Standard procedures in nonoperating room anesthesia.

PURPOSE OF REVIEW: This article provides an overview of standard procedures currently performed in nonoperating room anesthesia (NORA) and highlights anesthetic implications. RECENT FINDINGS: Novel noninvasive interventional procedures remain on the rise, accelerating demand for anesthesia support outside the conventional operating room. The field of interventional oncology has introduced a variety of effective minimally invasive therapies making interventional radiology gain a major role in the management of cancer. Technical innovation brings newer ablative and embolotherapy techniques into practice. Flexible bronchoscopy has replaced rigid bronchoscopy for many diagnostic and therapeutic indications. Endobronchial ultrasonography now allows sampling of mediastinal, paratracheal, or subcarinal lymph nodes rendering more invasive procedures such as mediastinoscopy unnecessary. Similarly, endoscopic ultrasonosgraphy currently plays a central position in the management of gastrointestinal disease. Sophisticated catheter techniques for ablating cardiac arrhythmias have become state of the art; Watchman procedure gaining position in the prevention of stroke resulting from atrial fibrillation. SUMMARY: NORA is a rapidly evolving field in anesthesia. Employing new technology to treat a wide variety of diseases brings new challenges to the anesthesiologist. Better understanding of emerging interventional techniques is key to safe practice and allows the anesthesia expert to be at the forefront of this swiftly expanding multidisciplinary arena.

Analysis of Multiple Routes of Analgesic Administration in the Immediate Postoperative Period: a 10-Year Experience.

PURPOSE OF REVIEW: An increasing amount of literature supports a multimodal approach to analgesic administration in the management of postoperative pain. The purpose of this study and review was to further evaluate the differences in efficacy in controlling immediate postoperative pain among the various routes of analgesia administration. RECENT FINDINGS: This study consisted of an analysis of the various routes of analgesic administration (parental, neuraxial, and oral/rectal) in 107,671 consecutive surgical cases performed over a 10-year period at Yale New Haven Hospital. This study included variables of postoperative pain score at initial request for analgesic, pain score at discharge, nausea and vomiting in the post-anesthesia care unit, and gender. The most common route of administration of analgesia in our study was via the parenteral route (29,962), and the least common route was the neuraxial route (1319). There was a significant decrease in pain scores at the time of discharge in all three groups relative to the pain score at first request for analgesia. Multimodal analgesia via various routes of administration targets numerous proponents of the nervous system with the intent to reduce the adverse side effects of the individual analgesics if given alone or as an additive to produce synergistic analgesia. Our study suggests that although all the routes investigated (parenteral, neuraxial (intrathecal/epidural), and per os or per rectum (PO/PR)) promote significant pain relief on discharge from the PACU, the group that received neuraxial analgesia reported the lowest incidence of nausea and vomiting.

Safety of Deep Sedation in Patients Undergoing Full-Thickness Skin Graft Harvesting and Skin Graft Reconstruction for Limb Salvage An Outcome Analysis.

BACKGROUND:: Studies on obtaining donor skin graft using intravenous sedation for patients undergoing major foot surgeries in the same operating room visit have not previously been reported. The objective of this retrospective study is to demonstrate that intravenous sedation in this setting is both adequate and safe in patients undergoing skin graft reconstruction of the lower extremities in which donor skin graft is harvested from the same patient in one operating room visit. METHODS:: Medical records of 79 patients who underwent skin graft reconstruction of the lower extremities by one surgeon at the Yale New Haven Health System between November 1, 2008, and July 31, 2014, were reviewed. The patients' demographic characteristics, American Society of Anesthesiologists class, comorbid conditions, intraoperative analgesic administration, estimated blood loss, total operating room time, total postanesthesia care unit time, and postoperative complications within the first 72 hours were reviewed. RESULTS:: This study found minimal blood loss and no postoperative complications, defined as any pulmonary or cardiac events, bleeding, admission to the intensive care unit, or requirement for invasive monitoring, in patients who underwent major foot surgery in conjunction with full-thickness skin graft. CONCLUSIONS:: We propose that given the short duration and peripheral nature of the procedures, patients can safely undergo skin graft donor harvesting and skin graft reconstruction procedures with intravenous sedation regardless of American Society of Anesthesiologists class in one operating room visit.

Transvaginal cholecystectomy learning curve.

BACKGROUND: There are few surgeons in the United States, within private practice and academic centers, currently performing transvaginal cholecystectomies (TVC). The lack of exposure to TVC during residency or fellowship training, coupled with a poorly defined learning curve, further limits interested surgeons who want to apply this technique to their practice. This study describes the learning curve encountered during the introduction of TVC to our academic facility. METHODS: This study is an analysis of consecutive TVCs performed between August 14, 2009 and August 3, 2012 at an academic center. The TVC patients were divided into sequential quartiles (n = 15/16). The learning curve outcome was measured as the operative time of TVC patients and compared to the operative time of female laparoscopic cholecystectomy (LC) patients performed during the same time period. RESULTS: Sixty-one patients underwent a TVC with a mean age of 38 ± 12 years and mean BMI was 29 ± 6 kg/m(2). Sixty-seven female patients who underwent a LC with average age 41 ± 15 years and average BMI 33 ± 12 kg/m(2). The average operative time of LC patients and TVC patients was 48 ± 20 and 60 ± 17 min, respectively. Significant improvement in TVC operative times was seen between the first (n = 15 TVCs) and second quartiles (p = 0.04) and stayed relatively constant for third quartile, during which there was no statistically significant difference between the mean LC operative time for the second and third TVC quartiles CONCLUSIONS: The learning curve of a fellowship-trained surgeon introducing TVC to their surgical repertoire, as measured by improved operative times, can be achieved with approximately 15 cases.

Concern for pain in the pre-operative period- is the internet being used for information by patients?

OBJECTIVES: This study was conducted to provide information regarding prevalence of pain, type of provider managing pain, and use of Internet for information regarding pain, among patients coming for presurgical anesthesia consultation at a major academic institution. METHODS: With IRB approval, patients were invited to participate in a voluntary and anonymous 14 question survey given to them when they presented for anesthesia consultation prior to their surgical procedure. The qualitative/categorical data were summarized by number (percentage [%]) and analyzed by Chi-square test or Fisher's exact test as appropriate. All data analyses were performed using the statistical software SAS, v9.2. RESULTS: A total of 1039 patients were asked to complete the survey and 670 patients returned their responses (response rate = 64.5%). 83% of patients had a history of prior surgery. 57% were concerned about postoperative pain. 30% of patients had chronic pain for more than 3 months pre-operatively. 16% of patients had looked online for information regarding pain. Pain physicians were involved in pain management only in 3.8% of these patients. DISCUSSION: Patients are presenting for surgery with significant pre-operative pain issues. Knowing this information pre-operatively will help healthcare personnel manage postsurgical pain more effectively. Patients are also using the Internet to obtain information regarding pain. As providers, there may be value to directing patients to reliable information online during consultation. As all physicians will eventually be managing chronic pain in their patients, pain education should be given priority in medical school curriculum.

Comparison of immediate postoperative pain after transvaginal versus traditional laparoscopic cholecystectomy.

BACKGROUND: Transvaginal cholecystectomy (TVC) is the most common natural orifice transluminal surgery (NOTES) performed in women, yet there is a paucity of data on intraoperative and immediate postoperative pain management. Previous studies have demonstrated that NOTES procedures are associated with less postoperative pain and faster recovery times. This study analyzes intraoperative and postoperative opioid use for TVC compared with traditional four-port laparoscopic cholecystectomies (LCs). METHODS: This is a retrospective analysis of consecutive TVC and LC female patients between August 2009 and August 2012 in an academic institution. We compared demographics, intraoperative and postoperative opioid use and times in the operating room (OR) and in the post anesthesia care unit (PACU). RESULTS: A total of 68 TVC and 67 LC patients were included in this study. The TVC and LC groups were similar in terms of age (both 41 years) and body mass index (29 and 31 kg/m2, respectively). The intraoperative preparation, surgical, and emergence times were significantly longer for the TVC than for the LC (p ≤ 0.01). Compared with the LC group, the intraoperative opioid requirement was significantly greater (TVC 27 mg vs. LC 25 mg; p = 0.003), but after adjusting for anesthesia time, the difference in OR opioid consumption became non-significant (p = 0.08). The PACU opioid requirement (TVC 2.5 vs. LC 5 mg; p = 0.04) was significantly lower for the TVC group, and a greater proportion of patients did not need any pain medications (TVC 38 % vs. LC 21 %; p = 0.04), compared with the LC group. The average PACU pain scores were not significantly different between the groups (p = 0.45). CONCLUSION: TVC patients did not experience more pain than LC patients. Although the average pain scores of TVC patients did not differ from those of the LC patients, TVC patients did require less pain medication in the PACU.

Intravenous dextrose administration reduces postoperative antiemetic rescue treatment requirements and postanesthesia care unit length of stay.

BACKGROUND: Postoperative nausea and vomiting (PONV) remains the most common postoperative complication, and causes decreased patient satisfaction, prolonged postoperative hospital stays, and unanticipated admission. There are limited data that indicate that dextrose may reduce nausea and vomiting. In this trial, we attempted to determine whether the rate of PONV can be decreased by postoperative administration of IV dextrose bolus. METHODS: To test the effect of postoperative dextrose administration on PONV rates, we conducted a double-blind, randomized, placebo-controlled trial. We enrolled 62 nondiabetic, ASA class I or II nonsmoking outpatients scheduled for gynecologic laparoscopic and hysteroscopic procedures. Patients were randomized into 2 groups: the treatment group received dextrose 5% in Ringer lactate solution, and the control (placebo) group received Ringer lactate solution given immediately after surgery. All patients underwent a standardized general anesthesia and received 1 dose of antiemetic a half hour before emergence from anesthesia. PONV scores, antiemetic rescue medications, narcotic consumption, and discharge time were recorded in the postanesthesia care unit (PACU) in half-hour intervals. RESULTS: The 2 groups were similar with regard to age, weight, anxiety scores, prior PONV, non per os status, presurgical glucose, anesthetic duration, intraoperative narcotic use, and total weight-based fluid volume received. Postoperative nausea scores were not significantly different in the dextrose group compared with the control group (P > 0.05) after Bonferroni correction for repeated measurements over time. However, patients who received dextrose 5% in Ringer lactate solution consumed less rescue antiemetic medications (ratio mean difference, 0.56; 95% confidence interval, 0.39-0.82; P = 0.02), and had a shorter length of stay in the PACU (ratio mean difference, 0.80; 95% confidence interval, 0.66-0.97; P = 0.03) compared with patients in the control group. CONCLUSION: In this trial, postanesthesia IV dextrose administration resulted in improved PONV management as defined by reductions in antiemetic rescue medication requirements and PACU length of stay that are worthy of further study. In light of its ease, low risk, and benefit to patient care and satisfaction, this therapeutic modality could be considered.

Hemispheric synchronized sounds and perioperative analgesic requirements.

BACKGROUND: Data on the effect of Hemisync sounds on perioperative analgesic requirements are scant. METHODS: We randomized surgical outpatients into a treatment group that received Hemisync sounds (n = 20), a music group that received music (n = 20), and a control group that had a blank cassette tape (n = 20). All subjects underwent a controlled standardized propofol-nitrous-vecuronium and fentanyl general anesthesia. RESULTS: The treatment group had significantly reduced intraoperative fentanyl consumption (P < 0.05). Postoperatively, pain visual analog scale scores were significantly lower in the Hemisync group at 1 h (P = 0.02) and 24 h (P = 0.005). Subjects in the Hemisync group were also discharged earlier (P = 0.048). CONCLUSION: The use of Hemisync sounds before and during general anesthesia reduces intraoperative analgesic requirements, postoperative pain scores, and discharge time.

Risk-benefit perspectives in COX-2 blockade.

The withdrawal of the celebrity arthritis drug, rofecoxib (Vioxx) has sparked an intense discussion and controversy about the safety of the selective COX-2 inhibitors. Laboratory, epidemiological, and clinical studies have surged and continued to evaluate and understand the safety of coxibs and traditional NSAIDs. This paper reviews the scientific and clinical basis of not only the risks, but also the benefits surrounding the use COX-2 inhibitors and NSAIDs. Discussion, debate, opinions, regulatory and clinical recommendations have evolved since the unexpected emergence of cardiac thrombotic events from the use of these drugs. The evidence by which coxibs and NSAIDs can potentially attenuate or exacerbate cardiovascular disease by affecting endothelial function is assessed; and how NSAIDs and coxibs affect renal function and blood pressure is revisited. Several investigations provide insight into their mechanism and clinical application.

Regional anesthesia and perioperative outcome: what is new?

PURPOSE OF REVIEW: This review of the most recent publications is aimed to look at the current developments regarding the effects of regional anesthesia on perioperative outcome. RECENT FINDINGS: The debate continues on whether regional anesthesia and analgesia improve outcome or not. Researchers are still divided in their views. While previous meta-analyses are more favorable, more recent trials are rather on the con side. In an attempt to lessen heterogeneity, meta-analyses have now incorporated data from more recent trials to perform subgroup analyses. Such analyses persistently show the same positive results. The established outcome effects of regional anesthesia are mostly due its ability to provide superior analgesia, its ability to reduce the perioperative stress response and subsequent physiologic perturbations, and its ability to reduce pulmonary complications. Its potential to prevent cardiac morbidity in patients undergoing coronary artery bypass grafting is investigated further by looking at valuable specific biological markers like troponin I and natriuretic peptides. Intrathecal opioids do not seem to improve outcome, unlike the intrathecal local anesthetics. The latter improve outcome presumably by blocking the surgical stress response. In contrast, opioids, non-steroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors have been shown not to impact outcome presumably by not being able to interfere with the stress response. The safety and efficacy of epidural or spinal anesthesia for spinal surgery continue to be demonstrated by current studies. SUMMARY: Despite the controversies, the numerous potential benefits and advantages of regional anesthesia are keys to its continued popularity. With constant search for new scientific clues by improving experimental designs, valuable evidence slowly unfolds. Regional anesthesia certainly takes a leading role in the current trends for a multimodal approach of perioperative pain management.

Hemispheric synchronized sounds and intraoperative anesthetic requirements.

Hemispheric synchronization is currently promoted as a treatment for preoperative anxiety and for reduction of intraoperative anesthetic and analgesic consumption. We designed this study to examine the effect of Hemisync sounds on anesthetic hypnotic depth. After obtaining informed consent, we randomized subjects undergoing general anesthesia and outpatient surgery into two groups: the treatment group received Hemisync sounds (n = 31), and the control group received a blank cassette tape (n = 29). Both groups received the intervention in the preoperative area and during the surgical procedure. Subjects underwent a propofol-based anesthetic regimen, and propofol doses required for the induction and maintenance of anesthesia were recorded. A bispectral index monitor was used to ensure that the hypnotic component of the anesthetic state was the same in all patients. We found no differences in the amount of propofol used during the induction of anesthesia (2.49 +/- 0.59 mg/kg versus 2.60 +/- 0.59 mg/kg; P = 0.48) or the maintenance of anesthesia (0.141 +/- 0.02 mg x kg(-1) x min(-1) versus 0.146 +/- 0.04 mg x kg(-1) x min(-1); P = 0.62) between the Hemisync and control groups. We also found no differences between the Hemisync group and the control group for participants with high state anxiety (P = not significant). We conclude that Hemisync sounds do not reduce the hypnotic component of the anesthetic state of patients undergoing general anesthesia and surgery.