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Renner RM, Ennis M, McKercher AE, Henderson JT, Edelman A. Local anaesthesia for pain control in first trimester surgical abortion. Cochrane Database Syst Rev 2024; 2:CD006712. [PMID: 38348912 PMCID: PMC10862555 DOI: 10.1002/14651858.cd006712.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Abortions prior to 14 weeks are among the most common outpatient surgical procedures performed on people capable of becoming pregnant. Various methods have been used to control pain; however, many people still experience pain with the procedure. OBJECTIVES To evaluate the benefits and harms of local anaesthesia given for pain control during surgical abortion at less than 14 weeks' gestation. SEARCH METHODS We searched CENTRAL (Ovid EBM Reviews), MEDLINE (Ovid), Embase, POPLINE, and Google Scholar to December 2022 for randomized controlled trials of pain control in surgical abortion at less than 14 weeks' gestation using suction aspiration. We searched the reference lists of related reviews and articles. SELECTION CRITERIA We selected effectiveness and comparative effectiveness randomized controlled trials that studied local anaesthesia with common local anaesthetics and administration routes given for pain control in surgical abortion at less than 14 weeks' gestation using uterine aspiration. Outcomes included intraoperative pain, patient satisfaction, and adverse events. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. We computed mean differences (MD) with 95% confidence intervals (CI) for continuous variables reporting a mean. We assessed the certainty of evidence using GRADE. MAIN RESULTS Thirteen studies with 1992 participants met the inclusion criteria. Due to heterogeneity of interventions, we could not pool more than two studies for any outcome. We used 13 mm improvement on a visual/verbal analogue scale to indicate a clinically meaningful difference in pain with surgical abortion (pain with dilation, aspiration, or during procedure). Based on type of pain control, we divided studies into three groups. Paracervical block (PCB) effectiveness trials A 20 mL 1% lidocaine PCB reduced pain with dilation (MD -37.00, 95% CI -45.64 to -28.36), and aspiration (MD -26.00, 95% CI -33.48 to -18.52) compared to a sham PCB (1 RCT, 120 participants; high-certainty evidence). A PCB with 14 mL of 1% chloroprocaine resulted in a slight reduction in pain with aspiration compared to a PCB with normal saline injected at two or four sites (MD -1.50, 95% CI -2.45 to -0.55; 1 RCT, 79 participants; high-certainty evidence). PCB comparative effectiveness trials An ultracaine PCB probably results in little to no clinically meaningful difference in pain during procedure compared to topical cervical lidocaine spray (median 1 point higher, interquartile range (IQR) 0 to 3; P < 0.001; 1 RCT, 48 participants; moderate-certainty evidence). A 1000 mg dose of intravenous paracetamol probably does not decrease pain as much as ultracaine PCB during procedure (median 2 points higher, IQR 1 to 3; P < 0.001; 1 RCT, 46 participants; moderate-certainty evidence). Various local anaesthetics in PCB comparative effectiveness trials A 10 mL buffered 2% lidocaine PCB probably does not result in a clinically meaningful difference in pain with dilation compared to a plain lidocaine PCB (MD -0.80, 95% CI -0.89 to -0.71; 1 RCT, 167 participants; moderate-certainty evidence). A buffered lidocaine PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to plain lidocaine PCB (MD -0.57, 95% CI -1.01 to -0.06; 2 RCTs, 291 participants; moderate-certainty evidence). Non-PCB local anaesthesia or PCB technique effectiveness trials PCB: waiting versus no waiting Waiting three to five minutes between 1% lidocaine PCB injection and dilation probably does not result in a clinically meaningful difference in pain with dilation compared to not waiting (MD -0.70, 95% CI -1.23 to -0.17; 2 RCTs, 357 participants; moderate-certainty evidence). Topical cervical analgesia Topical 10 mL 2% lignocaine gel probably does not result in a clinically meaningful difference in pain with aspiration compared to KY Jelly (MD -0.87, 95% CI -1.60 to -0.14; 1 RCT, 131 participants; moderate-certainty evidence). In participants who also received a PCB, 20 mg topical cervical lidocaine spray probably does not result in a clinically meaningful difference in pain during the procedure compared to two pumps of normal saline spray (median -1 point, IQR -2 to -1; P < 0.001; 1 RCT, 55 participants; moderate-certainty evidence). Intravenous paracetamol 1000 mg compared to two pumps of cervical lidocaine spray probably does not results in a clinically meaningful difference in pain procedure (median 1 point, IQR -2 to 2; P < 0.001; 1 RCT, 48 participants; low-certainty evidence). Non-PCB local anaesthesia or PCB technique comparative effectiveness trials Depth of PCB The evidence suggests that a 3-cm deep PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to a 1.5-cm deep PCB (MD -1.00, 95% CI -1.09 to -0.91; 2 RCTs, 229 participants; low-certainty evidence). PCB: four sites versus two sites A two-site (4-8 o'clock) 20 mL 1% lidocaine PCB does not result in a clinically meaningful difference in pain with dilation compared to a four-site (2-4-8-10 o'clock) PCB (MD 8.60, 95% CI 0.69 to 16.51; 1 RCT, 163 participants; high-certainty evidence). Overall, participants reported moderately high satisfaction with pain control and studies reported few adverse events. AUTHORS' CONCLUSIONS Evidence from this updated review indicates that a 20 mL 1% plain lidocaine PCB decreases pain during an abortion procedure. Evidence supports forgoing buffering lidocaine and a wait time between PCB injection and cervical dilation. A 1.5-cm deep injection as opposed to a 3-cm deep injection is sufficient. A two-site PCB injection as opposed to a four-site injection has similar effectiveness. Topical cervical anaesthesia (10 mL 2% lignocaine gel or 20 mg topical cervical lidocaine spray) as compared to placebo did not decrease pain based on moderate-certainty evidence, but then when compared to PCB, pain control was similar. Due to this inconsistency in evidence regarding the effectiveness of topical anaesthesia, its routine use is presently not supported. This review did not include studies of pain management with conscious sedation but, based on the results of our prior Cochrane review and the 2022 WHO guidelines, we recommend that the option of combination of pain management using conscious sedation plus PCB and non-steroidal anti-inflammatory drugs should be offered where conscious sedation is available as it further decreases pain.
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Affiliation(s)
- Regina-Maria Renner
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
| | - Madeleine Ennis
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
| | - Adrienne E McKercher
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
| | - Jillian T Henderson
- Fertility Regulation Group, Oregon Health & Science University, Portland, Oregon, USA
| | - Alison Edelman
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
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Abuelzein MLA, Baghdadi MA, Abbdelhady WA, Khairy MM. A prospective randomized controlled study on the role of restoring liver diaphragm surface tension and pain control at port sites in optimizing pain management following laparoscopic cholecystectomy. Ann Gastroenterol Surg 2022; 7:131-137. [PMID: 36643366 PMCID: PMC9831905 DOI: 10.1002/ags3.12602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/01/2022] [Indexed: 01/18/2023] Open
Abstract
Introduction After laparoscopic cholecystectomy (LC), pain is still a significant concern leading to extended hospital stays or readmissions. A standardized strategy is needed to offer effective pain relief postoperatively. The pain in the early postoperative period is mainly due to elimination of intraperitoneal surface tension. The aim of this study is to evaluate the restoration of intraabdominal surface tension and the use of bupivacaine-soaked tachosil to control parietal abdominal pain at the port sites to optimize postoperative pain management. Patients and methods Between March 2020 to December 2021, 816 patients undergoing LC were randomized into two groups after exclusion of 12 patients: Group A-interventional contained 402 patients; Group B-control contained 402 patients. Data to be compared were made in terms of operative time, shoulder pain, upper abdominal pain, and number of analgesic doses and hospital stay. Pain intensity was assessed by using the visual analog scale. Results There was no significant variation in the demographic data between the two groups. There was significant statistical difference between Groups (A) and (B) regarding severity of shoulder pain and port site pain and number of analgesic doses and hospital stay in favor of Group (A). The results were evaluated within 95% confidence intervals and significance was determined as P < .05. Conclusion The restoration of intraabdominal surface tension by absorbing as much CO2 as possible at the end of laparoscopic cholecystectomy via the epigastric port route, as well as the use of bupivacaine-soaked tachosil to control parietal abdominal pain at the port sites; both steps significantly improved postoperative pain management, reduced the number of analgesic doses, and decreased the length of hospital stay.
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Affiliation(s)
- Mohamed Lotfy Ali Abuelzein
- Department of General Surgery, Faculty of MedicineZagazig UniversityZagazigEgypt,King Khalid HospitalMinistry of HealthRiyadhSaudi Arabia
| | - Mohamed Ali Baghdadi
- Department of General Surgery, Faculty of MedicineZagazig UniversityZagazigEgypt
| | | | - Mostafa Mohamed Khairy
- Department of General Surgery, Faculty of MedicineZagazig UniversityZagazigEgypt,King Khalid HospitalMinistry of HealthRiyadhSaudi Arabia
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Myles PS, Leslie K, Silbert B, Paech MJ, Peyton P. A Review of the Risks and Benefits of Nitrous Oxide in Current Anaesthetic Practice. Anaesth Intensive Care 2019; 32:165-72. [PMID: 15957712 DOI: 10.1177/0310057x0403200202] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- P S Myles
- Department ofAnaesthesia and Pain Management, Alfred Hospital, Melbourne, Victoria
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Hounsome J, Greenhalgh J, Schofield-Robinson OJ, Lewis SR, Cook TM, Smith AF. Nitrous oxide-based vs. nitrous oxide-free general anaesthesia and accidental awareness in surgical patients: an abridged Cochrane systematic review. Anaesthesia 2017; 73:365-374. [PMID: 29034449 DOI: 10.1111/anae.14065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2017] [Indexed: 12/29/2022]
Abstract
Accidental awareness during general anaesthesia can arise from a failure to deliver sufficient anaesthetic agent, or from a patient's resistance to an expected sufficient dose of such an agent. Awareness is 'explicit' if the patient is subsequently able to recall the event. We conducted a systematic review into the effect of nitrous oxide used as part of a general anaesthetic on the risk of accidental awareness in people over the age of five years undergoing general anaesthesia for surgery. We included 15 randomised controlled trials, 14 of which, representing a total of 3439 participants, were included in our primary analysis of the frequency of accidental awareness events. The awareness incidence rate was rare within these studies, and all were considered underpowered with respect to this outcome. The risk of bias across all studies was judged to be high, and 76% of studies failed adequately to conceal participant allocation. We considered the available evidence to be of very poor quality. There were a total of three accidental awareness events reported in two studies, one of which reported that the awareness was the result of a kink in a propofol intravenous line. There were insufficient data to conduct a meta- or sub-group analysis and there was insufficient evidence to draw outcome-related conclusions. We can, however, recommend that future studies focus on potentially high-risk groups such as obstetric or cardiac surgery patients, or those receiving neuromuscular blocking drugs or total intravenous anaesthesia.
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Affiliation(s)
- J Hounsome
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - J Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - O J Schofield-Robinson
- Patient Safety Research Unit, Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - S R Lewis
- Patient Safety Research Unit, Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - T M Cook
- Royal United Hospital Bath NHS Foundation Trust, Bath, UK
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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Zaafouri H, Mrad S, Khedhiri N, Haddad D, Bouhafa A, Maamer AB. [First experience with outpatient laparoscopic cholecystectomy in Tunisia]. Pan Afr Med J 2017; 28:78. [PMID: 29255548 PMCID: PMC5724953 DOI: 10.11604/pamj.2017.28.78.9564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 08/07/2017] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones. There is some debate as to whether it should be performed in outpatient surgery or in one-day surgery to improve patient safety. This study aimed to evaluate the impact of laparoscopic cholecystectomy performed in outpatient surgery versus one-day surgery on standards such as mortality, serious adverse events and quality of life. METHODS We conducted a cross-sectional descriptive study in the Department of General Surgery at the Habib Thameur Hospital over the period May 2009-February 2010. We here report 67 cases of symptomatic vesical lithiasis treated with outpatient laparoscopic cholecystectomy (OLC). ASA III and IV patients, diabetic patients treated with sulfonamides or insulin, severely obese patients, patients over 65 years of age and under 18 years of age, patients with a history of major abdominal surgery, patients with suspected lithiasis of the common bile duct, acute cholecystitis or pancreatitis were excluded from the study. Patients had to reside within 50 km of the hospital and be accompanied by an adult to undergo OLC. RESULTS Seventeen patients were included and then excluded from our study because of the perioperative detection of signs of acute cholecystitis or difficulties in dissection leading to subhepatic drainage using Redon catheter at the end of the intervention. Finally, our study included 50 patients, 7 men and 43 women; the average age was 48 years. Surgery was based on the most common procedures. After leaving the recovery room, patients were conducted in the outpatient sector where they received a liquid diet. The patients were examined before 7 o'clock in the evening and discharge was established on the basis of the possibility of establishing an oral analgesic treatment, patients tolerance to liquid diet, the lack of urinary disorder, patients acceptance for discharge and analgesic and anti-inflammatory treatment if needed. Thirty-nine patients (78%) were discharged from hospital and 11 were kept in hospital. Patients > 45 years of age, anesthesia duration > 70 minutes and post operative fatigue were identified as risk factors for unsuccessful discharge. No readmission was observed. Discharged patients were satisfied with the therapeutic protocol, resulting in excellent and good outcome in the majority of cases (94%). CONCLUSION Outpatient laparoscopic cholecystectomy seems to be as safe as day surgery laparoscopic cholecystectomy having low rate of complications and of hospital readmissions in some selected patients and lower surgery costs.
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Affiliation(s)
- Haithem Zaafouri
- Service de Chirurgie Générale, Hôpital Habib Thameur, Tunis, Tunisie
| | - Skander Mrad
- Service de Chirurgie Générale, Hôpital Habib Thameur, Tunis, Tunisie
| | - Nizar Khedhiri
- Service de Chirurgie Générale, Hôpital Habib Thameur, Tunis, Tunisie
| | - Dhafer Haddad
- Service de Chirurgie Générale, Hôpital Habib Thameur, Tunis, Tunisie
| | - Ahmed Bouhafa
- Service de Chirurgie Générale, Hôpital Habib Thameur, Tunis, Tunisie
| | - Anis Ben Maamer
- Service de Chirurgie Générale, Hôpital Habib Thameur, Tunis, Tunisie
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Messina AG, Wang M, Ward MJ, Wilker CC, Smith BB, Vezina DP, Pace NL. Anaesthetic interventions for prevention of awareness during surgery. Cochrane Database Syst Rev 2016; 10:CD007272. [PMID: 27755648 PMCID: PMC6461159 DOI: 10.1002/14651858.cd007272.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND General anaesthesia is usually associated with unconsciousness. 'Awareness' is when patients have postoperative recall of events or experiences during surgery. 'Wakefulness' is when patients become conscious during surgery, but have no postoperative recollection of the period of consciousness. OBJECTIVES To evaluate the efficacy of two types of anaesthetic interventions in reducing clinically significant awareness:- anaesthetic drug regimens; and- intraoperative anaesthetic depth monitors. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, ISSUE 4 2016); PubMed from 1950 to April 2016; MEDLINE from 1950 to April 2016; and Embase from 1980 to April 2016. We contacted experts to identify additional studies. We performed a handsearch of the citations in the review. We did not search trial registries. SELECTION CRITERIA We included randomized controlled trials (RCTs) of either anaesthetic regimens or anaesthetic depth monitors. We excluded volunteer studies, studies of patients prior to skin incision, intensive care unit studies, and studies that only randomized different word presentations for memory tests (not anaesthetic interventions).Anaesthetic drug regimens included studies of induction or maintenance, or both. Anaesthetic depth monitors included the Bispectral Index monitor, M-Entropy, Narcotrend monitor, cerebral function monitor, cerebral state monitor, patient state index, and lower oesophageal contractility monitor. The use of anaesthetic depth monitors allows the titration of anaesthetic drugs to maintain unconsciousness. DATA COLLECTION AND ANALYSIS At least two authors independently scanned abstracts, extracted data from the studies, and evaluated studies for risk of bias. We made attempts to contact all authors for additional clarification. We performed meta-analysis statistics in packages of the R language. MAIN RESULTS We included 160 studies with 54,109 enrolled participants; 53,713 participants started the studies and 50,034 completed the studies or data analysis (or both). We could not use 115 RCTs in meta-analytic comparisons because they had zero awareness events. We did not merge 27 of the remaining 45 studies because they had excessive clinical and methodological heterogeneity. We pooled the remaining 18 eligible RCTs in meta-analysis. There are 10 studies awaiting classification which we will process when we update the review.The meta-analyses included 18 trials with 36,034 participants. In the analysis of anaesthetic depth monitoring (either Bispectral Index or M-entropy) versus standard clinical and electronic monitoring, there were nine trials with 34,744 participants. The overall event rate was 0.5%. The effect favoured neither anaesthetic depth monitoring nor standard clinical and electronic monitoring, with little precision in the odds ratio (OR) estimate (OR 0.98, 95% confidence interval (CI) 0.59 to 1.62).In a five-study subset of Bispectral Index monitoring versus standard clinical and electronic monitoring, with 34,181 participants, 503 participants gave awareness reports to a blinded, expert panel who adjudicated or judged the outcome for each patient after reviewing the questionnaires: no awareness, possible awareness, or definite awareness. Experts judged 351 patient awareness reports to have no awareness, 87 to have possible awareness, and 65 to have definite awareness. The effect size favoured neither Bispectral Index monitoring nor standard clinical and electronic monitoring, with little precision in the OR estimate for the combination of definite and possible awareness (OR 0.96, 95% CI 0.35 to 2.65). The effect size favoured Bispectral Index monitoring for definite awareness, but with little precision in the OR estimate (OR 0.60, 95% CI 0.13 to 2.75).We performed three smaller meta-analyses of anaesthetic drugs. There were nine studies with 1290 participants. Wakefulness was reduced by ketamine and etomidate compared to thiopental. Wakefulness was more frequent than awareness. Benzodiazepines reduces awareness compared to thiopental, ketamine, and placebo., Also, higher doses of inhaled anaesthetics versus lower doses reduced the risk of awareness.We graded the quality of the evidence as low or very low in the 'Summary of findings' tables for the five comparisons.Most of the secondary outcomes in this review were not reported in the included RCTs. AUTHORS' CONCLUSIONS Anaesthetic depth monitors may have similar effects to standard clinical and electrical monitoring on the risk of awareness during surgery. In older studies comparing anaesthetics in a smaller portion of the patient sample, wakefulness occurred more frequently than awareness. Use of etomidate and ketamine lowered the risk of wakefulness compared to thiopental. Benzodiazepines compared to thiopental and ketamine, or higher doses of inhaled anaesthetics versus lower doses, reduced the risk of awareness.
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Affiliation(s)
- Anthony G Messina
- School of Management, University of Texas at DallasThe Alliance for Medical Management EducationBox 2331920 N. Coit RoadRichardsonTXUSA75080
| | - Michael Wang
- University of LeicesterClinical Psychology UnitLancaster RoadLeicesterUKLE1 7HA
| | - Marshall J Ward
- Dartmouth‐Hitchcock Medical Center1 Medical Center DrLebanonNHUSA03766
| | - Chase C Wilker
- ARUP LaboratoriesClinical Toxicology IIISalt Lake CityUTUSA
| | - Brett B Smith
- University of UtahUniversity of Utah School of MedicineSalt Lake CityUTUSA84112
| | - Daniel P Vezina
- University of UtahDepartment of Anesthesiology, Department of Internal Medicine, Division of CardiologySalt Lake CityUTUSA
- Veteran's AdministrationEchocardiography LaboratorySalt Lake CityUTUSA
| | - Nathan Leon Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
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Hounsome J, Nicholson A, Greenhalgh J, Cook TM, Smith AF, Lewis SR. Nitrous oxide-based versus nitrous oxide-free general anaesthesia and accidental awareness during general anaesthesia in surgical patients. Cochrane Database Syst Rev 2016; 2016:CD011052. [PMID: 27508523 PMCID: PMC9284342 DOI: 10.1002/14651858.cd011052.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Accidental awareness during general anaesthesia (AAGA) is when a patient unintentionally becomes conscious during a procedure performed with general anaesthesia and subsequently has explicit recall of this event. Incidence estimates for AAGA vary, with the most common estimate being one to two cases per 1000 general anaesthetics. Evidence linking nitrous oxide use and an increased risk of AAGA has come from observational studies data but the literature is contradictory, with some studies finding a protective effect of nitrous oxide. OBJECTIVES To assess the effect of general anaesthesia including nitrous oxide on the risk of AAGA in patients aged five years and over. SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registers ((www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (www.who.int/ictrp/network/en/) and Current Controlled Trials (www.isrctn.com/)) for eligible studies on December 9 2015. In addition, we conducted forward and backward citation searching using key identified papers. SELECTION CRITERIA We considered all randomized controlled trials (RCTs), including quasi-randomized studies and cluster-randomized studies, of participants aged five years or older receiving general anaesthesia for any type of surgery.We included trials in which participants receiving general anaesthesia that included nitrous oxide for maintenance at a concentration of at least 30% were compared with participants receiving no nitrous oxide during general anaesthesia. The intervention group must have received nitrous oxide in conjunction with an additional anaesthetic. We excluded studies where the depth of anaesthesia differed between the study arms. For inclusion in the review, studies needed to state in their methods that they planned to assess AAGA. We defined this as when a patient becomes conscious during a procedure performed with general anaesthesia and subsequently has explicit recall of this event. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane to identify studies. We extracted data and conducted 'Risk of bias' assessment using the Covidence database. MAIN RESULTS We included 15 studies. The total number of participants included in the analyses was 3520. Most studies were small with fewer than 120 participants, although two larger studies with 2012 and 671 participants were included. There was considerable variation in many of the study characteristics, including the anaesthetics used. The concentrations of nitrous oxide varied between 50% and 70%, and half of the studies used clinical signs and haemodynamic changes to monitor depth of anaesthesia.As it was not possible to blind the anaesthetist to the anaesthetic used, we rated all studies at high risk of performance bias and we therefore downgraded the quality of evidence by one level for risk of bias using the GRADE approach. Other types of bias were generally low, or were rated unclear due to missing information.No studies were designed to measure AAGA as the primary outcome, and were therefore statistically underpowered to answer this review question. Despite the inclusion of 3520 participants, only three awareness events were reported by two studies. In one study the event was due to technical failure. Due to the rarity of the events, we did not consider it appropriate to pool the data, and we therefore downgraded the quality of evidence by a further level for imprecision using GRADE. AUTHORS' CONCLUSIONS It is not possible to draw any conclusions from this review. The included studies were mainly small (fewer than 120 participants) and there were limited estimates of effect, with only two studies reporting any events. We cannot therefore determine whether the use of nitrous oxide in general anaesthesia increases, decreases or has no effect on the risk of accidental awareness.
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Affiliation(s)
- Juliet Hounsome
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
| | - Amanda Nicholson
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
- Q Medical Technologies LimitedUnit 1A Summerlands Trading EstateEndmoorKendalUKLA8 0FB
| | - Janette Greenhalgh
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
| | - Tim M Cook
- Royal United HospitalDepartment of AnaesthesiaCombe ParkBathUKBA1 3NG
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
| | - Sharon R Lewis
- Royal Lancaster InfirmaryPatient Safety Research DepartmentPointer Court 1, Ashton RoadLancasterUKLA1 1RP
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Sun R, Jia WQ, Zhang P, Yang K, Tian JH, Ma B, Liu Y, Jia RH, Luo XF, Kuriyama A. Nitrous oxide-based techniques versus nitrous oxide-free techniques for general anaesthesia. Cochrane Database Syst Rev 2015; 2015:CD008984. [PMID: 26545294 PMCID: PMC9326975 DOI: 10.1002/14651858.cd008984.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise. OBJECTIVES To determine if nitrous oxide-based anaesthesia results in similar outcomes to nitrous oxide-free anaesthesia in adults undergoing surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites (http://clinicaltrials.gov/, http://controlled-trials.com/, and http://www.centerwatch.com). SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol-based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted the outcome data. We used meta-analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed-effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random-effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. MAIN RESULTS We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta-analyses showed that nitrous oxide-based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta-analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide-based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low. AUTHORS' CONCLUSIONS Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre-existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review.
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Affiliation(s)
- Rao Sun
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Wen Qin Jia
- Gansu Provincial HospitalDepartment of AnesthesiaNo. 204, Donggang West RoadLanzhou CityGansuChina730000
| | - Peng Zhang
- Nanyang Central HospitalDepartment of Pediatric SurgeryNanyangHenanChina473000
| | - KeHu Yang
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - Jin Hui Tian
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Bin Ma
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Yali Liu
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesLanzhou CityChina
| | - Run H Jia
- Chinese Medicine Hospital in Gansu ProvinceDepartment of RadiologyLanzhou CityGansuChina730000
| | - Xiao F Luo
- Lanzhou UniversityEpidemiology and Health Statistics Institution of School of Public HealthNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - Akira Kuriyama
- Kurashiki Central HospitalDepartment of General Medicine1‐1‐1 MiwaKurashikiOkayamaJapan710‐8602
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Öbrink E, Jildenstål P, Oddby E, Jakobsson JG. Post-operative nausea and vomiting: Update on predicting the probability and ways to minimize its occurrence, with focus on ambulatory surgery. Int J Surg 2015; 15:100-6. [DOI: 10.1016/j.ijsu.2015.01.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 01/06/2015] [Accepted: 01/26/2015] [Indexed: 02/08/2023]
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Ryksen E, Diedericks BJS. Calculation of comparative utilisation and cost: a South African perspective on intravenous vs. inhalational anaesthesia for procedures of differing duration. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2012.10872871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- E Ryksen
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Free State
| | - BJS Diedericks
- Department of Anaesthesiology, Faculty of Health Sciences, University of the Free State
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Role of Nitrous Oxide in Ambulatory Anaesthesia. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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Nitrous oxide-related postoperative nausea and vomiting depends on duration of exposure. Anesthesiology 2014; 120:1137-45. [PMID: 24401771 DOI: 10.1097/aln.0000000000000122] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inclusion of nitrous oxide in the gas mixture has been implicated in postoperative nausea and vomiting (PONV) in numerous studies. However, these studies have not examined whether duration of exposure was a significant covariate. This distinction might affect the future place of nitrous oxide in clinical practice. METHODS PubMed listed journals reporting trials in which patients randomized to a nitrous oxide or nitrous oxide-free anesthetic for surgery were included, where the incidence of PONV within the first 24 postoperative hours and mean duration of anesthesia was reported. Meta-regression of the log risk ratio for PONV with nitrous oxide (lnRR PONVN2O) versus duration was performed. RESULTS Twenty-nine studies in 27 articles met the inclusion criteria, randomizing 10,317 patients. There was a significant relationship between lnRR PONVN2O and duration (r = 0.51, P = 0.002). Risk ratio PONV increased 20% per hour of nitrous oxide after 45 min. The number needed to treat to prevent PONV by avoiding nitrous oxide was 128, 23, and 9 where duration was less than 1, 1 to 2, and over 2 h, respectively. The risk ratio for the overall effect of nitrous oxide on PONV was 1.21 (CIs, 1.04-1.40); P = 0.014. CONCLUSIONS This duration-related effect may be via disturbance of methionine and folate metabolism. No clinically significant effect of nitrous oxide on the risk of PONV exists under an hour of exposure. Nitrous oxide-related PONV should not be seen as an impediment to its use in minor or ambulatory surgery.
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Liu N, Le Guen M, Boichut N, Genty A, Hérail T, Schmartz D, Khefif G, Landais A, Bussac J, Charmeau A, Baars J, Rehberg B, Tricoche S, Chazot T, Sessler D, Fischler M. Nitrous oxide does not produce a clinically important sparing effect during closed-loop delivered propofol–remifentanil anaesthesia guided by the bispectral index: a randomized multicentre study. Br J Anaesth 2014; 112:842-51. [DOI: 10.1093/bja/aet479] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Imberger G, Orr A, Thorlund K, Wetterslev J, Myles P, Møller AM. Does anaesthesia with nitrous oxide affect mortality or cardiovascular morbidity? A systematic review with meta-analysis and trial sequential analysis. Br J Anaesth 2014; 112:410-26. [PMID: 24408738 DOI: 10.1093/bja/aet416] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The role of nitrous oxide in modern anaesthetic practice is contentious. One concern is that exposure to nitrous oxide may increase the risk of cardiovascular complications. ENIGMA II is a large randomized clinical trial currently underway which is investigating nitrous oxide and cardiovascular complications. Before the completion of this trial, we performed a systematic review and meta-analysis, using Cochrane methodology, on the outcomes that make up the composite primary outcome. METHODS We used conventional meta-analysis and trial sequential analysis (TSA). We reviewed 8282 abstracts and selected 138 that fulfilled our criteria for study type, population, and intervention. We attempted to contact the authors of all the selected publications to check for unpublished outcome data. RESULTS Thirteen trials had outcome data eligible for our outcomes. We assessed three of these trials as having a low risk of bias. Using conventional meta-analysis, the relative risk of short-term mortality in the nitrous oxide group was 1.38 [95% confidence interval (CI) 0.22-8.71] and the relative risk of long-term mortality in the nitrous oxide group was 0.94 (95% CI 0.80-1.10). In both cases, TSA demonstrated that the data were far too sparse to make any conclusions. There were insufficient data to perform meta-analysis for stroke, myocardial infarct, pulmonary embolus, or cardiac arrest. CONCLUSION This systematic review demonstrated that we currently do not have robust evidence for how nitrous oxide used as part of general anaesthesia affects mortality and cardiovascular complications.
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Affiliation(s)
- G Imberger
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Blegdamsvej 9, Copenhagen Ø DK-2100, Denmark
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15
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Kafali H, Karaoglanoglu M, Oksuzler C, Bozkurt S. Active intraperitoneal gas aspiration to reduce postoperative shoulder pain after laparoscopy. ACTA ACUST UNITED AC 2013. [DOI: 10.1163/156856904774134424] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Fernández-Guisasola J, Gómez-Arnau JI, Cabrera Y, del Valle SG. Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis. Anaesthesia 2010; 65:379-87. [DOI: 10.1111/j.1365-2044.2010.06249.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Ramosetron versus ondansetron for the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy. Surg Endosc 2010. [DOI: 10.1007/s00464-009-0851-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mraovic B, Šimurina T, Sonicki Z, Skitarelić N, Gan TJ. The Dose–Response of Nitrous Oxide in Postoperative Nausea in Patients Undergoing Gynecologic Laparoscopic Surgery: A Preliminary Study. Anesth Analg 2008; 107:818-23. [DOI: 10.1213/ane.0b013e318181f4aa] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Mathews DM, Gaba V, Zaku B, Neuman GG. Can Remifentanil Replace Nitrous Oxide During Anesthesia for Ambulatory Orthopedic Surgery with Desflurane and Fentanyl? Anesth Analg 2008; 106:101-8, table of contents. [DOI: 10.1213/01.ane.0000289526.20117.26] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Rascol N, Schneider E, Gindre G, Schoeffler P. [Progress in ambulatory anesthesia applied to gynecological surgery]. JOURNAL DE GYNECOLOGIE, OBSTETRIQUE ET BIOLOGIE DE LA REPRODUCTION 2006; 35:237-41. [PMID: 16645556 DOI: 10.1016/s0368-2315(06)78307-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Ambulatory gynecological surgery enables fast recovery of vital functions, ambulation and a relational life of quality. Patients whose disease is well-controlled at the anesthesia consultation can benefit from ambulatory procedures. Improved material and surgical practices broaden potential indications, limiting the risk of postoperative pain which can be controlled with simple analgesic protocols. The choice of the anesthesic techniques or the agents used during the intervention ensures fast recovery of higher functions. Nausea and vomiting, which may develop after returning home and compromise oral drug intake, must be prevented. More ambulatory gynecological procedures can be expected in the near future, pointing out the importance of developing more adapted medical structures.
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Affiliation(s)
- N Rascol
- Département d'Anesthésie Réanimation, Hôpital Gabriel-Montpied, CHU de Clermont-Ferrand, rue Montalembert, BP 69, 63011 Clermont-Ferrand Cedex 01
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Hopkins PM. Nitrous oxide: a unique drug of continuing importance for anaesthesia. Best Pract Res Clin Anaesthesiol 2005; 19:381-9. [PMID: 16013688 DOI: 10.1016/j.bpa.2005.03.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Early attempts to use nitrous oxide as a sole anaesthetic foundered because of its low potency. It has been used successfully as an adjunct to more potent anaesthetics, however, since 1868. By enabling reduced doses of more potent anaesthetics, nitrous oxide reduces the cost of anaesthesia and limits cardiorespiratory side effects. Nitrous oxide does increase the incidence of postoperative nausea and vomiting in cases where risk of this side effect is increased, but it seems likely that use of antiemetics prophylactically will negate this factor. Perhaps the greatest argument for the continued use of nitrous oxide is that it reduces the incidence of recall of intraoperative awareness. Reduced pharmacokinetic variability compared with other anaesthetics, especially intravenous agents, is likely to be a most important reason for this, although evidence is emerging that nitrous oxide also has pharmacodynamic advantages. There are specific situations in which nitrous oxide should not be used, but in the absence of these, its use can be favourably recommended.
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Affiliation(s)
- Philip M Hopkins
- Academic Unit of Anaesthesia, University of Leeds, St James's University Hospital, Leeds LS9 7TF, UK.
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Rognås LK, Elkjaer P. Anaesthesia in day case laparoscopic female sterilization: a comparison of two anaesthetic methods. Acta Anaesthesiol Scand 2004; 48:899-902. [PMID: 15242437 DOI: 10.1111/j.0001-5172.2004.00459.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laparoscopic sterilization (LS) in women is a procedure frequently carried out in a day case setting. The purpose of the study was to measure postoperative pain, nausea and vomiting (PONV), the incidence of unplanned overnight admissions and patient satisfaction with two different anaesthetic methods. METHODS From August 1997 to January 1999 the LS patients were anaesthetized with propofol + fentanyl/alfentanil, N2O and atracurium, and from January 1999 to end of 2001 they were given TIVA with propofol + remifentanil. Postoperative pain was managed with standardized high doses of paracetamol and NSAID in both groups. Data were collected from hospital records and from questionnaires given to all the patients. RESULTS Six hundred and eighty-one women were sterilized. There were no significant differences in postoperative pain between the two groups, with 8.2 and 12.1 per cent, respectively, experiencing severe pain. Significantly fewer patients experienced moderate or severe postoperative nausea after the introduction of remifentanil anaesthesia (3.3 vs. 11.7%, P = 0.001). Eleven patients (1.8%) were admitted overnight, with no difference between the two groups. 94.5% and 96.3% of the patients were either satisfied or very satisfied with their treatment (P = 0.50). CONCLUSION Both anaesthetic methods provide equally good postoperative pain relief, few unplanned admissions and a high degree of patient satisfaction when combined with postoperative paracetamol and NSAID. Patients anaesthetized with remifentanil and propofol have less postoperative nausea.
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Affiliation(s)
- L K Rognås
- Department of Anaesthesiology, Holstebro Hospital, Holstebro, Denmark.
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Tesniere A, Servin F. Intravenous techniques in ambulatory anesthesia. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2003; 21:273-88. [PMID: 12812395 DOI: 10.1016/s0889-8537(02)00081-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The growing importance of ambulatory surgery during the past decade has led to the development of efficient anesthetic techniques in terms of quality and safety of anesthesia and recovery. In these challenging objectives, intravenous techniques have played an important role, as they provide safe, efficient, and cost-effective anesthesia in the ambulatory setting. Among the numerous intravenous drugs, propofol, with its fast and smooth onset of action, short duration of action, and low incidence of postoperative side effects appears to be the anesthetic of choice in this situation. The recent development of new techniques of administration (such as TCI, monitored anesthesia care, or patient-controlled sedation) and monitoring (such as the BIS and the availability of "hit and run" drugs such as remifentanil) will optimize intraoperative conditions and recovery, thus allowing faster home readiness in the ambulatory setting.
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Affiliation(s)
- Antoine Tesniere
- University Hospital Bichat Claude Bernard, Department of Anesthesiology, 46 Rue H Huchard, Paris 18 75877, France
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25
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Joshi GP. Inhalational techniques in ambulatory anesthesia. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2003; 21:263-72. [PMID: 12812394 DOI: 10.1016/s0889-8537(02)00074-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In the current health care environment, anesthesia practitioners are frequently required to reevaluate their practice to be more efficient and cost-effective. Although IV induction with propofol and inhalational induction with sevoflurane are both suitable techniques for outpatients, patients prefer IV induction. Maintenance of anesthesia with the newer inhaled anesthetics (ie, desflurane and sevoflurane) provide for a rapid early recovery as compared with infusion of propofol (ie, TIVA), while allowing easy titratability of anesthetic depth. Titration of hypnotic sedatives using BIS monitoring may reduce the time to awakening and thereby may facilitate fast tracking (ie, bypassing the PACU) and reduce hospital stay. Inhalational anesthesia is associated with a higher incidence of PONV, but no differences have been demonstrated with respect to late recovery (eg, PACU stay and home readiness). Although clinical differences between desflurane and sevoflurane appear to be small, desflurane may be associated with faster emergence, particularly in elderly and morbidly obese patients. Balanced anesthesia with IV propofol induction and inhalation anesthesia with N2O for maintenance, and an LMA for airway management, may be an optimal technique for ambulatory surgery. Inhalational anesthesia may have an economic advantage over a TIVA technique.
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Affiliation(s)
- Girish P Joshi
- Perioperative Medicine and Ambulatory Anesthesia, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235-9068, USA.
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Campbell AE, Turley A, Wilkes AR, Hall JE. Cricoid yoke: the effect of surface area and applied force on discomfort experienced by conscious volunteers. Eur J Anaesthesiol 2003; 20:52-5. [PMID: 12553388 DOI: 10.1017/s0265021503000097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE The application of cricoid force is central to techniques that reduce the risk of gastric regurgitation and the subsequent pulmonary aspiration associated with obstetric and emergency anaesthesia. The discomfort associated with cricoid force in awake preoperative patients increases the incidence of coughing, struggling and pain during induction of anaesthesia. This study determined if increasing the surface area of a cricoid yoke reduced the associated discomfort in volunteers. METHODS Fifty volunteers participated in a randomized single-blinded study. The cricoid yoke was positioned using standard anatomical landmarks and forces of 10, 20, 30 and 40 N were applied in a random order for 20s, using two different yoke attachments with surface areas of 3 and 10 cm2. A rest of 30s was allowed between the application of forces. Discomfort was graded by volunteers on a scale from 0 to 10 (0: no discomfort; 10: worse discomfort imaginable). A score of 10 was allocated if the volunteers could not tolerate the applied force for 20s. RESULTS Median scores for the small yoke were always higher than those for the large yoke at each force. There were significant differences between the scores for the small and large yokes at 10 and 20 N (P < 0.001) and 30 N (P = 0.0233), but there was no significant difference at 40 N. CONCLUSIONS The larger yoke was tolerated better by volunteers when clinically relevant cricoid forces were applied.
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Affiliation(s)
- A E Campbell
- University of Wales College of Medicine, Department of Anaesthetics and Intensive Care Medicine, Cardiff, UK
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Browne I, Byrne H, Briggs L. Sickle cell disease in pregnancy. Eur J Anaesthesiol 2003; 20:75-6. [PMID: 12553395 DOI: 10.1017/s0265021503240138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Gaszyński T, Gaszyński W, Strzelczyk J. General anaesthesia with remifentanil and cisatracurium for a superobese patient. Eur J Anaesthesiol 2003; 20:77-8. [PMID: 12553396 DOI: 10.1017/s0265021503250134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Erhan E, Ugur G, Alper I, Gunusen I, Ozyar B. Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol. Eur J Anaesthesiol 2003; 20:37-43. [PMID: 12557834 DOI: 10.1017/s0265021503000073] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE In some situations, the use of muscle relaxants (neuromuscular blocking drugs) are undesirable or contraindicated. We compared intubating conditions without muscle relaxants in premedicated patients receiving either alfentanil 40 microg kg(-1) or remifentanil 2, 3 or 4 microg kg(-1) followed by propofol 2 mg kg(-1). METHODS In a randomized, double-blind study, 80 healthy patients were assigned to one of four groups (n = 20). After intravenous atropine, alfentanil 40 microg kg(-1) or remifentanil 2, 3 or 4 microg kg(-1) were injected over 90 s followed by propofol 2 mg kg(-1). Ninety seconds after administration of the propofol, laryngoscopy and tracheal intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of lung ventilation, jaw relaxation, laryngoscopy, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff. RESULTS Seven patients who received remifentanil 2 microg kg(-1) and one patient who received remifentanil 3 microg kg(-1) could not be intubated at the first attempts. Excellent intubating conditions (jaw relaxed, vocal cords open and no movement in response to tracheal intubation and cuff inflation) were observed in those who received either alfentanil 40 microg kg(-1) (45% of patients) or remifentanil in doses of 2 microg kg(-1) (20%), 3 microg kg(-1) (75%) or 4 microg kg(-1) (95%). Overall, intubating conditions were significantly better (P < 0.05), and the number of patients showing excellent conditions were significantly higher (P < 0.05) in patients who received remifentanil 4 microg kg(-1) compared with those who received alfentanil 40 microg kg(-1) or remifentanil 2 microg kg(-1). No patient needed treatment for hypotension or bradycardia. CONCLUSIONS Remifentanil 4 microg kg(-1) and propofol 2 mg kg(-1) administered in sequence intravenously provided good or excellent conditions for tracheal intubation in all patients without the use of muscle relaxants.
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Affiliation(s)
- E Erhan
- Ege University, Department of Anaesthesiology and Reanimation, Faculty of Medicine, Izmir, Turkey.
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Brimacombe J, Keller C. Stability of the LMA-ProSeal and standard laryngeal mask airway in different head and neck positions: a randomized crossover study. Eur J Anaesthesiol 2003; 20:65-9. [PMID: 12553391 DOI: 10.1017/s0265021503000127] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE The LMA-ProSeal laryngeal mask airway is a new laryngeal mask airway with a modified cuff and drainage tube. We compared oropharyngeal leak pressure, intracuff pressure and anatomical position (assessed fibreoptically) for the Size 5 LMA-ProSeal laryngeal mask airway and the classic laryngeal mask airway in different head-neck positions and using different intracuff inflation volumes. METHODS Thirty paralysed anaesthetized adult male patients were studied. The LMA-ProSeal laryngeal mask airway and the classic laryngeal mask airway were inserted into each patient in random order. The oropharyngeal leak pressure, intracuff pressure, and anatomical position of the airway tube and drainage tube (LMA-ProSeal laryngeal mask airway only) were documented in four head and neck positions (neutral first, then flexion, extension and rotation in random order), and at 0-40 mL cuff volumes in the neutral position in 10 mL increments. RESULTS Compared with the neutral position, the oropharyngeal leak pressure for both the LMA-ProSeal laryngeal mask airway and the classic laryngeal mask airway was higher in flexion and rotation (all P < or = 0.02), but lower in extension (all P < or = 0.01). Changes in head-neck position did not alter the anatomical position of the airway tube or the drainage tube. The oropharyngeal leak pressure was always higher for the LMA-ProSeal laryngeal mask airway (all P < or = 0.005) and anatomical position better for the classic laryngeal mask airway (all P < or = 0.04). CONCLUSIONS The anatomical position of the LMA-ProSeal and the classic laryngeal mask airway is stable in different head-neck positions, but head-neck flexion and rotation are associated with an increase, and head-neck extension a decrease, in oropharyngeal leak pressure and intracuff pressure. The Size 5 LMA-ProSeal laryngeal mask airway is capable of forming a more effective seal than the Size 5 classic laryngeal mask airway in males.
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Affiliation(s)
- J Brimacombe
- University of Queensland James Cook University, Department of Anaesthesia and Intensive Care, Cairns Base Hospital, The Esplanade, Australia.
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Kuhlen R, Max M, Dembinski R, Terbeck S, Jürgens E, Rossaint R. Breathing pattern and workload during automatic tube compensation, pressure support and T-piece trials in weaning patients. Eur J Anaesthesiol 2003; 20:10-6. [PMID: 12553382 DOI: 10.1017/s0265021503000024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Automatic tube compensation has been designed as a new ventilatory mode to compensate for the non-linear resistance of the endotracheal tube. The study investigated the effects of automatic tube compensation compared with breathing through a T-piece or pressure support during a trial of spontaneous breathing used for weaning patients from mechanical ventilation of the lungs. METHODS Twelve patients were studied who were ready for weaning after prolonged mechanical ventilation (10.2 +/- 8.4 days) due to acute respiratory failure. Patients with chronic obstructive pulmonary disease were excluded. Thirty minutes of automatic tube compensation were compared with 30 min periods of 7 cmH2O pressure support and T-piece breathing. Breathing patterns and workload indices were measured at the end of each study period. RESULTS During T-piece breathing, the peak inspiratory flow rate (0.65 +/- 0.20 L s(-1)) and minute ventilation (8.9 +/- 2.7L min(-1)) were lower than during either pressure support (peak inspiratory flow rate 0.81 +/- 0.25 L s(-1) minute ventilation 10.2 +/- 2.3 L min(-1), respectively) or automatic tube compensation (peak inspiratory flow rate 0.75 +/- 0.26L s(-1); minute ventilation 10.8 +/- 2.7 L min(-1)). The pressure-time product as well as patients' work of breathing were comparable during automatic tube compensation (pressure-time product 214.5 +/- 104.6 cmH2O s(-1) min(-1), patient work of breathing 1.1 +/- 0.4 J L(-1)) and T-piece breathing (pressure-time product 208.3 +/- 121.6 cmH2O s(-1) min(-1), patient work of breathing 1.1 +/- 0.4 J L(-1)), whereas pressure support resulted in a significant decrease in workload indices (pressure-time product 121.2 +/- 64.1 cmH2O s(-1) min(-1), patient work of breathing 0.7 +/- 0.4 J L(-1)). CONCLUSIONS In weaning from mechanical lung ventilation, patients' work of breathing during spontaneous breathing trials is clearly reduced by the application of pressure support 7 cmH2O, whereas the workload during automatic tube compensation corresponded closely to the values during trials of breathing through a T-piece.
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Affiliation(s)
- R Kuhlen
- University of Aachen Medical School, Department of Anesthesiology, Aachen, Germany.
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Abstract
This study reports a review of all comparative published studies of adult day case anaesthesia in the English language up to December 2000. Ten databases were searched using appropriate keywords and data were extracted in a standardized fashion. One hundred-and-one published studies were examined. Recovery measurements were grouped as early, intermediate, late, psychomotor and adverse effects. With respect to induction of anaesthesia, propofol was superior to methohexital, etomidate and thiopental, but equal to sevoflurane and desflurane. Desflurane and sevoflurane were both superior to thiopental. There was no detectable difference between sevoflurane and isoflurane. With respect to the maintenance of anaesthesia, isoflurane and halothane were the worst. There were no significant differences between propofol, desflurane, sevoflurane and enflurane. Propofol is the induction agent of choice in day case patients. The use of a propofol infusion and avoidance of nitrous oxide may help to reduce postoperative nausea and vomiting.
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Abstract
BACKGROUND AND OBJECTIVE Preoperative bedside screening tests for difficult tracheal intubation may be neither sensitive nor specific enough for clinical use. The aim was to investigate if a combination of the Mallampati classification of the oropharyngeal view with either the thyromental or sternomental distance measurement improved the predictive value. METHODS A total of 212 (109 male, 103 female) non-obstetric surgical patients, aged >18 yr, undergoing elective surgical procedures requiring tracheal intubation were assessed preoperatively with respect to the oropharyngeal (modified Mallampati) classification, thyromental and sternomental distances. An experienced anaesthetist, blinded to the preoperative airway assessment, performed laryngoscopy and graded the view according to Cormack and Lehane's classification. RESULTS Twenty tracheal intubations (9%) were difficult as defined by a Cormack and Lehane Grade 3 or 4, or the requirement for a bougie in patients with Cormack and Lehane Grade 2. Used alone, the Mallampati oropharyngeal view, and thyromental and sternomental distances were associated with poor sensitivity, specificity and positive predictive values. Combining the Mallampati Class III or IV with either a thyromental distance <6.5cm or a sternomental distance <12.5cm decreased the sensitivity (from 40 to 25 and 20%, respectively), but maintained a negative predictive value of 93%. The specificity and positive predictive values increased from 89 and 27% respectively for Mallampati alone to 100%. CONCLUSIONS The findings suggest that the Mallampati classification, in conjunction with measurement of the thyromental and sternomental distances, may be a useful routine screening test for preoperative prediction of difficult tracheal intubation.
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Affiliation(s)
- G Iohom
- Beaumont Hospital, Department of Anaesthesia and Intensive Care, Dublin, Ireland.
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Alper I, Erhan E, Ugur G, Ozyar B. Remifentanil versus alfentanil in total intravenous anaesthesia for day case surgery. Eur J Anaesthesiol 2003; 20:61-4. [PMID: 12553390 DOI: 10.1017/s0265021503000115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE We assessed the intraoperative haemodynamic responses and recovery profiles of total intravenous anaesthesia with remifentanil and alfentanil for outpatient surgery. METHODS Patients in Group 1 (n = 20) received alfentanil 20 microg kg(-1) followed by 2 microg kg(-1) min(-1) intravenously; patients in Group 2 (n = 20) received remifentanil 1 microg kg(-1) followed by 0.5 microg kg(-1) min(-1) intravenously. Both groups then received propofol 2 mg kg(-1) followed by 9 mg kg(-1) h(-1) intravenously. Five minutes after skin incision, infusion rates were decreased, and at the end of surgery, all infusions were discontinued. Early recovery was assessed by the Aldrete score, whereas intermediate recovery was assessed with the postanaesthetic discharge scoring system (PADS). RESULTS Perioperative arterial pressure was similar in both groups; heart rate was lower in Group 2 (P < 0.05). The times to spontaneous and adequate respiration, response to verbal commands, extubation and times for Aldrete score > or = 9 were shorter in Group 2 patients (P < 0.05). Pain scores were higher in Group 2 patients (P < 0.05). Overall times for postanaesthetic discharge scores > or = 9 were similar. CONCLUSIONS Early recovery of patients after day surgery is significantly shorter after total intravenous anaesthesia with remifentanil compared with that with alfentanil but postoperative pain management must be planned ahead.
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Affiliation(s)
- I Alper
- Ege University, Department of Anaesthesiology and Reanimation, Faculty of Medicine, Bornova, Izmir, Turkey.
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Turhanoğlu S, Kararmaz A, Ozyilmaz MA, Kaya S, Tok D. Effects of different doses of oral ketamine for premedication of children. Eur J Anaesthesiol 2003; 20:56-60. [PMID: 12553389 DOI: 10.1017/s0265021503000103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- S Turhanoğlu
- Dicle University Hospital, Department of Anaesthesiology, Diyarbakir, Turkey.
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Reuter DA, Felbinger TW, Schmidt C, Moerstedt K, Kilger E, Lamm P, Goetz AE. Trendelenburg positioning after cardiac surgery: effects on intrathoracic blood volume index and cardiac performance. Eur J Anaesthesiol 2003; 20:17-20. [PMID: 12553383 DOI: 10.1017/s0265021503000036] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE The efficacy of the Trendelenburg position, a common first step to treat suspected hypovolaemia, remains controversial. We evaluated its haemodynamic effects on cardiac preload and performance in patients after cardiac surgery. METHODS Twelve patients undergoing mechanical ventilation of the lungs who demonstrated left ventricular 'kissing papillary muscles' by transoesophageal echocardiography, thus suggesting hypovolaemia, were positioned 30 degrees head down for 15 min immediately after cardiac surgery. Cardiac output by thermodilution, central venous pressure, pulmonary artery occlusion pressure, left ventricular end-diastolic area by transoesophageal echocardiography and intrathoracic blood volume by thermo- and dye dilution were determined before, during and after this Trendelenburg manoeuvre. RESULTS Trendelenburg's manoeuvre was associated with increases in central venous pressure (9 +/- 2 to 12 +/- 3 mmHg) and pulmonary artery occlusion pressure (8 +/- 2 to 11 +/- 3 mmHg). The intrathoracic blood volume index increased slightly (dye dilution from 836 +/- 129 to 872 +/- 112 mL m(-2); thermodilution from 823 +/- 129 to 850 +/- 131 mL m(-2)) as did the left ventricular end-diastolic area index (7.5 +/- 2.1 to 8.1 +/- 1.7 cm2 m(-2)), whereas mean arterial pressure and the cardiac index did not change significantly. After supine repositioning, the cardiac index decreased significantly below baseline (3.0 +/- 0.6 versus 3.5 +/- 0.8 L min(-1) m(-2)) as did mean arterial pressure (76 +/- 12 versus 85 +/- 11 mmHg), central venous pressure (8 +/- 2 mmHg) and pulmonary artery occlusion pressure (6 +/- 4 mmHg). The intrathoracic blood volume index and left ventricular end-diastolic area index did not differ significantly from baseline. CONCLUSIONS Trendelenburg's manoeuvre caused only a slight increase of preload volume, despite marked increases in cardiac-filling pressures, without significantly improving cardiac performance.
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Affiliation(s)
- D A Reuter
- Ludwig-Maximilians-University, Department of Anaesthesiology, Munich, Germany
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Reisli R, Celik J, Tuncer S, Yosunkaya A, Otelcioglu S. Anaesthetic and haemodynamic effects of continuous spinal versus continuous epidural anaesthesia with prilocaine. Eur J Anaesthesiol 2003; 20:26-30. [PMID: 12553385 DOI: 10.1017/s026502150300005x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE To compare, using prilocaine, the effects of continuous spinal anaesthesia (CSA) and continuous epidural anaesthesia (CEA) on haemodynamic stability as well as the quality of anaesthesia and recovery in patients undergoing transurethral resection of the prostate gland. METHODS Thirty patients (>60 yr) were randomized into two groups. Prilocaine, 2% 40 mg, was given to patients in the CSA group, and prilocaine 1% 150mg was given to patients in the CEA group. Incremental doses were given if the level of sensory block was lower than T10 or if needed during surgery. RESULTS There was a significant decrease in mean arterial pressure in Group CEA compared with Group CSA (P < 0.01). The decrease in heart rate in Group CSA occurred 10 min after the first local anaesthetic administration and continued through the operation (P < 0.05). The level of sensory anaesthesia was similar in both groups. The times to reach the level of T10 and the upper level of sensory blockade (Tmax) were 18.0 +/- 4.7 and 25.3 +/- 7.0 min in Groups CSA and CEA, respectively, and were significantly longer in Group CEA. The duration of anaesthesia was 76.8 +/- 4min and was shorter in Group CSA (P < 0.01). CONCLUSIONS Spinal or epidural anaesthesia administered continuously was reliable in elderly patients undergoing transurethral resection of the prostate. Continuous spinal anaesthesia had a more rapid onset of action, produced more effective sensory and motor blockade and had a shorter recovery period. Prilocaine appeared to be a safe local anaesthetic for use with either continuous spinal anaesthesia or continuous epidural anaesthesia.
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Affiliation(s)
- R Reisli
- University of Selcuk, Faculty of Medicine, Department of Anaesthesiology, Konya, Turkey.
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Raymondos K, Münte S, Krauss T, Grouven U, Piepenbrock S. Cortical activity assessed by Narcotrend in relation to haemodynamic responses to tracheal intubation at different stages of cortical suppression and reflex control. Eur J Anaesthesiol 2003; 20:44-51. [PMID: 12553387 DOI: 10.1017/s0265021503000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Many anaesthesiologists still interpret haemodynamic responses as signs of insufficient cortical suppression. The aim was to illustrate how haemodynamics may only poorly reflect the level of cortical suppression and that electroencephalographic monitoring could indicate different relationships between cortical effects and haemodynamics. METHODS Anaesthesia was induced with thiopental (7 mg kg(-1)), and fentanyl (2 microg kg(-1)) with succinylcholine (1.5 mg kg(-1)) for neuromuscular blockade in the 11 patients of Group 1. In Group 2 (n = 15), thiopental (7 mg kg(-1)) and succinylcholine (1.5 mg kg(-1)) were given. In Group 3, the patients (n = 13) received thiopental (7 mg kg(-1)), fentanyl (2 microg kg(-1)) and cisatracurium (0.1 mg kg(-1)), and they were intubated 3 min later than the patients in Groups 1 and 2. We determined conventional electroencephalographic (EEG) variables and classified 14 EEG stages in real-time ranging from A (= 1), indicating full wakefulness, to F1 (= 14), at profound cortical suppression. RESULTS All groups had profound cortical suppression 45 s after thiopental administration, which rapidly decreased (EEG stage, 11 (6-13) versus 7 (2-13) at 4 min, P < 0.0001). Decreasing EEG stages were associated with increasing SEF 95, relative alpha and beta power and decreasing relative delta power. During tracheal intubation, profound cortical suppression remained unchanged in Groups 1 and 2. In Group 3, cortical suppression had decreased before laryngoscopy (P < 0.005). In Group 2, 11 patients had heart rate responses to tracheal intubation, whereas only two responded in Group 1 (P = 0.015) and three in Group 3 (P = 0.02). Thirteen patients in Group 2 had arterial pressure responses, and five in Group 1 (P = 0.038). Circulatory responses did not differ between Groups 1 and 3. CONCLUSIONS Electroencephalographic monitoring was suitable to indicate in real-time that haemodynamics only poorly reflect rapidly changing levels of cortical suppression, and how haemodynamics and cortical activity depend on the applied combination of hypnotic and analgesic drugs during anaesthesia induction with thiopental.
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Affiliation(s)
- K Raymondos
- Medical School of Hannover, Department of Anaesthesiology, Hannover, Germany.
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Ogawa-Okamoto C, Saito S, Nishihara F, Yuki N, Goto F. Blood pressure control with glyceryl trinitrate during electroconvulsive therapy in a patient with cerebral aneurysm. Eur J Anaesthesiol 2003; 20:70-2. [PMID: 12553392 DOI: 10.1017/s0265021503210139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Haltiavaara KM, Laitinen JO, Kaukinen S, Viljakka TJ, Laippala PJ, Luukkaala TH. Failure of interscalene brachial plexus blockade to produce pre-emptive analgesia after shoulder surgery. Eur J Anaesthesiol 2003; 20:72-3. [PMID: 12553393 DOI: 10.1017/s0265021503220135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Krenn H, Deusch E, Balogh B, Jellinek H, Oczenski W, Plainer-Zöchling E, Fitzgerald RD. Increasing the injection volume by dilution improves the onset of motor blockade, but not sensory blockade of ropivacaine for brachial plexus block. Eur J Anaesthesiol 2003; 20:21-5. [PMID: 12553384 DOI: 10.1017/s0265021503000048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Ropivacaine used for axillary plexus block provides effective motor and sensory blockade. Varying clinical dosage recommendations exist. Increasing the dosage by increasing the concentration showed no improvement in onset. We compared the behaviour of a constant dose of ropivacaine 150 mg diluted in a 30, 40 or 60 mL injection volume for axillary (brachial) plexus block. METHODS A prospective, randomized, observer-blinded study on patients undergoing elective hand surgery was conducted in a community hospital. Three groups of patients with a constant dose of ropivacaine 150 mg, diluted in 30,40 or 60 mL NaCl 0.9%, for axillary plexus blockade were compared for onset times of motor and sensory block onset by assessing muscle strength, two-point discrimination and constant-touch sensation. RESULTS Increasing the injection volume of ropivacaine 150 mg to 60 mL led to a faster onset of motor block, but not of sensory block, in axillary plexus block, compared with 30 or 40 mL volumes of injection. CONCLUSIONS The data show that the onset of motor, but not of sensory block, is accelerated by increasing the injection volume to 60 mL using ropivacaine 150 mg for axillary plexus block. This may be useful for a more rapid determination of whether the brachial plexus block is effective. However, when performing surgery in the area of the block, sensory block onset seems more important.
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Affiliation(s)
- H Krenn
- Department of Anaesthesia and Critical Care, City Hospital, Lainz, Vienna, Austria.
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Abstract
PURPOSE OF REVIEW Ambulatory surgery is now one of the major areas of surgical and anesthetic practice, with up to 70% of procedures performed in the ambulatory setting. This review focuses on some of the recent studies performed in day case anesthesia. RECENT FINDINGS Emphasizing the economic benefits of ambulatory surgery, investigators have studied the cost implications of various anesthetic techniques and their impact on patient recovery, discharge times and readmission rates. Quality anesthetic management measures such as mortality, morbidity, postoperative stay and patient satisfaction ensure that perioperative care and treatment are optimized. SUMMARY Careful patient selection can minimize perioperative events. The concept of multimodal analgesic and antiemetic therapy, in combination with newer anesthetic drugs, help expand the field of ambulatory surgery.
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Affiliation(s)
- Anne Marie Troy
- Department of Anaesthesia, Royal College of Surgeons in Ireland, Dublin, Ireland
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Awad IT, Murphy D, Stack D, Swanton BJ, Meeke RI, Shorten GD. A comparison of the effects of droperidol and the combination of droperidol and ondansetron on postoperative nausea and vomiting for patients undergoing laparoscopic cholecystectomy. J Clin Anesth 2002; 14:481-5. [PMID: 12477581 DOI: 10.1016/s0952-8180(02)00394-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVES To compare the prophylactic antiemetic efficacy of the combination of ondansetron and droperidol with that of droperidol alone in patients undergoing elective laparoscopic cholecystectomy. DESIGN Randomized, double-blind controlled trial. University affiliated teaching hospital after induction of standardized general anesthesia. PATIENTS 64 ASA physical status I or II patients aged 18 to 80 years, undergoing elective laparoscopic cholecystectomy. INTERVENTION Following induction of general anesthesia, patients received either droperidol 1.25 mg intravenously (IV; n = 30; Group D) or the combination of droperidol 1.25 mg IV and ondansetron 4 mg IV (n = 34; Group D+O). MEASUREMENTS Number and severity of nausea episodes, number of emetic episodes, total analgesic consumption, and rescue antiemetic administration were assessed at 1, 3, and 24 hours after admission to the recovery room. Data were analyzed using Fisher's Exact test and unpaired Student's t-test; a p-value <0.05 was considered significant. RESULTS The proportions of patients who experienced nausea (70% and 53% for D and D+O groups, respectively) and vomiting (30% and 19% for D and D+O groups, respectively) were similar in the two groups. The frequency of moderate and severe nausea (requiring administration of antiemetic) was less in group D + O (7%) compared with group D (19%; p < 0.05). CONCLUSIONS Patients who received the combination of droperidol and ondansetron experienced less severe nausea compared with patients who received droperidol alone.
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Affiliation(s)
- Imad T Awad
- Department of Anesthesia and Intensive Care Medicine, Cork University Hospital, Cork, Republic of Ireland
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Salinas FV, Liu SS. Spinal anaesthesia: local anaesthetics and adjuncts in the ambulatory setting. Best Pract Res Clin Anaesthesiol 2002; 16:195-210. [PMID: 12491552 DOI: 10.1053/bean.2002.0233] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Intrathecal lidocaine remains a popular choice for ambulatory spinal anaesthesia due to its reliability, rapid onset and predictable rapid recovery profile. However, concerns with transient neurological symptoms (TNS) and their significant association with lidocaine have generated interest in alternative local anaesthetic agents to provide adequate spinal anaesthesia with the briefest possible recovery period. This chapter updates current data on drug dose-response relationships for local anaesthetics and the increasing use of intrathecal adjuncts to improve the anaesthetic and recovery profile for ambulatory spinal anaesthesia. Newer spinal anaesthetic techniques for common ambulatory procedures highlight the success of combining subclinical doses of local anaesthetics and intrathecal adjuncts. Controversies regarding the possible lower risk of TNS with newer spinal anaesthetic techniques and new discharge criteria are reviewed. The final section provides technical pearls to optimize ambulatory spinal anaesthetic outcomes.
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Affiliation(s)
- Francis V Salinas
- Department of Anaesthesiology, Virginia Mason Medical Center, 1100 Ninth Avenue B2-AN, Seattle, WA 98111, USA
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Leonard IE, Cunningham AJ. Anaesthetic considerations for laparoscopic cholecystectomy. Best Pract Res Clin Anaesthesiol 2002; 16:1-20. [PMID: 12491540 DOI: 10.1053/bean.2001.0204] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Minimally invasive surgical procedures aim to minimize the trauma of the interventional process but still achieve a satisfactory therapeutic result. Tissue trauma is significantly less than that with conventional open procedures, offering the advantages of reduced post-operative pain, shorter hospital stay, more rapid return to normal activities and significant cost savings. Laparoscopic cholecystectomy is now a routinely performed procedure and has replaced conventional open cholecystectomy as the procedure of choice for symptomatic cholelithiasis. Public expectation and developments in instrumentation have fuelled this change. The physiological effects of intraperitoneal carbon dioxide insufflation combined with variations in patient positioning can have a major impact on cardiorespiratory function, particularly in elderly patients with co-morbidities. Intra-operative complications may include traumatic injuries associated with blind trocar insertion, gas embolism, pneumothorax and surgical emphysema associated with extraperitoneal insufflation. Appropriate monitoring and a high index of suspicion can result in early diagnosis of, and treatment of, complications. Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gallbladder disease.
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Affiliation(s)
- Irene E Leonard
- Department of Anaesthesia, Beaumont Hospital/Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
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Dexamethasone for the Prevention of Nausea and Vomiting After Dilatation and Curettage. Obstet Gynecol 2002. [DOI: 10.1097/00006250-200201000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stanley IR, Laurence AS, Hill JC. Disappearance of intraperitoneal gas following gynaecological laparoscopy. Anaesthesia 2002; 57:57-61. [PMID: 11843744 DOI: 10.1046/j.1365-2044.2002.02358.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We investigated 25 day case gynaecological laparoscopy patients to determine the duration of the pneumoperitoneum, the rate at which residual gas disappeared and the relative contribution of this gas to pain in the early postoperative period. The volume of gas was calculated from measurements of the subdiaphragmatic gas bubble obtained from an erect chest X-ray. Each patient was X-rayed twice, either immediately prior to discharge and at 24 h post laparoscopy, or at 24 h and 48 h post surgery. Patients were contacted by telephone at 24 and 48 h to confirm fitness to return for the X-ray and at the same time verbal pain and activity scores were recorded. We found that residual gas was almost entirely gone by 48 h following surgery and that it appeared to reduce in an exponential manner. The contribution of this gas to postoperative pain was significant in the first 24 h, but by 48 h it was considerably reduced. We conclude that in day case gynaecological laparoscopy patients, postoperative pneumoperitoneum is short-lived, and that by 48 h its volume and contribution to postoperative pain should be minimal.
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Affiliation(s)
- I R Stanley
- Anaesthetics, North Western Deanery, Royal Preston Hospital, Preston, UK
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Abstract
Fast-tracking in outpatient surgery is a new paradigm that allows for rapid throughput and early discharge, thereby facilitating perioperative efficiency. Compared with the conventional recovery process, bypassing the postanesthesia care unit reduces the time to discharge home. An ideal anesthetic technique for fast-tracking would provide for rapid emergence and the prevention of common postoperative complications such as pain, nausea, and vomiting using a multimodal approach.
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Affiliation(s)
- G P Joshi
- University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA.
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