovery and reduced nausea, pain, and fatigue in the early postoperative period.

Cerebral oxygen desaturation events assessed by near-infrared spectroscopy during shoulder arthroscopy in the beach chair and lateral decubitus positions.

BACKGROUND: Patients undergoing shoulder surgery in the beach chair position (BCP) may be at risk for adverse neurologic events due to cerebral ischemia. In this investigation, we sought to determine the incidence of cerebral desaturation events (CDEs) during shoulder arthroscopy in the BCP or lateral decubitus position (LDP). METHODS: Data were collected on 124 patients undergoing elective shoulder arthroscopy in the BCP (61 subjects) or LDP (63 subjects). Anesthetic management was standardized in all patients. Regional cerebral tissue oxygen saturation (Scto(2)) was quantified using near-infrared spectroscopy. Baseline heart rate, mean arterial blood pressure, arterial oxygen saturation, and Scto(2) were measured before patient positioning and then every 3 minutes for the duration of the surgical procedure. Scto(2) values below a critical threshold (> or = 20% decrease from baseline or absolute value < or = 55% for >15 seconds) were defined as a CDE and treated using a predetermined protocol. The number of CDEs and types of intervention used to treat low Scto(2) values were recorded. The association between intraoperative CDEs and impaired postoperative recovery was also assessed. RESULTS: Anesthetic management was similar in the BCP and LDP groups, with the exception of more interscalene blocks in the LDP group. Intraoperative hemodynamic variables did not differ between groups. Scto(2) values were lower in the BCP group throughout the intraoperative period (P < 0.0001). The incidence of CDEs was higher in the BCP group (80.3% vs 0% LDP group), as was the median number of CDEs per subject (4, range 0-38 vs 0, range 0-0 LDP group, all P < 0.0001). Among all study patients without interscalene blocks, a higher incidence of nausea (50.0% vs 6.7%, P = 0.0001) and vomiting (27.3% vs 3.3%, P = 0.011) was observed in subjects with intraoperative CDEs compared with subjects without CDEs. CONCLUSIONS: Shoulder surgery in the BCP is associated with significant reductions in cerebral oxygenation compared with values obtained in the LDP.

Morphine-based cardiac anesthesia provides superior early recovery compared with fentanyl in elective cardiac surgery patients.

BACKGROUND: Experimental and clinical data suggest that morphine possesses unique cardioprotective and antiinflammatory properties. In this clinical investigation, we sought to determine whether the choice of intraoperative opioid (morphine or fentanyl) influences early recovery after cardiac surgery. METHODS: Ninety patients undergoing cardiac surgery with cardiopulmonary bypass were randomized to receive either morphine (40 mg) or fentanyl (600 mug) as part of a standardized opioid-isoflurane anesthetic. Quality of recovery was assessed using the QoR-40 questionnaire administered preoperatively and daily on postoperative days 1-3. During the first three postoperative days, pain was measured using a 100-mm visual analog scale, and the use of IV and oral pain medications (morphine or acetaminophen/hydrocodone) was quantified. Hemodynamic variables, duration of tracheal intubation, postoperative febrile reactions, organ morbidities, and intensive care unit (ICU) and hospital length of stay were evaluated. RESULTS: Compared with patients given fentanyl, those receiving morphine had higher global QoR-40 scores on postoperative days 1 (173 vs 160, P < 0.0001), 2 (174 vs 164, P < 0.0001), and 3 (177 vs 167, P < 0.001). Differences between the groups were observed in the QoR-40 dimensions of emotional state, physical comfort, and pain (all P < 0.01-0.0001). Postoperative visual analog scale pain scores, use of pain medication in the ICU and surgical ward, and postoperative febrile reactions were reduced significantly in the morphine group (all P < 0.01). No differences between the groups were noted in duration of tracheal intubation, ICU and hospital length of stay, or postoperative complications. CONCLUSIONS: In patients undergoing elective cardiac surgery with cardiopulmonary bypass, postoperative quality-of-life measures and pain control during recovery were enhanced when morphine (40 mg) was administered intraoperatively as part of a balanced anesthetic technique compared with fentanyl.

Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit.

BACKGROUND: Incomplete recovery from neuromuscular blockade in the postanesthesia care unit (PACU) may contribute to adverse postoperative respiratory events. This study determined the incidence and degree of residual neuromuscular blockade in patients randomized to conventional qualitative train-of-four (TOF) monitoring or quantitative acceleromyographic monitoring. The incidence of adverse respiratory events in the PACU was also evaluated. METHODS: One hundred eighty-five patients were randomized to intraoperative acceleromyographic monitoring (acceleromyography group) or qualitative TOF monitoring (TOF group). Anesthetic management was standardized. TOF patients were extubated when standard criteria were met and no fade was observed during TOF stimulation. Acceleromyography patients had a TOF ratio of greater than 0.80 as an additional extubation criterion. Upon arrival in the PACU, TOF ratios of both groups were measured with acceleromyography. Adverse respiratory events during transport to the PACU and during the first 30 min of PACU admission were also recorded. RESULTS: A lower frequency of residual neuromuscular blockade in the PACU (TOF ratio < or = 0.9) was observed in the acceleromyography group (4.5%) compared with the conventional TOF group (30.0%; P < 0.0001). During transport to the PACU, fewer acceleromyography patients developed arterial oxygen saturation values, measured by pulse oximetry, of less than 90% (0%) or airway obstruction (0%) compared with TOF patients (21.1% and 11.1%, respectively; P < 0.002). The incidence, severity, and duration of hypoxemic events during the first 30 min of PACU admission were less in the acceleromyography group (all P < 0.0001). CONCLUSIONS: Incomplete neuromuscular recovery can be minimized with acceleromyographic monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intraoperative acceleromyography use.