Spinal 2-chloroprocaine: effective dose for ambulatory surgery

Background: There is an interest in finding a safe, short-acting spinal anaesthetic, suitable for ambulatory surgery. In this prospective study, we evaluated the effective dose of plain 2-chloroprocaine (2-CP) for lower limb surgery, including knee arthroscopy and saphenectomy.
Methods: Sixty-four ASA physical status I–III patients undergoing elective lower limb surgery were randomly allocated to one of the four local anaesthetic groups for spinal anaesthesia in a double-blind manner. The patients ( n =16 patients in each group) received 35, 40, 45 or 50 mg of 10 mg/ml isobaric 2-CP.
Results: In all patients, anaesthesia was sufficient for the planned surgery. The median peak block height (T9) was similar in all four groups ( P =0.66). Time to complete sensory block regression was faster in the 35 mg group (111 min, mean) and in the 40 mg group (108 min) than in the 50 mg group (134 min, P =0.005). No differences in time to complete motor block regression were observed ( P =0.3). Home discharge time was faster in the 35 mg group (123 min) and in the 40 mg group (122 min) than in the 50 mg group (165 min, P =0.001). No complications related to spinal anaesthesia were observed and no transient neurologic symptoms (TNS) were reported at the 3-day follow-up.
Conclusion: Spinal 2-CP, 10 mg/ml 35, 40, 45 and 50 mg provide reliable sensory and motor block for ambulatory surgery, while reducing the dose of 2-CP to 35 and 40 mg resulted in a spinal block of faster ambulation.     

Early recovery, cognitive function and costs of a desflurane inhalational vs. a total intravenous anaesthesia regimen in long-term surgery

BACKGROUND: The purpose of the study was to compare time of recovery, return of cognitive function, post-anaesthetic care unit (PACU) stay and costs of a propofol/remifentanil (TIVA) with a desflurane/fentanyl-based anaesthesia (desflurane group) in surgical procedures lasting more than 150 min. METHODS: Forty-nine patients undergoing elective abdominal prostatectomy were allocated randomly to receive bispectal index (BIS)-controlled desflurane/fentanyl (n=24) or propofol/remifentanil (n=25). Awakening, clinical recovery, direct drug acquisition and post-operative pain treatment were documented. Cognitive skills were tested using the Mini-Mental Status (MMST) test. RESULTS: Extubation was significantly faster with desflurane (6.9+/-3.5 min) than with TIVA (11.2+/-4.0 min) as well as times for stating name and date of birth (desflurane: 6.1+/-3.9 and 6.6+/-4.0 min; TIVA: 12.4+/-11.5 min and 13.4+/-11.3 min). There were no significant differences in PACU discharge times or MMS scores between the groups. Significantly more patients suffered post-operative nausea and vomiting (PONV) in the desflurane (33% vs. 0%) than the TIVA group. Overall costs were significantly higher in the TIVA (58.8+/-11.6 euro) than in the desflurane group (35.0+/-5.7 euro). CONCLUSION: Patients undergoing prolonged surgical procedures showed a faster early recovery after desflurane/fentanyl than using TIVA, whereas stay in the PACU and recovery of cognitive function were similar in both groups. Costs of a TIVA regimen were significantly higher than using a desflurane-based anaesthesia technique.     

Cost-effectiveness of inhalational, balanced and total intravenous anaesthesia for ambulatory knee surgery

Purpose

A randomized, blinded clinical trial was undeitaken to compare recovery charactenstics and cost-benefits associated with three general anaesthetic techniques for arthroscopic knee surgery in an ambulatory care setting.

Methods

Ninety three. ASA Physical Status l-ll patients were randomly allocated to receive one of three types of general anaesthesia: isoflurane /fentanyl/N₂O (Group INH); alfentanil/N₂O (Group BAL); or propofol/alfentanil/O₂ (Group TIVA). Postoperative recovery profiles were evaluated at 30, 60, 90 and 120 min after emergence from anaesthesia, and direct and indirect costs of each anaesthetic were compared.

Results

The most rapid emergence was observed in Group BAL (2.2 ± 1.5 min, P< 0.000l compared with groups INH and TIVA), although the incidence of post-operative nausea and vomiting was also highest in this group (P = 0.02 compared with groups INH and TIVA). However, overall patient satisfaction, and mean times to discharge from the Post Anaesthesia Recovery Unit and hospital, were rapid and similar in all three groups. During anaesthesia which lasted 40–45 min, nearly a four-fold difference was observed in the direct costs of anaesthetic drugs: $16.4 ± 4.4 (Group INH). $45.3 ± 11.4 (Group BAL) and $63.4 ± 17.9 (Group TIVA, P < 0.001 between groups): while indirect costs were similar.

Conclusions

For arthroscopic knee surgery. INH anaesthesia with isoflurane/fentanyl/N₂O is associated with similar hospital discharge times, and comparable levels of patient satisfaction as either BAL or TIVA. While indirect costs were similar, lower direct costs suggest that there may be a pharmacoeconomic benefit associated with the use of a “standard” isoflurane/fentanyl/N₂O anaesthetic in certain day care surgery procedures.     

Remifentanil vs alfentanil in the total intravenous anaesthesia for paediatric abdominal surgery

BACKGROUNDS: Our aim was to investigate whether total intravenous anaesthesia (TIVA) with remifentanil and alfentanil would ensure appropriate analgesia and recovery conditions in anaesthesia for children undergoing abdominal surgery. METHODS: Sixty children, scheduled for abdominal operations were randomized to receive, in a double-blind manner, either remifentanil (loading dose 1 microg x kg(-1); maintenance infusion, 0.25 microg x kg(-1) min(-1)) or alfentanil (loading dose 50 microg x kg(-1); maintenance infusion, 1 microg x kg(-1) min(-1)) as the analgesic component of TIVA. They were combined with propofol (loading dose, 2 mg x kg(-1); step 1 maintenance infusion, 10 mg x kg(-1) h(-1); step 2 maintenance infusion, 8 mg x kg(-1) h(-1); step 3 maintenance infusion, 6 mg x kg(-1) h(-1)) neuromuscular blockade was with mivacurium. Dose changes of the drugs, the times from cessation of anaesthesia to extubation, verbal responses, recovery of ventilation, orientation, and qualification for discharge from the postanaesthetic care unit (PACU) were recorded. RESULTS: Demographics, duration of surgery and anaesthesia were similar between the two groups. Times to extubation and stay in the PACU were significantly shorter in the remifentanil group compared with the alfentanil group. Quality of emergence (QE) from anaesthesia scale scores were higher in the remifentanil group compared with the alfentanil group. CONCLUSIONS: Remifentanil provides a more rapid recovery and adequate postoperative analgesia after TIVA for paediatric abdominal surgery, compared with alfentanil.     

A comparison of spinal anaesthesia and propofol-sevoflurane-anaesthesia for ambulatory knee arthroscopy

Background: The aim of this study was to compare spinal anaesthesia (SA) and general anaesthesia (GA) for outpatient knee arthroscopy in terms of recovery profiles and discharge times. Methods: Sixty ASA I–II patients were randomized to receive either SA (N = 30) with lidocaine 50 mg/ml, 1 mg/kg or standardized propofol-sevoflurane-fentanyl GA (n = 30). Postoperative pain, need for analgesics, recovery profiles, complications, discharge times and patient satisfaction were evaluated. Patients were asked to complete a questionnaire after 24 h and 1 week. Results: After GA, 27% of patients needed supplemental opioid analgesics in contrast to 3% after SA (P < 0.01). Also, after GA 21(71%) patients suffered knee pain during the postoperative week compared to 10 (33.3%) after SA (P < 0.004). Intensity of postoperative pain was low (VPS-values <2). Duration of knee pain tended to be longer in GA group: 2.97 days versus 1.37 days in SA group. There were no differences in discharge times. High degree of patient satisfaction was associated with both techniques without statistical difference. Conclusion: SA provided superior postoperative pain management and leads to reduced consumption of analgesics, especially strong opioids. Both techniques provide a high grade of patient satisfaction.     

Comparison of total intravenous anesthesia and sevoflurane-fentanyl anesthesia for outpatient otorhinolaryngeal surgery

STUDY OBJECTIVE: To compare the recovery characteristics of two widely used anesthetic techniques: remifentanyl-propofol and sevoflurane-fentanyl in a standardized ambulatory population.DESIGN: Randomized, single-blinded study. SETTING: University-affiliated medical center. PATIENTS: 50 ASA physical status I and II patients undergoing elective ambulatory otorhinolaryngeal surgery. INTERVENTIONS: Patients were randomized two groups to receive total intravenous anesthesia (TIVA group) with remifentanil and propofol or sevoflurane-fentanyl (SF group). TIVA patients received induction with propofol 1.5 mg/kg intravenously (IV) and remifentanil 0.5 microg/kg IV. The anesthesia was continued with a continuous infusion of propofol 100 microg/kg/min and remifentanil 0.0625-0.25 microg/kg/min. The SF group received, at induction, fentanyl 2 microg/kg followed by propofol 1.5 mg/kg IV. Maintenance was obtained with 1 to 1.5 minimum alveolar concentration of sevoflurane and bolus of fentanyl 1 microg/kg IV as needed. MEASUREMENTS AND MAIN RESULTS: Early recovery times (eye opening, response to commands, extubation, orientation, operating room stay after surgery, and Aldrete score > or =9) and patient satisfaction were similar between the two groups. Postanesthetic discharge scoring system (PADSS) > or = 9 was significantly shorter for the TIVA group (135.9 +/- 51 vs. 103 +/- 32 min) (p < 0.01) but this difference was not associated with a shorter postanesthesia care unit (PACU) length of stay. CONCLUSION: Early recovery times are comparable between total intravenous anesthesia and sevoflurane-based anesthesia. Even though patients in the TIVA group achieved home readiness criteria in a significantly shorter time, this technique does not shorten PACU length of stay, which depends instead on multiple nonmedical and administrative issues.     

Post-operative recovery profile after laparoscopic cholecystectomy: a prospective, observational study of a multimodal anaesthetic regime

BACKGROUND: Laparoscopic cholecystectomy is now often an ambulatory procedure, but dependent on short-term post-operative complaints of pain and post-operative nausea and vomiting (PONV). The efficacy of post-anaesthesia care units (PACUs) is therefore important to facilitate return to normal functions. We investigated the feasibility and efficacy of a standardized, evidence-based anaesthesia/analgesic regime to identify residual problems in the early post-operative phase. METHODS: One hundred and thirty-four consecutive patients admitted for elective laparoscopic cholecystectomy at Hvidovre University Hospital between 15 March and 30 September 2005 were included in the study. The standardized, evidence-based regime consisted of total intravenous (i.v.) anaesthesia (propofol-remifentanil), well-defined fluid therapy, dexamethasone, ketorolac, ondansetron, sufentanil and incisional bupivacaine intra-operatively, and in the PACU on demand (prn) administration of sufentanil, morphine, paracetamol, ondansetron, droperidol, oral fluids and oxygen (if SpO(2) < 93%) with PACU discharge using a modified Aldrete score. RESULTS: Protocol violations were moderate and occurred unsystematically, 8% had medical violations and 10% did not receive the pre-planned fluid amount. Severe PONV was seen in 2%. Thirteen per cent experienced severe pain, and the presence of any pain and/or PONV were predictors of an extended PACU stay. Mean oxygen demand was 46 min (range, 0-300 min), which influenced time to discharge (mean, 88 min). There were on average 2.7 treatment interventions (range, 0-11) before discharge. CONCLUSION: An evidence-based, multimodal approach to the anaesthetic/analgesic management in laparoscopic cholecystectomy is feasible and advantageous in the early post-operative phase. Pain and PONV are predictors of a complicated recovery profile and deserve further attention. Transient oxygen desaturations postpone discharge from the PACU, but the clinical significance of this fact is questionable.     

Kostenaspekte in der Anästhesie

Cost control is no longer an option, but a necessity. Propofol anaesthesia is expensive, however, the true differences in comparison to volatile anaesthetics (isoflurane) are not known. Methods. Sixty patients undergoing either thyroidectomy (n=30) or laparoscopic cholecystectomy (n=30) were randomly divided into 3 groups of 20 patients. In group I propofol and fentanyl were used for anaesthesia, in group II isoflurane (,standard` isoflurane anaesthesia), and in group III isoflurane using a low-flow system (fresh gas flow 2?l/min) was given. All patients were ventilated using 70% N<sub>2</sub>O in oxygen. Vecuronium was used in all cases for muscle relaxation. Isoflurane consumption was measured by weighing the isoflurane vaporiser. Results. Biometric data and time of administration of the anaesthetic were similar in the three groups. Propofol patients stayed significantly shorter than isoflurane patients in the postanaesthesia care unit (PACU). Costs of additional drugs (antiemetics, analgesics) in the PACU were least in the propofol patients. Costs were without differences between the propofol (78.30 DM/patient) and `standard' isoflurane groups (81.69 DM/patient). Patients in group III showed the lowest overall costs (57.46?DM/patient) (P<0.05). Conclusion. A climate of cost-consciousness and cost-containment prevails at the present time. The costs of propofol and `standard' isoflurane anaesthesia were without differences; however, isoflurane used in a low-flow system had the lowest cost in this study. Doubts are justified, however, as to whether the choice of anaesthetic agents may considerably lower the costs of an anaesthesia department.     

Multimodal approach to rapid discharge after endoscopic thoracic sympathectomy

BACKGROUND: After a large experience (more than 10 years) with bilateral endoscopic thoracic sympathectomy (ETS) surgery on an outpatient basis, we studied prospectively a multimodal approach to rapid discharge patients undergoing this procedure. METHODS: One hundred and seventeen consecutive patients, aged 13-60 years, ASA physical status I or II, undergoing outpatient ETS under general anaesthesia were enrolled in this study. All patients were managed using a predefined multimodal clinical care protocol consisting of a general balanced anaesthesia. Basic demographic information was collected from each patient. Duration of surgery and anaesthesia and times to PACU and home discharge were recorded as well as intraoperative and postoperative complications like nausea and vomiting. RESULTS: Surgery took 41.4 +/- 22.1 min and anaesthesia lasted 63 +/- 21.5 min. Time between induction of anaesthesia and beginning of surgery and end of surgery to extubation was 15.0 +/- 2.0 and 7.2 +/- 3.1 min, respectively. It took 4.9 +/- 1.5 min from extubation to OR discharge. Time from PACU arrival to discharge was 12.8 +/- 6.3 min. Time of hospital stay was 132 +/- 18 min. No patient experienced vomiting and two had nausea, representing an incidence of 1.7%. The only anaesthetic cause for hospital admission was a severe allergic reaction. CONCLUSION: Multimodal management to rapid discharge after ETS surgery did result in a short time to patient discharge. We confirm that endoscopic thoracic sympathectomy can be performed safely on an outpatient basis with brief postoperative hospital care and a low rate of complications.     

Randomized comparison of two anti-emetic strategies in high-risk patients undergoing day-case gynaecological surgery

Background: Postoperative nausea and vomiting (PONV) is a significant causeof morbidity among patients undergoing general anaesthesia.The optimal strategy for prevention of PONV, however, remainsunclear. This study compared two commonly used prophylacticstrategies in high-risk, day-case, gynaecological surgery patients. Methods: We conducted a randomized trial comparing sevoflurane combinedwith dolasetron (SD), with propofol-based total intravenousanaesthesia (TIVA) in 126 high-risk patients undergoing day-casegynaecological surgery. The primary endpoints included the incidenceand severity of nausea or vomiting before discharge and theincidence of nausea or vomiting between discharge and 24 h.To identify the factors most predictive of a complete response(no PONV at any time within the 24 h period), multiplelogistic regression models were fitted. Results: Before discharge, there was no significant difference betweenthe two treatment groups with respect to nausea and vomitingoutcomes (P = 0.3). Post-discharge nausea and vomiting (PDNV),however, were significantly more common for patients in theTIVA group (nausea, P = 0.004 and vomiting, P = 0.03). Typeof anaesthetic, adjusted for weight and anaesthesia durationwas significantly associated with complete response (odds ratio= 2.7, 95% confidence interval = 1.15 to 6.4). Conclusions: Although both TIVA and dolasetron prophylaxis reduce the predictedrate of PONV in the early postoperative period, the anti-emeticeffects of propofol are short-lived. A longer-acting drug suchas dolasetron may therefore be necessary to prevent PDNV.     

Fast-tracking (bypassing the PACU) does not reduce nursing workload after ambulatory surgery

Background. Postoperative day-case patients are usually allowedto recover from anaesthesia in a postanaesthesia care unit (PACU)before transfer back to the day surgical unit (DSU). Bypassingthe PACU can decrease recovery time after day surgery. Costsavings may result from a reduced nursing workload associatedwith the decreased recovery time. This study was designed toevaluate the effects of bypassing the PACU on patient recoverytime and nursing workload and costs. Methods. Two hundred and seven consenting outpatients undergoingday surgery procedures were enrolled. Anaesthesia was inducedand maintained with a standardized technique and the electroencephalographicbispectral index was monitored and maintained at 40–60during anaesthetic maintenance. At the end of surgery, patientswere randomly assigned to either a routine or fast-tracking(FT) group. Patients in the FT group were transferred from theoperating room to the DSU (i.e. bypassing the PACU) if theyachieved the FT criteria. All other patients were transferredto the PACU and then to the DSU. Nursing workload was evaluatedusing a patient care hour chart based on the type and frequencyof nursing interventions in the PACU and DSU. A cost associatedwith the nursing workload was calculated. Results. The overall time from end of anaesthesia to dischargehome was significantly decreased in the fast-tracking group.However, overall patient care hours and costs were similar inthe two recovery groups. Conclusion. Bypassing the PACU after these short outpatientprocedures significantly decreases recovery time without compromisingpatient satisfaction. However, the overall nursing workloadand the associated cost were not significantly affected.      

Tribloc (fémoral,sciatique, obturateur) pour la chirurgie ambulatoire arthroscopique de genou : étude prospective de faisabilité et d’efficacité

Background

The purpose of this study was to evaluate intra- and postoperative conditions of the triple nerve block technique (femoral, obturator, sciatic block) for outpatient knee arthrsopic procedures.

Methods

After written informed consent, ASA I-III patients received a combined triple nerve block with 30–40 ml lidocaine or mepivacaine (1,5%). Blocks were performed using a nerve stimulation technique. Onset time, block failure, supplemental general anesthesia (GA) or analgesia and pain score were recorded intraoperatively. After surgery, side effects (at days 0, 1, 3, 7 and after 4 weeks), patient and surgeon satisfactions were noted.

Results

Three hundred and twelve patients were screened and 115 triple blocks were performed (157 choosed GA, 19 spinal anaesthesia, 21 exclusion for regional anaesthesia). Failed blocks occurred for 12 (10%) patients. These 12 patients received GA before surgery incision. Time to complete block was 40 (10–60) min. Supplemental GA was required for 12 patients (12%) due to surgical (n = 7, 7%) or tourniquet (n = 5, 5%) pain. Intraoperative surgeon satisfaction was 90 (60–100). After surgery, time to discharge the postoperative care unit was 15 (5–60) min. Pain score at rest (Visual Analog Scale) until six hours was less than 30 /100, without any additionnal morphine. Two patients (< 2%) failed for ambulatory discharge criteria (no relation with triple block). At day 0, 3, 5% patients suffered PONV (8% at D1), paresthesia was noted in 1.7% at D0 (0,8% D3). No other secondary effects were observed after seven days and 91% patients “would like same anaesthesia” for next surgery.

Conclusion

We conclude that triple nerve block provided reliable intraoperative patient and surgical conditions for outpatient knee arthroscopy. Failed block (10%) was the major reason of supplemental anaesthesia. To increase surgical turn over under triple nerve block, a preoperative room may be required (block onset time).     

Desflurane vs. sevoflurane as the main inhaled anaesthetic for spontaneous breathing via a laryngeal mask for varicose vein day surgery: a prospective randomized study

BACKGROUND: Sevoflurane has become widely used in day surgery; however, desflurane may be a valuable alternative even in this setting. This study compares emergence from anaesthesia for day surgery with spontaneous breathing using either desflurane or sevoflurane. METHODS: This prospective, randomized, single-blinded study examined 70 ASA III patients undergoing elective ambulatory varicose vein surgery. Primary endpoint was emergence time (cessation of anaesthetic gas to communicating). Secondary endpoints included post-operative pain, nausea, time to discharge, and patient satisfaction. Patients were anaesthetized according to a standardized protocol including multimodal analgesia and antiemetic therapy and were randomized to receive sevoflurane or desflurane as the main anaesthetic while breathing spontaneously through a laryngeal mask airway. Fresh gas flow was oxygen in air 1 : 2 l/min. RESULTS: Intra-operative anaesthesia was uneventful apart from airway irritation observed in 5/35 desflurane and 1/35 sevoflurane patients. Emergence was 25-40% faster in patients anaesthetized with desflurane. Pain and post-operative nausea and vomiting (PONV) were equally infrequent in both groups. Overall, patient satisfaction was high with no difference between the groups. CONCLUSION: Desflurane is associated with a faster emergence with no differences during the post-operative course except a somewhat higher incidence of airway irritation.     

Randomized comparison of remifentanil-propofol with a sciatic-femoral nerve block for out-patient knee arthroscopy

BACKGROUND AND OBJECTIVE: To evaluate preparation and discharge times as well as the anaesthesia-related costs of out-patient knee arthroscopy performed with a combined sciatic-femoral nerve block, or a propofol-remifentanil general anaesthetic. METHODS: With Ethics Committee approval and written informed consent, 40 healthy patients were pre-medicated with intravenous midazolam (0.05 mg kg(-1)) and ketoprofen (50 mg). They were then randomly allocated to receive either a combined sciatic-femoral nerve block with 25 mL mepivacaine 2% (15 mL for the femoral nerve, 10 mL for the sciatic nerve) (PNB group, n = 20), or a general anaesthetic with a continuous intravenous infusion of remifentanil (0.1-0.3 microgkg(-1) min(-1)) and propofol (target plasma concentration 2-4 microg mL(-1)) with a laryngeal mask airway (GA group, n = 20). RESULTS: The median (range) preparation time was 16 (10-28)min in the PNB group and 13 (8-22)min in the GA group (P = 0.015). Ten PNB patients were directly discharged to the day-surgery unit after the procedure as compared with one GA patient (P = 0.003). Discharge from the postanaesthesia care unit (PACU) required 5 (5-20) min in the PNB group and 23 (7-95) min in the GA group (P = 0.001). Home discharge criteria were fulfilled after 277 (150-485) min in the PNB group and 170 (100-400) min in the GA group (P = 0.005). Costs related to the time spent in the PACU were lower for the PNB group (1.10 euro, range Euro 0-22 euro) compared with the GA group (30 euro, range 0-176 euro) (P = 0.0005). There were no differences in total costs: PNB group 158 euro (range 105-194 euro) versus GA group 160 euro (range 101-238 euro) (P = 0.61). CONCLUSIONS: In patients undergoing out-patient knee arthroscopy, the length of stay in the PACU can be shorter after a sciatic-femoral nerve block with a small volume of mepivacaine 2% compared with a propofol-remifentanil anaesthetic, and there is an increased likelihood that they will bypass the first phase of the postoperative recovery.     

Two percent lidocaine spinal anaesthesia compared with sevoflurane anaesthesia in ambulatory knee surgery – cost-effectiveness,home readiness and recovery profiles

A total of 60 patients scheduled for elective knee arthroscopy were randomized to receive spinal anaesthesia (SA) with 2% lidocaine (n=30) or general anaesthesia with sevoflurane (SE) (n=30). SA and SE were compared in terms of the total costs of anaesthesia. The time to reach home readiness and the total time spent in the recovery unit (RU) were assessed. The early postoperative period and recovery at 24 h and 1 week were evaluated in terms of the incidence of pain, sedation, nausea and general satisfaction with the method of anaesthesia and postoperative instructions. The total costs of anaesthetic materials in the operation theatre (OT) and anaesthetic materials and personnel costs until home readiness was achieved in the RU were 160.7 FIM (1 FIM=0.17 EUR) for SA and 171.0 FIM for SE (not significant). The corresponding sums were 197.2 FIM for SA and 224.4 FIM for SE (P=0.001) when the total stay in RU was considered. The time to reach home readiness was 140.8 min (S.D. 52) in the SA group and 96.4 min (S.D. 62) in the SE group (P=0.02). There were no differences in the total RU time (224.0 min (S.D. 67) for SA and 218.0 min (S.D. 59) for SE). The level of postoperative pain was generally low, as all the SA patients and 86.7% of the SE patients had VAS<4 2 h postoperatively. Six SA patients (20.0%) had postoperative headache and two of them also had headache in the supine position. There were no headaches in the SE group (P=0.024). None of the patients in the SA group and six SE patients (20.0%) had nausea (needed treatment) in the RU (P=0.024). Four patients (13.3%) in the SE group and 1 patient (3.3%) in the SA group had nausea during the first 24 h postoperatively. All the patients were alert 60 min postoperatively with no difference between the groups and they were very satisfied during the first 24 h. All patients would have liked to have a similar operation done on an ambulatory basis. 93.3% said they would choose the same kind of anaesthesia. 91.7% were satisfied with the first week.General anaesthesia with SE is more cost-effective than SA with 2% lidocaine in ambulatory knee surgery if a short RU time is needed. The patients do generally well, but the incidence of postspinal headache with SA, adequate postoperative pain treatment and the possibility to have nausea with SE must be kept in mind.     

General anaesthesia or spinal anaesthesia for outpatient urological surgery

BACKGROUND AND OBJECTIVE: A variety of drugs and techniques have been introduced into ambulatory anaesthesia. The technique as well as the drugs used may hasten or delay home discharge. We compared recovery profiles and side-effects of spinal anaesthesia and total intravenous anaesthesia. METHODS: Forty unpremedicated ASA I-II patients (18-65 yr) undergoing varicocele repair were randomly divided into two groups. Spinal anaesthesia (26-G atraumatic needle) with hyperbaric bupivacaine 0.5% 5 mg and fentanyl 25 microg were given to patients in Group Spinal (n = 20). Patients in Group TIVA (n = 20) received total intravenous anaesthesia with propofol and remifentanil given by continuous infusion; a laryngeal mask was used to secure the airway. The duration of surgery, time to home readiness and side-effects were recorded. RESULTS: The two groups were comparable with respect to patients' characteristics and duration of surgery. The times to achieve ambulation were similar between groups (Spinal = 78.4 +/- 40.9 min, TIVA = 75.9 +/- 13.8 min). Urinary voiding was a requirement for discharge after spinal anaesthesia and the time for home readiness was longer in Group Spinal (158.0 +/- 40.2 versus 94.9 +/- 18.8 min) (P < 0.05). Two patients reported pruritus and one reported postdural puncture headache in Group Spinal, whereas two patients reported nausea in Group TIVA. Patients in Group TIVA had a greater need for analgesia postoperation (P < 0.05). CONCLUSIONS: In healthy unpremedicated men undergoing minor urological operations, total intravenous anaesthesia with remifentanil and propofol provided as safe and effective anaesthesia as spinal block with the advantage of earlier home readiness.     

Postoperative epidural injection of saline can shorten postanesthesia care unit time for knee arthroscopy patients

Background and Objectives. The goal of this prospective, double-blind study was to ascertain if the postanesthesia care unit (PACU) stay of outpatients receiving epidural anesthesia for knee arthroscopy is decreased by injection of epidural saline at the end of the case. Methods. Twenty healthy patients undergoing knee arthroscopy received lumbar epidural anesthesia with 2% lidocaine. At the end of surgery, in a double-blind design, group 1 patients (intervention group) received 20 mL 0.9% saline injected into the epidural catheter. Patients in group 2 (control group) had 1 mL 0.9% saline injected into the epidural catheter. In the PACU, the epidural catheter was removed, and motor block was assessed at 15-minute intervals according to the Bromage scale. Standard discharge criteria for our ambulatory surgery center were followed. Results. Patients who received 20 mL epidural 0.9% saline remained in phase I (intensive nursing) 83 ± 8 minutes compared with control patients who stayed 110 ± 8 minutes (P < .01). Nonmedical issues related to the unavailability of the patients transportation or waiting for medications to be issued from the pharmacy delayed discharge from phase II (non-nursing) in 70% of group 1 patients and 60% of group 2 patients. Time to actual hospital dismissal for group 1 was 119 ± 14 minutes, compared with 159 ± 13 minutes (P < .05) for group 2. Conclusion. Patients receiving epidural anesthesia for knee arthroscopy had a shorter PACU stay if they received an injection of saline into the epidural space at the end of surgery.     

Does sevoflurane preserve regional cerebral oxygen saturation measured by near-infrared spectroscopy better than propofol?

Objective

The aim of this study was to compare the effect of sevoflurane and propofol on cerebral oxygenation, using regional cerebral oxygen saturation (SrO₂) measured by near-infrared spectroscopy (NIRS).

Study design

Prospective, randomized, controlled study.

Patients and methods

Fifty-four patients aged between 18 and 65 years who underwent elective minor surgery (tumorectomy for breast cancer or inguinal hernia repair) were randomly assigned to receive sevoflurane or propofol anaesthesia. Exclusion criteria included pre-existing cerebrovascular diseases, anaemia, ASA >III, blood loss ≥200 mL, arterial hypotension, baseline pulse oximetry <97%, sign of sensor low quality of SrO₂ or bispectral index, and patients with a forehead area <6.5 cm. SrO₂, bispectral index, haemodynamic data and anaesthetic doses were recorded during surgery.

Results

A total of 48 patients were included in the final analysis (24 in each group). There were no significant differences in mean, minimum and maximum SrO₂ between sevoflurane and propofol groups. The relative maximum decrease was higher in propofol anaesthesia than sevoflurane anaesthesia (9.6 ± 10.7 versus 4.2 ± 7.2%; P = 0.048). Cerebral desaturation (20% reduction from SrO₂ baseline during 15 seconds) occurred in 4 patients in propofol group exclusively (P = 0.109). SrO₂ adjusted for baseline was higher in the sevoflurane group than in the propofol group (67.3 ± 1.8% versus 64.2 ± 1.7%; P = 0.018). There were no significant differences in haemodynamic parameters between the two groups.

Conclusions

Cerebral cortical oxygenation measured by NIRS may be better preserved with sevoflurane than with propofol. These findings suggest that sevoflurane anaesthesia could be a good option in patients with compromised cerebral oxygenation, given the absence of intracranial hypertension. Further studies with larger sample sizes are required to support our results.     

Pharmacoeconomical model for cost calculation using a study on prophylaxis of nausea and vomiting in the postoperative phase as an example. Cost effectiveness analysis of a tropisetron supplemented desflurane anaesthesia in comparison to a propofol total intravenous anaesthesia (TIVA)

AIM OF THE STUDY: Postoperative nausea and vomiting (PONV) are among the most frequent complications after general anaesthesia. Avoiding these symptoms is of utmost importance for most patients; PONV is not only a major source of discomfort for patients but also a cause of additional costs for the patients and the health care provider. The economical impact of PONV will become even more important in the near future because the number of surgical procedures performed on an ambulatory basis is increasing. The following article gives a short overview of the terminology and measures used in pharmacoeconomical studies concerning PONV. Furthermore the economical aspects of a low-flow anaesthesia supplemented with the 5-HT(3)-antagonist tropisetron compared with a total intravenous anaesthesia (TIVA) using propofol are described. METHODS: For this comparison a decision analysis was performed using data of a randomised control trial on 150 female patients undergoing major gynaecological surgery. The patients were randomised to receive a total intravenous anaesthesia with propofol-alfentanil or a balanced anaesthesia with desfluran (fresh gas flow 1 l.min(-1)) supplemented by 2 mg tropisetron at the end of surgery. RESULTS: Indirect costs associated with anaesthesia using desflurane-tropisetron (4.94 Euro) are not different from that of propofol-TIVA (4.81 Euro) because of a similar incidence of PONV in the PACU. Furthermore, the total cost for 100 min general anaesthesia is higher in the desflurane-tropisetron group (30.94 Euro) compared with the TIVA group (24.55 Euro) due to the decreasing acquisition costs of propofol in the last 2 years. CONCLUSION: Total intravenous anaesthesia with propofol is more cost-efficient than balanced anaesthesia with desflurane and additional tropisetron as a prophylactic antiemetic.