The effects of oral ibuprofen and celecoxib in preventing pain, improving recovery outcomes and patient satisfaction after ambulatory surgery.

BACKGROUND: Nonsteroidal antiinflammatory drugs have become increasingly popular as part of multimodal analgesic regimens for pain management in the ambulatory setting. We designed this randomized, double-blind, placebo-controlled study to evaluate the effect of postoperative administration of either a nonselective nonsteroidal antiinflammatory drug (ibuprofen) or the cyclooxygenase-2 selective inhibitor (celecoxib when administered as part of a multimodal analgesic regimen) on the severity of pain, the need for rescue analgesics, and clinically relevant patient outcomes after ambulatory surgery. The primary end point was the time to resumption of normal activities of daily living. METHODS: One hundred eighty patients undergoing outpatient surgery were randomly assigned to 1 of 3 treatment groups: group 1 (control) received either 2 placebo capsules (matching celecoxib) or 1 placebo tablet (matching ibuprofen) in the recovery room and 1 placebo tablet at bedtime on the day of surgery, followed by 1 placebo capsule or tablet 3 times a day for 3 days after discharge; group 2 (celecoxib) received celecoxib 400 mg (2 capsules) orally in the recovery room and 1 placebo capsule and tablet at bedtime on the day of surgery, followed by celecoxib 200 mg (1 capsule) twice a day + placebo capsule every day at bedtime for 3 days after surgery; or group 3 (ibuprofen) received ibuprofen 400 mg (1 tablet) orally in the recovery room and 400 mg orally at bedtime on the day of surgery, followed by 400 mg orally 3 times a day for 3 days after surgery. Recovery times, postoperative pain scores, and the need for rescue analgesics were recorded before discharge. Follow-up evaluations were performed at 24 hours, 48 hours, 72 hours, 7 days, and 30 days after surgery to assess postdischarge pain, analgesic requirements, resumption of normal activities, opioid-related side effects, as well as quality of recovery and patient satisfaction with their postoperative pain management using a 5-point verbal rating scale. RESULTS: The 3 groups did not differ with respect to their demographic characteristics. Compared with the placebo treatment, both celecoxib and ibuprofen significantly decreased the need for rescue analgesic medication after discharge (P < 0.05). The effect sizes (celecoxib and ibuprofen versus control group) were 0.73 to 1 and 0.3 to 0.8, respectively. Quality of recovery scores and patient satisfaction with their postoperative pain management were also improved in the celecoxib and ibuprofen groups compared with the control group (P < 0.05, effect size [vs control group] = 0.67). The incidence of postoperative constipation was significantly higher in the control group (28%) compared with the celecoxib (5%) and ibuprofen (7%) groups, respectively (P < 0.05). Both active treatments were well tolerated in the postdischarge period. However, the time to resumption of normal activities of daily living was similar among the 3 groups. CONCLUSIONS: Both ibuprofen (1200 mg/d) and celecoxib (400 mg/d) significantly decreased the need for rescue analgesic medication in the early postdischarge period, leading to an improvement in the quality of recovery and patient satisfaction with their pain management after outpatient surgery.

Desflurane versus sevoflurane for maintenance of outpatient anesthesia: the effect on early versus late recovery and perioperative coughing.

BACKGROUND: There is controversy regarding the relative perioperative benefits of desflurane versus sevoflurane when used for maintenance of anesthesia in the ambulatory setting. Although studies have consistently demonstrated a faster emergence with desflurane (versus sevoflurane), the impact of this difference on the later recovery end points has not been definitively established. Furthermore, the effect of desflurane (versus sevoflurane) on the incidence of coughing is also controversial. METHODS: We randomized 130 outpatients undergoing superficial surgical procedures requiring general anesthesia to one of two maintenance anesthetic treatment groups. All patients were induced with propofol, 2 mg/kg IV, and after placement of a laryngeal mask airway, anesthesia was maintained with either sevoflurane 1%-3% or desflurane 3%-8% in an air/oxygen mixture. The inspired concentration of the volatile anesthetic was varied to maintain hemodynamic stability and a Bispectral Index value of 50-60. Analgesia was provided with local anesthetic infiltration and ketorolac (30 mg IV). Antiemetic prophylaxis consisted of a combination of ondansetron (4 mg), dexamethasone (4 mg), and metoclopramide (10 mg) at the end of surgery. Assessments included recovery times to eye opening, response to commands, orientation, fast-track score of 14, first oral intake, sitting, standing, ambulating unassisted, and actual discharge. Patient satisfaction with anesthesia, the ability to resume normal activities on the first postoperative day, adverse side effects (e.g., coughing, purposeful movement, oxygen desaturation <90%, sore throat, postoperative nausea, and vomiting), and the requirement for postoperative analgesic and antiemetic drugs were recorded in the early postoperative period and during the initial 24-h period after discharge. RESULTS: The two study groups had comparable demographic characteristics. Although the overall incidence of coughing during the perioperative period was higher in the desflurane group (60% versus 32% in the sevoflurane group, P < 0.05), the incidences of coughing during the actual administration of the volatile anesthetics (i.e., the maintenance period) did not differ between the two groups. Emergence from anesthesia was more rapid after desflurane; however, all patients achieved fast-track recovery criteria (fast-track score >or=12) before leaving the operating room. Finally, the time to discharge home (90 +/- 31 min in sevoflurane and 98 +/- 35 min in desflurane, respectively) and the percentage of patients able to resume normal activities on the first postoperative day (sevoflurane 48% and desflurane 60%) did not differ significantly between the two anesthetic groups. CONCLUSIONS: Use of desflurane for maintenance of anesthesia was associated with a faster emergence and a higher incidence of coughing. Despite the faster initial recovery with desflurane, no significant differences were found between the two volatile anesthetics in the later recovery period. Both volatile anesthetics should be available for ambulatory anesthesia.

Transdermal scopolamine: an alternative to ondansetron and droperidol for the prevention of postoperative and postdischarge emetic symptoms.

BACKGROUND: Given the controversy regarding the use of droperidol and the high cost of the 5-HT3 antagonists, a cost-effective alternative for routine use as a prophylactic antiemetic would be desirable. We designed two parallel, randomized, double-blind sham and placebo-controlled studies to compare the early and late antiemetic efficacy and adverse event profile of transdermal scopolamine (TDS) 1.5 mg, to ondansetron 4 mg IV, and droperidol 1.25 mg IV for antiemetic prophylaxis as part of a multimodal regimen in "at risk" surgical populations. METHODS: A total of 150 patients undergoing major laparoscopic (n = 80) or plastic (n = 70) surgery procedures received either an active TDS patch (containing scopolamine 1.5 mg) or a similar appearing sham patch 60 min before entering the operating room. All patients received a standardized general anesthetic technique. A second study medication was administered in a 2-mL numbered syringe containing either saline (for the two active TDS groups), droperidol, 1.25 mg, or ondansetron, 4 mg (for the sham patch groups), and was administered IV near the end of the procedure. The occurrence of postoperative nausea and vomiting/retching, need for rescue antiemetics, and the complete response rates (i.e., absence of protracted nausea or repeated episodes of emesis requiring antiemetic rescue medication) was reported. In addition, complaints of visual disturbances, dry mouth, drowsiness, and restlessness were noted up to 72 h after surgery. RESULTS: There were no significant differences in any of the emetic outcomes or need for rescue antiemetics among the TDS, droperidol, and ondansetron groups in the first 72 h after surgery. The complete response rates varied from 41% to 51%, and did not significantly differ among the treatment groups. The overall incidence of dry mouth was significantly more frequent in the TDS groups than in the droperidol and ondansetron groups (21% vs 3%). CONCLUSIONS: Premedication with TDS was as effective as droperidol (1.25 mg) or ondansetron (4 mg) in preventing nausea and vomiting in the early and late postoperative periods. However, the use of a TDS patch is more likely to produce a dry mouth.

The use of oral granisetron versus intravenous ondansetron for antiemetic prophylaxis in patients undergoing laparoscopic surgery: the effect on emetic symptoms and quality of recovery.

Based on comparative studies in patients receiving emetogenic chemotherapy, it has been suggested that granisetron would be more effective than ondansetron for the prevention of postdischarge nausea and vomiting (PDNV). However, there have been no direct comparisons of these two popular 5-HT3 antagonists with respect to PDNV and quality of recovery. We designed this randomized, double-blind study to compare the antiemetic efficacy of oral granisetron (1 mg) to a standard IV dose of ondansetron (4 mg) when administered for antiemetic prophylaxis as part of a multimodal regimen in a laparoscopic surgical population. A total of 220 patients undergoing laparoscopic surgery with a standardized general anesthetic technique were enrolled in this prospective study at two major medical centers. Patients were randomly assigned to one of two prophylactic treatment groups: the control (ondansetron) group received an oral placebo 1 h before surgery and ondansetron, 4 mg IV, at the end of the surgery, and the granisetron group received granisetron, 1 mg per os, 1 h before surgery, and normal saline, 2 mL IV, at the end of the surgery. The early recovery profiles, requirement for rescue antiemetics, incidence of PDNV, and the side effects were recorded over the 48 h study period. In addition, nausea scores were assessed using an 11-point verbal rating scale at specific intervals in the postoperative period. The quality of recovery and patient satisfaction scores were recorded at 48 h after surgery. The demographic characteristics were similar in the two prophylaxis treatment groups, as well as the recovery times to patient orientation, oral intake, and hospital discharge. The incidences of PDNV, requirements for rescue antiemetics, and quality of recovery did not differ between the two study groups. The antiemetic drug acquisition costs to achieve comparable patient satisfaction with ondansetron and granisetron were US 25.65 dollars and 47.05 dollars, respectively. Therefore, ondansetron (4 mg IV) was more cost-effective than granisetron (1 mg per os) for routine antiemetic prophylaxis as part of a multimodal regimen in patients undergoing either outpatient or inpatient laparoscopic surgery.

A comparison of state and response entropy versus bispectral index values during the perioperative period.

Cerebral monitoring indices are associated with a large degree of inter-patient variability and electrical signal interference during surgery. We designed this clinical study to test the hypothesis that use of the spectral entropy (Entropy) module is associated with less frequent intraoperative interference with the displayed indices than the bispectral index (BIS) monitor when used during general anesthesia with propofol and desflurane. Thirty consenting patients scheduled for major laparoscopic surgery procedures were enrolled in this prospective study. The elapsed time to obtain a baseline index value was recorded, as well as the simultaneous state entropy (SE), response entropy (RE), and BIS values at specific time intervals during the induction, maintenance, and emergence periods in patients administered a standardized general anesthetic technique. During the maintenance period, the changes in these indices were evaluated after a bolus dose of propofol (20 mg IV) and a 2% increase or decrease in the inspired concentration of desflurane. As expected, the baseline SE values were less than the RE and BIS values (88 +/- 2 versus 96 +/- 3 and 96 +/- 4, respectively). However, the SE and RE values correlated with the BIS value during the induction (r = 0.77 and 0.78, respectively) and emergence (r = 0.86 and 0.91, respectively) periods. The area under the receiver operating characteristic curve for detection of consciousness also indicated a similar performance of the SE (0.93 +/- 0.04) relative to the RE (0.98 +/- 0.04) and BIS (0.97 +/- 0.04). During the maintenance period, the responses to changes in propofol and desflurane concentrations were consistent with all three indices. Finally, the entropy indices were less interfered with by the electrocautery unit during the operation (12% versus 62% for the BIS monitor). Because the average selling prices of the Entropy and BIS disposable electrode strips (14.25 dollars versus 14.95 dollars USD, respectively) are comparable, we conclude that the Entropy module is a cost-equivalent alternative to the BIS monitor.

Is the patient state analyzer with the PSArray2 a cost-effective alternative to the bispectral index monitor during the perioperative period?

New disposable electrodes, the PSArray and XP sensor, have been developed for the patient state analyzer (PSA) and the bispectral index (BIS) monitors, respectively. We designed this clinical study to compare the sensitivity and specificity of the patient state index (PSI) with the BIS during the perioperative period when the new electrode sensors were used. Twenty-two consenting patients scheduled for elective laparoscopic procedures were enrolled in this prospective study. The elapsed time to apply electrodes and obtain a baseline index value was recorded, as were the comparative PSI and BIS values at specific time intervals during the induction, maintenance, and emergence periods in patients who were administered a standardized general anesthetic. In addition, the changes in these indices were recorded after a bolus dose of propofol (20 mg IV) or a 2% increase or decrease in the inspired concentration of desflurane during the maintenance period. The total elapsed time to obtain an index value was similar with both devices (66 +/- 32 s versus 72 +/- 41 s for the PSA and BIS, respectively). By using logistic regression models, both the BIS and PSI were found to be equally effective as predictors of unconsciousness (i.e., failure to respond to verbal stimuli). The PSI also correlated with the BIS during both the induction of (R = 0.85) and the emergence from (R = 0.74) general anesthesia. The area under the receiver operating characteristic curve for detection of consciousness also indicated a similar performance with the PSI (0.98 +/- 0.05) and the BIS (0.97 +/- 0.05). During the maintenance period, the PSI values tended to be lower than the BIS value; however, the responses to changes in propofol and desflurane were similar. Finally, the PSI (versus BIS) values showed less interference from the electrocautery unit during the operation (31% versus 73%, respectively). Although the list price of the PSArray(2) disposable electrode strip (USD $24.95) was higher than that of the BIS XP sensor (USD $17.50), the average sale price (USD $14.95) was identical for both electrode systems. Therefore, we conclude that the PSA monitor with the PSArray(2) is a cost-effective alternative to the BIS monitor with the XP sensor for evaluating consciousness during the induction of and emergence from general anesthesia, as well as for titrating propofol and desflurane during the maintenance period.

Does the use of electroencephalographic bispectral index or auditory evoked potential index monitoring facilitate recovery after desflurane anesthesia in the ambulatory setting?

BACKGROUND: Analogous to the Bispectral Index (BIS) monitor, the auditory evoked potential monitor provides an electroencephalographic-derived index (AAI), which is alleged to correlate with the central nervous system depressant effects of anesthetic drugs. This clinical study was designed to test the hypothesis that intraoperative cerebral monitoring guided by either the BIS or the AAI value would facilitate recovery from general anesthesia compared with standard clinical monitoring practices alone in the ambulatory setting. METHODS: Sixty consenting outpatients undergoing gynecologic laparoscopic surgery were randomly assigned to one of three study groups: (1) control (standard practice), (2) BIS guided, or (3) AAI guided. Anesthesia was induced with 1.5-2.5 mg/kg propofol and 1-1.5 microg/kg fentanyl given intravenously. Desflurane, 3%, in combination with 60% nitrous oxide in oxygen was administered for maintenance of general anesthesia. In the control group, the inspired desflurane concentration was varied based on standard clinical signs. In the BIS- and AAI-guided groups, the inspired desflurane concentrations were titrated to maintain BIS and AAI values in targeted ranges of 50-60 and 15-25, respectively. BIS and AAI values, hemodynamic variables, and the end-tidal desflurane concentration were recorded at 5-min intervals during the maintenance period. The emergence times and recovery times to achieve specific clinical endpoints were recorded at 1- to 10-min intervals. The White fast-track and modified Aldrete recovery scores were assessed on arrival in the PACU, and the quality of recovery score was evaluated at the time of discharge home. RESULTS: A positive correlation was found between the AAI and BIS values during the maintenance period. The average BIS and AAI values (mean +/- SD) during the maintenance period were significantly lower in the control group (BIS, 41 +/- 10; AAI, 11 +/- 6) compared with the BIS-guided (BIS, 57 +/- 14; AAI, +/- 11) and AAI-guided (BIS, 55 +/- 12; AAI, 20 +/- 10) groups. The end-tidal desflurane concentration was significantly reduced in the BIS-guided (2.7 +/- 0.9%) and AAI-guided (2.6 +/- 0.9%) groups compared with the control group (3.6 +/- 1.5%). The awakening (eye-opening) and discharge times were significantly shorter in the BIS-guided (7 +/- 3 and 132 +/- 39 min, respectively) and AAI-guided (6 +/- 2 and 128 +/- 39 min, respectively) groups compared with the control group (9 +/- 4 and 195 +/- 57 min, respectively). More importantly, the median [range] quality of recovery scores was significantly higher in the BIS-guided (18 [17-18]) and AAI-guided (18 [17-18]) groups when compared with the control group (16 [10-18]). CONCLUSION: Compared with standard anesthesia monitoring practice, adjunctive use of auditory evoked potential and BIS monitoring can improve titration of desflurane during general anesthesia, leading to an improved recovery profile after ambulatory surgery.

Perioperative rofecoxib improves early recovery after outpatient herniorrhaphy.

UNLABELLED: Non-opioid analgesics have become increasingly popular as part of a multimodal regimen for pain management in the ambulatory setting. We designed this randomized, double-blind, placebo-controlled study to evaluate the effect of perioperative administration of the cyclooxygenase-2 inhibitor rofecoxib on patient outcome after inguinal herniorrhaphy procedures. Sixty consenting outpatients undergoing elective hernia repair surgery were randomly assigned to one of two treatment groups: control (vitamin C, 500 mg) or rofecoxib (rofecoxib, 50 mg). The first oral dose of the study medication was administered 30-40 min before entering the operating room, and a second dose of the same medication was given on the morning of the first postoperative day. Recovery times, postoperative pain scores, the need for "rescue" analgesics, and side effects were recorded at 1- to 10-min intervals before discharge from the recovery room. Follow-up evaluations were performed at 36 h, 7 days, and 14 days after surgery to assess postdischarge pain, analgesic requirements, resumption of normal activities, as well as patient satisfaction with their postoperative pain management. Rofecoxib significantly decreased the early recovery times, leading to an earlier discharge home after surgery (88 +/- 30 vs 126 +/- 44 min, P < 0.05). When compared with the control group, the patients' median [range] quality of recovery score was also significantly higher in the rofecoxib group (18 [14-18] vs 16 [13-18], P < 0.05). In the predischarge period, a significantly larger percentage of patients required rescue pain medications in the control group (67% vs 37% in the rofecoxib group, P < 0.05). At the 36-h follow-up assessment, rofecoxib-treated patients reported significantly reduced oral analgesic requirements (0 [0-20] vs 9 [1-33] pills, P < 0.05) and lower maximal pain scores, resulting in improved patient satisfaction with their postoperative pain management (3 [1-4] vs 2 [0-3], P < 0.05). However, there were no differences in the times required to resume their activities of daily living. In conclusion, perioperative rofecoxib, 50 mg per os, significantly decreased postoperative pain and the need for analgesic rescue medication, leading to a faster and improved quality of recovery after outpatient hernia surgery. However, perioperative use of rofecoxib failed to improve recovery end points in the postdischarge period. IMPLICATIONS: Rofecoxib (50 mg per os), given before and after surgery, was effective in improving postoperative pain management, as well as the speed and quality of recovery after outpatient inguinal herniorrhaphy. However, it failed to accelerate the postdischarge resumption of normal activities of daily living.

The effect of intraoperative use of esmolol and nicardipine on recovery after ambulatory surgery.

UNLABELLED: There is controversy regarding the optimal technique for maintaining hemodynamic stability during anesthesia. We designed this prospective, randomized, double-blinded study to test the hypothesis that the technique used for maintaining hemodynamic stability during general anesthesia can influence recovery after ambulatory surgery. Forty-five healthy consenting women undergoing gynecologic laparoscopy procedures were randomly assigned to 1 of 3 treatment groups: Group 1 (control, n = 15) received normal saline 5 mL and 1 mL, followed by a saline infusion at a rate of 0.005 mL x kg(-1) x min(-1); Group 2 (n = 15) received esmolol 50 mg and saline 1 mL, followed by an esmolol infusion 5 microg x kg(-1) x min(-1); and Group 3 (n = 15) received esmolol 50 mg and nicardipine 1 mg, followed by an esmolol infusion 5 microg x kg(-1) x min(-1). The study drugs were administered after the induction of anesthesia with fentanyl 1.5 microg/kg, and propofol 2 mg/kg I.V. Tracheal intubation was facilitated with vecuronium 0.12 mg/kg I.V. Anesthesia was initially maintained with desflurane 2% end-tidal and N(2)O 67% in oxygen in all 3 groups. During surgery, the mean arterial blood pressure (MAP) was maintained within +/-15% of the baseline value by varying the study drug infusion rate and the inspired concentration of desflurane. In addition to MAP and heart rate values, electroencephalogram bispectral index values were recorded throughout the perioperative period. Recovery times and postoperative side effects were assessed. Compared with the control group, adjunctive use of esmolol and nicardipine attenuated the increase in heart rate (in Group 2) and MAP (in Group 3) after tracheal intubation. Furthermore, the use of an esmolol infusion as an adjunct to desflurane to control the acute autonomic responses during the maintenance period significantly decreased emergence times (4 +/- 2 versus 7 +/- 4 min), decreased the need for postoperative opioid analgesics (43% versus 80%), and reduced the time to discharge (209 +/- 89 versus 269 +/- 100 min). We conclude that the adjunctive use of esmolol alone or in combination with nicardipine during the induction of anesthesia reduced the hemodynamic response to tracheal intubation. Furthermore, use of an esmolol infusion as an adjuvant to desflurane-N(2)O anesthesia for controlling the acute hemodynamic responses during the maintenance period improved the recovery profile after outpatient laparoscopic surgery. IMPLICATIONS: The adjunctive use of the beta-adrenergic blocker esmolol to control the acute sympathetic responses during desflurane-based anesthesia provided a more rapid awakening from anesthesia, reduced the postoperative opioid analgesic requirement, and decreased the time to discharge home after ambulatory laparoscopic surgery.

Antiemetic prophylaxis for office-based surgery: are the 5-HT3 receptor antagonists beneficial?

BACKGROUND: Office-based surgery has become increasingly popular because of its cost-saving potential. However, the occurrence of postoperative nausea and vomiting (PONV) can delay patient discharge. Prophylaxis using a combination of antiemetic drugs has been suggested as an effective strategy for minimizing PONV. The authors designed this randomized, double-blinded, placebo-controlled study to assess the efficacy of ondansetron and dolasetron when administered in combination with droperidol and dexamethasone for routine antiemetic prophylaxis against PONV in the office-based surgery setting. METHODS: Following institutional review board approval, 135 consenting outpatients with American Society of Anesthesiologists physical status I-III who were undergoing superficial surgical procedures lasting 20-40 min were randomly assigned to one of three antiemetic treatment groups. Propofol was administered for induction of anesthesia, followed by 2-4% desflurane with 67% nitrous oxide in oxygen. Desflurane was subsequently adjusted to maintain a clinically adequate depth of anesthesia with an electroencephalographic Bispectral Index value between 50 and 60. All patients received 0.625 mg intravenous droperidol and 4 mg intravenous dexamethasone after induction of anesthesia. The study medication, containing normal saline (control), 12.5 mg intravenous dolasetron, or 4 mg intravenous ondansetron, was administered prior to the end of surgery. All patients received local anesthetics at the incisional site and 30 mg intravenous ketolorac to minimize postoperative pain. Recovery profiles, incidence of PONV, requirement for rescue antiemetic drugs, complete response rates, and patient satisfaction were assessed. RESULTS: The recovery times to patient orientation, oral intake, ambulation, and actual discharge did not differ among the three groups. The incidence of PONV, nausea scores, and requirement for rescue antiemetics were also similar in all three groups during the 24-h study period. In addition, the complete response rates to the prophylactic antiemetics (96-98%) and percentages of very satisfied patients (93-98%) were equally high in all three groups. However, the antiemetic drug acquisition costs were US $2.50, $15.50, and $18.50 in the control, dolasetron, and ondansetron groups, respectively. CONCLUSION: The addition of dolasetron (12.5 mg) or ondansetron (4 mg) failed to improve the antiemetic efficacy of droperidol (0.625 mg intravenous) and dexamethasone (4 mg intravenous) when they were used for routine prophylaxis in the office-based surgery setting.

Effect of maintenance bolus on the recovery profile of a short-acting nondepolarizing muscle relaxant.

STUDY OBJECTIVE: To evaluate the effect of different maintenance boluses of a short-acting nondepolarizing neuromuscular blocking drug on its spontaneous recovery profile during anesthesia. DESIGN: Prospective, randomized, double-blind, dose-ranging study. SETTING: University-based medical center. PATIENTS: 69 ASA physical status I and II consenting adult outpatients undergoing general anesthesia with an anticipated duration of at least 2 hours. INTERVENTIONS: Patients were randomized to one of three study groups. Following induction of anesthesia with propofol and fentanyl, rapacuronium 1.5 mg x kg(-1) intravenously (i.v.), was administered to facilitate tracheal intubation. Anesthesia was maintained with desflurane 4% end-tidal in combination with nitrous oxide 67% in oxygen. When the first twitch (T(1)) in the train-of-four (TOF) returned to 25% of its baseline value, a maintenance dose of rapacuronium 0.25 mg x kg(-1) i.v. (Group 1), 0.5 mg. kg(-1) i.v. (Group 2), or 0.75 mg. kg(-1) i.v. (Group 3) was administered. The time course of neuromuscular block was monitored at the wrist using standard electromyography. MEASUREMENTS AND MAIN RESULTS: The times for recovery of the T(1) to 25% of the baseline value following different maintenance doses of rapacuronium were only 6.3 +/- 2.2, 7.5 +/- 2.3, and 9.6 +/- 2.5 minutes, in Groups 1, 2 and 3, respectively. However, the times for the TOF ratio to return to 0.7 were 44 +/- 15, 53 +/- 20, and 66 +/- 30 minutes in Groups 1, 2, and 3, respectively. Although recovery times were significantly longer after rapacuronium 0.75 mg x kg(-1) i.v. (Group 3), there were no significant differences in any of the recovery variables between Groups 1 and 2. CONCLUSIONS: Spontaneous recovery of the T(1) to 25% of the baseline value occurred 6 to 10 minutes after a maintenance bolus dose of rapacuronium 0.25 to 0.75 mg x kg(-1) i.v. However, recovery to a TOF>0.7 required 44 to 66 minutes during desflurane anesthesia.

A comparison of patient state index and bispectral index values during the perioperative period.

UNLABELLED: The patient state index (PSI), a quantitative electroencephalographic index, has been recently introduced into clinical practice as a monitor for assessing consciousness during sedation and general anesthesia. We designed this observational study to compare the sensitivity and specificity of the PSI with that of the bispectral index (BIS) with respect to their ability to predict the loss of consciousness and emergence from anesthesia, as well as to assess changes in IV (propofol) and inhaled (desflurane) anesthetics during the maintenance period. Twenty consenting patients scheduled for elective laparoscopic surgical procedures were enrolled in this prospective clinical study. Anesthesia was induced with propofol 2 mg/kg IV and fentanyl 1 micro g/kg IV, and tracheal intubation was facilitated with cisatracurium 0.3 mg/kg IV. Desflurane 4% in combination with nitrous oxide 60% in oxygen was administered for the maintenance of anesthesia. Comparative PSI and BIS values were obtained at specific time intervals during the induction, maintenance, and emergence periods. The changes in these indices were recorded after the administration of propofol (20 mg IV) or with 2% increases or decreases in the inspired concentration of desflurane during the maintenance period. With logistic regression models, both the BIS and PSI were found to be effective as predictors of unconsciousness (i.e., failed to respond to verbal stimuli) (P < 0.01). The PSI also correlated with the BIS during both the induction of (r = 0.78) and emergence from (r = 0.73) general anesthesia. However, the area under the receiver operating characteristic curve for detection of consciousness indicated a better performance with the PSI (0.95 +/- 0.04) than the BIS (0.79 +/- 0.04). During the maintenance period, the PSI values were comparable to the BIS in response to changes in propofol and desflurane but displayed greater interpatient variability. Finally, the PSI (versus BIS) values were less interfered with by the electrocautery unit during surgery (16% versus 65%, respectively). In conclusion, the PSI may prove to be a viable alternative to the BIS for evaluating consciousness during the induction of and emergence from general anesthesia, as well as for titrating the administration of propofol and desflurane during the maintenance period. However, further studies with the PSA device are needed to determine its role in anesthesia. IMPLICATIONS: The patient state index could be a useful alternative to the bispectral index for assessing level of consciousness during the induction of and emergence from anesthesia, as well as for titrating IV and volatile anesthetics during surgery.

Effect of parecoxib, a novel intravenous cyclooxygenase type-2 inhibitor, on the postoperative opioid requirement and quality of pain control.

BACKGROUND: The analgesic efficacy and side effect profile of intravenous parecoxib, a novel cyclooxygenase type-2 (COX-2) inhibitor, was assessed in a double-blinded, placebo-controlled study involving patients undergoing major gynecologic surgical procedures. METHODS: After Institutional Review Board approval, 60 consenting women, American Society of Anesthesiologists (ASA) physical status I-III, undergoing lower abdominal surgery with a standardized general anesthetic technique were randomly assigned to receive one of three study medications: group 1 (control) received normal saline; group 2 received intravenous parecoxib, 20 mg; and group 3 received intravenous parecoxib, 40 mg. The initial dose of study medication was administered when the patient first requested pain medication after surgery. All patients had access to patient-controlled analgesia (PCA) with intravenous morphine, 1 or 2 mg, with a 6-min lockout period. Subsequent doses of the same study medication were administered at 12-h and 24-h intervals after the initial dose. The postoperative opioid analgesic requirement (PCA morphine usage), pain scores, pain relief scores, side effects, and need for supplemental medications (e.g., antiemetics, antipruritics, laxatives) were recorded. RESULTS: Compared with saline, intravenous parecoxib, 20 mg and 40 mg every 12 h, significantly decreased the PCA morphine usage during the first 6 h postoperatively (group 1, 25 +/- 13 mg; group 2, 16 +/- 11 mg; group 3, 17 +/- 10 mg) and at 12 h (group 1, 34 +/- 18 mg; group 2, 24 +/- 14 mg; group 3, 23 +/- 13 mg) and 24 h (group 1, 51 +/- 27 mg; group 2, 34 +/- 20 mg; group 3, 33 +/- 21 mg) after surgery. However, there were no significant differences in the patients' global evaluation of the study medications at 12 h and 24 h between those who received intravenous parecoxib (20 or 40 mg) and saline. Moreover, the postoperative pain scores and side effect profiles were similar in the three treatment groups. CONCLUSION: Intravenous parecoxib (20 or 40 mg) was effective in decreasing the PCA opioid requirement after lower abdominal surgical procedures. However, it failed to improve pain management or reduce opioid-related side effects in the early postoperative period.