Neves, Patrícia Ribeiro; Ribeiro, Ricardo Pereira; Streit, Danilo Pedro; Natali, Maria Raquel M; Fornari, Darci Carlos; Santos, Alexandra Inês; Godoy, Leandro C
Although the sperm cryopreservation of freshwater and marine teleosts has been feasible for years, the cryopreservation of some fish embryos still remains elusive. Thus, the objective of this experiment was to analyze the embryo morphology after freezing and thawing 40 embryos of Piaractus mesopotamicus immersed into methanol and ethylene glycol, both at 7, 10 and 13% plus 0.1 M sucrose for 10 min. Soon after thawing, three embryos were treated with historesin, stained with hematoxylin-eosin and analyzed under an optical microscope. From every treatment, one palette containing embryos was thawed and incubated, but none of the eggs hatched. Samples containing two embryos were immersed into 10% methanol or 10% ethylene glycol both in association with sucrose, and embryos immersed into only water or sucrose solution were frozen, processed and analyzed using scanning electron microscopy (SEM). In both cases, the control group was immersed into only water. Although the embryos had the chorion, vitello, yolk syncytial layer and blastoderm, all of them were found altered under the optical microscope and by SEM. The chorion was irregular and injured; there was no individuality in the yolk granules; the yolk syncytial layer had an irregular shape, thickness and size; the blastoderm showed injuries in the nucleus shape and sometimes was absent; the blastoderm was located in atypical areas and absent in some embryos. In conclusion, no treatment was effective in preserving the embryos, and none of the embryos avoided injury from intracellular ice formation. These morphological injuries during the freezing process made the P. mesopotamicus embryos unfeasible for hatching.
Makrakis, M.C.; Miranda, L.E.; Makrakis, S.; Xavier, A.M.M.; Fontes, H.M.; Morlis, W.G.
A mark-recapture study was conducted in 1997–2005 to investigate movements of stocked pacu, Piaractus mesopotamicus, in the Paraná River Basin of Brazil, Paraguay, and Argentina. Fish raised in cages within the Itaipu Reservoir and in ponds were tagged externally (n = 2976) and released in the Itaipu Reservoir (53.2%) and bays of its major tributaries (46.8%). In total, 367 fish (12.3%) were recaptured. In all, 91% of the pacu moved away from the release site; upstream movements were more extensive than downstream movements. Pacu traveled upstream a maximum of 422 km (average of 41.3 km) at a maximum rate of 26.4 km day−1 (av. 0.8). Downstream movements were limited in terms of number of individuals and distance moved. Fish released during the wet season moved farther than those released during the dry season, and feeding rather than spawning might have been the compelling reason for movement. Although fish passed downstream through dams, none of the marked fish were detected to have moved upstream through the passage facilities. Pacu showed movement patterns not radically different from those of other neotropical migratory species, but their migratory movements may not be as extensive as those of other large migratory species in the basin.
Aguilar, Fredy A A; Cruz, Thaline M P DA; Mourão, Gerson B; Cyrino, José Eurico P
Knowledge on fasting heat production (HEf) of fish is key to develop bioenergetics models thus improving feeding management of farmed species. The core of knowledge on HEf of farmed, neotropical fish is scarce. This study assessed the effect of body mass and water temperature on standard metabolism and fasting heat production of pacu, Piaractus mesopotamicus, an omnivore, Neotropical fresh water characin important for farming and fisheries industries all through South American continent. An automated, intermittent flow respirometry system was used to measure standard metabolic rate (SMR) of pacu (17 - 1,050 g) at five water temperatures: 19, 23, 26, 29 and 33 °C. Mass specific SMR increased with increasing water temperature but decreased as function of body mass. The allometric exponent for scaling HEf was 0.788, and lied in the range recorded for all studied warm-water fish. The recorded van't Hoff factor (Q10) for pacu (2.06) shows the species low response to temperature increases. The model HEf = 0.04643×W0.7882×T1.837 allows to predict HEf (kJ d-1) from body mass (W, kg) and water temperature (T, °C), and can be used in bioenergetical models for the species.
Venturini, Francine P; Moraes, Fernanda D; Cortella, Lucas R X; Rossi, Priscila A; Cruz, Claudinei; Moraes, Gilberto
Fish parasites are among the crucial limiting factors in aquaculture. The organophosphorous pesticide trichlorfon is widely used as an insecticide and against fish parasites worldwide. In this study, the effects of environmental trichlorfon on biochemical and physiological parameters were investigated in Piaractus mesopotamicus (pacu), a widely farmed fish in South America, through sublethal exposure (8 µg L(-1), 10 % of the LC50; 96 h) and recovery. The activity of brain acetylcholinesterase (AChE) was reduced after exposure (15.5 %) and remained decreased during the recovery (21.5 %). In white muscle, AChE activity decreased 31 % only after recovery. Alkaline phosphatase (ALP) and acid phosphatase (ACP) activities of the liver, muscle and plasma were steady during exposure. However, after the recovery period, ALP activity was increased in the liver and muscle and decreased in plasma, while ACP was increased in the liver and decreased in muscle. Intermediary metabolism was also affected by trichlorfon, depicting increase of energetic demand (hypoglycemia, neoglucogenesis and lipid catabolism), which remained even after recovery. These results indicate that P. mesopotamicus is adversely affected by sublethal concentrations of trichlorfon and are useful for assessing the impact as well as the pros and cons of its use in controlling fish parasites in aquaculture.
Gutierrez de Paula, Tassiana; de Almeida, Fernanda Losi Alves; Carani, Fernanda Regina; Vechetti-Júnior, Ivan José; Padovani, Carlos Roberto; Salomão, Rondinelle Arthur Simões; Mareco, Edson Assunção; Dos Santos, Vander Bruno; Dal-Pai-Silva, Maeli
Pacu (Piaractus mesopotamicus) is a fast-growing fish that is extensively used in Brazilian aquaculture programs and shows a wide range of thermal tolerance. Because temperature is an environmental factor that influences the growth rate of fish and is directly related to muscle plasticity and growth, we hypothesized that different rearing temperatures in juvenile pacu, which exhibits intense muscle growth by hyperplasia, can potentially alter the muscle growth patterns of this species. The aim of this study was to analyze the muscle growth characteristics together with the expression of the myogenic regulatory factors MyoD and myogenin and the growth factor myostatin in juvenile pacu that were submitted to different rearing temperatures. Juvenile fish (1.5 g weight) were distributed in tanks containing water and maintained at 24°C (G24), 28 °C (G28) and 32 °C (G32) (three replicates for each group) for 60 days. At days 30 and 60, the fish were anesthetized and euthanized, and muscle samples (n=12) were collected for morphological, morphometric and gene expression analyses. At day 30, the body weight and standard length were lower for G24 than for G28 and G32. Muscle fiber frequency in the <25 μm class was significantly higher in G24, and the >50 μm class was lower in G24. MyoD gene expression was higher in G24 compared with that in G28 and G32, and myogenin and myostatin mRNA levels were higher in G24 than G28. At day 60, the body weight and the standard length were higher in G32 but lower in G24. The frequency distribution of the <25 μm diameter muscle fibers was higher in G24, and that of the >50 μm class was lower in G24. MyoD mRNA levels were higher in G24 and G32, and myogenin mRNA levels were similar between G24 and G28 and between G24 and G32 but were higher in G28 compared to G32. The myostatin mRNA levels were similar between the studied temperatures. In light of our results, we conclude that low rearing temperature altered the expression of muscle
Volkoff, Hélène; Estevan Sabioni, Rafael; Coutinho, Luiz Lehmann; Cyrino, José Eurico Possebon
The pacu Piaractus mesopotamicus is an omnivorous fish considered a promising species for aquaculture. Little is known about the endocrine regulation of feeding in this species. In this study, transcripts for orexin, cocaine and amphetamine regulated transcript (CART), cholecystokinin (CCK) and leptin were isolated in pacu. Orexin, CCK and leptin have widespread mRNA distributions in brain and periphery, CART is limited to the brain. To examine the role of these peptides in the regulation of feeding and energy status, mRNA expression levels were compared between fed and fasted fish and around feeding time. Both orexin and CART brain expressions were affected by fasting and displayed periprandial changes, suggesting a role in both short- and long-term regulation of feeding. CCK intestinal expression decreased in fasted fish and displayed periprandial changes, suggesting CCK acts as a peripheral satiety factor. Leptin was not affected by fasting but displayed periprandial changes, suggesting a role as a short-term regulator. To examine if these peptides are affected by diet, brain and gut expressions were assessed in fish fed with different diets containing soy protein concentrate. Food intake, weight gain and expressions of orexin, CART, CCK and leptin were little affected by replacement of fish protein with soy protein, suggesting that pacu is able to tolerate and grow well with a diet rich in plant material. Overall, our results suggest that orexin, CART, CCK and leptin are involved in the physiology of feeding of pacu and that their expressions are little affected by plant-based diets.
Kuradomi, Rafael Y; De Souza, Thiago G; Foresti, Fausto; Schulz, Rüdiger W; Bogerd, Jan; Moreira, Renata G; Furlan, Luiz R; Almeida, Eduardo A; Maschio, Lucilene R; Batlouni, Sergio R
Seminal characteristics in teleost fish with an annual reproductive period, such as pacu (Piaractus mesopotamicus), may vary during the breeding season. The sperm formed before the beginning of the spawning period may be stored for a long time, causing damage to the cells. Therefore, re-stripping may be an important way to eliminate the "old" and allow for the collection of "new" spermatozoids. In this study, we analyzed the seminal characteristics of hormonally induced pacu at the beginning, middle and end of the breeding season, and we analyzed samples from re-stripped males (stripped first at the beginning, re-stripped in the middle, and re-stripped again at the end of the season) during two breeding seasons. The sperm density, ionic composition, pH, and osmolality were similar among the groups. The semen volume, seminal plasma protein concentration and incidence of morphologically anomalous sperm increased over time. In addition, some parameters that are associated with good-quality semen decreased, such as sperm motility, viability and DNA integrity. Moreover, we observed a positive association among motility, viability and DNA integrity for sperm with elevated 11-ketotestosterone, but there was no such association for fshb or lhb mRNA levels in the pituitary. The semen that was obtained earlier (at the beginning) or from re-stripped males exhibited better characteristics than the other samples collected. In conclusion, collecting semen from pacu at the end of breeding season should be avoided; it is preferable to strip early and then re-strip later in the season, and this approach may be used for diverse aquaculture purposes.
Santos, Edson Aparecido dos; Cruz, Claudinei da; Carraschi, Silvia Patrícia; Marques Silva, José Roberto; Grossi Botelho, Rafael; Velini, Edivaldo Domingues; Pitelli, Robinson Antonio
The aim of this study was to determine the environmental concentration of atrazine (ATZ) in five streams located in the north of São Paulo state (Brazil) and evaluate its toxicological impact on young specimens of the pacu fish Piaractus mesopotamicus. Samples of water were collected on three occasions between 2010 and 2011, corresponding to periods signifying the beginning, middle, and end of rain season. ATZ levels were estimated by a high-performance liquid chromatography coupled with a mass spectrometry (HPLC-MS/MS) triple quadrupole. Later, the quotient of environmental risk (QR) was determined based on the medium lethal concentration (LC50 48 h), non-observable effect concentration (NOEC), and the estimated environmental concentration (EEC) of ATZ detected in the environment. Histological changes in gills and liver were also studied, along with the brain activity of the enzyme acetylcholinesterase (AChE). The highest concentration of ATZ measured was 10.4 μg L(-1). The ATZ LC50 (48 h) for young P. mesopotamicus was 24.46 mg L(-1) and the QR was classified as "safe". Although the QR indicated that ATZ could be safe for the tested species, it caused many histological alterations in the liver and gills of the exposed specimens, and an increase in the AChE levels.
Carriero, M M; Mendes Maia, A A; Moro Sousa, R L; Henrique-Silva, F
This study provides a detailed description and characterization of a strain of Aeromonas dhakensis isolated from a diseased juvenile Piaractus mesopotamicus obtained from the fish farm of the National Center for Continental Fish Research and Conservation (CEPTA/ICMBio), in the state of São Paul, Brazil. Biochemical tests using the VITEK 2 automated bacterial identification system identified the isolate to genus level; however, further molecular analysis of the 16S rRNA, gyrB and rpoD genes showed that the strain belonged to the species A. dhakensis. As expected, the isolated A. dhakensis strain was resistant to ampicillin and ampicillin/sulbactam, as resistance to ampicillin is a typical characteristic of the genus Aeromonas. Resistance to cefoxitin and meropenem was also observed, but the strain was susceptible to most of the tested antibiotics. The isolated strain of A. dhakensis caused acute haemorrhagic septicaemia in experimentally infected P. mesopotamicus, with a fifty per cent lethal dose of 1.14 × 10(5) CFU/fish. This is the first report of the occurrence of an A. dhakensis strain causing an infection in a fish species of South America, providing important epidemiologic data relating to this important pathogenic species. © 2016 John Wiley & Sons Ltd.
Dal Pai, V; Pai-Silva, M D; Carvalho, E D; Fujihara, C Y; Gregório, E A; Curi, P R
Histochemical, ultrastructural and morphometric methods were used to study growth patterns of red, pink and white muscle fibres and their relation to body weight and total length in the fast-growing freshwater fish Piaractus mesopotamicus Holmberg. The correlations amongst body weight, body length and diameter of red, pink and white fibres were low. From 10-15 to 40-50 cm, body weight increased 102.7 times, while the diameter of each type of fibre increased by factors of 0.94, 0.74 and 0.70, respectively. Muscle fibres revealed different morphological and histochemical stages of maturation. The frequencies of < 20 microns fibres of red, pink and white muscle tissue in the youngest and oldest classes were 64.5 and 11.0, 38.2 and 7.7 and 24.0 and 1.4%, respectively. In 30-40 cm fish, the frequency of < 20 microns fibres in the red and pink tissue was 24.5 and 25.5%, while in the white tissue it was 11.5%. During sexual maturity (40-50 cm), the recruitment of < 20 microns fibres in white muscle was 1.4%. Muscle fibres of this species showed continuous growth by both hyperplastic and hypertrophic mechanisms, and hyperplasia was particularly active in the juvenile phase.
Valladão, G M R; Gallani, S U; Ikefuti, C V; da Cruz, C; Levy-Pereira, N; Rodrigues, M V N; Pilarski, F
In vitro effect of the Melaleuca alternifolia, Lavandula angustifolia and Mentha piperita essential oils (EOs) against Ichthyophthirius multifiliis and in vivo effect of M. alternifolia for treating ichthyophthiriasis in one of the most important South American fish, Piaractus mesopotamicus (Holmberg), were evaluated. The in vitro test consisted of three EOs, each at concentrations of 57 μL L(-1) , 114 μL L (-1) , 227 μL L(-1) and 455 μL L (-1) , which were assessed once an hour for 4 h in microtitre plates (96 wells). The in vitro results demonstrated that all tested EOs showed a cytotoxic effect against I. multifiliis compared to control groups (P < 0.05). The in vivo treatment for white spot disease was performed in a bath for 2 h day(-1) for 5 days using the M. alternifolia EO (50 μL L (-1) ). In this study, 53.33% of the fish severely infected by I. multifiliis survived after the treatment with M. alternifolia (50 μL L (-1) ) and the parasitological analysis has shown an efficacy of nearly 100% in the skin and gills, while all the fish in the control group died. Furthermore, the potential positive effect of M. alternifolia EO against two emergent opportunistic bacteria in South America Edwardsiella tarda and Citrobacter freundii was discussed. © 2016 John Wiley & Sons Ltd.
Garcia Sampaio, Fernanda; de Lima Boijink, Cheila; Tie Oba, Eliane; Romagueira Bichara dos Santos, Laila; Lúcia Kalinin, Ana; Tadeu Rantin, Francisco
The effect of combined-factors (hypoxia+copper) on the biochemical parameters and antioxidant defenses were studied in the neotropical fish Piaractus mesopotamicus. Fish were exposed for 48 h to 0.4 mg Cu(2+) L(-1) (0.4Cu), hypoxia=50 mm Hg (Hpx), and 0.4 mg Cu(2) L(-1)+hypoxia=50 mm Hg (0.4CuHpx). The exposure to 0.4Cu increased the reactive oxygen species (ROS) in the liver, accompanied by increases in superoxide dismutase (SOD) and decreases in catalase (CAT) activity, showing the influence of copper in this protection. The exposure to Hpx decreased the activity of glutathione peroxidase (GSH-Px) and CAT. Exposure to a combined-factor caused an increase in the ROS production followed by an increase in SOD and a decrease in GSH-Px and CAT. At 0.4Cu, fish presented a reduction in CAT, while in Hpx decreases in SOD, CAT and GSH-Px were observed in red muscles. Single-factors were insufficient to cause ROS production. In combined-factors, increased ROS formation and decreased SOD, CAT and GSH-Px were observed. RBC increased in all groups, but only under combined-factors was there an increase in hemoglobin. Copper plasma concentration increased in groups exposed to copper. Na(+)/K(+)-ATPase activity in gills decreased in 0.4Cu and 0.4CuHpx, and increased in Hpx. Metallothionein concentration in gills increased under combined-factors. Combined-factors caused significant disturbances in the antioxidant defenses and biochemical parameters than single-factors.
Quesada, Silvia Pilco; Paschoal, Jonas Augusto Rizzato; Reyes, Felix Guillermo
The use of antimicrobials in livestock production is a powerful resource applied throughout the world to guarantee high yield and control bacterial diseases in aquaculture. However, residues of these substances in animal products represent a potential risk to consumer health when residue levels are above the established maximum residue limits (MRLs). Fluoroquinolones (FQs) are antimicrobials commonly used worldwide in aquaculture. The aim of this work was to develop and validate a simple analytical method for the simultaneous determination of norfloxacin, danofloxacin, enrofloxacin and ciprofloxacin levels in tilapia (Oreochromis niloticus) and pacu (Piaractus mesopotamicus) fillets using liquid chromatography-tandem mass spectrometry (LC-MS/MS) quadrupole time of flight (QToF). The FQs were extracted from the fillets with 1% acetic acid-methanol and 1% acetic acid-acetonitrile solutions using ultrasonic assistance. The clean-up was performed with hexane. Chromatographic separation was conducted in an XTerra RP18 column (2.1 × 150 mm, 5 µm) at 25 °C with a flow of 0.2 mL min⁻¹. The mobile phase consisted of 0.1% aqueous formic acid and acetonitrile, with gradient elution. The validation parameters for all FQs were linearity (>0.99), intra-day precision (CV of 1%-9%), inter-day precision (CV of 3%-17%), decision limit (63-126 ng g⁻¹), detection capability (76 -152 ng g⁻¹) and accuracy (90%-111%). The limit of quantification was lower than the MRL for each FQ, indicating that the method is suitable for the determination of the FQ levels in the fish fillets. The mass analyser of the QToF type was able to confirm the identities of the FQs with an error of the accuracy of the mass (reasons m/z) of less than 10 ppm.
Paula, Tassiana Gutierrez de; Zanella, Bruna Tereza Thomazini; Fantinatti, Bruno Evaristo de Almeida; Moraes, Leonardo Nazário de; Duran, Bruno Oliveira da Silva; Oliveira, Caroline Bredariol de; Salomão, Rondinelle Artur Simões; Silva, Rafaela Nunes da; Padovani, Carlos Roberto; Santos, Vander Bruno Dos; Mareco, Edson Assunção; Carvalho, Robson Francisco; Dal-Pai-Silva, Maeli
Skeletal muscle is capable of phenotypic adaptation to environmental factors, such as nutrient availability, by altering the balance between muscle catabolism and anabolism that in turn coordinates muscle growth. Small noncoding RNAs, known as microRNAs (miRNAs), repress the expression of target mRNAs, and many studies have demonstrated that miRNAs regulate the mRNAs of catabolic and anabolic genes. We evaluated muscle morphology, gene expression of components involved in catabolism, anabolism and energetic metabolism and miRNAs expression in both the fast and slow muscle of juvenile pacu (Piaractus mesopotamicus) during food restriction and refeeding. Our analysis revealed that short periods of food restriction followed by refeeding predominantly affected fast muscle, with changes in muscle fiber diameter and miRNAs expression. There was an increase in the mRNA levels of catabolic pathways components (FBXO25, ATG12, BCL2) and energetic metabolism-related genes (PGC1α and SDHA), together with a decrease in PPARβ/δ mRNA levels. Interestingly, an increase in mRNA levels of anabolic genes (PI3K and mTORC1 complex: mTOR, mLST8 and RAPTOR) was also observed during food restriction. After refeeding, muscle morphology showed similar patterns of the control group; the majority of genes were slightly up- or down-regulated in fast and slow muscle, respectively; the levels of all miRNAs increased in fast muscle and some of them decreased in slow muscle. Our findings demonstrated that a short period of food restriction in juvenile pacu had a considerable impact on fast muscle, increasing the expression of anabolic (PI3K and mTORC1 complex: mTOR, mLST8 and RAPTOR) and energetic metabolism genes. The miRNAs (miR-1, miR-206, miR-199 and miR-23a) were more expressed during refeeding and while their target genes (IGF-1, mTOR, PGC1α and MAFbx), presented a decreased expression. The alterations in mTORC1 complex observed during fasting may have influenced the rates of protein
Takahashi, Leonardo Susumu; Biller-Takahashi, Jaqueline Dalbello; Mansano, Cleber Fernando Menegasso; Urbinati, Elisabeth Criscuolo; Gimbo, Rodrigo Yukihiro; Saita, Marcos Vinícius
Selenium (Se) is an essential nutrient for antioxidant defenses in fish because of its role in preventing immunosuppression caused by oxidative stress. In this study it was demonstrated the relation between the oxidative stress and immune status after a long Se supplementation period, as a result of the evaluation of immunological, hematological and antioxidant responses, as well as growth performance of pacu fed diets supplemented with different concentrations of organic selenium (0, 0.3, 0.6, 0.9, and 1.8 mg Se-yeast/kg, but the final analyzed selenium concentrations were 0.72, 0.94, 1.15, 1.57 and 2.51 mg/kg, respectively) for 65 days. Dietary Se supplementation at 1.15 mg Se-yeast/kg (analyzed value) restored the production of antioxidant enzymes (glutathione peroxidase (GPx) and glutathione S-transferase (GST)), and consequently allowed the increased of some immunological parameters (leukocyte respiratory burst activity and lysozyme activity), hematological parameters (red blood cell count (RBC), hematocrit (HTC), mean corpuscular volume (MCV), and white blood cell count (WBC)). Se supplementation in pacu diets at 1.15 mg Se-yeast/kg for 65 days improved immune response and antioxidant defenses, suggesting that oxidative stress impairs immune system response to prevent excessive reactive oxygen species in cells and indicating the occurrence of a physiological trade-off between immune and antioxidant systems. Higher Se levels, such as 1.57 mg Se-yeast/kg increased the leukocyte respiratory burst activity, the WBC and thrombocyte counts, the RBC and HTC, and the GST and GPx enzymes. However, 2.51 mg Se-yeast/kg decreased the lysozyme levels, the WBC and thrombocyte counts, the RBC, HTC and MCV, and the GST and GPx enzymes. Those findings are important to future studies because showed the negative effect of oxidative stress on immunity, and may help to prevent any inhibition of the expected immune response after immunomodulators administration and
Castro, Marcello Pardi; de Moraes, Flávio Ruas; Fujimoto, Rodrigo Yudi; da Cruz, Claudinei; Belo, Marco Antonio de Andrade; de Moraes, Julieta Rodini Engrácia
This study evaluated the toxicity of hexavalent and trivalent compounds of chromium to the pacu, Piaractus mesopotamicus, in acute exposures of 96 h through mortality and histopathological responses. Hexavalent potassium dichromate was more toxic than trivalent compounds of chromium chloride, chromium oxide and chromium carbochelate. Sufficient mortalities occurred only with potassium dichromate to yield an LC50 value at 124.2 mg L(-1). Hexavalent chromium caused reversible and irreversible lesions, which may affect organ functionality. Histopathological evaluation showed that trivalent chromium caused lesions of lower severity. Pacu subjected to different concentrations of chromium carbochelate showed no histopathological changes in the kidneys, liver, skin and gills, being similar to those of the control fish. Among the three sources of Cr(3+), only chromium chloride at 200 mg L(-1) resulted in mortality, which reached 100 % within the first 18 h. These findings confirm that trivalent chromium, when administered within recommended levels, may be used safely in aquaculture.
Fornari, Darci Carlos; Ribeiro, Ricardo Pereira; Streit, Danilo Pedro; Vargas, Lauro; Barrero, Nelson M Lopera; de Moraes, Gentil Vanini
Cryopreservation of mammal embryos has been technically feasible for many years, but morphological injuries still persist in fish embryos during cryopreservation. Thus, the objective of the present study was to describe these freezing injuries in Piaractus mesopotamicus embryos. Two hundred and twenty-five embryos were collected at the post-gastrula stage and assigned into four treatments of sucrose at 8.5, 17.0, 25.0 or 34.0% plus 9.0% methanol. The control was prepared with distilled water only. The gradual decrease in the temperature was 0.5°C/min. After the seeding stage, the fish embryos were stored in liquid nitrogen at -33°C. Thereafter, they were thawed for evaluating per cent hatching, and the samples collected from every treatment were submitted to scanning electron microscopy for morphological analysis. The micrographic images showed that there was substantial alterations in embryo morphology under the highest concentrations of sucrose. These solutions did not prevent the formation of ice crystals, which lead to deformities and killed the embryos, but the observed reduced level of morphological structure in these embryos when treated with 17.0% sucrose plus 9.0% methanol is a compelling argument for additional studies.
Silva, Dilson; Cortez-Moreira, Madelayne; Cunha Bastos, Vera L F; Cunha Bastos, Jayme; Martins Cortez, Célia
The interaction of methyl-parathion with serum and albumin of pacu, Piaractus mesopotamicus, was studied, using the fluorescence quenching technique. Pacu is a neo-tropical fish specie inhabitant of rivers from western regions of Brazil. Methyl-parathion (O,O-dimethyl O-p-nitrophenyl phosphorothioate) is an organophosphorous pesticide still used in agriculture and fish farming in many countries. The quenching of fluorescence can be mathematically expressed by the Stern-Volmer equation to calculate quenching constants. Stern-Volmer curves analysis is able to give important information about the pesticide-albumin interaction. Our results showed that the serum quenching reached 10% when the molar ratio of pesticide/albumin was about 7:1 for the three temperatures of the experiment. For the pure albumin quenching of 10%, methyl-parathion concentrations were 6, 7 and 9 times higher than albumin at 20, 25 and 30 degrees C, respectively. The calculated Stern-Volmer constants at 25 degrees C were 9.73x10(3)(+/-4.9x10(2))M(-1) for serum and 9.20x10(3)(+/-2.0x10(2))M(-1) for albumin. It was observed that albumin quenching is the phenomenon contributing to the quenching of the pacu serum fluorescence for methyl-parathion concentration lower than 10microM, suggesting that the protein is the most important carrier for the pesticide in serum.
Leão, M S L; Justo, M C N; Bueno, G W; Cohen, S C; São Clemente, S C
This study investigated the occurrence, prevalence, mean abundance and mean intensity of monogenoidean parasites in Piaractus mesopotamicus farmed in cages in the reservoir of the Itaipu Hydroelectric Power Station, Paraná River, Brazil. The parasite distribution pattern and the correlation of prevalence and abundance with the total length of hosts were also investigated. Four monogenoidean species were collected: Anacanthorus penilabiatus, A. toledoensis, Mymarothecium ianwhitingtoni and M. viatorum. All the parasites collected in P. mesopotamicus showed the typical aggregated distribution pattern, and the abundance and the prevalence did not shown any correlation with the total length of hosts.
Manrique, Wilson Gómez; Figueiredo, Mayra Araguaia Pereira; de Andrade Belo, Marco Antonio; Martins, Maurício Laterça; Molnár, Kálmán
This study evaluated the myxozoan infection and histopathology of the kidney of freshwater fish Piaractus mesopotamicus from intensive fish farming in Brazil. A total of 55 fish were examined for myxozoan infection. Infected organs were processed by usual histology and stained with hematoxylin-eosin (H&E) and Ziehl-Neelsen (ZN). From the total of 55 fish analyzed, 47 (85.45%) presented myxospores, being 9.09% (5/55) only with Myxobolus sp., 5.45% (3/55) only with Henneguya sp., and 70.91% (39/55) presenting both parasites. The presence of myxospores was associated with histological alterations in both stromal and renal parenchyma. Myxospores were found mostly in the peritubular interstitial tissue and in low intensity in the glomerulus which caused nuclear hypertrophy and loss of Bowman space. An increase in the glomerular tuft and a reduction in the lumen of the collector tubules were also observed, besides the high number of melanomacrophage cells in the glomerulus. This study reports for the first time detection of myxozoan mixed infection in one organ of pacu and discuss the possible transportation of myxospores in the circulating blood.
Duran, Bruno Oliveira da Silva; Fernandez, Geysson Javier; Mareco, Edson Assunção; Moraes, Leonardo Nazario; Salomão, Rondinelle Artur Simões; Gutierrez de Paula, Tassiana; Santos, Vander Bruno; Carvalho, Robson Francisco; Dal-Pai-Silvca, Maeli
Pacu (Piaractus mesopotamicus) is a Brazilian fish with a high economic value in pisciculture due to its rusticity and fast growth. Postnatal growth of skeletal muscle in fish occurs by hyperplasia and/or hypertrophy, processes that are dependent on the proliferation and differentiation of myoblasts. A class of small noncoding RNAs, known as microRNAs (miRNAs), represses the expression of target mRNAs, and many studies have demonstrated that miR-1, miR-133, miR-206 and miR-499 regulate different processes in skeletal muscle through the mRNA silencing of hdac4 (histone deacetylase 4), srf (serum response factor), pax7 (paired box 7) and sox6 ((sex determining region Y)-box 6), respectively. The aim of our work was to evaluate the expression of these miRNAs and their putative target mRNAs in fast- and slow-twitch skeletal muscle of pacu during growth. We used pacus in three different development stages: larval (aged 30 days), juvenile (aged 90 days and 150 days) and adult (aged 2 years). To complement our study, we also performed a pacu myoblast cell culture, which allowed us to investigate miRNA expression in the progression from myoblast proliferation to differentiation. Our results revealed an inverse correlation between the expression of the miRNAs and their target mRNAs, and there was evidence that miR-1 and miR-206 may regulate the differentiation of myoblasts, whereas miR-133 may regulate the proliferation of these cells. miR-499 was highly expressed in slow-twitch muscle, which suggests its involvement in the specification of the slow phenotype in muscle fibers. The expression of these miRNAs exhibited variations between different development stages and between distinct muscle twitch phenotypes. This work provides the first identification of miRNA expression profiles in pacu skeletal muscle and suggests an important role of these molecules in muscle growth and in the maintenance of the muscle phenotype. PMID:26529415
Claudiano, Gustavo da Silva; Petrillo, Thalita R; Manrique, Wilson G; Castro, Marcello P; Loureiro, Bruna A; Marcusso, Paulo F; Belo, Marco A A; Moraes, Julieta R E; de Moraes, Flávio Ruas
A total of 360 pacus (Piaractus mesopotamicus) were used to study vascular permeability (VP) and inflammatory cell component (CC) in induced aerocystitis in P. mesopotamicus through inoculation of inactivated Aeromonas hydrophila, and the effect of steroidal and nonsteroidal anti-inflammatory drugs. It was observed that after inoculation of A. hydrophila, the maximum VP occurred 180 min post-stimulus (MPS). Pretreatment with anti-inflammatory drugs inhibited VP, and the inhibitory effect of dexamethasone was seen earlier than the effects caused by meloxicam and indomethacin. Inoculation of the bacterium caused a gradual increase in the accumulation of cells, which reached a maximum 24 h post-stimulus (HPS). Pretreatment with dexamethasone, indomethacin and meloxicam reduced the accumulation of lymphocytes, thrombocytes, granulocytes and macrophages. There was no significant difference between the different doses of the drugs tested. The results suggest that eicosanoids and pro-inflammatory cytokines participate in chemical mediation in acute inflammation in pacus.
Schalch, Ergio H C; de Moraes, Flávio R; de Moraes, Julieta R E
This work described the lesions caused in different species of fish by gill parasites from fee-fishing at Guariba, State of São Paulo. The research was developed from april, 1997 to march to 1999, seeking to verified the kind tissues lesions from fish. Of these, forty and seven were Leporinus macrocephalus and fifty and five Piaractus mesopotamicus. About 87.2% of the L. macrocephalus, and 58.1% of the P. mesopotamicus were sponged by several species of parasites. The parasite most abundant in L. macrocephalus was Piscinoodinium pillulare, while monogenean, Trichodina sp and myxosporidian infected P. mesopotamicus. Severe gill lesions have been observed in L. macrocephalus and P. mesopotamicus caused by monogenean, P. pillulare e Trichodina sp. parasitism, such as intersticial hemorrhage, sub-epithelium edema, inflammation, epitelial hiperplasy in filaments and lamina, proliferation of mucosal cells and laminar fusion.
Manrique, Wilson Gómez; Figueiredo, Mayra Araguaia Pereira; de Andrade Belo, Marco Antonio; Martins, Maurício Laterça; Azevedo, Carlos
This study characterizes by transmission electron microscopy (TEM) and morphometric features the myxozoan Myxobolus cuneus (Myxosporea) in Piaractus mesopotamicus and reports the skeletal muscle and kidney as site of infection. The register was based in 21 young fish from intensive fish farming in Southeast Brazil and the spores were analyzed in fresh-mounted slides of the infected organs stained with Toluidine blue and processed as usual for TEM. It differs from Myxobolus cunhai from the fish host and different polar capsule size, and from Myxobolus serrasalmi on the pyriform spore shape and an oval macrospore, differently to that reported in this study. Morphometric characteristics and TEM study confirmed the present material as M. cuneus.
Shiogiri, Natália S; Paulino, Marcelo G; Carraschi, Silvia P; Baraldi, Flávia G; da Cruz, Claudinei; Fernandes, Marisa Narciso
The aim of this study was to determine the acute toxicity of Roundup(®) Ready (RR) in Piaractus mesopotamicus, and evaluate the effects on the morphology of the gills and liver of exposed surviving fish. Fish were exposed to 3.0, 3.5, 4.0 and 4.5mgL(-1) of glyphosate, and the LC(50);48h was estimated at 3.74±0.2mgL(-1). Gill histopathology was rare, and the activity of Na(+)/K(+)-ATPase enzyme did not change, suggesting normal function. However, the damage to the liver was classified as moderate to severe. Cytoplasmic vacuolization, lipid accumulation, nuclear and cellular membrane alterations and glycogen depletion were found in the liver, suggesting a reduction in the liver function. The glyphosate in the RR formulation was classified as moderately toxic for P. mesopotamicus, and the severe damage in the liver may affect the detoxification and/or tissue repair process and contribute to fish death.
Ribeiro, Leila Braga; Moraes Neto, Americo; Artoni, Roberto Ferreira; Matoso, Daniele Aparecida; Feldberg, Eliana
Some species of Characiformes are known for their high economic value, such as Colossoma macropomum and Piaractus mesopotamicus, and are used in aquaculture programs to generate hybrid tambacu (interbreeding of C. macropomum females and P. mesopotamicus males). The present work aimed to investigate the location of the Rex3 and Rex6 transposable elements in the hybrid and in the species, in addition to checking the genomic organization of the 18S and 5S rDNA in tambacu. The diploid number found for the hybrid was equal to 54 chromosomes, with heterochromatic blocks distributed mainly in the centromeric portions. The chromosomal location of the mobile elements Rex3 and Rex6 in C. macropomum, P. mesopotamicus, and in the hybrid between these species enabled knowledge expansion and the generation of data on such mobile elements. In addition, the location of such elements is not related to the distribution of ribosomal DNA sites. The mapping of the 18S rDNA was shown to be effective in cytogenetic identification of the hybrid tambacu, allowing for differentiation from the parent species and from the hybrid between C. macropomum and the other species from Piaractus (P. brachypomus).
Manrique, Wilson Gómez; da Silva Claudiano, Gustavo; de Castro, Marcello Pardi; Petrillo, Thalita Regina; Figueiredo, Mayra Araguaia Pereira; de Andrade Belo, Marco Antonio; Berdeal, María Isabel Quiroga; de Moraes, Julieta Engracia Rodini; de Moraes, Flávio Ruas
The present study aimed to describe and characterize the cellular components during the evolution of chronic granulomatous inflammation in the teleost fish pacus (P. mesopotamicus) induced by Bacillus Calmette-Guerin (BCG), using S-100, iNOS and cytokeratin antibodies. 50 fish (120±5.0 g) were anesthetized and 45 inoculated with 20 μL (40 mg/mL) (2.0 x 106 CFU/mg) and five inoculated with saline (0,65%) into muscle tissue in the laterodorsal region. To evaluate the inflammatory process, nine fish inoculated with BCG and one control were sampled in five periods: 3rd, 7th, 14th, 21st and 33rd days post-inoculation (DPI). Immunohistochemical examination showed that the marking with anti-S-100 protein and anti-iNOS antibodies was weak, with a diffuse pattern, between the third and seventh DPI. From the 14th to the 33rd day, the marking became stronger and marked the cytoplasm of the macrophages. Positivity for cytokeratin was initially observed in the 14th DPI, and the stronger immunostaining in the 33rd day, period in which the epithelioid cells were more evident and the granuloma was fully formed. Also after the 14th day, a certain degree of cellular organization was observed, due to the arrangement of the macrophages around the inoculated material, with little evidence of edema. The arrangement of the macrophages around the inoculum, the fibroblasts, the lymphocytes and, in most cases, the presence of melanomacrophages formed the granuloma and kept the inoculum isolated in the 33rd DPI. The present study suggested that the granulomatous experimental model using teleost fish P. mesopotamicus presented a similar response to those observed in mammals, confirming its importance for studies of chronic inflammatory reaction. PMID:25811875
[Praziquantel, levamisole and diflubenzuron in the control of Dolops carvalhoi (Crustacea: Branchiura) and Anacanthorus penilabiatus (Monogenea: Dactylogyridae) in Piaractus mesopotamicus Holmberg, 1887 (Osteichthyes: Characidae)].
Schalch, Sergio Henrique Canello; de Moraes, Flávio Ruas; Soares, Vando Edésio
This assay evaluated the control efficacy of diflubenzuron, praziquantel and levamisole added to the diet of pacu (Piaractus mesoptamicus) infected with Anacanthorus penilabiatus and Dolops carvalhoi. 19 water tanks of 300 L capacity were utilized with 28 fish in each one. The treatments were made by mixing the active principles in the diet. The experiment was evaluated in four harvests done 1 day before and 3, 7 and 15 days after the treatment. The medicated feeding was applied for 7 days. The results of efficacy suggest that the diflubenzuron alone or associated with levamisole and praziquantel was efficient against the crustacean D. carvalhoi and the efficacy in the 3, 7 and 15 days evaluations ranged from 96.2 to 100%. Against the monogenean the drugs did not present efficacy. The results suggest the use of diflubenzuron for the control of D. carvalhoi in captive fishes in special conditions.
Kalinin; Severi; Guerra; Costa; Rantin
Ventilation volume Vg - mlH2O.min-1 ), respiratory frequency (fR - breaths.min-1) and tidal volume (VT - mlH2O.breath-1 ) were measured in a group of Piaractus mesopotamicus (650.4 +/- 204.7 g; n = 10) during normoxia and in response to graded hypoxia. The fR was maintained constant, around 100 breaths.min-1, from normoxia until the O2 tension of the inspired water (PiO2) of 53 mmHg, below which it increased progressively, reaching maximum values (157.6 +/- 6.3 breaths.min-1) at 10 mmHg. The VT rose from 1.8 +/- 0.1 to 6.0 +/- 0.5 and 5.7 +/- 0.4 mlH2O. breath-1 in the PiO2 of 16 and 10 mmHg, respectively. The Vg increased from 169.3 11.0 (normoxia) to 940.1 +/- 85.6 mlH2O. min-1 at the PiO2 of 16 mmHg, below which it also tended to decrease. A second group of fish (29 to 1510.0 g, n = 34) was used for the evaluation of allometric relationships concerning ventilation and dimensions of the buccal and opercular cavities. At maximum Vg, the VT corresponded to 93.2 +/- 2.4% of the buccal volume and 94.9 2.3% of the opercular volume, suggesting that the Vg of P. mesopotamicus is limited by the volumes of buccal and opercular cavities in severe hypoxia.
Bastos, F F; Tobar, S A L; Dantas, R F; Silva, E S; Nogueira, N P A; Paes, M C; Righi, B D P; Bastos, J Cunha; Bastos, V L F Cunha
In cytosol from liver of pacu, Piaractus mesopotamicus, a hypoxia-tolerant fish that dwells in Pantanal, we found an enzyme activity capable of modulating the alkenal 4-hydroxy-2-nonenal (HNE) by conjugating it with glutathione (GST-HNE activity). HNE is a downstream metabolite from the oxidation of polyunsaturated fatty acids by reactive oxygen species arisen from mitochondria of animal cells. HNE production may increase more intensively under oxidative stress. Harmful effects to cell survival may occur when HNE increases over 10(-4) M. Pacus submitted to hypoxia in July (cold season in Pantanal) showed 40% less of this GST-HNE conjugating activity in their liver cytosol. Injecting pacus subjected to hypoxia during the cold season with a summer physiological dose of melatonin caused their liver cytosolic GST-HNE activity to increase up to the levels found in the warm season. From October to March (warm season in Pantanal), pacus are prone to oxidative stress particularly during potamodromous active oxygen-demanding swimming, when they migrate up rivers to spawn. Thus, our findings point out that the higher levels of melatonin in circulation during the summer are important to avoid the increase of 4-HNE inside liver cells of this fish species.
Takahashi, L S; Biller, J D; Criscuolo-Urbinati, E; Urbinati, E C
A 36-day trial was conducted to determine the effects of repetitive periods of food restriction and refeeding on growth and energy metabolism in pacu (Piaractus mesopotamicus). A total 264 juvenile fish (36.9±2.8 g) were fed with the experimental diet for 36 days using three regimes: (i) feeding daily to satiation (FD); (ii) no feed for 3 days, then feeding the same amount offered to the control groups for the next 3 days (NF/R controlled); and (iii) no feed for 3 days, then feeding to apparent satiation for the next 3 days (NF/R at satiation). The treatments were distributed into four tanks each. WG and SGR were higher in FD group. Fish refed showed hyperphagia just up to the second day of refeeding. The worst feed conversion rate and the lowest protein efficiency ratio were found in fish NF/R controlled. The lowest values of visceral fat somatic index were found in both fasted fish groups, particularly in NF/R at satiation. The LL and glycogen concentrations, and the hepatosomatic index were all elevated in both feed restricted fish. Muscle lipid showed a tendency to decrease after the cycle of fasting and refeeding. Plasma free fatty acids and glucose levels were elevated in fish subjected to feeding restrictions while serum triglycerides levels were reduced. Triiodothyronine levels were significantly depressed in fish from the NF/R-controlled group and remained at the same levels as the control fish in fish NF/R at satiation. Results indicated that fish subjected to cyclic periods of 3-day satiation or controlled feeding after 3-days of fasting were unable to achieve the final body weight of fish fed to satiation after 36 days. © 2010 Blackwell Verlag GmbH.
As redesign and renovation of patient care units occur, health care providers are looking to the literature and finding evidence for the importance of lowering environmental stressors. In the PACU at Memorial Sloan Kettering Cancer Center, patients historically expressed dissatisfaction with excessive noise levels and frequently cited overhearing staff conversations as most troubling. Nurses found the noise stressful and wearing. When the time approached to design the new PACU, we took the opportunity to explore a unique floor plan to minimize noise and improve privacy.
Pirapitinga (or red-bellied pacu, Piaractus brachypomus, Characiforme, Serrasalmidae) is an economically important South American fish for which the endocrine mechanism of the regulation of feeding has never been examined. To better understand these mechanisms, cDNAs encoding the appetite-regulating peptides orexin, cocaine- and amphetamine-regulated transcript (CART), apelin, cholecystokinin (CCK), peptide YY (PYY), leptin and ghrelin were isolated in pirapitinga and their mRNA distributions examined in peripheral tissues and brain. When compared to other fish, the sequences obtained for all peptides were most similar to those of other Characiforme fish (i.e. Mexican cavefish) and Siluriformes (catfish) as well as Cypriniformes (i.e. goldfish, zebrafish). All peptides were widely expressed within the brain. With the exception of CART, which was only expressed in brain, the mRNAs of all peptides were present in several peripheral tissues, including gastrointestinal tract, kidneys and gills. The widespread and peptide-specific distributions suggest that each peptide might have distinct physiological actions in the brain and on peripheral tissues, in particular on the gastrointestinal tract, which include feeding regulation. This preliminary study opens new avenues for further functional studies on the endocrine regulation of feeding in Serrasalmidae fish, including pirapitinga.
Chen, Huanpu; Li, Shuisheng; Xie, Zhenzhen; Zhang, Yong; Zhu, Chunhua; Deng, Siping; Li, Guangli; Huang, Hai
The complete mitochondrial genome of the Piaractus brachypomus is described in the present study. The mitochondrial genome is 16,561 bp long and consists of 13 protein-coding genes, 2 rRNA genes, 22 tRNA genes and a control region. The P. brachypomus mitochondrial genome shows the similar gene order and composition with those of most other vertebrates. The nucleotide compositions of the light strand in descending order is 31.57% of A, 26.19% of C, 26.18% of T and 16.06% of G. With the exception of the NADH dehydrogenase subunit 6 (ND6) and eight tRNA genes, all other mitochondrial genes are encoded on the heavy strand.
Darm, R M; Hecker, R B; Rubal, B J
Critical measurement of patient body temperature in the PACU is an important parameter in patient management. Failure to achieve minimal acceptable body temperature standards has been associated with physiological derangement, the application of additional therapy, and prolonged PACU stays. Newer methods to monitor temperature have been introduced into the PACU that have been touted to be adequate for detecting clinically significant changes in temperature. This study compares skin core temperature-corrected liquid crystal thermography, axillary electronic, and oral electronic thermistor readings with temperatures obtained by infrared tympanic membrane thermometry in 215 PACU patients. Regression analysis suggests that when compared with tympanic temperature, the oral method is more accurate and has greater precision than either the liquid crystal or axillary methods. That the incidence of hypothermia depends on the method chosen to assess body temperature is a significant nursing implication.
halogenated anesthetic agents such as Sevoflurane and Desflurane have expedient recoveries and theoretically, limit exposure time to waste anesthetic...gases in PACU. Exposure of recovery room nurses to Sevoflurane was measured in this descriptive study. Sequential air samples from PACU nurse’s...to patients only anesthetized with Sevoflurane . Other variables of interest were recorded which included; patients’ age sex, weight, body mass index
Easter, Betty; DeBoer, Laura; Settlemyre, Gail; Starnes, Carolyn; Marlowe, Vickie; Tart, Rebecca Creech
Pain is a normal finding in the postoperative patient, and noise can accentuate one's perception of discomfort. In this study, physiological measurements, intravenous (IV) opioid administration, length of stay, and satisfaction for postoperative patients who listened to music were compared with patients not provided music during their PACU stay. Of the 213 subjects enrolled, 163 experienced postoperative pain. The mean change in experimental subjects' respiratory rate was significantly lower than the controls. Decreases in heart rate and blood pressure from admission to discharge were similar between the two groups. On average, peripheral oxygen saturation and opioid pain control were not significantly different between control and experimental subjects. Subjects provided with music reported acceptable noise levels and increased satisfaction with their PACU experience. Music intervention is therefore a viable, minimal cost, and alternative therapy that PACU nurses can use to assist patients coping with postoperative pain. Copyright 2010 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
Giaquinto, Percilia Cardoso; de Sá, Marina Borges; Sugihara, Vanessa Seiko; Gonçalves, Bruno Bastos; Delício, Helton Carlos; Barki, Assaf
Glyphosate-based herbicides are widely used in agricultural systems. Although the target organism are particularly plant organisms, there are numerous studies showing adverse effects in aquatic animals, such as inhibition of acetyl cholinesterase, effects on kidney, liver, and gill and stressors effects. This study analyzed the effects of commercial formulation of glyphosate on feeding behavior in Pacu (Piaractus mesopotamicus). Fish were exposed to three glyphosate concentrations (0.2, 0.6, and 1.8 ppm) for 15 days. At concentrations of 0.2 and 0.6 ppm, food intake decreased on day 13 and then returned to normal on day 15. At the highest glyphosate-based herbicide concentration, 1.8 ppm, food consumption decreased dramatically and did not recover on day 15. This study showed that glyphosate-based herbicide at sub-lethal concentrations can affect feed intake in pacu and consequently inhibits its growth.
Milanin, Tiago; Maia, Antônio Augusto Mendes; Silva, Márcia Ramos Monteiro; Carriero, Mateus Maldonado; Adriano, Edson Aparecido
Through morphological, histopathological and ultrastructural analysis of Myxobolus cuneus Adriano, Arana et Cordeiro, 2006 and Henneguya pseudoplatystoma Naldoni, Arana, Maia, Ceccarelli, Tavares, Borges, Pozo et Adriano, 2009 were identified infecting pacu respectively (Piaractus mesopotamicus) and hybrid pintado (Pseudoplatystoma corruscans x Pseudoplatystoma reticulatum) taken from Brazilian fish farms. The present study describes 18S rDNA sequencing of Myxobolus cf. cuneus infecting the spleen of farmed patinga, a hybrid fish resulting from the crossing of P. mesopotamicus x Piaractus brachypomus, and H. pseudoplatystoma found in farmed hybrid pintado from the state of Sao Paulo, Brazil. The study also provides new details of the host-parasite interface of M. cf. cuneus, which reveal that the plasmodial wall is composed of a single membrane connected to the plasmodium ectoplasm by numerous pinocytic canals. The plasmodia also displayed asynchronous development but had disporic pansporoblasts at different developmental stages; immature and mature spores were found at different depth levels of the plasmodium. Maximum likelihood phylogenetic analysis showed that M. cf. cuneus appeared as a sister species of Henneguya pellucida Adriano, Arana et Cordeiro, 2005 in a sub-clade composed mainly of myxosporean parasites of characiforms, and that H. pseudoplatystoma clustered in a sub-clade composed of Henneguya/Myxobolus spp. parasites of siluriform fish.
Wagner, Ricardo Luiz; Makrakis, Sergio; Castro-Santos, Theodore R.; Makrakis, Maristela Cavicchioli; Dias, João Henrique Pinheiro; Belmont, René Fuster
This paper presents results of a fishway evaluation performed at the Engenheiro Sérgio Motta Hydroelectric Power Plant (known as Porto Primavera) - CESP, Paraná River, Brazil. The evaluation was designed to quantify entry and passage proportions of 4 long-distance migratory fish species: Brycon orbignyanus (piracanjuba), Piaractus mesopotamicus (pacu), Prochilodus lineatus (curimba), and Rhinelepis aspera (cascudo-preto). Proportions finding and entering the fishway differed between species, ranged from 7.4 % (Prochilodus lineatus) to 55.4% (Piaractus mesopotamicus). Also, proportion passing was different between species, ranged from 31% (R. aspera) to 100% (Prochilodus lineatus). Fish that were marked and released within the fishway had greater failure rates than those that entered volitionally. Total time to pass ranged from 1.48 hours (Prochilodus lineatus) to 178.9 hours (R. aspera). Failure rates were greatest in the lower end of the fishway. Although some individuals of all species passed successfully, significant challenges remain to restoring connectivity of the upper Paraná River.
Lutter, Norbert O; Urankar, Sabine; Kroeber, Steffi
The objective of this clinical study was to determine alarm rates--in particular the frequency of false positive alarms--of three third-generation pulse oximeters in the postanesthesia care unit (PACU), the intensive care unit (ICU), and in patients with an intra-aortic balloon pump (IABP): Nellcor Symphony N-3000, a Masimo IVY 2000, and Agilent Viridia CMS 2000. All alarms were classified into technical/physiological and false/correct. 235 consecutive ASA physical status I-IV patients after surgery were included into the study. In the PACU false positive alarms were rare: CMS n = 60, N-3000 n = 60, Masimo n = 87. Bland-Altman testing discovered only negligible differences of alarm rates and dropout times. Out of a total of 728 alarms 67.3% were classified as false positive in ICU-patients: 97 alarms by CMS, 176 by N-3000 and 218 by Masimo SET. If IABP was present, CMS indicated a significant smaller number of false positive alarms (n = 35, 7.2%) when compared to Masimo SET (n = 188, 38.9%) and N-3000 (n = 229, 47.4%), consecutively the majority of false positive alarms (76.2%) can be rated as a result of the interference of IABP. Unless IABP (and to a considerably smaller extent cardiac arrhythmia) is present the pulse oximeters do not differ significantly regarding sensitivity and specificity.
Czeczuga, B; Godlewska, A; Mazalska, B; Muszyńska, E
We investigated the growth of straminipilous organisms on the skin, muscles and liver of herbivorous pirapitinga (Piaractus brachypomus) and carnivorous piranha (Pygocentrus nattereri) in water of three different eutrophication levels. Sixteen straminipilous organism species were found growing on the investigated body parts of both species of fish used as baits. The higher number of species was found on the baits of carnivorous species (15) when compared with the ones from the herbivorous pirapitinga (10 species). The highest number of straminipilous organisms species developed on the skin of both species of fish. The highest number of species of straminipilous organisms was observed growing in the water of the BiaBa river (middle eutrophication), while the lowest number occurred in the baits of vessels with water from the Dojlidy pond (low eutrophication).
Silva, Dilson; Cortez-Moreira, Madelayne; Bastos, Vera Lúcia Freire Cunha; Bastos, Jayme Cunha; Cortez, Célia Martins
The interaction of methyl-parathion with the albumin of Piaractus mesopotamicus (Holmberg 1887) (= pacu), a fish species typical of Brazilian rivers, was studied and the results compared with known values for human and bovine albumin obtained in an earlier investigation. Methyl-parathion (O,O-dimethyl O-p-nitrophenyl phosphorothioate) is an organophosphorous pesticide still used in agriculture and fish farming in many countries. The fluorescence quenching technique with tryptophan as a natural probe was used to detect for the presence of methyl-parathion. Fluorescence can be mathematically expressed by the Stern-Volmer equation to calculate quenching constants, and changes in the behavior of Stern-Volmer curves at different temperatures indicate the nature of the mechanism causing the quenching. Our results indicate that methyl-parathion forms a complex with fish albumin. The estimated association constant is 9.73 x 103 (+/- 4.9 x 102) M(-1) at 25 degrees C.
Peng, Yuming; Zhang, Wei; Kass, Ira S; Han, Ruquan
Perioperative lidocaine infusion has been reported to reduce postoperative pain in patients after abdominal surgery; however, no study has examined lidocaine's effect on acute postoperative pain after supratentorial tumor surgery. A total of 94 patients scheduled for supratentorial craniotomy were enrolled. Patients received either lidocaine through an intravenous bolus (1.5 mg/kg) after induction followed by infusion at a rate of 2 mg/kg/h until the end of surgery or the same volume of normal saline. Mean arterial blood pressure, heart rate, and bispectral index were recorded at different intraoperative time points. Patients were assessed for pain in the postoperative anesthesia care unit (PACU) by the numeric rating scale (NRS). Other complications including hypertension, tachycardia, dysphoria, and postoperative nausea and vomiting (PONV) were reported. There was no significant difference between the normal saline and lidocaine group for mean arterial blood pressure, heart rate, and bispectral index at any time point (P>0.05). There was no significant difference in the incidence of hypertension, tachycardia, dysphoria, and PONV between groups (P>0.05). The incidence of mild pain (NRS between 1 and 3) after surgery in PACU was lower in lidocaine group than that in the normal saline group (P=0.014); the number of patients with an NRS pain score of 0 before leaving the PACU was significantly greater in the lidocaine group. No patient in either group had moderate or severe pain. Intraoperative infusion of lidocaine significantly decreases the proportion of patients with acute pain after supratentorial tumor surgery in the PACU.
Tan, Edwin T.; Martin, Sarah R.; Fortier, Michelle A.; Kain, Zeev N.
Objective To develop and validate a behavioral coding measure, the Children's Behavior Coding System-PACU (CBCS-P), for children's distress and nondistress behaviors while in the postanesthesia recovery unit. Methods A multidisciplinary team examined videotapes of children in the PACU and developed a coding scheme that subsequently underwent a refinement process (CBCS-P). To examine the reliability and validity of the coding system, 121 children and their parents were videotaped during their stay in the PACU. Participants were healthy children undergoing elective, outpatient surgery and general anesthesia. The CBCS-P was utilized and objective data from medical charts (analgesic consumption and pain scores) were extracted to establish validity. Results Kappa values indicated good-to-excellent (κ's > .65) interrater reliability of the individual codes. The CBCS-P had good criterion validity when compared to children's analgesic consumption and pain scores. Conclusions The CBCS-P is a reliable, observational coding method that captures children's distress and nondistress postoperative behaviors. These findings highlight the importance of considering context in both the development and application of observational coding schemes. PMID:22167123
Hauser-Davis, Rachel Ann; Bastos, Frederico Freire; Dantas, Rafael Ferreira; Tobar, Santiago Alonso Leitão; da Cunha Bastos Neto, Jayme; da Cunha Bastos, Vera Lucia Freire; Ziolli, Roberta Lourenço; Arruda, Marco Aurélio Zezzi
The pacu (Piaractus mesopotamicus) is a hypoxia-tolerant neotropical fish species. There is little or no information in this species regarding biochemical adaptations to waters with different oxygen concentrations, such as the production of reactive oxygen species and antioxidant scavengers, which might be of interest in the study of antioxidant defense mechanisms. Metallothioneins (MT) have been widely applied as biomarkers for metal exposure in fish liver, and, recently, in bile. These metalloproteins, however, have also been reported as free radical scavengers, although studies in this regard are scarce in fish. In this context, normoxic and hypoxic controlled experiments were conducted with pacu specimens and MT levels were quantified in both liver and bile. Reduced glutathione (GSH) indicative of oxidative stress, and thiobarbituric acid reactive substances (TBARS), indicative of lipid peroxidation, were also determined in liver. The results demonstrate that hypoxic fish present significantly lower metallothionein levels in liver and bile and lower reduced glutathione levels in liver, whereas lipid peroxidation was not significantly different between hypoxic and normoxic fish. The results of the present study seem to suggest that metallothioneins may actively participate in redox regulation in hypoxic fish in both bile and liver. MT levels in these organs may be temporarily suppressed, supporting the notion that down-regulation of oxidant scavengers during the oxidative burst is important in defense signaling in these adapted organisms.
Voscopoulos, Christopher; Theos, Kimberly; Tillmann Hein, H A; George, Edward
Late detection of respiratory depression in non-intubated patients compromises patient safety. SpO2 is a lagging indicator of respiratory depression and EtCO2 has proven to be unreliable in non-intubated patients. A decline in minute ventilation (MV) is the earliest sign of respiratory depression. A non-invasive respiratory volume monitor (RVM) that provides accurate, continuous MV measurements enables clinicians to predict and quantify respiratory compromise. For this observational study, practitioners were blinded to the RVM measurements and pain management followed the usual routine. Patients were stratified by their MV on PACU admission and classified as "At-Risk" or "Not-At-Risk," with progression to "Low MV" status following opioids assessed for each category. The purpose was to determine if stratifying based on MV on PACU arrival could identify patients at higher risk for respiratory depression. Ability to identify in advance patients at higher risk for respiratory depression following standard opioid dosing would drive changes in pain management and improve patient care. RVM and opioid administration data from 150 PACU patients following elective joint-replacement surgery were collected in an observational study. "Predicted" MV (MVPRED) and "Percent Predicted" (MVMEASURED/MVPRED × 100 %) were calculated for each patient using standard formulas. Prior to opioid administration, patients were classified as either "Not-At-Risk" (MV ≥ 80 % MVPRED) or "At-Risk" (MV < 80 % MVPRED). "Low MV" was defined as MV < 40 % MVPRED. Post-operative apnea (POA) was defined as ≥5 ten-second apneas per hour of PACU stay. We compared the incidences of Low MV following a single opioid dose, POA, and Low MV at discharge for both groups. In the PACU, 74/150 patients received opioids. Within 15 min of opioid administration, 32 % (24/74) developed Low MV. The risk-stratification algorithm identified 22/24 patients (92 % sensitivity). Only 46 % of them had POA
de Salles, João Bosco; Lopes, Renato Matos; de Salles, Cristiane M C; Cassano, Vicente P F; de Oliveira, Manildo Marcião; Bastos, Vera L F Cunha; Bastos, Jayme Cunha
Three species of freshwater Brazilian fishes (pacu, Piaractus mesopotamicus; piavussu, Leporinus macrocephalus, and curimbatá, Prochilodus lineatus) were exposed to an acute dose of 5 ppm methyl parathion organophosphate pesticide. Three to five individuals per species were exposed, one at a time, to 40 liters tap water spiked with Folidol 600. Pesticide concentrations and cholinesterase (ChE) activities were evaluated in serum, liver, brain, heart, and muscle. The bioconcentration of methyl parathion was similar for all studied fishes. Brain tissue showed the highest pesticide concentration, reaching 80 ppm after exposure for 30 min to methyl parathion. Three to 5 hours of 5 ppm methyl parathion exposure provoked the death of all P. lineatus at 92% brain AChE inhibition, whereas fish from the other two species survived for up to 78 hours with less than 80% brain AChE inhibition. Our results indicate that acute toxic effects of methyl parathion to fish are correlated with brain AChE sensitivity to methyl paraoxon.
Bosco de Salles, João; Matos Lopes, Renato; de Salles, Cristiane M. C.; Cassano, Vicente P. F.; de Oliveira, Manildo Marcião; Cunha Bastos, Vera L. F.; Bastos, Jayme Cunha
Three species of freshwater Brazilian fishes (pacu, Piaractus mesopotamicus; piavussu, Leporinus macrocephalus, and curimbatá, Prochilodus lineatus) were exposed to an acute dose of 5 ppm methyl parathion organophosphate pesticide. Three to five individuals per species were exposed, one at a time, to 40 liters tap water spiked with Folidol 600. Pesticide concentrations and cholinesterase (ChE) activities were evaluated in serum, liver, brain, heart, and muscle. The bioconcentration of methyl parathion was similar for all studied fishes. Brain tissue showed the highest pesticide concentration, reaching 80 ppm after exposure for 30 min to methyl parathion. Three to 5 hours of 5 ppm methyl parathion exposure provoked the death of all P. lineatus at 92% brain AChE inhibition, whereas fish from the other two species survived for up to 78 hours with less than 80% brain AChE inhibition. Our results indicate that acute toxic effects of methyl parathion to fish are correlated with brain AChE sensitivity to methyl paraoxon. PMID:26339593
Delimiting Evolutionarily Significant Units of the Fish, Piaractus brachypomus (Characiformes: Serrasalmidae), from the Orinoco and Amazon River Basins with Insight on Routes of Historical Connectivity.
Escobar, Maria Doris; Andrade-López, Juana; Farias, Izeni P; Hrbek, Tomas
The freshwater fish Piaractus brachypomus is an economically important for human consumption both in commercial fisheries and aquaculture in all South American countries where it occurs. In recent years the species has decreased in abundance due to heavy fishing pressure. The species occurs in the Amazon and Orinoco basins, but lack of meristic differences between fishes from the 2 basins, and extensive migration associated with reproduction, have resulted in P. brachypomus being considered a single panmictic species. Analysis of 7 nuclear microsatellites, mitochondrial DNA sequences (D-loop and COI), and body shape variables demonstrated that each river basin is populated by a distinct evolutionarily significant unit (ESU); the 2 groups had an average COI divergence of 3.5% and differed in body depth and relative head length. Historical connection between the 2 basins most probably occurred via the Rupununi portal rather than via the Casiquiare canal. The 2 ESUs will require independent fishery management, and translocation of fisheries stocks between basins should be avoided to prevent loss of local adaptations or extinction associated with outbreeding depression. Introductions of fishes from the Orinoco basin into the Putumayo River basin, an Amazon basin drainage, and evidence of hybridization between the 2 ESUs have already been detected.
Perry, S F; Reid, S G; Gilmour, K M; Boijink, C L; Lopes, J M; Milsom, W K; Rantin, F T
Experiments were performed to assess the afferent and efferent limbs of the hypoxia-mediated humoral adrenergic stress response in selected hypoxia-tolerant tropical fishes that routinely experience environmental O(2) depletion. Plasma catecholamine (Cat) levels and blood respiratory status were measured during acute aquatic hypoxia [water Po(2) (Pw(O(2))) = 10-60 mmHg] in three teleost species, the obligate water breathers Hoplias malabaricus (traira) and Piaractus mesopotamicus (pacu) and the facultative air breather Hoplerythrinus unitaeniatus (jeju). Traira displayed a significant increase in plasma Cat levels (from 1.3 +/- 0.4 to 23.3 +/- 15.1 nmol/l) at Pw(O(2)) levels below 20 mmHg, whereas circulating Cat levels were unaltered in pacu at all levels of hypoxia. In jeju denied access to air, plasma Cat levels were increased markedly to a maximum mean value of 53.6 +/- 19.1 nmol/l as Pw(O(2)) was lowered below 40 mmHg. In traira and jeju, Cat release into the circulation occurred at abrupt thresholds corresponding to arterial Po(2) (Pa(O(2))) values of approximately 8.5-12.5 mmHg. A comparison of in vivo blood O(2) equilibration curves revealed low and similar P(50) values (i.e., Pa(O(2)) at 50% Hb-O(2) saturation) among the three species (7.7-11.3 mmHg). Thus Cat release in traira and jeju occurred as blood O(2) concentration was reduced to approximately 50-60% of the normoxic value. Intravascular injections of nicotine (600 nmol/kg) elicited pronounced increases in plasma Cat levels in traira and jeju but not in pacu. Thus the lack of Cat release during hypoxia in pacu may reflect an inoperative or absent humoral adrenergic stress response in this species. When allowed access to air, jeju did not release Cats into the circulation at any level of aquatic hypoxia. The likeliest explanation for the absence of Cat release in these fish was that air breathing, initiated by aquatic hypoxia, prevented Pa(O(2)) values from falling to the critical threshold required
Houlton, Jeffrey J; Pechter, William; Steward, David L
To determine if a serum parathyroid hormone (PTH)-based discharge algorithm can be used to safely facilitate outpatient total thyroidectomy. Case series with chart review of consecutive total and completion thyroidectomies performed by the senior author from March 2008 to November 2009. An academic tertiary care center. At the authors' institution, patients undergoing total or completion thyroidectomy are subject to a same-day discharge algorithm that incorporates postanesthesia care unit rapid PTH as the major discharge criterion. Patients with PTH >30 pg/mL are eligible for same-day discharge without supplementation, patients with PTH between 20 and 30 pg/mL are eligible for discharge but receive calcium supplementation, and patients with PTH <20 pg/mL are observed overnight (23 hours) with calcium and vitamin D supplementation. One hundred eighty patients (mean age, 48.9 years; 83.3% female) underwent total (77.2%) or completion (22.7%) thyroidectomy with or without node dissection. Forty-two percent were performed with minimally invasive video-assisted (MIVA) technique. Seventy-six percent (137/180) of patients had a PTH >20 pg/mL, meeting the PTH discharge criterion. Sixty-nine percent (95/137) of eligible patients were discharged on the same day (53.1% of total). Ten percent of discharge-eligible patients were admitted due to drain placement. Of the 95 patients undergoing outpatient surgery, none were admitted, seen, or called for symptoms of hypocalcemia in the postoperative period. All 180 patients were eucalcemic at postoperative day (POD) 7 and POD 30 office visits. No patients were hypoparathyroid at POD 30. No significant difference in postoperative hypoparathyroidism existed between completion versus total thyroidectomy (11.1% vs 22.2%, P = .28) or MIVA versus standard technique (P = .37). A PTH-based discharge algorithm can safely facilitate outpatient total or completion thyroidectomy, with minimal risk of clinically significant outpatient hypocalcemia.
Cohen, Simone Chinicz; Kohn, Anna
Mymarothecium boegeri sp. n. (Monogenea: Dactylogyridae) is described from the gills of Colossoma macropomum Cuvier (Characidae), collected from the aquaria of the "Centro de Pesquisas em Aquicultura, Departamento Nacional de Obras Contra as Secas (DNOCS)", Pentecoste City, State of Ceará, Brazil. Mymarothecium viatorum Boeger, Piasecki et Sobecka, 2002 is reported from the type host, Piaractus brachypomus (Cuvier) (Characidae) and from a new host, P. mesopotamicus (Holmberg) (Characidae), confirming the occurrence of M. viatorum in the Neotropical Region. The new species differs from the congeneric species in the structure of male copulatory complex; it is more closely related to M. viatorum by the presence of a posteromedial projection on ventral bar.
Ribeiro, Leila Braga; Matoso, Daniele Aparecida; Feldberg, Eliana
The Serrasalmidae family is composed of a number of commercially interesting species, mainly in the Amazon region where most of these fishes occur. In the present study, we investigated the genomic organization of the 18S and 5S rDNA and telomeric sequences in mitotic chromosomes of four species from the basal clade of the Serrasalmidae family: Colossoma macropomum, Mylossoma aureum, M. duriventre, and Piaractus mesopotamicus, in order to understand the chromosomal evolution in the family. All the species studied had diploid numbers 2n = 54 and exclusively biarmed chromosomes, but variations of the karyotypic formulas were observed. C-banding resulted in similar patterns among the analyzed species, with heterochromatic blocks mainly present in centromeric regions. The 18S rDNA mapping of C. macropomum and P. mesopotamicus revealed multiple sites of this gene; 5S rDNA sites were detected in two chromosome pairs in all species, although not all of them were homeologs. Hybridization with a telomeric probe revealed signals in the terminal portions of chromosomes in all the species and an interstitial signal was observed in one pair of C. macropomum. PMID:24688290
Computed materials data using density functional theory calculations. These calculations determine the electronic structure of bulk materials by solving approximations to the Schrodinger equation. For more information, see https://materialsproject.org/docs/calculations
28 Plan for Data Analysis ...29 CHAPTER FOUR PRESENTATION, ANALYSIS AND INTERPRETATION OF...inorganic fluoride metabolites. Sevoflurane is oxidized by the cytochrome P-450 2E1 enzymes in the liver. Inhibition of the P450 2E1 enzymes by
Moura Costa, Daniele Dietrich; Bozza, Dandie Antunes; Rizzo, Luiz Eduardo; Garcia, Juan; Costa, Michele Dietrich Moura; de Oliveira Ribeiro, Ciro Alberto
Endocrine-disrupting chemicals (EDCs) are widespread used and can interfere on hormone regulation with adverse consequences for both biota and human. Vitellogenin (vtg) is a yolk precursor protein synthesized by the liver in response to estrogen. In order to characterize the vtg of tropical fish Rhamdia quelen and establish a molecular biomarker, adult male individuals were exposed to 17-β-estradiol (E2) for vtg induction and anti-R. quelen vtg polyclonal antibodies production. Vitellogenic female fish were used as positive control group. E2-induced vtg was characterized as a glycolipophosphoprotein of high molecular mass with peptide mass fingerprint very similar in E2-exposed male and vitellogenic female fish. A polyclonal serum containing anti-R. quelen vtg antibodies was produced and showed high specificity and sensibility to detect the vtg of three fish species: R. quelen, Piaractus mesopotamicus and Prochilodus lineatus. Wildlife and laboratory studies reported that EDCs released into the environment may alter the levels of plasma vtg in male fish, making this protein a valuable biomarker of xenoestrogens exposure. Then, we propose the use of anti-R. quelen vtg as a tool for biomonitoring studies and water quality assessment in Brazil and South American countries where the three fish species occur.
Pereira, Felipe B; Tavares, Luiz E R; Paiva, Fernando; Scholz, Tomáš; Luque, José L
Spectatus spectatus Travassos, 1923 (Nematoda: Kathlaniidae) found in the intestine of Piaractus mesopotamicus (Holmberg, 1887) (Characiformes: Serrasalmidae) from the River Miranda, Mato Grosso do Sul, Brazil is redescribed based on morphological evaluation of newly collected material and examination of type and voucher specimens from the Coleção Helmintológica do Instituto Oswaldo Cruz. The following characteristics previously unreported or insufficiently described were observed: morphology of lips, presence of lamellae-like supplementary lips, presence of pharynx and cuticular ring surrounding the oral opening associated with a complex cuticular apparatus anterior to the pharynx, the number and arrangement of caudal papillae (13 pairs plus 1 unpaired), and the position of nerve ring. Since S. spectatus is the type species of Spectatus, the diagnosis of this Neotropical genus is amended. Synonymy of Chabaudinema Díaz-Ungría, 1968 with Spectatus, first proposed in 1980 by Baker, is supported by the present data. Molecular data that include the first sequence of the SSU rDNA for any species of Spectatus indicate a basal position of S. spectatus within Cosmocercoidea, forming a distant lineage from that comprising 2 species of Falcaustra Lane, 1915. This separate position of S. spectatus supports validity of the genus.
Garcia de la Serrana, Daniel; Mareco, Edson A; Johnston, Ian A
Teleost fish underwent whole-genome duplication around 450 Ma followed by diploidization and loss of 80-85% of the duplicated genes. To identify a deep signature of this teleost-specific whole-genome duplication (TSGD), we searched for duplicated genes that were systematically and uniquely retained in one or other of the superorders Ostariophysi and Acanthopterygii. TSGD paralogs comprised 17-21% of total gene content. Some 2.6% (510) of TSGD paralogs were present as pairs in the Ostariophysi genomes of Danio rerio (Cypriniformes) and Astyanax mexicanus (Characiformes) but not in species from four orders of Acanthopterygii (Gasterosteiformes, Gasterosteus aculeatus; Tetraodontiformes, Tetraodon nigroviridis; Perciformes, Oreochromis niloticus; and Beloniformes, Oryzias latipes) where a single copy was identified. Similarly, 1.3% (418) of total gene number represented cases where TSGD paralogs pairs were systematically retained in the Acanthopterygian but conserved as a single copy in Ostariophysi genomes. We confirmed the generality of these results by phylogenetic and synteny analysis of 40 randomly selected linage-specific paralogs (LSPs) from each superorder and completed with the transcriptomes of three additional Ostariophysi species (Ictalurus punctatus [Siluriformes], Sinocyclocheilus species [Cypriniformes], and Piaractus mesopotamicus [Characiformes]). No chromosome bias was detected in TSGD paralog retention. Gene ontology (GO) analysis revealed significant enrichment of GO terms relative to the human GO SLIM database for "growth," "Cell differentiation," and "Embryo development" in Ostariophysi and for "Transport," "Signal Transduction," and "Vesicle mediated transport" in Acanthopterygii. The observed patterns of paralog retention are consistent with different diploidization outcomes having contributed to the evolution/diversification of each superorder.
Garcia de la serrana, Daniel; Mareco, Edson A.; Johnston, Ian A.
Teleost fish underwent whole-genome duplication around 450 Ma followed by diploidization and loss of 80–85% of the duplicated genes. To identify a deep signature of this teleost-specific whole-genome duplication (TSGD), we searched for duplicated genes that were systematically and uniquely retained in one or other of the superorders Ostariophysi and Acanthopterygii. TSGD paralogs comprised 17–21% of total gene content. Some 2.6% (510) of TSGD paralogs were present as pairs in the Ostariophysi genomes of Danio rerio (Cypriniformes) and Astyanax mexicanus (Characiformes) but not in species from four orders of Acanthopterygii (Gasterosteiformes, Gasterosteus aculeatus; Tetraodontiformes, Tetraodon nigroviridis; Perciformes, Oreochromis niloticus; and Beloniformes, Oryzias latipes) where a single copy was identified. Similarly, 1.3% (418) of total gene number represented cases where TSGD paralogs pairs were systematically retained in the Acanthopterygian but conserved as a single copy in Ostariophysi genomes. We confirmed the generality of these results by phylogenetic and synteny analysis of 40 randomly selected linage-specific paralogs (LSPs) from each superorder and completed with the transcriptomes of three additional Ostariophysi species (Ictalurus punctatus [Siluriformes], Sinocyclocheilus species [Cypriniformes], and Piaractus mesopotamicus [Characiformes]). No chromosome bias was detected in TSGD paralog retention. Gene ontology (GO) analysis revealed significant enrichment of GO terms relative to the human GO SLIM database for “growth,” “Cell differentiation,” and “Embryo development” in Ostariophysi and for “Transport,” “Signal Transduction,” and “Vesicle mediated transport” in Acanthopterygii. The observed patterns of paralog retention are consistent with different diploidization outcomes having contributed to the evolution/diversification of each superorder. PMID:24732281
Influence of water temperature on induced reproduction by hypophysation, sex steroids concentrations and final oocyte maturation of the "curimatã-pacu" Prochilodus argenteus (Pisces: Prochilodontidae).
Arantes, Fábio P; Santos, Hélio B; Rizzo, Elizete; Sato, Yoshimi; Bazzoli, Nilo
Most fishes with commercial importance from the São Francisco basin are migratory and do not complete the reproductive cycle in lentic environments, such as hydroelectric plant reservoirs, hence natural stocks are declining and there is an urgent need to reduce the pressure of fishing on those wild populations. Therefore, studies on reproductive biology and its relationship with endocrine and environmental factors are key to improving the cultivation techniques of Brazilian fish species. This study examined the influence of water temperature on sex steroid concentrations (testosterone, 17β-estradiol and 17α-hydroxyprogesterone), spawning efficiency, fecundity, fertilisation rate, larval abnormality rates and involvement of the cytoskeleton during the final oocyte maturation of Prochilodus argenteus under experimental conditions. The results of our study showed that in captivity, sex steroid plasma concentrations and spawning performance of P. argenteus were clearly different for fish kept in water with different temperature regimes. In lower water temperature (23°C), it was observed that: 33% of females did not ovulate, fecundity was lower and vitellogenic oocytes after the spawning induction procedure exhibited a smaller diameter. Moreover, concentrations of 17β-estradiol and 17α-hydroxyprogesterone were lower and there was a delay in the final oocyte maturation and, consequently, ovulation and spawning. Our experiments showed direct influence of water temperature in the process of induced spawning of P. argenteus. Changes in water temperature also suggest the tubulin involvement in the nuclear dislocation process and the possible action of actin filaments in the release of polar bodies during final oocyte maturation of P. argenteus.
Andrade, M C; Jesus, A J S; Giarrizzo, T
This study reports on the length-weight relationships and condition factor for the endangered rheophilic fish Ossubtus xinguense Jégu from Rio Xingu rapids. This species is threatened by construction of the third largest hydroelectric in the world, the Belo Monte dam close to the city of Altamira, northern Brazil. Specimens were collected in the dry season between July 2012 and September 2012. Male specimens have body length larger than females, atypical in serrasalmid fishes, and different length-weight relationships were found between adult and juvenile specimens. This study presents the first biological characteristics for O. xinguense.
Gandhi, Kishor; Baratta, Jaime L; Heitz, James W; Schwenk, Eric S; Vaghari, Benjamin; Viscusi, Eugene R
Pain management in the postanesthesia care unit (PACU) is continually evolving, with several new nonopioids expanding the list of available agents. Pain in the PACU is not an inevitable outcome of surgery. With careful planning, multimodal analgesic techniques instituted preoperatively will reduce pain in the PACU. Accurate assessment of the characteristics of pain will direct rational drug choices while minimizing side effects. Better management of pain in the PACU setting will likely improve patient satisfaction and facilitate shorter PACU stays.
American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) Joint Consensus Statement on Optimal Analgesia within an Enhanced Recovery Pathway for Colorectal Surgery: Part 2-From PACU to the Transition Home.
Scott, Michael J; McEvoy, Matthew D; Gordon, Debra B; Grant, Stuart A; Thacker, Julie K M; Wu, Christopher L; Gan, Tong J; Mythen, Monty G; Shaw, Andrew D; Miller, Timothy E
Within an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver "optimal analgesia", which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects. With input from a multidisciplinary, international group of experts and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients. As a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery within an ERP. The goal was twofold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus on care in the post-anesthesia care unit, general care ward, and transition to home after discharge. The preoperative and operative consensus statement for analgesia was covered in Part 1 of this paper. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of "optimal analgesia" as set forth in this document.
Arantes, Fábio P; Santos, Helio B; Rizzo, Elizete; Sato, Yoshimi; Bazzoli, Nilo
The present study evaluated for the first time sex steroid profiles and fecundity in females of Prochilodus argenteus from two sections of the São Francisco River Brazil, downstream from the Três Marias Dam, which influences characteristics of their water habitat. The model species in the study, P. argenteus, is an important commercial and recreational species in Brazil. In the region closest to the dam (section 1), females did not reach final oocyte maturation, failed to spawn, and displayed lesser circulating concentrations of testosterone, 17(-hydroxyprogesterone (17(-P) and 17beta-estradiol (E2) than those farther downstream of the dam (section 2). The endocrine and fecundity deficiencies probably are attributed to lower water temperature and oxygen concentration in (section 1). The follicular atresia rate in the region closest to the dam (26%) was greater than those fish captured farther downstream of the dam (13%), after the Abaeté River (section 2). Variations in testosterone, E2 and 17(-P concentrations in section 2, followed gonadal maturation which are typical features of species which have seasonal reproduction, group-synchronous oocyte development, and are single batch spawners such as P. argenteus. Results document the first evidence of endocrine and reproductive dysfunctions caused by inadequate water conditions in a wild population of the migratory species P. argenteus in the São Francisco River, downstream from the Três Marias dam.
Carter, Amy J; Deselms, JoAnn; Ruyle, Shelley; Morrissey-Lucas, Marcella; Kollar, Suzie; Cannon, Shelly; Schick, Lois
Despite advocacy by professional nursing organizations, no randomized controlled trials (RCTs) have evaluated the response of family members to a visit with an adult patient during a postanesthesia care unit (PACU) stay. Therefore, the purpose of this RCT was to evaluate the impact of a brief PACU visitation on the anxiety of family members. The study was conducted in a phase I PACU of a large community-based hospital. Subjects were designated adult family members or significant others of an adult PACU patient who had undergone general anesthesia. A pretest-posttest RCT design was used. The dependent variable was the change in anxiety scores of the visitor after seeing his or her family member in the PACU. Student t test (unpaired, two tailed) was used to determine if changes in anxiety scores (posttest score-pretest score) were different for the PACU visit and no visit groups. A total of 45 participants were studied over a 3-month period, with N=24 randomly assigned to a PACU visit and N=21 assigned to usual care (no PACU visit). Participants in the PACU visit group had a statistically significant (P=.0001) decrease in anxiety after the visitation period (-4.11±6.4); participants in the usual care group (no PACU visit) had an increase in anxiety (+4.47±6.6). The results from this study support the value and importance of PACU visitation for family members.
A recent series of articles instructed PACU nurses on steps in developing pencil-and-paper instruments for research studies. What questions should PACU nurses ask when considering the use of existing pencil-and-paper instruments for use in research studies? The purpose of this article is to present nine steps in critiquing existing instrument before conducting research studies. Included are ethical considerations when using instruments and a checklist to assist PACU nurses in critiquing existing instruments.
Lardner, David R; Dick, Bruce D; Crawford, Susan
The effects on children of parental presence in the postanesthesia care unit (PACU) have not been extensively studied. The few published studies are retrospective, nonrandomized, or lack adequate controls. They suggest that parental presence in the PACU decreases crying and negative behavior change postoperatively. We performed this prospective, randomized, controlled study to determine whether the presence of a parent affected crying behaviors in the PACU and behavior change 2 weeks postoperatively. Randomly selected patients, aged 2.0 to 8 years 11 months, ASA physical status I or II, and scheduled for elective outpatient surgery with an anticipated PACU stay of >10 minutes were randomly assigned to the parent present group (n = 150) or parent absent group (n = 150) in the PACU. All parents underwent the same preparation program. Reunification occurred once children's eyes had opened for the parent present group. In the PACU, crying was scored each minute after eye opening using a 5-point scale. Negative behavior change 2 weeks after discharge was determined using the Post Hospitalization Behavior Questionnaire. Because the anesthesia technique to be used was not determined a priori, data on the technique used were collected to ensure that groups were similar. Multiple and logistic regression techniques were used to determine predictors of crying in the PACU and behavior change 2 weeks postoperatively. Parental presence in the PACU made no difference in crying in the PACU. Negative behavior change 2 weeks postoperatively occurred more frequently in the parent absent group than the parent present group (45.8% vs 29.3%; P = 0.007). Multiple regression identified the following significant factors as predictive of larger proportion of time spent crying in the PACU (R(2) = 0.256, F[5, 273] = 15.66, P < 0.001): age <5 years (P < 0.001) and higher Children's Hospital of Eastern Ontario Pain Scale score at 15 minutes after arrival in day surgery (P < 0.001). Parental
Card, E.; Pandharipande, P.; Tomes, C.; Lee, C.; Wood, J.; Nelson, D.; Graves, A.; Shintani, A.; Ely, E. W.; Hughes, C.
Background Emergence from anaesthesia is often accompanied by signs of delirium, including fluctuating mental status and inattention. The evolution of these signs of delirium requires investigation since delirium in the post-anaesthesia care unit (PACU) may be associated with worse outcomes. Methods Adult patients emerging from anaesthesia were assessed for agitated emergence in the operating room using the Richmond Agitation-Sedation Scale (RASS). The Confusion Assessment Method for the Intensive Care Unit was then used to evaluate delirium signs at PACU admission and during PACU stay at 30 min, 1 h, and discharge. Signs consistent with delirium were classified as hyperactive vs hypoactive based upon a positive CAM-ICU assessment and the concomitant RASS score. Multivariable logistic regression was utilized to assess potential risk factors for delirium during PACU stay including age, American Society of Anesthesiologists classification, and opioid and benzodiazepine exposure. Results Among 400 patients enrolled, 19% had agitated emergence. Delirium signs were present at PACU admission, 30 min, 1 h, and PACU discharge in 124 (31%), 59 (15%), 32 (8%), and 15 (4%) patients, respectively. In patients with delirium signs, hypoactive signs were present in 56% at PACU admission and in 92% during PACU stay. Perioperative opioids were associated with delirium signs during PACU stay (P=0.02). Conclusions A significant proportion of patients develop delirium signs in the immediate postoperative period, primarily manifesting with a hypoactive subtype. These signs often persist to PACU discharge, suggesting the need for structured delirium monitoring in the PACU to identify patients potentially at risk for worse outcomes in the postoperative period. PMID:25540068
Ehrenfeld, Jesse M; Dexter, Franklin; Rothman, Brian S; Minton, Betty Sue; Johnson, Diane; Sandberg, Warren S; Epstein, Richard H
When the phase I postanesthesia care unit (PACU) is at capacity, completed cases need to be held in the operating room (OR), causing a "PACU delay." Statistical methods based on historical data can optimize PACU staffing to achieve the least possible labor cost at a given service level. A decision support process to alert PACU charge nurses that the PACU is at or near maximum census might be effective in lessening the incidence of delays and reducing over-utilized OR time, but only if alerts are timely (i.e., neither too late nor too early to act upon) and the PACU slot can be cleared quickly. We evaluated the maximum potential benefit of such a system, using assumptions deliberately biased toward showing utility. We extracted 3 years of electronic PACU data from a tertiary care medical center. At this hospital, PACU admissions were limited by neither inadequate PACU staffing nor insufficient PACU beds. We developed a model decision support system that simulated alerts to the PACU charge nurse. PACU census levels were reconstructed from the data at a 1-minute level of resolution and used to evaluate if subsequent delays would have been prevented by such alerts. The model assumed there was always a patient ready for discharge and an available hospital bed. The time from each alert until the maximum census was exceeded ("alert lead time") was determined. Alerts were judged to have utility if the alert lead time fell between various intervals from 15 or 30 minutes to 60, 75, or 90 minutes after triggering. In addition, utility for reducing over-utilized OR time was assessed using the model by determining if 2 patients arrived from 5 to 15 minutes of each other when the PACU census was at 1 patient less than the maximum census. At most, 23% of alerts arrived 30 to 60 minutes prior to the admission that resulted in the PACU exceeding the specified maximum capacity. When the notification window was extended to 15 to 90 minutes, the maximum utility was <50%. At most, 45
Wanderer, Jonathan P; Shi, Yaping; Schildcrout, Jonathan S; Ehrenfeld, Jesse M; Epstein, Richard H
Measurement of postoperative pain scores on arrival to the postanesthesia care unit (PACU) is a potential quality metric for supervising anesthesiologists. Our goal in this study was to determine whether rank-ordering by initial PACU numeric rating scale (NRS) pain score, as collected by nurses in a nonresearch clinical setting, could be used to compare anesthesiologists after adjusting for confounding factors. For a large population of adult patients, the admission PACU NRS pain scores (0-10) were evaluated using proportional odds mixed effects models. Fixed effects included age, gender, race, opioids in the preoperative medication list, American Society of Anesthesiologists (ASA) physical status classification, emergency surgery, laparoscopic approach, outpatient status, anesthesiologist, and PACU nurse; surgeon and surgical procedure were included as random effects. A total of 26,680 initial PACU pain scores were analyzed. The PACU nurse had the largest observed association with initial PACU pain score. Compared with the nurse with the median covariate adjusted NRS score, the odds ratio (OR) for an increased reported pain score ranged from 0.16 (95% confidence interval [CI] 0.11 to 0.24) to 2.95 (95% CI 2.43 to 3.59). For anesthesiologists, the ORs for an increase in reported pain ranged from 0.60 (95% CI 0.37 to 0.99) to 1.44 (95% CI 0.98 to 2.11). Factors associated with increased pain scores were preoperative opioids, female gender, and ASA physical status 2 and 3. Lower pain scores were associated with outpatient surgery, laparoscopy, African American race, and older patients. There is little to no evidence to suggest that supervising anesthesiologists can be compared with one another effectively using admission PACU NRS pain scores. The confounding association of the PACU nurse eliciting the admission pain score greatly exceeded the contribution by the anesthesiologist.
achieved. There were no reported incidents of central nervous system toxicity, neuralgia , or neuropathy in any of the 16 administered regional...Events: Antiemetics used in PACU(circle one): yes no CNS toxicity yes no Neuralgia
Heitz, L; Symreng, T; Scamman, F L
This study examined the effect of music on pain, hemodynamic variables, and respiration in the PACU, and the impact of music on patients' recall of their PACU experience. Sixty patients scheduled for thyroid, parathyroid, or breast surgery under general anesthesia were studied. Patients were randomly assigned into three groups: group 1, control, not wearing headphones; group 2, wearing headphones but hearing no music; and group 3, wearing headphones and listening to music. A visual analogue pain scale was used to rate patients' perception of pain. There was no difference in pain level, morphine requirement, hemodynamics, respiration, or length of stay in the PACU among the 3 groups, yet the music group was able to wait significantly longer before requiring analgesia on the nursing unit. Patients who listened to music perceived their PACU experience as significantly more pleasant than the patients in the other two groups as recalled both 1 day and 1 month later.
Mendonça, J; Pereira, H; Xará, D; Santos, A; Abelha, F J
Obesity has been associated with respiratory complications, and the majority of these complications occur in the Post-Anesthesia Care Unit (PACU). The aim of this study was to evaluate the outcome and incidence of adverse respiratory events (AREs) in obese patients during their stay in the PACU METHODS: We conducted a prospective control study that included 27 obese patients matched with an equal number of patients with body mass index (BMI)<30 (non-obese control group); the 2 groups of patients were similar in respect to gender distribution, age, and type of surgery and had been admitted into the PACU after elective surgery (May 2011). The AREs were identified during PACU stay. Descriptive analysis of variables was performed, and the Mann-Whitney U test, Chi-square test, or Fisher's exact test were used for comparisons. Associations with AREs were studied using univariate and multivariate logistic regression models. There was a higher frequency of STOP-BANG ≥3 (89% vs. 11%, P<.001) among obese patients and they were less frequently scheduled to undergo high-risk surgery (7% vs. 41%, P=.005) and major surgery (4% vs. 15%, P=.008). Obese patients had more frequent AREs in the PACU (33% vs. 7%, P<.018). Multivariate analysis identified obesity and residual neuromuscular blockade as independent risk factors for the occurrence of AREs. Stay in the PACU was longer for obese patients (120min vs. 84min, P<.01). Obesity was considered an independent risk factor for AREs in the PACU. Obese patients stayed longer in the PACU, but they did not stay longer in the hospital. Copyright © 2012 Sociedade Portuguesa de Pneumologia. Published by Elsevier España. All rights reserved.
patient’s experience of pain. Exceptions to this are studies involving the use of music in the PACU. Recommendations are made in some reports for...block the noise. Some investigations related to noise in the PACU have involved the use of music in order to promote comfort, however the rationales...for employing music are different. Ten patients in one study (Heiser et al., 1997) were divided in to a study group that selected their own music , and
Phan, V H Giang; Thambi, Thavasyappan; Duong, Huu Thuy Trang; Lee, Doo Sung
In this study, a new pH-/temperature-sensitive, biocompatible, biodegradable, and injectable hydrogel based on poly(ethylene glycol)-poly(amino carbonate urethane) (PEG-PACU) copolymers has been developed for the sustained delivery of human growth hormone (hGH). In aqueous solutions, PEG-PACU-based copolymers existed as sols at low pH and temperature (pH 6.0, 23 °C), whereas they formed gels in the physiological condition (pH 7.4, 37 °C). The physicochemical characteristics, including gelation rate, mechanical strength and viscosity, of the PEG-PACU hydrogels could be finely tuned by varying the polymer weight, pH and temperature of the copolymer. An in vivo injectable study in the back of Sprague-Dawley (SD) rats indicated that the copolymer could form an in situ gel, which exhibited a homogenous porous structure. In addition, an in vivo biodegradation study of the PEG-PACU hydrogels showed controlled degradation of the gel matrix without inflammation at the injection site and the surrounding tissue. The hGH-loaded PEG-PACU copolymer solution readily formed a hydrogel in SD rats, which subsequently inhibited the initial hGH burst and led to the sustained release of hGH. Overall, the PEG-PACU-based copolymers prepared in this study are expected to be useful biomaterials for the sustained delivery of hGH.
Phan, V. H. Giang; Thambi, Thavasyappan; Duong, Huu Thuy Trang; Lee, Doo Sung
In this study, a new pH-/temperature-sensitive, biocompatible, biodegradable, and injectable hydrogel based on poly(ethylene glycol)-poly(amino carbonate urethane) (PEG-PACU) copolymers has been developed for the sustained delivery of human growth hormone (hGH). In aqueous solutions, PEG-PACU-based copolymers existed as sols at low pH and temperature (pH 6.0, 23 °C), whereas they formed gels in the physiological condition (pH 7.4, 37 °C). The physicochemical characteristics, including gelation rate, mechanical strength and viscosity, of the PEG-PACU hydrogels could be finely tuned by varying the polymer weight, pH and temperature of the copolymer. An in vivo injectable study in the back of Sprague-Dawley (SD) rats indicated that the copolymer could form an in situ gel, which exhibited a homogenous porous structure. In addition, an in vivo biodegradation study of the PEG-PACU hydrogels showed controlled degradation of the gel matrix without inflammation at the injection site and the surrounding tissue. The hGH-loaded PEG-PACU copolymer solution readily formed a hydrogel in SD rats, which subsequently inhibited the initial hGH burst and led to the sustained release of hGH. Overall, the PEG-PACU-based copolymers prepared in this study are expected to be useful biomaterials for the sustained delivery of hGH.
Phan, V. H. Giang; Thambi, Thavasyappan; Duong, Huu Thuy Trang; Lee, Doo Sung
In this study, a new pH-/temperature-sensitive, biocompatible, biodegradable, and injectable hydrogel based on poly(ethylene glycol)-poly(amino carbonate urethane) (PEG-PACU) copolymers has been developed for the sustained delivery of human growth hormone (hGH). In aqueous solutions, PEG-PACU-based copolymers existed as sols at low pH and temperature (pH 6.0, 23 °C), whereas they formed gels in the physiological condition (pH 7.4, 37 °C). The physicochemical characteristics, including gelation rate, mechanical strength and viscosity, of the PEG-PACU hydrogels could be finely tuned by varying the polymer weight, pH and temperature of the copolymer. An in vivo injectable study in the back of Sprague-Dawley (SD) rats indicated that the copolymer could form an in situ gel, which exhibited a homogenous porous structure. In addition, an in vivo biodegradation study of the PEG-PACU hydrogels showed controlled degradation of the gel matrix without inflammation at the injection site and the surrounding tissue. The hGH-loaded PEG-PACU copolymer solution readily formed a hydrogel in SD rats, which subsequently inhibited the initial hGH burst and led to the sustained release of hGH. Overall, the PEG-PACU-based copolymers prepared in this study are expected to be useful biomaterials for the sustained delivery of hGH. PMID:27436576
Maher, Dermot P; Wong, Waylan; Woo, Pauline; Padilla, Cesar; Zhang, Xiao; Shamloo, Bahman; Rosner, Howard; Wender, Ronald; Yumul, Roya; Louy, Charles
To determine perioperative treatments and events associated with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey responses. Retrospective analysis. Single tertiary care, academic, urban, level-1 trauma center. Final cohort represents 2,758 consecutive surgical inpatients meeting criteria for evaluation by HCAHPS. Responses to four HCAHPS questions were compared against 19 perioperative treatments and events. Positive and negative responses to HCAHPS questions. Patients responding affirmatively with a "9" or "10" to "what number would you use to rate this hospital" were associated with decreased lengths of hospitalization, greater lengths of surgery, decreased intraoperative opioid equianalgesic doses, greater preoperative midazolam doses, shorter post anesthesia care unit (PACU) lengths of stay and decreased last PACU numerical rating scale (NRS) pain scores. Patients responding affirmatively with "yes, definitely" to "would you recommend this hospital to your family" were associated with decreased last PACU NRS pain scores. Patients responding affirmatively with "yes, always" to "How often did the hospital staff do everything to help with your pain" were associated with decreased hospital lengths of stay, decreased chronic benzodiazepine use, greater chronic NSAID use, and decreased PACU lengths of stay. Patients responding affirmatively with "yes, always" to "how often was your pain well controlled" were associated with decreased chronic opioid use, decreased chronic benzodiazepine use, greater chronic NSAID use, increased length of surgery, decreased last PACU NRS pain score, and decreased first PACU NRS pain scores. Subgroup analysis of patients undergoing different types of surgery further characterized factors associated with HCAHPS responses among different surgical populations. These data suggest that demographic factors, preadmission medications, and PACU pain scores but not analgesic medications are associated with patient
Dolkart, Oleg; Amar, Eyal; Weisman, Daniela; Flaishon, Ron; Weinbroum, Avi A
The present study aimed to evaluate subjective reactions of post-surgery and anesthesia patients who stay in post-anesthesia care units (PACU) longer than necessary medically, due to administrative causes. We interviewed consenting postoperative patients during an 18-month period. All patients who remained in the PACU twice our obligatory PACU length of stay (> 4 hours) due to lack of an available bed in the appropriate hospital ward, were interviewed at the time of discharge. The study group consisted of those who remained > 4 hours after surgery and a control group of patients who were discharged within 4 hours. The questions were chosen from different sources, including generic and condition-specific questionnaires. A total of 67 patients stayed > 4 hours and 63 < 4 hours. The overall mean PACU length of stay for the former was 14.23 +/- 5.77 hours (range 1.5-30 hours). No significant differences were found between the groups in terms of age, gender, surgical time or postoperative pain visual analogue scale. Irritability due to lack of independence were statistically higher, and satisfaction rates were lower in patients who stayed > 12 hours compared to those who were discharged after 4-12 hours (P < 0.05). Overcrowded wards may lead to significant delays in discharge from the PACU. Prolonged stay in the PACU requires attention, both from the administrative and the medical standpoints, because it may irritate the patient. Patients' irate behavior may distract the medical staff from effectively performing their duties and interferes with optimal medical care in the PACU.
Bruins, Suze Dominique; Leong, Pauline Meng Choo; Ng, Shin Yi
We reviewed patients with critical incidents that occurred in the post-anaesthesia care unit (PACU) at a major tertiary hospital, and assessed the effect of these incidents on PACU length of stay and discharge disposition. A retrospective review was conducted of patients in the PACU over a two-year period from 24 June 2011 to 23 August 2013. Data on critical incidents was recorded in the administrative database using a standardised data form. There were 701 incidents involving 364 patients; 203 (55.8%) patients had American Society of Anesthesiologists (ASA) physical status I or II. The most common critical incidents were cardiovascular-related (n = 293, 41.8%), respiratory (n = 155, 22.1%), neurological (n = 52, 7.4%), surgical (n = 47, 6.7%) and airway-related (n = 34, 4.9%). There were two incidents of cardiac arrest and 25 incidents of unexpected reintubations. Many patients (n = 186, 51.2%) stayed for over four hours in the PACU due to critical incidents and 184 (50.5%) patients required a higher level of care postoperatively than initially planned. Some patients (n = 34, 9.3%) returned to the operation theatre for further management. A proportion of patients (n = 64, 17.6%) had unplanned intensive care unit admissions due to adverse events in the PACU. A wide spectrum of critical incidents occur in the PACU, many of which are related to the cardiovascular and respiratory systems. Critical incidents have a major impact on healthcare utilisation and result in prolonged PACU stays and higher levels of postoperative care than initially anticipated.
Whitaker Chair, D K; Booth, H; Clyburn, P; Harrop-Griffiths, W; Hosie, H; Kilvington, B; Macmahon, M; Smedley, P; Verma, R
1. After general, epidural or spinal anaesthesia, all patients should be recovered in a specially designated area (henceforth 'post-anaesthesia care unit', PACU) that complies with the standards and recommendations described in this document. 2. The anaesthetist must formally hand over the care of a patient to an appropriately trained and registered PACU practitioner. 3. Agreed, written criteria for discharge of patients from the PACU to the ward should be in place in all units. 4. An effective emergency call system must be in place in every PACU and tested regularly. 5. No fewer than two staff (of whom at least one must be a registered practitioner) should be present when there is a patient in a PACU who does not fulfil the criteria for discharge to the ward. 6. All registered practitioners should be appropriately trained in accordance with the standards and competencies detailed in the UK National Core Competencies for Post Anaesthesia Care. 7. All patients must be observed on a one-to-one basis by an anaesthetist or registered PACU practitioner until they have regained control of their airway, have stable cardiovascular and respiratory systems and are awake and able to communicate. 8. All patients with tracheal tubes in place in a PACU should be monitored with continuous capnography. The removal of tracheal tubes is the responsibility of the anaesthetist. 9. There should be a specially designated area for the recovery of children that is appropriately equipped and staffed. 10. All standards and recommendations described in this document should be applied to all areas in which patients recover after anaesthesia, to include those anaesthetics given for obstetric, cardiology, imaging and dental procedures, and in psychiatric units and community hospitals. Only registered PACU practitioners who are familiar with these areas should be allocated to recover patients in them as and when required. 11. Patients' dignity and privacy should be respected at all times but
Abdulla, Susanne; Eckhardt, Regina; Netter, Ute; Abdulla, Walied
Purpose. In a randomized, double-blind trial, the efficacy of nonopioid analgesics on postoperative piritramide consumption was compared for pain relief during the first 24 h in patients recovering from arthroscopic knee surgery. Methods. 120 patients were treated with normal saline and/or one of the nonopioid analgesics (parecoxib, metamizole, paracetamol) in addition to piritramide using the PCA pump. Beginning in the postanesthesia care unit (PACU), patients were asked to quantify their pain experience at rest while piritramide consumption was recorded. Results. Piritramide consumption upon arrival in the PACU was high in all groups. However, cumulative consumption in the parecoxib group was significantly lower than that in the placebo group at 6 and 12 h after surgery. At discharge from the PACU, VAS scores dropped in all groups and were significantly lower in the parecoxib group. In the PACU, satisfaction of the patients was moderate and improved with time after surgery. Conclusions. There was statistically significant opioid-saving effect by administering parecoxib with better VAS scores and satisfaction level compared to placebo. The high pain score in the PACU in all groups immediately after recovering from remifentanil-based anesthesia would be prevented if local anesthetics were administered intra-articularly as part of a multimodal analgesic approach. PMID:23213511
Abdulla, Susanne; Eckhardt, Regina; Netter, Ute; Abdulla, Walied
Purpose. In a randomized, double-blind trial, the efficacy of nonopioid analgesics on postoperative piritramide consumption was compared for pain relief during the first 24 h in patients recovering from arthroscopic knee surgery. Methods. 120 patients were treated with normal saline and/or one of the nonopioid analgesics (parecoxib, metamizole, paracetamol) in addition to piritramide using the PCA pump. Beginning in the postanesthesia care unit (PACU), patients were asked to quantify their pain experience at rest while piritramide consumption was recorded. Results. Piritramide consumption upon arrival in the PACU was high in all groups. However, cumulative consumption in the parecoxib group was significantly lower than that in the placebo group at 6 and 12 h after surgery. At discharge from the PACU, VAS scores dropped in all groups and were significantly lower in the parecoxib group. In the PACU, satisfaction of the patients was moderate and improved with time after surgery. Conclusions. There was statistically significant opioid-saving effect by administering parecoxib with better VAS scores and satisfaction level compared to placebo. The high pain score in the PACU in all groups immediately after recovering from remifentanil-based anesthesia would be prevented if local anesthetics were administered intra-articularly as part of a multimodal analgesic approach.
Zoremba, Martin; Kratz, Thomas; Dette, Frank; Wulf, Hinnerk; Wiesmann, Thomas
Background. After shoulder surgery performed in patients with interscalene nerve block (without general anesthesia), fast track capability and postoperative pain management in the PACU are improved compared with general anesthesia alone. However, it is not known if these evidence-based benefits still exist when the interscalene block is combined with general anesthesia. Methods. We retrospectively analyzed a prospective cohort data set of 159 patients undergoing shoulder arthroscopy with general anesthesia alone (n = 60) or combined with an interscalene nerve block catheter (n = 99) for fast track capability time. Moreover, comparisons were made for VAS scores, analgesic consumption in the PACU, pain management, and lung function measurements. Results. The groups did not differ in mean time to fast track capability (22 versus 22 min). Opioid consumption in PACU was significantly less in the interscalene group, who had significantly better VAS scores during PACU stay. Patients receiving interscalene blockade had a significantly impaired lung function postoperatively, although this did not affect postoperative recovery and had no impact on PACU times. Conclusion. The addition of interscalene block to general anesthesia for shoulder arthroscopy did not enhance fast track capability. Pain management and VAS scores were improved in the interscalene nerve block group. PMID:26064898
Zoremba, Martin; Kratz, Thomas; Dette, Frank; Wulf, Hinnerk; Steinfeldt, Thorsten; Wiesmann, Thomas
After shoulder surgery performed in patients with interscalene nerve block (without general anesthesia), fast track capability and postoperative pain management in the PACU are improved compared with general anesthesia alone. However, it is not known if these evidence-based benefits still exist when the interscalene block is combined with general anesthesia. We retrospectively analyzed a prospective cohort data set of 159 patients undergoing shoulder arthroscopy with general anesthesia alone (n = 60) or combined with an interscalene nerve block catheter (n = 99) for fast track capability time. Moreover, comparisons were made for VAS scores, analgesic consumption in the PACU, pain management, and lung function measurements. The groups did not differ in mean time to fast track capability (22 versus 22 min). Opioid consumption in PACU was significantly less in the interscalene group, who had significantly better VAS scores during PACU stay. Patients receiving interscalene blockade had a significantly impaired lung function postoperatively, although this did not affect postoperative recovery and had no impact on PACU times. The addition of interscalene block to general anesthesia for shoulder arthroscopy did not enhance fast track capability. Pain management and VAS scores were improved in the interscalene nerve block group.
Herrero, Silvia; Carrero, Enrique; Valero, Ricard; Rios, Jose; Fábregas, Neus
We examined the additive effect of the Ramsay scale, Canadian Neurological Scale (CNS), Nursing Delirium Screening Scale (Nu-DESC), and Bispectral Index (BIS) to see whether along with the assessment of pupils and Glasgow Coma Scale (GCS) it improved early detection of postoperative neurological complications. We designed a prospective observational study of two elective neurosurgery groups of patients: craniotomies (CG) and non-craniotomies (NCG). We analyze the concordance and the odds ratio (OR) of altered neurological scales and BIS in the Post-Anesthesia Care Unit (PACU) for postoperative neurological complications. We compared the isolated assessment of pupils and GCS (pupils-GCS) with all the neurologic assessment scales and BIS (scales-BIS). In the CG (n=70), 16 patients (22.9%) had neurological complications in PACU. The scales-BIS registered more alterations than the pupils-GCS (31.4% vs. 20%; p<0.001), were more sensitive (94% vs. 50%) and allowed a more precise estimate for neurological complications in PACU (p=0.002; OR=7.15, 95% CI=2.1-24.7 vs. p=0.002; OR=9.5, 95% CI=2.3-39.4). In the NCG (n=46), there were no neurological complications in PACU. The scales-BIS showed alterations in 18 cases (39.1%) versus 1 (2.2%) with the pupils-GCS (p<0.001). Altered CNS on PACU admission increased the risk of neurological complications in the ward (p=0.048; OR=7.28, 95% CI=1.021-52.006). Applied together, the assessment of pupils, GCS, Ramsay scale, CNS, Nu-DESC and BIS improved early detection of postoperative neurological complications in PACU after elective craniotomies. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Herrero, Silvia; Carrero, Enrique; Valero, Ricard; Rios, Jose; Fábregas, Neus
We examined the additive effect of the Ramsay scale, Canadian Neurological Scale (CNS), Nursing Delirium Screening Scale (Nu-DESC), and Bispectral Index (BIS) to see whether along with the assessment of pupils and Glasgow Coma Scale (GCS) it improved early detection of postoperative neurological complications. We designed a prospective observational study of two elective neurosurgery groups of patients: craniotomies (CG) and non-craniotomies (NCG). We analyze the concordance and the odds ratio (OR) of altered neurological scales and BIS in the Post-Anesthesia Care Unit (PACU) for postoperative neurological complications. We compared the isolated assessment of pupils and GCS (pupils-GCS) with all the neurologic assessment scales and BIS (scales-BIS). In the CG (n=70), 16 patients (22.9%) had neurological complications in PACU. The scales-BIS registered more alterations than the pupils-GCS (31.4% vs. 20%; p<0.001), were more sensitive (94% vs. 50%) and allowed a more precise estimate for neurological complications in PACU (p=0.002; OR=7.15, 95% CI=2.1-24.7 vs. p=0.002; OR=9.5, 95% CI=2.3-39.4). In the NCG (n=46), there were no neurological complications in PACU. The scales-BIS showed alterations in 18 cases (39.1%) versus 1 (2.2%) with the pupils-GCS (p<0.001). Altered CNS on PACU admission increased the risk of neurological complications in the ward (p=0.048; OR=7.28, 95% CI=1.021-52.006). Applied together, the assessment of pupils, GCS, Ramsay scale, CNS, Nu-DESC and BIS improved early detection of postoperative neurological complications in PACU after elective craniotomies. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Ruiz, Joseph R; Kee, Spencer S; Frenzel, John C; Ensor, Joe E; Selvan, Mano; Riedel, Bernhard J; Apfel, Christian
The effect of the type of surgical procedure on postoperative nausea and vomiting (PONV) rate has been debated in the literature. Our goal in this retrospective database study was to investigate the effect the type of surgical procedure (categorized and compared anatomically) has on antiemetic therapy within 2 h of admission to the postanesthesia care unit (PACU). We retrospectively analyzed data for oncology surgeries (n = 18,109), from our automated anesthesia information system database. We classified the types of surgical procedures anatomically into seven categories, with the integumentary musculoskeletal and the superficial surgeries chosen as the referent group. Our analysis included nine other risk factors for each patient, such as gender, smoking status, history of PONV or motion sickness, duration of anesthesia, number of prophylactic antiemetics administered, intraoperative opioids, ketorolac, epidural use, and postoperative opioids. Multivariate logistic regression was used to assess the effect of the type of surgery on antiemetic administration within the first 2 h of PACU admission, while adjusting for the other risk factors. Compared with integumentary musculoskeletal and superficial surgeries, patients undergoing neurological (P < 0.0001), head or neck (P < 0.0001), and abdominal (P < 0.0001) surgeries were administered PACU antiemetic significantly more often, whereas patients undergoing thoracic surgeries were administered PACU antiemetic significantly less often (P = 0.02). Breast or axilla (P = 0.74) and endoscopic (P = 0.28) procedures did not differ from the referent category. Female, nonsmoker, history of PONV or motion sickness, anesthesia duration, and intraoperative and postoperative opioid administration were significantly associated with antiemetic administration during early PACU admission. Using our automated anesthesia information system database, we found that the type of surgery, when categorized anatomically, was associated with an
Meng, Li; Metro, David G; Patel, Rita M
To implement a 360-degree resident evaluation instrument on the postanesthesia care unit (PACU) rotation and to determine the reliability, feasibility, and validity of this tool for assessing residents' professionalism and interpersonal and communication skills. Thirteen areas of evaluation were selected to assess the professionalism and interpersonal and communication skills of residents during their PACU rotation. Each area was measured on a 9-point Likert scale (1, unsatisfactory performance, to 9, outstanding performance). Rating forms were distributed to raters after the completion of the PACU rotation. Raters included PACU nurses, secretarial staff, nurse aides, and medical technicians. Residents were aware of the 360-degree assessment and participated voluntarily. The multiple raters' evaluations were then compared with those of the traditional faculty. Intraclass correlation coefficients were calculated to measure the reliability of ratings within each category of raters by the Pearson correlation coefficient. Four hundred twenty-nine rating forms were returned during the study period. Fifteen residents were evaluated. The response rate was 88%. Residents were ranked highest on availability and lowest on management skill. The average rating across all areas was high (8.23). The average mean rating across all items from PACU nurses was higher (8.34) than from secretarial staff (7.99, P > .08). The highest ranked resident ranked high with all raters and the lowest ranked was low with most raters. The intraclass coefficients of correlations were 0.8719, 0.7860, 0.8268, and 0.8575. This type of resident assessment tool may be useful for PACU rotations. It appears to correlate with traditional faculty ratings, is feasible to use, and provides formative feedback to residents regarding their professionalism and interpersonal and communication skills.
Weinger, Matthew B; Slagle, Jason M; Kuntz, Audrey H; Schildcrout, Jonathan S; Banerjee, Arna; Mercaldo, Nathaniel D; Bills, James L; Wallston, Kenneth A; Speroff, Theodore; Patterson, Emily S; France, Daniel J
Failures of communication are a major contributor to perioperative adverse events. Transitions of care may be particularly vulnerable. We sought to improve postoperative handovers. We introduced a multimodal intervention in an adult and a pediatric postanesthesia care unit (PACU) to improve postoperative handovers between anesthesia providers (APs) and PACU registered nurses (RNs). The intervention included a standardized electronic handover report form, a didactic webinar, mandatory simulation training focused on improving interprofessional communication, and post-training performance feedback. Trained, blinded nurse observers scored PACU handovers during 17 months using a structured tool consisting of 8 subscales and a global score (1-5 scale). Multivariate logistic regression assessed the effect of the intervention on the proportion of observed handovers receiving a global effectiveness rating of ≥3. Four hundred fifty-two clinicians received the simulation-based training, and 981 handovers were observed and rated. In the adult PACU, the estimated percentages of acceptable handovers (global ratings ≥3) among AP-RN pairs, where neither received simulation-based training (untrained dyads), was 3% (95% confidence interval, 1%-11%) at day 0, 10% (5%-19%) at training initiation (day 40), and 57% (33%-78%) at 1-year post-training initiation (day 405). For AP-RN pairs where at least one received the simulation-based training (trained dyads), these percentages were estimated to be 18% (11%-28%) and 68% (57%-76%) on days 40 and 405, respectively. The percentage of acceptable handovers was significantly greater on day 405 than it was on day 40 for both untrained (P < 0.001) and trained dyads (P < 0.001). Similar patterns were observed in the pediatric PACU. Three years later, the unadjusted estimate of the probability of an acceptable handover was 87% (72%-95%) in the adult PACU and 56% (40%-72%) in the pediatric PACU. A multimodal intervention substantially improved
Jo, Youn Yi; Lee, Dongchul; Jung, Wol Seon; Cho, Noo Ree; Kwak, Hyun Jeong
Background Despite the high frequency of hypotension during spinal anesthesia with proper sedation, no previous report has compared the hemodynamic effects of dexmedetomidine and midazolam sedation during spinal anesthesia. We compared the effects of bispectral index (BIS)-guided intravenous sedation using midazolam or dexmedetomidine on hemodynamics and recovery profiles in patients who underwent spinal anesthesia. Material/Methods One hundred and sixteen adult patients were randomly assigned to receive either midazolam (midazolam group; n=58) or dexmedetomidine (dexmedetomidine group; n=58) during spinal anesthesia. Systolic, diastolic, and mean arterial pressures; heart rates; peripheral oxygen saturations; and bispectral index scores were recorded during surgery, and Ramsay sedation scores and postanesthesia care unit (PACU) stay were monitored. Results Hypotension occurred more frequently in the midazolam group (P<0.001) and bradycardia occurred more frequently in the dexmedetomidine group (P<0.001). Mean Ramsay sedation score was significantly lower in the dexmedetomidine group after arrival in the PACU (P=0.025) and PACU stay was significantly longer in the dexmedetomidine group (P=0.003). Conclusions BIS-guided dexmedetomidine sedation can attenuate intraoperative hypotension, but induces more bradycardia, prolongs PACU stay, and delays recovery from sedation in patients during and after spinal anesthesia as compared with midazolam sedation. PMID:27701366
Jo, Youn Yi; Lee, Dongchul; Jung, Wol Seon; Cho, Noo Ree; Kwak, Hyun Jeong
BACKGROUND Despite the high frequency of hypotension during spinal anesthesia with proper sedation, no previous report has compared the hemodynamic effects of dexmedetomidine and midazolam sedation during spinal anesthesia. We compared the effects of bispectral index (BIS)-guided intravenous sedation using midazolam or dexmedetomidine on hemodynamics and recovery profiles in patients who underwent spinal anesthesia. MATERIAL AND METHODS One hundred and sixteen adult patients were randomly assigned to receive either midazolam (midazolam group; n=58) or dexmedetomidine (dexmedetomidine group; n=58) during spinal anesthesia. Systolic, diastolic, and mean arterial pressures; heart rates; peripheral oxygen saturations; and bispectral index scores were recorded during surgery, and Ramsay sedation scores and postanesthesia care unit (PACU) stay were monitored. RESULTS Hypotension occurred more frequently in the midazolam group (P<0.001) and bradycardia occurred more frequently in the dexmedetomidine group (P<0.001). Mean Ramsay sedation score was significantly lower in the dexmedetomidine group after arrival in the PACU (P=0.025) and PACU stay was significantly longer in the dexmedetomidine group (P=0.003). CONCLUSIONS BIS-guided dexmedetomidine sedation can attenuate intraoperative hypotension, but induces more bradycardia, prolongs PACU stay, and delays recovery from sedation in patients during and after spinal anesthesia as compared with midazolam sedation.
Abdulla, S; Eckhardt, R; Netter, U; Abdulla, W
Following laparoscopic cholecystectomy, an effective post-operative pain control is necessary, at least during the first 24 hours. We present a randomized, double-blind trial on the effect of the combined use of intravenous parecoxib, and metamizol or paracetamol on piritramide consumption using a patient-controlled analgesia (PCA) pump in patients recovering from laparoscopic cholecystectomy. 120 patients were randomly allocated to four patient groups treated with normal saline or one of non-opioid analgesics (parecoxib 40 mg twice daily, metamizol 1 g three times daily, paracetamol 1 g three times daily) in addition to piritramide using the PCA pump. Beginning in the post-anesthesia care unit (PACU), patients were asked every 2 h for 6 hours and afterwards once every 6 h to quantify their pain experience at rest while piritramide consumption was recorded. In all groups, piritramide consumption was high in PACU. Only metamizol significantly reduced piritramide consumption compared to the others upon discharge from PACU. Overall, cumulative piritramide consumption was slightly lower in the metamizol group and higher in the NaCl group; however, these findings were statistically not significant. VAS scores were highest upon arrival in PACU and dropped almost continuously after surgery. A significantly lower postoperative pain intensity was only found in the parecoxib group at 24 h after surgery compared to the metamizol group. The efficacy of tested additive medications on piritramide consumption and pain relief is weak and there is no clear-cut difference between the non-opioid drugs used.
Landsman, Ira S; Mitzel, Heather M; Peters, Sarika U; Bichell, Terry J
To review seven children with Angelman syndrome (AS) undergoing 16 general anesthetics for both invasive and noninvasive procedures to determine if these children are at greater risk for anesthetic-related complications than the general population. Children with AS may exhibit unpredictable responses to GABA agonists because of abnormal GABA receptors. These abnormal receptors may affect AS patients' responses to sedation and general anesthesia. The study design was a retrospective chart review of seven patients with AS who underwent a total of 16 general anesthetics for a variety of invasive and noninvasive procedures between the years 4/25/2005 and 12/31/2010. We reviewed the preoperative orders, anesthesia record and PACU records for preoperative medication orders and intraoperative and PACU adverse events. We could not find documentation of complications attributed to the delivery of general anesthesia regardless of chromosomal defect, the use of GABA activating drugs, or a history of seizures. Six patients received a propofol-based anesthetic while 10 patients received potent inhalation agent for anesthetic maintenance. There were no statistical differences between the PACU lengths of stay (LOS) for AS patients as compared to the average PACU LOS for the 60 969 postprocedure patients cared for between 1/1/06 through 12/31/10. We found no data to suggest that these patients demonstrate exaggerated responses to GABA stimulating drugs. In fact, it appears that regardless of the anesthetic agent, the perioperative course was unremarkable. © 2011 Blackwell Publishing Ltd.
Brousseau, Claire A; Dobson, Gregory R; Milne, Andrew D
Obstructive sleep apnea (OSA) is a form of sleep-disordered breathing characterized by periods of partial or complete obstruction of the upper airway during sleep, resulting in oxygen desaturations. Symptoms and risk factors for OSA are of particular importance in the management of OSA patients in the perioperative setting. The present study collected data regarding the intraoperative airway management of OSA patients and their course in the postanesthesia care unit (PACU) over a six-month period. A total of 86 patients underwent general anesthesia, 63 of whom were intubated by direct laryngoscopy. Of these, 43% were classified as a grade 1 view by direct laryngoscopy, 43% were grade 2 and 14% were classified as grade 3. Apnea events or periods of desaturation in the PACU were observed in 27% of cases. Length of stay was significantly longer for cases in which PACU nurses had indicated that OSA had affected the individuals' postoperative course of treatment. Overall, OSA patients had an increased frequency of grade 3 views compared with the general population, and adjuncts were commonly used to help secure the airway in OSA patients. Symptomatic OSA patients placed increased demands on the PACU in terms of length of stay and hospital resources.
Rapacuronium bromide (Raplon; Organon Inc, West Orange, NJ) is a new, fast-onset, short-duration surgical muscle relaxant. While anesthesia providers are learning how to use this new relaxant, PACU nurses must become aware of the potential problems associated with rapacuronium. This article compares and contrasts the effects of succinylcholine and rapacuronium.
Ma, Jia-Ying; Chen, Po-Cheng; Chang, Huan-Tsung
We have developed a one-pot, inexpensive, simple and rapid method to synthesize photoluminescent copper nanocluster (Cu NC) aggregates from Cu2+ ions in 65% (v v-1) dimethylformamide aqueous solution containing penicillamine (PA) as a capping and reducing agent. As-prepared PA-Cu NC aggregates emit at 580 nm when excited at 326 nm, with a quantum yield of 2.0%. The photoluminescence of PA-Cu NC aggregates originate from ligand-to-metal charge transfer, which is supported by a long lifetime (126.5 ns) and a large Stokes shift (254 nm). As-prepared PA-Cu NC aggregates have different emission wavelengths with the same excitation wavelength in various organic-aqueous solutions. The PA-Cu NC aggregates are highly selective and sensitive to the detection of hydrogen sulfide (H2S), based on analyte-induced photoluminescence quenching through the formation of CuS nanoparticles. The probe allows the detection of H2S, with a linear range of 1-100 μM and a limit of detection (signal-to-noise ratio = 3) of 500 nM. The practicality of this probe has been validated through the analysis of hot spring water samples.
Ma, Jia-Ying; Chen, Po-Cheng; Chang, Huan-Tsung
We have developed a one-pot, inexpensive, simple and rapid method to synthesize photoluminescent copper nanocluster (Cu NC) aggregates from Cu(2+) ions in 65% (v v(-1)) dimethylformamide aqueous solution containing penicillamine (PA) as a capping and reducing agent. As-prepared PA-Cu NC aggregates emit at 580 nm when excited at 326 nm, with a quantum yield of 2.0%. The photoluminescence of PA-Cu NC aggregates originate from ligand-to-metal charge transfer, which is supported by a long lifetime (126.5 ns) and a large Stokes shift (254 nm). As-prepared PA-Cu NC aggregates have different emission wavelengths with the same excitation wavelength in various organic-aqueous solutions. The PA-Cu NC aggregates are highly selective and sensitive to the detection of hydrogen sulfide (H₂S), based on analyte-induced photoluminescence quenching through the formation of CuS nanoparticles. The probe allows the detection of H₂S, with a linear range of 1-100 μM and a limit of detection (signal-to-noise ratio = 3) of 500 nM. The practicality of this probe has been validated through the analysis of hot spring water samples.
Erickson, R S; Yount, S T
An unintended fall in body temperature is commonly associated with surgery. One promising strategy to help conserve body heat is use of covers made of aluminum-coated plastic. We compared the effect of three combinations of the covers (head cover, body covers, both) and a control condition on tympanic temperature in 60 adults having major abdominal surgery under general anesthesia. The covers were applied from the time of transport to the operating room until exit from the postanesthesia care unit (PACU). Tympanic temperature was measured with an infrared thermometer. Between transport and PACU entry, the four groups had mean temperature decreases ranging from 1.6 degrees to 2.3 degrees F (0.9 degree to 1.3 degrees C). After controlling for background variables affecting body temperature, adjusted PACU entry temperature was higher in the two groups with aluminized body covers. Regression analysis showed that use of the body covers accounted for 7% of the temperature variance at PACU entry and predicted a 0.9 degree F (0.5 degree C) higher temperature at that time. These findings indicate that aluminized body covers help to reduce heat loss in patients having major abdominal surgery.
Pazar, Berrin; Yava, Ayla
Objective To determine the effect of nursing guide application developed for the present study and to evaluate the Early Warning Scoring System (EWSS) in post-anaesthesia care unit (PACU). Methods The study was carried out as a randomised-controlled experimental study. The study sample comprised of 123 adult patients having thoracic and abdominal surgery between January 2011 and April 2011 in the Anaesthesiology and Reanimation Department of a training and research hospital. Patients were randomised during the pre-operative period; the patients who were followed-up according to the EWSS and a nursing guide constituted the study group (SG=63) and the patients whose EWSS score was calculated but routine follow-up in PACU was not intervened constituted the control group (CG=60). Results During the PACU, complications developed in in 34.92% of SG patients and in 30.00% of CG patients. Of the SG patients, 95.45% developing complications and of the CG patients, 22.22% developing complications were treated in the first 10 minutes, and it was determined that in 61.12% of CG patients, complications were not treated. There was a significant difference between the SG and CG patients in terms of treatment duration against complications (p<0.05). Conclusion The EWSS and nurse’s guide provides early determination and treatment of patients developing complications. Thus, it is recommended to use the EWSS and a nursing guide in PACU. PMID:27366375
Rafer, Lorenzo; Austin, Flower; Frey, Jessica; Mulvey, Christie; Vaida, Sonia; Prozesky, Jansie
Anesthesiologists use various medications to provide surgical patients with pain relief in the postoperative period. Other modalities, such as music, could be used in conjunction with opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) to decrease pain and lower heart rate and blood pressure. Our hypothesis was that patients listening to jazz in a postanesthesia care unit (PACU) would have lower heart rates and blood pressures and reduced pain and anxiety. The study objective was to determine if listening to jazz music in the PACU, when compared to wearing noise-canceling headphones with no music playing, would decrease heart rate, blood pressure, pain, or anxiety in patients undergoing a hysterectomy. The research design was a prospective, randomized study. The study was conducted in the PACU at the Penn State Hershey Medical Center in Hershey, PA, USA. A total of 56 patients, aged 18-75 y, who were categorized as status 1 or 2 according to the American Society of Anesthesiologists (ASA) Physical Status Classification System, and who were undergoing elective laparoscopic or abdominal hysterectomies, were enrolled in the study. Patients were randomly assigned either to listen to jazz music where the beats per min (BPM) was <100 (experimental group, n = 28) or to wear noise-canceling headphones (control group, n = 28) for 30 min while in the PACU after their surgery. Heart rate was the primary outcome, and secondary outcomes included systolic and diastolic blood pressure, an anxiety score, and a pain score. All outcome measures were initially recorded at baseline upon the patient's arrival in the PACU. Heart rate and blood pressure were recorded postoperatively every 5 min for the initial 30 min that a patient was in the PACU. Pain was checked every 10 min during the 30-min period; anxiety was checked at 30 min. Heart rates of patients in the noise-cancellation group were significantly lower when compared with baseline (P < .05), at all time points. For
Rose, D K; Cohen, M M; Wigglesworth, D F; DeBoer, D P
Previous studies have noted a high incidence of adverse outcomes in the postanesthesia care unit (PACU), but few have examined associated factors and patient outcomes. To determine the frequency of acute, unanticipated respiratory problems and to examine the associated patient, surgical, and anesthetic factors, we prospectively collected preoperative, intraoperative, and postoperative data on 24,157 consecutive PACU patients who received a general anesthetic during a 33-month period. A PACU critical respiratory event (CRE), was defined as any unanticipated hypoxemia (hemoglobin oxygen saturation < 90%), hypoventilation (respiratory rate < 8 breaths/min or arterial carbon dioxide tension > 50 mmHg) or upper-airway obstruction (stridor or laryngospasm) requiring an active and specific intervention (ventilation, tracheal intubation, opioid or muscle relaxant antagonism, insertion of oral/nasal airway or airway manipulation). These problems were documented by PACU nurses whereas data on case-mix, surgical factors, and intraoperative management were retrieved from the anesthetic record. Significant patient, surgical, and anesthetic factors were identified by logistic regression analysis. Other morbidity experienced by patients with a CRE was also noted. For patients given general anesthesia the risk of a CRE was 1.3% (hypoxemia 0.9%, hypoventilation 0.2%, airway obstruction 0.2%). Preoperative factors that increase risk were age > 60 yr, male gender, diabetes, and obesity (P < 0.05). Patients who underwent operative procedures on an emergency basis and whose operation was longer than 4 h were also at increased risk, but those undergoing perineal procedures were at lower risk (P < 0.05). Anesthetic risk factors (P < 0.05) included opioid premedication (relative odds 1.8), sedatives preoperatively (2.0), fentanyl > 2.0 micrograms.kg-1.h-1 as the sole opioid (1.9), fentanyl used in combination with morphine (1.6) and atracurium > or = 0.25 mg.kg-1.h-1 (2.2). Patients in
Murphy, Glenn S; Szokol, Joseph W; Avram, Michael J; Greenberg, Steven B; Marymont, Jesse H; Vender, Jeffery S; Gray, Jayla; Landry, Elizabeth; Gupta, Dhanesh K
The subjective experience of residual neuromuscular blockade after emergence from anesthesia has not been examined systematically during postanesthesia care unit (PACU) stays. The authors hypothesized that acceleromyography monitoring would diminish unpleasant symptoms of residual paresis during recovery from anesthesia by reducing the percentage of patients with train-of-four ratios less than 0.9. One hundred fifty-five patients were randomized to receive intraoperative acceleromyography monitoring (acceleromyography group) or conventional qualitative train-of-four monitoring (control group). Neuromuscular management was standardized, and extubation was performed when defined criteria were achieved. Immediately upon a patient's arrival to the PACU, the patient's train-of-four ratios were measured using acceleromyography, and a standardized examination was used to assess 16 symptoms and 11 signs of residual paresis. This examination was repeated 20, 40, and 60 min after PACU admission. The incidence of residual blockade (train-of-four ratios less than 0.9) was reduced in the acceleromyography group (14.5% vs. 50.0% control group, with the 99% confidence interval for this 35.5% difference being 16.4-52.6%, P < 0.0001). Generalized linear models revealed the acceleromyography group had less overall weakness (graded on a 0-10 scale) and fewer symptoms of muscle weakness across all time points (P < 0.0001 for both analyses), but the number of signs of muscle weakness was small from the time of arrival in the PACU and did not differ between the groups at any time. Acceleromyography monitoring reduces the incidence of residual blockade and associated unpleasant symptoms of muscle weakness in the PACU and improves the overall quality of recovery.
Schwarzkopf, Ran; Snir, Nimrod; Sharfman, Zachary T; Rinehart, Joseph B; Calderon, Michael-David; Bahn, Esther; Harrington, Brian; Ahn, Kyle
A Perioperative Surgical Home (PSH) care model applies a standardized multidisciplinary approach to patient care using evidence-based medicine to modify and improve protocols. Analysis of patient outcome measures, such as postoperative nausea and vomiting (PONV), allows for refinement of existing protocols to improve patient care. We aim to compare the incidence of PONV in patients who underwent primary total joint arthroplasty before and after modification of our PSH pain protocol. All total joint replacement PSH (TJR-PSH) patients who underwent primary THA (n=149) or TKA (n=212) in the study period were included. The modified protocol added a single dose of intravenous (IV) ketorolac given in the operating room and oxycodone immediate release orally instead of IV Hydromorphone in the Post Anesthesia Care Unit (PACU). The outcomes were (1) incidence of PONV and (2) average pain score in the PACU. We also examined the effect of primary anesthetic (spinal vs. GA) on these outcomes. The groups were compared using chi-square tests of proportions. The incidence of post-operative nausea in the PACU decreased significantly with the modified protocol (27.4% vs. 38.1%, p=0.0442). There was no difference in PONV based on choice of anesthetic or procedure. Average PACU pain scores did not differ significantly between the two protocols. Simple modifications to TJR-PSH multimodal pain management protocol, with decrease in IV narcotic use, resulted in a lower incidence of postoperative nausea, without compromising average PACU pain scores. This report demonstrates the need for continuous monitoring of PSH pathways and implementation of revisions as needed.
Khobrani, Moteb A.; Camamo, James M.; Patanwala, Asad E.
Objectives The primary objective was to assess whether the use of intravenous acetaminophen (APAP) in the ambulatory surgery setting is associated with a decreased length of stay in the post-anesthesia care unit (PACU). The secondary outcomes evaluated were pain scores, opioid consumption, and total cost of analgesics used in the PACU. Methods This was a retrospective cohort study conducted in adult patients (18 years of age or older) who received an eye, ear, nose, or throat (EENT) procedure at an outpatient surgery center between January 2014 and January 2015. Patients were consecutively included until the desired sample was reached during two six-month time periods: 1) intravenous APAP available on the formulary (APAP group) and 2) intravenous APAP not available on the formulary (non-APAP group). Results The cohort included 174 patients who received an EENT procedure (87 patients in the APAP group and 87 patients in the non-APAP group). The median PACU length of stay was 66 minutes (interquartile range [IQR], 48–92) in the APAP group and 71 minutes (IQR, 52–89) in the non-APAP group (P = 0.269). Mean pain score categories in the APAP versus non-APAP group were mild (85% versus 53%, respectively; P < 0.001), moderate (13% versus 33%, respectively; P = 0.002), and severe (2% versus 14%, respectively; P = 0.005). The median opioid consumption in morphine equivalents was 9 mg (IQR, 5–13) in the APAP group and 8 mg (IQR, 5–12) in the non-APAP group (P = 0.081). The total cost of analgesics used in the PACU was significantly greater in the APAP group ($15 versus $1; P < 0.001). Conclusions Intravenous APAP use in EENT ambulatory surgery is not associated with decreased PACU length of stay. However, it may decrease postoperative pain following EENT procedures. PMID:28163558
Petersen Tym, Mitchell K; Ludbrook, Guy L; Flabouris, Arthas; Seglenieks, Richard; Painter, Thomas W
Accurate identification of patients at risk of early postoperative deterioration allows needs-based allocation of patients to appropriate levels of care. This study aimed to record the incidence of early postoperative deterioration and identify factors predictive of at-risk patients. Doing so may assist future evidence-based perioperative planning and allocation of patients to high-acuity facilities. With ethical approval, data from elective non-cardiac surgical patients were collected between May and August 2013. Patient and surgical factors potentially related to postoperative deterioration were collected from preoperative assessment records. Data on deterioration in the postanaesthesia care unit (PACU), and on the wards were collected prospectively for a period of 72 h postoperatively. Patient factors, surgical factors and PACU events were compared with ward events using binomial logistic regression analysis. Of the 747 patients, postoperative deterioration was common both in PACU (155 (20.1%) patients) and on the wards (125 (16.7%)). Common ward events included hypotension (64 (8.2%)) and desaturation (59 (6.2%)). A rapid response team call occurred for 33 (4.4%) patients and an unplanned ICU admission for seven (0.9%) patients. A history of atrial fibrillation and chronic liver disease, duration of surgery and excessive sedation in PACU, among others, were strongly associated with subsequent ward deterioration. However, measures of surgical complexity were not. Patient factors, duration of surgery and events in PACU can be predictive of subsequent early postoperative ward clinical deterioration. Such information may aid appropriate perioperative decision-making with respect to postoperative utilization of high-acuity facilities. © 2017 Royal Australasian College of Surgeons.
Urban, Michael K; Mangini-Vendel, Michele; Lyman, Stephen; Pan, Ting Jung; Magid, Steven K
The goal of elective orthopedic surgery is to return patients to their expected level of activity without an increased incidence of postoperative complications. The first step is identifying patient and/or surgical characteristics responsible for these complications. This study sought to identify predictors of a step-up in medical care after non-ambulatory elective orthopedic surgery. At a single specialty orthopedic hospital, we identified all in-hospital postoperative patients who were transferred to a higher level of medical care ((PACU) post-anesthesia care unit). The characteristics of both transferred and non-transferred patients were compared. A model was built which incorporated predictors of return to a higher level of care. During a 1-year period, 155 of 7967 patients (1.95%) required transfer to the PACU within 5 days of surgery. Cardiac complications were the major reason for transfer (50.3%), followed by pulmonary (11.0%) and neurological complications (9.7%). Patients who returned to the PACU were older, had more Exlihauser comorbidities, and had obstructive sleep apnea (OSA). In a model adjusting for all patient characteristics: age, American Society of Anesthesiologists (ASA) status, congestive heart failure (CHF), the Charlson comorbidity index and OSA predicted return to the PACU. In an elderly population with multiple comorbidities undergoing elective common major orthopedic procedures, approximately 2% of patients required readmission to the PACU. The most common problems requiring this step-up in care were cardiac and pulmonary, which resulted in an increased length of hospital stay. Patients with OSA and multiple comorbidities undergoing total knee arthroplasty carry an increased risk for postoperative complications.
Choi, Jin Woo; Joo, Jin Deok; Kim, Dae Woo; In, Jang Hyeok; Kwon, So Young; Seo, Kwonhui; Han, Donggyu; Cheon, Ga Young; Jung, Hong Soo
We aimed to compare fentanyl, remifentanil and dexmedetomidine with respect to hemodynamic stability, postoperative pain control and achievement of sedation at the postanesthetic care unit (PACU). In this randomized double-blind study, 90 consecutive total laparoscopic hysterectomy patients scheduled for elective surgery were randomly assigned to receive fentanyl (1.0 μg/kg) over 1 minute followed by a 0.4 μg/kg/hr infusion (FK group, n = 30), or remifentanil (1.0 μg/kg) over 1 minute followed by a 0.08 μg/kg/min infusion (RK group, n = 30), or dexmedetomidine (1 μg/kg) over 10 minutes followed by a 0.5 μg/kg/hr infusion (DK group, n = 30) initiating at the end of main procedures of the operation to the time in the PACU. A single dose of intravenous ketorolac (30 mg) was given to all patients at the end of surgery. We respectively evaluated the pain VAS scores, the modified OAA/S scores, the BIS, the vital signs and the perioperative side effects to compare the efficacy of fentanyl, remifentanil and dexmedetomidine. Compared with other groups, the modified OAA/S scores were significantly lower in DK group at 0, 5 and 10 minutes after arrival at the PACU (P < 0.05), whereas the pain VAS and BIS were not significantly different from other groups. The blood pressure and heart rate in the DK group were significantly lower than those of other groups at the PACU (P < 0.05). DK group, at sedative doses, had the better postoperative hemodynamic stability than RK group or FK group and demonstrated a similar effect of pain control as RK group and FK group with patient awareness during sedation in the PACU. (World Health Organization registry, KCT0001524).
Carron, Michele; Zarantonello, Francesco; Lazzarotto, Nadia; Tellaroli, Paola; Ori, Carlo
Sugammadex has been introduced for reversal of neuromuscular blockade (NMB) induced by rocuronium (or vecuronium). Although its efficacy and safety have been established, data are conflicting as to whether it accelerates discharge to the surgical ward compared with neostigmine, which is traditionally used for reversing NMB. The object of this systematic review and meta-analysis was to review the research comparing sugammadex and neostigmine in the context of patient discharge after general anesthesia. Systematic review and meta-analysis. University medical hospital. Five-hundred eighteen patients from six studies were included. A comprehensive search was conducted using PubMed, Web of Science, Google Scholar, and Cochrane Library electronic databases to identify randomized controlled trials written in English. Two reviewers independently selected the studies, extracted data regarding postoperative discharge, and assessed the trials' methodological quality and evidence level. Postoperative discharge time was determined from the operating room (OR) to the postanesthesia care unit (PACU) and from the PACU to the surgical ward. This study was conducted using PRISMA methodology. Time to discharge after NMB reversal with sugammadex or neostigmine. Compared with neostigmine, sugammadex was associated with a significantly faster discharge from the OR to the PACU (mean difference [MD]=22.14min, 95% CI (14.62, 29.67), P<0.0001, I(2)=0%) and from the PACU to the surgical ward (MD=16.95min, 95% CI (0.23, 33.67), P=0.0469, I(2)=98.4%). Similarly, discharge-readiness was shorter for sugammadex than for neostigmine from the OR to the PACU (MD=5.58min, 95% CI (3.03, 8.14), P≤0.0001, I(2)=0%). However, discharge-readiness was similar in both groups for patients moving from the PACU to the surgical ward (MD=-1.10min, 95% CI (-5.69, 3.50), P=0.6394, I(2)=25.3%). Results from this meta-analysis suggest that sugammadex accelerates postoperative discharge of patients after general
Ali Hassan, Hossam Ibrahim Eldesuky
Background: There were several studies using either low dose Bupivacaine as unilateral selective spinal anesthesia (SSA) or low dose lidocaine SSA for ambulatory knee arthroscopy. There were many concerns about high failure rate, complications, and different times to home readiness discharges. Aim of the Study: The study aimed to: (1) Compare the clinical efficacy and side effects of two different techniques of SSA in subarachnoid block for ambulatory knee arthroscopy (2) evaluate the possibility of a shorter stay in post-anesthesia care unit (PACU) or eligibility for fast tracking anesthesia (bypassing PACU) after SSA and numbers of patient bypassed PACU (3) compare the time to ambulate and time to home readiness. Patients and Methods: Prospective, randomized and open study was conducted, including 50 outpatients undergoing knee arthroscopy. Patients allocated into two groups: Bupivacaine group (group B); was injected with 3 mg bupivacaine and 10 ug fentanyl intrathecally in lateral decubitus position and remained for 20 min then supine position. Lidocaine group (group L) was injected with 20 mg lidocaine, plus 25 ug fentanyl intrathecally and immediately keeps in the supine position after injection. The quality and durations of motor and sensory block were compared between groups. Sensory block assessed by pin brick method and motor block assessed by Bromage scale. Time spent in PACU, the time to ambulate, and times to home-readiness were compared. Number of patients bypassed PACU was recorded. Side effects as pain, nausea, vomiting, postdural puncture headache, transient neurological symptoms, retention of urine and pruritus were evaluated and compared after SSA. Results: Bupivacaine group provided unilateral spinal anesthesia with significantly longer duration of both motor and sensory blocks than bilateral spinal of lidocaine group P < 0.001 and P < 0.01 respectively. The upper dermatomal height of sensory block reached was T9 and T8 in groups B and L
Ali Hassan, Hossam Ibrahim Eldesuky
There were several studies using either low dose Bupivacaine as unilateral selective spinal anesthesia (SSA) or low dose lidocaine SSA for ambulatory knee arthroscopy. There were many concerns about high failure rate, complications, and different times to home readiness discharges. The study aimed to: (1) Compare the clinical efficacy and side effects of two different techniques of SSA in subarachnoid block for ambulatory knee arthroscopy (2) evaluate the possibility of a shorter stay in post-anesthesia care unit (PACU) or eligibility for fast tracking anesthesia (bypassing PACU) after SSA and numbers of patient bypassed PACU (3) compare the time to ambulate and time to home readiness. Prospective, randomized and open study was conducted, including 50 outpatients undergoing knee arthroscopy. Patients allocated into two groups: Bupivacaine group (group B); was injected with 3 mg bupivacaine and 10 ug fentanyl intrathecally in lateral decubitus position and remained for 20 min then supine position. Lidocaine group (group L) was injected with 20 mg lidocaine, plus 25 ug fentanyl intrathecally and immediately keeps in the supine position after injection. The quality and durations of motor and sensory block were compared between groups. Sensory block assessed by pin brick method and motor block assessed by Bromage scale. Time spent in PACU, the time to ambulate, and times to home-readiness were compared. Number of patients bypassed PACU was recorded. Side effects as pain, nausea, vomiting, postdural puncture headache, transient neurological symptoms, retention of urine and pruritus were evaluated and compared after SSA. Bupivacaine group provided unilateral spinal anesthesia with significantly longer duration of both motor and sensory blocks than bilateral spinal of lidocaine group P < 0.001 and P < 0.01 respectively. The upper dermatomal height of sensory block reached was T9 and T8 in groups B and L respectively. Group B showed more intense motor block than group L
Pelster, Bernd; Wood, Chris M; Speers-Roesch, Ben; Driedzic, William R; Almeida-Val, Vera; Val, Adalberto
Three closely related characids, Tambaqui (omnivore), black Piranha (carnivore), and Pacu (herbivore), all Serrasalmidae, inhabit the ion-poor, acidic Rio Negro. We compared O2-consumption and N excretion rates in vivo, and sodium, chloride, glucose, and ammonia transport characteristics of gut sac preparations in vitro. The Pacu had a significantly higher weight-specific oxygen consumption, and a lower N/Q ratio than the omnivorous Tambaqui, and a significantly lower urea-N excretion rate than the carnivorous black Piranha, suggesting N-limitation in the herbivorous Pacu. With a value of 2.62 ± 0.15, gut to fork length ratio in the Pacu was about 2.5 times higher than in the black Piranha, and 2.0 times higher than in the Tambaqui. Anterior intestinal activities of three enzymes involved in N-fixation for amino acid synthesis (glutamate dehydrogenase, glutamate-oxaloacetate transferase, and glutamate-pyruvate transferase) were generally greatest in the carnivore and lowest in the herbivore species. In all three species, sodium, chloride, glucose, and ammonia were taken up at high rates from the intestine, resulting in an isosmotic fluid flux. Comparing the area-specific fluid flux of the anterior, mid, and posterior gut sections, no difference was detected between the three sections of the Pacu, while in the Tambaqui, it was highest in the anterior section, and in the black Piranha highest in the middle section. Overall, the area-specific uptake rates for sodium, chloride, glucose, and ammonia of anterior, mid, and posterior sections were similar in all three species, indicating that there is no difference in the area-specific transport rates associated with trophic position. The net ammonia uptake flux from gut interior was not significantly different from the net ammonia efflux to the serosal fluid, so that the ammonia removed from the intestine by the mucosal epithelium was quantitatively transferred through the tissue to the serosal side in all three
Research supports the practice of preprocedure warming as a method to prevent the development of unplanned perioperative hypothermia. ASPAN defines hypothermia as a core temperature lower than 36°C. The purpose of this quality improvement project was to explore the idea that preprocedure warming maintains perioperative normothermia. Information was obtained through retrospective chart reviews (n = 148). Temperatures were compared for patients who received standard preprocedure care versus patients who were warmed with a warming gown for one hour preprocedure. Before the institution of warming, about 50% of the patients received in the PACU were hypothermic. After the warming was instituted, only 12% of patients were received in a hypothermic state in the PACU. Concepts discussed in this paper include preprocedure warming, postprocedure hypothermia, and complications associated with hypothermia.
Manser, Tanja; Foster, Simon; Gisin, Stefan; Jaeckel, Dalit; Ummenhofer, Wolfgang
Effective handoff practices (ie, mechanisms for transferring information, responsibility and authority) are critical to ensure continuity of care and patient safety. This study aimed to develop a rating tool (self-rating and external rating) for handoff quality that goes beyond mere information transfer. The rating tool was piloted during 126 patient handoffs performed in three different clinical settings in a tertiary care hospital: (1) paramedic to emergency room staff, (2) anaesthesia care provider to postanaesthesia care unit (PACU) and (3) PACU nurse to ward nurse. We identified three factors (information transfer, shared understanding, working atmosphere) predicting handoff quality. This study provides insights into the multidimensional concept of handoff quality. Our rating tool is feasible and comprehensive by including not only characteristics of the information process but also aspects of teamwork and, thus, provides an important tool for future research on patient handoff.
Kim, Jung T; Wajda, Michael; Cuff, Germaine; Serota, David; Schlame, Michael; Axelrod, Deborah M; Guth, Amber A; Bekker, Alex Y
This study compared the analgesic efficacy of postoperative lavender oil aromatherapy in 50 patients undergoing breast biopsy surgery. Twenty-five patients received supplemental oxygen through a face mask with two drops of 2% lavender oil postoperatively. The remainder of the patients received supplemental oxygen through a face mask with no lavender oil. Outcome variables included pain scores (a numeric rating scale from 0 to 10) at 5, 30, and 60 minutes postoperatively, narcotic requirements in the postanesthesia care unit (PACU), patient satisfaction with pain control, as well as time to discharge from the PACU. There were no significant differences in narcotic requirements and recovery room discharge times between the two groups. Postoperative lavender oil aromatherapy did not significantly affect pain scores. However, patients in the lavender group reported a higher satisfaction rate with pain control than patients in the control group (P = 0.0001).
Umholtz, Matthew; Cilnyk, John; Wang, Christopher K; Porhomayon, Jahan; Pourafkari, Leili; Nader, Nader D
Recovery from anesthesia may be complicated with development of severe panic symptoms and anxiety. Preexisting anxiety disorder has been reported as a risk factor for development of these symptoms. We aimed to examine the frequency of emergence delirium (EDL) among veterans diagnosed with posttraumatic stress disorders (PTSDs). Retrospective cohort. Postoperative recovery area. Perioperative information of 1763 consecutive patients who underwent a surgical procedure requiring general anesthesia were collected. The patients were grouped on the basis of previous diagnosis of PTSD. A total of 317 patients were identified with a positive history of PTSD and were compared to 1446 patients without such a history for the occurrence of EDL in the postanesthesia care unit (PACU) as the primary endpoint. Duration of stay in PACU in minutes and the frequency of hospital admission were the secondary endpoints. Multivariate binary logistic regression analysis was performed to identify the predictors of EDL among the veteran population. Emergence delirium was reported in 37 cases (2.1%) after general anesthesia. Fifteen (4.7%) of 317 patients with PTSD and 22 (1.5%) of 1446 patients without history of PTSD demonstrated symptoms related to EDL in the PACU (P=.002). After propensity matching, there were 8 patients with EDL in the PTSD group whereas there were only 2 patients with EDL among controls. Posttraumatic stress disorder was also an independent predictor of EDL in multivariate analysis with an odds ratio of 6.66 and a 95% confidence interval of 2.04 to 21.72 (P=.002). Posttraumatic stress disorder independently predicted the frequency of EDL even after correcting for preexisting depression and anxiety disorders. A relatively longer duration of PACU stay in PTSD patients may reflect raised awareness of the health care workers about this debilitating mental disorder. Published by Elsevier Inc.
Gaur, Pallavi; Harde, Minal; Gujjar, Pinakin; Deosarkar, Devanand; Bhadade, Rakesh
Background and Aim: Monitoring carbon dioxide (CO2) is of utmost importance in neurosurgical patients. It is measured by partial pressure of arterial CO2 (PaCO2) and end-tidal CO2 (ETCO2). We aimed to study the correlation between PaCO2 and ETCO2 in neurosurgical patients in the intraoperative and postoperative period on mechanical ventilation in Postanesthesia Care Unit (PACU). Methodology: This was prospective observational study done at tertiary care teaching public hospital over a period of 1 year. We studied 30 patients undergoing elective craniotomy intraoperatively and in the postoperative period on mechanical ventilation for 24 h. Serial measurement of ETCO2 and PaCO2 at baseline, hourly intraoperatively and every 6 hourly in the PACU were studied. Data analysis was done using SPSS software version 20. Results: The mean PaCO2–ETCO2 gradient intraoperatively over 4 h is 3.331 ± 2.856 and postoperatively over 24 h is 2.779 ± 2.932 and lies in 95% confidence interval. There was statistically significant correlation between PaCO2 and ETCO2 intraoperatively baseline, 1 h, 2 h, 3 h, and 4 h with Pearson's correlation coefficients of 0.799, 0.522, 0582, 0.439, and 0.547, respectively (P < 0.05). In PACU at baseline, 6 h, 12 h, 18 h, and 24 h Pearson's correlation coefficients were. 534, −0.032, 0.522, 0.242, 0.592, and 0.547, respectively, which are highly significant at three instances (P < 0.01). Conclusion: ETCO2 correlates PaCO2 with acceptable accuracy in neurosurgical patients in the intraoperative and postoperative period on mechanical ventilation in Intensive Care Unit. Thus, continuous and noninvasive ETCO2 can be used as a reliable guide to estimate arterial PCO2 during neurosurgical procedures and in PACU. PMID:28761526
Harde, Minal; Bhadade, Rakesh; Iyer, Hemlata; Jatale, Amol; Tiwatne, Sagar
Infection is a potentially serious complication of epidural analgesia and with an increase in its use in wards there is a necessity to demonstrate its safety. We aimed to compare the incidence of colonization of epidural catheters retained for short duration (for 48 h) postoperative analgesia in postanesthesia care unit and wards. It was a prospective observational study done in a tertiary care teaching public hospital over a period of 2 years and included 400 patients with 200 each belonged to two groups PACU and ward. We also studied epidural tip culture pattern, skin swab culture at the entry point of the catheter, their relation to each other and whether colonization is equivalent to infection. Data were analyzed using statistical software GraphPad. Overall positive tip culture was 6% (24), of them 7% (14) were from PACU and 5% (10) were from ward (P = 0.5285). Positive skin swab culture was 38% (150), of them 20% (80) were from PACU and 18% (70) were from ward (P = 0.3526). The relation between positive tip culture and positive skin swab culture in same patients is extremely significant showing a strong linear relationship (95% confidence interval = 0.1053-0.2289). The most common microorganism isolated was Staphylococcus epidermidis. No patient had signs of local or epidural infection. There is no difference in the incidence of epidural catheter tip culture and skin swab culture of patients from the general ward and PACU. Epidural analgesia can be administered safely for 48 h in general wards without added risk of infection. The presence of positive tip culture is not a predictor of epidural space infection, and colonization is not equivalent to infection; hence, routine culture is not needed. Bacterial migration from the skin along the epidural track is the most common mode of bacterial colonization; hence, strict asepsis is necessary.
Chan, Conny S M; Molassiotis, Alexander
In Hong Kong, some hospitals have established the practice of Parental Presence Induction (PPI) and visitation in Postanaesthesia Care Units (PACU) for children receiving surgery. The literature indicates that parents reported extreme anxiety and discomfort after being present at induction of anaesthesia and suggests that it would seem appropriate to devise a programme of education to reduce anxiety for parents. A quasi-experimental pretest and post-test design was employed. Parents in the experimental group received an educational programme about the role and expectations of parents having PPI and visitation in PACU together with an information pamphlet. The comparison group received routine (verbal) instructions. The Chinese version of the State and Trait Anxiety Inventory and the Parental Satisfaction with Care Questionnaire were used to assess parents' anxiety and satisfaction with care. A total of 50 parents (mostly mothers) were recruited. Twenty-five were allocated in the intervention group and 25 in the comparison group. The children were aged 1--9 years with a mean age of 2.9 years. There were 46 male and four female children. The results demonstrate that parents who received an education programme reported a decrease in anxiety (P < 0.001) and an increase in their satisfaction with the care provided (P < 0.001). A significant negative relationship (r= -0.61, P < 0.001) between parental anxiety postoperatively and the satisfaction with care score was also obtained, suggesting that lower levels of parental anxiety are associated with higher levels of satisfaction. The study suggests that an educational programme preparing parents for their child's induction of anaesthesia and visitation to the PACU should be offered, as it can reduce their anxiety with the practice of PPI and visitation in the PACU and increase parents' satisfaction with care.
Cheng, Xinqi; Huang, Yue; Zhao, Qing; Gu, Erwei
Children with obstructive sleep apnea (OSA) are particularly at risk under anesthesia after uvulopalatopharyngoplasty (UPPP). This prospective randomized double-blind study focused on the comparison of dexmedetomidine-ketamine and sevoflurane-sufentanil anesthesia on children with respect to safety, feasibility, and clinical effects. A total of 60 children, aged 2-10 years, classified as American Society of Anesthesiologists (ASA) status I and II scheduled for UPPP were prospectively studied. Patients were randomly allocated to receive either dexmedetomidine-ketamine-based anesthesia (group DK, n = 30) or sevoflurane-sufentanil-based anesthesia (group SS, n = 3 0). Heart rate (HR) and systolic blood pressure during the first 60 min of the procedure, Ramsay sedation score, the Pediatric Anesthesia Emergence Delirium (PAED) scale and a 5-point scale used to evaluate emergence agitation (EA) in postanesthesia care unit (PACU) and postoperative outcomes data were recorded. During the first 60 min of anesthesia, mean HR, and mean diastolic noninvasive arterial blood pressure (NIBP) were not statistically different in the two groups (P > 0.05) Compared with group SS, the patients in group DK had lower rescue tramadol requirement and lower pain score, PAED score, and EA score at 5, 10, 15, and 30 min in PACU; but had a higher Ramsay scale at 10, 15, 30, 45, and 60 min in PACU and the incidence of SpO2 below 95%, also the time of first bowel movement and ambulation in group DK was shorter. The dexmedetomidine-ketamine combination was not superior to a sevoflurane-sufentanil combination because of late awake time and a high potential for adverse respiratory events in PACU, the benefit of dexmedetomidine administration being a decreased incidence of EA and a lower recovery time of bowel movement and ambulation.
Brueckmann, B; Sasaki, N; Grobara, P; Li, M K; Woo, T; de Bie, J; Maktabi, M; Lee, J; Kwo, J; Pino, R; Sabouri, A S; McGovern, F; Staehr-Rye, A K; Eikermann, M
This study aimed to investigate whether reversal of rocuronium-induced neuromuscular blockade with sugammadex reduced the incidence of residual blockade and facilitated operating room discharge readiness. Adult patients undergoing abdominal surgery received rocuronium, followed by randomized allocation to sugammadex (2 or 4 mg kg(-1)) or usual care (neostigmine/glycopyrrolate, dosing per usual care practice) for reversal of neuromuscular blockade. Timing of reversal agent administration was based on the providers' clinical judgement. Primary endpoint was the presence of residual neuromuscular blockade at PACU admission, defined as a train-of-four (TOF) ratio <0.9, using TOF-Watch® SX. Key secondary endpoint was time between reversal agent administration and operating room discharge-readiness; analysed with analysis of covariance. Of 154 patients randomized, 150 had a TOF value measured at PACU entry. Zero out of 74 sugammadex patients and 33 out of 76 (43.4%) usual care patients had TOF-Watch SX-assessed residual neuromuscular blockade at PACU admission (odds ratio 0.0, 95% CI [0-0.06], P<0.0001). Of these 33 usual care patients, 2 also had clinical evidence of partial paralysis. Time between reversal agent administration and operating room discharge-readiness was shorter for sugammadex vs usual care (14.7 vs. 18.6 min respectively; P=0.02). After abdominal surgery, sugammadex reversal eliminated residual neuromuscular blockade in the PACU, and shortened the time from start of study medication administration to the time the patient was ready for discharge from the operating room. Clinicaltrials.gov:NCT01479764. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Turner, Taylor B; Habib, Ashraf S; Broadwater, Gloria; Valea, Fidel A; Fleming, Nicole D; Ehrisman, Jessie A; Di Santo, Nicola; Havrilesky, Laura J
To retrospectively evaluate perioperative pain and analgesic and antiemetic use in patients who underwent surgical staging for endometrial cancer using traditional versus robotic-assisted laparoscopy. We identified women in a single institution who underwent minimally hysterectomy for endometrial cancer from 2008 to 2012. Patient characteristics and perioperative outcomes, including analgesic and antiemetic use and pain scores, were analyzed. After univariate analysis, a multivariate linear regression model was generated to determine factors associated with narcotic use in the post anesthesia care unit (PACU) (Canadian Task Force Classification II-3). A single academic institution in the United States from 2008 to 2012. Women undergoing total laparoscopic hysterectomy or robotic-assisted laparoscopic hysterectomy for endometrial cancer. Laparoscopic or robotic-assisted laparoscopic hysterectomy. Three hundred thirty-five women were included (213 laparoscopy and 122 robotic-assisted laparoscopy). There was no difference in pain scores at 0 to 6 and 6 to 12 hours after surgery; at 12 to 24 hours, robotic-assisted surgery was associated with higher median pain scores (5/10 vs 4/10, p = .012). Robotic-assisted surgery was associated with a longer anesthesia time (289 vs 255 minutes, p < .001), similar antiemetic use (p = .40), and lower narcotic use in the postanesthesia care unit (PACU) (1.3 mg vs 2.5 mg morphine equivalents, p = .003). There was no difference in narcotic use on the postoperative floor (p = .46). In multivariate analysis controlling for age, menopausal status, anesthesia duration, and local anesthetic use, hysterectomy type was not a significant predictor of PACU narcotic use (p = .86). In a retrospective analysis, a robotic-assisted approach to endometrial cancer was not associated with reduced PACU narcotic or antiemetic use compared with the traditional laparoscopic approach. Twenty-four-hour narcotic and antiemetic use was also not different
Jensen, K; Kehlet, H; Lund, C M
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. 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. 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. 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.
Byrne, Kelly; Nolan, Aoife; Barnard, John; Tozer, Megan; Harris, David; Sleigh, Jamie
This study aimed to discover whether co-analgesia with tramadol or additional morphine was more effective for patients who still had severe pain despite being given 10 mg intravenous morphine in the post-anesthesia care unit (PACU). All eligible patients were consented and recruited to the trial pre-operatively, but only a small subgroup – whose pain was not successfully controlled (pain score 6/10 or more) after receiving 10 mg of morphine in the PACU—were then randomized to enter the trial and receive, in a double blinded fashion, the analgesic study drug; which consisted of either a further 10 mg of morphine, or 100 mg of tramadol, titrated intravenously to control their pain. The groups were compared as to: the time to readiness for discharge, the patient’s pain scores over time, and the presence of side effects. There was no statistically significant difference in any of the outcomes measured. The time to readiness for discharge from PACU was 119 minutes in the morphine group and 120 minutes in the tramadol group. However in approximately half the cases who entered the trial (i.e., where pain had not been controlled with the pre-enrollment baseline 10 mg of morphine in PACU) neither a further 10 mg of morphine nor 100 mg of tramadol effectively relieved the patient’s pain. We found no difference between additional morphine and co-analgesia with tramadol in this study. Patients who don’t respond to reasonable doses of opioids in PACU are very likely to be unresponsive to further opioids, and other non-opioid analgesic techniques (such as regional anesthesia) should be considered early in this group of patients.
Ruiz-Patiño, Alejandro; Acosta-Ospina, Laura Elena; Rueda, Juan-David
Congestion in the postanesthesia care unit (PACU) leads to the formation of waiting queues for patients being transferred after surgery, negatively affecting hospital resources. As patients recover in the operating room, incoming surgeries are delayed. The purpose of this study was to establish the impact of this phenomenon in multiple settings. An operational mathematical study based on the queuing theory was performed. Average queue length, average queue waiting time, and daily queue waiting time were evaluated. Calculations were based on the mean patient daily flow, PACU length of stay, occupation, and current number of beds. Data was prospectively collected during a period of 2 months, and the entry and exit time was recorded for each patient taken to the PACU. Data was imputed in a computational model made with MS Excel. To account for data uncertainty, deterministic and probabilistic sensitivity analyses for all dependent variables were performed. With a mean patient daily flow of 40.3 and an average PACU length of stay of 4 hours, average total lost surgical opportunity time was estimated at 2.36 hours (95% CI: 0.36-4.74 hours). Cost of opportunity was calculated at $1592 per lost hour. Sensitivity analysis showed that an increase of two beds is required to solve the queue formation. When congestion has a negative impact on cost of opportunity in the surgical setting, queuing analysis grants definitive actions to solve the problem, improving quality of service and resource utilization. Copyright © 2016 Elsevier Inc. All rights reserved.
Henker, Richard A; Lewis, Allison; Dai, Feng; Lariviere, William R; Meng, Li; Gruen, Gary S; Sereika, Susan M; Pape, Hans; Tarkin, Ivan S; Gowda, Indira; Conley, Yvette P
Previous studies have associated mu-opioid receptor (OPRM1) genotype with pain and analgesia responses in postoperative and patient populations. This study investigates the role of catechol-O-methyltransferase (COMT) and OPRM1 genotypes in acute postoperative pain scores, opioid use, and opioid-induced sedation after surgical procedures for orthopedic trauma in an otherwise healthy patient population. Verbal pain/sedation scores, opioid use, and physiologic responses in the immediate postoperative period were examined for association with genetic variants in Caucasians genotyped for OPRM1 single nucleotide polymorphisms (SNPs) A118G and C17T and COMT SNPs. The OPRM1 A118G genotype was associated with patients' postoperative Numerical Pain scale (NPS) ratings at 15 min in the postanesthesia care unit (PACU) (p = .01) and patients' sedation scores at 15 min in the PACU (p = .02). COMT genotype (rs4818) was associated with opioid consumption in the first 45 min in the PACU (p = .04). NPS ratings at 45 min were also higher in the group of patients with A/A genotype of rs4680 than in patients with the other two genotypes at this SNP (p = .03). Our haplotype trend analysis identified a COMT haplotype "GCGG" significantly associated with NPS at 15 min (p = .0013), amount of opioids consumed in the first 45 min (p = .0024), and heart rate at 45 min in the PACU (p = .017). The results indicate that genetic variations in COMT contribute to the acute postoperative pain and analgesia responses and physiologic responses in this group of otherwise healthy postoperative orthopedic trauma patients.
Nassar, Adrienne A; Boyle, Mary E; Seifert, Karen M; Beer, Karen A; Apsey, Heidi A; Schlinkert, Richard T; Stearns, Joshua D; Cook, Curtiss B
To assess perioperative management of patients with diabetes mellitus who were being treated with insulin pump therapy. We reviewed records for documentation of insulin pump status and glucose monitoring during preoperative, intraoperative, and postanesthesia care unit (PACU) phases of surgery. Thirty-five patients (21 men) with insulin pumps underwent surgical procedures between January 1, 2006, and December 31, 2010. Mean age was 56 years, mean diabetes duration was 31 years, and mean duration of insulin pump therapy was 7 years. All patients were white, and 29 had type 1 diabetes mellitus. Of the 50 surgical procedures performed during the study period, 16 were orthopedic, 9 were general surgical, 7 were urologic, and 7 were kidney transplant operations; the remaining 11 procedures were in other surgical specialties. The mean (± standard deviation) time in the preoperative area was 118 ± 75 minutes, mean intraoperative time was 177 ± 102 minutes, and mean PACU time was 170 ± 78 minutes. Of the 50 procedures, status of pump use was documented in 32 cases in the preoperative area, 14 cases intraoperatively, and 30 cases in the PACU. Glucose values were recorded in 47 cases preoperatively, 30 cases intraoperatively, and 48 cases in the PACU. Results showed inconsistent documentation of pump use and glucose monitoring throughout the perioperative period, even for patients with prolonged anesthesia and recovery times. It was often unclear whether the pump was in place and operational during the intraoperative period. Guidelines should be developed for management of insulin pump-treated patients who are to undergo surgery.
Phillips, Maxie L; Willis, Bryan C; Broman, Aaron J; Lam, Humphrey V; Nguyen, Thanh T; Austin, Thomas M
Bilateral myringotomy and tympanostomy tube placement (BMT) is one of the most frequently performed pediatric outpatient procedures with 667,000 children receiving tympanostomy tubes annually. Because of this high volume, discovering the ideal analgesic regimen may lead to decreased overall postanesthesia care unit (PACU) costs while increasing patient and parent satisfaction. The purpose of this study is to determine if there is any benefit in supplementing intranasal (IN) fentanyl with intramuscular (IM) ketorolac with regard to immediate recovery characteristics. Retrospective, cohort study. University-affiliated teaching hospital. One thousand one hundred forty American Society of Anesthesiologists physical status 1 and 2 pediatric patients scheduled for BMT. No interventions were performed. A propensity matched cohort of pediatric patients who underwent BMT at Vanderbilt Children's Hospital from 2011 to 2014 was analyzed. The authors compared PACU recovery time, rescue analgesic administration, maximal PACU pain scores, and maximal PACU agitation scores between subgroups of patients given either IN fentanyl and IM ketorolac or IN fentanyl alone intraoperatively. After adjusting for patient demographics and fentanyl dose, the fentanyl/ketorolac group received rescue analgesics 4.7% (95% confidence interval [CI], 2.0%-7.5%) less often, displayed moderate to severe pain 4.7% (95% CI, 1.5%-8.0%) less often, and experienced emergence agitation 3.6% (95% CI, 1.5%-5.8%) less often than patients in the fentanyl-only group. This corresponded to a relative risk reduction of 127%, 76%, and 200%, respectively. Based on our retrospective analysis, adding IM ketorolac to IN fentanyl may be beneficial to pediatric patients undergoing BMT. However, these results should be confirmed with a prospective, double-blinded, randomized study. Copyright © 2016 Elsevier Inc. All rights reserved.
Son, Ji-Seon; Jang, Eunjoo; Oh, Min Wook; Lee, Ji-Hye; Han, Young Jin
Background This study was performed to compare the incidence of emergence agitation (EA) between inhalation and intravenous anesthesia induction in children after sevoflurane anesthesia. Methods In this prospective and double-blind study, 100 children aged 3 to 7 years were enrolled. Subjects were randomly assigned to the sevoflurane (Group S) or thiopental (Group T) anesthesia induction groups. Anesthesia was induced using 8% sevoflurane and 4-6 mg/kg thiopental in Groups S and T, respectively. Anesthesia was maintained with nitrous oxide and sevoflurane. The children were evaluated at 5 and 20 min after arrival in the postanesthesia care unit (PACU) with a four-point agitation scale and the Pediatric Anesthesia Emergence Delirium scale. The incidence of EA and administration of the rescue agent were recorded. Results The incidence of EA was significantly lower in Group T compared to Group S at 5 min after PACU arrival (3/49 patients, 6% vs. 12/47 patients, 26%, P = 0.019). However, there was no difference between the two groups at 20 min after PACU arrival (23/49 vs. 19/47 patients in Group T vs. Group S, P = 0.425). The overall incidence of EA was 60% (28/47 patients) in Group S and 41% (20/49 patients) in Group T (P = 0.102). The number of children who received propofol as a rescue agent was significantly lower in Group T (Group S: 14/47 vs. Group T: 5/49, P = 0.031). Conclusions Intravenous anesthesia induction with thiopental reduced the incidence of EA in the early PACU period compared to inhalation induction with sevoflurane in 3- to 7-year-old children undergoing sevoflurane anesthesia. PMID:26257850
Yang, Xudong; Li, Zhenzhen; Gao, Chunyan; Liu, Ruichang
To determine whether dexmedetomidine sedation in the postanesthesia care unit (PACU) could decrease agitation and delirium after free flap surgery. Eighty patients were randomly divided into 2 groups. In the experimental group, dexmedetomidine was given at an hourly infusion rate of 0.5 μg/kg for 1 hour before the operation was completed and continued in the PACU at 0.2 to 0.7 μg/kg continuously until the next morning. In the control group, normal saline was given during the same periods. Patients in the 2 groups received sufentanil and midazolam for sedation and pain relief when necessary. Agitation was monitored with the Riker Sedation-Agitation Scale in the PACU and delirium was monitored with the Confusion Assessment Method for the Intensive Care Unit for 5 days postoperatively. The overall incidence of agitation was similar between the 2 groups. However, when the influence of patient shifting was excluded, the incidence of agitation in the dexmedetomidine group was apparently lower than that in the control group (10.3 vs 30%; P = .029). No difference was found in the occurrence of delirium between the experimental and control groups (5.1 vs 12.5%; P = .432). Dexmedetomidine does not change the overall incidence of agitation after free flap surgery; however, it does decrease agitation after PACU admission. It does not prevent delirium within 5 days postoperatively. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Helling, Thomas S; Martin, Larry C; Martin, Magdeline; Mitchell, Marc E
Unexpected clinical deterioration (failure events) in surgical patients on standard nursing units (WARDs) could have a significant impact on eventual survival. We sought to investigate failure events requiring intensive care (surgical ICU [SICU]) transfer of surgical patients on WARDs in a single-center academic setting. Surgical patients admitted to WARDs over a 12-month period, who developed failure events, were retrospectively reviewed. Time to deterioration since WARD arrival, clinical factors, notification chain, and outcomes were identified. A physician review panel determined the preventability of failure events. Ninety-eight patients experienced 111 failure events requiring SICU transfer. Most patients (85%) were emergency admissions. Of 111 events, 90% had been previously discharged from an SICU or a postanesthesia care unit (PACU). Recognition of failure was by nursing (54%) and on routine physician rounds (34%). Rapid response or code blue alone was less common (12%). A second physician notification was needed in 29%, with delays due to failure to identify severity of illness. Most commonly, respiratory events prompted notification (77 of 111, 69%). Overall mortality was 26 of 98 (27%). Median time to failure was 2 days and was associated with early transfer from the SICU or PACU. Rapid response or code blue activation was associated with higher mortality than physician notification. Patients most at risk for WARD failures were those with acute surgical emergencies or recently discharged from the SICU or PACU. Respiratory complications were the most common cause of WARD failure events. Many early failures may have been due to premature transfer from the SICU or PACU. Failure events on WARDs can have lethal consequences. Awareness, monitoring, and communication are important components of preventative measures. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
A review of current literature highlighted the lack of national or local guidelines for post anaesthetic care unit (PACU) practitioners/recovery room nurses to extubate their own patients. This article documents the findings of a systematic literature review and gives simple diagrammatic representations from a comprehensive flow chart that has been developed to assist nurses in the extubation process. A knowledge and skills competency validated training package was developed locally with the anaesthetic department to train practitioners to undertake endotracheal extubation safely.
Patelarou, Athina; Melidoniotis, Evangelos; Sgouraki, Maria; Karatzi, Maria; Souvatzis, Xenia
Surgical procedures pose stressful events for patients and their family members. The main purpose of this study was to determine if visiting patients in the postanesthesia care unit (PACU) would reduce the anxiety levels of Greek patients' family members. A prospective study with a one-group quasi-experimental pretest/post-test design was used. Situational anxiety of surgical patients' relatives was assessed using the state subscale of the State-Trait Anxiety Inventory (STAI; Greek validation) at the beginning of the surgical procedure and again after their visitation of patients in the PACU. STAI scores were significantly higher preoperatively (57 [23-80]) than postoperatively (51 [21-77]; P=.000008). Clinically significant levels of anxiety were present in 76% and 58% of the participants, pre- and postoperatively, respectively. Although postoperative STAI scores were reduced, family visitation in the PACU did not sufficiently reduce the anxiety of Greek family members to clinically acceptable levels. Copyright © 2014 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
Karcz, Marcin; Papadakos, Peter J
General anesthesia and mechanical ventilation impair pulmonary function, even in normal individuals, and result in decreased oxygenation in the postanesthesia period. They also cause a reduction in functional residual capacity of up to 50% of the preanesthesia value. It has been shown that pulmonary atelectasis is a common finding in anesthetized individuals because it occurs in 85% to 90% of healthy adults. Furthermore, there is substantial evidence that atelectasis, in combination with alveolar hypoventilation and ventilation-perfusion mismatch, is the core mechanism responsible for postoperative hypoxemic events in the majority of patients in the postanesthesia care unit (PACU). Many concomitant factors also must be considered, such as respiratory depression from the type and anatomical site of surgery altering lung mechanics, the consequences of hemodynamic impairment and the residual effects of anesthetic drugs, most notably residual neuromuscular blockade. The appropriate use of anesthetic and analgesic techniques, when combined with meticulous postoperative care, clearly influences pulmonary outcomes in the PACU. The present review emphasizes the major pathophysiological mechanisms and treatment strategies of critical respiratory events in the PACU to provide health care workers with the knowledge needed to prevent such potentially adverse outcomes from occurring. PMID:26078599
Ganapathy, S; Herrick, I A; Gelb, A W; Kirkby, J
Little information is available regarding the use of patient-controlled sedation (PCS) among the elderly. This study evaluated the safety and efficacy of propofol PCS among elderly patients undergoing hip or knee arthroplasty. Forty patients, aged 65-78 yr, undergoing hip or knee arthroplasty under regional anaesthesia were randomized to receive propofol PCS (dose = 0.3 mg.kg-1, delay = three min; n = 20) or anaesthetist-administered midazolam-fentanyl sedation (n = 20). Sedation, anxiety and discomfort visual analogue scores (VAS) were measured, by an independent observer, preoperatively, immediately at the end of surgery and one hour following admission to the postanaesthetic care unit (PACU). Cognition was evaluated, using an abbreviated Mini Mental Status Examination, preoperatively and in the PACU. Patient satisfaction, based on VAS and a brief questionnaire, was measured in the PACU. The incidence of intraoperative complications was also compared. Patient satisfaction was high in each group. Sedation and anxiety VAS were similar in each group. A high incidence of pain with drug injection was noted among patients receiving propofol (80%). Transient deeper levels of sedation (6 vs 1; P = 0.05) were observed more commonly in the propofol PCS group. Propofol PCS provides effective sedation. Using a propofol dose of 0.3 mg.kg-1, transient episodes of deeper sedation were noted more frequently among patients receiving PCS. These episodes did not require intervention but, suggest that this propofol PCS dose approaches the limit of safety and should be further reduced for some elderly patients.
Nguyen, Thanh T.; Lam, Humphrey V.; Phillips, Maxie; Edwards, Clasherrol; Austin, Thomas M.
Background Craniofacial reconstructive surgery for craniosynostosis is associated with large blood loss and intraoperative transfusion. This blood loss may continue through the initial postoperative period, potentially resulting in transfusion postoperatively. The purpose of this study is to determine if there is an association between any modifiable intraoperative factors and postoperative blood transfusion in this patient population. Methods A cohort of 55 pediatric patients who underwent primary craniofacial reconstruction at Vanderbilt Children’s Hospital from January 1, 2013 to April 31, 2014 was analyzed. The authors analyzed 20 different demographic and perioperative variables for statistical associations with postoperative PRBC transfusion using multiple logistic regression with optimal models being selected by Bayesian Model Averaging. Results The optimal regression model only included initial PACU Hct as a predictor and showed a significant association between this variable and postoperative PRBC transfusion (odds ratio 0.69, 95%CI 0.55–0.87, P = 0.0016). Based on the average decrease in postoperative hematocrit (Hct) and the postoperative transfusion trigger, an initial PACU Hct threshold of 30 was calculated. In our patient sample, an initial PACU Hct above 30 was associated with a 50% decrease in the absolute risk of receiving a PRBC transfusion postoperatively. Conclusions Based on this retrospective analysis, it may be justifiable to transfuse residual volume from previously exposed intraoperative PRBCs to a Hct above 30 to decrease the likelihood of subsequent blood transfusions from different donors in the postoperative period. PMID:25495602
Boku, Aiji; Hanamoto, Hiroshi; Oyamaguchi, Aiko; Inoue, Mika; Morimoto, Yoshinari; Niwa, Hitoshi
In infants, there is a high incidence of emergence agitation (EA) after sevoflurane (Sev) anesthesia. This study aimed to test the hypothesis that dexmedetomidine (Dex) administration would reduce the incidence and severity of EA after Sev-based anesthesia in infants undergoing palatoplasty. A prospective randomized clinical trial was conducted with 70 patients undergoing palatoplasty, aged 10-14 months. Infants were randomly allocated into two groups: Dex (n=35) and saline (n=35). In the Dex group, Dex (6μg/kg/h) was administered approximately 10min before the end of the surgery for 10min, followed by 0.4μg/kg/h until 5min after extubation. In the saline group, an equivalent amount of saline was administered in a similar manner. After the surgery, patients were transferred to the postanesthetic care unit (PACU). The infant's behavior and pain were assessed with scoring system for EA (5-point rating scale) and pain scale (PS; 10-point rating scale), respectively. EA and PS were estimated at six time points (after extubation, leaving the operating room, 0, 30, 60, and 120min after arrival in PACU). EA and PS scores were significantly lower in the Dex group than in the saline group from extubation to 120min after arrival in PACU. Dex administration has the advantage of a reduced EA and PS without any adverse effects. Dex provided satisfactory recovery in infants undergoing palatoplasty. Copyright © 2015 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Boku, Aiji; Hanamoto, Hiroshi; Oyamaguchi, Aiko; Inoue, Mika; Morimoto, Yoshinari; Niwa, Hitoshi
In infants, there is a high incidence of emergence agitation (EA) after sevoflurane (Sev) anesthesia. This study aimed to test the hypothesis that dexmedetomidine (Dex) administration would reduce the incidence and severity of EA after Sev-based anesthesia in infants undergoing palatoplasty. A prospective randomized clinical trial was conducted with 70 patients undergoing palatoplasty, aged 10-14 months. Infants were randomly allocated into two groups: Dex (n=35) and saline (n=35). In the Dex group, Dex (6 μg/kg/h) was administered approximately 10 min before the end of the surgery for 10 min, followed by 0.4 μg/kg/h until 5 min after extubation. In the saline group, an equivalent amount of saline was administered in a similar manner. After the surgery, patients were transferred to the postanesthetic care unit (PACU). The infant's behavior and pain were assessed with scoring system for EA (5-point rating scale) and pain scale (PS; 10-point rating scale), respectively. EA and PS were estimated at six time points (after extubation, leaving the operating room, 0, 30, 60, and 120 min after arrival in PACU). EA and PS scores were significantly lower in the Dex group than in the saline group from extubation to 120 min after arrival in PACU. Dex administration has the advantage of a reduced EA and PS without any adverse effects. Dex provided satisfactory recovery in infants undergoing palatoplasty. Copyright © 2015 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Boyle, Mary E; Seifert, Karen M; Beer, Karen A; Mackey, Patricia; Schlinkert, Richard T; Stearns, Joshua D; Cook, Curtiss B
An institutional policy was previously established for patients with diabetes on insulin pump therapy undergoing elective surgical procedures. Electronic medical records were reviewed to assess documentation of insulin pump status and glucose monitoring during preoperative, intraoperative, and postanesthesia care unit (PACU) phases of care. Twenty patients with insulin pumps underwent 23 procedures from March 1 to December 31, 2011. Mean (standard deviation) age was 58 (13) years, mean diabetes duration was 28 (17) years, and mean duration of insulin pump therapy was 7 (6) years. Nearly all cases (86%) during the preoperative phase had the presence of the device documented--an improvement over the 64% noted in data collected before the policy. Intraoperatively, 13 cases (61%) had the presence of the pump documented, which was higher than the 28% before implementation of the policy. However, documentation of pump status was found in only 38% in the PACU and was actually less than the 60% documented previously. Over 90% of cases had glucose checked in the preoperative area and the PACU, and only 60% had it checked intraoperatively, which was nearly identical to the percentages seen before policy implementation. No adverse events occurred when insulin pump therapy was continued. Although some processes still require improvement, preliminary data suggest that the policy for perioperative management of insulin pumps has provided useful structure for care of these cases. The data thus far indicate that insulin pump therapy can be continued safely during the perioperative period. © 2012 Diabetes Technology Society.
Boyle, Mary E.; Seifert, Karen M.; Beer, Karen A.; Mackey, Patricia; Schlinkert, Richard T.; Stearns, Joshua D.; Cook, Curtiss B.
Background An institutional policy was previously established for patients with diabetes on insulin pump therapy undergoing elective surgical procedures. Method Electronic medical records were reviewed to assess documentation of insulin pump status and glucose monitoring during preoperative, intraoperative, and postanesthesia care unit (PACU) phases of care. Results Twenty patients with insulin pumps underwent 23 procedures from March 1 to December 31, 2011. Mean (standard deviation) age was 58 (13) years, mean diabetes duration was 28 (17) years, and mean duration of insulin pump therapy was 7 (6) years. Nearly all cases (86%) during the preoperative phase had the presence of the device documented—an improvement over the 64% noted in data collected before the policy. Intraoperatively, 13 cases (61%) had the presence of the pump documented, which was higher than the 28% before implementation of the policy. However, documentation of pump status was found in only 38% in the PACU and was actually less than the 60% documented previously. Over 90% of cases had glucose checked in the preoperative area and the PACU, and only 60% had it checked intraoperatively, which was nearly identical to the percentages seen before policy implementation. No adverse events occurred when insulin pump therapy was continued. Conclusions Although some processes still require improvement, preliminary data suggest that the policy for perioperative management of insulin pumps has provided useful structure for care of these cases. The data thus far indicate that insulin pump therapy can be continued safely during the perioperative period. PMID:23063026
Modell, Jerome H; Gravenstein, Nikolaus; Morey, Timothy E
The American Society of Anesthesiologists has announced that perioperative normothermia is a "Quality Incentive in Anesthesiology." We examined whether we could meet this quality incentive in a simple population: patients undergoing anesthesia for electroconvulsive therapy (ECT). We compared infrared-measured ear temperature before anesthesia to temperature upon delivery of patients to the postanesthesia care unit (PACU) after 101 consecutive brief anesthetics to facilitate ECT. For 35 procedures, the patients had an infrared ear thermometer temperature of <36 degrees C before anesthesia was administered, and 18 had a temperature of <36 degrees C after anesthesia when transferred to the PACU. For 30 anesthetics, the patients' temperature decreased during anesthesia, for 64 anesthetics it increased during anesthesia, and for 7 it did not change. Overall examination of the data demonstrated no correlation between preprocedure and postprocedure temperature. We conclude that there was no consistent change in temperature during anesthesia between our study patients when anesthesia was administered to facilitate ECT. If patients' tympanic temperatures were below 36 degrees C upon admission to the PACU, it would be incorrect to conclude that intraprocedural temperature management measures were substandard. Also, current methods of measuring temperature may be inadequate to ascertain if patients are hypothermic after surgery. As the avoidance of hypothermia is a meritorious goal, anesthesia departments need to ensure that their temperature monitoring equipment is adequate to ensure accurate measurement of postanesthetic temperature if this variable is to be used as a quality incentive.
Jackson, D A
The adaptation model developed by Sister Callista Roy, RN, PhD, was used as the organizing framework for developing a preoperative assessment tool for PACU nurses. The purpose of preoperative assessment of a surgical patient by a PACU nurse is to determine the patient's location on the health-illness continuum. This is done by analyzing data regarding the patient's biopsychosocial needs, evaluating the data, and determining from that information what problems need intervention. Roy's theory advocates assessing the patient's biopsychosocial needs using four different adaptive modes: self-concept, physiological function, role function, and interdependence (level I assessment). After completing the PACU preoperative assessment tool, each mode in level I assessment is identified as either positive (adaptive) or negative (maladaptive) depending on the patient's behavior identified by the tool. If a maladaptive behavior is identified during the preoperative assessment, a level II assessment is made to collect data regarding focal, contextual, and residual stimuli. A nursing diagnosis, expected outcomes, nursing interventions, and evaluation are listed on the patient care plan based on the data obtained from the assessment.
Karcz, Marcin; Papadakos, Peter J
General anesthesia and mechanical ventilation impair pulmonary function, even in normal individuals, and result in decreased oxygenation in the postanesthesia period. They also cause a reduction in functional residual capacity of up to 50% of the preanesthesia value. It has been shown that pulmonary atelectasis is a common finding in anesthetized individuals because it occurs in 85% to 90% of healthy adults. Furthermore, there is substantial evidence that atelectasis, in combination with alveolar hypoventilation and ventilation-perfusion mismatch, is the core mechanism responsible for postoperative hypoxemic events in the majority of patients in the postanesthesia care unit (PACU). Many concomitant factors also must be considered, such as respiratory depression from the type and anatomical site of surgery altering lung mechanics, the consequences of hemodynamic impairment and the residual effects of anesthetic drugs, most notably residual neuromuscular blockade. The appropriate use of anesthetic and analgesic techniques, when combined with meticulous postoperative care, clearly influences pulmonary outcomes in the PACU. The present review emphasizes the major pathophysiological mechanisms and treatment strategies of critical respiratory events in the PACU to provide health care workers with the knowledge needed to prevent such potentially adverse outcomes from occurring.
Karkera, Megha M; Harrison, Dale R; Aunspaugh, Jennifer P; Martin, Timothy W
Caudal blocks are a significant and efficacious aspect of pediatric anesthesia, especially in urologic and many general surgery cases. This type of regional anesthesia is common because it has a high success rate and provides between 6 and 8 hours of postoperative pain control. The aim of this study was to determine whether the concentration of bupivacaine or the addition of intravascular (i.v.) fentanyl affected the postanesthesia care unit (PACU) discharge time. A retrospective cohort study comparing the outcomes in pediatric patients who have received varying caudal concentrations with and without the addition of i.v. fentanyl was performed. A total of 849 consecutive patients undergoing hypospadias repairs or circumcisions were reviewed and placed in one of the following 3 groups: 0.125% bupivacaine (group 1), 0.25% bupivacaine (group 2), or one of these concentrations of bupivacaine + i.v. fentanyl intraoperatively (group 3). Total PACU time for each group was 46.1 minutes (group 1), 48.9 minutes (group 2), and 49.7 minutes (group 3). Our results revealed that there is no statistically significant difference between concentrations of bupivacaine administered in a caudal block with or without i.v. fentanyl with regard to the outcome of PACU duration (P = 0.16). Overall, based on the retrospective cohort design, there is no difference in primary and secondary outcomes based on the concentration of bupivacaine, when administered at a volume of 1 mL/kg.
Talab, Hesham F; Zabani, Ibrahim Ali; Abdelrahman, Hassan Saad; Bukhari, Waleed L; Mamoun, Irfan; Ashour, Majed A; Sadeq, Bakr Bin; El Sayed, Sameh Ibrahim
Atelectasis occurs regularly after induction of general anesthesia, persists postoperatively, and may contribute to significant postoperative morbidity and additional health care costs. Laparoscopic surgery has been reported to be associated with an increased incidence of postoperative atelectasis. It has been shown that during general anesthesia, obese patients have a greater risk of atelectasis than nonobese patients. Preventing atelectasis is important for all patients but is especially important when caring for obese patients. We randomly allocated 66 adult obese patients with a body mass index between 30 and 50 kg/m(2) scheduled to undergo laparoscopic bariatric surgery into 3 groups. According to the recruitment maneuver used, the zero end-expiratory pressure (ZEEP) group (n = 22) received the vital capacity maneuver (VCM) maintained for 7-8 s applied immediately after intubation plus ZEEP; the positive end-expiratory pressure (PEEP) 5 group (n = 22) received the VCM maintained for 7-8 s applied immediately after intubation plus 5 cm H(2)O of PEEP; and the PEEP 10 group (n = 22) received the VCM maintained for 7-8 s applied immediately after intubation plus 10 cm H(2)O of PEEP. All other variables (e.g., anesthetic and surgical techniques) were the same for all patients. Heart rate, noninvasive mean arterial blood pressure, arterial oxygen saturation, and alveolar-arterial Pao(2) gradient (A-a Pao(2)) were measured intraoperatively and postoperatively in the postanesthesia care unit (PACU). Length of stay in the PACU and the use of a nonrebreathing O(2) mask (100% Fio(2)) or reintubation were also recorded. A computed tomographic scan of the chest was performed preoperatively and postoperatively after discharge from the PACU to evaluate lung atelectasis. Patients in the PEEP 10 group had better oxygenation both intraoperatively and postoperatively in the PACU, lower atelectasis score on chest computed tomographic scan, and less postoperative pulmonary
Elnabtity, Ali Mohamed Ali; Tawfeek, Mohamed M.; Keera, Amr Ali; Badran, Yasser Ali
Background: Various sedative and analgesic techniques have been used during shock wave lithotripsy (SWL). Aim: This study aimed at evaluating the efficacy of ultrasound-guided unilateral transversus abdominis plane (TAP) block as an analgesic technique alternative during ureteric SWL. Settings and Design: Prospective randomized comparative study. Materials and Methods: Fifty patients scheduled for ureteric SWL were randomly allocated into two equal groups: Group (F) received 1.5 mcg/kg fentanyl intravenous and group (T) received unilateral TAP block with injection of 25 ml of bupivacaine 0.25% (62.5 mg). Statistical Analysis: Statistical analysis was performed using SPSS program version 19 and EP16 program. Results: The visual analog scale was significantly less in group (T) than in group (F) both intra-operatively (at 10, 20, 30, and 40 min) and postoperatively (at 10 min intervals in the postanesthesia care unit [PACU]) (P < 0.001). Rescue analgesia with pethidine during the procedure and in the PACU was less (P < 0.001) in the group (T) than group (F) with a median of 20 mg versus 55 mg, respectively. The higher sedation scores observed in group (F) at 15, 25, and 35 min during the procedure, and at 20 min during the PACU time were statistically highly significant (P < 0.001), but only significant at 10 min (P = 0.03) and 30 min (P = 0.007) during the PACU time. There was also highly significant decrease (P < 0.001) in the time of PACU stay in group (T) (38.2 ± 6.6 min) compared with group (F) (89.2 ± 13.39 min). We recorded 6 patients in group (F) (24%) who have developed respiratory depression (respiratory rate < 10 breaths/min) compared to 0% in group (T) (P = 0.022). In addition, in group (F) nausea was noted in 8 patients (32%) and vomiting in 6 patients (24%), which was statistically significant when compared to group (T) (0%) (P = 0.01 and 0.022, respectively). Conclusion: Ultrasound-guided unilateral TAP block is an effective alternative analgesic
Anderson, Jill T; Saldaña Rojas, Joe; Flecker, Alexander S
Seed dispersal is a critical stage in the life history of plants. It determines the initial pattern of juvenile distribution, and can influence community dynamics and the evolutionary trajectories of individual species. Vertebrate frugivores are the primary vector of seed dispersal in tropical forests; however, most studies of seed dispersal focus on birds, bats and monkeys. Nevertheless, South America harbors at least 200 species of frugivorous fishes, which move into temporarily flooded habitats during lengthy flood seasons and consume fruits that fall into the water; and yet, we know remarkably little about the quality of seed dispersal they effect. We investigated the seed dispersal activities of two species of large-bodied, commercially important fishes (Colossoma macropomum and Piaractus brachypomus, Characidae) over 3 years in Pacaya-Samiria National Reserve (Peru). We assessed the diet of these fishes during the flood season, conducted germination trials with seeds collected from digestive tracts, and quantified fruit availability. In the laboratory, we fed fruits to captive Colossoma, quantified the proportion of seeds defecated by adult and juvenile fish, and used these seeds in additional germination experiments. Our results indicate that Colossoma and Piaractus disperse large quantities of seeds from up to 35% of the trees and lianas that fruit during the flood season. Additionally, these seeds can germinate after floodwaters recede. Overexploitation has reduced the abundance of our focal fish species, as well as changed the age structure of populations. Moreover, older fish are more effective seed dispersers than smaller, juvenile fish. Overfishing, therefore, likely selects for the poorest seed dispersers, thus disrupting an ancient interaction between seeds and their dispersal agents.
Katznelson, Rita; Van Rensburg, Adriaan; Friedman, Zeev; Wasowicz, Marcin; Djaiani, George N; Fedorko, Ludwik; Minkovich, Leonid; Fisher, Joseph A
We conducted a prospective controlled clinical trial of the effect of isocapnic hyperpnoea (IH) on the times-to-recovery milestones in the operating room (OR) and postanesthetic care unit (PACU) after 1.5 to 3 hours of isoflurane anesthesia. Thirty ASA grade I-III patients undergoing elective gynecological surgery were randomized at the end of surgery to either IH or the conventional recovery (control). Six patients with duration of anesthesia of <90 minutes were excluded from the analysis. The anesthesia protocol included propofol, fentanyl, morphine, rocuronium, and isoflurane in air/O(2). Unpaired t tests and analyses of variance were used to test for differences in times-to-recovery indicators between the two groups. The durations of anesthesia in IH and control groups were 140.8 + or - 32.7 and 142 + or - 55.6 minutes, respectively (P = 0.99). The time to extubation was much shorter in the IH group than in the control group (6.6 + or - 1.6 (SD) vs. 13. 6 + or - 3.9 minutes, respectively; P < 0.01). The IH group also had shorter times to eye opening (5.8 + or - 1.3 vs. 13.7 + or - 4.5 minutes; P < 0.01), eligibility for leaving the OR (8.0 + or - 1.7 vs. 17.4 + or - 6.1 minutes; P < 0.01), and eligibility for PACU discharge (74.0 + or - 16.5 vs. 94.5 + or - 14.7 minutes; P < 0.01). There were no differences in other indicators of recovery. IH accelerates recovery after 1.5 to 3 hours of isoflurane anesthesia and shortens OR and PACU stay.
Miziara, Luiz Eduardo de Paula Gomes; Simoni, Ricardo Francisco; Esteves, Luís Otávio; Cangiani, Luis Henrique; Grillo-Filho, Gil Fernando Ribeiro; Paula, Anderson Garcia Lima E
Aim. A double-blind, randomized, placebo-controlled trial was designed to evaluate the efficacy of continuous intraoperative infusion of S(+)-ketamine under intravenous anesthesia with target-controlled infusion of remifentanil and propofol for postoperative pain control. Methods. Forty-eight patients undergoing laparoscopic cholecystectomy were assigned to receive continuous S(+)-ketamine infusion at a rate of 0.3 mg·kg(-1)·h(-1) (n = 24, intervention group) or an equivalent volume of saline at the same rate (n = 24, placebo group). The same target-controlled intravenous anesthesia was induced in both groups. Pain was assessed using a 0 to 10 verbal numeric rating scale during the first 12 postoperative hours. Pain scores and morphine consumption were recorded in the postanesthesia care unit (PACU) and at 4 and 12 hours after surgery. Results. Pain scores were lower in the intervention group at all time points. Morphine consumption did not differ significantly between groups during PACU stay, but it was significantly lower in the intervention group at each time point after PACU discharge (P = 0.0061). At 12 hours after surgery, cumulative morphine consumption was also lower in the intervention group (5.200 ± 2.707) than in the placebo group (7.525 ± 1.872). Conclusions. Continuous S(+)-ketamine infusion during laparoscopic cholecystectomy under target-controlled intravenous anesthesia provided better postoperative pain control than placebo, reducing morphine requirement. Trial Registration. This trial is registered with ClinicalTrials.gov NCT02421913.
Sargin, Mehmet; Uluer, Mehmet Selcuk; Ozmen, Sadık
General anesthesia is often preferred for dental surgery or rehabilitation in developmentally delayed pediatric patients. Bispectral index monitoring is used to monitor the depth of anesthesia and to ensure early recovery. However, studies on the topic in developmentally delayed pediatric patients are limited. To evaluate the effects of Bispectral Index Scale (BIS) on hemodynamics and recovery profile in developmentally delayed pediatric patients undergoing dental surgery. Forty children between the ages of 6-16 years were studied in this prospective and randomized study. The children were randomized into two groups. In Group 1 (n = 20), general anesthesia was maintained with 1-2 minimum alveolar concentration (MAC) of sevoflurane in oxygen by standard practice. In Group 2 (n = 20), the depth of anesthesia was monitored by BIS. BIS values were continuously recorded from awake status to tracheal extubation. The duration of the surgical procedure, anesthesia, postanesthesia care unit (PACU) stay was noted. To evaluate recovery profile, time to spontaneous ventilation, extubation, open eyes, and PACU discharge were also noted. There were significant differences between recovery times and Non-communicating Children's Pain Checklist - Postoperative Version (NCCPC-PV) scores of two groups. Time to spontaneous ventilation [Difference in means (95% CI); 3.17 (1.79-4.54) P < 0.001], extubation [Difference in means (95% CI); 3.13 (1.66-4.60) P < 0.001], open eyes [Difference in means (95% CI); 3.97 (2.34-5.59) P < 0.001], and PACU stay time [Difference in means (95% CI); 23.55 (18.08-29.01) P < 0.001] were significantly shorter in Group 2. In conclusion, results suggest that routine BIS monitoring may be beneficial due to its favorable effects on the recovery profile in developmentally delayed pediatric patients. © 2015 John Wiley & Sons Ltd.
Lee, Hong Sik; Jo, Hyong Rae; Je, Ui Jin; Paek, Jin Hyub
Background Glycopyrrolate given as reversing agents of muscle relaxants has been reported to be effective in reducing postoperative catheter-related bladder discomfort (CRBD). However, it remains unclear whether glycopyrrolate as premedication is also effective. This study aims to investigate the effectiveness of glycopyrrolate as premedication on preventing CRBD in the post-anesthesia care unit (PACU). Methods Eighty-three patients who received elective ureteroscopic removal of ureteral stone were randomly assigned to the control (n = 43) or the glycopyrrolate group (n = 40). The glycopyrrolate group was treated with glycopyrrolate 0.3 mg as premedication while the control group received 0.9% saline 1.5 ml. The incidence and severity of CRBD and pain score using numerical rating scale (NRS) were measured in the PACU. Results The incidence of CRBD (26 of 40 patients vs. 41 of 43 patients, relative risk [RR] = 0.68, 95% Confidence interval [CI] = 0.53–0.86, P = 0.001) and the moderate to severe CRBD incidence (6 of 40 patients vs. 20 of 43 patients, RR = 0.32, 95% CI = 0.14–0.72, P = 0.002) were lower in the glycopyrrolate group than in the control group. Also, postoperative pain NRS score was found to be lower in the glycopyrrolate group (median = 1 [Q1 = 0, Q3 = 2]) compared to the control group (3 [1, 5], median difference = 1.00, 95% CI = 0.00–2.00, P = 0.002). Conclusions The use of glycopyrrolate 0.3 mg as premedication in patients receiving ureteroscopic removal of ureteral stone reduced the incidence and severity of CRBD, and decreased postoperative pain in the PACU. PMID:27924195
Milby, A; Böhmer, A; Gerbershagen, M U; Joppich, R; Wappler, F
Anaesthesiology plays a key role in promoting safe perioperative care. This includes the perioperative phase in the post-anaesthesia care unit (PACU) where problems with incomplete information transfer may have a negative impact on patient safety and can lead to patient harm. The objective of this study was to analyse information transfer during post-operative handovers in the PACU. With a self-developed checklist including 59 items the information transfer during post-operative handovers was documented and subsequently compared with patient information in anaesthesia records during a 2-month period. A total number of 790 handovers with duration of 73 ± 49 s was analysed. Few items were transferred in most of the cases such as type of surgery (97% of the cases), regional anaesthesia (94% of the cases) and cardiac instability (93% of the cases). However, some items were rarely transferred, such as American Society of Anesthesiologists physical status (7% of the cases), initiation of post-operative pain management (12% of the cases), antibiotic therapy (14% of the cases) and fluid management (15% of the cases). There was a slight correlation between amount of information transferred and duration of post-operative handovers (r = 0.5). The study shows that post-operative handovers in the PACU are in most cases incomplete. It appears useful to optimise the post-operative handover process, for example by implementing a standardised handover checklist. © 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
Mukherjee, Chirojit; Koch, Eva; Banusch, Joergen; Scholz, Markus; Kaisers, Udo X; Ender, Joerg
Aim of our study was to evaluate the beneficial effect of low dose intrathecal morphine on postoperative analgesia, over the use of intravenous patient controlled anesthesia (PCA), in patients undergoing fast track anesthesia during minimally invasive cardiac surgical procedures. A randomized controlled trial was undertaken after approval from local ethical committee. Written informed consent was obtained from 61 patients receiving mitral or tricuspid or both surgical valve repair in minimal invasive technique. Patients were assigned randomly to 2 groups. Group 1 received general anesthesia and intravenous patient controlled analgesia (PCA) pump with Piritramide (GA group). Group 2 received a single shot of intrathecal morphine (1.5 μg/kg body weight) prior to the administration of general anesthesia (ITM group). Site of puncture was confined to lumbar (L1-2 or L2-3) intrathecal space. The amount of intravenous piritramide used in post anesthesia care unit (PACU) and the first postoperative day was defined as primary end point. Secondary end points included: time for tracheal extubation, pain and sedation scores in PACU upto third postoperative day. For statistical analysis Mann-Whitney-U Test and Fishers exact test (SPSS) were used. We found that the demand for intravenous opioids in PACU was significantly reduced in ITM group (P <0.001). Pain scores were significantly decreased in ITM group until second postoperative day (P <0.01). There was no time delay for tracheal extubation in ITM group, and sedation scores did not differ in either group. We conclude that low dose single shot intrathecal morphine provides adequate postoperative analgesia, reduces the intravenous opioid consumption during the early postoperative period and does not defer early extubation.
Abdulla, Susanne; Eckhardt, Regina; Netter, Ute; Abdulla, Walied
In a randomized, double-blind trial, the synergistic action of intravenous parecoxib, metamizol or paracetamol on postoperative piritramide consumption was compared in patients recovering from total thyroidectomy during the first 24 h while evaluating pain intensity and patient satisfaction. 120 patients were randomly allocated to four patient groups treated with normal saline and/or one of non-opioid analgesics (parecoxib 40 mg twice daily, metamizol 1 g three times daily, paracetamol 1 g three times daily) in addition to piritramide using the PCA pump. Beginning in the recovery room (PACU), patients were asked every 2 h for 6 hours and afterwards once every 6 h to quantify their pain experience and patient satisfaction while piritramide consumption was recorded. Upon arrival in the PACU piritramide consumption was high and decreased thereafter significantly in all groups (P < 0.05). There were no significant differences between groups in incremental and cumulative piritramide consumption during the investigation. Also, VAS scores were high upon arrival in the PACU and dropped in all groups continuously after surgery: At 2 h and 4 h after surgery they were significantly lower in parecoxib group compared with NaCl (P < 0.01). For overall patient satisfaction, no significant differences were observed. Pain relief scores at 24 h were significantly higher in parecoxib group as compared to metamizol and paracetamol (P < 0.01). Mild PONV was observed frequently in all groups and was treated with metoclopramide. There is no clear-cut difference between the non-opioid drugs used, even though parecoxib seems to be superior in regard to VAS scores and piritramide consumption. However, the clinical significance is debatable.
Torensma, Bart; Martini, Chris H.; Boon, Martijn; Olofsen, Erik; in ‘t Veld, Bas; Liem, Ronald S. L.; Knook, Mireille T. T.; Swank, Dingeman J.; Dahan, Albert
Background It remains unknown whether the administration of a deep neuromuscular block (NMB) during bariatric surgery improves surgical conditions and patient outcome. The authors studied the effect of deep versus moderate NMB in laparoscopic bariatric surgery on surgical conditions and postoperative pain. Methods and Results One hundred patients scheduled to undergo elective bariatric surgery were randomized to a deep NMB (post-tetanic-count 2–3) or a moderate NMB (train-of-four 1–2). The quality of the surgical field was scored using the Leiden-Surgical Rating Scale (L-SRS), a 5-point scale ranging from 1 (extremely poor conditions) to 5 (optimal conditions). Three surgeons scored the L-SRS at 10-min intervals during surgery; postoperative pain scores were obtained in the postanesthesia-care-unit (PACU) and on the ward. Mean (95% confidence interval) L-SRS scores in moderate NMB 4.2 (4.0–4.4) versus 4.8 (4.7–4.9) in deep NMB (p < 0.001). Moderate NMB resulted in 17% of scores at L-SRS scores of 1–3, while deep NMB resulted in 100% scores at the high end of the L-SRS (4–5). Deep NMB led to improved pain scores in the PACU (4.6 (4.2–4.9) versus 3.9 (3.6–4.4), p = 0.03) and reduced shoulder pain on the ward (1.8 (1.5–2.1) versus 1.3 (1.1–1.5), p = 0.03). A composite score of pain and opioid use in the PACU favoured deep NMB (p = 0.001). Conclusions In bariatric surgery, deep relaxation has advantages for surgeon and patient. Compared to moderate NMB, deep NMB produced stable and improved surgical conditions with less postoperative pain. PMID:27936214
Darvall, J N; Handscombe, M; Leslie, K
A novel treatment, chewing gum, may be non-inferior to ondansetron in inhibiting postoperative nausea and vomiting (PONV) in female patients after laparoscopic or breast surgery. In this pilot study, we tested the feasibility of a large randomized controlled trial. We randomized 94 female patients undergoing laparoscopic or breast surgery to ondansetron 4 mg i.v. or chewing gum if PONV was experienced in the postanaesthesia care unit (PACU). The primary outcome was full resolution of PONV, with non-inferiority defined as a difference between groups of <15% in a per protocol analysis. Secondary outcomes were PACU stay duration, anti-emetic rescue use, and acceptability of anti-emetic treatment. The feasibility of implementing the protocol in a larger trial was assessed. Postoperative nausea and vomiting in the PACU occurred in 13 (28%) ondansetron patients and 15 (31%) chewing gum patients (P=0.75). Three chewing gum patients could not chew gum when they developed PONV. On a per protocol basis, full resolution of PONV occurred in five of 13 (39%) ondansetron vs nine of 12 (75%) chewing gum patients [risk difference 37% (6.3-67%), P=0.07]. There was no difference in secondary outcomes between groups. Recruitment was satisfactory, the protocol was acceptable to anaesthetists and nurses, and data collection was complete. In this pilot trial, chewing gum was not inferior to ondansetron for treatment of PONV after general anaesthesia for laparoscopic or breast surgery in female patients. Our findings demonstrate the feasibility of a larger, multicentred randomized controlled trial to investigate this novel therapy. Australian New Zealand Clinical Trials Registry: ACTRN12615001327572. © The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: email@example.com.
Chen, Jia-Yao; Jia, Ji-E; Liu, Ting-Jie; Qin, Ming-Ju; Li, Wen-Xian
Children undergoing strabismus surgery under sevoflurane anesthesia often experience emergence agitation (EA) and postoperative vomiting (POV). This study compared the effects of intraoperative dexmedetomidine, ketamine, and placebo on postoperative EA and POV. Eighty-four children (aged two to seven years) undergoing elective strabismus surgery under sevoflurane anesthesia were randomly assigned to one of three groups (n = 28 each). Intraoperatively, the placebo, dexmedetomidine, and ketamine groups received normal saline, dexmedetomidine 1 μg·kg(-1) iv plus a 1 μg·kg(-1)·hr(-1) infusion, and ketamine 1 mg·kg(-1) iv plus a 1 mg·kg(-1)·hr(-1) infusion, respectively. Agitation scores (Pediatric Anesthesia Emergence Delirium [PAED] scale) and POV were assessed in the postanesthetic care unit (PACU) and for 24 hr on the ward. Pain scores and times to laryngeal mask airway (LMA™) removal, resumption of mental orientation, and discharge from the PACU were also assessed. Seventy-eight children completed the study. Peak PAED scores for EA were lower in the dexmedetomidine (P < 0.001) and ketamine (P = 0.002) groups than in the placebo group. Incidence of POV was lower in the dexmedetomidine group (15%) than in the ketamine (44%; P = 0.02) or placebo (45.8%; P = 0.02) groups. Pain scores on the ward were lower in the dexmedetomidine (P < 0.001) and ketamine (P < 0.001) groups than in the placebo group. Time to LMA removal was similar in all groups. Time for resumption of mental orientation and time to discharge from PACU were longer in the dexmedetomidine and ketamine groups than in the placebo group. Dexmedetomidine and ketamine appear to prevent postoperative agitation and pain after sevoflurane anesthesia for pediatric strabismus surgery. Dexmedetomidine also prevents POV.
Abback, P-S; Ben Sallah, T; Hilly, J; Skhiri, A; Silins, V; Brasher, C; François, M; Van Den Abeele, T; Wood, C; Nivoche, Y; Dahmani, S
In the adult population, Ketamine is currently used as an antihyperalgesic and opioid-sparing agent during the perioperative period. However, for doses of ketamine up to 0.5mg/kg, these effects have not been found in pediatric population. The aim of the present study was to evaluate the efficacy of a preoperative bolus of 1mg/kg of ketamine on postoperative pain intensity and morphine consumption in children undergoing tonsillectomy. We have undertaken a retrospective comparison of 60 consecutive children operated for tonsillectomy in our institution before (first 30 patients) and after (last 30 patients) the introduction of a preoperative bolus of 1mg/kg of ketamine. Data collected were: age, ASA score, dose of intraoperative sufentanil, OPS score during PACU stay and the first postoperative day, morphine consumption during PACU stay and the first postoperative day, psychodysleptic manifestations, pain at first solid oral intake and postoperative respiratory complications or haemorrhage. No difference was found between the two groups in terms of demographic characteristics. Perioperative doses of sufentanil, postoperative opioid consumption or pain score in PACU or during 24hours were similar between the two groups. The two groups did not differ in terms of pain at first oral intake, or other adverse effects. These results suggest that 1mg/kg of ketamine administered right after anaesthesia induction in children undergoing tonsillectomy did not result in an opioid sparing effect. Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.
Grodofsky, Samuel Robert; Sinha, Ashish C
Intraoperative administration of opiates for postoperative analgesia requires a dosing strategy without clear indicators of pain in an anesthetized patient. Preoperative patient characteristics such as body mass index (BMI), gender, age, and other patient characteristics may provide important information regarding opiate requirements. This study intends to determine if there is an association between gender or BMI and the immediate postoperative pain scores after undergoing an open reduction and internal fixation (ORIF) of an ankle fracture with general anesthesia and morphine only analgesia. Using a retrospective cohort design, the perioperative records were reviewed at a university healthcare hospital. One hundred and thirty-seven cases met all inclusion and no exclusion criteria. Postanesthesia care unit (PACU) records were reviewed for pain scores at first report and 30 min later as well as PACU opiate requirements. T-test, chi-square, and Mann-Whitney tests compared univariate data and multivariate analysis was performed by linear regression. There were no statistically significant PACU pain score group differences based on gender or BMI. Post hoc analysis revealed that in the setting of similar pain scores, obese patients received a similar weight based intraoperative morphine dose when using adjusted body weight (ABW) compared to nonobese subjects. A further finding revealed a negative correlation between age and pain score (P = 0.001). This study did not find an association between obesity or gender and postoperative pain when receiving morphine only preemptive analgesia. This study does support the use of ABW as a means to calculate morphine dosing for obese patients and that age is associated with lower immediate pain scores.
Grodofsky, Samuel Robert; Sinha, Ashish C
Background: Intraoperative administration of opiates for postoperative analgesia requires a dosing strategy without clear indicators of pain in an anesthetized patient. Preoperative patient characteristics such as body mass index (BMI), gender, age, and other patient characteristics may provide important information regarding opiate requirements. This study intends to determine if there is an association between gender or BMI and the immediate postoperative pain scores after undergoing an open reduction and internal fixation (ORIF) of an ankle fracture with general anesthesia and morphine only analgesia. Materials and Methods: Using a retrospective cohort design, the perioperative records were reviewed at a university healthcare hospital. One hundred and thirty-seven cases met all inclusion and no exclusion criteria. Postanesthesia care unit (PACU) records were reviewed for pain scores at first report and 30 min later as well as PACU opiate requirements. T-test, chi-square, and Mann-Whitney tests compared univariate data and multivariate analysis was performed by linear regression. Results: There were no statistically significant PACU pain score group differences based on gender or BMI. Post hoc analysis revealed that in the setting of similar pain scores, obese patients received a similar weight based intraoperative morphine dose when using adjusted body weight (ABW) compared to nonobese subjects. A further finding revealed a negative correlation between age and pain score (P = 0.001). Conclusion: This study did not find an association between obesity or gender and postoperative pain when receiving morphine only preemptive analgesia. This study does support the use of ABW as a means to calculate morphine dosing for obese patients and that age is associated with lower immediate pain scores. PMID:24803767
Elakany, Mohamed Hamdy; Abdelhamid, Sherif Ahmed
Background: Thoracic spinal anesthesia has been used for laparoscopic cholecystectomy and abdominal surgeries, but not in breast surgery. The present study compared this technique with general anesthesia in breast cancer surgeries. Materials and Methods: Forty patients were enrolled in this comparative study with inclusion criteria of ASA physical status I-III, primary breast cancer without known extension beyond the breast and axillary nodes, scheduled for unilateral mastectomy with axillary dissection. They were randomly divided into two groups. The thoracic spinal group (S) (n = 20) underwent segmental thoracic spinal anesthesia with bupivacaine and fentanyl at T5-T6 interspace, while the other group (n = 20) underwent general anesthesia (G). Intraoperative hemodynamic parameters, intraoperative complications, postoperative discharge time from post-anesthesia care unit (PACU), postoperative pain and analgesic consumption, postoperative adverse effects, and patient satisfaction with the anesthetic techniques were recorded. Results: Intraoperative hypertension (20%) was more frequent in group (G), while hypotension and bradycardia (15%) were more frequent in the segmental thoracic spinal (S) group. Postoperative nausea (30%) and vomiting (40%) during PACU stay were more frequent in the (G) group. Postoperative discharge time from PACU was shorter in the (S) group (124 ± 38 min) than in the (G) group (212 ± 46 min). The quality of postoperative analgesia and analgesic consumption was better in the (S) group. Patient satisfaction was similar in both groups. Conclusions: Segmental thoracic spinal anesthesia has some advantages when compared with general anesthesia and can be considered as a sole anesthetic in breast cancer surgery with axillary lymph node clearance. PMID:25885990
Sadhasivam, Senthilkumar; Zhang, Xue; Chidambaran, Vidya; Mavi, Jagroop; Pilipenko, Valentina; Mersha, Tesfaye B.; Meller, Jaroslaw; Kaufman, Kenneth M.; Martin, Lisa J.; McAuliffe, John
Opioid effects are potentiated by cannabinoid agonists including anandamide, an endocannabinoid. Inter-individual variability in responses to opioids is a major clinical problem. Multiple deaths and anoxic brain injuries occur every year in due to opioid induced respiratory depression in surgical patients and drug abusers of opioids and cannabinoids. This study aimed to determine specific associations between genetic variants of fatty acid amide hydrolase (FAAH) and postoperative central opioid adverse effects in children undergoing tonsillectomy. This is a prospective genotype blinded observational study 259 healthy children between 6 and 15 years that received standard perioperative care with a standard anesthetic and an intraoperative dose of morphine were enrolled. Associations between frequent polymorphisms of FAAH and central postoperative opioid adverse effects including, respiratory depression (RD), postoperative nausea and vomiting (PONV) and prolonged stay in Post Anesthesia Recovery Room (PACU) due to RD and PONV were analyzed. Five specific FAAH SNPs had significant associations with more than 2 fold increased risk for refractory PONV (adjusted p<0.0018), and nominal associations (p<0.05) with RD and prolonged PACU stay in white children undergoing tonsillectomy. FAAH SNP, rs324420 is a missense mutation with altered FAAH function and it is linked with other FAAH SNPs associated with PONV and RD in our cohort; association between PONV and rs324420 was confirmed in our extended cohort with additional 66 white children. Specific FAAH polymorphisms are associated with refractory PONV, opioid-related respiratory depression, and prolonged PACU stay due to opioid adverse effects in white children undergoing tonsillectomy. PMID:25558980
Sadhasivam, S; Zhang, X; Chidambaran, V; Mavi, J; Pilipenko, V; Mersha, T B; Meller, J; Kaufman, K M; Martin, L J; McAuliffe, J
Opioid effects are potentiated by cannabinoid agonists including anandamide, an endocannabinoid. Inter-individual variability in responses to opioids is a major clinical problem. Multiple deaths and anoxic brain injuries occur every year because of opioid-induced respiratory depression (RD) in surgical patients and drug abusers of opioids and cannabinoids. This study aimed to determine specific associations between genetic variants of fatty acid amide hydrolase (FAAH) and postoperative central opioid adverse effects in children undergoing tonsillectomy. This is a prospective genotype-blinded observational study in which 259 healthy children between 6 and 15 years of age who received standard perioperative care with a standard anesthetic and an intraoperative dose of morphine were enrolled. Associations between frequent polymorphisms of FAAH and central postoperative opioid adverse effects including, RD, postoperative nausea and vomiting (PONV) and prolonged stay in Post Anesthesia Recovery Room (postoperative anesthesia care unit, PACU) due to RD and PONV were analyzed. Five specific FAAH single nucleotide polymorphisms (SNPs) had significant associations with more than twofold increased risk for refractory PONV (adjusted P<0.0018), and nominal associations (P<0.05) with RD and prolonged PACU stay in white children undergoing tonsillectomy. The FAAH SNP, rs324420, is a missense mutation with altered FAAH function and it is linked with other FAAH SNPs associated with PONV and RD in our cohort; association between PONV and rs324420 was confirmed in our extended cohort with additional 66 white children. Specific FAAH polymorphisms are associated with refractory PONV, opioid-related RD, and prolonged PACU stay due to opioid adverse effects in white children undergoing tonsillectomy.
Bashandy, Ghada Mohammad Nabih; Elkholy, Abeer Hassan Hamed
Many multimodal analgesia techniques have been tried to provide adequate analgesia for midline incisions extending above and below the umbilicus aiming at limiting the perioperative use of morphine thus limiting side effects. Ultrasound (US) guidance made the anesthesiologist reconsider old techniques for wider clinical use. The rectus sheath block (RSB) is a useful technique under-utilized in the adult population. Our study examined the efficacy of a preemptive single-injection rectus sheath block in providing better early postoperative pain scores compared to general anesthesia alone. Sixty patients were recruited in this randomized controlled trial. These patients were divided into two groups: RSB group had an RSB after induction of anesthesia and before surgical incision, and GA (general anesthesia) group had general anesthesia alone. Both groups were compared for verbal analogue scale (VAS) score, opioid consumption and hemodynamic variables in the post-anesthesia care unit (PACU). Analgesic requirements in surgical wards were recorded in postoperative days (POD) 0, 1 and 2. The median VAS score was significantly lower in RSB group compared with GA group in all 5 time points in the PACU (P ˂ 0.05). Also PACU morphine consumption was lower in RSB group than GA group patients (95% confidence interval [CI] of the difference in means between groups, -4.59 to -2.23 mg). Morphine consumption was also less in the first 2 postoperative days (POD0 and POD1). Ultrasound-guided rectus sheath block is an easy technique to learn. This technique, when it is used with general anesthesia, will be more effective in reducing pain scores and opioid consumption compared with general anesthesia alone.
Simsek, Esen; Karaman, Yucel; Gonullu, Mustafa; Tekgul, Zeki; Cakmak, Meltem
The incidence of perioperative respiratory complications and postoperative care unit recovery time investigated in patients with passive tobacco smoke exposure according to the degree of exposure. Total 270 patients ranging in age from 18 to 60 years with the ASA physical status I or II exposed and not exposed to passive tobacco smoke received general anesthesia for various elective surgical operations evaluated for the study. Patients divided into two groups as exposed and non-exposed to passive tobacco smoke, those exposed to passive smoke are also divided into two groups according to the degree of exposure. Patients taken to the postoperative care unit (PACU) at the end of the operation and monitorized until Modified Aldrete's Scores became 9 and more. Respiratory complications evaluated and recorded in intraoperative and postoperative period. A total of 251 patients were enrolled; 63 (25.1%) patients had airway complications, 11 (4.4%) had complications intraoperatively and 52 (20.7%) patients had complications postoperatively. There has been found significant relation with passive tobacco smoke exposure and high incidences of perioperative and postoperative respiratory complications. The risk of cough, desaturation and hypersecretion complications were found to be increased depending on the degree of exposure. There was significant relation between the degree of passive smoke exposure and the duration of PACU stay. Passive tobacco smoke exposed general anesthesia receiving patients also regarding to the degree of exposure having high rates of perioperative respiratory complications and prolongation of PACU stays when compared with unexposed patients. Copyright © 2015 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Simsek, Esen; Karaman, Yucel; Gonullu, Mustafa; Tekgul, Zeki; Cakmak, Meltem
The incidence of perioperative respiratory complications and postoperative care unit recovery time investigated in patients with passive tobacco smoke exposure according to the degree of exposure. Total 270 patients ranging in age from 18 to 60 years with the ASA physical status I or II exposed and not exposed to passive tobacco smoke received general anesthesia for various elective surgical operations evaluated for the study. Patients divided into two groups as exposed and non-exposed to passive tobacco smoke, those exposed to passive smoke are also divided into two groups according to the degree of exposure. Patients taken to the postoperative care unit (PACU) at the end of the operation and monitorized until Modified Aldrete's Scores became 9 and more. Respiratory complications evaluated and recorded in intraoperative and postoperative period. A total of 251 patients were enrolled; 63 (25.1%) patients had airway complications, 11 (4.4%) had complications intraoperatively and 52 (20.7%) patients had complications postoperatively. There has been found significant relation with passive tobacco smoke exposure and high incidences of perioperative and postoperative respiratory complications. The risk of cough, desaturation and hypersecretion complications were found to be increased depending on the degree of exposure. There was significant relation between the degree of passive smoke exposure and the duration of PACU stay. Passive tobacco smoke exposed general anesthesia receiving patients also regarding to the degree of exposure having high rates of perioperative respiratory complications and prolongation of PACU stays when compared with unexposed patients. Copyright © 2015 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Santos, Filipe Nadir Caparica; Braga, Angelica de Fátima de Assunção; Ribeiro, Carla Josefine Barbosa de Lima; Braga, Franklin Sarmento da Silva; Carvalho, Vanessa Henriques; Junqueira, Fernando Eduardo Feres
Evaluate the incidence of postoperative residual curarization (PORC) in the post-anesthesia care unit (PACU) after the use of protocol and absence of intraoperative acceleromyography (AMG). Randomized clinical trial with 122 patients allocated into two groups (protocol and control). Protocol group received initial and additional doses of rocuronium (0.6mg.kg(-1) and 10mg, respectively); the use of rocuronium was avoided in the final 45minutes; blockade reversal with neostigmine (50μg.kg(-1)); time ≥ 15minutes between reversion and extubation. initial and additional doses of rocuronium, blockade reversal, neostigmine dose, and extubation time, all at the discretion of the anesthesiologist. AMG was used in the PACU and PORC considered at T4/T1 ratio<1.0. The incidence of PORC was lower in protocol group than in control group (25% vs. 45.2%, p=0.02). In control group, total dose of rocuronium was higher in patients with PORC than without PORC (0.43 vs. 0.35mg.kg(-1).h(-1), p=0.03) and the time interval between the last administration of rocuronium and neostigmine was lower (75.0 vs. 101.0min, p<0.01). In protocol group, there was no difference regarding the analyzed parameters (with PORC vs. without PORC). Considering the entire study population and the presence or absence of PORC, total dose of rocuronium was higher in patients with PORC (0.42 vs. 0.31mg.kg(-1).h(-1), p=0.01), while the time interval between the last administration of rocuronium and neostigmine was lower (72.5 vs. 99.0min, p ≤ 0.01). The proposed systematization reduced PORC incidence in PACU in the absence of intraoperative AMG. Copyright © 2017. Publicado por Elsevier Editora Ltda.
Webster, Joan; Lister, Carolyn; Corry, Jean; Holland, Michelle; Coleman, Kerrie; Marquart, Louise
To assess the incidence of hospital-acquired, surgery-related pressure injury (ulcers) and identify risk factors for these injuries. We used a prospective cohort study to investigate the research question. The study was conducted at a major metropolitan hospital in Brisbane, Australia. Five hundred thirty-four adult patients booked for any surgical procedure expected to last more than 30 minutes were eligible for inclusion. Patients who provided informed consent for study participation were assessed for pressure ulcers, using the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel Guidelines, before entering the operating room and again in the post-anesthetic care unit (PACU). Research nurses and all PACU nurses were trained in skin assessment and in pressure ulcer staging. Patients were not assessed again after their discharge from the PACU. Seven patients (1.3%) had existing pressure injuries (ulcers) and a further 6 (1.3%) developed a surgery-related pressure ulcer. Risk factors associated with surgery-related pressure injuries were similar to non-surgically related risks and included older age, skin condition, and being admitted from a location other than one's own home. Length of surgery was not associated with pressure ulcer development in this cohort. Perioperative nurses play an important role in identifying existing or new pressure injuries. However, many of these nurses are unfamiliar with pressure ulcer classification, so education in this area is essential. Although the incidence of surgically acquired pressure ulcers was low in this cohort, careful skin inspection before and after surgery provides an opportunity for early treatment and may prevent existing lesions progressing to higher stages.
Faulk, Debra J.; Twite, Mark D.; Zuk, Jeannie; Pan, Zhaoxing; Wallen, Brett; Friesen, Robert H.
Background Emergence agitation (EA) and negative postoperative behavioral changes (NPOBC) are common in children, though the etiology remains unclear. We investigated whether longer times under deep hypnosis as measured by Bispectral Index™ (BIS) monitoring would positively correlate with a greater incidence of EA in the post anesthesia care unit (PACU) and a greater occurrence of NPOBC in children after discharge. Methods We enrolled 400 children, ages 1–12 years old, scheduled for dental procedures under general anesthesia. All children were induced with high concentration sevoflurane and BIS monitoring was continuous from induction through recovery in the PACU. A BIS reading <45 was considered deep hypnosis. The presence of EA was assessed in the PACU using the Pediatric Anesthesia Emergence Delirium Scale (PAED). NPOBC were assessed using the Post-Hospital Behavior Questionnaire (PHBQ), completed by parents 3–5 days post-operatively. Data were analyzed using logistic regression, with a p<0.05 considered statistically significant. Results The incidence of EA was 27% (99/369) and the incidence of NPOBC was 8.8% (28/318). No significant differences in the incidence of EA or NPOBC were seen with respect to length of time under deep hypnosis as measured by a BIS value of less than 45. Conclusion Our data revealed no significant correlation between the length of time under deep hypnosis (BIS<45) and the incidence of EA or NPOBC. Within this population, these behavioral disturbances do not appear to be related to the length of time under a deep hypnotic state as measured by the BIS. PMID:19968807
The effect of dexmedetomidine added to preemptive (2% lignocaine with adrenaline) infiltration on intraoperative hemodynamics and postoperative pain after ambulatory maxillofacial surgeries under general anesthesia
Mandal, Debabrata; Das, Anjan; Chhaule, Subinay; Halder, Partha Sarathi; Paul, Joydip; RoyBasunia, Sandip; Chattopadhyay, Surajit; Mandal, Subrata Kumar
Background: Lignocaine + adrenaline; a local anesthetic agent; frequently used for perilesional infiltration, maintains the stable hemodynamics and decreases the postoperative pain after maxillofacial surgery. α2 agonists have peripheral analgesic effects. This prospective study was to evaluate the effectiveness of perilesional dexmedetomidine administered preincisionally in addition to conventional lignocaine adrenaline combinations for reconstructive maxillofacial surgery in an ambulatory care setting. Materials and Methods: 76, American Society of Anesthesiologists I-II patients scheduled for unilateral traumatic maxillofacial surgeries were randomly allocated into group DL (n = 38) receiving 15 cc of 2% lignocaine + adrenaline (1:200,000) mixed with 1 μg/kg dexmedetomidine and group PL receiving 15 cc of 2% lignocaine + adrenaline with normal saline (placebo) via local wound infiltration 5 min prior to skin incision. Perioperative hemodynamics, time to first analgesic use, total analgesic need, bleeding, and side effects were recorded for each patient. Results: Dosage of supplemental propofol; total perioperative, postoperative, and postanesthesia care unit (PACU) fentanyl consumption was significantly lower (P = 0.0001, P= 0.0001, P= 0.0001, P= 0.004, respectively) in dexmedetomine treated group than placebo. Rescue analgesic requirement was significantly earlier in group PL than group DL. Group DL patients suffered from significantly less (P = 0.02) bleeding and surgeon's satisfaction score was also high in this group. Discharge from PACU was significantly earlier in group DL. Intraoperative hemodynamic parameters were significantly lower in group DL (P < 0.05) without any appreciable side effects. Conclusion: Thus, prior dexmedetomidine local infiltration at the site of maxillofacial trauma has significantly reduced bleeding from wound site; perioperative fentanyl, propofol consumption, and subsequently ensured earlier discharge from PACU, better surgeon
Kim, Hyunzu; Min, Kyeong Tae; Lee, Jeong Rim; Ha, Sang Hee; Lee, Woo Kyung; Seo, Jae Hee
Purpose During emergence from anesthesia for a craniotomy, maintenance of hemodynamic stability and prompt evaluation of neurological status is mandatory. The aim of this prospective, randomized, double-blind study was to compare the effects of dexmedetomidine and remifentanil on airway reflex and hemodynamic change in patients undergoing craniotomy. Materials and Methods Seventy-four patients undergoing clipping of unruptured cerebral aneurysm were recruited. In the dexmedetomidine group, patients were administered dexmedetomidine (0.5 µg/kg) for 5 minutes, while the patients of the remifentanil group were administered remifentanil with an effect site concentration of 1.5 ng/mL until endotracheal extubation. The incidence and severity of cough and hemodynamic variables were measured during the recovery period. Hemodynamic variables, respiration rate, and sedation scale were measured after extubation and in the post-anesthetic care unit (PACU). Results The incidence of grade 2 and 3 cough at the point of extubation was 62.5% in the dexmedetomidine group and 53.1% in the remifentanil group (p=0.39). Mean arterial pressure (p=0.01) at admission to the PACU and heart rate (p=0.04 and 0.01, respectively) at admission and at 10 minutes in the PACU were significantly lower in the dexmedetomidine group. Respiration rate was significantly lower in the remifentanil group at 2 minutes (p<0.01) and 5 minutes (p<0.01) after extubation. Conclusion We concluded that a single bolus of dexmedetomidine (0.5 µg/kg) and remifentanil infusion have equal effectiveness in attenuating coughing and hemodynamic changes in patients undergoing cerebral aneurysm clipping; however, dexmedetomidine leads to better preservation of respiration. PMID:27189295
Phillips, Nicole M; Kent, Bridie; Colgan, Stephen; Mohebbi, Mohammadreza
Introduction While the risk of adverse events following surgery has been identified, the impact of nursing care on early detection of these events is not well established. A systematic review of the evidence and an expert consensus study in post-anaesthetic care identified essential criteria for nursing assessment of patient readiness for discharge from the post-anaesthetic care unit (PACU). These criteria were included in a new nursing assessment tool, the Post-Anaesthetic Care Tool (PACT), and incorporated into the post-anaesthetic documentation at a large health service. The aim of this study is to test the clinical reliability of the PACT and evaluate whether the use of PACT will (1) enhance the recognition and response to patients at risk of deterioration in PACU; (2) improve documentation for handover from PACU nurse to ward nurse; (3) result in improved patient outcomes and (4) reduce healthcare costs. Methods and analysis A prospective, non-randomised, pre-implementation and post-implementation design comparing: (1) patients (n=750) who have surgery prior to the implementation of the PACT and (2) patients (n=750) who have surgery after PACT. The study will examine the use of the tool through the observation of patient care and nursing handover. Patient outcomes and cost-effectiveness will be determined from health service data and medical record audit. Descriptive statistics will be used to describe the sample and compare the two patient groups (pre-intervention and post-intervention). Differences in patient outcomes between the two groups will be compared using the Cochran-Mantel-Haenszel test and regression analyses and reported as ORs with the corresponding 95% CIs. Conclusions This study will test the clinical reliability and cost-effectiveness of the PACT. It is hypothesised that the PACT will enable nurses to recognise and respond to patients at risk of deterioration, improve handover to ward nurses, improve patient outcomes, and reduce healthcare
Boonmak, Suhattaya; Boonmak, Polpun; Pothiruk, Kittawan; Hoontanee, Nattakhan
Study the satisfaction of parents with ambulatory anesthesia and associated factors, including characteristics of the patients and their parents. This was a prospective, descriptive, observation study. The authors included children who were scheduled for ambulatory anesthetic service between birth and 14 years of age and attended at Srinagarind Hospital, Khon Kaen, Thailand. The authors excluded patients whose parents could not be reached by telephone. Before anesthesia, the authors recorded the patients and parents' characteristics, level of information perception (pre-, peri- and post-anesthesia and complications). After anesthesia, the anesthesia technique and any complications were recorded. The day after anesthesia, the authors made phone calls to the patients to record the parents' satisfaction score (viz, of overall, pre-, peri- and post-anesthesia care, and information about the level of patient care at home), and any anesthesia related complications. Ninety-two patients and their parents were included in the present study. Overall parents 'satisfaction with the anesthesia service was 96.7% (i.e., 89/92) (95% CI 90.8-99.3). Parents' satisfaction with pre- and peri-anesthesia care was 100% (95% CI 96.1-100) and 97.9% (95% CI 92.4-99.7), respectively. Parents' satisfaction with the PACU care and information of patient care at home was 96.7% (95% CI 90.8-99.3) and 91.3% (95% CI 83.6-96.2), respectively. Associated factors where parents were dissatisfied included PACU care satisfaction (i.e., relative risk 22.5 (95% CI 3.2-158)) and patient care information at home (i.e., relative risk 13.3 (95% CI 1.3-136.0)). The present study showed a high level of parents' satisfaction. Parents' dissatisfaction associated with PACU care and information about post anesthesia care at home. Additionally information on parents' characteristics provides invaluable data for improving pediatric ambulatory anesthesia in Srinagarind Hospital.
Aydogan, Mustafa Said; Ozturk, Erdogan; Erdogan, Mehmet Ali; Yucel, Aytac; Durmus, Mahmut; Ersoy, Mehmet Ozcan; Colak, Cemil
Although the need for increased postoperative analgesia in smokers has been described, the effect of secondhand smoke on postoperative analgesia requirements has not been studied. We examined the effects of secondhand smoke on fentanyl consumption and postoperative pain. In this study, 101 patients (American Society of Anesthesiology physical status I and II) who underwent abdominal hysterectomy were divided into 3 groups according to history of exposure to cigarette smoke as per medical records which was retrospectively confirmed by measurement of serum cotinine: smokers (n = 28), nonsmokers (n = 31), and secondhand smokers (n = 32). All patients received propofol-remifentanil total intravenous anesthesia and used fentanyl patient controlled analgesia for postoperative pain. The fentanyl consumption visual analogue scale-pain intensity (VAS-PI) score and side effects were recorded in the postanesthesia care unit (PACU) and at 2, 4, 6, and 24 h after surgery. Fentanyl consumption at all the evaluation time points was significantly higher in secondhand smokers than in nonsmokers (P < 0.05). However, fentanyl consumption in secondhand smokers was lower than that in smokers in the PACU and at 24 h (P < 0.05). VAS-PI scores during movement and at rest in the PACU and at 4, 6, and 24 h after surgery were higher in secondhand smokers than in nonsmokers (P < 0.05). There were no statistically significant differences between the groups with regard to side effects such as nausea, vomiting, and dizziness (P > 0.05). Secondhand smoking was associated with increased postoperative fentanyl consumption, and increased VAS-PI scores. These findings may be beneficial for managing postoperative pain in secondhand smokers.
Zaremba, Sebastian; Shin, Christina H; Hutter, Matthew M; Malviya, Sanjana A; Grabitz, Stephanie D; MacDonald, Teresa; Diaz-Gil, Daniel; Ramachandran, Satya Krishna; Hess, Dean; Malhotra, Atul; Eikermann, Matthias
Bariatric surgery patients are vulnerable to sleep-disordered breathing (SDB) early after recovery from surgery and anesthesia. The authors hypothesized that continuous positive airway pressure (CPAP) improves postoperative oxygenation and SDB and mitigates opioid-induced respiratory depression. In a randomized crossover trial, patients after bariatric surgery received 30% oxygen in the postanesthesia care unit (PACU) under two conditions: atmospheric pressure and CPAP (8 to 10 cm H2O). During 1 h of each treatment, breathing across cortical arousal states was analyzed using polysomnography and spirometry. Arousal state and respiratory events were scored in accordance with American Academy of Sleep Medicine guidelines. Data on opioid boluses in the PACU were collected. The primary and secondary outcomes were the apnea hypopnea index (AHI) and apnea after self-administration of opioids in the PACU. Linear mixed model analysis was used to compare physiologic measures of breathing. Sixty-four percent of the 33 patients with complete postoperative polysomnography data demonstrated SDB (AHI greater than 5/h) early after recovery from anesthesia. CPAP treatment decreased AHI (8 ± 2/h vs. 25 ± 5/h, P < 0.001), decreased oxygen desaturations (5 ± 10/h vs. 16 ± 20/h, P < 0.001), and increased the mean oxygen saturation by 3% (P = 0.003). CPAP significantly decreased the respiratory-depressant effects observed during wakefulness-sleep transitions without affecting hemodynamics. The interaction effects between CPAP treatment and opioid dose for the dependent variables AHI (P < 0.001), inspiratory flow (P = 0.002), and minute ventilation (P = 0.015) were significant. This pharmacophysiologic interaction trial shows that supervised CPAP treatment early after surgery improves SDB and ameliorates the respiratory-depressant effects of opioids without undue hemodynamic effects.
Florman, Jeffrey E; Cushing, Deborah; Keller, Lynne A; Rughani, Anand I
OBJECTIVE Selecting the appropriate patients undergoing craniotomy who can safely forgo postoperative intensive care unit (ICU) monitoring remains a source of debate. Through a multidisciplinary work group, the authors redefined their institutional care process for postoperative monitoring of patients undergoing elective craniotomy to include transfer from the postanesthesia care unit (PACU) to the neurosurgical floor. The hypothesis was that an appropriately selected group of patients undergoing craniotomy could be safely managed outside the ICU in the postoperative period. METHODS The work group developed and implemented a protocol for transfer of patients to the neurosurgical floor after 4-hour recovery in the PACU following elective craniotomy for supratentorial tumor. Criteria included hemodynamically stable adults without significant new postoperative neurological impairment. Data were prospectively collected including patient demographics, clinical characteristics, surgical details, postoperative complications, and events surrounding transfer to a higher level of care. RESULTS Of the first 200 consecutive patients admitted to the floor, 5 underwent escalation of care in the first 48 hours. Three of these escalations were for agitation, 1 for seizure, and 1 for neurological change. Ninety-eight percent of patients meeting criteria for transfer to the floor were managed without incident. No patient experienced a major complication or any permanent morbidity or mortality following this care pathway. CONCLUSIONS Care of patients undergoing uneventful elective supratentorial craniotomy for tumor on a neurosurgical floor after 4 hours of PACU monitoring appears to be a safe practice in this patient population. This tailored practice safely optimized hospital resources, is financially responsible, and is a strong tool for improving health care value.
Ozturk, Nilgun Kavrut; Kavakli, Ali Sait
OBJECTIVE: Postoperative urinary retention (POUR) is a common complication after spinal anesthesia. Ultrasound (US) is a simple, non-invasive method to estimate bladder volume before and after surgery. Primary aim of the present study was to investigate utility of bladder volume measured before and after surgery in prediction of POUR risk. Secondary aim was to investigate necessity of urethral catheter use and risk of urethral catheter-related infections. METHODS: Eighty patients who received spinal anesthesia for arthroscopic knee surgery were included in the study. Level and duration of sensory and motor block; bladder volume measured preoperatively, in post-anesthetic care unit (PACU), and when discharged from PACU; use of urethral catheter; and incidence of urinary tract infection data were recorded. RESULTS: POUR was observed in 28.7% of patients. Length of time for sensory block regression was significantly shorter in patients without POUR (p=0.012). Spontaneous urination was not observed in 3 of 23 patients with POUR, although bladder volume was less than 600 mL. Bladder volume over 600 mL without urination was recorded in 20 patients. There was no statistical difference in preoperative bladder volume between patients who did or did not develop POUR. Bladder volume on admission to PACU was higher in patients with POUR (p=0.023). Urgency and dysuria were observed in 5 patients who required urethral catheterization during postoperative period. Urinary tract infection developed in 1 patient. There was no statistical difference in development of urinary tract infection between patient groups who did and did not undergo urethral catheterization. CONCLUSION: Assessment of patient bladder volume with US before arthroscopic knee surgery may be used to foresee development of POUR. Avoiding elective urinary catheterization may reduce urinary infections. PMID:28275753
Kim, Jung T; Ren, Christine J; Fielding, George A; Pitti, Abhishek; Kasumi, Takeo; Wajda, Michael; Lebovits, Allen; Bekker, Alex
Parenteral administration of opioids and NSAIDs has been the mainstay for postoperative pain control in patients undergoing laparoscopic adjustable gastric banding (LAGB). Both classes of drugs, however, are associated with serious adverse effects. An addition of complimentary analgesic techniques may decrease requirement for traditional analgesics, thus reducing the incidence of side-effects. We designed the study to evaluate the effectiveness of Lavender aromatherapy in reducing opioid requirements after LAGB. A prospective randomized placebo controlled study was carried out on 54 patients undergoing LAGB. Upon arrival to the post-anesthesia care unit (PACU), patients in the study group were treated with lavender oil, which was applied to the oxygen face mask; the control group patients received nonscented baby oil. Postoperative pain was treated with morphine. Numerical rating scores (0-10) were used to measure the level of pain at 5, 30, and 60 min. Sedation was evaluated using the Observer Assessment of Alertness/Sedation scale (0-5). Data analyzed included the amount of opioids, NRS, OAA/S, PACU discharge time, as well as the incidence of side-effects. The two groups were comparable with regard to patient characteristics, intraoperative drug use, and surgical time. Significantly more patients in the Placebo group (PL) required analgesics for postoperative pain (22/27, 82%) than patients in the Lavender group (LAV) (12/26, 46%) (P = .007). Moreover, the LAV patients required significantly less morphine postoperatively than PL patients: 2.38 mg vs 4.26 mg, respectively (P = .04). There were no differences in the requirements for post-operative antiemetics, antihypertensives, or PACU discharge time. Our results suggest that lavender aromatherapy can be used to reduce the demand for opioids in the immediate postoperative period. Further studies are required to assess the effect of this therapy on clinically meaningful outcomes, such as the incidence of
Perioperative clinical and economic outcomes associated with replacing first-generation high molecular weight hydroxyethyl starch (Hextend®) with low molecular weight hydroxyethyl starch (Voluven®) at a large medical center.
Bartz, Raquel R; White, William D; Gan, Tong J
Several plasma volume expander alternatives exist to enhance intravascular volume status in patients undergoing surgery. The optimal intravascular volume expander in the perioperative setting is currently unknown. Low molecular weight hetastarch, Voluven® (130/0.4), may have a better safety profile than high molecular weight hetastarch, Hextend® (450/0.7). We examined the clinical and cost outcomes of converting from Hextend® to Voluven® in a large tertiary medical center. Using a large electronic database, we retrospectively compared two different time periods (2009 and 2010) where the availability of semisynthetic colloids changed. Perioperative and postoperative outcomes including the use of red blood cells (RBC), platelets and coagulation factors, length of stay in the postoperative acute care unit (PACU), intensive care unit and hospital, as well as 30-day and 1-year mortality were compared. In addition, direct acquisition costs of all intraoperative and PACU colloids and crystalloid use were determined. A total of 4,888 adult subjects were compared of which 1,878 received Hextend® (pre-conversion) and 2,759 received Voluven® (post-conversion) during two separate 7-month periods within 1 year apart, with the remainder receiving Plasmanate. The patients were similar in terms of patient demographics, preoperative comorbidities, ASA status, emergency surgery, types of surgery, intraoperative, and PACU times. In unadjusted outcomes, patients in the Hextend® group received more lactated Ringer's than in the Voluven® group (2,220 + 1,312 vs. 1,946 ± 1,097 ml; P < 0.0001). The use of albumin (Plasmanate) was reduced from 10.5% of patients to 1.1% when Voluven® was substituted for Hextend®. Unadjusted outcomes were similar in each group including hospital LOS, percent change from baseline creatinine and receipt of intraoperative and PACU blood product administration. However, overall unadjusted total fluid costs were greater in the Voluven
Li, B Y; Geng, Z Y; Wang, D X
To evaluate the effect of intraoperative dexmedetomidine (DEX) infusion during propofol intravenous anesthesia on postoperative recovery after major spinal surgery. Sixty patients aged 18 to 65 (American Society of Anesthesiologists, ASA I-II), scheduled for spinal surgery from January 2014 to May 2014 were randomized into two groups. The DEX group (n=30) received 0.5 μg/kg of DEX ten minutes before anesthesic induction, followed by an infusion of DEX at 0.2 μg/(kg×h) intraoperatively and the control group (n=30) was given identical amounts of normal saline. At the end of surgery, the patients of both groups received patient-controlled intravenous analgesia (PCIA) with morphine 0.5 mg/h (1 mg demand dose and 8 min lockout). Heart rate and mean arterial pressure (MAP) were continually monitored during operation and in the post-anesthesia care unit (PACU). The propofol and sufentanil consumptions during operation and the morphine consumption 48 h after surgery were recorded. The time for recovery and extubation were recorded. The followed-up evaluations were performed to assess Ramsay scores, visual analogue scale (VAS) pain scores as well as side effects in PACU and 48 h after surgery. Heart rate of DEX group was lower than that of control group after intubation and extubation and in PACU 10 min (P<0.05). MAP was lower in DEX group than that in control group after extubation and in PACU (P<0.05). Compared with control group, the propofol consumption during anesthesic induction, the sufentanil consumption during operation and the cumulative consumption of morphine 2 h and 6 h after surgery were decreased (P<0.05). There were no differences between the two groups as to the time for recovery or extubation. Compared with control group, the VAS pain scores were significantly decreased (P<0.01), the incidence of postoperative nausea and vomiting in DEX group were significantly decreased (P<0.05) 48 h after surgery. Intraoperative infusion of DEX improved quality of
Parente, Daniela; Luís, Clara; Veiga, Dalila; Silva, Hugo; Abelha, Fernando
Postoperative delirium (POD) is a frequent post-surgical complication that is associated with increased mortality and poor patient outcomes. POD is a complex disorder with multiple risk factors such as pre-existing patient comorbidities and perioperative complications. The aim of this study was to evaluate the incidence of POD and to identify risk factors for the development of POD in a post-anesthesia care unit (PACU). We enrolled 97 adult patients admitted to a PACU over a five-day period (start date September 6, 2010). Patient demographics and intraoperative and postoperative data were collected. Patients were followed for the development of delirium using the Intensive Care Delirium Screening Checklist. Descriptive analyses of variables were used to summarize data, and the Mann-Whitney U test was used to compare continuous variables; the chi-square or Fisher's exact test was used for comparisons. Univariate analysis was performed using simple binary logistic regression with odds ratios (OR) and 95% confidence intervals (95% CI). The significance level for multiple comparisons was controlled by applying the Bonferroni correction for multiple comparisons and variables were deemed significant if p≤0.0025. Six percent of patients developed POD. These patients were older and more likely to have higher American Society of Anesthesiologists (ASA) physical status (83 vs. 22% with ASA III/IV, p=0.004) as well as a higher frequency of congestive heart failure (50 vs. 3%, p=0.003) and a higher Revised Cardiac Risk Index (RCRI) score (33 vs. 6% with RCRI ≥2, p=0.039). The duration of anesthesia for patients with POD was also longer and they received a greater volume of crystalloids, colloids, and erythrocytes during surgery. Congestive heart disease was an independent risk factor for POD (OR 29.3, 95% CI 4.1-210.6; p<0.001). In addition, patients who developed POD had higher in-hospital mortality and longer PACU and hospital stays. Patients who developed POD had longer
This article describes the development of a new service - the post-anaesthesia care unit (PACU) - that provides extended care in a recovery unit for patients who would have formerly been 'fast-tracked' through a high dependency unit (HDU). Patients requiring major surgery who stay in the recovery unit overnight are invasively monitored, have tight fluid management, blood chemistry analysis and frequently have pharmacological support. However, our overnight recovery service is not considered suitable for ventilated patients. Over 90% of patients are able to be discharged to a surgical ward within 24 hours of admission, following medical review.
Muffly, Matthew K; Chen, Michael I; Claure, Rebecca E; Drover, David R; Efron, Bradley; Fitch, William L; Hammer, Gregory B
In the perioperative period, anesthesiologists and postanesthesia care unit (PACU) nurses routinely prepare and administer small-volume IV injections, yet the accuracy of delivered medication volumes in this setting has not been described. In this ex vivo study, we sought to characterize the degree to which small-volume injections (≤0.5 mL) deviated from the intended injection volumes among a group of pediatric anesthesiologists and pediatric postanesthesia care unit (PACU) nurses. We hypothesized that as the intended injection volumes decreased, the deviation from those intended injection volumes would increase. Ten attending pediatric anesthesiologists and 10 pediatric PACU nurses each performed a series of 10 injections into a simulated patient IV setup. Practitioners used separate 1-mL tuberculin syringes with removable 18-gauge needles (Becton-Dickinson & Company, Franklin Lakes, NJ) to aspirate 5 different volumes (0.025, 0.05, 0.1, 0.25, and 0.5 mL) of 0.25 mM Lucifer Yellow (LY) fluorescent dye constituted in saline (Sigma Aldrich, St. Louis, MO) from a rubber-stoppered vial. Each participant then injected the specified volume of LY fluorescent dye via a 3-way stopcock into IV tubing with free-flowing 0.9% sodium chloride (10 mL/min). The injected volume of LY fluorescent dye and 0.9% sodium chloride then drained into a collection vial for laboratory analysis. Microplate fluorescence wavelength detection (Infinite M1000; Tecan, Mannedorf, Switzerland) was used to measure the fluorescence of the collected fluid. Administered injection volumes were calculated based on the fluorescence of the collected fluid using a calibration curve of known LY volumes and associated fluorescence.To determine whether deviation of the administered volumes from the intended injection volumes increased at lower injection volumes, we compared the proportional injection volume error (loge [administered volume/intended volume]) for each of the 5 injection volumes using a linear
Rubio-Moraga, Angela; Candel-Perez, David; Lucas-Borja, Manuel E; Tiscar, Pedro A; Viñegla, Benjamin; Linares, Juan C; Gómez-Gómez, Lourdes; Ahrazem, Oussama
Eight Pinus nigra Arn. populations from Southern Spain and Northern Morocco were examined using inter-simple sequence repeat markers to characterize the genetic variability amongst populations. Pair-wise population genetic distance ranged from 0.031 to 0.283, with a mean of 0.150 between populations. The highest inter-population average distance was between PaCU from Cuenca and YeCA from Cazorla, while the lowest distance was between TaMO from Morocco and MA Sierra Mágina populations. Analysis of molecular variance (AMOVA) and Nei's genetic diversity analyses revealed higher genetic variation within the same population than among different populations. Genetic differentiation (Gst) was 0.233. Cuenca showed the highest Nei's genetic diversity followed by the Moroccan region, Sierra Mágina, and Cazorla region. However, clustering of populations was not in accordance with their geographical locations. Principal component analysis showed the presence of two major groups-Group 1 contained all populations from Cuenca while Group 2 contained populations from Cazorla, Sierra Mágina and Morocco-while Bayesian analysis revealed the presence of three clusters. The low genetic diversity observed in PaCU and YeCA is probably a consequence of inappropriate management since no estimation of genetic variability was performed before the silvicultural treatments. Data indicates that the inter-simple sequence repeat (ISSR) method is sufficiently informative and powerful to assess genetic variability among populations of P. nigra.
Teran, Lara; Hawkins, John K
We evaluated preemptive treatment for postoperative nausea and vomiting (PONV) with intravenous (IV) granisetron, 0.1 mg, introoperatively as compared with the use of 70% inhalation isopropyl alcohol and a control group for the prevention of PONV. We randomly assigned 57 women, 18 to 50 years old, undergoing laparoscopic procedures to 1 of 3 groups: (1) inhalation of 70% isopropyl alcohol, (2) 0.1 mg granisetron IV, and (3) no prophylactic treatment control. Participants were asked to rate their nausea and vomiting preoperatively, on arrival to postanesthesia care unit (PACU), at discharge from PACU, 6 hours after extubation, and 24 hours after extubation and any occurrence of nausea and vomiting using the numeric rating scale (NRS), 0 to 10. Group 1 experienced more PONV episodes than groups 2 and 3 during the 6- to 24-hour postsurgical timeframe (P = .02). There were no significant differences among the 3 groups in demographics, first episode of PONV, total number of episodes in 24 hours, NRS rating at rescue, and anesthetic duration. PONV and menstrual cycle phase had no positive correlation (P > .05). History of smoking, PONV, and motion sickness had no significant difference against any measure of PONV (P > .05).
Kim, Kyung Mi; Lee, Ki Hwa; Kim, Yong Han; Ko, Myoung Jin; Jung, Jae-Wook; Kang, Eunsu
A prospective, double-blind, randomized controlled trial to compare the effect of preoperative midazolam or ketamine on the incidence of emergence agitation (EA) following sevoflurane anaesthesia in children. Paediatric patients (2-6 years old) undergoing ophthalmic surgery were allocated to receive premedication with either 0.1 mg/kg midazolam or 1 mg/kg ketamine. Incidence of EA and postoperative pain scores were recorded at 10-min intervals in the postanaesthetic care unit (PACU). The use of EA rescue medications (fentanyl or midazolam) was recorded. The incidence of EA was significantly lower in the ketamine group (n = 33) than the midazolam group (n = 34) at 10 and 20 min after transfer to PACU. There was no significant difference in overall incidence of EA. The frequency of midazolam use as rescue medication was significantly lower in the katamine group than in the midazolam group. Premedication with ketamine is more effective than midazolam in preventing EA during the early emergence period after sevoflurane anaesthesia in children. © The Author(s) 2016.
Windle, Pamela E; Krenzischek, Dina A; Mamaril, Myrna
The perianesthesia environment of care is a unique high-risk health care setting that has a high susceptibility to error because of the vulnerability of patients who are undergoing surgery and anesthesia as well as the high levels of activity in these units. Safe practice in this environment is essential to quality patient care and positive patient outcomes. Consequently, ASPAN conducted a descriptive cross-sectional pilot study to test initial reliability and validity of the Perianesthesia Safe Practices Survey Instrument. The instrument was designed to assess specific safe practices in perianesthesia areas by identifying the following: (1) what are the current perianesthesia safety practices, (2) what are the recommended safety practices that are not in place, and (3) what are the differences in safety practices within areas along the perianesthesia continuum of care. Thirty-six respondents found the instrument to be clear, easy to complete, and containing appropriate content. The alpha coefficients for internal consistency for the unit specific components were preadmission testing (.79), pre-op (.94), Phase I PACU recovery (.92), and Phase II PACU recovery (.90). The results of this pilot study provided information about areas of excellence and areas for improvement for safe clinical practice in the specialty setting, as well as initial reliability and validity for the safe practices questionnaire.
Postoperative Pharyngolaryngeal Adverse Events with Laryngeal Mask Airway (LMA Supreme) in Laparoscopic Surgical Procedures with Cuff Pressure Limiting 25 cmH2O: Prospective, Blind, and Randomised Study
Kang, Joo-Eun; Choi, Jae Won; Son, Il Soon
To reduce the incidence of postoperative pharyngolaryngeal adverse events, laryngeal mask airway (LMA) manufacturers recommend maximum cuff pressures not exceeding 60 cmH2O. We performed a prospective randomised study, comparing efficacy and adverse events among patients undergoing laparoscopic surgical procedures who were allocated randomly into low (limiting 25 cmH2O, L group) and high (at 60 cmH2O, H group) LMA cuff pressure groups with LMA Supreme. Postoperative pharyngolaryngeal adverse events were evaluated at discharge from postanaesthetic care unit (PACU) (postoperative day 1, POD 1) and 24 hours after discharge from PACU (postoperative day 2, POD 2). All patients were well tolerated with LMA without ventilation failure. Before pneumoperitoneum, cuff volume and pressure and oropharyngeal leak pressure (OLP) showed significant differences. Postoperative sore throat at POD 2 (3 versus 12 patients) and postoperative dysphagia at POD 1 and POD 2 (0 versus 4 patients at POD 1; 0 versus 4 patients at POD 2) were significantly lower in L group, compared with H group. In conclusion, LMA with cuff pressure limiting 25 cmH2O allowed both efficacy of airway management and lower incidence of postoperative adverse events in laparoscopic surgical procedures. This clinical trial is registered with KCT0000334. PMID:24778598
Anderson, Lynn A; Gross, Jeffrey B
To determine whether aromatherapy can reduce postoperative nausea, the investigators studied 33 ambulatory surgery patients who complained of nausea in the PACU. After indicating the severity of nausea on a 100-mm visual analogue scale (VAS), subjects received randomized aromatherapy with isopropyl alcohol, oil of peppermint, or saline (placebo). The vapors were inhaled deeply through the nose from scented gauze pads held directly beneath the patients' nostrils and exhaled slowly through the mouth. Two and 5 minutes later, the subjects rated their nausea on the VAS. Overall nausea scores decreased from 60.6 +/- 4.3 mm (mean +/- SE) before aromatherapy to 43.1 +/- 4.9 mm 2 minutes after aromatherapy (P <.005), and to 28.0 +/- 4.6 mm 5 minutes after aromatherapy (P < 10(-6)). Nausea scores did not differ between the treatments at any time. Only 52% of the patients required conventional intravenous (IV) antiemetic therapy during their PACU stay. Overall satisfaction with postoperative nausea management was 86.9 +/- 4.1 mm and was independent of the treatment group. Aromatherapy effectively reduced the perceived severity of postoperative nausea. The fact that a saline "placebo" was as effective as alcohol or peppermint suggests that the beneficial effect may be related more to controlled breathing patterns than to the actual aroma inhaled.
Kim, Dae Seong; Kang, Hyun; Baek, Chong Wha; Jung, Yong Hun; Woo, Young Cheol; Kim, Jin Yun; Park, Sun Gyoo
Background We made a comparative study on the antiemetic effect of midazolam and ondansetron added to intravenous patient-controlled analgesia (PCA) using fentanyl with gynecologic patients undergoing pelviscopic surgery. Methods The PCA using 20 µg/kg of fentanyl was started in all groups postoperatively. A dose of 16 mg of ondansetron was added to the PCA of group O (n = 30). A dose of 5 mg of midazolam was added to the PCA of group M (n = 30). While 16 mg of ondansetron and 5 mg of midazolam were added to the PCA of group MO (n = 30). Total volume of the PCA was 60 ml, and the PCA system was programmed to deliver 0.5 ml/h of continuous doses and a 0.5 ml bolus on demand, with a 15 minutes lockout interval. The incidence of postoperative nausea and vomiting (PONV), sedation score, visual analog scale (VAS) for pain, and rescue drug dose for PONV were investigated at the postanesthesia care unit (PACU), 6 hours, and 24 hours after recovery. Results The incidence of PONV in group MO was significantly lower than in group O at PACU, 24 hours after recovery (P < 0.05). The sedation score and VAS pain score showed no differences among all groups. Conclusions Midazolam added to PCA using fentanyl proved more effective than ondansetron in preventing PONV without adverse effects. PMID:22558501
Rubio-Moraga, Angela; Candel-Perez, David; Lucas-Borja, Manuel E.; Tiscar, Pedro A.; Viñegla, Benjamin; Linares, Juan C.; Gómez-Gómez, Lourdes; Ahrazem, Oussama
Eight Pinus nigra Arn. populations from Southern Spain and Northern Morocco were examined using inter-simple sequence repeat markers to characterize the genetic variability amongst populations. Pair-wise population genetic distance ranged from 0.031 to 0.283, with a mean of 0.150 between populations. The highest inter-population average distance was between PaCU from Cuenca and YeCA from Cazorla, while the lowest distance was between TaMO from Morocco and MA Sierra Mágina populations. Analysis of molecular variance (AMOVA) and Nei’s genetic diversity analyses revealed higher genetic variation within the same population than among different populations. Genetic differentiation (Gst) was 0.233. Cuenca showed the highest Nei’s genetic diversity followed by the Moroccan region, Sierra Mágina, and Cazorla region. However, clustering of populations was not in accordance with their geographical locations. Principal component analysis showed the presence of two major groups—Group 1 contained all populations from Cuenca while Group 2 contained populations from Cazorla, Sierra Mágina and Morocco—while Bayesian analysis revealed the presence of three clusters. The low genetic diversity observed in PaCU and YeCA is probably a consequence of inappropriate management since no estimation of genetic variability was performed before the silvicultural treatments. Data indicates that the inter-simple sequence repeat (ISSR) method is sufficiently informative and powerful to assess genetic variability among populations of P. nigra. PMID:22754321
Faiz, Saadia A.; Hernandez, Mike; Bashoura, Lara; Cherian, Sujith V.; French, Katy E.
Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m2 (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients. PMID:27610133
Postoperative pharyngolaryngeal adverse events with laryngeal mask airway (LMA Supreme) in laparoscopic surgical procedures with cuff pressure limiting 25 cmH₂O: prospective, blind, and randomised study.
Kang, Joo-Eun; Oh, Chung-Sik; Choi, Jae Won; Son, Il Soon; Kim, Seong-Hyop
To reduce the incidence of postoperative pharyngolaryngeal adverse events, laryngeal mask airway (LMA) manufacturers recommend maximum cuff pressures not exceeding 60 cmH₂O. We performed a prospective randomised study, comparing efficacy and adverse events among patients undergoing laparoscopic surgical procedures who were allocated randomly into low (limiting 25 cmH₂O, L group) and high (at 60 cmH₂O, H group) LMA cuff pressure groups with LMA Supreme. Postoperative pharyngolaryngeal adverse events were evaluated at discharge from postanaesthetic care unit (PACU) (postoperative day 1, POD 1) and 24 hours after discharge from PACU (postoperative day 2, POD 2). All patients were well tolerated with LMA without ventilation failure. Before pneumoperitoneum, cuff volume and pressure and oropharyngeal leak pressure (OLP) showed significant differences. Postoperative sore throat at POD 2 (3 versus 12 patients) and postoperative dysphagia at POD 1 and POD 2 (0 versus 4 patients at POD 1; 0 versus 4 patients at POD 2) were significantly lower in L group, compared with H group. In conclusion, LMA with cuff pressure limiting 25 cmH₂O allowed both efficacy of airway management and lower incidence of postoperative adverse events in laparoscopic surgical procedures. This clinical trial is registered with KCT0000334.
To explore and characterize how the implementation and use of an electronic nursing module supports the care process, the interrelation of interdisciplinary documentation and the role of redundant information in the interplay between technology and clinical practice. A qualitative case study was carried out at a surgical ward and a post-anesthesia care unit (PACU). A mixed method of data collection was used, including semi-structured interviews, observation and document analysis. The study revealed that the electronic care plan was used in daily practice, and international nursing classifications were extensively used. However, the study also illustrates a gap between nurse-specific documentation (care plans) and other sources of information used in the documentation of the care process, such as the medication sheet, medical chart, and a custom-designed medical chart used by the post-anesthesia care unit (PACU). Moreover, the study also highlights how redundant information can serve as a "glue" in the socio-technical network to facilitate information sharing and coordination across domain-specific boundaries. Differentiating between negative and positive redundancy provides increased understanding of how the correlation of supplementary information has a role in the integration between work processes and computer systems. Coordination and pragmatic redundancies are emphasized to inform the further design and implementation of process-based electronic patient records (EPR). Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Lee, Wen-Ping; Wu, Pao-Yuan; Lee, Meng-Ying; Ho, Lun-Hui; Shih, Whei-Mei
The aim of this study was to explore the effects of listening to music on the anxiety levels and physiological responses of surgical patients receiving spinal anesthesia. An experimental design was used in the study with an experimental group (n=50) and a control group (n=50). The experimental group received 30min of musical intervention and routine nursing care in the Post-Anesthesia Care Unit (PACU) while the control group received only routine nursing care. The study found significant differences in both anxiety and physiological indices between the two groups. The mean score of the State-Trait Anxiety Inventory (STAI) in the study group decreased from a pre-test score of 59.0 to a post-test score of 31.20 (t=28.63, p<0.001). Physiological indices such as heart rate (t=2.61, p=0.012), respiration rate (t=2.29, p=0.026), systolic blood pressure (t=2.30, p=0.026), and diastolic blood pressure (t=3.02, p=0.004) decreased significantly as well. Control group was not seeing significant changes from pre-op values. Listening to music while in the recovery room may decrease the level of anxiety in surgical patients receiving spinal anesthesia. The results of this study can serve as a reference for PACU nurses in utilizing music listening programs to achieve the goal of holistic care. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.
2-Chloroprocaine is a local anesthetic with a very short half-life and a favorable evolution of spinal block for ultra-short outpatient procedures. The aim of this retrospective study is to evaluate the clinical impact of the introduction of spinal 1% 2-chloroprocaine compared to general anesthesia at the ARS Medica Clinic (Switzerland). We retrospectively evaluated the charts of all patients who underwent knee arthroscopy under general anesthesia (group GA) or spinal 2-chloroprocaine (group SA) between June 2012, when chloroprocaine was available for the first time, and December 2012. We collected the anesthesia time and the number of patients able to bypass the PACU. Moreover, we looked at hospital discharge time and we performed a pharmaco-economic analysis. 61 charts were evaluated, 5 patients were excluded for insufficient data. The anesthesia time was comparable between the two groups. All patients in group SA were able to bypass the PACU versus only 18% in group GA. We observed a clinically significant reduction in terms of discharge time (203 vs 326 minutes) and cost of materials and employers involved patients' care (53 vs 78 swiss franks) when spinal 1% 2-chloroprocaine was used. The right selection of the local anesthetic makes spinal anesthesia a suitable anesthetic technique for ultra-short outpatient procedures. If short acting local anesthetics are involved, spinal anesthesia could be competitive versus general anesthesia.
Chen, Yanqing; Wu, Weilan; Yao, Yusheng; Yang, Yang; Zhao, Qiuyan; Qiu, Liangcheng
Background: Transcutaneous electric acupoint stimulation (TEAS) at Jiaji acupuncture points has therapeutic potential for relieving viscera pain and opioid-related side effects. This prospective, randomized, triple-blinded, placebo-controlled trial was to investigate the efficacy of TEAS on abdominal pain after colonoscopy. Methods: Consecutive outpatients with American Society of Anesthesiologists (ASA) physical status I or II underwent selective colonoscopy were randomly assigned into two groups for either TEAS or sham pretreatment. The primary outcomes were the incidence of abdominal pain after colonoscopy. The secondary outcomes included the incidence of abdominal distension, postoperative nausea and vomiting (PONV), duration of PACU stay, and patient’s satisfaction and acceptance. Results: Among the 229 patients analyzed, fewer occurrence of post-procedural abdominal pain (11.4% vs 25.2%, P = 0.007) and distension (1.8% vs 7.8%, P = 0.032) were observed in TEAS group, when compared with the sham group. The duration of PACU stay was significant shortened in TEAS group (P < 0.001). Meanwhile, patients’ satisfaction score to medical service was higher (P < 0.001), and their acceptance to colonoscopy was improved (P = 0.011). Conclusion: Pretreatment with TEAS can reduce post-procedural discomfort, provide more efficient medical resources utilization, and improved patient’s satisfaction and colonoscopy acceptance. PMID:26131193
Chen, Yanqing; Yang, Yang; Yao, Yusheng; Dai, Dongsheng; Qian, Bin; Liu, Pingping
Background: We evaluated the effects of transcutaneous electric acupoint stimulation (TEAS) on the postoperative quality of recovery after thyroidectomy with general anesthesia in this prospective, randomized, double-blind, placebo-controlled study. Methods: Eight-four American Society of Anesthesiologists physical status (ASA) I or II patients undergoing thyroidectomy were randomly allocated to TEAS or control groups. The primary outcome was the quality of recovery, which was assessed on the day before surgery and 24 h after surgery using the Quality of Recovery 40 questionnaire (QoR-40). Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), postoperative pain intensity, duration of post anesthesia care unit (PACU) stay and patient’s satisfaction. Results: Global QoR-40 score at 24 h after surgery was higher in the TEAS group (median [interquartile range], 183 [172-190]) compared with the control group (168 [154-183]) (P < 0.001). Compared with the control group, postoperative pain intensity and the cumulative number of opioids administered was lower in the TEAS group patients (P < 0.001). TEAS reduced the incidence of PONV and dizziness (P = 0.001), as well as the duration of PACU stay (P < 0.001). Simultaneously, the patient’s satisfaction scores were higher in the TEAS group (P = 0.002). Conclusion: Preoperative TEAS enhances the quality of recovery, postoperative analgesia and patient’s satisfaction, alleviates postoperative side effects and accelerates discharge after general anesthesia for thyroidectomy. PMID:26550304
Balachandran, Diwakar D; Faiz, Saadia A; Hernandez, Mike; Kowalski, Alicia M; Bashoura, Lara; Goravanchi, Farzin; Cherian, Sujith V; Rebello, Elizabeth; Kee, Spencer S; French, Katy E
Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m(2) (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.
Yao, Yusheng; Zhao, Qiuyan; Gong, Cansheng; Wu, Yihuan; Chen, Ying; Qiu, Liangcheng; Wu, Xiaodan; Chen, Yanqing
Background. We conducted this prospective, randomized, double-blind, placebo-controlled study to evaluate the effects of transcutaneous electric acupoint stimulation (TEAS) on the quality of recovery (QoR) and postoperative analgesia after gynecological laparoscopic surgery. Methods. 74 American Society of Anesthesiologists physical status (ASA) I or II patients undergoing gynecological laparoscopic surgery were randomly allocated to TEAS or control groups. The primary outcome was the quality of recovery, which was assessed on the day before surgery and 24 h after surgery using a 40-item questionnaire. Secondary outcomes included postoperative pain scores, the incidence of postoperative nausea and vomiting (PONV), duration of postanesthesia care unit (PACU) stay, and patient's satisfaction. Results. The TEAS group had higher QoR scores than control group upon 24 h after surgery (177 versus 165; P < 0.001). Compared with the control group, postoperative pain scores and the cumulative number of opioids administered were lower in the TEAS group patients (P = 0.04). TEAS reduced the incidence of PONV and dizziness, as well as duration of PACU stay. Simultaneously, the patient's satisfaction scores were higher in the TEAS group (P = 0.002). Conclusion. Preoperative TEAS enhances QoR, improves postoperative analgesia and patient's satisfaction, alleviates postoperative side effects, and accelerates discharge after general anesthesia for gynecological laparoscopic surgery. PMID:26170873
Winslow, Elizabeth H; Cooper, Susan K; Haws, Dianne M; Balluck, Julie P; Jones, Carol M; Morse, Elizabeth C; Edwards, Terri D; Kelly, Patricia A
Accurate body core temperature measurement is essential in perioperative areas to quickly recognize and address abnormal temperatures. The purposes of this prospective, descriptive study were to accurately identify unplanned perioperative hypothermia (UPH) in 64 elective major surgery patients; to describe factors that increased the risk of UPH; to describe active/passive warming measures; to describe thermal comfort in patients with and without UPH; and to compare oral, temporal artery, and bladder temperatures. Based on bladder temperatures, 52% of the patients had UPH in the operating room (OR) and 42% on postanesthesia care unit (PACU) admission. The temporal artery thermometer did not detect any hypothermia. Descriptive data and Bland-Altman plots showed lack of agreement between the temporal artery thermometer readings and those of the oral and bladder thermometers. The patient's thermal comfort report did not accurately reflect hypothermia. Factors found to increase the risk of UPH included older age, BMI lower than 30, and OR ambient temperature lower than 68°F. All but one patient had active warming in the OR; active warming was infrequently used in the PACU. Based on our findings and findings in previous studies, we do not recommend using the temporal artery thermometer in perioperative areas. To prevent UPH, we recommend aggressive use of convective and conductive warming measures in perioperative areas and increasing OR ambient temperatures. Copyright © 2012 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
Raft, J; Millet, F; Meistelman, C
The aim of this study was to evaluate the cost of an operating room using data from our hospital. Using an accounting-based method helped us. Over the year 2012, the sum of direct and indirect expenses with cost sharing expenses allowed us to calculate the cost of the operating room (OR) and of the post-anaesthesia care unit (PACU). The cost of the OR and PACU was €10.8 per minute of time offered. Two thirds of the direct expenses were allocated to surgery and one third to anaesthesia. Indirect expenses were 25% of the direct expenses. The cost of medications and single use medical devises was €111.45 per anaesthesia. The total cost of anaesthesia (taking into account wages and indirect expenses) was €753.14 per anaesthesia as compared to the total cost of the anaesthesia. The part of medications and single use devices for anaesthesia was 14.8% of the total cost. Despite the difficulties facing cost evaluation, this model of calculation, assisted by the cost accounting controller, helped us to have a concrete financial vision. It also shows that a global reflexion is necessary during financial decision-making. Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
Liu, Dan-Shu; Guan, Feng; Wang, Bin; Zhang, Tian
Postoperative pain is the main obstacle for safely rapid recovery of patients undergoing laparoscopic cholecystectomy (LC). In this study, we systemically evaluated the analgesic efficacy of intraperitoneal and incisional ropivacaine injected at the end of the LC. A total of 160 patients, scheduled for elective LC, were allocated into four groups. Group Sham received intraperitoneal and incisional normal saline (NS). Group IC received incisional ropivacaine and intraperitoneal NS. Group IP received incisional NS and intraperitoneal ropivacaine. Group ICP received intraperitoneal and incisional ropivacaine. At the end of the surgery, ropivacaine was injected into the surgical bed through the right subcostal port and infiltrated at the four ports. Dynamic pain by a visual analogue scale (VAS) and cumulative morphine consumption at 2 h, 6 h, 24 h, and 48 h postoperatively, as well as incidence of side-effects over 48 h after LC was recorded. Compared with those in group Sham, the time of post-anesthesia care unit (PACU) stay, dynamic VAS score (VAS-D) 2 h and 6 h postoperatively, cumulative morphine consumption 6 h and 24 h postoperatively, and incidence of nausea and vomiting 48 h after LC in group IC and ICP were less (P<0.05). Furthermore, intraperitoneal and incisional ropivacaine exerts more powerful analgesic effect than single usage with intraperitoneal or incisional ropivacaine (P<0.05). No patients exhibited signs of local anesthetic toxicity. In conclusion, intraperitoneal and incisional ropivacaine might facilitate PACU transfer and effectively and safely reduce pain intensity after LC.
Sakamoto, Bryan; Harker, Gene; Eppstein, Andrew C; Gwirtz, Kenneth
the postoperative care unit (PACU) (median [IQR], 1 [0-5] and 3.5 [0-6.8], respectively), pain after discharge (median [IQR], 3 [2-5] and 3 [1-5.5], respectively), opiate use after discharge (median [IQR], 6.7 [5-10] and 6.7 [3.3-10], respectively), and incidence of nausea and vomiting in the PACU (4 of 19 [21.1%] and 6 of 24 [25%], respectively) were not significantly different from the control group (median [IQR], 4 [3-6] for pain scores in the PACU; 4 [3-7] for pain scores after discharge; 6.7 [3.3-10] for opioid use after discharge; and 6 of 23 [26.1%] for incidence of nausea/vomiting in the PACU). While there was a significant reduction of opioid use in the PACU in the TAP block group (median [IQR], 0 [0-1.3]) when compared with the control group (median [IQR], 4 [1.3-6.7]) (P = .001), this was not seen in the PILA group (median [IQR], 2 [0-6.4]). This study demonstrates a better quality of recovery in patients' receiving PILA with dexamethasone compared with control for a TEP-IHR surgery. clinicaltrials.gov Identifier: NCT02036983.
Rastogi, Amit; Gyanesh, Prakhar; Nisha, Surbhi; Agarwal, Appurva; Mishra, Priya; Tiwari, Akhilesh Kumar
The airway is the foremost challenge in maxillofacial surgery. The major concerns are difficulty in managing the patient's airway and sharing it between the anaesthetist and surgeons. General anaesthesia, with endotracheal intubation, is the commonly used technique for maxillofacial procedures. We assessed the efficacy and safety of a regional block with sedation technique in certain maxillofacial operations, specifically temporomandibular joint (TMJ) ankylosis and mandibular fracture cases, and compared it with conventional general anaesthesia. We compared the time to discharge from the post anaesthesia care unit (PACU) and the occurrence of side effects, as well as surgeon and patient satisfaction with the anaesthetic technique, between the two groups. We enrolled 50 patients of ASA grade 1 or 2, aged 15-50 years, scheduled for maxillofacial surgery (mandibular fracture or TMJ ankylosis). The patients were divided into two groups of 25 each, to receive sedation with a regional block with the use of a peripheral nerve stimulator in group I and general anaesthesia in group II. We observed haemodynamic parameters, intraoperative and postoperative complications and the amount of surgical bleeding in the two groups. Total anaesthesia time, patient and surgeon satisfaction, time to rescue analgesia, the number of rescue doses required, and the time to discharge from the PACU were compared. The groups were comparable with respect to demographic profile, intraoperative haemodynamic parameters, surgical time, and amount of blood loss. Postoperative pain was assessed using the visual analogue score (VAS). Patients in group I had lower VAS scores after surgery and remained pain-free for longer than those in group II. The mean pain-free interval in group I was 159.12 ± 43.95 min and in group II was 60.36 ± 19.77 min (p < 0.005). Patients in group I required lower doses of rescue analgesia than those undergoing the surgery under general anaesthesia (p < 0.005). Patients
Liu, Yang; Kang, Dao-Lin; Na, He-Yi; Li, Bi-Lian; Xu, Ying-Yi; Ni, Jin; Wu, Jun-Zheng
Children with cerebral palsy can demonstrate irritability following emergence from general anaesthesia. As well, an elevated rate of emergence delirium (ED) in children has been associated with the application of sevoflurane. The current study’s intent is to administer dexmedetomidine, in a single dosage administration, at the initial phase of sevoflurane based anesthesia with regard to the occurrence and severity of ED in children afflicted with cerebral palsy. Participating in the study (American Society of Anesthesiologists I-II) are eighty children ranging in ages two through twelve years. They would be anaesthetised with sevoflurane based anesthesia while undergoing lower limb surgical procedures. The participants were equally distributed to either Group c or Group D. Group C was administered 10 ml saline 0.9%, and Group D was administered dexmedetomidine 0.5 μg•kg-1. Five minutes prior to commencement of the surgical procedures, the participants received the prescribed pharmaceutical dosages under the anesthesia of sevoflurane. In order to sustain the BIS values in a range of 45 and 55, at 60 second increments, endtidal sevoflurane concentrations (ETsev) were modified. After conclusion of the surgical procedures, in post anesthesia care unit (PACU), the frequency of ED was gauged with Aonos four point scale and the severity of ED was gauged with pediatric anesthesia emergence delirium scale upon admission (T0), after intervals of five minutes (T5), fifteen minutes (T15) and thirty minutes (T30). Extubation time, emergence time and length of at stay at the PACU were assessed. Relative to Group C, participants of Group D exhibited noticeably shortened times of emergence, extubation and PACU duration of stay. Prior to surgical incision, ETsev was elevated in the control group, (1.9±0.2 vs 1.6±0.3; P = 0.023) and amid the initial 20 minutes following the surgical incision (1.6±0.2 vs 1.1±0.2; P = 0.016). At intervals of commencement, T0, of five minutes
Postoperative analgesic and behavioral effects of intranasal fentanyl, intravenous morphine, and intramuscular morphine in pediatric patients undergoing bilateral myringotomy and placement of ventilating tubes.
Hippard, Helena K; Govindan, Kalyani; Friedman, Ellen M; Sulek, Marcelle; Giannoni, Carla; Larrier, Deidre; Minard, Charles G; Watcha, Mehernoor F
Bilateral myringotomy and placement of ventilating tubes (BMT) is one of the most common pediatric surgical procedures in the United States. Many children who undergo BMT develop behavioral changes in the postanesthesia care unit (PACU) and require rescue pain medication. The incidence of these changes is lower in children receiving intraoperative opioids by the nasal, IM, or IV route compared with placebo. However, there are no data to indicate which route of administration is better. Our study was designed to compare the immediate postoperative analgesic and behavioral effects of 3 frequently used intraoperative techniques of postoperative pain control for patients undergoing BMT under general anesthesia. One hundred seventy-one ASA physical status I and II children scheduled for BMT were randomized into 1 of 3 groups: group 1-nasal fentanyl 2 μg/kg with IV and IM saline placebo; group 2-IV morphine 0.1 mg/kg with nasal and IM placebo; or group 3-IM morphine 0.1 mg/kg with nasal and IV placebo. All subjects received a standardized general anesthetic with sevoflurane, N(2)O, and O(2) and similar postoperative care. The primary end point of the study was the pain scores measured by the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale in the PACU. There were no significant differences in peak FLACC pain among the 3 groups (mean [95% CI] 2.0 [1.2-2.8] for intranasal fentanyl, 2.7 [1.7-3.6] for IV morphine, and 2.9 [2.1-3.7] for IM morphine, respectively). There were no differences in the scores on the Pediatric Anesthesia Emergence Delirium (PAED) scale, incidence of postoperative emergence delirium (PAED score ≥ 12), emesis, perioperative hypoxemia, or need for airway intervention, and postoperative rescue analgesia. There were also no differences in the duration of PACU stay or parental satisfaction among the groups. In this double-blind, double-dummy study, there was no difference in the efficacy of intranasal fentanyl, IM and IV morphine in
Davis, P J; Lerman, J; Suresh, S; McGowan, F X; Coté, C J; Landsman, I; Henson, L G
Remifentanil hydrochloride is a new, ultrashort-acting opioid metabolized by nonspecific plasma and tissue esterases. We conducted this multicenter study to examine the hemodynamic response and recovery profile of premedicated children undergoing strabismus repair who were randomly assigned to receive one of four treatment drugs (remifentanil, alfentanil, isoflurane, or propofol) along with nitrous oxide and oxygen for maintenance of anesthesia. Induction of anesthesia was by nitrous oxide, oxygen, and halothane or nitrous oxide, oxygen, and propofol. Anesthesia was then maintained with remifentanil 1.0 microgram/kg over 30-60 s, followed by a constant infusion of 1.0 microgram.kg-1.min-1, alfentanil 100 micrograms/kg bolus followed by a constant infusion of 2.5 micrograms.kg-1.min-1, propofol 2.5 mg/kg bolus followed by a constant infusion of 200 micrograms.kg-1.min-1, or isoflurane 1.0 minimum alveolar anesthetic concentration. The infusions of the anesthetics and the administration of the inhaled gases were adjusted clinically by predetermined protocols. Elapsed time intervals from the end of surgery to the time the patients were tracheally extubated and displayed purposeful movement, as well as the time the patients met the postanesthesia care unit (PACU) and hospital discharge times, were recorded. Heart rate and systolic and diastolic blood pressure were measured at fixed intervals. In addition, cardiovascular side effects (bradycardia, hypotension, and hypertension) as well as vomiting, pruritus, agitation, and postoperative hypoxemia were also noted. There were no significant differences in patient demographics among the treatment groups. There was no difference in the early recovery variables (times to extubation and purposeful movement) or the times to PACU and hospital discharge among groups. There were significant differences in side effects among the groups. Patients who received remifentanil had higher PACU objective pain-discomfort scores than those
Elnabtity, Ali Mohamed Ali; Selim, Mohamed Fouad
Background: Various sedative and analgesic techniques have been used for pain relief during oocyte retrieval which is the most painful part of in vitro fertilization (IVF) procedures. Aim: This study aimed at comparing dexmedetomidine and midazolam for conscious sedation in women undergoing transvaginal oocyte retrieval during an IVF program. Settings and Design: Prospective randomized double-blinded comparative study. Patients and Methods: Fifty-two patients undergoing oocyte retrieval in their first IVF cycle were randomly allocated into two equal groups. The intervention started with giving fentanyl1 mcg/kg intravenous (IV) followed by paracervical block in both groups. Then, subjects in group (D) received dexmedetomidine at a loading dose of 1 μg/kg IV over 10 min followed by 0.5 μg/kg/h infusion until Ramsay Sedation Scale (RSS) reached 3–4. Patients in group (M) received a loading dose of midazolam 0.06 mg/kg IV over 10 min followed by 0.5 mg incremental doses until RSS reached 3–4. Statistical Analysis: Statistical analysis was performed using SPSS program version 19 and EP 16 program. Results: Visual analog scale scores significantly decreased in group D than group M at 5 and 10 min during the procedure (P = 0.03 and 0.01, respectively), and at 20 min during postanesthesia care unit (PACU) time (P = 0.04). Intraoperative rescue sedation by propofol and postoperative rescue analgesia by acetaminophen showed a highly significant decrease (P < 0.01) in group D compared with group M. Furthermore, the time of PACU stay was significantly less (P < 0.01) in group D (49.03 ± 12.8 min) compared to group M (62.5 ± 18.34 min). Although significant bradycardia was noted in group D (23% of patients) during the procedure (P = 0.02), no cases were reported in group M. Patient satisfaction was significantly higher in group D (P < 0.1). Conclusion: Dexmedetomidine is an effective analgesic alternative to midazolam during oocyte retrieval for IVF. It offered not only
Yazicioglu, D; Akkaya, T; Kulacoglu, H
Two spinal anaesthesia techniques were compared with local infiltration anaesthesia (LIA) to test the hypothesis that the addition of lidocaine to bupivacaine would decrease the spinal block's duration and provide shorter recovery to discharge. Ninety-three patients undergoing outpatient herniorrhaphy were randomised into three groups. Spinal anaesthesia: the BL Group (bupivacaine-lidocaine) received 2 ml hyperbaric bupivacaine (10 mg) + 0.6 ml 1% lidocaine (6 mg), the BS Group (bupivacaine-saline) received 2 ml hyperbaric bupivacaine (10 mg) + 0.6 ml saline. LIA: the LIA group received plain bupivacaine + lidocaine. Resolution of the nerve blocks were compared between spinal anaesthesia groups, and post-operative pain scores, analgesic requirements, post-anaesthesia care unit (PACU) time, and discharge time were compared among all groups. Spinal block resolved faster in the BL group vs. the BS group: 194.8 [standard deviation (SD) 29.2] min vs. 236.8 (SD 36.5) min (P = 0.000). PACU and discharge time were shortest in the LIA group [PACU time: 108.7 (SD 27.6) min vs. 113.0 (SD 39.4) min and 151.9 (SD 43.7) min in the BL and BS groups (P = 0.000), and discharge time 108.5 (SD 29.5) min vs. 145.8 (SD 37.3) min and 177.1 (SD 32.0) min in the BL and BS groups, respectively (P = 0.000)]. Pain scores and analgesic consumption were lower, with the time to first analgesic intake being longer in the LIA group. Addition of lidocaine to bupivacaine reduced the duration of the spinal block and was associated with shorter recovery times. However, LIA provided the fastest recovery to discharge after outpatient inguinal herniorrhaphy. © 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
Breazu, Caius Mihai; Ciobanu, Lidia; Hadade, Adina; Bartos, Adrian; Mitre, Călin; Mircea, Petru Adrian; Ionescu, Daniela
Introduction Pain control after a laparoscopic cholecystectomy can represent a challenge, considering the side effects due to standard analgesia methods. Recently the transversus abdominis plane block (TAP Block) has been used as a part of multimodal analgesia with promising results. The subcostal approach (OSTAP Block), a variant on the TAP block, produces reliable unilateral supraumbilical analgesia. This study evaluated the efficacy of the OSTAP block with bupivacaine in laparoscopic cholecystectomy compared with the placebo OSTAP block. Material and Methods Sixty ASA I/II adult patients listed for elective laparoscopic cholecystectomy were randomly allocated in one of two groups: Group A (OSTAP placebo) received preoperatively bilateral OSTAP block with sterile normal saline and Group B (OSTAP bupivacaine) received bilateral preoperatively OSTAP block with the same volumes of 0.25% bupivacaine. Twenty-four hours postoperative opioid consumption, the dose of opioid required during surgery, opioid dose in the recovery unit (PACU) and PACU length of stay were evaluated. The quality of analgesia was assessed by the Visual Analogue Scale (VAS) at specific interval hours during 24 h, at rest and with movement. Results The mean intraoperative opioid consumption showed a significant difference between the two groups, (385 ± 72.52 mg in group A vs 173.67 ± 48.60 mg in group B, p < 0.001). The mean 24 h opioid consumption showed a statistically significant difference between groups (32 ± 26.05 mg vs 79 ± 16.68 mg, p < 0.001). PACU length of stay was significantly lower for group B patients compared with group A patients (20.67 ± 11.27 min vs 41.67 ± 12.41 min, p < 0.001). The OSTAP bupivacaine group had a statistically significant lower pain score than the OSTAP placebo group at 0, 2, 4, 6, 12, 24 h, both at rest and with movement. No signs or symptoms of local anaesthetic systemic toxicity or other complications were detected. Conclusion OSTAP block with
Street, Maryann; Phillips, Nicole M; Kent, Bridie; Colgan, Stephen; Mohebbi, Mohammadreza
While the risk of adverse events following surgery has been identified, the impact of nursing care on early detection of these events is not well established. A systematic review of the evidence and an expert consensus study in post-anaesthetic care identified essential criteria for nursing assessment of patient readiness for discharge from the post-anaesthetic care unit (PACU). These criteria were included in a new nursing assessment tool, the Post-Anaesthetic Care Tool (PACT), and incorporated into the post-anaesthetic documentation at a large health service. The aim of this study is to test the clinical reliability of the PACT and evaluate whether the use of PACT will (1) enhance the recognition and response to patients at risk of deterioration in PACU; (2) improve documentation for handover from PACU nurse to ward nurse; (3) result in improved patient outcomes and (4) reduce healthcare costs. A prospective, non-randomised, pre-implementation and post-implementation design comparing: (1) patients (n=750) who have surgery prior to the implementation of the PACT and (2) patients (n=750) who have surgery after PACT. The study will examine the use of the tool through the observation of patient care and nursing handover. Patient outcomes and cost-effectiveness will be determined from health service data and medical record audit. Descriptive statistics will be used to describe the sample and compare the two patient groups (pre-intervention and post-intervention). Differences in patient outcomes between the two groups will be compared using the Cochran-Mantel-Haenszel test and regression analyses and reported as ORs with the corresponding 95% CIs. This study will test the clinical reliability and cost-effectiveness of the PACT. It is hypothesised that the PACT will enable nurses to recognise and respond to patients at risk of deterioration, improve handover to ward nurses, improve patient outcomes, and reduce healthcare costs. Published by the BMJ Publishing Group
Liu, Yang; Kang, Dao-Lin; Na, He-Yi; Li, Bi-Lian; Xu, Ying-Yi; Ni, Jin; Wu, Jun-Zheng
Children with cerebral palsy can demonstrate irritability following emergence from general anaesthesia. As well, an elevated rate of emergence delirium (ED) in children has been associated with the application of sevoflurane. The current study's intent is to administer dexmedetomidine, in a single dosage administration, at the initial phase of sevoflurane based anesthesia with regard to the occurrence and severity of ED in children afflicted with cerebral palsy. Participating in the study (American Society of Anesthesiologists I-II) are eighty children ranging in ages two through twelve years. They would be anaesthetised with sevoflurane based anesthesia while undergoing lower limb surgical procedures. The participants were equally distributed to either Group c or Group D. Group C was administered 10 ml saline 0.9%, and Group D was administered dexmedetomidine 0.5 μg•kg(-1). Five minutes prior to commencement of the surgical procedures, the participants received the prescribed pharmaceutical dosages under the anesthesia of sevoflurane. In order to sustain the BIS values in a range of 45 and 55, at 60 second increments, endtidal sevoflurane concentrations (ETsev) were modified. After conclusion of the surgical procedures, in post anesthesia care unit (PACU), the frequency of ED was gauged with Aonos four point scale and the severity of ED was gauged with pediatric anesthesia emergence delirium scale upon admission (T0), after intervals of five minutes (T5), fifteen minutes (T15) and thirty minutes (T30). Extubation time, emergence time and length of at stay at the PACU were assessed. Relative to Group C, participants of Group D exhibited noticeably shortened times of emergence, extubation and PACU duration of stay. Prior to surgical incision, ETsev was elevated in the control group, (1.9±0.2 vs 1.6±0.3; P = 0.023) and amid the initial 20 minutes following the surgical incision (1.6±0.2 vs 1.1±0.2; P = 0.016). At intervals of commencement, T0, of five minutes
Cobb, Benjamin; Cho, Yuri; Hilton, Gillian; Ting, Vicki; Carvalho, Brendan
The aim of this study was to apply both IV fluid and forced-air warming to decrease perioperative hypothermia in women undergoing cesarean delivery with spinal anesthesia. The authors hypothesize that combined-modality active warming (AW) would increase maternal temperature on arrival at the postanesthesia care unit (PACU) and decrease the incidence of maternal perioperative hypothermia (<36°C) compared with no AW. Forty-six healthy women (n = 23 per group) undergoing scheduled cesarean delivery with spinal anesthesia (10-12 mg bupivacaine + 10 μg fentanyl) were enrolled in this double-blinded, randomized controlled trial. Women were randomly assigned to receive either AW (warmed IV fluid and lower body forced-air warmer) or no warming (NW; blankets only). SpotOn Monitoring System was used to measure core temperature intraoperatively and for 1 hour postoperatively. The primary outcome measure was maternal temperature on arrival at the PACU. Secondary outcome measures included incidence of maternal perioperative hypothermia (<36°C), incidence of shivering, thermal comfort scores (0-100 scale), Apgar scores, and umbilical cord blood gas analysis. Demographic, obstetric, and surgical data were similar between study groups. The AW group (35.9°C ± 0.5°C) had a significantly higher temperature on arrival at the PACU compared with the NW group (35.5°C ± 0.5°C, P = 0.006; 95% confidence interval of mean difference, 0.1°C-0.7°C). Fourteen (64%) women in the AW group and 20 (91%) in the NW group were hypothermic during the study period (P = 0.031). Median (interquartile range) thermal comfort scores were 100 (95-100) in the AW group and 90 (70-100) in the NW group (P = 0.008). There were no significant differences in the incidence of intraoperative shivering (22% in the AW and 45% in the NW groups; P = 0.11), Apgar scores, or umbilical vein blood gas values between the study groups. Fluid combined with forced-air warming is effective in decreasing the incidence of
Rocha, Raphael Grossi; Almeida, Eduardo Giarola; Carneiro, Lara Moreira Mendes; Almeida, Natália Farias de; Boas, Walkíria Wingester Vilas; Gomez, Renato Santiago
There is a strong demand for fast and predictable anesthesia recovery with few side effects. Choice of the hypnotic agent could impact on that. This study investigated the differences between recoveries after remifentanil-propofol and remifentanil-desflurane anesthesias guided by bispectral index (BIS(®)). Forty patients were randomly assigned into 2 groups according to the anesthesia technique applied: remifentanil-propofol (REM-PRO) and remifentanil-desflurane (REM-DES). After the discontinuation of the anesthetics, the times to extubation, to obey commands and to recover the airway protection reflex were recorted. In the post-anesthetic recovery room (PACU) it was recorded the occurrence of nausea and vomiting (PONV), scores of Ramsay sedation scale and of numeric pain scale (NPS), morphine dose and length of stay in the unit. Data from 38 patients were analyzed: 18 from REM-PRO and 20 from REM-DES group. Anesthesia times were similar (REM-PRO=193min, SD 79.9 vs. 175.7min, SD 87.9 REM-DES; p=0.5). REM-DES had shorter times than REM-PRO group: time to follow command (8.5min; SD 3.0 vs. 5.6min; SD 2.5; p=0.0) and extubation time (6.2 minutes; 3.1-8.5 vs. 9.5 minutes; 4.9-14.4; p=0.0). Times to recover airway protective reflex were similar: 16 patients from REM-PRO (88.9%) restored the airway protective reflex 2min after extubation vs. 17 from REM-DES (89.5%); and 2 patients from REM-PRO (11.1%) vs. 2 from REM-DES (10.5%) 6min after extubation, p=1. Ramsay sedation score, NPS, PONV incidents, morphine dose and PACU stay of length PACU were also similar. Remifentanil-desflurane-based anesthesia has a faster extubation time and to follow command than remifentanil-propofol-based anesthesia when both guided by BIS(®). Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Bontemps, G; Daver, C; Ecoffey, C
Day surgery is often considered as a marker of the necessity of reorganizing the hospital to take care globally and so better meet the expectations of improvement of the management of patients. But the actual deployment of day surgery can also act as a real revelation of the stakes of conciliation between the regulations, which supervise professional practices and organization, and the functioning of hospitals. Between the regulations supervising hospitals and professional practices and the place of the recommendations, between the general legal framework of the medical activity and specific legal framework (decree of anesthesia of 1994) and the Evidence-Based Medicine, the pretext of the improvement of the patient flow in day surgery, recommended by several institutions (Sfar, ANAP, HAS), questions about the legal obligation of the passage of all the patients in the postanesthesia care unit (PACU). Seen under the angle of a legal action against a medical doctor, the study of the French jurisprudence reveals that every practitioner has to respect the recommendations and the Evidence-Based Medicine, and this in the standardized frame of the MD's activity and the respect for a very strict legal environment. The question of an obvious conciliation between all these measures arises today clearly. In the case of a potential conflict, the key of resolution, based only on legal standards (constitution, laws, decrees), is not enough for arbitrating. Applying that the only respect for the decree of anesthesia would be enough for exempting itself from any contentious risk does not satisfy more. There is a real difficulty defining the legal precise nature of the recommendations, so best practices as better organization, which are more and more frequently. Even if these recommendations originally had not their place in the hierarchy of the legal standards, they are brought in there today. There is a real brake in the deployment of the day surgery because the strict respect for
Abstract Species of the genus Singilis Rambur, 1837 (Phloeozeteus Peyron, 1856, syn. n., Agatus Motschulsky, 1845, syn. n.), occurring in the Middle East and Central Asia are reviewed, with 24 species now recognized in the region, including ten species described as new: Singilis makarovi sp. n. (Tajikistan), Singilis jedlickai sp. n. (Afghanistan), Singilis kolesnichenkoi sp. n. (Iran), Singilis kabakovi sp. n. (Afghanistan, Iran), Singilis timuri sp. n. (Uzbekistan), Singilis klimenkoi sp. n. (Iran), Singilis saeedi sp. n. (Iran), Singilis felixi sp. n. (UAE), Singilis kryzhanovskii sp. n. (Iran, Turkmenistan), and Singilis timidus sp. n. (Iran); Singilis libani (Sahlberg, 1913) is recognized as a valid species; and Singilis solskyi nom. n. is proposed as a replacement name for Agatus bicolor (Solsky, 1874, not Rambur 1837), now placed in Singilis as junior homonym. New synonymies include: Singilis cingulatus (Gebler, 1843) = Singilis jakeschi Jedlička, 1967, syn. n.; Singilis mesopotamicus Pic, 1901 = Singilis apicalis Jedlička, 1956, syn. n. A key to species is provided. Habitus and aedeagal illustrations are provided for all species. Distributional data include many new country records. PMID:22291510
Maller, C E; Twitty, V J; Sauve, A
A quality improvement model presents the stages of designing and producing a preoperative videotape for improved patient satisfaction outcomes. PACU nurses formed an interdisciplinary team of providers and patients to update an existing preoperative sound/slide program into video. Improved patient outcomes were reflected in greater availability, accessibility, and consistency of preoperative instruction. A videotape program for home viewing was instituted to reach out to the surgical patient population served by the Albuquerque Veterans Affairs Medical Center in New Mexico. A quality improvement storyboard approach to videotape production met Joint Commission on Accreditation of Health Care Organization (JCAHO) standards for interactive patient education at a recent JCAHO survey. Preliminary evaluative data from patients supports a growing appeal of videos to patients and family members as an additional preoperative teaching strategy for adult surgical patients.
Nord, DeeAnn; Belew, John
This randomized, controlled, blinded study examined the effectiveness of an aromatherapy intervention on the reduction of children's distress in a perianesthesia setting. The sample included children with and without developmental disabilities (n = 94). Subjects in the intervention group received an aromatherapy intervention of lavender and ginger essential oils. The control group received a placebo intervention of jojoba oil. Distress was measured at two times: before induction and in the PACU, using the Faces, Legs, Arms, Cry and Consolability (FLACC) scale. The mean distress level was lower for the children in the essential oil group, but the effect was not statistically significant (P = .055). Parents' responses to survey questions about satisfaction with aromatherapy did not differ between groups, although open-ended comments indicated a more positive opinion of the benefits of the intervention in the aromatherapy group.
Park, Eui-Seok; Lim, Byung Gun; Lee, Won-Joon; Lee, Il Ok
In many countries, routine clinical anaesthesia does not always involve neuromuscular monitoring. In these clinical settings, the efficacy and safety of sugammadex use has not yet been confirmed. We investigated the efficacy and safety of sugammadex in the absence of neuromuscular monitoring. One hundred and forty patients who underwent laryngeal microsurgery with the use of rocuronium as a neuromuscular blocking agent, without the use of a neuromuscular monitoring device, were retrospectively investigated. The patients were randomly chosen among all the patients who met the inclusion criteria at a tertiary university hospital between July 2013 and February 2015 and were allocated to group S (sugammadex group) or group P (pyridostigmine group) according to the neuromuscular reversal agent administered. Five patients were excluded from analysis and 135 patients completed the study. Primary outcome was extubation time. Secondary outcomes were anaesthesia time, the correlation between anaesthesia time and extubation time, the total amount of rocuronium, and postoperative adverse events in the post-anaesthesia care unit (PACU). Extubation time was significantly shorter in group S (6.3 ± 3.9 min) than in group P (9.0 ± 5.4 min). Anaesthesia time was also significantly shorter in group S (30.7 ± 10.3 min) than in group P (35.8 ± 12.6 min). In the patients with an anaesthesia time of 30 min or less, there was a positive correlation between anaesthesia time and extubation time in group P (r = 0.453), but there was no significant relationship in group S. The total amount of rocuronium used was higher in group S (0.62 ± 0.11 mg kg(-1)) than in group P (0.38 ± 0.14 mg kg(-1)). Postoperative adverse events in the PACU were comparable between the groups, except for tachycardia events: the incidence of tachycardia was significantly lower in group S (8.0 %) than in group P (17.3 %). Sugammadex could shorten anaesthesia and extubation
Rieben, Melissa A; Appling, Susan; MacDonald, Ryan
Vascular closure devices (VCDs) can shorten the time to hemostasis, ambulation and discharge and improve patient comfort.(1) An evidence-based practice (EBP) project was initiated to assess impact of a shortened postoperative compression and bed rest protocol on patients undergoing arteriotomy using a wire vascular closure device (WVCD). Following protocol development, a post-implementation evaluation was initiated to assess selected outcomes including compression and bed rest time, complication rate and possible related variables. Following implementation of the new protocol, clinicians were able to shorten both compression and bed rest times by 50%, and Post-Anesthesia Care Unit (PACU) length of stay decreased to a maximum of 5 hours. Copyright © 2013 Society for Vascular Nursing, Inc. Published by Mosby, Inc. All rights reserved.
Wesmiller, Susan W; Bender, Catherine M; Conley, Yvette P; Bovbjerg, Dana H; Ahrendt, Gretchen; Bonaventura, Marguerite; Sereika, Susan M
Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) continue to be common and disturbing complications experienced after surgery, particularly in women and especially in women undergoing breast cancer surgery. The purpose of this study was to assess the incidence and risk factors associated with PONV and PDNV from preoperative to 48 hours postoperatively in 97 women scheduled for breast cancer surgery. Prospective, comparative design. After informed consent was obtained, women scheduled for breast cancer surgery were evaluated for incidence of vomiting, as well as the presence and severity of nausea from the preoperative holding area for 48 hours following surgery. Vomiting was assessed as both a nominally scaled, binary variable (Yes/No) and as a continuous variable to measure separate emetic events. Nausea was measured on an 11point verbal numeric scale with 0 being the absence of nausea and 10 representing the highest level of nausea ever experienced. Twenty-nine (29.8%) women experienced nausea, and nine (9%) women experienced nausea and vomiting while in the post-anesthesia care unit despite close attention to the need for prophylactic antiemetic medications. Women who experienced PONV had higher levels of pain and received more opioids than those women who did not experience PONV. Women who received intravenous acetaminophen did not experience less PONV in this study. PDNV occurred more frequently than PONV, with 34 women (35%) reporting occurrence after discharge. About 13 women who did not experience PONV while in the PACU subsequently experienced PDNV after leaving the hospital, evidence for the importance of patient discharge teaching regarding these symptoms. Although clinical guidelines are necessary, our observation is that nurses in the PACU setting continuously challenge themselves to individualize the combination of medications and activities for each patient to reduce PONV after surgery. Copyright © 2016 American
Kozanhan, Betul; Iyisoy, Mehmet S
Respiratory adverse events are commonly observed after adenotonsillectomy in children with sleep-disordered breathing. Preoperative prediction of these events enhances quality of care and resource management in facilities while encouraging precautions against them. Red cell distribution width, a measure of erythrocyte size variability, has recently been linked to adverse outcomes in a variety of disorders. Red cell distribution width has also been found to be associated with severity of obstructive sleep apnea in adults due to hypoxia-mediated inflammation. The objective of this study was to evaluate whether elevated red cell distribution width is associated with postoperative respiratory adverse events in children with symptoms of sleep-disordered breathing. A prospective, observational, assessor-blinded study was conducted with consecutive children undergoing elective adenotonsillectomy for treatment of sleep-disordered breathing. Under general anesthesia, adenoidectomy was performed by curettage, and tonsillectomy was carried out by dissection. The primary outcome was the occurrence of an adverse event during emergence or in the postanesthesia care unit (PACU). Among 287 patients, with mean ± sd age 7.49 ± 3.21, the frequency of respiratory complications during emergence was 62 (22.30%) and in PACU was 56 (20.14%). Mean ± sd red cell distribution width was 14.36 ± 1.06 in patients with complications and higher than that in those without complications 13.53 ± 0.59. Red cell distribution width had an adjusted odds ratio 7.28 (95% CI: 4.30-13.28) and area under the curve value 0.74 (95% CI: 0.67-0.81) to predict postoperative complications. A cutoff value for red cell distribution width was found to be 14.7. Our study showed that preoperative elevated red cell distribution width is associated with an increased risk of respiratory adverse events in children undergoing adenotonsillectomy for sleep-disordered breathing. © 2017 John Wiley & Sons Ltd.
Casati, Andrea; Rapotec, Alessandro; Dalsasso, Massimiliano; Barzan, Luigi; Fanelli, Guido; Pellis, Tommaso
Purpose The aim of the study was to compare the efficacy of parecoxib for postoperative analgesia after endoscopic turbinate and sinus surgery with the prodrug of acetaminophen, proparacetamol. Materials and Methods Fifty American Society of Anesthesiology (ASA) physical status I-II patients, receiving functional endoscopic sinus surgery (FESS) and endoscopic turbinectomy, were investigated in a prospective, randomized, double-blind manner. After local infiltration with 1% mepivacaine, patients were randomly allocated to receive intravenous (IV) administration of either 40 mg of parecoxib (n = 25) or 2 g of proparacetamol (n = 25) 15 min before discontinuation of total IV anaesthesia with propofol and remifentanil. A blinded observer recorded the incidence and severity of pain at admission to the post anaesthesia care unit (PACU) at 10, 20, and 30 min after PACU admission, and every 1 h thereafter for the first 6 postoperative h. Results The area under the curve of VAS (AUCVAS) calculated during the study period was 669 (28 - 1901) cm·min in the proparacetamol group and 635 (26 - 1413) cm·min in the parecoxib group (p = 0.34). Rescue morphine analgesia was required by 14 patients (56%) in the proparacetamol group and 12 patients (48%) in the parecoxib (p ≥ 0.05), while mean morphine consumption was 5 - 3.5 mg and 5 - 2.0 mg in the proparacetamol groups and parecoxib, respectively (p ≥ 0.05). No differences in the incidence of side effects were recorded between the 2 groups. Patient satisfaction was similarly high in both groups, and all patients were uneventfully discharged 24 h after surgery. Conclusion In patients undergoing endoscopic nasal surgery, prior infiltration with local anaesthetics, parecoxib administered before discontinuing general anaesthetic, is not superior to proparacetamol in treating early postoperative pain. PMID:18581586
Braz, José Reinaldo Cerqueira; Volney, Alexandre; Navarro, Laís Helena Camacho; Braz, Leandro Gobbo; Nakamura, Giane
To study endotracheal tube (ETT) cuff pressures during nitrous oxide (N2O) anesthesia when the cuffs are inflated with air to achieve sealing pressure, and to evaluate the frequency of postoperative laryngotracheal complaints. Prospective, randomized, blind study. Metropolitan teaching hospital. 50 ASA physical status I and II patients scheduled for elective abdominal surgery. Patients received standard general anesthesia with 66% N2O in oxygen. In 25 patients, the ETT cuff was inflated with air to achieve a sealing pressure (Pseal group). In 25 patients, the ETT cuff was inflated with air to achieve a pressure of 25 cm H2O (P25 group). ETT intracuff pressures were recorded before (control) and at 30, 60, 90, 120, and 150 minutes during N2O administration. We investigated the frequency and intensity of sore throat, hoarseness, and dysphagia in patients in the Post-Anesthesia Care Unit (PACU) and 24 hours following tracheal extubation. The cuff pressures in the Pseal group were significantly lower than in the P25 group at all time points studied (p < 0.001), with a significant increase with time in both groups (p < 0.001). The cuff pressures exceeded the critical pressure of 30 cm H2O only after 90 minutes in the Pseal group and already by 30 minutes in the P25 group. The frequency and intensity of sore throat, hoarseness, and dysphagia were similar in both groups in the PACU and 24 hours after tracheal extubation (p > 0.05). Minimum ETT sealing cuff pressure during N2O anesthesia did not prevent, but instead attenuated, the increase in cuff pressure and did not decrease postoperative laryngotracheal complaints. Copyright 2004 Elsevier Inc.
Nakahara, Haruna; Kimoto, Ayako; Beppu, Yuki; Yoshimura, Maki; Kojima, Toshiyuki; Fukano, Taku
OBJECTIVES: Emergence agitation (EA) is a common and troublesome problem in pediatric patients recovering from general anesthesia. The incidence of EA is reportedly higher after general anesthesia maintained with sevoflurane, a popular inhalational anesthetic agent for pediatric patients. We conducted this prospective, randomized, double-blind study to test the effect of an intravenous ultra-short–acting barbiturate, thiamylal, administered during induction of general anesthesia on the incidence and severity of EA in pediatric patients recovering from Sevoflurane anesthesia. METHODS: Fifty-four pediatric patients (1 to 6 years of age) undergoing subumbilical surgeries were randomized into 2 groups. Patients received either intravenous thiamylal 5mg/kg (Group T) or inhalational Sevoflurane 5% (Group S) as an anesthetic induction agent. Following induction, general anesthesia was maintained with Sevoflurane and nitrous oxide (N2O) in both groups. To control the intra- and post-operative pain, caudal block or ilioinguinal/iliohypogastric block was performed. The incidence and severity of EA were evaluated by using the Modified Objective Pain Scale (MOPS: 0 to 6) at 15 and 30 min after arrival in the post-anesthesia care unit (PACU). RESULTS: Fifteen minutes after arrival in the PACU, the incidence of EA in Group T (28%) was significantly lower than in Group S (64%; p = 0.023) and the MOPS in Group T (median 0, range 0 to 6) was significantly lower than in Group S (median 4, range 0 to 6; p = 0.005). The interval from discontinuation of Sevoflurane to emergence from anesthesia was not significantly different between the 2 groups. CONCLUSIONS: Thiamylal induction reduced the incidence and severity of EA in pediatric patients immediately after Sevoflurane anesthesia. PMID:26472953
Hadi, B A; Al Ramadani, R; Daas, R; Naylor, I; Zelkó, R
This study is aimed at conducting a program for two different anesthetic methods used during a spinal fusion surgery to ensure better intra-operative hemodynamic stability and post-operative pain control. A prospective, randomized, double blind study in patients scheduled for spinal fusion surgery, who were randomly allocated to two groups, G1 and G2, (n = 15 per group), class I-II ASA, was carried out. Both groups received pre-operatively midazolam, followed intra-operatively by propofol, sevoflurane, atracurium, and either remifentanil infusion 0.2 microg/kg/min (G1), or the same dose of remifentanil infusion and low doses of ketamine infusion 1 microg/kg/min (G2) anesthetics, antidote medication and post-operative morphine doses. HR, MAP, vital signs, surgical bleeding, urine output, duration of surgery and duration of anesthesia were recorded. In a 24-h recovery period in a post-anesthesia care unit (PACU) the recovery time, the first pain score and analgesic requirements were measured. Intra-operative HR and arterial BP were significantly less (p < 0.05) in G1 as compared to G2. In the PACU the first pain scores were significantly less (p < 0.05) in G2 than in G1. The time for the first patient analgesia demand dose was greater in G2, as also morphine consumption which was greater in G1 than G2 (p < 0.05). Other results were the same. None of the patients had any adverse drug reaction. Adding low doses of ketamine hydrochloride could be a routine therapy to improve the hemodynamic stability and reduce the post-operative morphine consumption during spinal fusion surgery.
Kline, R; Wong, E; Haile, M; Didehvar, S; Farber, S; Sacks, A; Pirraglia, E; de Leon, MJ; Bekker, A
Increasingly, postoperative cognitive dysfunction (POCD) is recognized as a complication after surgery in the elderly; but it's etiology remains unclear. Here we examine changes in cytokine levels during both the pre-operative and postoperative period, comparing them with long term variation in cognitive test scores. Forty-one patients aged 65 and older undergoing major surgery with general anesthesia were recruited after written consent in this IRB approved study. Thirty went on to complete this prospective, non-interven-tional and non-randomized study. Plasma levels of cytokines Il-6, Il-8, Il-10, and TNF were determined using ELISA with MILLIPLEX Multi-Analyte Profiling (Billerica, MA). All subjects had neurocognitive tests pre-operatively and 6 months post-surgery, including Paragraph Recall Immediate and Delayed, Digit Span Forward (DSF) and Backward (DSB), and Trail Making A and B. Spearman's Rho and repeated measure rank analysis were used to examine the dependence of z score changes in cognitive tests (baseline versus 6 months) as a function of 3 cytokine time points (presurgical, post anesthesia care unit (PACU), and post-operative day one (POD1)). A greater increase in PACU inflammatory burden correlated with a greater decline in performance on the DSB (IL6, IL8; r>−0.560; p<= 0.008). DSF changes correlated slightly better with pre-surgical cytokines, declining more with higher cytokines (IL6, r= −0.551, p=0.002; IL8, −0.468, 0.009). TNF, examining all 3 values, changed only slightly postoperatively, but still correlated with a decline in DSB (p=0.014). Thus, cognitive performance, over 6 months post surgery, declines with elevated perioperative inflammation. Specific cytokines at specific perioperative times may impact specific cognitive functions, serving as diagnostics as well as contributing causation. PMID:28317003
Das, A; Mukherje, A; Chhaule, S; Chattopadhyay, S; Halder, PS; Mitra, T; Basunia, SR; Mandal, SK
Background: Functional endoscopic sinus surgery (FESS) is the mainstay of a therapeutic technique for nasal pathologies. This study is to compare the ability of preoperative dexmedetomidine versus clonidine for producing controlled hypotensive anesthesia during FESS in adults in an ambulatory care setting. Materials and Methods: Sixty patients (25-50 years) posted for ambulatory FESS procedures under general anesthesia were randomly divided into Group C and D (n = 33 each) receiving dexmedetomidine 1 μg/kg and clonidine 1.5 μg/kg, respectively; both diluted in 100 ml saline solution 15 min before anesthetic induction. Nasal bleeding and surgeon's satisfaction score; amount and number of patients receiving fentanyl and nitroglycerine for analgesia and deliberate hypotension, duration of hypotension, post anesthesia care unit (PACU) and hospital stay; hemodynamic parameters and side effects were recorded for each patient. Results: Number and dosage of nitroglycerine used was significantly (P = 0.034 and 0.0001 respectively) lower in Group D compared to that in Group C. Similarly, number of patients requiring fentanyl and dosage of same was significantly lower in Group D. But, the duration of controlled hypotension was almost similar in both the groups. Group D patients suffered from significantly less nasal bleeding and surgeon's satisfaction score was also high in this group. Discharge from PACU was significantly earlier in Group D, but hospital discharge timing was quite comparable among two groups. Intraoperative hemodynamics was significantly lower in Group D (P < 0.05) without any appreciable side effects. Conclusion: Dexmedetomidine found to be providing more effectively controlled hypotension and analgesia, and thus, allowing less nasal bleeding as well as more surgeons’ satisfaction score. PMID:26955315
Siribumrungwong, Koopong; Cheewakidakarn, Julin; Tangtrakulwanich, Boonsin; Nimmaanrat, Sasikaan
Poor postoperative pain control is frequently associated with complications and delayed discharge from a hospital. Preemptive analgesia is one of the methods suggested for reducing postoperative pain. Opioids are effective for pain control, but there known addictive properties make physicians cautious about using them. Parecoxib and ketorolac are potent non-opioid NSAIDs that are attractive alternative drugs to opioids to avoid opioid-related side effects. However, there are no good head-to-head comparisons between these two drugs in the aspect of preemptive analgesic effects in lumbar spinal fusion surgery. This study aimed to compare the efficacy in terms of postoperative pain control and safety of parecoxib with ketorolac as preemptive analgesia in posterior lumbar spinal fusion patients. A prospective, double-blinded randomized controlled trial was carried out in patients undergoing posterior lumbar spinal fusion, who were randomized into 3 groups (n = 32). Parecoxib, ketorolac or a placebo was given to each patient via injection around 30 minutes prior to incision. The efficacy of postoperative pain control was assessed by a verbal numerical rating score (0-10). And various postoperative things were monitored for analysis, such as total opioid consumption, complications, and estimated blood loss. Both the ketorolac and parecoxib groups showed significantly better early postoperative pain reduction at the postanesthesia care unit (PACU) than the control group (p < 0.05). There were no differences between the pain scores of ketorolac and parecoxib at any time points. Complications and bleeding were not significantly different between all three groups. Preemptive analgesia using both ketorolac and parecoxib showed a significantly better early postoperative pain control in the PACU than the control group in patients undergoing lumbar spinal fusion. ClinicalTrials.gov NCT01859585. Registered 15 May 2013.
Ammar, A S; Mahmoud, K M; Kasemy, Z A
Sugammadex is designed to be a reversal agent for steroidal muscle relaxants. The current trial was aimed to compare between sugammadex and neostigmine concerning the recovery time from neuromuscular blockade. We hypothesised that sugammadex might have shorter recovery time than neostigmine. Sixty paediatric patients aged 2-10 years scheduled for lower abdominal surgeries were randomly assigned into two equal groups to receive 4 mg/kg sugammadex (Group S) or 0.35 mg/kg neostigmine and 0.02 mg/kg atropine (Group N) as a reversal agent for rocuronium at the end of surgery. Primary outcome was the recovery time [time from starting of sugammadex or neostigmine till reaching train of four (TOF) ratio> 0.9] whereas secondary outcomes included number of patients who needed another dose of sugammadex or neostigmine to reach TOF ratio> 0.9, extubation time (time from stoppage of anaesthetic inhalation until the patient fulfilled criteria for safe extubation, post-anaesthesia care unit (PACU) discharge time and post-operative adverse effects. The mean recovery and extubation times were significantly shorter (P = 0.002 and 0.005) in Group S compared with Group N (2.5 and 2.0 min vs. 12.6 min and 4.3 min respectively). In the Group N, eight patients needed another reversal dose compared with one patient in Group S (P = 0.035). PACU discharge time showed no significant difference between both groups. Incidence of nausea, vomiting, tachycardia, and dry mouth were significantly higher in Group N. Sugammadex administration in children resulted in faster recovery and extubation times and lower incidence of adverse events compared with neostigmine. © 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
Tian, Yue; Li, Lu; Ma, Ling; Li, Yun-feng
Introduction The laryngeal mask airway (LMA)-Supreme is a disposable double-lumen laryngeal mask airway that is widely used in clinical practice. However, its use in obese children has not been evaluated. The aim of this study was to determine whether the LMA-Supreme could perform equally as well as endotracheal intubation in obese children having a minor surgical procedure. Material and methods After ethical board approval, 100 obese male children receiving non-emergent appendectomy for chronic appendicitis or surgery to correct concealed penis were randomly divided into an endotracheal intubation group and an LMA-Supreme group. Endotracheal intubation was performed under direct vision laryngoscopy. In the LMA group, a size-3 LMA-Supreme was placed and a stomach tube inserted via the drainage tube of the mask. Cardiovascular and respiratory parameters, time taken for placement, placement attempts, time to removal of the endotracheal tube/LMA, length of stay in the post-anesthesia care unit (PACU), and complications were recorded. Results Insertion time was significantly longer (p < 0.001) in the LMA-Supreme group than in the endotracheal intubation group. Peak airway pressure was significantly higher, and pulmonary compliance and PACU stay time lower in the LMA-Supreme group. No significant differences between endotracheal intubation and the LMA-Supreme were seen in other parameters, except for a higher incidence of coughing in the endotracheal intubation group. Conclusions The LMA-Supreme can be easily inserted and effectively used for airway management in obese children undergoing minor surgery. PMID:28144270
Randle, Reese W.; Balentine, Courtney J.; Pitt, Susan C.; Schneider, David F.; Sippel, Rebecca S.
Background The optimal pre-operative alpha-blockade strategy is debated for patients undergoing laparoscopic adrenalectomy for pheochromocytomas. We evaluated the impact of selective versus non-selective alpha-blockade on intra-operative hemodynamics and post-operative outcomes. Methods We identified patients having laparoscopic adrenalectomy for pheochromocytomas from 2001-2015. As a marker of overall intra-operative hemodynamics, we combined systolic blood pressure (SBP) >200, SBP <80, SBP <80 AND >200, pulse >120, vasopressor infusion, and vasodilator infusion into a single variable. Similarly, the combination of vasopressor infusion in the post-anesthesia care unit (PACU) and need for intensive care unit (ICU) admission provided an overview of post-operative support. Results We identified 52 patients undergoing unilateral laparoscopic adrenalectomy for pheochromocytoma. Selective alpha-blockade (i.e. Doxazosin) was performed in 35% (n=18), and non-selective blockade with Phenoxybenzamine was performed in 65% (n=34). Demographics and tumor characteristics were similar between groups. Patients blocked selectively were more likely to have a SBP <80 (67%) than those blocked with phenoxybenzamine (35%) (p=0.03), but we found no significant difference in overall intra-operative hemodynamics between patients blocked selectively and non-selectively (p=0.09). Post-operatively, however, patients blocked selectively were more likely to require additional support with vasopressor infusions in the PACU or ICU admission (p=0.02). Hospital stay and complication rates were similar. Conclusion Laparoscopic adrenalectomy for pheochromocytoma is safe regardless of the pre-operative alpha-blockade strategy employed, but patients blocked selectively may have a higher incidence of transient hypotension during surgery and a greater need for post-operative support. These differences did not result in longer hospital stay or increased complications. PMID:27561909
Bedirli, Nurdan; Akçabay, Mehmet; Emik, Ulku
This study was designed to compare the efficacy of an intraoperative single dose administration of tramadol and dexmedetomidine on hemodynamics and postoperative recovery profile including pain, sedation, emerge reactions in pediatric patients undergoing adenotonsillectomy with sevoflurane anesthesia. Seventy-seven patient, aged 2-12, undergoing adenotonsillectomy with sevoflurane anesthesia was enrolled in this study. Patients were randomly assigned to receive either intravenous 2 mg/kg tramadol (Group T; n = 39) or 1 μg/kg dexmedetomidine (Group D; n = 38) after intubation. Heart rates (HR), mean arterial pressure (MAP) were recorded before induction, at induction and every 5 min after induction. Observational pain scores (OPS), pediatric anesthesia emergence delirium (PAED) scores, percentage of patients with OPS ≥ 4 or PAED scale items 4 or 5 with an intensity of 3 or 4, and Ramsay sedation scores (RSS) were recorded on arrival to the postoperative care unit (PACU) and at 5, 10, 15, 30, 45, 60 min. Extubation time and time to reach Alderete score > 9 were recorded. Dexmedetomidine significantly decreased the HR and MAP 10 and 15 min after induction; increased the RSS 15, 30 and 45 min after arrival to PACU. OPS and PAED scores and percentage of patients with OPS ≥ 4 or PAED scale items 4 or 5 with an intensity of 3 or 4 in both groups did not show any significant difference. Extubation time and time to have Alderete score > 9 was significantly longer in Group D. Both tramadol and dexmedetomidine were effective for controlling pain and emergence agitation. When compared with tramadol intraoperative hypotension, bradycardia and prolonged sedation were problems related with dexmedetomidine administration. Retrospectively registered, registration number: ISRCTN89326952 registration date: 14.07.2016.
Mulroy, M F; Larkin, K L; Siddiqui, A
Fentanyl is used as an additive to prolong intrathecal anesthesia with both lidocaine and low-dose bupivacaine in the outpatient setting to minimize voiding or discharge delays. Pruritus is the most common side effect. When using procaine as a substitute for lidocaine, we perceived an increased frequency and severity of pruritus. We compared prospectively the frequency and severity of itching with combinations of fentanyl with lidocaine, bupivacaine, and procaine. After institutional review board approval, 135 patients requesting neuraxial anesthesia were asked to evaluate the presence and severity (using a 100 point verbal pruritus score [VPS]) of itching 30 minutes after injection of their spinal anesthetic, on arrival to the postanesthesia care unit (PACU), and at the time of resolution of their block. Choice of anesthetic drug and dose and the use of intravenous sedation was left to the discretion of the attending and resident anesthesiologist. Thirty-three patients received lidocaine and fentanyl, 47 received bupivacaine and fentanyl, and 55 received procaine and fentanyl. In the lidocaine group, 21% of patients experienced pruritus compared with 55% of the bupivacaine group and 55% of the procaine group (P =.003). The average VPS at 30 minutes postblock was 18.4 in the procaine group compared with 0 and 5.5 in the lidocaine and bupivacaine groups (P =.06). On admission to the PACU, it was 37 compared with 16 and 20 for lidocaine and bupivacaine, respectively (P =.006). Procaine produces a higher frequency of pruritus than that seen with lidocaine-fentanyl combinations and a greater severity of pruritus than seen with lidocaine-fentanyl and bupivacaine-fentanyl spinal anesthesia. Reg Anesth Pain Med 2001;26:252-256.
Poorzamany Nejat Kermany, Mahtab; Dahi, Mastaneh; Yamini Sharif, Reyhaneh; Radpay, Badiozaman
Background Dexmedetomidine is a potent and highly specific α2-adrenoreceptor agonist that induces sedative and analgesic effects over a short-term period. As a result of these benefits, dexmedetomidine may be a better alternative than other available drugs for keeping the patient’s cognition state in an acceptable condition after outpatient ophthalmic surgeries. Objectives This randomized study was conducted to compare the sedative effects of dexmedetomidine and remifentanil on the cognitive state of patients who have undergone cataract surgery. Patients and Methods A total of 100 patients who were candidates for cataract surgery under local anesthesia received either dexmedetomidine (50 patients; D group) or remifentanil (50 patients; R group) in a double-blind, randomized study. The baseline cardiovascular status and mini mental state examination (MMSE) score for each patient were recorded. As a loading dose, dexmedetomidine (0.5 µg/kg) and remifentanil (0.1 µg/kg) were infused at 10 minutes and 5 minutes before topical anesthesia, respectively. Subsequently, the maintenance dose was administered at 0.2 µg/kg/hour and 0.05 µg/kg/minutes in the D and R groups, respectively. The surgical procedure was begun when the bispectral index (BIS) reached 70 - 80. MMSE test was done at a postanesthetic care unit (PACU) 120 minutes after the discontinuation of the drug. Results There was no statistically significant difference between the MMSE scores of the two groups before surgery (P = 0.6), but the MMSE test conducted at the PACU revealed significantly better cognitive outcomes in the D group than in the R group in patients younger and older than 65 years (P = 0.03 and P = 0.0001, respectively). Conclusions This study revealed that dexmedetomidine may be a suitable agent for sedation in cataract surgery because it results in a more favorable postoperative cognitive status than remifentanil. Likewise, dexmedetomidine had no significant adverse effects on
Won, Young Ju; Lim, Byung Gun; Yeo, Gwi Eun; Lee, Min Ki; Lee, Dong Kyu; Kim, Heezoo; Lee, Il Ok; Kong, Myoung Hoon
Abstract Background: The effectiveness of surgical pleth index (SPI) for managing nociception-antinociception balance during general anesthesia with vasodilators, including nicardipine has not been demonstrated. We aimed to compare the time course during surgery in SPI values in patients receiving nicardipine or remifentanil infusion during thyroidectomy. Methods: Forty patients undergoing thyroidectomy were randomly assigned to receive nicardipine (group N; n = 19) or remifentanil (group R; n = 21) along with induction (propofol, fentanyl, and rocuronium) and maintenance (50% desflurane/nitrous oxide in oxygen) anesthesia (goal bispectral index [BIS] ∼50). The infusion of nicardipine or remifentanil was started before the 1st incision and adjusted to keep mean blood pressure (MBP) within ±20% of the preoperative value. SPI, BIS, end-tidal desflurane concentration (EtDes), MBP, and heart rate were recorded at 2.5 minute intervals from the 1st incision to the end of surgery. Extubation and recovery times, pain score/rescue ketorolac consumption, and adverse events in postanesthesia care unit (PACU) were recorded. Results: The trend of SPI during surgery was comparable between the 2 groups (P = 0.804), although the heart rates in group N were significantly higher than those in group R (P = 0.040). The patient characteristics, trends of BIS, EtDes, and MBP during surgery, extubation and recovery times, and incidence of nausea/vomiting were comparable between the groups. Group N had significantly lower pain scores and rescue ketorolac consumption at PACU. Conclusion: SPI was comparable between patients receiving nicardipine or remifentanil infusion during thyroidectomy under general anesthesia, which suggests that the administration of nicardipine may confound the interpretation of SPI values during general anesthesia. Clinical trial registration: This trial was registered in the UMIN clinical trials registry (unique trial number: UMIN000019058
Brookes, Carolyn Dicus; Turvey, Timothy A.; Phillips, Ceib; Kopp, Vincent; Anderson, Jay A.
Purpose To assess the prevalence of postdischarge nausea and vomiting (PDNV) after Le Fort I osteotomy with and without the use of a multimodal antiemetic protocol shown to decrease postoperative nausea and vomiting (PONV). Materials and Methods Consecutive patients undergoing Le Fort I osteotomy with or without additional procedures at a single academic institution formed the intervention cohort for an institutional review board–approved prospective clinical trial with a retrospective comparison group. The intervention cohort was managed with a multimodal antiemetic protocol. The comparison group consisted of consecutive patients who underwent similar surgical procedures at the same institution before protocol implementation. All patients were asked to complete a postdischarge diary documenting the occurrence of nausea and vomiting. Those who completed the diaries were included in this analysis. Data were analyzed with the Fisher exact test and the Wilcoxon rank sum test. A P value less than .05 was considered significant. Results Diaries were completed by 85% of patients in the intervention group (79 of 93) and 75% of patients in the comparison group (103 of 137). Patients in the intervention (n = 79) and comparison (n = 103) groups were similar in the proportion of patients with validated risk factors for PDNV, including female gender, history of PONV, age younger than 50 years, opioid use in the postanesthesia care unit (PACU), and nausea in the PACU (P = .37). The prevalence of PDNV was unaffected by the antiemetic protocol. After discharge, nausea was reported by 72% of patients in the intervention group and 60% of patients in the comparison group (P = .13) and vomiting was reported by 22% of patients in the intervention group and 29% of patients in the comparison group (P = .40). Conclusion Modalities that successfully address PONV after Le Fort I osteotomy might fail to affect PDNV, which is prevalent in this population. Future investigation will focus on
Amorim, Marco Aurélio Soares; Govêia, Catia Sousa; Magalhães, Edno; Ladeira, Luís Cláudio Araújo; Moreira, Larissa Govêia; Miranda, Denismar Borges de
Sevoflurane is often used in pediatric anesthesia and is associated with high incidence of psychomotor agitation. In such cases, dexmedetomidine (DEX) has been used, but its benefit and implications remain uncertain. We assessed the effects of DEX on agitation in children undergoing general anesthesia with sevoflurane. Meta-analysis of randomized clinical and double-blind studies, with children undergoing elective procedures under general anesthesia with sevoflurane, using DEX or placebo. We sought articles in English in PubMed database using the following terms: Dexmedetomidine, sevoflurane (Methyl Ethers/sevoflurante), and agitation (Psychomotor Agitation). Duplicate articles with children who received premedication and used active control were excluded. It was adopted random effects model with DerSimonian-Laird testing and odds ratio (OR) calculation for dichotomous variables, and standardized mean difference for continuous variables, with their respective 95% confidence interval (CI). Of 146 studies identified, 10 were selected totaling 558 patients (282 in DEX group and 276 controls). The use of DEX was considered a protective factor for psychomotor agitation (OR=0.17; 95% CI 0.13-0.23; p<0.0001) and nausea and vomiting in PACU (OR=0.49; 95% CI 0.35-0.68; p<0.0001). Wake-up time and PACU discharge time were higher in the dexmedetomidine group. There was no difference between groups for extubation time and duration of anesthesia. Dexmedetomidine reduces psychomotor agitation during wake-up time of children undergoing general anesthesia with sevoflurane. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Amorim, Marco Aurélio Soares; Govêia, Catia Sousa; Magalhães, Edno; Ladeira, Luís Cláudio Araújo; Moreira, Larissa Govêia; de Miranda, Denismar Borges
Sevoflurane is often used in pediatric anesthesia and is associated with high incidence of psychomotor agitation. In such cases, dexmedetomidine (DEX) has been used, but its benefit and implications remain uncertain. We assessed the effects of DEX on agitation in children undergoing general anesthesia with sevoflurane. Meta-analysis of randomized clinical and double-blind studies, with children undergoing elective procedures under general anesthesia with sevoflurane, using DEX or placebo. We sought articles in English in PubMed database using the following terms: Dexmedetomidine, sevoflurane (Methyl Ethers/sevoflurante), and agitation (Psychomotor Agitation). Duplicate articles with children who received premedication and used active control were excluded. It was adopted random effects model with DerSimonian-Laird testing and odds ratio (OR) calculation for dichotomous variables, and standardized mean difference for continuous variables, with their respective 95% confidence interval (CI). Of 146 studies identified, 10 were selected totaling 558 patients (282 in DEX group and 276 controls). The use of DEX was considered a protective factor for psychomotor agitation (OR=0.17; 95% CI 0.13 to 0.23; p<0.0001) and nausea and vomiting in PACU (OR=0.49; 95% CI 0.35 to 0.68; p<0.0001). Wake-up time and PACU discharge time were higher in the dexmedetomidine group. There was no difference between groups for extubation time and duration of anesthesia. Dexmedetomidine reduces psychomotor agitation during wake-up time of children undergoing general anesthesia with sevoflurane. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Munk, L; Andersen, G; Møller, A M
Emergence delirium (ED) after general anaesthesia (GA) is a well-known phenomenon, yet the risk factors are still unclear. The aims of this study were to determine the incidence and independent predictors of ED and secondly to determine to which degree ED has any relevant, clinical consequences to medical staff as well as to patients. This prospective, observational cohort study assessed adult patients emerging from GA in the operating room, using the Richmond Agitation-Sedation Scale (RASS). Signs of ED, defined as RASS≥1 along with possible clinical consequences were noted. Patients with ED were re-evaluated in the post-anaesthesia care unit (PACU) and concomitant patient and anaesthesia related factors were noted. Among the 1970 patients enrolled, 73 (3.7%) showed signs of ED when emerging from anaesthesia. When reassessed in PACU, the number had declined to 25 patients (1.3%). Male sex, endotracheal tube (ETT) and volatile anaesthetics were found to be significantly related to developing ED after anaesthesia. In 20 cases, additional staff had to be called for and in one case, an i.v. access was accidentally removed. Neither patients nor staff were hurt. Male sex, volatile anaesthetics and ETT were factors significantly related to ED. Whether gender, choice of respiratory devices and anaesthetics are true predictors or derived factors of surgery procedures, duration of surgery and the patients' physical condition need further investigation. The most notable clinical consequence of ED was the need of additional staff in order to restrain the agitated patient. © 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
Sing, Kimberly Anne; Hryhorczuk, Daniel; Saffirio, Giovanni; Sinks, Thomas; Paschal, Daniel C; Sorensen, John; Chen, Edwin H
The Catrimani River basin in northern Brazil is the home of the Yanomama and has been the site of renegade gold mining since 1980. Gold-mining operations release inorganic mercury (Hg) into the environment where it is organified and biomagnified in aquatic ecosystems. Ingestion of mercury-contaminated fish poses a potential hazard to fish-eating populations such as the Yanomama. We surveyed Hg levels in Yanomama villagers living near mined and unmined rivers in 1994 and 1995, and analyzed Hg levels in piranha caught by villagers. In 1994, 90 Yanomama Indians from 5 villages and in 1995, 62 Yanomama Indians from 3 villages participated in the studies. Four villages surveyed in 1994 were located directly on the Catrimani River, approximately 140-160 km downstream from past gold-mining activities. The other village surveyed in 1994 was situated on the unmined Ajaraní River. In 1995, 2 of the Catrimani River villages were revisited, and a third Yanomama village, on the unmined Pacu River, was surveyed. Blood organic mercury levels among all villagers surveyed ranged from 0 to 62.6 microg L(-1) (mean levels in each village between 21.2 microg L(-1) and 43.1 microg L(-1)). Mercury levels in piranha from the mined Catrimani River ranged from 235 to 1084 parts per billion (ppb). Nine of 13 piranhas, measuring 30 cm or longer had total mercury levels which exceeded mercury consumption limits (500 ppb) set by both the World Health Organization and the Brazilian Ministry of Health. Unexpectedly, high mercury levels were also observed in fish and villagers along the unmined Ajaraní and Pacu Rivers suggesting that indirect sources may contribute to environmental mercury contamination in the Amazon basin.
Das, A; Chhaule, S; Bhattacharya, S; Basunia, SR; Mitra, T; Halder, PS; Chattopadhyay, S; Mandal, SK
Background: Functional endoscopic sinus surgery (FESS) is the cornerstone of therapeutic management for nasal pathologies. This study is to compare the ability of preoperative and intraoperative esmolol versus dexmedetomidine for producing induced hypotension during FESS in adults in a day care setting. Materials and Methods: Sixty patients (20-45 years) posted for FESS under general anesthesia were randomly divided into Group E (n = 30) receiving esmolol, loading dose 1 mg/kg over 1 min followed by 0.5 mg/kg/h infusion during maintenance and Group D (n = 30) receiving dexmedetomidine 1 μg/kg over 15 min before induction of anesthesia followed by 0.5 μg/Kg/h infusion during maintenance, respectively. Nasal bleeding and Surgeon's satisfaction score; amount and number of patients receiving fentanyl and nitroglycerine for analgesia and deliberate hypotension, Postanesthesia Care Unit (PACU) and hospital stay; hemodynamic parameters and side effects were recorded for each patient. Results: Significantly less number and dosage of nitroglycerine was required (P = 0.0032 and 0.0001, respectively) in Group D compared to that in Group E. Again the number and dosage of patients requiring fentanyl were significantly lower in Group D. However, the duration of controlled hypotension was almost similar in both the groups. Group D patients suffered from significantly less nasal bleeding, and surgeon's satisfaction score was also high in this group. Discharge from PACU and hospital were significantly earlier in Group D. Intraoperative hemodynamics were quite comparable (P > 0.05) without any appreciable side effects. Conclusion: Dexmedetomidine found to be providing more effectively controlled hypotension and analgesia and thus allowing less nasal bleeding as well as more surgeons’ satisfaction score. PMID:27375381
Günaydın, Rıza Önder; Aygenc, Erdinc; Karakullukcu, Selma; Fidan, Fatih; Celikkanat, Serdar
The objective of this study is to compare the nasal packing and the transseptal suturing techniques regarding the extubation difficulty evaluation scores, follow-up times in post-anaesthesia care unit (PACU), pain scores, and postoperative complications. Two hundred patients who underwent septoplasty from January 2009 to October 2009 were randomly assigned either to have nasal packs (n: 100) or transeptal sutures (n: 100). In the transseptal suture group, extubation was easier and PACU follow-up times were shorter, when compared to the nasal packing group (p < 0.001). Patients with nasal packing had significantly higher pain scores (p < 0.001). Minor bleeding was significantly higher in the transseptal group with seven cases, compared to the nasal packing group without any bleeding cases (p = 0.014). There were two patients who had postoperative major bleeding, and two patients who had septal hematoma in the transseptal suture group. One patient with nasal packing had postoperative infection. Septal perforation was not seen in any of the cases. While patients in both groups experienced postoperative crusting, patients in the transseptal suture group also complained about foreign body sensation. Extubation was more comfortable; post-anaesthesia monitorization duration was shorter, and postoperative pain was less, but minor bleeding was seen more with transseptal sutures. There was no significant difference in terms of major bleeding, hematoma, infection or perforation. Foreign body sensation was the main cause of postoperative discomfort in the transseptal suture group. Transseptal suturing might be a significantly comfortable, cost-effective and reliable alternative to nasal packing.
Moustafa, Ahmed A M; Abdelazim, Ibrahim A
To determine impact of obesity on recovery parameters and pulmonary functions of women undergoing major abdominal gynecological surgeries. Eighty women undergoing major gynecological surgeries were included in this study. Anesthesia was induced by remifentanil bolus, followed by propofol and cisatracurium to facilitate oro-tracheal intubation and was maintained by balanced anesthesia of remifentanil intravenous infusion and sevoflurane in oxygen and air. Time from discontinuation of maintenance anesthesia to fully awake were recorded at 1-min intervals and time from discontinuation of anesthesia until patient was transferred to post-anesthesia care unit (PACU) and discharged from PACU was also recorded. Pulmonary function tests were performed before surgery and repeated 4 h, days 1, 2 and 3 post-operative for evaluation of forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate. Occurrence of post-operative complications, re-admission to ICU, hospital stay and morbidities were also recorded. Induction of anesthesia using remifentanil bolus injection resulted in significant decrease of heart rate and arterial pressures compared to pre-operative and pre-induction values. Recovery times were significantly shorter in obese compared to morbidly obese women. Post-operative pulmonary function tests showed significant deterioration compared to pre-operative measures but showed progressive improvement through first 3 post-operative days. Hospital stay was significantly shorter for obese compared to morbid obese women. Obesity delays recovery from general anesthesia, adversely affects pulmonary functions and increases post-operative complications. Remifentanil infusion and sevoflurane could be appropriate combination for obese and morbidly obese women undergoing major surgeries.
Kundra, Sandeep; Gupta, Vishnu; Bansal, Hanish; Grewal, Anju; Katyal, Sunil; Choudhary, Ashwini Kumar
Background: Epidural application of morphine has been used for postoperative analgesia following spine surgery but short duration of action of single application limits its widespread use. Materials and Methods: One hundred and fifty patients undergoing lumbar laminectomy were randomly allocated to two groups of 75 patients each. Anesthetic technique was standardized in both the groups. In Group I, at the completion of laminectomy, a 5 × 1-cm strip of gelfoam soaked in 5 mg morphine (1 mg/ml) was contoured to be placed in the epidural space whereas, in group II, gelfoam soaked in saline was placed in the epidural space and 5 mg morphine (1mg/ml) was instilled over the intact epidural space. Analgesic consumption for 48 hours, time-of first analgesic request, time of ambulation, time of discharge from post anesthesia care unit (PACU) and hospital and adverse effects were recorded. The data was analyzed using appropriate statistical tests. Results: Mean analgesic consumption in 48 hours was significantly less in group I (8.47 ± 3.674 mg) as compared to group II (24.80 ± 6.009 mg). Supplemental analgesia was requested at 30.03 ± 6.796 hours in Group I, vs 10.25 ± 2.243 in group II (P < 0.001). Group I patients were discharged earlier from PACU as compared to group II (P < 0.001) though time of discharge from hospital was similar in both the groups. There were no major adverse effects except pruritis, which was observed in 30.6% patients in group I and 37.3% in group II (statistically insignificant (P > 0.01)). Conclusion: Epidural application of morphine soaked in gelfoam is an effective method for prolonging the postoperative analgesia after spine surgery. PMID:24574593
Rajan, Shobana; Cata, Juan P; Nada, Eman; Weil, Robert; Pal, Rakhi; Avitsian, Rafi
The anesthetic plan for patients undergoing awake craniotomy, when compared to craniotomy under general anesthesia, is different, in that it requires changes in states of consciousness during the procedure. This retrospective review compares patients undergoing an asleep-awake-asleep technique for craniotomy (group AW: n = 101) to patients undergoing craniotomy under general anesthesia (group AS: n = 77). Episodes of desaturation (AW = 31% versus AS = 1%, p < 0.0001), although temporary, and hypercarbia (AW = 43.75 mmHg versus AS = 32.75 mmHg, p < 0.001) were more common in the AW group. The mean arterial pressure during application of head clamp pins and emergence was significantly lower in AW patients compared to AS patients (pinning 91.47 mmHg versus 102.9 mmHg, p < 0.05 and emergence 84.85 mmHg versus 105 mmHg, p < 0.05). Patients in the AW group required less vasopressors intraoperatively (AW = 43% versus AS = 69%, p < 0.01). Intraoperative fluids were comparable between the two groups. The post anesthesia care unit (PACU) administered significantly fewer intravenous opioids in the AW group. The length of stay in the PACU and hospital was comparable in both groups. Thus, asleep-awake-asleep craniotomies with propofol-dexmedetomidine infusion had less hemodynamic response to pinning and emergence, and less overall narcotic use compared to general anesthesia. Despite a higher incidence of temporary episodes of desaturation and hypoventilation, no adverse clinical consequences were seen.
Chen, X Z; Lou, Q B; Sun, C C; Zhu, W S; Li, J
Objective: To investigate the effect of intravenous infusion with lidocaine on rapid recovery of laparoscopic cholecystectomy. Methods: This study was a prospective randomized controlled trial. From February to August 2016 in Affiliated Yiwu Hospital of Wenzhou Medical University, 60 patients scheduled for laparoscopic cholecystectomy under general anesthesia were involved and randomly divided into control group (n=30) and lidocaine group (n=30). Patients in lidocaine group received lidocaine 1.5 mg/kg intravenously before induction and followed by 2.0 mg·kg(-1)·h(-1) to the end of surgery. Patients in control group received equal volumes of saline intravenously. Anesthesia induction in both groups were given intravenous midazolam 0.03 mg/kg, sufentanil 0.2 μg/kg, propofol 2.0 mg/kg and cisatracuium 0.2 mg/kg. Anesthesia was maintained with propofol 0.05-0.20 mg·kg(-1)·min(-1) and remifentanil 0.1-0.5 μg·kg(-1)·min(-1) for laryngeal mask airway which bispectral index (BIS) value maintained at 40-60. BIS, heart rate(HR) and mean arterial pressure(MAP) were recorded before anesthesia induction, before and immediately after laryngeal mask implantation, intraoperative 30 min and anesthesia awake. Pain scores were assessed using visual analogue scales (VAS) at postoperation immediately, 30 min during postanesthesia care unit (PACU), 2, 6, 12, and 24 h after surgery. The time of PACU retention, postoperative ambulation, first intestine venting and discharge were recorded. The dosage of propofol and remifentanil, the frequency of sufentanil used, the incidence of postoperative nausea and vomiting were also recorded. Patient satisfaction was evaluated by using Simple Restoration Quality Score (QoR-9). Results: BIS values before and after laryngeal mask implantation in lidocaine group were 50.50±3.47 and 54.63±1.25 respectively, which was lower than those in control group(54.30±4.78, 55.80±2.33; t=3.542, 2.423, all P<0.05). The VAS score at postoperation
Perea, Aide; Gómez, Elieth; Mayorga, Yamile; Triana, Cora Yohanna
This research involves the nutritional characterization of the most commonly cultivated fish in the region. The species under study were: Rainbow trout (Salmo gairdnerii), tilapia roja (Oreocliromis sp), cachama blanca (Piaractus brachypomus), bocachico (Prochilodus reticulatus magdalenae) and catfish (Pseudoplatystoma faciatum). A sea fish, coho Salmon (Oncorhynchus kisutch), was used as reference because it is the imported species most used in the region, and it also contains n-3 fatty acids. For each fish sample moisture, ash, protein content, total fat, minerals (iron, calcium and phosphorous) and a fatty acid profile were determined. Results show a total protein content in between 16.4 and 22.6 g/100 g fillet for fresh water fish. Total fat amounts for trout are the highest (8.1 g/100 g fillet), while catfish has the lowest fat content (0.4 g/100 g fillet). Trout was found to be the most important source of n-3 fatty acids (EPA+DHA) and phosphorous, with values ranging from 0.25% to 0.52%, and 250 to 346 mg/100 g fillet, respectively. Catfish and trout exhibited the highest iron content, with values ranging from 3 to 6mg/100 g fillet. Salmon, on the other hand, showed a high n-3 fatty acid content of 1.16% to 2.25%, when compared to fresh water fish. Calcium content is low in all species under scrutiny. Fresh water fish, other than trout, show no significant amount of n-3 fatty acids. However, all of them are a good source of protein. The obtained results allowed to determine the profile of oily acids of produced fish for human consumption in the region, demonstrating that the trout is the species with major quantity of oily acids n-3 specially DHA and of the minerals the phosphorus. Other species (kinds) catfish, bocachico, tilapia and cachama, are not a source of oily acids n-3, but they are an important source of protein.
Stricker, Paul A; Muhly, Wallis T; Jantzen, Ellen C; Li, Yue; Jawad, Abbas F; Long, Alexander S; Polansky, Marcia; Cook-Sather, Scott D
Bilateral myringotomy and pressure equalization tube insertion (BMT) is the most common surgery in children. Multiple anesthetic techniques for BMT have been proposed, but that which reliably promotes ideal recovery remains unclear. We sought to assess associations between anesthetic regimens that included single-agent (fentanyl or ketorolac) or dual-agent (fentanyl and ketorolac) analgesic therapy and the primary outcome of maximal postanesthesia care unit (PACU) pain score. Secondary outcomes included in-hospital rescue analgesic administration, recovery time, and emesis incidence. Principal analysis was conducted on a retrospective cohort of 3669 children aged 6 months to <7 years who underwent BMT over a 16-month period and received intraoperative fentanyl and/or ketorolac. Routine anesthetic care included preoperative oral midazolam, general anesthesia via a mask maintained with sevoflurane and N2O or air in O2, and intramuscular analgesic administration. Multivariable analyses were performed examining relationships between analgesic regimen with the following outcomes: maximum PACU Face, Legs, Activity, Cry, and Consolability (FLACC) score = 0 or 7 to 10, oxycodone administration, and time to discharge readiness. Demographic variables, midazolam exposure, and location (main hospital vs ambulatory surgery center) were included in the multivariable analyses as potential confounders. Associations with postoperative vomiting were studied separately in 2725 children from a subsequent, nonoverlapping 12-month period using similar inclusion criteria. Fentanyl and ketorolac dose-response relationships were evaluated for selected outcome variables. Maximum FLACC = 0, maximum FLACC score of 7 to 10, and oxycodone rescue were most strongly associated with dual-agent therapy versus single-agent ketorolac: odds ratios 4.89 (95% confidence interval [CI], 4.04-5.93), 0.13 (95% CI, 0.10-0.16), and 0.11 (98.3% CI, 0.09-0.14), respectively, P < .001 for each). Minor
Adamson, Tim; Godil, Saniya S; Mehrlich, Melissa; Mendenhall, Stephen; Asher, Anthony L; McGirt, Matthew J
OBJECTIVE In an era of escalating health care costs and pressure to improve efficiency and cost of care, ambulatory surgery centers (ASCs) have emerged as lower-cost options for many surgical therapies. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed, and the frequency of its performance is rapidly increasing as the aging population grows. Although ASCs offer significant cost advantages over hospital-based surgical centers, concern over the safety of outpatient ACDF has slowed its adoption. The authors intended to 1) determine the safety of the first 1000 consecutive ACDF surgeries performed in their outpatient ASC, and 2) compare the safety of these outpatient ACDFs with that of consecutive ACDFs performed during the same time period in the hospital setting. METHODS A total of 1000 consecutive patients who underwent ACDF in an ACS (outpatient ACDF) and 484 consecutive patients who underwent ACDF at Vanderbilt University Hospital (inpatient ACDF) from 2006 to 2013 were included in this retrospective study of patients' medical records. Data were collected on patient demographics, comorbidities, operative details, and perioperative and 90-day morbidity. Perioperative morbidity and hospital readmission were compared between the outpatient and inpatient ACDF groups. RESULTS Of the first 1000 outpatient ACDF cases performed in the authors' ASC, 629 (62.9%) were 1-level and 365 (36.5%) were 2-level ACDFs. Mean patient age was 49.5 ± 8.6, and 484 (48.4%) were males. All patients were observed postoperatively at the ASC postanesthesia care unit (PACU) for 4 hours before being discharged home. Eight patients (0.8%) were transferred from the surgery center to the hospital postoperatively (for pain control [n = 3], chest pain and electrocardiogram changes [n = 2], intraoperative CSF leak [n = 1], postoperative hematoma [n = 1], and profound postoperative weakness and surgical reexploration [n = 1]). No perioperative
Macario, Alex; Claybon, Louis; Pergolizzi, Joseph V
Background When patients are asked what they find most anxiety provoking about having surgery, the top concerns almost always include postoperative nausea and vomiting (PONV). Only until recently have there been any published recommendations, mostly derived from expert opinion, as to which regimens to use once a patient develops PONV. The goal of this study was to assess the responses to a written survey to address the following questions: 1) If no prophylaxis is administered to an ambulatory patient, what agent do anesthesiologists use for treatment of PONV in the ambulatory Post-Anesthesia Care Unit (PACU)?; 2) Do anesthesiologists use non-pharmacologic interventions for PONV treatment?; and 3) If a PONV prophylaxis agent is administered during the anesthetic, do anesthesiologists choose an antiemetic in a different class for treatment? Methods A questionnaire with five short hypothetical clinical vignettes was mailed to 300 randomly selected USA anesthesiologists. The types of pharmacological and nonpharmacological interventions for PONV treatment were analyzed. Results The questionnaire was completed by 106 anesthesiologists (38% response rate), who reported that on average 52% of their practice was ambulatory. If a patient develops PONV and received no prophylaxis, 67% (95% CI, 62% – 79%) of anesthesiologists reported they would administer a 5-HT3-antagonist as first choice for treatment, with metoclopramide and dexamethasone being the next two most common choices. 65% (95% CI, 55% – 74%) of anesthesiologists reported they would also use non-pharmacologic interventions to treat PONV in the PACU, with an IV fluid bolus or nasal cannula oxygen being the most common. When PONV prophylaxis was given during the anesthetic, the preferred PONV treatment choice changed. Whereas 3%–7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% (95% confidence intervals, 18% – 36%) of practitioners would re-dose the 5-HT3-antagonist
Fan, Qing; Hu, Chunbo; Ye, Min; Shen, Xia
Remifentanil and dexmedetomidine are well known to suppress airway reflexes during airway procedures. Smooth tracheal extubation is important after otologic surgery. The purpose of this study is to compare the effectiveness of dexmedetomidine or remifentanil infusion for producing smooth tracheal extubation in deeply anesthetized patients after otologic surgery. Seventy-four ASA I-II adult patients (18-60 years old) scheduled for elective otologic surgery were randomly assigned to one of three groups: sevoflurane-remifentanil (Group SR, n = 25), sevoflurane-dexmedetomidine (0.5 μg/kg) (Group SD5, n = 24), or sevoflurane-dexmedetomidine (0.7 μg/kg) (Group SD7, n = 25). Remifentanil or dexmedetomidine were administered for 10 min at the end of surgery. The primary outcome was the rate of smooth extubation. Respiratory pattern, airway obstruction, hemodynamic and respiratory profiles, time to awake, rescue analgesics in the post-anesthesia care unit (PACU), and postoperative nausea and vomiting (PONV) were also recorded. The rate of smooth tracheal extubation as defined 1 min post-extubation was the same for Groups SR and SD7 (P > 0.05), but the rate of smooth extubation was lower for Group SD5 than for the other two groups (p < 0.05). During extubation, the respiratory rate was lower in Group SR than in both dexmedetomidine groups (p < 0.05). The hemodynamic profiles at extubation were similar between groups (p > 0.05), but the mean arterial pressure and heart rate were higher in Group SR at 10 and 15 min after extubation (p < 0.05). The incidence of airway obstruction and time to awake were comparable for all groups (p > 0.05). The need for rescue analgesic in the PACU was more common in Group SR than in both dexmedetomidine groups (P < 0.01). Compared to Group SR, both dexmedetomidine groups had less PONV on postoperative day 1 (p < 0.05). Combined with 1 MAC sevoflurane, dexmedetomidine 0.7 ug/kg and remifentanil
Chen, Jiayao; Li, Wenxian; Hu, Xiao; Wang, Dingding
The aim of this study was to determine whether the concurrent use of either of a subhypnotic dose of midazolam, propofol or ketamine with fentanyl just before discontinuing the sevoflurane anesthesia would effectively sedate the children as they recovered and significantly decrease the incidence and severity of emergence agitation and would not delay patient awakening and discharge. Postoperative emergence agitation may occur in children after general anesthesia with volatile anesthetics. Children who undergo cataract surgery after sevoflurane induction and sevoflurane-remifentanil maintenance may experience this type of agitation. In 120 un-premedicated children aged 1-7 years, mask induction with sevoflurane was performed and they were then randomly assigned to one of the three antiagitation postoperative groups (n = 40). We studied the postoperative antiagitation effects of subhypnotic doses of midazolam combined with fentanyl, propofol with fentanyl or ketamine with fentanyl administered just before discontinuing the sevoflurane anesthesia. A score for the level of agitation can be assigned based on the recovery mental state (RMS) scale and the recently published pediatric anesthesia emergence delirium scale (PAED). Postoperative factors assessed included emergence behaviors, the time to eye opening, the time to discharge from the postanesthesia care unit (PACU) to the ward. There were significantly more agitated children in the ketamine-group when compared to the midazolam-group or to the propofol-group at all time P < 0.05), especially at 10 and 15 min. The PAED scale showed a significant advantage for midazolam-fentanyl [5 (2-15)] and propofol-fentanyl [6 (3-15)] versus ketamine-fentanyl [10 (3-20)] (P < 0.05). The time to discharge from the PACU to the ward was not significantly different among the groups. Intravenous administration of a subhypnotic dose of midazolam or propofol in addition to a low dose of fentanyl just before discontinuing the sevoflurane
Zhu, Min; Wang, Haiyun; Zhu, Ai; Niu, Kaijun; Wang, Guolin
The objective of this article is to evaluate the effect of dexmedetomidine on emergence agitation (EA) and recovery profiles in children after sevoflurane anesthesia and its pharmacological mechanisms. Standard bibliographic databases, including MEDLINE, EMBASE, PsycINFP, Springer and ISI Web of Knowledge, were artificially searched to identify all randomized controlled trials (RCTs) comparing the impact of dexmedetomidine with placebo, fentanyl and midazolam on EA and recovery profiles after sevoflurane anesthesia in post-anesthesia care unit (PACU). Two authors assessed the quality of each study independently in accordance with strict inclusion criteria and extracted data. RevMan 5.0 software was applied for performing statistic analysis. The outcomes analyzed included: 1) incidence of EA, 2) emergence time, 3) time to extubation, 4) incidence of post-operation nausea and vomiting, 5) number of patients requiring an analgesic, and 6) time to discharge from PACU. A total of 1364 patients (696 in the dexmedetomidine group and 668 in the placebo, fentanyl and midazolam group) from 20 prospective RCTs were included in the meta-analysis. Compared with placebo, dexmedetomidine decreased the incidence of EA (risk ratio [RR] 0.37; 95% CI 0.30 to 0.46), incidence of nausea and vomiting (RR 0.57; 95% CI 0.38 to 0.85) and number of patients requiring an analgesic (RR 0.43; 95% CI 0.31 to 0.59). However, dexmedetomidine had a significantly delayed effect on the emergence time (weighted mean differences [WMD] 1.16; 95% CI 0.72 to 1.60), time to extubation (WMD 0.61; 95% CI 0.27 to 0.95), and time to discharge from recovery room (WMD 2.67; 95% CI 0.95 to 4.39). Compared with fentanyl (RR 1.39; 95% CI 0.78 to 2.48) and midazolam (RR 1.12; 95% CI 0.54 to 2.35), dexmedetomidine has no significantly difference on the incidence of EA. However, the analgesia effect of dexmedetomidine on postoperation pain has no significantly statistical differences compared with fentanyl (RR 1
Ünal, Dilek Yazıcıoğlu; Baran, İlkay; Mutlu, Murad; Ural, Gülçin; Akkaya, Taylan; Özlü, Onur
Objective To compare sugammadex and neostigmine regarding the efficacy in reversing rocuronium-induced neuromuscular block, the incidence of post-operative respiratory complications and costs in patients undergoing surgery for the treatment of obstructive sleep apnoea (OSA). Methods After obtaining ethical approval and patient consent, 74 patients in ASA physical status I or II were randomised into two groups to receive 2-mg kg−1 sugammadex (Group S) or 0.04-mg kg−1 neostigmine+0.5-mg atropine (Group N). Groups were compared regarding time to TOF (train-of-four) 0.9, operating room time, post-anaesthesia care unit (PACU) stay, post-operative respiratory complications, costs related to neuromuscular block reversal, anaesthesia care and complication treatment. Results Patient demographics, anaesthesia, surgical data and total rocuronium doses were similar between groups. Time to TOF 0.9 was shorter for group S [Group N: 8 (5–18) min; Group S: 2 (1.5–6) min (p<0.001)]. Operating room time [Group S: 72.4±14.3 min; Group N: 96.6±22.8 min (p<0.001)] and PACU stay [Group S: 22.9±10.1 dk; Group N: 36.3±12.6 dk (p<0.001)] were also shorter in Group S. After extubation, desaturation was observed in 12 (32.4%) patients in group N and in 4 (8%) patients in group S (p=0.048). In group N, three patients were reintubated; there were eight (21.6%) unplanned intensive care unit (ICU) admissions. There was one unplanned ICU admission in group S. Negative pressure pulmonary oedema was observed in one patient in group N. The results regarding costs were as follows. The reversal cost was higher in the sugammadex group (vial cost 98.14 TL) than that in the neostigmine group (ampoule cost 0.27 TL; total 6147.88 TL vs. 3569.5 TL); however, complication treatment cost and total cost were lower in group S than those in group N (199.5 TL vs. 3944.6 TL) (staff anaesthesia doctor cost was 0.392 TL per min and the cost of nurse anaesthetist was 0.244 TL per min). Conclusion This
Andreoli, Steven M; Kofmehl, Emma; Sobol, Steven E
To determine the need for postoperative admission following airway foreign body retrieval by examining the preoperative presentation, operative details, and postoperative recovery. Inpatient admission following foreign body removal is common, however little evidence supports this practice. In the era of cost containment and prudent utilization of hospital resources, careful examination of the postoperative course following airway foreign body removal is required. A retrospective review of cases over a four year period from a pediatric tertiary care pediatric hospital was performed. All children presenting with concerns for airway foreign bodies were included. Children without identification of an airway foreign body during bronchoscopy were excluded. Microlaryngoscopy and bronchoscopy with airway foreign body extraction was performed. Details concerning demographics, operative findings, and pre and postoperative course including pulse oximetry were collected. All respiratory events, intubations, and persistent oxygen requirements were investigated. Thirty five children underwent successful airway foreign body removal. The mean age was 3.2±2.6 years with a preponderance of males (68.6%). The retrieved items included: nuts (31.4%), popcorn (14.3%), seeds (8.6%), and inorganic materials (34.3%). Mean operative time was 29.7±25.6min. The mean length of stay following surgery was 1.3±1.9 days. Most patients (31/35) (88.6%) were extubated prior to transfer to recovery. 30/35 (85.7%) patients required no supplemental oxygen without desaturations following post anesthesia care unit (PACU) recovery. One patient developed laryngospasm requiring reintubation within 15min of surgery. Two patients were intubated prior to transfer for respiratory distress and remained intubated following surgery. Two patients breathing spontaneously prior to surgery were left intubated following surgery secondary to prolonged pneumonia treatment or multifocal foreign bodies with airway edema
Costi, David; Ellwood, James; Wallace, Andrew; Ahmed, Samira; Waring, Lynne; Cyna, Allan
Emergence agitation (EA) is a common behavioral disturbance after sevoflurane anesthesia in children. Propofol 1 mg · kg(-1) bolus at the end of sevoflurane anesthesia has had mixed results in reducing the incidence of EA, whereas propofol infusion throughout anesthesia maintenance seems effective but is more complex to administer. If a simple, short transition to propofol anesthesia was found to be effective in reducing EA, this could enhance the recovery of children following sevoflurane anesthesia. We therefore aimed to determine whether transition to propofol over 3 min at the end of sevoflurane anesthesia reduces the incidence of EA in children. In this prospective randomized controlled trial, 230 children aged 1-12 years, undergoing magnetic resonance imaging (MRI) scans under sevoflurane anesthesia were randomized to receive either propofol 3 mg · kg(-1) over 3 min (propofol group), or no propofol (control group), at the end of sevoflurane anesthesia. EA was assessed by a blinded assessor using the Pediatric Emergence Anesthesia Delirium (PAED) scale and the Watcha scale until 30 min after emergence. EA on the PAED scale was defined as a PAED score >12. EA on the Watcha scale was defined as a score ≥ 3. Times to emergence, postanesthesia care unit (PACU) discharge, and discharge home were also recorded. Data were analyzed for 218 children. The incidence of EA was lower in the propofol group on both PAED (29% vs 7%; relative risk = 0.25; 95% confidence interval 0.12-0.52; P < 0.001) and Watcha (39% vs 15%; relative risk = 0.37; 95% confidence interval 0.22-0.62; P < 0.001) scales. Duration and severity of EA were also reduced in the propofol group. Preplanned subgroup analyses for midazolam premedication, preexisting cognitive or behavioral disturbance, and age group did not alter our findings. Emergence time and time in PACU were both increased by a mean of 8 min in the propofol group (P < 0.001) with no difference in time to discharge home. Transition
Cao, Jun-Li; Pei, Yu-Ping; Wei, Jing-Qiu; Zhang, Yue-Ying
Abstract Postoperative emergence agitation/delirium (POED) is a common complication in pediatric surgery patients, which increases the risk of developing postoperative airway obstruction and respiratory depression. This study aims to investigate the safety and efficacy of intraoperative infusion of dexmedetomidine (DEX) and its effects on POED in pediatric patients undergoing tonsillectomy with or without adenoidectomy. Sixty patients scheduled for tonsillectomy with or without adenoidectomy, aged 2 to 8 years, were randomly allocated into 2 groups (n = 30). Pediatric patients in the group DEX received intravenous (IV) DEX 1 μg/kg over 10 minutes, followed by 0.5 μg/kg/h continuous infusion, and the same volume of 0.9% saline was administrated in the group control. Anesthesia was maintained with target-controlled infusion (TCI) of propofol and remifentanyl. Intraoperative heart rate (HR), noninvasive blood pressure (NIBP), blood oxygen saturation (SPO2), recovery time, and extubation time were recorded. Pain level was evaluated using the objective pain score (OPS), pediatric anesthesia emergence delirium (PAED) scale and Cole 5-point scale (CPS) was used to evaluate POED when patients at 0, 5, 15 minutes, and then at intervals of 15 minutes for 60 minutes after parents arrival at postanesthesia care unit (PACU). The results showed that intraoperative HR was significantly lower in group DEX (P <0.05), mean diastolic and systolic NIBP was not statistically different between groups. Time to wake and time to extubation were lengthened in group DEX as compared with group control (P <0.05). OPS and CPS were lower in group DEX at 15, 30, and 45 minutes time points (P <0.05); however, there were no significantly differences in the PAED score at different time points in the PACU. The present data suggested that intraoperative infusion of dexmedetomidine combined with intravenous anesthetics can provide satisfactory intraoperative conditions for pediatric
Hernandez, Maria A; Vecchione, Tricia; Boretsky, Karen
Several techniques for the transversus abdominis plane (TAP) block have been described. The extent of sensory changes using an ultrasound-guided posterior TAP block (pTAP) remains unclear in pediatric patients. The primary aim of this study was to report the extent of sensory changes achieved with pTAP; specifically the highest thoracic dermatome anesthetized. Secondary outcomes were pain scores (PS), opioid consumption, and complications. We retrospectively reviewed the medical records of patients less than 21 years of age undergoing abdominal surgery with a unilateral or bilateral pTAP(s) for postoperative analgesia. The local anesthetic was placed posterior to the termination of the transversus abdominis muscle where the thoracolumbar fascia overrides the quadratus lumborum muscle. The extent of sensory changes, pain scores, and opioid consumption were analyzed. A total of 10 patients (15 pTAP blocks) met the inclusion criteria. The mean (sd; range) age and weight were 15 years (5 years; range 7-20 years) and 57 kg (21 kg; 27-97 kg), respectively. The cephalad dermatome levels achieved were: T7 in 6/15 (40%); T8 in 10/15 (67%); and T9 in 14/15 (93%). An inferior dermatome level of T12/L1 and sensory extension from midaxillary line to the midline was documented in 15/15 blocks. The mean intraoperative and postanesthesia care unit (PACU) opioid consumption in morphine equivalents were 0.34 mg·kg(-1) (sd = 0.12 mg·kg(-1) ) and 0.04 mg·kg(-1) (sd = 0.05 mg·kg(-1) ), respectively. PACU pain scores were mild (<4) in 60%, moderate (4-7) in 30%, and severe (>7) in 10% of patients. No complications were reported. The current uncertainty regarding sensory blockade limits the clinical application of TAP blocks. While the midaxillary approach results in unpredictable sensory changes of the abdomen, we reliably achieved sensory changes up to a T9 level in 93% of the blocks. In this small series of patients, we demonstrate a high technical success rate of achieving
Isaac, V J; Almeida, M C; Cruz, R E A; Nunes, L G
The present study characterises the commercial fisheries of the basin of the Xingu River, a major tributary of the Amazon River, between the towns of Gurupá (at the mouth of the Amazon) and São Félix do Xingu. Between April, 2012, and March, 2014, a total of 23,939 fishing trips were recorded, yielding a total production of 1,484 tons of fish, harvested by almost three thousand fishers. The analysis of the catches emphasizes the small-scale and artisanal nature of the region's fisheries, with emphasis on the contribution of the motorised canoes powered by "long-tail" outboard motors. Larger motorboats operate only at the mouth of the Xingu and on the Amazon. Peacock bass (Cichla spp.), croakers (Plagioscion spp.), pacu (a group containing numerous serrasalmid species), aracu (various anostomids), and curimatã (Prochilodus nigricans) together contributed more than 60% of the total catch. Mean catch per unit effort was 18 kg/fisher-1.day-1, which varied among fishing methods (type of vessel and fishing equipment used), river sections, and time of the year. In most cases, yields varied little between years (2012 and 2013). The technical database provided by this study constitutes an important resource for the regulation of the region's fisheries, as well as for the evaluation of future changes resulting from the construction of the Belo Monte dam on the Xingu River.
Yin, Xiaorong; Ye, Ling; Zhao, Liang; Li, Lisha; Song, Jinping
The purpose of our study was to determine the safety and tolerability of early oral hydration (EOH) compared with delayed oral hydration (DOH) after general anesthesia. One thousand anesthesiology (ASA) I to III adult patients undergoing non-gastrointestinal surgery with general anesthesia were randomized assigned into two groups: DOH (n=500, patients were given water 4 h after general anesthesia), EOH (n=500, patients were given 0.5 ml/kg water once recovered from general anesthesia.) in the postanesthesia care unit (PACU). Patients were evaluated for nausea, vomiting, drink desire, thirsty scale, oropharyngeal discomfort scale, and satisfaction scale. Statistical analysis was performed with Student’s t and Chi-Square tests. Complete data were available for 983 patients (EOH=488, DOH=495). Twenty minutes after receiving water the incidence of vomiting in EOH group was very low. And there was no significant difference between the two groups at the same time point (p > 0.05). Compared with DOH group, after receiving water there was a significant decrease of patients’ thirsty scales (p < 0.0001) and oropharyngeal discomfort scales (p < 0.0001) in EOH group. Significantly more patients’ satisfaction were reported in EOH group (p < 0.001). No serious adverse effects were reported during the study period. For patients undergoing non-gastrointestinal surgery, early oral hydration after recovery from general anesthesia was safe, with lower thirsty scale and oropharyngeal discomfort scales, and higher satisfaction. PMID:25419388
Maranhão, Marcius Vinícius M; Nóbrega, Dyluzia Kelly Amaral da; Anunciação, Carlos Eduardo Caiado; Maia, Barbara de Alcântara Brito; Mariano, Paulo Virgílio Dantas
We present a case of allergic reaction to patent blue in a patient who underwent excision of sentinel lymph node associated with segmental breast resection. About 20minutes after the dye injection, the patient developed hypotension (BP=70×30mmHg) associated with increased heart frequency. The patient was treated successfully with decreased inspired fraction of inhaled anesthetic and fluid replacement. At the end of the procedure, she presented with bluish urticarial - like plaques on the head, neck, upper limbs, and trunk; hydrocortisone was then used. The patient recovered uneventfully and was discharged from the PACU two hours after the end of surgery without skin changes, and was discharged from hospital on the morning after surgery. The incidence of allergic reactions with the use of patent blue is far superior to the hypersensitivity reactions seen with anesthetic and adjuvant drugs. Therefore, the anesthesiologist must be aware of cardiovascular instability associated with skin changes during the use of patent blue, for early diagnosis and appropriate treatment of this hypersensitivity reaction to this dye. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Maranhão, Marcius Vinícius M; da Nóbrega, Dyluzia Kelly Amaral; Anunciação, Carlos Eduardo Caiado; Maia, Barbara de Alcântara Brito; Mariano, Paulo Virgílio Dantas
We present a case of allergic reaction to patent blue in a patient who underwent excision of sentinel lymph node associated with segmental breast resection. About 20min after the dye injection, the patient developed hypotension (BP=70×30mmHg) associated with increased heart frequency. The patient was treated successfully with decreased inspired fraction of inhaled anesthetic and fluid replacement. At the end of the procedure, she presented with bluish urticarial-like plaques on the head, neck, upper limbs, and trunk; hydrocortisone was then used. The patient recovered uneventfully and was discharged from the PACU 2h after the end of surgery without skin changes, and was discharged from hospital on the morning after surgery. The incidence of allergic reactions with the use of patent blue is far superior to the hypersensitivity reactions seen with anesthetic and adjuvant drugs. Therefore, the anesthesiologist must be aware of cardiovascular instability associated with skin changes during the use of patent blue, for early diagnosis and appropriate treatment of this hypersensitivity reaction to this dye. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Fan, Hongtao; Sun, Ting; Li, Weijia; Sui, Dianpeng; Jin, Shuang; Lian, Xiaojing
An aqueous solution containing sodium polyacrylate (PA, 0.0030M) was used in diffusive gradients in thin-films technique (DGT) to measure DGT-labile Cu(2+) and Cd(2+) concentrations. The DGT devices (PA DGT) were validated in four types of solutions, including synthetic river waters containing metal ions with or without complexing EDTA, natural river water (Hun River, Shenyang, China) spiked with Cu(2+) and Cd(2+), and an industrial wastewater (Shenyang, China). Results showed that only free metal ions were measured by PA DGT, recovery=98.79% for Cu(2+) and recovery=97.80% for Cd(2+) in solutions containing only free metal ions, recovery=51.02% for Cu(2+) and recovery=51.92% for Cd(2+) in solution with metal/EDTA molar ratio of 2:1 and recovery=0 in solutions with metal/EDTA molar ratio of 1:1 and 1:2. These indicated that the complexes of Cu-EDTA and Cd-EDTA were DGT-inert or not DGT-labile. The DGT performance in spiked river water (recovery=8.47% for Cu(2+) and recovery=27.48% for Cd(2+)) and in industrial wastewater (recovery=14.16% for Cd(2+)) were also investigated. Conditional stability constants (logK) of PA-Cu and PA-Cd complexes were determined as 6.98 and 5.61, respectively, indicating strong interaction between PA and the metals.
Santos, H B; Sato, Y; Moro, L; Bazzoli, N; Rizzo, E
Early ovarian regression was analyzed in the neotropical freshwater teleost, curimatã-pacu (Prochilodus argenteus), in order to evaluate follicular apoptosis, basement membrane morphology, and integrin beta1 and collagen type IV immunostainning in postovulatory follicles. Mature females were induced to spawn by using carp pituitary extract for study of ovarian regression up to 5 days post-spawning. Morphometric analyses showed that the postovulatory follicle area decreased progressively after spawning and was coupled to the gonadosomatic index (r=0.92). During ovarian regression, follicular cells detached from the neighboring cells and basement membrane and then died by apoptosis. The follicular basement membrane became thicker and diffuse and was breached during regression of the postovulatory follicles. Follicular apoptosis was detected by TUNEL, histology, and electron microscopy. The ladder pattern of apoptotic DNA was revealed by agarose gel electrophoresis. The apoptotic index for the follicular cells increased until 3 days post-spawning and decreased thereafter. Immunohistochemistry reactions detected caspase 3, integrin beta1, and collagen type IV in the follicular layer of the postovulatory follicles. Labeling for integrin beta1 and collagen type IV decreased significantly, whereas a peak in cell death occurred 3 days post-spawning. At 4-5 days post-spawning, the connective theca was more thickened and vascularized. Simultaneously, granulocytes migrated toward the follicular lumen. Thus, follicular apoptosis contributes to early ovarian regression in P. argenteus. Additionally, our findings suggest integrin beta1 and collagen type IV as possible survival factors for follicular cells in teleost ovary.
Chhabra, Anjolie; Subramaniam, Rajeshwari; Srivastava, Anurag; Prabhakar, Hemanshu; Kalaivani, Mani; Paranjape, Saloni
Anaesthetic drugs during general anaesthesia are titrated according to sympathetic or somatic responses to surgical stimuli. It is now possible to measure depth of anaesthesia using electroencephalography (EEG). Entropy, an EEG-based monitor can be used to assess the depth of anaesthesia using a strip of electrodes applied to the forehead, and this can guide intraoperative anaesthetic drug administration. The primary objective of this review was to assess the effectiveness of entropy monitoring in facilitating faster recovery from general anaesthesia. We also wanted to assess mortality at 24 hours, 30 days, and one year following general anaesthesia with entropy monitoring.The secondary objectives were to assess the effectiveness of the entropy monitor in: preventing postoperative recall of intraoperative events (awareness) following general anaesthesia; reducing the amount of anaesthetic drugs used; reducing cost of the anaesthetic as well as in reducing time to readiness to leave the postanaesthesia care unit (PACU). We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), MEDLINE via Ovid SP (1990 to September 2014) and EMBASE via Ovid SP (1990 to September 2014). We reran the search in CENTRAL, MEDLINE via Ovid SP and EMBASE via Ovid SP in January 2016. We added one potential new study of interest to the list of 'Studies awaiting Classification' and we will incorporate this study into the formal review findings during the review update. We included randomized controlled trials (RCTs) conducted in adults and children (aged greater than two years of age), where in one arm entropy monitoring was used for titrating anaesthesia, and in the other standard practice (increase in heart rate, mean arterial pressure, lacrimation, movement in response to noxious surgical stimuli) was used for titrating anaesthetic drug administration. We also included trials with an additional third arm, wherein another EEG monitor, the Bispectral index
Martín, Nuria; Valero, Ricard; Hurtado, Paola; Gracia, Isabel; Fernández, Carla; Rumià, Jordi; Valldeoriola, Francesc; Carrero, Enrique J; Tercero, Francisco Javier; de Riva, Nicolás; Fàbregas, Neus
A 24-h-stay in the post-anesthesia care unit (PACU) is a common postoperative procedure after deep brain stimulation surgery (DBS). We evaluated the impact of a fast-track (FT) postoperative care protocol. An analysis was performed on all patients who underwent DBS in 2 periods: 2006, overnight monitored care (OMC group), and 2007-2013, FT care (FT group). The study included 19 patients in OMC and 95 patients in FT. Intraoperative complications occurred in 26.3% patients in OMC vs. 35.8% in FT. Post-operatively, one patient in OMC developed hemiparesis, and agitation in 2 patients. In FT, two patients with intraoperative hemiparesis were transferred to the ICU. While on the ward, 3 patients from the FT developed hemiparesis, two of them 48h after the procedure. Thirty eight percent of FT had an MRI scan, while the remaining 62% and all patients of OMC had a CT-scan performed on their transfer to the ward. One patient in OMC had a subthalamic hematoma. Two patients in FT had a pallidal hematoma, and 3 a bleeding along the electrode. A FT discharge protocol is a safe postoperative care after DBS. There are a small percentage of complications after DBS, which mainly occur within the first 6h. Copyright © 2016 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.
Tripi, Paul A; Palermo, Tonya Mizell; Thomas, Susan; Goldfinger, Mark M; Florentino-Pineda, Ivan
Emergence distress commonly occurs in children recovering from the immediate effects of general anaesthesia. This study was performed to (1) examine whether parental presence in the operating room during emergence from anaesthesia reduces the incidence or severity of emergence distress behaviour, and (2) assess psychosocial risk factors, including child temperament and sleep behaviour, for development of emergence distress. A randomized and controlled trial of parental presence at emergence was conducted in 100 ASA class I and II children having general anaesthesia for inguinal or penile surgery. Children in the study group had a parent present at induction and emergence of anaesthesia, while children in the control group had a parent present only at induction. Emergence and postanaesthesia care unit (PACU) behaviour was monitored using both the Operating Room Behaviour Rating Scale (ORBRS) and a 7-point Likert type cooperation scale. One-way anovas showed no significant differences between the control group and the study group on emergence distress behaviour. The frequency of negative postoperative behavioural changes at 1 and 4 weeks postsurgery was low in both groups. Children described as clingy/dependent (chi2 = 5.57, P < 0.06) and children with frequent temper tantrums (chi2 = 7.44, P < 0.02) were more likely to have emergence distress behaviour. Parental presence during emergence from anesthesia did not decrease the incidence or severity of emergence distress behaviour in children. Young children and children with a history of temper tantrums or separation anxiety may be more likely to develop such behaviour.
Leeth, Dianne; Mamaril, Myrna; Oman, Kathleen S; Krumbach, Barbara
ASPAN guidelines for the prevention of unplanned perioperative hypothermia define normothermia as a core temperature between 36 and 38 degrees C and an acceptable level of warmth. Over a six-month period, more than 30% of the same-day surgery patients experienced hypothermic core temperatures on admission to the preoperative unit. The purpose of the study was to compare two preoperative warming methods (forced-air gowns vs traditional warmed cotton blankets) on oral body temperatures, and patients reported "thermal" comfort in ambulatory surgery patients. A repeated measures experimental design study included 150 subjects in Pre-op who were randomly assigned to either the control warmed blankets group or the experimental forced-air gown group. Oral temperatures and thermal comfort assessments were measured every 30 minutes while the patients were in Pre-op, and on admission and discharge from the Phase I PACU. There was no significant difference in postoperative temperature between the subjects warmed with blankets and the warm-air gowns. Subjects warmed with the warm-air gowns reported higher comfort scores after 30 minutes of warming than those warmed with blankets. The change in comfort score from baseline to 30 minutes post warming was greater in the warm-air gown group (P = .001), indicating that warm-air gowns contribute to patients' increased thermal comfort.
Zarif, Pierre; Abdelhaq, Mohamed Mohamed; Mikhail, Hany M. S.; Farag, Ahmed
Objectives. To compare dexmedetomidine versus magnesium during laparoscopic colectomy. Patients and Methods. 51 patients were randomly allocated into 3 groups: group C (control) received saline infusion, group D dexmedetomidine 1 g/kg and then 0.4 g/kg/hr, and group M MgSO4 2 g and then 15 g/kg/min. Intraoperative hemodynamics were measured before and 1 min after intubation (T1 and T2), before and 5 min after peritoneal insufflation (T3 and T4), before and 5 min after 30° Trendelenburg position (T5 and T6), 5 min after resuming flat position (T7), 5 min after peritoneal deflations (T8), after extubation (T9), and at time of admission to PACU (T10). Recovery time and degree of sedation were assessed. Results. HR and MAP were significantly higher in T2, T4, and T6 compared to T1, T3, and T5, respectively, in all groups with lower measurements in groups D and M compared to group C. Mean of collective measurements was significantly higher in group C. Recovery time and sedation score were significantly higher in groups D and M. Time to Aldrete score of ≥9 was significantly longer in groups D and M. Conclusion. Both drugs ameliorate the pressor responses during LC with a nonsignificant difference. This study is registered with PACTR201602001481308. PMID:27051421
De Rojas, Joaquin O; Syre, Peter; Welch, William C
Lumbar spine surgery can be performed using different anesthetic techniques such as general endotracheal anesthesia (GA) or spinal-based regional anesthesia (RA). Several studies have been performed comparing these two anesthetic techniques and have revealed disparate results. As such, we set out to review the relevant literature. We performed a literature search for clinical articles comparing cohorts of patients who underwent RA versus GA for lumbar spine surgeries. We compared results of these studies between groups with respect to the following outcome variables: heart rate (HR), mean arterial pressure (MAP), blood loss, duration of surgery, time spent in the PACU, post-operative analgesic use or pain scores, urinary retention rates, and nausea or anti-emetic requirements. Eleven studies were identified that compared cohorts of patients who underwent GA or RA. Of these, 4 were randomized control trials, 3 were case control trials, 2 were prospective cohorts, and 2 retrospective analyses. Seven-out-of-seven studies reported reduced HRs and MAPs in the RA compared to GA group, and 7/9 studies reported a lower incidence of post-operative analgesic requirement and/or decreased pain scores for the RA group. Our review of the literature suggests that both RA and GA are safe and effective techniques for lumbar spine surgery and that RA may prove a better alternative than GA for healthy patients undergoing simple lumbar decompression procedures or for patients who are at high risk for general anesthetic complications.
Lee, Peter J
Respiratory rate has been shown to be an important predictor of cardiac arrest, respiratory adverse events and intensive care unit admission and has been designated a vital sign. However it is often inadequately monitored in hospitals. We test the hypothesis that RespiraSense, a piezoelectric-based novel respiratory rate (RR) monitor which measures the differential motion of the chest and abdomen during respiratory effort, is not inferior to commonly used methods of respiratory rate measurement. Respiratory rate was compared between the developed RespiraSense device and both electrocardiogram and direct observation by nursing staff. Data was collected from 48 patients admitted to the post-anaesthesia care unit in a tertiary level hospital. The primary outcome measure was difference in average RR calculated over a 15 min interval between (1) RespiraSense and ECG and (2) RespiraSense and nurses' evaluation. The secondary outcome measure was the correlation between the respiratory rates measured using these three methods. The 95 % confidence interval for the difference in average RR between RespiraSense and ECG was calculated to be [-3.9, 3.1]. The 95 % confidence interval for the difference in average RR between RespiraSense and nurses' evaluation was [-5.5, 4.3]. We demonstrate a clinically relevant agreement between RR monitored by the RespiraSense device with both ECG-derived and manually observed RR in 48 post-surgical patients in a PACU environment.
Ebert, Thomas J; Shankar, Hariharan; Haake, Rachel M
The anesthetic management of the MO patient requires an important focus on a number of issues beginning with a careful preoperative evaluation and synthesizing pre-existing disease processes with the anesthetic management plan. The common misperception that all MO patients are "full stomach" has been challenged and may be a nonissue. New approaches to pre-oxygenation to lessen the likelihood of desaturation during apnea may be a valuable tool if difficulty is encountered in tracheal intubation. In addition, promising results have been demonstrated with the use of the ILMA for ventilation and for blindly establishing tracheal tube placement. Proper patient positioning is essential to aid in successful intubation when a laryngoscope is employed. Intraoperative anesthetic management can be guided with a processed electroencephalogram monitor to help improve emergence and to enhance wakefulness in the PACU. Careful consideration must be given to postoperative analgesic needs by minimizing the use of opioids and employing nonopioid analgesics including NSAIDs, alpha2-adrenergic agonists, and low doses of ketamine.
Laurion, Shari; Fetzer, Susan Jane
Anecdotal reports support research findings in documenting the high incidence of negative postoperative outcomes after gynecologic (GYN) laparoscopic surgery. Three outcome measures, postoperative pain, postoperative nausea and vomiting (PONV), and length of stay, have received considerable attention. Two nursing interventions frequently suggested for their positive effects are guided imagery and music therapy. An experimental pilot study was conducted to determine the effects of these nursing inventions on postoperative pain, PONV, and length of stay for GYN laparoscopic patients (n = 84). During the perioperative period, patients were randomly assigned to one of 3 interventions: guided imagery audiotapes (GI), music audiotapes (MU), or standard care (C), and outcome measures were evaluated. Results indicated that patients in both the guided imagery and music groups had significantly less pain on PACU discharge to home than the patients in the control group. These findings suggest that both guided imagery and music are effective strategies in improving pain, a difference that becomes apparent when the patient is ready to be discharged. It is possible that these interventions act as distractions in reducing the report of negative postoperative outcomes.
Wang, Wuchao; Huang, Panchuan; Gao, Weiwei; Cao, Fangli; Yi, Mingling; Chen, Liyong; Guo, Xiaoli
Emergence agitation preventive medicine should be combined with pediatric anesthesia because of the high frequency of emergence agitation. However, it is challenging to determine the most appropriate medication that can be introduced into pediatric anesthesia for the sake of emergence agitation prevention. We reviewed and retrieved the data from PubMed and Embase. Various medications were assessed based on several endpoints including Emergence agitation outcomes (EA), postoperative nausea and vomiting (PONV), the number of patients who required analgesic (RA), pediatric anesthesia emergence delirium (PAED), the extubation time, the emergency time and the duration of post-anesthesia care unit (PACU) stay. Both traditional and network meta-analysis were carried in this study. A total of 45 articles were complied with the selection criteria and the corresponding articles were reviewed. Fentanyl demonstrated the highest cumulative ranking probability which was followed by those of ketamine and dexmedetomidine with respect to EA and PAED. When PONV and RA were concerned together, clonidine exhibited the highest cumulative ranking probability compared to other medications. Our study suggested that dexmedetomidine perhaps is the most appropriate prophylactic treatment which can be introduced into anesthesia for preventing emergence agitation. PMID:27830713
Moore, Carolyn; Edward, Karen-Leigh; King, Karolin; Giandinoto, Jo-Ann
Despite the substantial risks posed in the surgical environment, compliance in wearing appropriate personal protective equipment (PPE) in the operating room (OR) and the post-anaesthetic care unit (PACU) amongst health care workers is considered poor globally. Lack of awareness and limited access to information about the appropriate precautions to prevent exposure contribute to continued high-risk behaviours amongst the team in the perioperative setting. The aim of this project was to assess current compliance rates of staff in the use of PPE and to develop and implement an educational program to increase staff compliance in the perioperative setting of a large, private hospital (450 beds). A convenience sample of perioperative nurses were invited to complete a questionnaire. Eighty (80) registered nurses RNs) were invited to participate response rate of 69%), giving a sample size of n = 55. Questionnaires not completed in full were not included in the final analysis, leaving n = 31 fully completed questionnaires. There was an education group (n = 14) and a control group (n = 17). Between the groups, educational background, type of work and patient contact were very similar. Of those that did respond regarding exposure, only 20% reported the incident. Both groups identified their manager and team as frequently discussing safer work practices and being supportive. PPE was identified as essential; however, participants reported not enough time to always follow standard precautions (education 15%; control 25%). Team and good leadership was identified as essential to ongoing professional knowledge and support with regard to risk minimisation in the perioperative setting.
Schotola, Hanna; Kirsch, Karl-Christian; Höcker, Jan; Egan, Michael; Büttner, Benedikt; Wiese, Christoph; Mansur, Ashham; Hinz, José Maria
Background Pain after arthroscopic shoulder surgery is often severe, and establishing a pain treatment regimen that does not delay discharge can be challenging. The reported ability of ketamine to prevent opioid-induced hyperalgesia has not been investigated in this particular setting. Methods 300 adult patients scheduled for shoulder arthroscopy under general anesthesia were recruited for this observational clinical trial and were allotted to either receive 1mg/kg IV bolus of ketamine before surgery (ketamine group, KG) or to a control group (CG) without ketamine. NRS pain scores were obtained on the operative day and on postoperative days 1 and 2 and compared between groups. Secondary variables were blood pressure, heart rate, process times, satisfaction with the anesthetic and unwanted effects. Results Pain severity did not differ significantly between the groups at any time. Propofol injection rate and cumulative dose were higher in the KG. Heart rates and blood pressures were similar. Time to emergence and time in PACU were longer and vomiting was more frequent in patients given ketamine. Conclusion Preoperative low-dose ketamine added to a general anesthetic does not reduce perioperative pain after outpatient shoulder arthroscopy. It increases procedural times and the incidence of PONV. PMID:28352709
Rasooli, Sousan; Moslemi, Farnaz; Golzari, Samad E. J.
Background: Pain following laparoscopy could be due to different causes requiring effective postoperative analgesia. Objectives: In the present study, we evaluated the combined effect of intraperitoneal infiltration of bupivacaine-meperidine versus intravenous infusion of paracetamol on pain relief after diagnostic gynecologic laparoscopy. Patients and Methods: In this prospective study, 90 female subjects with ASA class I or II scheduled for gynecologic diagnostic laparoscopy were studied in two groups; group B + M received intraperitoneal infiltration of 40 mL bupivacaine 0.25% with 50 mg of meperidine, group P received normal saline via abdominal trocar and ten minutes before the end of operation, group P received infusion of paracetamol 1000 mg in normal saline. Postoperative pain was evaluated using VAS score in PACU and 1, 2, 4, 8, 12 and 24 hours after the operation. The time to the first analgesic administration and total analgesic requirements were recorded. Results: Group B + M had significantly lower pain score in the first 8 postoperative hours than group P (P < 0.05). Rescue meperidine (IM) requirement was significantly less in B + M group compared to group P. Time to first request for analgesia was different between the two groups (78 versus 60 min); however, the difference was not statistically significant. Conclusions: Intraperitoneal Infiltration of bupivacaine with meperidine following surgery provided more appropriate analgesia after gynecologic diagnostic laparoscopy than administration of IV paracetamol. PMID:26161328
Hudcova, Jana; Scopa, Caitlin; Rashid, Jawad; Waqas, Ahsan; Ruthazer, Robin; Schumann, Roman
Early allograft dysfunction (EAD) following liver transplantation (LT) remains a challenge for patients and clinicians. We retrospectively analyzed the effect of pre-defined EAD on outcomes in a 10-year cohort of deceased-donor LT recipients with clearly defined exclusion criteria. EAD was defined by at least one of the following: AST or ALT >2000 IU/L within first-week post-LT, total bilirubin ≥10 mg/dL, and/or INR ≥1.6 on post-operative day 7. Ten patients developed primary graft failure and were analyzed separately. EAD occurred in 86 (36%) recipients in a final cohort of 239 patients. In univariate and multivariate analyses, EAD was significantly associated with mechanical ventilation ≥2 days or death on days 0, 1, PACU/SICU stay >2 days or death on days 0-2 and renal failure (RF) at time of hospital discharge (all P<.05). EAD was also significantly associated with higher one-year graft loss in both uni- and multivariate Cox hazard analyses (P=.0203 and .0248, respectively). There was no difference in patient mortality between groups in either of the Cox proportional hazard models. In conclusion, we observed significant effects of EAD on short-term post-LT outcomes and lower graft survival.
Langeland, Aubrey L.; Hardin, Rebecca D.; Neitzel, Richard L.
Artisanal and small-scale gold mining (ASGM) has been an important source of income for communities in the Madre de Dios River Basin in Peru for hundreds of years. However, in recent decades, the scale of ASGM activities in the region has increased dramatically, and exposures to a variety of occupational and environmental hazards related to ASGM, including mercury, are becoming more widespread. The aims of our study were to: (1) examine patterns in the total hair mercury level of human participants in several communities in the region and compare these results to the 2.2 µg/g total hair mercury level equivalent to the World Health Organization (WHO) Expert Committee of Food Additives (JECFA)’s Provisional Tolerable Weekly Intake (PTWI); and (2), to measure the mercury levels of paco (Piaractus brachypomus) fish raised in local aquaculture ponds, in order to compare these levels to the EPA Fish Tissue Residue Criterion of 0.3 µg Hg/g fish (wet weight). We collected hair samples from 80 participants in four communities (one control and three where ASGM activities occurred) in the region, and collected 111 samples from fish raised in 24 local aquaculture farms. We then analyzed the samples for total mercury. Total mercury levels in hair were statistically significantly higher in the mining communities than in the control community, and increased with increasing geodesic distance from the Madre de Dios headwaters, did not differ by sex, and frequently exceeded the reference level. Regression analyses indicated that higher hair mercury levels were associated with residence in ASGM communities. The analysis of paco fish samples found no samples that exceeded the EPA tissue residue criterion. Collectively, these results align with other recent studies showing that ASGM activities are associated with elevated human mercury exposure. The fish farmed through the relatively new process of aquaculture in ASGM areas appeared to have little potential to contribute to human
Rivera, S J; Pacheco, L F; Achá, D; Molina, C I; Miranda-Chumacero, G
Mercury contamination in the River Beni basin is an important health risk factor, primarily for indigenous communities that live along the river. Among them are the Tacana, living in their original territory with sustainable use of their natural resources, consuming fish, Caiman yacare, and other riverine resources as their main source of protein. To assess mercury exposure to Tacana people, total mercury (THg) was evaluated in the muscle of seven commercial fish, and Caiman yacare (yacare caiman) during 2007 and 2008. THg was extracted by acid digestion and concentrations were determined by atomic absorption spectrometry. Mean mercury concentrations in C. yacare was 0.21 ± 0.22 μg g(-1)Hg w.w. (wet weight), which is lower than expected given its high trophic level, and its long life-span. It is possible that mercury in C. yacare is accumulated in other organs, not included in this study; but it is also possible that physiological mechanisms are involved that help caimans get rid of ingested mercury, or simply that C. yacare's diverse diet reduces THg accumulation. Carnivorous fishes (Pygocentrus nattereri, Pseudoplatystoma tigrinum, Zungaro zungaro, Plagioscion squamosissimus, and Leiarius marmoratus) had the highest total mercury concentrations, ranging from 0.35 to 1.27 μg g(-1)Hg w.w. moreover, most were above the limit recommended by WHO (0.5 μg g(-1)Hg w.w.); except for Leiarius marmuratus, which presented a mean of 0.353 ± 0.322 μg g(-1)Hg w.w. The two non-carnivorous fish species (Prochilodus nigricans, and Piaractus brachypomus) present mean concentrations of 0.099 ± 0.027, and 0.041 ± 0.019 μg g(-1)Hg w.w., respectively. Finally, recommendations on the consumption habits of Tacana communities are discussed. Copyright © 2016 Elsevier Ltd. All rights reserved.
Langeland, Aubrey L; Hardin, Rebecca D; Neitzel, Richard L
Artisanal and small-scale gold mining (ASGM) has been an important source of income for communities in the Madre de Dios River Basin in Peru for hundreds of years. However, in recent decades, the scale of ASGM activities in the region has increased dramatically, and exposures to a variety of occupational and environmental hazards related to ASGM, including mercury, are becoming more widespread. The aims of our study were to: (1) examine patterns in the total hair mercury level of human participants in several communities in the region and compare these results to the 2.2 µg/g total hair mercury level equivalent to the World Health Organization (WHO) Expert Committee of Food Additives (JECFA)'s Provisional Tolerable Weekly Intake (PTWI); and (2), to measure the mercury levels of paco (Piaractus brachypomus) fish raised in local aquaculture ponds, in order to compare these levels to the EPA Fish Tissue Residue Criterion of 0.3 µg Hg/g fish (wet weight). We collected hair samples from 80 participants in four communities (one control and three where ASGM activities occurred) in the region, and collected 111 samples from fish raised in 24 local aquaculture farms. We then analyzed the samples for total mercury. Total mercury levels in hair were statistically significantly higher in the mining communities than in the control community, and increased with increasing geodesic distance from the Madre de Dios headwaters, did not differ by sex, and frequently exceeded the reference level. Regression analyses indicated that higher hair mercury levels were associated with residence in ASGM communities. The analysis of paco fish samples found no samples that exceeded the EPA tissue residue criterion. Collectively, these results align with other recent studies showing that ASGM activities are associated with elevated human mercury exposure. The fish farmed through the relatively new process of aquaculture in ASGM areas appeared to have little potential to contribute to human
Su, Shiyu; Ren, Chunguang; Zhang, Hongquan; Liu, Zhong; Zhang, Zongwang
Background: Approximately 60% of patients experience moderate-to-severe pain after neurosurgery, which primarily occurs in the first 24–72 h. Despite this, improved postoperative analgesia solutions after neurosurgery have not yet been devised. This retrospective study was conducted to evaluate the effect of intra- and post-operative infusions of dexmedetomidine (DEX) plus sufentanil on the quality of postoperative analgesia in patients undergoing neurosurgery. Methods: One hundred and sixty-three post-neurosurgery patients were divided into two groups: Group D (DEX infusion at 0.5 μg·kg−1 for 10 min, then adjusted to 0.3 μg·kg−1·h−1 until incision suturing) and Group ND (no DEX infusion during surgery). Patient-controlled analgesia was administered for 72 h after surgery (Group D: sufentanil 0.02 μg·kg−1·h−1 plus DEX 0.02 μg·kg−1·h−1, Group ND: sufentanil 0.02 μg·kg−1·h−1) in this retrospective study. The primary outcome measure was postoperative sufentanil consumption. Hemodynamics, requirement of narcotic, and vasoactive drugs, recovery time and the incidence of concerning adverse effects were recorded. Pain intensity [Visual Analogue Scale (VAS)], Ramsay sedation scale (RSS) and Bruggemann comfort scale (BCS) were also evaluated at 1, 4, 8, 12, 24, 48, and 72 h after surgery. Results: Postoperative sufentanil consumption was significantly lower in Group D during the first 72 h after surgery (P < 0.05). Compared with Group ND, heart rate (HR) in Group D was significantly decreased from intubation to 20 min after arriving at post anesthesia care unit (PACU), while mean arterial pressure (MAP) in Group D was significantly decreased from intubation to 5 min after arriving at PACU (P < 0.05). The intraoperative requirements for sevoflurane, remifentanil, and fentanyl were approximately 35% less in Group D compared with Group ND. VAS at rest at 1, 4, and 8 h and with cough at 12, 24, 48, and 72 h after surgery were significantly
Gupta, Anita; Abubaker, Hawa; Demas, Eleni; Ahrendtsen, Leigh
All surgical procedures are associated with a degree of pain. The experience of uncontrolled post-operative pain can have significant implications on health care costs. Recent studies have demonstrated that intravenous (IV) ibuprofen is an effective, safe, well-tolerated analgesic when administered for both abdominal hysterectomy and orthopedic surgery. The use of ibuprofen leads to a reduction in pain severity at rest and with movement and also decreases narcotic consumption. IV acetaminophen has also been shown to be effective in alleviating pain for surgical procedures. Given the established safety and efficacy of IV ibuprofen and IV acetaminophen for perioperative pain, we were interested in determining if any potential synergies are afforded by the simultaneous administration of both medications in orthopedic surgery patients. Compare the safety and efficacy of the perioperative administration of IV ibuprofen alone and in combination with IV acetaminophen in total knee or hip arthroplasty. Randomized, single center, trial. Tertiary care center in Philadelphia, Pennsylvania, United States. Seventy-eight patients undergoing elective knee or hip arthroplasty were randomized into 2 groups. Group 1 received 800 mg of IV ibuprofen at induction, and 800 mg of IV ibuprofen every 6 hours until discharge or for up to 5 days. Group 2 received 800 mg IV ibuprofen at induction and 1000 mg IV acetaminophen at closure, and 800 mg IV ibuprofen plus 1000 mg IV acetaminophen every 6 hours until discharge for up to 5 days. The primary endpoint was demonstrated using the visual analog scale (VAS) pain scores. Secondary endpoints included opioid requirements, quality of recovery scale (QoR), length of post-anesthesia care unit (PACU) stay, antiemetic consumption, opioid consumption, and opioid related adverse events. Patients in Group 2 had lower VAS scores (P < 0.002) by day 3 only. Opioid requirements and adverse events were significantly less in Group 2 which was also
Valero, R; Carrero, E; Fàbregas, N; Iturri, F; Saiz-Sapena, N; Valencia, L
The analysis of surgical processes should be a standard of health systems. We describe the circuit of care and postoperative treatment for neurosurgical interventions in the centres of our country. From June to October 2014, a survey dealing with perioperative treatments and postoperative circuits after neurosurgical procedures was sent to the chiefs of Anaesthesiology of 73 Spanish hospitals with neurosurgery and members of the Neuroscience Section of SEDAR. We obtained 45 responses from 30 centres (41.09%). Sixty percent of anaesthesiologists perform preventive locoregional analgesic treatment. Pain intensity is systematically assessed by 78%. Paracetamol, non-steroidal anti-inflammatory and morphine combinations are the most commonly used. A percentage of 51.1 are aware of the incidence of postoperative nausea after craniotomy and 86.7% consider multimodal prophylaxis to be necessary. Dexamethasone is given as antiemetic (88.9%) and/or anti-oedema treatment (68.9%). A percentage of 44.4 of anaesthesiologists routinely administer anticonvulsive prophylaxis in patients with supratentorial tumours (levetiracetam, 88.9%), and 73.3% of anaesthesiologists have postoperative surveillance protocols. The anaesthesiologist (73.3%) decides the patient's destination, which is usually ICU (83.3%) or PACU (50%). Postoperative neurological monitoring varied according to the type of intervention, although strength and sensitivity were explored in between 70-80%. There is great variability in the responses, probably attributable to the absence of guidelines, different structures and hospital equipment, type of surgery and qualified personnel. We need consensual protocols to standardize the treatment and the degree of monitoring needed during the postoperative period. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.
Sinha, Aparna; Sharma, Bimla; Sood, Jayashree
ProSeal LMA (PLMA), one of the advanced supraglottic devices has been successfully used to provide both spontaneous and controlled ventilation in children with upper respiratory tract infection (URTI). URTI does not imply restriction of disease to upper respiratory tract; it has been shown to produce pulmonary dysfunction. PEEP has been shown to improve oxygenation in such cases. This randomized prospective study was designed to compare postoperative adverse events associated with spontaneous respiration (SR) and pressure control ventilation (PCV) with PEEP in infants and toddlers with URTI when using PLMA as an airway device. In the present study, 90 children, 6 months-2 years, scheduled for infra umbilical surgery were randomized to receive either SR or PCV with PEEP of 5cm H2O. Patients with risk of aspiration, bronchial asthma, anticipated difficult airway, snoring, passive smoking, morbid obesity, coexisting pulmonary and cardiac disease, lower respiratory tract infection, fever > 38 degrees C and sneezing, were excluded. At emergence, airway secretions, coughing, breath holding, bronchospasm, upper airway obstruction or laryngospasm (LS) were assessed. The adverse events were significantly higher in spontaneously breathing patients. Score of adverse events was 6.33 +/- 1.6 in PCV and 7.7 +/- 2.2 in SR group (P = 0.001). The mean SpO2 (%) in PACU was 96.5 +/- 2 in PCV and 94.4 +/- 1.37 in SR (P = 000). Pressure control ventilation with PEEP using PLMA is associated with lower incidence of adverse events in comparison to spontaneous respiration in infants and toddlers with upper respiratory tract infection undergoing infra umbilical surgeries under general anesthesia.
Borges, Joana; Moreira, Joana; Moreira, Adriano; Santos, Alice; Abelha, Fernando J
Regardless the progress in perioperative care postoperative cognitive decline (PCD) has been accepted unequivocally as a significant and frequent complication of surgery in older patients. The aim of this study was to evaluate the incidence of postoperative cognitive decline and its influence on quality of life three months after surgery. Observational, prospective study in a Post-Anesthesia Care Unit (PACU) in patients aged above 45 years, after elective major surgery. Cognitive function was assessed with Montreal Cognitive Assessment (MOCA); Quality of life (QoL) was assessed using SF-36 Health Survey (SF-36). Assessments were performed preoperatively (T0) and 3 months after surgery (T3). Forty-one patients were studied. The incidence of PCD 3 months after surgery was 24%. At T3 MOCA scores were lower in patients with PCD (median 20 vs. 25, p=0.009). When comparing the median scores for each of SF-36 domains, there were no differences between patients with and without PCD. In patients with PCD, and comparing each of SF-36 domains obtained before and three months after surgery, had similar scores for every of the 8 SF-36 areas while patients without PCD had better scores for six domains. At T3 patients with PCD presented with higher levels of dependency in personal activities of daily living (ADL). Three months after surgery patients without PCD had significant improvement in MOCA scores. Patients with PCD obtained no increase in SF-36 scores but patients without PCD improved in almost all SF-36 domains. Patients with PCD presented higher rates of dependency in personal ADL after surgery. Copyright © 2017. Publicado por Elsevier Editora Ltda.
Sungurtekin, Hulya; Sungurtekin, Ugur; Erdem, Ergun
To evaluate two anesthetic techniques, namely, local anesthesia with sedation, and spinal anesthesia, with respect to recovery times, postoperative side effects, pain scores, patient satisfaction, and hospital costs for ambulatory pilonidal disease surgery. Prospective, randomized study. University Hospital of Pamukkale. 60 consenting patients scheduled for pilonidal disease operation with Limberg flap technique. Patients were randomly allocated into two groups: Group 1 (n = 30) received spinal anesthesia with hyperbaric bupivacaine 1.5 mL 0.5%, and Group 2 (n = 30) received local infiltration with a 50-mL mixture containing 10 mL bupivacaine 0.5%, 10 mL prilocaine HCl 2%, and 30 mL isotonic solution with 1:200,000 epinephrine in combination with intravenous (i.v.) midazolam sedation. Perioperative and postoperative side effects, patient satisfaction, preoperative visual analog scale (VAS) pain scores, and VAS scores from the fourth hour postoperatively until the seventh day were assessed. Anesthesia, operation, surgery, and total hospital time, and costs (drug, resources, and labor) were recorded. No difference was found between groups in the frequency of side effects. Urinary retention was diagnosed in two patients in the spinal anesthesia group. There was no statistical significant difference seen in satisfaction scores between groups. No statistical significance in VAS pain scores between groups was noted except for the fourth postoperative hour values. The average time spent in the operating room (OR) was greater in the spinal anesthesia group. All Group 2 patients achieved fast-tracking criteria in the OR and were able to bypass the postanesthesia care unit (PACU). Total hospital time and total cost were significantly higher in the spinal anesthesia group than local anesthesia-sedation group (p < 0.05). The use of local anesthesia-sedation for ambulatory anorectal surgery resulted in a shorter hospital time, lower hospital costs, and no side effects compared
Becke, Karin; Albrecht, Sven; Schmitz, Bernd; Rech, Dorit; Koppert, Wolfgang; Schüttler, Jürgen; Hering, Werner
Clinical studies suggest low-dose ketamine may have preemptive effects on postoperative pain in adults. The objective of this study was to determine whether intraoperative low-dose S-ketamine reduces postoperative pain and morphine consumption in children undergoing major urological surgery. Thirty children scheduled for major urological surgery were included in this prospective study. Anesthesia was performed as total intravenous anesthesia (TIVA) with alfentanil and propofol. Fifteen patients additionally received an intravenous bolus of S-ketamine (0.2 mg.kg-1) followed by a continuous infusion of 5 microg.kg-1.min-1, which was stopped immediately after skin closure (Ketamine Group). Another 15 patients received an infusion of saline (CONTROL group). After transfer to the PACU, pain intensity was evaluated using a numeric rating scale (NRS). First patient controlled analgesia (PCA) request, cumulative morphine consumption and pain intensities within the first 72 h were compared. Morphine consumption was not significantly different during the first 72 h ( 0.4 mg.kg-1, 0.24-0.51 mg.kg-1, Ketamine: 0.32 mg.kg-1, 0.19-0.61 mg.kg-1; median, 25-75% percentile; n.s.). However, differences were found in pain intensity during the first postoperative hour ( 4.0, 3.2-4.6, Ketamine: 2.5, 1.3-3.5; median, 25-75% percentile; P<0.05) and in the time to first PCA use ( 37, 28-46 min, Ketamine: 62, 38-68 min; median, 25-75% percentile; P<0.05). Intraoperative low-dose S-ketamine had no effect on morphine consumption during the first 72 h after surgery. The differences in pain intensity and time to first PCA use probably reflect additional sedation and antinociceptive effects of S-ketamine rather than a true 'prevention' of pain.
Oh, Eunjung; Ahn, Hyun Joo; Sim, Woo Seog; Lee, Jin Young
An intravenous form of ibuprofen has recently been approved by the Food and Drug Administration (FDA) and reports are rare on its co-administration with opioids. We researched whether an intravenous ibuprofen-hydromorphone combination is synergistic, additive, or infra-additive on postoperative pain. A parallel-group, 1:1:1 allocation, randomized, double-blind controlled trial. University teaching hospital in Korea. Ninety patients, undergoing breast surgery, were divided into one of the 3 groups (I, H, IH groups). Positive analgesic efficacy was defined as a numeric rating scale (NRS)= 3 on a 0 - 10 NRS, 30 minutes after the drug administration. Drugs were administered by the Dixon's up-and-down method. Starting doses were ibuprofen (I) 50 mg, hydromorphone (H) 0.25 mg, or ibuprofen 25 mg + hydromorphone 0.125 mg (IH). The maximum doses were ibuprofen 800 mg, hydromorphone 2 mg, or ibuprofen 400 mg + hydromorphone 1 mg. Combination index (CI) (additive: 0.9 - 1.1, synergism: < 0.9, antagonism: > 1.1), dose reduction index (DRI, a measure of how much the dose of each drug in a combination can be reduced), and isobologram were used to define the nature of their interaction. One way ANOVA, Kruskal Wallis test, and Chi square test, significance level P < 0.05. The median effective doses (ED50) of ibuprofen and hydromorphone were 1,447 mg and 1.5 mg, respectively. The median ED50 of the combination was ibuprofen 71 mg and hydromorphone 0.3 mg. Ibuprofen and hydromorphone showed a strong synergy (CI 0.2, DRI 20 and 5 for ibuprofen and hydromorphone at ED50). Analgesic efficacy was observed during post-anesthesia care unit (PACU) period only. The combination of intravenous ibuprofen and hydromorphone produces a strong synergistic analgesia on postoperative pain.
[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)].
Eberhart, L H J; Bernert, S; Wulf, H; Geldner, G
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. 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. 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. Total intravenous anaesthesia with propofol is more cost-efficient than balanced anaesthesia with desflurane and additional tropisetron as a prophylactic antiemetic.
Aveline, C; Le Roux, A; Le Hetet, H; Vautier, P; Cognet, F; Bonnet, F
Nasogastric tube placement (NTP) is no more systematically recommended in patients scheduled for elective colorectal surgery but could be necessary in case of postoperative vomiting. The aim of this study was to determine independent risk factors for NTP after colorectal surgery. We performed an observational study including 290 patients scheduled for elective colorectal surgery included in an enhanced recovery programme: immunonutrition, thoracic epidural analgesia, antiemetic prophylaxis, respiratory physiotherapy, absence of NT and drainage, forced mobilization and oral nutrition. The main outcome was the occurrence of vomiting requiring NTP. Univariate analysis included: age, sex, BMI, American Society of Anesthesiologist Physical Status Classification System (ASA), duration of surgery, epidural analgesia, and mobilization, intraoperative fluid, temperature, laparotomy, use of droperidol, parenteral nutrition, stoma, diabetes, hypertension or coronary disease, COPD, type of surgery. A logistic regression was performed to determine independent risk factors of NTP. Among the 290 patients included, 277 were analyzed. The incidence of NTP was 10.5% (95%CI [7.4-14.6%]). Univariate analysis documented BMI, low temperature in PACU (<35°C), ASA scores, duration of surgery and epidural analgesia, rectal and sigmoid resections, diabetes, transfusion, no use of droperidol, duration of mobilization, conversion to laparotomy. Three independent risk factors were associated with NTP: temperature in SSPI<35.5°C (OR: 14.49; IC95% [4.52-45.45], P<0.0001), BMI<21kg/m(2) (8.40; [1.99-35.71], P=0.0038) and lack of postoperative droperidol administration (3.37 [1.02-11.39], P=0.04). After colorectal surgery tolerance to rapid oral feeding is impaired by denutrition and postoperative hypothermia. The combined used of postoperative droperidol should also be considered to avoid postoperative NTP. Copyright © 2012. Published by Elsevier SAS.
Navarro, Laís Helena Camacho; Lima, Rodrigo Moreira e; Aguiar, Andressa Simões; Braz, José Reinaldo Cerqueira; Carness, Jeffrey M; Módolo, Norma Sueli Pinheiro
We evaluated whether endotracheal tube (ETT) intracuff alkalinized lidocaine was superior to saline in blunting emergence coughing, postoperative sore throat, and hoarseness in smokers. In our prospective, double-blind trial, we enrolled 50 smoking patients undergoing surgery under general anesthesia including nitrous oxide (N2O). Patients were randomly allocated to receive either ETT intracuff 2% lidocaine plus 8.4% sodium bicarbonate (L group), or ETT intracuff 0.9% saline (S group). The ETT cuff was inflated to achieve a cuff pressure that prevented air leak during positive pressure ventilation. Incidence of emergence coughing, sore throat, and hoarseness were analyzed. The volume of inflation solution, the intracuff pressure, the duration of anesthesia, the time elapsed to extubation after discontinuation of anesthesia, and the volume of the inflation solution and the air withdrawn from the ETT cuff were also recorded. Intracuff alkalinized 2% lidocaine was superior to saline in blunting emergence coughing (p < 0.001). The incidence of sore throat was significantly lower in the L group at the post-anesthesia care unit (PACU) (p = 0.02). However, at 24 hours after extubation, sore throat incidence was similar in both groups (p = 0.07). Incidence of hoarseness was similar in both groups. Intracuff pressure in the saline group increased with time while the intracuff pressure in the lidocaine group remained constant. The present study demonstrated that the intracuff alkalinized 2% lidocaine was superior to saline in decreasing the incidence of emergence coughing and sore throat during the postoperative period in smokers.
Lai, Hou-Chuan; Chan, Shun-Ming; Lu, Chueng-He; Wong, Chih-Shung; Cherng, Chen-Hwan; Wu, Zhi-Fu
Abstract Reducing anesthesia-controlled time (ACT) may improve operation room (OR) efficiency result from different anesthetic techniques. However, the information about the difference in ACT between desflurane (DES) anesthesia and propofol-based total intravenous anesthesia (TIVA) techniques for open major upper abdominal surgery under general anesthesia (GA) is not available in the literature. This retrospective study uses our hospital database to analyze the ACT of open major upper abdominal surgery without liver resection after either desflurane/fentanyl-based anesthesia or TIVA via target-controlled infusion with fentanyl/propofol from January 2010 to December 2011. The various time intervals including waiting for anesthesia time, anesthesia time, surgical time, extubation time, exit from OR after extubation, total OR time, and postanesthetic care unit (PACU) stay time and percentage of prolonged extubation (≥15 minutes) were compared between these 2 anesthetic techniques. We included data from 343 patients, with 159 patients receiving TIVA and 184 patients receiving DES. The only significant difference is extubation time, TIVA was faster than the DES group (8.5 ± 3.8 vs 9.4 ± 3.7 minutes; P = 0.04). The factors contributed to prolonged extubation were age, gender, body mass index, DES anesthesia, and anesthesia time. In our hospital, propofol-based TIVA by target-controlled infusion provides faster emergence compared with DES anesthesia; however, it did not improve OR efficiency in open major abdominal surgery. Older, male gender, higher body mass index, DES anesthesia, and lengthy anesthesia time were factors that contribute to extubation time. PMID:28207547
Motamed, Cyrus; Bourgain, Jean Louis
Anaesthesia Information Management Systems (AIMS) generate large amounts of data, which might be useful for quality assurance programs. This study was designed to highlight the multiple contributions of our AIMS system in extracting quality indicators over a period of 10years. The study was conducted from 2002 to 2011. Two methods were used to extract anaesthesia indicators: the manual extraction of individual files for monitoring neuromuscular relaxation and structured query language (SQL) extraction for other indicators which were postoperative nausea and vomiting (PONV), pain, sedation scores, pain-related medications, scores and postoperative hypothermia. For each indicator, a program of information/meetings and adaptation/suggestions for operating room and PACU personnel was initiated to improve quality assurance, while data were extracted each year. The study included 77,573 patients. The mean overall completeness of data for the initial years ranged from 55 to 85% and was indicator-dependent, which then improved to 95% completeness for the last 5years. The incidence of neuromuscular monitoring was initially 67% and then increased to 95% (P<0.05). The rate of pharmacological reversal remained around 53% throughout the study. Regarding SQL data, an improvement of severe postoperative pain and PONV scores was observed throughout the study, while mild postoperative hypothermia remained a challenge, despite efforts for improvement. The AIMS system permitted the follow-up of certain indicators through manual sampling and many more via SQL extraction in a sustained and non-time-consuming way across years. However, it requires competent and especially dedicated resources to handle the database. Copyright © 2016 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
Moro, Eduardo Toshiyuki; Silva, Manoel Arthur Nóbrega da; Couri, Marcelo Gouvêa; Issa, Danielle da Silva; Barbieri, Julia Morais
For patients undergoing regional anesthesia for orthopedic surgery, a common situation in our work environment, the quality of recovery may be influenced in different ways, which justifies studies to identify possible predictive factors of dissatisfaction. The aim of this study was to assess the opinion of patients on recovery from anesthesia for lower limb orthopedic surgeries. We also identified potential predictive factors for poor quality of recovery. We evaluated patients undergoing lower limb orthopedic surgeries and able to participate in the study. Data related to surgery, anesthesia, possible complications in the post-anesthetic care unit (PACU) and in the ward were recorded. In the morning after surgery, patients were evaluated by a medical student who applied the QoR-40 questionnaire. The resulted score-between 40 and 200-was used to determine the quality of recovery and identify the potential predictors. We evaluated 172 patients. The questionnaire average score was 192 points. The chance to have lower scores in the QoR-40 was two times higher among males. Patients who remained under sedation, classified as greater than or equal to 4 on the scale proposed by Ramsay, had a 3.5 times higher risk of having lower scores in the QoR-40 compared to those who remained with level 1 or 2 of sedation. Regarding pain, at every increase of one unit in the numerical scale (0-10), there was a 19% increase in risk for QoR-40 ≤ 195. Similarly, the risk for a score below the median was 2.3 times higher among those presenting with nausea and/or vomiting in the ward. Male, nausea, vomiting, pain while in the ward, and deeper levels of sedation are possible predictive factors for lower scores according to the adopted instrument. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Moro, Eduardo Toshiyuki; Silva, Manoel Arthur Nóbrega da; Couri, Marcelo Gouvêa; Issa, Danielle da Silva; Barbieri, Julia Morais
For patients undergoing regional anesthesia for orthopedic surgery, a common situation in our work environment, the quality of recovery may be influenced in different ways, which justifies studies to identify possible predictive factors of dissatisfaction. The aim of this study was to assess the opinion of patients on recovery from anesthesia for lower limb orthopedic surgeries. We also identified potential predictive factors for poor quality of recovery. We evaluated patients undergoing lower limb orthopedic surgeries and able to participate in the study. Data related to surgery, anesthesia, possible complications in the post-anesthetic care unit (PACU) and in the ward were recorded. In the morning after surgery, patients were evaluated by a medical student who applied the QoR-40 questionnaire. The resulted score-between 40 and 200-was used to determine the quality of recovery and identify the potential predictors. We evaluated 172 patients. The questionnaire average score was 192 points. The chance to have lower scores in the QoR-40 was two times higher among males. Patients who remained under sedation, classified as greater than or equal to 4 on the scale proposed by Ramsay, had a 3.5 times higher risk of having lower scores in the QoR-40 compared to those who remained with level 1 or 2 of sedation. Regarding pain, at every increase of one unit in the numerical scale (0-10), there was a 19% increase in risk for QoR-40≤195. Similarly, the risk for a score below the median was 2.3 times higher among those presenting with nausea and/or vomiting in the ward. Male, nausea, vomiting, pain while in the ward, and deeper levels of sedation are possible predictive factors for lower scores according to the adopted instrument. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Lee, Yoon Sook; Kim, Woon Young; Choi, Jae Ho; Son, Joo Hyung; Kim, Jae Hwan; Park, Young Cheol
The rapid emergence and recovery from general anesthesia afforded by sevoflurane is associated with a high incidence of emergence agitation in children. Small doses of ketamine reduce the incidence of emergence agitation. This study compared the effects of ketamine 0.25 mg/kg and 0.5 mg/kg on emergence agitation and postoperative pain. The effects of added intravenous ketamine were evaluated in 93 children, ASA I-II, 2-14 years old, undergoing an adenotonsillectomy. The patients were allocated randomly to one of three groups receiving saline (group C), ketamine 0.25 mg/kg (group K0.25) or ketamine 0.5 mg/kg (group K0.5). The children in each group were administered the study drugs 10 minutes before the end of surgery. The recovery characteristics, including the time to extubation, delivery time from the PACU, postoperative nausea and vomiting, agitation and pain were assessed. There were no significant differences in the extubation time, delivery time and postoperative nausea and vomiting between the three groups. There were significant differences in modified CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) between the three groups. The incidence of emergence agitation was low in the K0.25 and K0.5 groups compared to the control group. However, there was no significant difference between the K0.25 and K0.5 groups. There was no significant difference in the incidence of emergence agitation between K0.25 and K0.5 groups. However, K0.5 group showed a lower pain score than K0.25 group.
Keller, Deborah S; Smalarz, Amy; Haas, Eric M
Financial pressures have limited the ability of providers to use medication that may improve clinical outcomes and patient satisfaction. New interventions are often fraught with resistance from individual cost centers. A value realization tool (VRT) is essential for separate cost centers to communicate and comprehend the overall financial and clinical implications of post-surgical pain management medication interventions (PSMI). The goal was to describe development of a VRT. An evaluation of common in-patient PSMI approaches, impacts, and costs was performed. A multidisciplinary task force guided development of the VRT to ensure appropriate representation and relevance to clinical practice. The main outcome was an Excel-based tool that communicates the overall cost/benefit of PSMI for the post-operative patient encounter. The VRT aggregated input data on costs, clinical impact, and nursing burden of PSMI assessment and monitoring into two high-level outcome reports: Overall Cost Impact and Nurse & Patient Impact. Costs included PSMI specific medication, equipment, professional placement, labor, overall/opioid-related adverse events, re-admissions, and length of stay. Nursing impact included level of practice interference, job satisfaction, and patient care metrics. Patient impact included pain scores, opioid use, PACU time, and satisfaction. Reference data was provided for individual institutions that may not collect all variables included in the VRT. The VRT is a valuable way for administrators to assess PSMI cost/benefits and for individual cost centers to see the overall value of individual interventions. The user-friendly, decision-support tool allows the end-user to use built-in referenced or personalized outcome data, increasing relevance to their institutions. This broad picture could facilitate communication across cost centers and evidence-based decisions for appropriate use and impacts of PSMI.
Duval, Melanie; Wilkes, Jacob; Korgenski, Kent; Srivastava, Rajendu; Meier, Jeremy
To review the causes, costs, and risk factors for unplanned return visits and readmissions after pediatric adenotonsillectomy (T&A). Review of administrative database of outpatient adenotonsillectomy performed at any facility within a vertically integrated health care system in the Intermountain West on children age 1-18 years old between 1998 and 2012. Data reviewed included demographic variables, diagnosis associated with return visit and costs associated with return visits. Data from 39,906 children aged 1-18 years old were reviewed. A total of 2499 (6.3%) children had unplanned return visits. The most common reasons for return visits were bleeding (2.3%), dehydration, (2.3%) and throat pain (1.2%). After multivariate analysis, the main risk factors for any type of return visits were Medicaid insurance (OR=1.64 95% CI 1.47-1.84), Hispanic race (OR=1.36 95% CI 1.13-1.64), and increased severity of illness (SOI) (OR=11.29 95% CI 2.69-47.4 for SOI=3). The only factor associated with increased odds of requiring an inpatient admission on return visit was length of time spent in PACU (p<0.001). A linear relationship was also observed between the child's age and the risk of post-tonsillectomy hemorrhage. Children with increased severity of illness, those insured with Medicaid, and children of Hispanic ethnicity should be targeted with increased education and interventions in order to reduce unplanned visits after T&A. Further studies on post-tonsillectomy complications should include evaluating the effect of surgical technique and post-operative pain management on all complications and not solely post-tonsillectomy hemorrhage. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Stierer, Tracey L.; Wright, Christopher; George, Anu; Thompson, Richard E.; Wu, Christopher L.; Collop, Nancy
Study Objectives: The aims of this study were to: (a) assess the prevalence of diagnosed OSA and symptoms of undiagnosed OSA in a cohort of ambulatory surgical patients, and (b) characterize the frequency of postoperative complications in outpatients with a diagnosis of or a propensity to OSA. Methods: Patients presenting for ambulatory surgery completed a self-administered questionnaire. Using a previously validated prediction model, the probability for OSA was determined. Patients with ≥ 70% propensities were considered to be at high risk of having the disorder. Relevant perioperative data and complications were tracked and recorded, and differences in median estimated propensities for OSA were considered by these data. Results: Three-thousand five hundred fifty-three patients completed the preoperative survey. A total of 2139 patients had perioperative data and estimated propensity scores. Ninety-four of the 2139 (4.4%) patients gave a self-reported prior diagnosis of OSA. One hundred three (4.8%) patients were found to be at high risk of OSA based on the survey and prediction model. Seventy-five percent of the patients with > 70% propensity for OSA had not yet been diagnosed. There was no association between OSA propensity scores and unplanned hospital admission, however there was an association of increased propensity with difficult intubation, intraoperative use of pressors, and postoperative oxygen saturation in the PACU. Conclusion: The results of this study suggest that undiagnosed OSA may be relatively common in an ambulatory surgical population. There was no relationship between unplanned hospital admission and diagnosis of or increased risk of OSA. However, there was an association of increased perioperative events requiring additional anesthetic management in patients with a diagnosis of, or with a higher propensity to OSA. Citation: Stierer TL; Wright C; George A; Thompson RE; Wu CL; Collop N. Risk assessment of obstructive sleep apnea in a
Pawlowski, Julius; Orr, Kevin; Kim, Ku-Mie; Pappas, Ana Lucia; Sukhani, Radha; Jellish, W Scott
To compare isobaric lidocaine and mepivacaine in outpatient arthroscopic surgery. Prospective, randomized, double-blinded study. Ambulatory surgery center affiliated with an academic tertiary-care hospital. 84 adult, ASA physical status 1, 2, and 3 ambulatory patients, age 18-70 years, undergoing arthroscopic knee surgery. Patients were randomized to receive a combination spinal-epidural anesthetic using 80 mg of either isobaric 2% mepivacaine or isobaric 2% lidocaine. Patients also received a femoral 3-in-1 block with 0.5% bupivacaine applied to the affected extremity. Demographic data and level and duration of the block were recorded. The use of supplemental epidural anesthesia was noted along with frequency of bradycardia, hypotension, and episodes of nausea and vomiting. Duration of block and times to ambulation and voiding were recorded. Delayed variables, including fatigue, difficulty urinating, back pain, and transient neurologic symptoms (TNS) were obtained. No demographic differences were noted between groups, and surgical duration was similar. Satisfactory anesthesia was achieved in all cases, with no differences noted in hypotension, bradycardia, nausea, or vomiting. Onset of sensory and motor block was similar. Duration of block before epidural supplementation was 94 ± 21 minutes with lidocaine versus 122 ± 23 minutes for mepivacaine (P < 0.011). Times to ambulation and voiding were longer in patients receiving mepivacaine but did not affect PACU stay. Twenty-four and 48-hour recovery was similar with no TNS symptoms reported. No major differences were noted between lidocaine and mepivacaine spinal anesthesia. Time to ambulation and voiding were longer in patients who received mepivacaine as was time to first dose of epidural catheter. Neither group had TNS symptoms. Lidocaine and mepivacaine are both appropriate spinal anesthetics for ambulatory orthopedic lower extremity procedures. Copyright Â© 2012 Elsevier Inc. All rights reserved.
Tarola, Christopher L; Al-Amodi, Hussein A; Balasubramanian, Sankar; Fox, Stephanie A; Harle, Christopher C; Iglesias, Ivan; Sridhar, Kumar; Teefy, Patrick J; Chu, Michael W A; Kiaii, Bob B
Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward. In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics. Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days. In patients undergoing robotic-assisted CABG, ultrafast-track cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery
Olesnicky, Benjamin L; Traill, Catherine; Marroquin-Harris, Frank B
Postoperative residual curarisationf is a preventable cause of postoperative morbidity. Although sugammadex has been shown to reduce the risk of residual curarisation, it has not yet been shown if this directly translates to a reduction in morbidity. We aimed to demonstrate whether the introduction of unrestricted sugammadex for routine reversal changed the incidence of post-operative respiratory diagnoses and the rate of airway and respiratory complications in the post-operative care unit. A historical cohort study of 1257 patients who underwent general surgical or ear, nose and throat (ENT) procedures before and after the introduction of unrestricted availability of sugammadex. Patient records were used to identify the incidence of postoperative in-hospital respiratory diagnoses and of airway complications in PACU, the pattern of muscle relaxant use and the relative costs associated with the routine availability of sugammadex. Unrestricted sugammadex availability was associated with a significant reduction in the rate of a postoperative in-hospital respiratory diagnosis; Odds Ratio (OR) = 0.20 (95%CI 0.05-0.72, p=0.01). Furthermore, the use of sugammadex itself was also associated with a reduction in inhospital respiratory diagnoses; OR = 0.26 (95%CI 0.08-0.94, p=0.04). Unrestricted sugammadex was also associated with a decrease in the need for manual airway support in the recovery room (3.2% vs 1.1%, p=0.02) and a decrease in patients being transferred intubated to ICU (5.5% vs 1.3%, p<0.001). Unrestricted sugammadex availability is associated with a reduction in post-operative respiratory complications. A well-designed, prospective randomised trial is needed to provide further validation of the data.
Reza, Nikandish; Ali, Sahmedini Mohammad; Saeed, Khademi; Abul-Qasim, Avand; Reza, Tabatabaee Hamid
The relief of post-cesarean delivery pain is important. Good pain relief improves mobility and reduces the risk of thromboembolic disease, which may have been increased during pregnancy. Pain may impair the mother's ability to optimally care for her infant in the immediate postpartum period and may adversely affect early interactions between mother and infant. It is necessary, therefore that pain relief be safe and effective and results in no adverse neonatal effects during breast-feeding. Music may be considered as a potential method of post cesarean pain therapy due to its noninvasiveness and lack of side effects. In this study we evaluated the effect of intraoperative music under general anesthesia for reducing the postoperative morphine requirements after cesarean section. In a double blind placebo-controlled trial, 100 women (ASA I) scheduled for elective cesarean section under general anesthesia, were randomly allocated into two groups of fifty. After standardization of anesthesia, patients in the music group were exposed to a compact disk of Spanish guitar after induction of anesthesia up to the time of wound dressing. In the control group patients were exposed to white music. Post operative pain and anxiety were evaluated by visual analog scale (VAS) up to six hours after discharge from PACU. Morphine was given intravenously for reducing pain to VAS < or = 3 postoperatively. There was not statistically significant difference in VAS for pain between two groups up to six hours postoperatively (P>0.05). In addition, morphine requirements were not different between two groups at different time intervals up to six hours postoperatively (P>0.05). There were not statistically significant difference between two groups regarding postoperative anxiety score and vomiting frequency (P>0.05). As per conditions of this study, intraoperative Spanish music was not effective in reducing postoperative pain after cesarean section. In addition postoperative morphine
Álvarez, Nora Elizabeth Rojas; Ledesma, Rosemberg Jairo Gomez; Hamaji, Adilson; Hamaji, Marcelo Waldir Mian; Vieira, Joaquim Edson
Knee arthroplasty leads to postoperative pain. This study compares analgesia and postoperative bleeding achieved by intrathecal morphine with a continuous femoral plus single-shot sciatic nerve block. A randomized non-blinded clinical trial enrolled patients aged over 18 years old, ASA I to III who underwent total knee arthroplasty. All patients underwent spinal anesthesia with isobaric bupivacaine, 20 mg. One group received 100 mcg of intrathecal morphine (M group), and the other received a femoral nerve block by continuous infusion plus a "single shot" block of the sciatic nerve at the end of the surgery (FI group). Pain score from verbal numeric rating scale (VNRS) and morphine consumption during the first 72 h, as well as motor blockade, adverse effects, and postoperative bleeding were recorded. Analysis of variance of repeated measures with Bonferroni post-test, t-test and Fisher exact test were used for statistical analysis. Thirty nine patients completed the study (M = 20; FI = 19 patients) and were similar except for higher age in the FI group. Motor blockade as well as movement pain during postanesthesia care unit (PACU) staying were not different between the groups, but movement pain was significantly lower in FI group after 24 h. Postoperative bleeding (ml) was lower in FI group. Continuous femoral nerve block combined with sciatic nerve block provides effective for postoperative analgesia in patients undergoing total knee arthroplasty, with lower pain scores after 24 h and a lower incidence of adverse effects and bleeding compared to intrathecal morphine. Retrospectively registered on https://clinicaltrials.gov/ under identifier NCT02882152 , 23(rd) December, 2016.
Cottet, P; d'Hollander, A; Cahana, A; Van Gessel, E; Tassaux, D
In the healthcare domain, different analytic tools focused on accidents appeared to be poorly adapted to sub-accidental issues. Improving local management and intra-institutional communication with simpler methods, allowing rapid and uncomplicated meta-reporting, could be an attractive alternative. A process-centered structure derived from the industrial domain - DEPOSE(E) - was selected and modified for its use in the healthcare domain. The seven exclusive meta-categories defined - Patient, Equipment, Process, Actor, Supplies, work Room and Organization- constitute 7CARECAT™. A collection of 536 "improvement" reports from a tertiary hospital Post anesthesia care unit (PACU) was used and four meta-categorization rules edited prior to the analysis. Both the relevance of the metacategories and of the rules were tested to build a meta-reporting methodology. The distribution of these categories was analyzed with a χ 2 test. Five hundred and ninety independent facts were collected out of the 536 reports. The frequencies of the categories are: Organization 44%, Actor 37%, Patient 11%, Process 3%, work Room 3%, Equipment 1% and Supplies 1%, with a p-value <0.005 (χ 2). During the analysis, three more rules were edited. The reproducibility, tested randomly on 200 reports, showed a <2% error rate. This meta-reporting methodology, developed with the 7CARECAT™ structure and using a reduced number of operational rules, has successfully produced a stable and consistent classification of sub-accidental events voluntarily reported. This model represents a relevant tool to exchange meta-informations important for local and transversal communication in healthcare institutions. It could be used as a promising tool to improve quality and risk management. Copyright © 2013. Published by Elsevier SAS.
Koch, Cody A.; Greenlee, Susan M.; Larson, Dirk R.; Harrington, Jeffrey R.
Background: Fixation of the mesh during laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is thought to be necessary to prevent recurrence. However, mesh fixation may increase postoperative pain and lead to an increased risk of complications. We questioned whether elimination of fixation of the mesh during TEP inguinal hernia repair leads to decreased postoperative pain or complications, or both, without an increased rate of recurrence. Methods: A randomized prospective single-blinded study was carried out in 40 patients who underwent laparoscopic TEP inguinal hernia repair with (Group A=20) or without (Group B=20) fixation of the mesh. Results: Patients in whom the mesh was not fixed had shorter hospital length of stay (8.3 vs 16.0 hours, P=0.01), were less likely to be admitted to the hospital (P=0.001), used less postoperative narcotic analgesia in the PACU (P=0.01), and were less likely to develop urinary retention (P=0.04). No significant differences occurred in the level of pain, time to return to normal activity, or the difficulty of the operation between the 2 groups. No hernia recurrences were observed in either group (follow-up range, 6 to 30 months, median=19). Conclusions: Elimination of tack fixation of mesh during laparoscopic TEP inguinal hernia repair significantly reduces the use of postoperative narcotic analgesia, hospital length of stay, and the development of postoperative urinary retention but does not lead to a significant reduction in postoperative pain. Eliminating tacks does not lead to an increased rate of recurrence. PMID:17575757
Hache, John J; Vallejo, Manuel C; Waters, Jonathan H; Williams, Brian A
Postoperative and postdischarge nausea and vomiting (PONV and PDNV, respectively) add morbidity to perioperative outcomes. Combining some antiemetic agents of different mechanisms is more effective than using single agents, although this concept has not yet been tested extensively with aprepitant. Consecutive high-risk patients for PONV (n = 100) were given preoperative aprepitant 40 mg before surgery and were followed perioperatively. Female patients receiving general anesthesia (n = 81) were selected for data analysis. The primary endpoints were PONV/PDNV in the 48 h after surgery. For patients included in the data analysis, using Apfel PONV risk factors, the median risk count was four out of four. PONV and PDNV incidences were 21% (95% CI: 14-31%) and 37% (95% CI: 27-48%), respectively. Two patients experienced PACU (postanesthesia care unit) vomiting and two patients experienced emesis postdischarge. When using regression modeling and comparing patients who received one or two vs. three or four mechanistically unique antiemetics (added to preoperative aprepitant), while adjusting for surgical case duration, the three or four additional antiemetic group showed more PONV/PDNV (Odds Ratio 3.73, 95% CI 1.3-10.9, p = 0.016) than did the one or two additional drug group. There were no other predictors of PONV/PDNV (transabdominal surgery, four vs. three Apfel risk factors) in these patients. The low incidence of vomiting (2-5%) suggests the potential importance of aprepitant in a multimodal antiemetic regimen. However, there may be the potential that too many unique antiemetic mechanisms combined with preoperative aprepitant may actually increase the incidence of perioperative nausea.
Pérez Herrero, M A; López Álvarez, S; Fadrique Fuentes, A; Manzano Lorefice, F; Bartolomé Bartolomé, C; González de Zárate, J
The quality of postoperative recovery is one of the most important among all the quality indicators used in clinical situations. This is even more important after cancer surgery. Our aim was to evaluate this after non-reconstructive breast surgery under general anesthesia and paravertebral blockade or serratus-intercostal plane blockade, in the early and late post-operative period. A prospective observational study was conducted on 60 patients (25 paravertebral blockade group and 35 serratus-intercostal plane blockade group) scheduled for non-reconstructive breast surgery during a 6 month period. Every patient received general anaesthesia and were randomised to receive either paravertebral blockade or serratus-intercostal plane blockade. The quality of post-anaesthetic recovery was quantified by Postoperative Quality Recovery Scale, which is used to assess physiological, nociceptive, emotional, autonomy, cognitive and general state domains at different times: baseline (before surgery), 15min after the end of surgery, at discharge to home, and one month after surgery. A total recovery of 95.93% was achieved in the early postoperative period (15min PACU), 99.07% at discharge to home, and 99.25% at one month after the intervention. No significant differences were found between groups in total score or in each evaluated area. A progressive improvement was observed in the scores assessed with the Postoperative Quality Recovery Scale, reaching values that would allow the discharge to home and early return to usual active life from the immediate postoperative period, with no significant differences between the 2 analgesic techniques. Savings in opioid use and the excellent recovery were observed in all measured domains observed. Copyright © 2016 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.
Abdellatif, Ashraf Abualhassan; Ali, Monaz Abdulrahman
Context: Supraglottic airway devices have been used as an alternative to tracheal intubation during laparoscopic surgery. Aims: The study was designed to compare the efficacy of Streamlined Liner of the Pharynx Airway (SLIPA) for positive pressure ventilation and postoperative complications with the Laryngeal Mask Airway ProSeal (PLMA) for patients undergoing lower abdominal laparoscopies under general anesthesia with controlled ventilation. Settings and Design: Prospective, crossover randomized controlled trial performed on patients undergoing lower abdominal laparoscopic surgeries. Methods: A total of 120 patients undergoing lower abdominal laparoscopic surgeries were randomly allocated into two equal groups; PLMA and SLIPA groups. Number of intubation attempts, insertion time, ease of insertion, and fiberoptic bronchoscopic view were recorded. Lung mechanics data were collected 5 minutes after securing the airway, then after abdominal insufflation. Blood traces and regurgitation were checked for; postoperative sore throat and other complications were recorded. Statistical Analysis: Arithmetic mean and standard deviation values were calculated and statistical analyses were performed for each group. Independent sample t-test was used to compare continuous variables exhibiting normal distribution, and Chi-squared test for noncontinuous variables. P value <0.05 was considered significant. Results: Insertion time, first insertion success rate, and ease of insertion were comparable in both groups. Fiberoptic bronchoscopic view was significantly better and epiglottic downfolding was significantly lower in SLIPA group. Sealing pressure and lung mechanics were similar. Gastric distension was not observed in both groups. Postoperative sore throat was significantly higher in PACU in PLMA group. Blood traces on the device were significantly more in SLIPA group. Conclusions: SLIPA can be used as a useful alternative to PLMA in patients undergoing lower abdominal laparoscopic
Khalili, Gholamreza; Salimianfard, Marzieh; Zarehzadeh, Abolghasem
Background: Therapeutic superiority of a combination of Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) over either drug alone remains controversial. We evaluated the efficiency of a combination of Paracetamol and Piroxicam versus each drug alone and also placebo in the management of postoperative pain, in patients who had undergone elective upper limb orthopedic surgery under general anesthesia. Materials and Methods: A total of 100 patients were randomly divided into four groups to receive either intravenous (IV) infusion of Paracetamol, 15 mg/kg., intramuscular (IM) injection of Piroxicam 0.4 mg/kg., their combination or placebo. The pain scores were recorded at the first; second, fourth, sixth, twelfth, and 24 hours after Post Anesthesia Care Unit (PACU) admission. After the operation 0.1 mg/kg of morphine was administered, if the patient needed. Result: The means of the pain scores were 5.26 ± 1.53, 4.09 ± 0.88, 4.36 ± 1.48, and 4.11 ± 1.29, in groups A, B, C, and D, respectively, (Group A: received placebo; Group B: received both Paracetamol and Piroxicam; Group C received Piroxicam; Group D received Paracetamol). Except for differences between the mean pain scores in Groups B and D, the other differences were statistically significant (P value < 0.05). No adverse effect was reported in the four groups. Conclusion: IV infusion of 15 mg/kg Paracetamol used as a preventive may provide effective analgesia in comparison with IM 0.4 mg/kg Piroxicam or placebo. Addition of Piroxicam to Paracetamol has not much more benefit than Paracetamol alone, in reducing pain after upper limb orthopedic surgery. PMID:27403409
Imarengiaye, C O; Asudo, F D; Akpoguado, D D; Akhideno, I I; Omoifo, C E; Ogunsakin, A T
This study determined the quality of perioperative analgesia and side effect profile of spinal bupivacaine plus pethidine for caesarean section. Patients were randomised to receive 2.0mL of bupivacaine + pethidine 7.5mg or 2.0mL bupivacaine + saline of equal volume. Spinal anaesthesia was instituted at L2/3, L3/4 or L4/5 using a 25G pencil point spinal needle. Heart rate, blood pressure and oxygen saturation were monitored. Timelines such as time of injection of study medication, skin incision, delivery time, termination of surgery and time to first request for analgesia as well as complications were noted. Demographic characteristics were also recorded. 50 patients were studied in 2 groups and the demographic characteristics were similar. Addition of pethidine resulted in block height greater than T6 and longer duration of analgesia (256.9 ± 112.2 min.) compared with the saline group (160.5 ± 65.0 min; p = 0.0005). Maternal hypotension occurred more in the pethidine group (10/25 vs 2/25; p = 0.01). Peritoneal irritation and inadequate anaesthesia were more frequent in the saline group. Nausea and vomiting and drowsiness were mild and occurred only in the pethidine group. In the Post Anaesthetic Care Unit (PACU), more patients reported pain in the saline group (p = 0.002). Bupivacaine with pethidine 7.5mg resulted in better quality of anaesthesia, longer postoperative analgesia with acceptable side effect profile. This will be of value in the management of post-caesarean section pain particularly in the resource poor setting.
Parsa, Fereydoun Don; Cheng, Justin; Stephan, Brad; Castel, Nikki; Kim, Leslie; Murariu, Daniel; Parsa, Alan A
Breast reduction has traditionally been performed under general anesthesia with adjunct opioid use. However, opioids are associated with a wide variety of adverse effects, including nausea, vomiting, constipation, postoperative sedation, dizziness, and addiction. This study compares bilateral breast reduction using a multimodal opioid-free pain management regimen vs traditional general anesthesia with adjunct opioids. A total of 83 female patients were enrolled in this study. Group 1 includes a retrospective series of 39 patients that underwent breast reduction via general anesthesia with adjunct opioid use. This series was compared to 2 prospective groups of patients who did not receive opioids either preoperatively or intraoperatively. In group 2, twenty-six patients underwent surgery under intravenous sedation and local anesthesia. In group 3, eighteen patients underwent surgery with general anesthesia. All patients in groups 2 and 3 received preoperative gabapentin and celecoxib along with infiltration of local anesthetics during the operation and prior to discharge to the Post-Anesthesia Care Unit (PACU). Primary outcome measures included the duration of surgery, time from end of operation to discharge home, postoperative opioid and antiemetic use, and unplanned postoperative hospitalizations. When compared to group 1, groups 2 and 3 experienced a shorter time from end of operation to discharge home (P < 0.05), fewer unplanned hospital admissions (P < 0.05), and highly significant decrease in postoperative opioid use (P < 0.001). This multimodal approach allows patients to safely undergo opioid-free bilateral breast reduction either under local or general anesthesia as an outpatient. This method resulted in significantly less morbidity, use of opioids postoperatively, as well as unplanned hospital admissions compared to "traditional" breast reduction under general anesthesia with the use of opioids.
Yi, Jie; Lei, Yongjing; Xu, Shiyuan; Si, Yongyu; Li, Shiyang; Xia, Zhongyuan; Shi, Yisa; Gu, Xiaoping; Yu, Jianshe; Xu, Guohai; Gu, Erwei; Yu, Yonghao; Chen, Yanqing; Jia, Hequn; Wang, Yinglin; Wang, Xiuli; Chai, Xiaoqing; Jin, Xiaoju; Chen, Junping; Xu, Meiying; Xiong, Junyu; Wang, Guonian; Lu, Kaizhi; Yu, Wenli; Lei, Weifu; Qin, Zaisheng; Xiang, Jingguo; Li, Longyun; Xiang, Ziyong; Pan, Shuang; Zhan, Lujing; Qiu, Kai; Yao, Min; Huang, Yuguang
Inadvertent intraoperative hypothermia (core temperature <36°C) is a frequently preventable complication with several adverse consequences. Our study aimed to determine the overall incidence of inadvertent intraoperative hypothermia and its risk factors associated with clinical outcomes in this national survey in China. We conducted a national cross-sectional study with 30 days postoperative follow-up from November 2014 through August 2015. A total of 3132 eligible patients underwent general anesthesia were randomly selected from 28 hospitals in the nationwide of China. The overall incidence of intraoperative hypothermia was as high as 44.3%, in which cumulative incidence rates of hypothermia being 17.8%, 36.2%, 42.5% and 44.1% within 1 h, 2 h, 3 h and 4 h respectively following induction of anesthesia. All patients were warmed passively by covering of surgical draping, sheets or cotton blankets, whereas only 14.2% of patients received active warming with space heaters or electric heater or electronic blankets. Compared to normothermic patients, patients with hypothermia is associated with more postoperative ICU admit, longer PACU and more postoperative hospital days, but no difference in surgical site infection (SSI) rates or 30-day mortality. Several factors were shown to be associated with decreased risk of hypothermia. They are active warming (OR = 0.46, 95% CI 0.26-0.81), BMI ≥ 25 (OR = 0.54, 95% CI 0.45-0.65), higher baseline core temperature (OR = 0.04, 95% CI 0.03-0.06), and higher ambient temperature (OR = 0.83, 95% CI 0.78-0.88). Risk factors associated with an increased risk of hypothermia included major-plus surgery (OR = 1.49, 95% CI 1.23-1.79), and long anesthesia (>2 h) (OR = 2.60, 95% CI 2.09-3.24). The incidence of intraoperative hypothermia in China is high, and the rate of active warming of patients during operation is low. Hypothermia is associated with more postoperative shivering, increased ICU admissions, and longer postoperative hospital
Kaplan, D. A.; Lima, M. A.; Doria, C.
Amazonian river systems are characterized by a strongly seasonal flood pulse and important hydrologic effects have been observed in the dynamics of fish stocks and fishing yields. Changes in the Amazon's freshwater ecosystems from hydropower development will have a cascade of physical, ecological, and social effects and impacts on fish and fisheries are expected to be potentially irreversible. In this work we investigate shared trends and causal factors driving fish catch in the Madeira River (a major tributary of the Amazon) before dam construction to derive relationships between catch and natural hydrologic dynamics. We applied Dynamic Factor Analysis to investigate dynamics in fish catch across ten commercially important fish species in the Madeira River using daily fish landings data including species and total weight and daily hydrological data obtained from the Brazilian Geological Service. Total annual catch averaged over the 18-yr period (1990-2007) was 849 tons yr-1. Species with the highest catch included curimatã, dourada/filhote and pacu, highlighting the importance of medium and long-distance migratory species for fisheries production. We found a four-trend dynamic factor model (DFM) to best fit the observed data, assessed using the Akaike Information Criteria. Model goodness of fit was fair (R2=0.51) but highly variable across species (0.16 ≤ R2 ≤ 0.95). Fitted trends exhibited strong and regular year-to-year variation representative of the seasonal hydrologic pulsing observed on the Madeira River. Next, we considered 11 candidate explanatory time series and found the best DFM used four explanatory variables and only one common trend. While the model fit with explanatory variables was lower (R2=0.31) it removed much reliance on unknown common trends. The most important explanatory variable in this model was maximum water level followed by days flooded, river flow of the previous year and increment. We found unique responses to hydrological
Comparison of continuous femoral nerve block (CFNB/SA) and continuous femoral nerve block with mini-dose spinal morphine (CFNB/SAMO) for postoperative analgesia after total knee arthroplasty (TKA): a randomized controlled study.
Sundarathiti, Petchara; Thammasakulsiri, Jadesadha; Supboon, Supawadee; Sakdanuwatwong, Supalak; Piangjai, Molruedee
Unsatisfactory analgesia for major knee surgery with femoral nerve block (FNB) alone was reported and the additional benefit of sciatic block to continuous femoral nerve block (CFNB) was not conclusive. The aim of the present study was to find the benefit of the additional mini-dose spinal morphine (0.035 mg) to CFNB for postoperative pain control and to compare their associated side effects after total knee arthroplasty (TKA). After written informed consent and with Institutional Ethics Committee approval, 68 American Society of Anesthesiologists (ASA) Physical Status I-III patients scheduled for elective unilateral TKA under spinal anesthesia (SA) were included in the present prospective, randomized controlled study. The patients were allocated into two groups. CFNB was placed in all patients by the inguinal paravascular approach with 20 ml of 0.25 % levobupivacaine. Group I (named CFNB/SA group), SA was administered with 2.8 ml levobupivacaine and Group II (named CFNB/SAMO group), SA with 2.8 ml levobupivacaine plus morphine 0.035 mg. At Post Anesthesia Care Unit (PACU), pain and other adverse effects were recorded. Pain was assessed by visual analog scale (VAS) 0-10. Tramadol 50 mg intravenous (IV) was given if the VAS > 4. In the ward, all patients were maintained by continuous femoral infusion of 0.125 % levobupivacaine rate 7 ml/hr and then reduced to 5 ml/hr if VAS ≤3. Patient's demographics data in each group were not different. At post-operative (PO) 12-24 h, the VAS scores were significantly lesser in the CFNB/SAMO group. Cumulative tramadol IV requirement for PO48h were also significantly lesser in the CFNB/SAMO group. Nausea, vomiting and numbness were significantly greater in the CFNB/SAMO group during early postoperative period (PO1-6 h). Though in some patients CFNB was inadequate, a mini-dose of intrathecal morphine (0.035 mg) in addition to CFNB was found to be effective with minimal side effects. Thai Clinical Trial Registry
Cantekin, Kenan; Yildirim, Mustafa Denizhan; Delikan, Ebru; Çetin, Seçil
Objective: To find out postoperative discomfort in children undergoing dental rehabilitation under general anesthesia (DRGA). Methods: This study involved 78 (4 to 10 year-old) healthy patients who were scheduled for DRGA and were needed extensive dental treatment because of severe caries, and showed high dental fear and/or behavioral management problems. The children had to be fit for DRGA administration by fulfilling the American Society of Anesthesiologists physical status I or II and no associated mental health or communication problems. Data were collected by structured interview either face to face (immediately post operation) or using a telephone (post operation after discharge). One of the study’s investigators recorded all data related to the immediate postoperative period during the child’s stay in the post-anesthesia care unit (PACU). The questionnaire consisted of questions related to postoperative problems experienced by the patient in the period after their day-stay attendance. The questionnaire, consisting of questions regarding and generally related to the child’s activities. In addition, pain was assessed using the face, legs, activity, cry, consolability (FLACC) scale. Results: The prevalence of postoperative problems was 46 out of 78 (59%). The mean FLACC score was 1.8 (SD=2.1). Some of the patients having more than one reported problem. Forty-one percent of the children showed nasal discomfort (P<0.01). Thirty-three percent and 43% of the children experienced throat or mouth discomfort. The most common experienced postoperative symptom after DRGA was bleeding. Nasal bleeding, however, was an uncommon complication and did not cause serious morbidity or mortality in children intubated nasotracheally. In addition, postoperative discomfort was related to number of the extractions. Children who had 4 or more extractions were more likely to experience pain. Findings associated with other bodily functions were assessed. Nausea and vomiting were
Batra, Y K; Shamsah, M; Al-Khasti, M J; Rawdhan, H J F; Al-Qattan, A R; Belani, K G
Ketamine inhibits the NMDA receptors via non-competitive antagonism, resulting in an antihyperalgesic effect achieved by doses of ketamine much smaller than are required for analgesia. The aim of this study was to determine the extent to which small-dose ketamine, when used in conjunction with remifentanil, has a morphine-sparing effect in the perioperative period. In this randomized, double-blind, placebo-controlled prospective study, we enrolled 40 children undergoing tonsillectomy. Anesthetic care was standardized. Intraoperative analgesia was provided with remifentanil 0.5 microg x kg(-1) followed by an infusion of 0.25 microg x kg(-1) x min(-1). Group I (ketamine, n = 20) received a bolus dose of ketamine 0.5 mg x kg(-1) followed by a continuous infusion of 2 microg x kg(-1) x min(-1) before start of surgery. The infusion was stopped when surgery ended. Group II (placebo, n=20) received normal saline in the same manner. Pain was assessed postoperatively using the Children's Hospital Eastern Ontario Pain Scale (CHEOPS; range of scores 4 13), and total morphine consumption was recorded in the postanesthesia care unit (PACU). Patients were transferred to the ward and morphine was administered via a patient-controlled analgesia (PCA) device and analgesia was recorded using a visual analogue scale (VAS) (0 - 10). Intraoperative remifentanil consumption was not different between the ketamine group (0.29+/-0.09 microg x kg x min(-1) ) and the control group (0.24+/-0.07 microg x kg x min(-1)). There were no significant differences between CHEOPS scores and VAS score between the two groups. The total mean morphine consumption in the ward was not significantly different between the two groups: 376.5 +/-91.6 microg x kg(-1) with ketamine and 384.4+/-97.3 microg x kg(-1) with placebo. The time-to-first analgesic requirement was also similar in both groups. Small-dose ketamine did not decrease postoperative pain after tonsillectomy in children when added to a continuous
Schwenk, Eric S.; Gandhi, Kishor; Baratta, Jaime L.; Torjman, Marc; Epstein, Richard H.; Chung, Jaeyoon; Vaghari, Benjamin A.; Beausang, David; Bojaxhi, Elird; Grady, Bernadette
Background: Continuous interscalene blocks provide excellent analgesia after shoulder surgery. Although the safety of the ultrasound-guided in-plane approach has been touted, technical and patient factors can limit this approach. We developed a caudad-to-cephalad out-of-plane approach and hypothesized that it would decrease pain ratings due to better catheter alignment with the brachial plexus compared to the in-plane technique in a randomized, controlled study. Objectives: To compare an out-of-plane interscalene catheter technique to the in-plane technique in a randomized clinical trial. Patients and Methods: Eighty-four patients undergoing open shoulder surgery were randomized to either the in-plane or out-of-plane ultrasound-guided continuous interscalene technique. The primary outcome was VAS pain rating at 24 hours. Secondary outcomes included pain ratings in the recovery room and at 48 hours, morphine consumption, the incidence of catheter dislodgments, procedure time, and block difficulty. Procedural data and all pain ratings were collected by blinded observers. Results: There were no differences in the primary outcome of median VAS pain rating at 24 hours between the out-of-plane and in-plane groups (1.50; IQR, [0 - 4.38] vs. 1.25; IQR, [0 - 3.75]; P = 0.57). There were also no differences, respectively, between out-of-plane and in-plane median PACU pain ratings (1.0; IQR, [0 - 3.5] vs. 0.25; IQR, [0 - 2.5]; P = 0.08) and median 48-hour pain ratings (1.25; IQR, [1.25 - 2.63] vs. 0.50; IQR, [0 - 1.88]; P = 0.30). There were no differences in any other secondary endpoint. Conclusions: Our out-of-plane technique did not provide superior analgesia to the in-plane technique. It did not increase the number of complications. Our technique is an acceptable alternative in situations where the in-plane technique is difficult to perform. PMID:26705526
Liang, Peng; Zhou, Cheng; Li, Kai-Yu; Guo, Li-Juan; Liu, Bin; Liu, Jin
It is controversial that whether the GABA receptors contribute to the hypnotic action of volatile anesthetics. This study was to detect the effect of GABA receptors on the hypnotic action of volatile anesthetics by evaluation of the effect of intravenous flumazenil on sevoflurane minimum alveolar anesthetic concentration-awake (MAC-Awake) and emergence mental status. This study included two steps. Firstly, 49 healthy patients, aged 20-40 years scheduled for elective surgeries, were randomly assigned to two groups, a flumazenil group (n=24) and a saline group (n=25). The flumazenil group received 0.006 mg/Kg IV, and the control group received the same volume of saline 20 min before induction. The flumazenil group and the control group were compared with regard to MAC-Awake (anesthetic concentration achieving 50% probability of eye opening in response to a verbal command). We used the mask inhalation to measure the MAC-Awake by up-and-down method. The second steps, 60 patients undergoing lower abdomen surgeries were randomly divided into two groups, a experimental group (n=30) and a saline group (n=30). All patients were anesthetized with sevoflurane/sulfentanil. The experimental group received flumazenil at 0.006 mg/Kg IV, and the control group received the same volume of saline at the end of surgery. We recorded the time to awake and extubation. After extubation, the patients' recovery status was scored with the Mini-Mental state examination (MMSE) system in post anesthesia care unit (PACU). The MAC-Awake was 0.65% in the control group and 0.82% in the flumazenil group (p=0.34). After extubation, the recovery time and time to extubation showed no difference between the flumazenil group and the saline group (p>0.05). But the 10 min and 15 min MMSE scores after extubation were better in the flumazenil group than those in the saline group (p<0.05). There was no difference for MMSE scores after 30 min between two groups. We found that an IV flumazenil (0.006 mg/Kg) has
Khattab, Ahmed Metwally; El-Seify, Zeinab Ahmed
The use of sevoflurane in pediatric anesthesia, which could enable a more rapid emergence and recovery, is complicated by the frequent occurrence of post-anesthesia agitation. This study aims to test the efficacy of adding a low dose of ketamine orally, as a supplement to the midazolam-based oral premedication for reducing sevoflurane-related emergence agitation. Ninety-two preschool children, aged between two and six years, with an American Society of Anesthesiologists physical status I or II, scheduled for elective dental filling and extractions under general anesthesia were included. The patients were allocated into two groups: Group M (46 patients) received oral midazolam 0.5 mg/kg, mixed with ibuprofen 10 mg/kg, while group KM (46 patients) received a similar premedication mixture, in addition to ketamine 2 mg/kg. The acceptance of the drug mixture, the onset of action, and the occurrence of vomiting were monitored over the next 30 minutes. Induction of anesthesia was carried out using sevoflurane 8 Vol% in 100% oxygen via face mask. Anesthesia was maintained with sevoflurane 1.5-2 Vol% in an oxygen-nitrous oxide mixture. After extubation, the standard scoring scale was used for assessing the quality of emergence. Agitation parameters were measured using a five-point scale. Agitated children were managed by giving intravenous increments of fentanyl 1 mug/ kg. The time of hospital discharge allowance was recorded. Drug palatability, vomiting, and onset of action of premedication; showed no significant differences between both groups. Time of eye opening after discontinuation of sevoflurane showed no significant differences between both groups. Postoperative agitation score and rescue fentanyl consumption were higher in group M than in group KM on admission to the PACU (P < 0.01). The time of hospital discharge allowance in group M was longer than in group KM (P < 0.05). Adding a low dose of oral ketamine to midazolam-based oral premedication in preschool
Kiberd, Mathew B; Clarke, Suzanne K; Chorney, Jill; d'Eon, Brandon; Wright, Stuart
Postoperative nausea and vomiting (PONV) is one of the most common postoperative complications of general anesthesia in pediatrics. Aromatherapy has been shown to be effective in treating PONV in adults. Given the encouraging results of the adult studies, we planned to determine feasibility of doing a large-scale study in the pediatric population. Our group conducted a pilot randomized controlled trial examining the effect of aromatherapy on post-operative nausea and vomiting in patients 4-16 undergoing ambulatory surgery at a single center. Nausea was defined as a score of 4/10 on the Baxter Retching Faces Scale (BARF scale). A clinically significant reduction was defined as a two-point reduction in Nausea. Post operatively children were administered the BARF scale in 15 min internals until discharge home or until nausea score of 4/10 or greater. Children with nausea were randomized to saline placebo group or aromatherapy QueaseEase™ (Soothing Scents, Inc, Enterprise, AL: blend of ginger, lavender, mint and spearmint). Nausea scores were recorded post intervention. A total of 162 subjects were screened for inclusion in the study. Randomization occurred in 41 subjects of which 39 were included in the final analysis. For the primary outcome, 14/18 (78 %) of controls reached primary outcome compared to 19/21 (90 %) in the aromatherapy group (p = 0.39, Eta 0.175). Other outcomes included use of antiemetic in PACU (control 44 %, aromatherapy 52 % P = 0.75, Eta 0.08), emesis (Control 11 %, 9 % aromatherapy, P = 0.87, Eta = 0.03). There was a statistically significant difference in whether subjects continued to use the intervention (control 28 %, aromatherapy 66 %, p-value 0.048, Eta 0.33). Aromatherapy had a small non-significant effect size in treating postoperative nausea and vomiting compared with control. A large-scale randomized control trial would not be feasible at our institution and would be of doubtful utility. ClinicalTrials.gov NCT
Cantekin, Kenan; Yildirim, Mustafa Denizhan; Delikan, Ebru; Cetin, Seçil
To find out postoperative discomfort in children undergoing dental rehabilitation under general anesthesia (DRGA). This study involved 78 (4 to 10 year-old) healthy patients who were scheduled for DRGA and were needed extensive dental treatment because of severe caries, and showed high dental fear and/or behavioral management problems. The children had to be fit for DRGA administration by fulfilling the American Society of Anesthesiologists physical status I or II and no associated mental health or communication problems. Data were collected by structured interview either face to face (immediately post operation) or using a telephone (post operation after discharge). One of the study's investigators recorded all data related to the immediate postoperative period during the child's stay in the post-anesthesia care unit (PACU). The questionnaire consisted of questions related to postoperative problems experienced by the patient in the period after their day-stay attendance. The questionnaire, consisting of questions regarding and generally related to the child's activities. In addition, pain was assessed using the face, legs, activity, cry, consolability (FLACC) scale. The prevalence of postoperative problems was 46 out of 78 (59%). The mean FLACC score was 1.8 (SD=2.1). Some of the patients having more than one reported problem. Forty-one percent of the children showed nasal discomfort (P<0.01). Thirty-three percent and 43% of the children experienced throat or mouth discomfort. The most common experienced postoperative symptom after DRGA was bleeding. Nasal bleeding, however, was an uncommon complication and did not cause serious morbidity or mortality in children intubated nasotracheally. In addition, postoperative discomfort was related to number of the extractions. Children who had 4 or more extractions were more likely to experience pain. Findings associated with other bodily functions were assessed. Nausea and vomiting were reported in 20.5% of children
Liang, Peng; Zhou, Cheng; Li, Kai-Yu; Guo, Li-Juan; Liu, Bin; Liu, Jin
Objective: It is controversial that whether the GABA receptors contribute to the hypnotic action of volatile anesthetics. This study was to detect the effect of GABA receptors on the hypnotic action of volatile anesthetics by evaluation of the effect of intravenous flumazenil on sevoflurane minimum alveolar anesthetic concentration–awake (MAC-Awake) and emergence mental status. Methods: This study included two steps. Firstly, 49 healthy patients, aged 20-40 years scheduled for elective surgeries, were randomly assigned to two groups, a flumazenil group (n=24) and a saline group (n=25). The flumazenil group received 0.006 mg/Kg IV, and the control group received the same volume of saline 20 min before induction. The flumazenil group and the control group were compared with regard to MAC-Awake (anesthetic concentration achieving 50% probability of eye opening in response to a verbal command). We used the mask inhalation to measure the MAC-Awake by up-and-down method. The second steps, 60 patients undergoing lower abdomen surgeries were randomly divided into two groups, a experimental group (n=30) and a saline group (n=30). All patients were anesthetized with sevoflurane/sulfentanil. The experimental group received flumazenil at 0.006 mg/Kg IV, and the control group received the same volume of saline at the end of surgery. We recorded the time to awake and extubation. After extubation, the patients’ recovery status was scored with the Mini-Mental state examination (MMSE) system in post anesthesia care unit (PACU). Results: The MAC-Awake was 0.65% in the control group and 0.82% in the flumazenil group (p=0.34). After extubation, the recovery time and time to extubation showed no difference between the flumazenil group and the saline group (p>0.05). But the 10 min and 15 min MMSE scores after extubation were better in the flumazenil group than those in the saline group (p<0.05). There was no difference for MMSE scores after 30 min between two groups. Conclusion: We
Brouillette, Mark A; Aidoo, Alfred J; Hondras, Maria A; Boateng, Nana A; Antwi-Kusi, Akwasi; Addison, William; Hermanson, Alec R
of 27 million. Providers were heavily concentrated in urban areas, and NAs frequently practiced independently. Two teaching hospitals provided accredited postgraduate training modeled after European curricula to 22 anesthesia resident physicians. While important limitations to capacity exist in Ghana, the overall situation is good compared to other LMICs. Many of the challenges encountered resulted from insufficient PACU and CCU provisions and few providers. Inadequate outcomes reporting made analysis and resolution of problem areas difficult. While many shortcomings stemmed from limited funding, strengthening physician commitment to overseeing care, ensuring oxygen supplies are uninterrupted, keeping ventilators in working order, and making vital signs monitors ubiquitously available are feasible ways to increase patient safety with the tools currently in place.
Elevated Extravascular Lung Water Index (ELWI) as a Predictor of Failure of Continuous Positive Airway Pressure Via Helmet (Helmet-CPAP) in Patients With Acute Respiratory Failure After Major Surgery.
Redondo Calvo, Francisco Javier; Bejarano Ramirez, Natalia; Uña Orejon, Rafael; Villazala Garcia, Ruben; Yuste Peña, Ana Sofia; Belda, Francisco Javier
NIV is increasingly used for prevention and treatment of respiratory complications and failure. Some of them are admitted to the PACU with advanced hemodynamic monitors which allow quantification of Extravascular Lung Water (EVLW) by transpulmonary thermodilution technique (TPTD) and Pulmonary Vascular Permeability (PVP) providing information on lung edema. The objective of this study was to ascertain if EVLW Index and PVP Index may predict failure (intubation) or success (non-intubation) in patients developing acute respiratory failure (ARF) in the postoperative period following major abdominal surgery, where the first line of treatment was non-invasive continuous positive airway pressure via a helmet. Hemodynamic variables, EVLWI and PVPI were monitored with a transpulmonary thermodilution hemodynamic monitor device (PiCCO™) before and after the application of CPAP. Avoidance of intubation was observed in 66% of patients with Helmet-CPAP. In these patients after the first hour of application of CPAP, PaO2/FiO2 ratio significantly increased (303.33±65.2 vs. 141.6±14.6, P<.01). Before starting Helmet-CPAP values of EVLWI and PVPI were significantly lower in non-intubated patients (EVLWI 8.6±1.08 vs. 11.8±0.99ml/kg IBW, P<.01 and PVPI 1.7±0.56 vs. 3.0±0.88, P<.01). An optimal cut-off value for EVLWI was established at 9.5, and at 2.45 for PVPI (sensitivity of 0.7; specificity of 0.9, P<.01). In this type of patient the physiological parameters that predict the failure of Helmet-CPAP with the greatest accuracy were the value of the EVLWI and PVPI before Helmet-CPAP institution and the PaO2/FiO2 ratio and the respiratory rate after one hour of CPAP. Copyright © 2014 SEPAR. Published by Elsevier Espana. All rights reserved.
Teunkens, A; Vanhaecht, K; Vermeulen, K; Fieuws, S; Van de Velde, M; Rex, S; Bruyneel, L
To evaluate patient satisfaction and patient reported anaesthesia related outcome parameters after outpatient surgery. A three-year (2013-2016) observational study. A surgical day care centre embedded in a tertiary care, university hospital. Adult Dutch-speaking patients who underwent surgery under general or regional anaesthesia on an outpatient basis (n=5424). A questionnaire was developed to evaluate patients' satisfaction with care during their hospitalisation in the surgical day centre, as well as to assess their reports of anaesthesia related outcomes. Various aspects of care were measured, including care by nurses, care by doctors, organisational and safety items. Variation in satisfaction and surgery and anaesthesia related outcomes as a function of different categories (gender, age, education, type of anaesthesia, discipline and era) were also investigated. Confirmatory factor analysis showed an excellent fit to the hypothesized factors of the survey. Satisfaction scores were very high for different aspects of care, resulting in 98% of patients being (very) satisfied (59.1% very satisfied, 38.9% satisfied). Male (p=0.0003), higher educated (p<0.0001) and older patients (p<0.0001) were more likely to be very satisfied. Postoperative nausea and vomiting (PONV) were frequent (nausea: 13.9%, vomiting: 3.3%), and more present in female than in male patients (p<0.0001). Pain scores at the PACU differed among disciplines (p<0.0001) were higher in female patients compared to male patients (3.41% versus 2.54%, p<0.0001) and after general anaesthesia compared to regional anaesthesia (3.25% versus 0.39%, p<0.0001) and decreased with higher age (p=0.0001) and education level (p=0.0033). Whereas satisfaction with all aspects of care is generally high, the results regarding pain and PONV should inspire quality improvement initiatives. The questionnaire developed in this study can be a vehicle to assess and improve the quality of care in surgical day care centres
Wermelt, Julius Z; Ellerkmann, Richard K
Emergence Delirium in children after general anesthesia is a common and self limitating event. Although it might be seen as being harmless it can cause other serious complications and might leave both parents and other caregivers with a negative impression behind. Although the cause may still not be clear, potential predictors can be named: preschool age, the use of fast acting volatile anesthestics, higher preoperative anxiety levels and postoperative pain.A child-focused approach to reduce preoperative anxiety focusing on distraction methods rather than pharmacological sedation may be the key as well as sufficient postoperative pain control and the use of total intravenous anesthesia. Parenteal presence during induction of anaesthesia (PPIA) may be beneficial to reduce preoperative anxiety levels, but has failed to prove a better outcome regarding ED.The use of age adopted scores/scales to diagnose ED and Pain are mandatory.In the case of an ED event it is most important to protect the child from self injury and the loss of the iv-line. Postoperative pian needs to be ruled out before treating ED. Most cases can be treated by interrupting the situation and putting the child "back to sleep". Short acting drugs as Propofol have been used successfully due to its pharmacodynamics and short acting profile. Alternatively alpha-agonists or ketamin may be preferred by other authors. If potential predictors and a positive history are present, prophylactic treatment should be considered. A TIVA or the use of alpha-2-agonists have proven to be successful in reducing the risk of an ED. Midazolam may reduce preoperative anxiety but not the incidence of ED and should therefore be used carefully and is not a good choice in PACU for the treatment of ED.Parents who witnessed ED in their children should be guided and followed up. Explaining this phenomenon to parents beforehand should be part of the pre anaesthesia clinic talk and written consent.Standard protocols should be in
Xiong, Wei; Zhou, Qin; Yang, Peng; Huang, Xiongqing
Background and Objectives The goal of this meta-analysis study was to assess the effects of fentanyl on emergence agitation (EA) under sevoflurane anesthesia in children. Subjects and Methods We searched electronic databases (PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials) for articles published until December 2014. Randomized controlled trials (RCTs) that assessed the effects of fentanyl and placebo on EA under sevoflurane anesthesia in children that the outcome were the incidence of EA, postoperative pain, emergence time or adverse effects were included in this meta-analysis. Results A total of 16 studies, including 1362 patients (737 patients for the fentanyl group and 625 for the placebo group), were evaluated in final analysis. We found that administration of fentanyl decreased the incidences of EA (RR = 0.37, 95% CI 0.27~0.49, P<0.00001) and postoperative pain (RR = 0.59, 95% CI 0.41~0.85, P = 0.004) but increased the incidence of postoperative nausea and vomiting (PONV) (RR = 2.23, 95% CI 1.33~3.77, P = 0.003). The extubation time (WMD = 0.71 min, 95% CI 0.12~1.3, P = 0.02), emergence time (WMD = 4.90 min, 95% CI 2.49~7.30, P<0.0001), and time in the postanesthesia care unit (PACU) (WMD = 2.65 min, 95% CI 0.76~4.53, P = 0.006) were slightly increased. There were no significant differences in the time to discharge of day patients (WMD = 3.72 min, 95% CI -2.80~10.24, P = 0.26). Conclusion Our meta-analysis suggests that fentanyl decreases the incidence of EA under sevoflurane anesthesia in children and postoperative pain, but has a higher incidence of PONV. Considering the inherent limitations of the included studies, more RCTs with extensive follow-up should be performed to validate our findings in the future. PMID:26275039
Gupta, Bhawna; Katyal, Sunil; Gautam, Nikhil
Introduction Extreme hot climatic conditions constitute a major public health threat. Recent studies have shown higher rate of perioperative complications during hot weather. Although a lot of researches have been carried out to evaluate effect of hot climatic conditions and its correlation with other medical conditions, but very little has been studied in trauma patients. Aim To evaluate the impact of hot climatic conditions on perioperative morbidity in trauma patients. Materials and Methods We enrolled 100 trauma patients scheduled for surgery after approval by the Hospital and University Ethical Committee. Patients were grouped as Control Group (C) when outdoor temperature ranged in comfortable zone i.e., 20-290C and Study Group (S) when outdoor temperature ranged 400C or more. Patients living in regular air conditioned atmosphere (more than 18 hours per day) and with co-morbid conditions or on drugs interfering with temperature regulation were excluded. Student’s t-test, z-test and chi-square tests were used for statistical analysis. Results Both groups were comparable in terms of demographics, age (control group C=38.2±12.93 years and in group S= 40.14 ± 15.98 years), sex, socioeconomic status and type of surgery. Mean Trauma Index Score (TIS) were 6.20±1.56 and 5.80±1.31 respectively. All patients were of low risk as per Shoe Maker’s risk criteria. Post Anaesthesia Care Unit (PACU) stay was similar. Mean duration of hospital stay was 12.16 ± 8.50 days in group C and 10.98 ± 6.90 days in group S (p-value 0.21). 20% patients in group C whereas 54% in group S had complications (p= 0.009). There was a higher incidence of infections as well as respiratory distress in group S. On multiple logistic regression analysis peak environmental temperature was found to be the single independent risk factor for predicting perioperative morbidity. Conclusion High ambient temperature adversely affects the outcome of surgery even in low risk young trauma patients
Turgut, Namigar; Turkmen, Aygen; Ali, Achmet; Altan, Aysel
The aim of the present study was to compare the perioperative hemodynamics, propofol consumption and recovery profiles of remifentanil and dexmedetomidine when used with air-oxygen and propofol, in order to evaluate a postoperative analgesia strategy and explore undesirable side-effects (nausea, vomiting, shivering). In a prospective randomized double-blind study 50 ASAI-III patients scheduled for supratentorial craniotomy, were allocated into two equal Groups. Group D patients (n = 25), received i.v. dexmedetomidine 1 microg kg(-1) as preinduction over a 15-min period and 0.2-1 microg kg(-1) hr(-1) by continuous i.v. infusion during the operation period. Group R patients (n = 25), received remifentanil 1 microg kg(-1) as induction i.v. over a 15-min period and 0.05-1 microg kg(-1) min(-1) as maintenance. The propofol infusion was started at a rate of 10 mg kg(-1) h(-1) and titrated to maintain BIS in the range 40-50. Propofol doses for induction and maintenance of anesthesia was lower with dexmedetomidine (respectively p < 0.05, p < 0.01). The time for BIS to reach 50 was significantly shorter in Group D (p < 0.01). Comparison of the parameters of recovery revealed; extubation time (p < 0.01); response to verbal commands (p < 0.05) and time for orientation (p < 0.05) were longer with Group D. With respect to Post Anesthesia Care Unit (PACU) discharge time, dexmedetomidine patients required longer time when compared to remifentanil patients to achieve their first normal neurological score (33 min vs 31 min). The earliest opioid administration was at 38 min. in the dexmedetomidine group and 33 min. in the remifentanil group. Propofol-remifentanil and propofol-dexmedetomidine are both suitable for elective supratentorial craniotomy and provide similar intraoperative hemodynamic responses and postoperative adverse events. Propofol-remifentanil allows earlier cognitive recovery; however, it leads to earlier demand for postoperative analgesics. Undesirable side
Weinberg, Laurence; Faulkner, Matthew; Tan, Chong O; Liu, Daniel H; Tay, Stanley; Nikfarjam, Mehrdad; Peyton, Philip; Story, David
Routine fluid prescription is common practice amongst anesthesiologists caring for patients undergoing colonoscopy. However there is limited information about routine procedural fluid prescription practices of anesthesiologists in this setting. Routine fluid administration may also have important pharmaco-economic implications for the health care budget. Therefore we performed a prospective observational study assessing the fluid prescription practices of anesthesiologists caring for patients undergoing elective colonoscopy. With Institutional Review Board approval, adult patients receiving procedural fluid intervention during elective colonoscopy were included. size of intravenous cannula inserted, volumes of fluid administered, adverse events, procedure duration, and pharmaco-economic costs associated with fluid prescription. Anesthesiologists and gastroenterologists were blinded to the study. We collected data on 289 patients who received fluid prescription by their attending anesthesiologist. Median patient age: 48 yrs (range 18-83), gender: 174 (60%) female; median duration of procedure: 24 minutes (range 12-48). Cannula size: 181 (63%) patients received a 22G cannula or smaller. Median volume of fluid administered during the colonoscopy was 325 ml (range 0 to 1000 ml). Median duration of the procedure: 25 minutes (range 12 to 48 minutes). Median volume of fluid administered in the post anaesthesia recovery unit: 450 ml (range 0 to 1000 ml). Fifteen patients (5%) became hypotensive during the procedure and two patients (<1%) developed hypotension in the PACU. There was no difference in the median fluid requirements between patients with hypotension and those without. Fluid volumes were strongly associated with increasing cannula diameter (p = 0.0001), however there was no association between fluid volumes administered and vasopressor use, peri-procedural adverse events, or procedure duration. At our institution fluid therapy currently cost about
Background Routine fluid prescription is common practice amongst anesthesiologists caring for patients undergoing colonoscopy. However there is limited information about routine procedural fluid prescription practices of anesthesiologists in this setting. Routine fluid administration may also have important pharmaco-economic implications for the health care budget. Therefore we performed a prospective observational study assessing the fluid prescription practices of anesthesiologists caring for patients undergoing elective colonoscopy. Methods With Institutional Review Board approval, adult patients receiving procedural fluid intervention during elective colonoscopy were included. Data collected: size of intravenous cannula inserted, volumes of fluid administered, adverse events, procedure duration, and pharmaco-economic costs associated with fluid prescription. Anesthesiologists and gastroenterologists were blinded to the study. Results We collected data on 289 patients who received fluid prescription by their attending anesthesiologist. Median patient age: 48 yrs (range 18–83), gender: 174 (60%) female; median duration of procedure: 24 minutes (range 12–48). Cannula size: 181 (63%) patients received a 22G cannula or smaller. Median volume of fluid administered during the colonoscopy was 325 ml (range 0 to 1000 ml). Median duration of the procedure: 25 minutes (range 12 to 48 minutes). Median volume of fluid administered in the post anaesthesia recovery unit: 450 ml (range 0 to 1000 ml). Fifteen patients (5%) became hypotensive during the procedure and two patients (<1%) developed hypotension in the PACU. There was no difference in the median fluid requirements between patients with hypotension and those without. Fluid volumes were strongly associated with increasing cannula diameter (p = 0.0001), however there was no association between fluid volumes administered and vasopressor use, peri-procedural adverse events, or procedure duration. At our
Leitao, Mario M; Malhotra, Vivek; Briscoe, Gabriel; Suidan, Rudy; Dholakiya, Priyal; Santos, Kevin; Jewell, Elizabeth L; Brown, Carol L; Sonoda, Yukio; Abu-Rustum, Nadeem R; Barakat, Richard R; Gardner, Ginger J
Laparoscopy (LSC) offers superior patient outcomes compared to laparotomy. Small retrospective/prospective series have suggested robotics offers further reduction in postoperative pain and pain medication use compared to standard LSC. Our objective was to compare postoperative pain in patients undergoing robotically assisted (RBT) versus standard LSC for newly diagnosed endometrial cancer. All preoperative endometrial cancer cases scheduled for RBT and LSC from May 1, 2007 to June 9, 2010 were identified. For this analysis, we only included cases not requiring conversion to laparotomy. All patients were offered intravenous (IV) patient-controlled analgesia (PCA) postoperatively. Intraoperative equivalent fentanyl doses (IEFDs) and pain scores in the postanesthesia care unit (PACU) were assessed. IV PCA was used in 206 RBTs (86 %) and 208 LSCs (88 %). Median IEFD was 425 μg for LSCs and 500 μg for RBTs (P = 0.03). Median pain scores on PACU arrival were similar in both groups. Median highest pain score was 5 for LSCs and 4 for RBTs (P = 0.007). Linear regression demonstrated that the IEFD was not correlated with the highest pain score (R = 0.09; P = 0.07). Fentanyl was used postoperatively in 196 of 206 RBTs (95 %) and 187 of 208 LSCs (90 %). The total fentanyl doses were 242.5 (range 0-2705) μg and 380 (range 0-2625) μg, respectively (P < 0.001). The median hourly fentanyl doses were 16.7 (range 0-122.5) μg and 23.5 (range 0-132.4) μg, respectively (P = 0.005). Simultaneous multiple regression analysis further demonstrated RBT was independently associated with a lower total fentanyl dose compared to LSC (P = 0.02). RBT is independently associated with significantly lower postoperative pain and pain medication requirements compared to LSC. The amount of intraoperative fentanyl analgesia does not appear to correlate with postoperative pain.Endometrial cancer is the most common gynecologic malignancy in the United States, with an estimated 47,130 new cases in
Zhang, Hongquan; Fang, Baojun; Zhou, Wenjing
Flexible bronchoscopy has been more and more used for diagnosis and management diseases of respiratory system in pediatrics. Previous studies have reported that remifentanil (RF) and propofol are safe and effective for flexible bronchoscopy in adults, however, there have no trials evaluate the efficacy of DEX-RF versus dexmedetomidine-propofol in children undergoing flexible bronchoscopy.We divided 123 children undergoing flexible bronchoscopy with DEX-RF or dexmedetomidine-propofol into 2 groups: Group DR (n = 63, DEX infusion at 1.0 μg kg for 10 minutes, then adjusted to 0.5-0.7 μg kg h; RF infusion at 1.0 μg kg for 5 minutes, then adjusted to 0.05-0.2 μg kg min), Group DP (n = 60, DEX infusion at 1.0 μg kg for 10 minutes, then adjusted to 0.5-0.7 μg kg h; propofol infusion at 10 μg kg for 5 minutes, then adjusted to 0.05-0.1 μg kg min). Ramsay sedation scale of the 2 groups was maintained at 3. Anesthesia onset time; total number of intraoperative patient movements; hemodynamics; total cumulative dose of DEX; amount of and time to first-dose rescue midazolam and lidocaine; postoperative recovery time; adverse events; and bronchoscopist satisfaction score were recorded.Anesthesia onset time was significantly shorter in DP (8.22 ± 2.48 vs 12.25 ± 6.43 minutes, respectively, for DP, DR, P = 0.015). The perioperative hemodynamic profile was more stable in DR than DP group. More children moved during flexible bronchoscopy in DP group (P = 0.009). Total dose of rescue midazolam and lidocaine was significantly higher in DR than in DP (P < 0.001). Similarly, the time to first dose of rescue midazolam and lidocaine was significantly longer in DP than in DR (P < 0.001). Total cumulative dose of DEX was more in DR than DP group (P < 0.001). The time to recovery for discharge from the postanesthesia care unit (PACU) was significantly shorter in DP than in DR group (P < 0
Zhang, Hongquan; Fang, Baojun; Zhou, Wenjing
(PACU) was significantly shorter in DP than in DR group (P < 0.001). The bronchoscopist-satisfaction scores were higher for DR than DP (P = 0.036). There were significant differences between the 2 groups in terms of the overall incidence of hypertension, tachycardia, and hypoxemia (P < 0.05). Although underwent longer recovery time and more incidence of rescue scheme, DEX-RF resulted in more stable hemodynamic profiles and bronchoscopist-satisfaction scores, lesser patient movements, and can hence be more effectively used in children undergoing flexible bronchoscopy than dexmedetomidine-propofol. PMID:28072737
Xu, Rui; Lian, Ying; Li, Wen Xian
Objective Flexible laryngeal mask airways (FLMAs) have been widely used in thyroidectomy as well as cleft palate, nasal, upper chest, head and neck oncoplastic surgeries. This systematic review aims to compare the incidence of airway complications that occur during and after general anesthesia when using the FLMA and endotracheal intubation (ETT). We performed a quantitative meta-analysis of the results of randomized trials. Methods A comprehensive search of the PubMed, Embase and Cochrane Library databases was conducted using the key words "flexible laryngeal mask airway" and "endotracheal intubation". Only prospective randomized controlled trials (RCTs) that compared the FLMA and ETT were included. The relative risks (RRs) and the corresponding 95% confidence intervals (95% CIs) were calculated using a quality effects model in MetaXL 1.3 software to analyze the outcome data. Results Ten RCTs were included in this meta-analysis. There were no significant differences between the FLMA and ETT groups in the incidence of difficulty in positioning the airway [RR = 1.75, 95% CI = (0.70–4.40)]; the occurrence of sore throat at one hour and 24 hours postoperative [RR = 0.90, 95% CI = (0.13–6.18) and RR = 0.95, 95% CI = (0.81–1.13), respectively]; laryngospasms [RR = 0.58, 95% CI = (0.27–1.23)]; airway displacement [RR = 2.88, 95% CI = (0.58–14.33)]; aspiration [RR = 0.76, 95% CI = (0.06–8.88)]; or laryngotracheal soiling [RR = 0.34, 95% CI = (0.10–1.06)]. Patients treated with the FLMA had a lower incidence of hoarseness [RR = 0.31, 95% CI = (0.15–0.62)]; coughing [RR = 0.28, 95% CI = (0.15–0.51)] during recovery in the postanesthesia care unit (PACU); and oxygen desaturation [RR = 0.43, 95% CI = (0.26–0.72)] than did patients treated with ETT. However, the incidence of partial upper airway obstruction in FLMA patients was significantly greater than it was for ETT patients [RR = 4.01, 95% CI = (1.44–11.18)]. Conclusion This systematic review showed
Smith, Lisa; Medves, Jennifer; Harrison, Margaret B; Tranmer, Joan; Waytuck, Brett
Policies concerning restricted or open visiting hours are being challenged in health care institutions internationally, with no apparent consensus on the appropriateness of the visiting hour policies for pediatric and adult patients. The rules that govern practice are often based on the institutional precedent and assumptions of staff, and may have little or no evidence to support them. Policy and practice related to visiting hours is of pressing concern in Canada, and in Ontario specifically, following the reaction to the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 and subsequent changes in visiting policies in most health care settings. A systematic investigation of the impact of hospital visiting hours on visitors (including patients, families, and significant others) would inform decision-makers who are responsible for hospital policies about the best available evidence. The objective of this review was to appraise and synthesize the best available evidence on the impact of hospital visiting hours on patients and their visitors. Types of participants This review considered studies that included both pediatric and adult hospital patients and their visitors. Participants were either patients, visitors, or health care providers in the following hospital settings: medical/surgical units, critical care (ICU, CCU, NICU), pediatrics, maternity, or general hospital wards.Articles were excluded if participants came from the following settings: post-operative and post-anaesthesia care units (PACU), dementia wards, long-term care settings or retirement homes, or delivery rooms. PACUs were excluded because there are aspects of the presence of visitors to these units that are very specific, and differ from the general visits to patients who are not in the immediate post-operative stage. Dementia wards, long-term care settings and retirement homes were excluded because these were considered to be their "home", so visiting would be quite different from that on
Wang, Wenming; Feng, Lei; Bai, Fenfen; Zhang, Zongwang; Zhao, Yong; Ren, Chunguang
.001). Significantly fewer patients in groups S and D2 required rescue fentanyl to relieve pain (62.69 vs. 21.33 vs. 27.40%, respectively, for D1, D2, S; P < 0.001). Additionally, total dose of rescue fentanyl in group D1 group was significantly higher (212.5 ± 43.6 vs. 107.2 ± 35.9 vs. 98.6 ± 32.2 μg, respectively, for D1, D2, S; P < 0.001). Total number of patient movements during the burr-hole surgery was higher in groups D1 and S (47.76 vs. 20.00 vs. 47.95%, respectively, for D1, D2, S; P < 0.001). Four patients in D1 and five in S converted to propofol. The time to recovery for discharge from the PACU was significantly shorter in group D2 (16.24 ± 4.15 vs. 12.48 ± 3.29 vs. 15.91 ± 3.66 min, respectively, for D1, D2, S; P < 0.001). Results from the patient and surgeon satisfaction scores showed significant differences favoring group D2 (P < 0.05). More patients in groups D1 and S showed higher levels of the overall incidence of tachycardia and hypertension, and required higher doses of urapidil and esmolol (P < 0.05). Six patients experienced respiratory depression in group S. Conclusion: Compared with sufentanil, DEX infusion at 1 μg·kg−1 was associated with fewer intraoperative patient movements, fewer rescue interventions, faster postoperative recovery, and better patient and surgeon satisfaction scores and could be safely and effectively used for MAC during burr-hole surgery for CSDH. PMID:27857689
Li, Xia; Wang, Xue; Jin, Shuguang; Zhang, Dongsheng; Li, Yanuo
score were recorded. Anesthesia onset time was significantly shorter in DR3 group (14.23 ± 5.45 vs 14.45 ± 5.12 vs 11.13 ± 4.51 minutes, respectively, of DR1, DR2, DR3, P = 0.003). Additionally, the perioperative hemodynamic profile was more stable in group DR3 than that in the other 2 groups. Total number of children movements during flexible bronchoscopy was higher in DR1 group than the other 2 groups (46.81% 22/47 vs 34.88% 15/43 vs 17.78% 8/45, respectively, of DR1, DR2, DR3, P = 0.012). Total doses of rescue midazolam and lidocaine were significantly higher in DR1 and DR2 groups than that of DR3 group (P = 0.000). The time to first dose of rescue midazolam and lidocaine was significantly longer in DR3 group than DR1 and DR2 groups (P = 0.000). Total cumulative dose of dexmedetomidine was more in DR2 and DR3 groups (P = 0.000), while the amount of remifentanil was more in DR1 and DR2 groups (P = 0.000). The time to recovery for discharge from the PACU was significantly shorter in DR1 group compared with the other 2 groups (P = 0.000). Results from bronchoscopist satisfaction score showed significantly higher in DR2 and DR3 groups than that of DR1 group (P = 0.025). There were significant differences among the 3 groups in terms of the overall incidence of hypertension, tachycardia, hypoxemia, and cough (P < 0.05). Though it required longer recovery time, high dose of DEX-RF, which provided better stable hemodynamic profiles and bronchoscopist satisfaction score, less amount of rescue scheme, and children movements, could be safely and efficacy used in children undergoing flexible bronchoscopy. PMID:28296782
Li, Xia; Wang, Xue; Jin, Shuguang; Zhang, Dongsheng; Li, Yanuo
.45 vs 14.45 ± 5.12 vs 11.13 ± 4.51 minutes, respectively, of DR1, DR2, DR3, P = 0.003). Additionally, the perioperative hemodynamic profile was more stable in group DR3 than that in the other 2 groups. Total number of children movements during flexible bronchoscopy was higher in DR1 group than the other 2 groups (46.81% 22/47 vs 34.88% 15/43 vs 17.78% 8/45, respectively, of DR1, DR2, DR3, P = 0.012). Total doses of rescue midazolam and lidocaine were significantly higher in DR1 and DR2 groups than that of DR3 group (P = 0.000). The time to first dose of rescue midazolam and lidocaine was significantly longer in DR3 group than DR1 and DR2 groups (P = 0.000). Total cumulative dose of dexmedetomidine was more in DR2 and DR3 groups (P = 0.000), while the amount of remifentanil was more in DR1 and DR2 groups (P = 0.000). The time to recovery for discharge from the PACU was significantly shorter in DR1 group compared with the other 2 groups (P = 0.000). Results from bronchoscopist satisfaction score showed significantly higher in DR2 and DR3 groups than that of DR1 group (P = 0.025). There were significant differences among the 3 groups in terms of the overall incidence of hypertension, tachycardia, hypoxemia, and cough (P < 0.05).Though it required longer recovery time, high dose of DEX-RF, which provided better stable hemodynamic profiles and bronchoscopist satisfaction score, less amount of rescue scheme, and children movements, could be safely and efficacy used in children undergoing flexible bronchoscopy.