Showing papers in "Anesthesia & Analgesia in 1999"
TL;DR: Patients’ preferences for postoperative anesthesia outcomes are quantified to help improve healthcare quality and customize care to meet the needs of the patient.
Abstract: Healthcare quality can be improved by eliciting patient preferences and customizing care to meet the needs of the patient. The goal of this study was to quantify patients’ preferences for postoperative anesthesia outcomes. One hundred one patients in the preoperative clinic completed a written surve
777 citations
TL;DR: Point-of-care coagulation monitoring using TEG resulted in fewer transfusions in the postoperative period, and this data support the use of TEG in an algorithm to guide transfusion therapy in complex cardiac surgery.
Abstract: Transfusion therapy after cardiac surgery is empirically guided, partly due to a lack of specific point-of-care hemostasis monitors. In a randomized, blinded, prospective trial, we studied cardiac surgical patients at moderate to high risk of transfusion. Patients were randomly assigned to either a thromboelastography (TEG)-guided transfusion algorithm (n 5 53) or routine transfusion therapy (n 5 52) for intervention after cardiopulmonary bypass. Coagulation tests, TEG variables, mediastinal tube drainage, and transfusions were compared at multiple time points. There were no demographic or hemostatic test result differences between groups, and all patients were given prophylactic antifibrinolytic therapy. Intraoperative transfusion rates did not differ, but there were significantly fewer postoperative and total transfusions in the TEG group. The proportion of patients receiving freshfrozen plasma (FFP) was 4 of 53 in the TEG group compared with 16 of 52 in the control group (P , 0.002). Patients receiving platelets were 7 of 53 in the TEG group compared with 15 of 52 in the control group (P , 0.05). Patients in the TEG group also received less volume of FFP (36 6 142 vs 217 6 463 mL; P , 0.04). Mediastinal tube drainage was not statistically different 6, 12, or 24 h postoperatively. Point-of-care coagulation monitoring using TEG resulted in fewer transfusions in the postoperative period. We conclude that the reduction in transfusions may have been due to improved hemostasis in these patients who had earlier and specific identification of the hemostasis abnormality and thus received more appropriate intraoperative transfusion therapy. These data support the use of TEG in an algorithm to guide transfusion therapy in complex cardiac surgery. Implications: Transfusion of allogeneic blood products is common during complex cardiac surgical procedures. In a prospective, randomized trial, we compared a transfusion algorithm using point-of-care coagulation testing with routine laboratory testing, and found the algorithm to be effective in reducing transfusion requirements. (Anesth Analg 1999;88:312‐9)
763 citations
TL;DR: To evaluate the failure rate, patient acceptance, effective volumes of local anesthetic solution, and incidence of neurologic complications after peripheral nerve block performed using the multiple injection technique with a nerve stimulator, 3996 patients undergoing combine are prospectively studied.
Abstract: To evaluate the failure rate, patient acceptance, effective volumes of local anesthetic solution, and incidence of neurologic complications after peripheral nerve block performed using the multiple injection technique with a nerve stimulator, we prospectively studied 3996 patients undergoing combine
405 citations
TL;DR: A patient-rated quality of recovery score is developed by constructing a 61-item questionnaire that asked individuals to rate the importance of certain aspects of recovery after anesthesia.
Abstract: A variety of methods have been used to quantify aspects of recovery after anesthesia.Most are narrowly focused, are not patient-rated, and have not been validated. We therefore set out to develop a patient-rated quality of recovery score. We constructed a 61-item questionnaire that asked individuals
390 citations
TL;DR: Animal studies have shown that large volumes of IV lactated Ringer's solution decrease serum osmolality, thereby increasing cerebral water, thus leading to recommendations to limit LR to avoid cerebral edema in neurosurgical patients.
Abstract: Animal studies have shown that large volumes of IV lactated Ringer's solution (LR) decrease serum osmolality, thereby increasing cerebral water. These studies have led to recommendations to limit LR to avoid cerebral edema in neurosurgical patients. Eighteen healthy human volunteers aged 20-48 yr received 50 mL/kg LR over 1 h on one occasion and 0.9% sodium chloride (NS) on another. Venous samples were taken at baseline (T1), at infusion end (T2), and 1 h after T2 (T3). Time until first urination was noted. With LR, serum osmolality decreased by 4+/-3 mOsm/kg from T1 to T2 and increased insignificantly with NS. At T3, osmolality returned almost to baseline in the LR group. Blood pH increased from T1 to T2 with LR by 0.04+/-0.04 and decreased with NS by 0.04+/-0.04. These pH changes persisted at T3. Subjective mental changes occurred only with NS. Abdominal discomfort was more common with NS. Time until first urination was longer with NS (106+/-11 min) than with LR (75+/-10 min) (P Implications Large volumes of lactated Ringer's solution administered to healthy humans produced small transient changes in serum osmolality. Large volumes of sodium chloride did not change osmolality but resulted in lower pH.
365 citations
TL;DR: In this article, the authors surveyed a panel of expert anesthesiologists to determine which clinical outcomes associated with routine outpatient surgery were judged to occur frequently and to be important to avoid.
Abstract: UNLABELLED Anesthesia groups may need to determine which clinical anesthesia outcomes to track as part of quality improvement efforts. The goal of this study was to poll a panel of expert anesthesiologists to determine which clinical anesthesia outcomes associated with routine outpatient surgery were judged to occur frequently and to be important to avoid. Outcomes scoring highly in both scales could then be prioritized for measurement and improvement in ambulatory clinical practice. A mailed survey instrument instructed panel members to rate 33 clinical anesthesia outcomes in two scales: how frequently they believe the outcomes occur and which outcomes they expect patients find important to avoid. A feedback process (Delphi process) was used to gain consensus rankings of the outcomes for each scale. Importance and frequency scores were then weighted equally to qualitatively rank order the outcomes. Of the 72 anesthesiologists, 56 (78%) completed the questionnaire. The five items with the highest combined score were (in order): incisional pain, nausea, vomiting, preoperative anxiety, and discomfort from IV insertion. To increase quality of care, reducing the incidence and severity of these outcomes should be prioritized. IMPLICATIONS Expert anesthesiologists reached a consensus on which low-morbidity clinical outcomes are common and important to the patient. The outcomes identified may be reasonable choices to be monitored as part of ambulatory anesthesia clinical quality improvement efforts.
352 citations
351 citations
TL;DR: Patients at high risk of cardiac complications after vascular surgery were identified and it was shown that if their heart rate was carefully controlled for 48 h after surgery, myocardial ischemia, a common marker of heart injury, was markedly reduced.
Abstract: Patients undergoing vascular surgery have a high risk of suffering major postoperative cardiac events.Preoperative myocardial ischemia as detected by Holter monitoring identifies a high-risk subgroup whose postoperative ischemia, similarly detected, seems to herald major cardiac events. In this stud
337 citations
332 citations
TL;DR: Computer simulation was used to model OR scheduling and found that operating room utilization can be maximized by allocating block time for the electives based on expected total hours of elective cases, scheduling patients into the first available date provided open block time is available within 4 wk, and otherwise scheduling patients in "overflow" time outside of the block time.
Abstract: Determining the appropriate amount of block time to allocate to surgeons and selecting the days on which to schedule elective cases can maximize operating room (OR) use.We used computer simulation to model OR scheduling. Inputs in the computer model included different methods to determine when a pat
324 citations
TL;DR: In this article, the authors present a set of guidelines for performing a comprehensive intraoperative transesophageal echocardiography (TEE) examination composed of anatomically directed cross-sectional views.
Abstract: Since the introduction of transesophageal echocardiography (TEE) to the operating room in the early 1980s,1-4 its effectiveness as a clinical monitor to assist in the hemodynamic management of patients during general anesthesia and its reliability to make intraoperative diagnoses during cardiac operations has been well established.5-26 In recognition of the increasing clinical applications and use of intraoperative TEE, the American Society of Echocardiography (ASE) established the Council for Intraoperative Echocardiography in 1993 to address issues related to the use of echocardiography in the operating room. In June 1997, the Council board decided to create a set of guidelines for performing a comprehensive TEE examination composed of a set of anatomically directed cross-sectional views. The Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography has endorsed these guidelines and standards of nomenclature for the various anatomically directed cross-sectional views of the comprehensive TEE examination. This document, therefore, is the collective result of an effort that represents the consensus view of both anesthesiologists and cardiologists who have extensive experience in intraoperative echocardiography. The writing group has several goals in mind in creating these guidelines. The first is to facilitate training in intraoperative TEE by providing a framework in which to develop the necessary knowledge and skills. The guidelines may also enhance quality improvement by providing a means to assess the technical quality and completeness of individual studies. More consistent acquisition and description of intraoperative echocardiographic data will facilitate communication between centers and provide a basis for multicenter investigations. In recognition of the increasing availability and advantages of digital image storage, the guidelines define a set of cross-sectional views and nomenclature that constitute a comprehensive intraoperative TEE examination that could be stored in a digital format. These guidelines will encourage industry to develop echocardiography systems that allow quick and easy acquisition, labeling, and storage of images in the operating room, as well as a simple mechanism for side-by-side comparison of views made at different times. ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography
TL;DR: It is determined whether children who are extremely anxious during the induction of anesthesia are more at risk of developing postoperative negative behavioral changes compared with children who appear calm During the induction process.
Abstract: We determined whether children who are extremely anxious during the induction of anesthesia are more at risk of developing postoperative negative behavioral changes compared with children who appear calm during the induction process.Children (n = 91) aged 1-7 yr scheduled for general anesthesia and
TL;DR: It was showed that nonpharmacologic techniques were equivalent to commonly used antiemetic drugs in preventing vomiting after surgery and may be an alternative to receiving no treatment or first-line antiemetics.
Abstract: UNLABELLED: We assessed the efficacy of nonpharmacologic techniques to prevent postoperative nausea and vomiting (PONV) by systematic review. These studies included acupuncture, electroacupuncture, transcutaneous electrical nerve stimulation, acupoint stimulation, and acupressure. Of the 24 randomized trials retrieved by a search of articles indexed on the MEDLINE and EMBASE databases (1980-1997), 19 were eligible for meta-analysis. The primary outcomes were the incidence of nausea, vomiting, or both 0-6 h (early efficacy) or 0-48 h (late efficacy) after surgery. The pooled relative risk (RR) and numbers needed to treat (NNT) were calculated. In children, no benefit was found. Some results in adults were significant. Nonpharmacologic techniques were similar to antiemetics in preventing early vomiting (RR = 0.89 [95% confidence interval 0.47-1.67]; NNT = 63 [10-infinity]) and late vomiting (RR = 0.80 [0.35-1.81]; NNT = 25 [5-infinity]) in adults. Nonpharmacologic techniques were better than placebo at preventing early nausea (RR = 0.34 [0.20-0.58]; NNT = 4 [3-6]) and early vomiting in adults (RR = 0.47 [0.34-0.64]; NNT = 5 [4-8]). Nonpharmacologic techniques were similar to placebo in preventing late vomiting in adults (RR = 0.81 [0.46-1.42]; NNT = 14 [6-infinity]). Using nonpharmacologic techniques, 20%-25% of adults will not have early PONV compared with placebo. It may be an alternative to receiving no treatment or first-line antiemetics. IMPLICATIONS: This systematic review showed that nonpharmacologic techniques were equivalent to commonly used antiemetic drugs in preventing vomiting after surgery. Nonpharmacologic techniques were more effective than placebo in preventing nausea and vomiting within 6 h of surgery in adults, but there was no benefit in children.
TL;DR: Current knowledge regarding the assessment of home-readiness after ambulatory surgery is reviewed and potential complications and appropriate treatment regimens are discussed.
Abstract: I n recent years, the emphasis in providing surgical services has undergone remarkable change. Previously, patients undergoing surgical procedures remained in a hospital for many days after the operation. In 1994, 66% of all elective operations in the United States were performed on an outpatient basis (1). More complex ambulatory procedures are being performed on sicker patients (2). With the increased emphasis on early discharge after surgery and anesthesia, it is important to identify criteria that can be used to determine when patients can safely go home under the care of a friend or relative. In this article, we review current knowledge regarding the assessment of home-readiness after ambulatory surgery and discuss potential complications and appropriate treatment regimens.
TL;DR: It is hypothesized that using this new scoring system to determine a patient’s fast-track eligibility would reduce the need for nursing interventions to administer parenteral medications in the Phase II recovery area.
Abstract: T he modified Aldrete’s scoring system (1) is commonly used for determining when patients can be safely discharged from the postanesthesia care unit (PACU) to either the postsurgical ward or to the second stage (Phase II) recovery area. Recently, these discharge criteria have also been used in the operating room (OR) to determine the fast-track eligibility of outpatients undergoing ambulatory surgery (2,3). Because fast-tracking in the ambulatory setting implies taking a patient from the OR directly to the less extensively monitored Phase II step-down unit, this scoring system may not be adequate after ambulatory procedures requiring general anesthesia because it fails to consider common side effects that have traditionally been treated in the PACU (e.g., pain, nausea, and vomiting). Therefore, a new fasttrack scoring system that incorporates the essential elements of the modified Aldrete system, as well as an assessment of pain and emesis, has been proposed (4). We hypothesized that using this new scoring system to determine a patient’s fast-track eligibility would reduce the need for nursing interventions to administer parenteral medications in the Phase II recovery area. The times to fast-track eligibility were compared using the modified Aldrete and new fasttrack criteria in outpatients undergoing laparoscopic surgery with one of three standardized general anesthetic techniques. Methods
TL;DR: Available neurotoxicity data on drugs that have a clinical application, classified as spinal local anesthetics, spinal analgesics, or spinal adjuvants are reviewed.
Abstract: A growing understanding of the neuropharmacology of spinal cord processing of nociceptive input has led to intense interest in the use of spinal drugs in anesthesia and pain management. The direct application of receptor-specific therapeutics at the spinal cord can potentially interrupt specific pain pathways and limit systemic side effects, but this practice also carries the inherent risk of injury to the central nervous system. Thus, the neurotoxicity of spinal drugs is a central safety issue. Spinal cord or nerve root toxicity may manifest itself as histologic, physiologic, or behavioral/clinical derangements after exposure to a spinal drug. Neurohistopathology is broadly classified as neural injury, gliosis, or damage to the myelin sheath, and it also describes inflammatory changes and involvement of the arachnoid cell layers. Physiologic neurotoxicity of spinal drugs includes changes in spinal cord blood flow, disruption of the blood-brain barrier, and changes in the electrophysiology of impulse conduction. Behavioral and clinical signs of neurotoxicity include pain, motor and sensory deficits, and bowel and bladder dysfunction. Ideally, a complete roster of histological, physiologic, and behavioral testing would be performed on spinal drugs in several animal species, followed by safety trials in humans before widespread use. In practice, drugs have taken a variety of roads from conception to application, and often without safety data. In this article, we review available neurotoxicity data on drugs that have a clinical application, classified as spinal local anesthetics, spinal analgesics, or spinal adjuvants.
TL;DR: The VAS is linear for mild-to-moderate pain, and the VAS score can be treated as ratio data, and use of theVAS in comparative analgesic trials can now meaningfully quantify differences in potency and efficacy.
Abstract: The visual analog scale (VAS) is a tool widely used to measure pain, yet controversy surrounds whether the VAS score is ratio or ordinal data. We studied 52 postoperative patients and measured their pain intensity using the VAS. We then asked them to consider different amounts of pain (conceptually twice as much and then half as much) and asked them to repeat their VAS rating after each consideration (VAS2 and VAS3, respectively). Patients with unrelieved pain had their pain treated with IV fentanyl and were then asked to rate their pain intensity when they considered they had half as much pain. We compared the baseline VAS (VAS1) with VAS2 and VAS3. The mean (95% confidence interval) for VAS2:1 was 2.12 (1.81‐2.43) and VAS3:1 was 0.45 (0.38 ‐ 0.52). We conclude that the VAS is linear for mild-to-moderate pain, and the VAS score can be treated as ratio data. Implications: A change in the visual analog scale score represents a relative change in the magnitude of pain sensation. Use of the VAS in comparative analgesic trials can now meaningfully quantify differences in potency and efficacy. (Anesth Analg 1999;89:1517‐20)
TL;DR: Improvements in operating room efficiency were achieved by analyzing operating room data on causes of delays, devising strategies for minimizing the most common delays, and subsequently measuring delay data.
Abstract: UNLABELLED In this prospective study, we evaluated the etiology of operating room (OR) delays in an academic institution, examined the impact of multidisciplinary strategies to improve OR efficiency, and established OR timing benchmarks for use in future OR efficiency studies. OR times and delay etiologies were collected for 94 cases during the initial phase of the study. Timing data and delay etiologies were analyzed, and 2 wk of multidisciplinary OR efficiency awareness education was conducted for the nursing, surgical, and anesthesia staff. After the education period, timing data were collected from 1787 cases, and monthly reports listing individual case delays and timing data were sent to the Chiefs of Service. For the first case of the day, patient in room, anesthesia ready, surgical preparation start, and procedure start time were significantly earlier (P < 0.01) in the posteducation period compared with the preeducation period, and the procedure start time for the first case of the day occurred, on average, 22 min earlier than all other procedures. For all cases combined, turnover time decreased, on average, by 16 min. Unavailability of surgeons, anesthesiologists, and residents decreased significantly (P < 0.05) as causes of OR delays. Anesthesia induction times were consistently longer for the vascular and cardiothoracic services, whereas surgical preparation time was increased for the neurosurgical and orthopedic services (P < 0.05). Identification of the etiology of OR inefficiency, combined with multidisciplinary awareness training and personal accountability, can improve OR efficiency. The time savings realized are probably most cost-effective when combined with more flexible OR staffing and improved OR scheduling. IMPLICATIONS We achieved significant improvements in operating room efficiency by analyzing operating room data on causes of delays, devising strategies for minimizing the most common delays, and subsequently measuring delay data. Personal accountability, streamlining of procedures, interdisciplinary team work, and accurate data collection were all important contributors to improved efficiency.
TL;DR: It is concluded that TEA (but not i.v. clonidine) combined with general anesthesia for CABG demonstrates a beneficial effect on the perioperative stress response and postoperative myocardial ischemia.
Abstract: In this prospective study, we evaluated whether high thoracic epidural anesthesia (TEA) or IV clonidine, in addition to general anesthesia, affects the cardiopulmonary bypass-and surgery-associated stress response and incidence of myocardial ischemia by their sympatholytic properties. Seventy patien
TL;DR: The effect of an insulin infusion on perioperative neutrophil function in diabetic patients with high risk of wound infection is tested.
Abstract: Diabetic patients are at increased risk of wound infection after major surgery, but the effect of perioperative glucose control on postoperative wound infection rates after surgery is uncertain.We tested the effect of an insulin infusion on perioperative neutrophil function in diabetic patients sche
TL;DR: The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and untoward cardiovascular events.
Abstract: We identified predictors for prolonged postoperative stay after ambulatory surgery using multiple logistic regression models. We collected perioperative data for 16,411 ambulatory surgical patients. A log-transformed time to discharge variable was modeled by multiple linear regression, including patient-, anesthesia-, and surgery-specific variables. The impact of hypothetical elimination of perioperative adverse events on mean length of stay was also estimated. Separate analyses were performed among patients who received general anesthesia (GA) and monitored anesthesia care (MAC). Patients receiving GA stayed 50 min longer than patients receiving MAC. Patients receiving GA and undergoing strabismus, transurethral, or otorhinolaryngological/dental procedures had the longest postoperative stay. Among patients receiving GA, smokers had a 4% shorter stay compared with nonsmokers; among patients receiving MAC, those with congestive heart failure (CHF) had a 11% longer stay compared with patients without CHF. Postoperative nausea and vomiting, dizziness, excessive pain, and cardiovascular events predicted 22%‐79% increases in postoperative stay. The hypothetical elimination of all adverse events resulted in a 9.6% decrease in mean length of stay among patients receiving GA, but in only a 3.8% decrease among patients receiving MAC. The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and cardiovascular events. Patients with CHF and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving GA. Implications: The length of postoperative stay among ambulatory surgical patients is mainly determined by the type of surgery and by adverse events, such as excessive pain, postoperative nausea and vomiting, dizziness, drowsiness, and untoward cardiovascular events. Patients with congestive heart failure and those who underwent long procedures had a higher risk of a prolonged stay. Appropriate prevention and management of postoperative symptoms could significantly decrease the length of stay among patients receiving general anesthesia.
TL;DR: It is found that complications after routine, moderate-risk, elective surgery are common and involve multiple organ systems, and the 9-point survey can be used by healthcare providers and payers to characterize postoperative morbidity in their respective settings.
Abstract: Vital healthcare resources are devoted to caring for patients with prolonged hospitalization after routine, moderate-risk surgery. Despite the significant cost,little is known about the overall incidence and pattern of complications in these patients. Four hundred thirty-eight patients undergoing a diverse group of routine, moderate-risk, elective surgical procedures were enrolled into a prospective, blinded, cohort study. Complications were assessed using a postoperative morbidity survey. The main outcome was postoperative complication, defined as either in-hospital death or prolonged postoperative hospitalization (>7 days). The mortality rate was 1.6%. Postoperative complications occurred in 118 patients (27% [95% CI 23-31]). Complications frequently observed in these patients included: gastrointestinal 51% (42-60), pulmonary 25% (17-33), renal 21% (14-28), and infectious 13% (7-19). Most complications were not directly related to the type/site of surgery. indices of tissue trauma (blood loss [P < 0.001], surgical duration [P = 0.001]) and tissue perfusion (arterial base deficit [P = 0.008], gastric pHi [P = 0.02]) were the strongest intraoperative predictors of complications. Despite a low mortality rate, we found that complications after routine, moderate-risk, elective surgery are common and involve multiple organ systems. Our 9-point survey can be used by healthcare providers and payers to characterize postoperative morbidity in their respective settings. Implications: Little is known about the overall incidence and pattern of complications in patients with prolonged hospitalization after routine, elective surgery. We prospectively assessed these complications using a novel postoperative morbidity survey. The postoperative morbidity survey can be used in future clinical outcome trials, as well as in routine hospital-based quality assurance.
TL;DR: The Bispectrals Index decreased during increasing depth of sleep in a fashion very similar to the decrease in Bispectral Index that occurs during general anesthesia.
Abstract: How does physiological sleep affect the Bispectral Index (BIS)? We collected electroencephalographic (EEG) data from five subjects during the early part of the night, comparing the changes in the BIS with the conventional EEG stages of sleep. We found that the BIS was a consistent marker of depth of sleep. Light sleep occurred at BIS values of 75‐90, slow-wave sleep occurred at BIS values of 20 ‐70, and rapid eye movement sleep occurred at BIS values of 75‐92. The effects of natural sleep on the BIS seem to be similar to the effects of general anesthesia on the BIS. The BIS may have a role in monitoring depth of sleep. Implications: Electroencephalographic data were collected from five subjects during sleep. We found that the Bispectral Index decreased during increasing depth of sleep in a fashion very similar to the decrease in Bispectral Index that occurs during general anesthesia. This study further highlights the electroencephalographic similarities of states of sleep and general anesthesia. (Anesth Analg 1999;88:659 ‐61)
TL;DR: It is demonstrated that continuous interscalene analgesia requires a background infusion to provide efficient pain relief after open shoulder surgery and a basal infusion rate of 5 mL/h combined with patient-controlled analgesia boluses seems to be the most appropriate technique.
Abstract: In this prospective, randomized, double-blinded study, we assessed the efficacy of patient-controlled analgesia (PCA) for continuous interscalene analgesia after open shoulder surgery. Sixty patients were divided into three groups of 20. During a 48-h period, they received, via an interscalene catheter, a continuous infusion of 0.125% bupivacaine with sufentanil 0.1 microg/mL and clonidine 1 microg/mL at 10 mL /h in Group 1; a continuous infusion of the same solution at 5 mL/h plus PCA boluses (2.5 mL/30 min) in Group 2; and only PCA boluses (5 mL/30 min) of the same solution in Group 3. Pain scores, sensory block, supplemental analgesia, bupivacaine consumption, side effects, and satisfaction scores were recorded. At 24 and 48 h, sensory block was more frequent and pain control was significantly better in Groups 1 and 2 than in Group 3 (P < 0.001). In Group 3, larger doses of paracetamol were required. Bupivacaine consumption was significantly less in Groups 2 and 3 than in Group 1 (P < 0.001). Satisfaction was significantly higher in Groups 1 and 2 than in Group 3 (P < 0.01). Side effects were comparable in the three groups. We conclude that continuous interscalene analgesia requires a background infusion after open shoulder surgery. Because it reduces the local anesthetic consumption and allows the patients to rapidly reinforce the block shortly before physiotherapy, a basal infusion rate of 5 mL/h combined with PCA boluses (2.5 mL/ 30 min) is the recommended technique. IMPLICATIONS: In this study, we demonstrated that continuous interscalene analgesia requires a background infusion to provide efficient pain relief after open shoulder surgery. A basal infusion of 5 mL/h combined with patient-controlled analgesia boluses (2.5 mL/30 min) seems to be the most appropriate technique.
TL;DR: It is concluded that cell salvage in orthopedic surgery decreases the proportion of patients requiring allogeneic blood transfusion perioperatively, but postoperative cell salvage is only marginally effective in cardiac surgery.
Abstract: Concern about risks of allogeneic transfusion has led to an interest in methods for decreasing perioperative transfusion. To determine whether cell salvage reduces patient exposure to allogeneic blood, we performed meta-analyses of randomized trials, evaluating the effectiveness and safety of cell salvage in cardiac or orthopedic elective surgery. The primary outcome was the proportion of patients who received at least one perioperative allogeneic red cell transfusion. Twenty-seven studies were included in the meta-analyses. Cell salvage devices that do not wash salvaged blood were marginally effective in cardiac surgery patients when used postoperatively (relative risk [RR] = 0.85, 95% confidence interval [CI] = 0.79-0.92). Devices that wash or do not wash salvaged blood considerably decreased the proportion of orthopedic surgery patients who received allogeneic transfusion (RR = 0.39, 95% CI = 0.30-0.51 and RR = 0.35, 95% CI 0.26-0.46, respectively). No studies of cell savers that wash salvaged blood during cardiac surgery were included. Cell salvage did not appear to increase the frequency of adverse events. We conclude that cell salvage in orthopedic surgery decreases the risk of patients' exposure to allogeneic blood transfusion perioperatively. Postoperative cell salvage in cardiac surgery, with devices that do not wash the salvaged blood, is only marginally effective. Implications : This meta-analysis of all published randomized trials provides the best current estimate of the effectiveness of cell salvage and is useful in guiding clinical practice. We conclude that cell salvage in orthopedic surgery decreases the proportion of patients requiring allogeneic blood transfusion perioperatively, but postoperative cell salvage is only marginally effective in cardiac surgery.
TL;DR: The purpose of this study was to determine whether intraoperative hemodynamic abnormalities were associated with mortality, stroke, or perioperative myocardial infarction in a large cohort of patients undergoing surgery.
Abstract: Evidence that intraoperative hemodynamic abnormalities influence outcome is limited. The purpose of this study was to determine whether intraoperative hemodynamic abnormalities were associated with mortality, stroke, or perioperative myocardial infarction (PMI) in a large cohort of patients undergoi
Journal Article•
TL;DR: Hextend® as discussed by the authors is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and physiological levels of glucose for the treatment of hypovolemia during major surgery.
Abstract: Hextend® (BioTime, Inc., Berkeley, CA) is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and physiological levels of glucose. In preclinical studies, its use in shock models was associated with an improvement in outcome compared with alternatives, such as albumin or 6% hetastarch in saline. In a prospective, randomized, two-center study (n = 120), we compared the efficacy and safety of Hextend® versus 6% hetastarch in saline (HES) for the treatment of hypovolemia during major surgery. Patients at one center had a blood sample drawn at the beginning and the end of surgery for thromboelastographic (TEG) analysis. Hextend® was as effective as HES for the treatment of hypovolemia. Patients received an average of 1596 mL of Hextend®: 42% received >20 mL/kg up to a total of 5000 mL. No patient received albumin. Hextend®-treated patients required less intraoperative calcium (4 vs 220 mg; P < 0.05). In a subset analysis of patients receiving red blood cell transfusions (n = 56; 47%), Hextend®-treated patients had a lower mean estimated blood loss (956 mL less; P = 0.02) and were less likely to receive calcium supplementation (P = 0.04). Patients receiving HES demonstrated significant prolongation of time to onset of clot formation (based on TEG) not seen in the Hextend® patients (P < 0.05). No Hextend® patient experienced a related serious adverse event, and there was no difference in the total number of adverse events between the two groups. The results of this study demonstrate that Hextend®, with its novel buffered, balanced electrolyte formulation, is as effective as 6% hetastarch in saline for the treatment of hypovolemia and may be a safe alternative even when used in volumes up to 5 L. Implications: Hextend® (BioTime, Inc., Berkeley, CA) is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and a physiological level of glucose. It is as effective as 6% hetastarch in saline for the treatment of hypovolemia but has a more favorable side effects profile in volumes of up to 5 L compared with 6% hetastarch in saline.
TL;DR: Using the multiple injections technique with a nerve stimulator results in a success rate of >90% with a volume of <30 mL of local anesthetic solution and an incidence of transient neurologic complication of <2%.
Abstract: UNLABELLED To evaluate the failure rate, patient acceptance, effective volumes of local anesthetic solution, and incidence of neurologic complications after peripheral nerve block performed using the multiple injection technique with a nerve stimulator, we prospectively studied 3996 patients undergoing combined sciatic-femoral nerve block (n = 2175), axillary blocks (n = 1650), and interscalene blocks (n = 171). The success rate and mean injected volumes of local anesthetic were: 93% with 22.6 +/- 4.5 mL in the axillary, 94% with 24.5 +/- 5.4 mL in the interscalene, and 93% with 28.1 +/- 4.4 mL in the sciatic-femoral nerve blocks. Patients receiving combined sciatic-femoral nerve block showed more discomfort during block placement and worse acceptance of the anesthetic procedure than patients receiving brachial plexus anesthesia. During the first month after surgery, 69 patients (1.7%) developed neurologic dysfunction on the operated limb. Complete recovery required 4-12 wk in all patients but one, who required 25 wk. The only variable showing significant association with the development of postoperative neurologic dysfunction was the tourniquet inflation pressure ( 400 mm Hg, odds ratio 2.9, 95% confidence intervals 1.6-5.4; P 90% with a volume of <30 mL of local anesthetic solution and an incidence of transient neurologic complication of <2%. IMPLICATIONS Based on a prospective evaluation of 3996 consecutive peripheral nerve blocks, the multiple injection technique with nerve stimulator allows for up to 94% successful nerve block with <30 mL of local anesthetic solution. Although the data collection regarding neurologic dysfunction was limited, the withdrawal and redirection of the stimulating needle was not associated with an increased incidence of neurologic complications. Sedation/analgesia should be advocated during block placement to improve patient acceptance.
TL;DR: These studies included acupuncture, electroacupuncture, transcutaneous electrical nerve stimulation, acupoint stimulation, and acupressure, which assessed the efficacy of nonpharmacologic techniques to prevent postoperative nausea and vomiting by systematic review.
Abstract: We assessed the efficacy of nonpharmacologic techniques to prevent postoperative nausea and vomiting (PONV) by systematic review.These studies included acupuncture, electroacupuncture, transcutaneous electrical nerve stimulation, acupoint stimulation, and acupressure. Of the 24 randomized trials ret