Is it time to re-evaluate the routines about stopping/keeping platelet inhibitors in conjunction to ambulatory surgery?

PURPOSE OF REVIEW: To assess the influence of antiplatelet drugs (APDs) in outpatients' perioperative care and to propose up-to-date management of those patients. RECENT FINDINGS: Evidence is spreading on the risk of adverse cardiovascular events (ACEs) when APD therapy is discontinued, specifically in patients with coronary stents. Conversely, maintaining such treatments throughout the operative period appears usually safe. Bridging with low-molecular-weight heparins poorly protects against ACEs. In outpatients, major surgical bleeding is rare, but sometimes a minor hemorrhage may jeopardize the success of a surgical procedure. Despite the paucity of properly sized randomized trials in this setting, recommendations have been issued by scientific societies and can be used as guidelines. Variability in APD efficiency is now better appraised, and research on versatile bedside testing of platelet function is active. New drugs are expected to be launched in the near future, all this aiming at improving individualized drug dosage and therefore both safety and efficiency of APD therapies. SUMMARY: In surgical patients APD therapy should be maintained in all situations in which the risk of surgical bleeding is low, which is usually the case in the ambulatory setting. In clearly identified cases in which bleeding might threaten either the patient's life or the success of the surgical procedure in patients at high risk of ACE, the discontinuation protocol must be established in conjunction with the cardiologist and the APD therapy resumed as soon as possible. Bridging with low-molecular-weight heparins is not recommended.

Development and feasibility of a scale to assess postoperative recovery: the post-operative quality recovery scale.

BACKGROUND: Good postoperative recovery is increasingly recognized as an important outcome after surgery. The authors created a new Post-operative Quality Recovery Scale (PQRS) that tracks multiple domains of recovery from immediate to long-term time periods in patients of varying ages, languages, and cultures. METHODS: The parameters of importance to both clinicians and patients were identified. After an initial pilot study of 133 patients, the PQRS was refined. It consists of six domains (physiologic, nociceptive, emotive, activities of daily living, cognitive, and overall patient perspective). An observational study of 701 patients was performed with the refined PQRS to assess its capacity to evaluate and track recovery and to discriminate between patients. It was conducted in eight countries and in five languages, involving patients more than or equal to 6 yr undergoing elective surgery with general anesthesia. Recovery was assessed before surgery and at multiple time periods postoperatively. Recovery was defined as return to baseline values or better. RESULTS: Seven hundred one patients completed the PQRS. Mean completion time was 4.8 (SD 2.8) min. Recovery scores improved with time. Physiologic recovery was complete in 34% of subjects by 40 min. By the third postoperative day, complete recovery was obtained in 11% of cases (all domains): 48.7% nociceptive, 81.8% emotive, 68.8% activities of daily living, and only 33.5% cognitive. Overall, 95.8% of the patients reported that they were "satisfied or totally satisfied" with their anesthetic care. CONCLUSION: The scores on the PQRS demonstrated an improvement over time, consistent with an expected recovery after surgery and anesthesia, and an ability to discriminate between individuals. Many patients had incomplete recovery by the third postoperative day.

Update on pharmacology of hypnotic drugs.

PURPOSE OF REVIEW: This review is intended to provide an update on pharmacology of hypnotic drugs and current state of published research for new or improved agents. RECENT FINDINGS: Albeit no completely new drugs have been launched in the last few years, research on pharmacology of existing drugs is still ongoing, and new formulations of existing drugs are proposed (propofol, isoflurane). Xenon, an old but so far unavailable drug, has elicited new interests and this review will examine the recent publications on this fascinating agent. SUMMARY: These results will improve our handling of existing drugs and open new perspectives on drug monitoring through measurement of propofol concentrations in expired air.

Pharmacokinetics of propofol administered by target-controlled infusion to alcoholic patients.

BACKGROUND: Chronic alcoholic patients are frequently presented for anesthesia and surgery. These patients require higher doses of propofol than control patients for induction of anesthesia, but whether this is because of changes in pharmacokinetics or pharmacodynamics is not known. This study was designed to investigate the influence of chronic ethanol intake on propofol pharmacokinetics. METHODS: Fifteen chronic alcoholic and 15 control patients, receiving propofol by target-controlled infusion for otolaryngologic surgery, were studied. Blood propofol concentrations were measured at regular intervals during and after the propofol infusion. Nonlinear mixed-effects population models (NONMEM) examining the influence of alcoholism were constructed. The influence of recovery on propofol pharmacokinetic parameters was also addressed. RESULTS: The total amount of propofol and the predicted and measured concentrations during all phases of anesthesia did not differ between the two groups. The fact that the measured concentrations at the time of opening eyes were similar further confirmed that the potency of propofol was not modified by the alcoholic status of the patients. Chronic alcoholism was associated with only mild changes in propofol pharmacokinetics (increase in rapid intercompartmental clearance and greater interindividual variability in the central volume of distribution). The rebound in concentration frequently observed during the recovery phase could be related to decreased propofol peripheral volumes of distribution despite an increase in elimination clearance. CONCLUSIONS: Chronic alcoholism induces only mild changes in the pharmacokinetics of propofol. Conversely, propofol pharmacokinetics are markedly different during anesthesia and surgery or after opening eyes in the recovery period.

Remifentanil: an update.

PURPOSE OF REVIEW: Remifentanil has now reached maturity, as reflected by the increasing number of clinical papers relating to its use. Its position among anaesthetic drugs is now better understood, and this review will attempt to place it in the context of current clinical practice. RECENT FINDINGS AND SUMMARY: Propofol reduces the initial distribution of remifentanil, leading to higher concentrations during induction. Propofol and remifentanil administered together at sedative doses display a major synergistic interaction on the respiratory drive. Remifentanil accelerates the penetration of sevoflurane to its site of effect. The risk of intraoperative awareness seems to be low when remifentanil is associated to very low concentrations of hypnotic drugs, but this field warrants further investigation. Acute tolerance to opioids and its prevention remain controversial. SUMMARY: Remifentanil is the opioid of choice for tracheal intubation without muscle relaxants. It provides an alternative to regional anaesthesia in labour pain control. Target-controlled infusion may further improve the administration of remifentanil.