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1.  Anesthesia-controlled time and turnover time for ambulatory upper extremity surgery performed with regional versus general anesthesia 
Journal of clinical anesthesia  2009;21(4):253-257.
Study Objective
To test the hypothesis that regional anesthesia (RA) employing a block room reduces anesthesia-controlled time for ambulatory upper extremity surgery compared with general anesthesia (GA).
Design
Retrospective cohort study.
Setting
Outpatient surgery center of a university hospital.
Patients
229 adult patients who underwent ambulatory upper extremity surgery over one year.
Interventions
Upper extremity surgery performed with three different anesthetic techniques: 1) GA, 2) nerve block (NB) performed preoperatively, or 3) local anesthetic (LA), either Bier block or local anesthetic, administered in the operating room (OR).
Measurements
Demographic data, anesthesia-controlled time, and turnover time were recorded. Since the data were not normally distributed, differences in anesthesia-controlled time and turnover time were analyzed using the Kruskal-Wallis test and post-hoc testing using one-way analysis of variance on the ranks of the observations, with Tukey-Kramer correction for multiple comparisons.
Results
Anesthesia-controlled time for NB (median 28 min) was significantly shorter than for GA (median 32 min, P=0.0392). Anesthesia-controlled time for patients who received LA (median 25 min) was also significantly shorter than GA (P<0.0001). However, turnover time did not differ significantly among the three groups.
Conclusions
Peripheral nerve block performed preoperatively in an induction area or LA injected in the OR significantly reduces anesthesia-controlled time for ambulatory upper extremity surgery compared with GA. Turnover time is unaffected by anesthetic technique. These results may increase acceptance of RA in the ambulatory surgery setting.
doi:10.1016/j.jclinane.2008.08.019
PMCID: PMC2745934  PMID: 19502033
Ambulatory surgery; orthopedic; anesthesia; regional; anesthesia-controlled time; operating room efficiency; turnover time
2.  The impact of remifentanil on incidence and severity of postoperative nausea and vomiting in a university hospital-based ambulatory surgery center: a retrospective observation study 
Korean Journal of Anesthesiology  2013;65(2):142-146.
Background
Ambulatory surgery, including short-stay surgery, has become a common choice in clinical practice. For the success of ambulatory surgery, perioperative care with safe and effective anesthesia and postoperative analgesia, which can reduce the occurrence of postoperative nausea and vomiting (PONV), is essential. The effect of remifentanil on the occurrence and severity of PONV has not been thoroughly examined, particularly, in an ambulatory surgery setting. Here, we investigate whether remifentanil influences the occurrence and severity of PONV in a university hospital-based ambulatory unit.
Methods
We retrospectively analyzed a total of 1,765 cases of patients who had undergone general anesthesia at our ambulatory surgery unit. Parameters, such as occurrence and severity of nausea, vomiting or retching, use of antiemetic drugs, amount of postoperative analgesic and patient satisfaction, were extracted from the records and analyzed between the groups that received and not received remifentanil.
Results
Within 565 patients of the RF group, 39 patients (6.6%) experienced nausea, 7 patients (1.2%) experienced vomiting or retching, and 10 patients (1.8%) were given antiemetic; in addition, the maximum VAS value for nausea was 12.1 mm. In 1,200 patients of the non RF group, 102 patients (8.5%) experienced nausea, 19 patients (1.6%) experienced vomiting or retching, and 34 patients (2.8%) were given antiemetic, and the maximum VAS value was 13.2 mm. There were no statistically significant differences between the two groups.
Conclusions
Our results indicate that remifentanil did not increase the occurrence of PONV in patients within the ambulatory surgery unit.
doi:10.4097/kjae.2013.65.2.142
PMCID: PMC3766780  PMID: 24023997
Ambulatory surgery; Postoperative nausea and vomiting; Remifentanil
3.  Changes in anesthesia related factors in ambulatory knee and shoulder surgery: United States 1996–2006 
Background
Analyses of existing nationally representative information on how changes in ambulatory orthopedic surgery have affected anesthesia practice over time are rare. We sought to characterize temporal changes in factors surrounding ambulatory orthopedic surgery and anesthesia.
Methods
Data from the National Survey of Ambulatory Surgery for the years of 1996 and 2006 were analyzed. Entries indicating the performance of knee ligamentoplasty, meniscectomy or shoulder arthroscopy were identified and included in the sample. Temporal changes in a number of variables associated with orthopedic ambulatory surgery were assessed, including: 1) the number of procedures being performed, 2) patient and health care system related demographics and 3) anesthesia related variables.
Results
Nationwide, the total number of ligamentoplasties, meniscectomies and shoulder arthroscopies increased from 1996 to 2006 by 66% (N=258,932 to N=428,712), 51% (N=456,698 to N=690,164), and 349% (N=93,105 to N=418,188) respectively (P<0.0001). Between 1996 and 2006 the use of peripheral nerve blocks increased from 0.6% to 9.8% for meniscectomies (P<0.0001), from 1.5% to 13.7% for ligamentoplasties (P<0.0001), and from 11.5% to 23.9% for shoulder arthroscopies (P<0.0001), respectively. Neuraxial anesthesia utilization fell from 11.8% to 6.3% for meniscectomies (P<0.0001) and 13.6% to 7.3% for ligamentoplasties (P<0.0001) from 1996 to 2006, respectively.
Conclusion
Substantial increases in the number of ambulatory knee and shoulder procedures occurred over time, relating to increased demand for anesthesia providers in this field. Trends towards increased use of peripheral nerve blocks may have to be considered by educators when preparing residents for practice.
doi:10.1097/AAP.0b013e318217703c
PMCID: PMC3121915  PMID: 21490521
4.  Factors influencing unexpected disposition after orthopedic ambulatory surgery 
Journal of Clinical Anesthesia  2012;24(2):89-95.
Study Objective
To analyze whether patient characteristics, ambulatory facility type, anesthesia provider and technique, procedure type, and temporal factors impact the outcome of unexpected disposition after ambulatory knee and shoulder surgery.
Design
Retrospective analysis of a national database.
Setting
Freestanding and hospital-based ambulatory surgery facilities.
Measurements
Ambulatory knee and shoulder surgery cases from 1996 and 2006 were identified through the National Survey of Ambulatory Surgery. The incidence of unexpected disposition status was determined and risk factors for such outcome were analyzed.
Main Results
Factors independently increasing the risk for unexpected disposition included procedures performed in hospital-based versus freestanding facilities [odds ratio (OR) 6.83 (95% confidence interval [CI] 4.34; 10.75)], shoulder versus knee procedures [OR 3.84 (CI 2.55; 5.77)], anesthesia provided by nonanesthesiology professionals and certified registered nurse-anesthetists versus anesthesiologists [OR 7.33 (CI 4.18; 12.84) and OR 1.80 (CI 1.09; 2.99), respectively]. Decreased risk for unexpected disposition were found for procedures performed in 2006 versus 1996 [OR 0.15 (CI 0.10; 0.24)] and the use of anesthesia other than regional and general [OR 0.34 (CI 0.18; 0.68)].
Conclusions
The decreased risk for unexpected disposition associated with more recent data and with freestanding versus hospital-based facilities may represent improvements in efficiency, while the decreased odds for such disposition status associated with the use of other than general and regional anesthesia may be related to a lower invasiveness of cases. We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. No difference in this outcome was noted when an anesthesia care team provided care.
doi:10.1016/j.jclinane.2011.10.002
PMCID: PMC3303976  PMID: 22305625
Ambulatory surgery; orthopedic surgery: knee, shoulder; unexpected disposition
5.  Regional Anesthesia for Children Undergoing Orthopedic Ambulatory Surgeries in the United States, 1996–2006 
HSS Journal  2012;8(2):133-136.
Background
Our objective was to evaluate national trends in regional anesthetic techniques among children undergoing ambulatory orthopedic procedures.
Purpose and Questions
We aimed to determine whether an increase in regional anesthetics was primarily driven by an increase in the number of peripheral nerve blocks performed rather than an increase in neuraxial techniques. We further aimed to determine whether the proportion of peripheral nerve blocks performed in conjunction with general anesthesia has increased over time.
Patients and Methods
Our study sample included any pediatric patient (i.e., <18 years old) who underwent an orthopedic ambulatory procedure in 1996 and 2006. We obtained data on ambulatory surgical procedures by accessing the Centers for Disease Control and Prevention’s National Survey of Ambulatory Surgery. Patient demographics (age, gender), procedure information, and anesthesia-related variables were analyzed for each year.
Results
The proportion of peripheral nerve blocks performed for ambulatory surgery more than doubled from 1996 (4.4 %) to 2006 (8.1 %). A significantly larger proportion of orthopedic procedures were being performed with a combination of peripheral nerve blocks and general anesthesia (1.2 % in 1996 and 43 % 2006). The use of neuraxial anesthesia for lower extremity surgeries decreased over the 10-year period (1.1 and 0.4 % in 1996 and 2006, respectively).
Conclusions
There was a significant increase in the use of peripheral nerve blocks for children undergoing ambulatory orthopedic procedures in the USA, while neuraxial techniques became less common over the 10-year period. The peripheral nerve blocks were frequently performed in conjunction with general anesthesia.
doi:10.1007/s11420-012-9278-8
PMCID: PMC3715624  PMID: 23874253
regional anesthesia; pediatrics; ambulatory surgery
6.  Specialized Ambulatory Anesthesia Teams Contribute to Decreased Ambulatory Surgery Recovery Room Length of Stay 
The Ochsner Journal  2012;12(2):94-100.
Background
Many institutions have organized specialized groups of ambulatory surgery anesthesiologists with the aim of improving ambulatory surgery patient care and efficiency. We hypothesized that specialized ambulatory anesthesia teams produce better patient outcomes such as lower postoperative nausea and vomiting (PONV) rates, lower postoperative pain scores, and shorter postanesthesia care unit (PACU) lengths of stay (LOS).
Methods
In this prospective observational study, we collected outcomes data on 1,299 patients including incidence of PONV, PACU LOS, maximum and average pain scores, amount of postoperative opioid use, and rescue antiemetic use.
Results
Ambulatory anesthesiologists had statistically shorter phase 2 PACU LOS times (P < .05) and overall recovery times (P < .01). The PONV incidence odds ratio for ambulatory versus nonambulatory anesthesiologists was 1.31 (95% CI 1.01-1.72). We found no significant difference in the amount of postoperative opioid use, maximum postoperative pain scores, or PACU phase 1 LOS time.
Conclusions
The decreased PACU LOS for the study group's patients occurred despite the increased incidence of PONV. Ambulatory anesthesiologists contributed to decreased PACU LOS while practicing evidence-based anesthesia with regard to PONV and pain control. Ambulatory subspecialization may benefit institutions as a way to increase perioperative efficiency and improve surgeon and patient satisfaction.
PMCID: PMC3387853  PMID: 22778673
Ambulatory anesthesia; ambulatory surgery; operating room efficiency
7.  Auricular acupuncture for pain relief after ambulatory knee surgery: a randomized trial 
Background
Auricular acupuncture is a promising method for postoperative pain relief. However, there is no evidence for its use after ambulatory surgery. Our aim was to test whether auricular acupuncture is better than invasive needle control for complementary analgesia after ambulatory knee surgery.
Methods
One hundred and twenty patients undergoing ambulatory arthroscopic knee surgery under standardized general anesthesia were randomly assigned to receive auricular acupuncture or a control procedure. Fixed indwelling acupuncture needles were inserted before surgery and retained in situ until the following morning. Postoperative rescue analgesia was directed to achieve pain intensity less than 40 mm on a 100-mm visual analogue scale. The primary outcome measure was the postoperative requirement for ibuprofen between surgery and examination the following morning.
Results
Intention-to-treat analysis showed that patients from the control group (n = 59) required more ibuprofen than patients from the auricular acupuncture group (n = 61): median (interquartile range) 600 (200–800) v. 200 (0–600) mg (p = 0.012). Pain intensity on a visual analogue scale was similar in both groups at all time points registered. The majority of patients in both groups believed that they had received true acupuncture and wanted to repeat it in future.
Interpretation
Auricular acupuncture reduced the requirement for ibuprofen after ambulatory knee surgery relative to an invasive needle control procedure.
doi:10.1503/cmaj.060875
PMCID: PMC1764794  PMID: 17224599
8.  Use of Articaine in loco-regional anesthesia for day care surgical procedures 
The popularity of day case surgical procedures has increased immensely over the last few years. Though various techniques are available for carrying out day-case anesthesia, preference for a technique depends upon the type of procedure, patient profile, associated co-morbidities, available infrastructure and back-up facilities, monitoring devices and comfort of the attending anesthesiologist with the technique. Day-case spinal anesthesia for ambulatory surgery has gained a wider acceptance and numerous drugs are available for use in loco-regional anesthesia. Articaine is one such amide local anesthetic drug which is increasingly being used in day care surgeries. Properties of articaine such as faster onset, shorter elimination time and rapid recovery from sensory and motor blockade make it a very useful agent in local and regional anesthesia for day care surgical procedures. This article aims to review these properties of articaine so as to evaluate how useful articaine can be for ambulatory surgical procedures.
doi:10.4103/0970-9185.101898
PMCID: PMC3511938  PMID: 23225921
Articaine; Bupivacaine; Day-care surgery; Lignocaine; Neuraxial anesthesia; Prilocaine; Regional anesthesia
9.  Auricular Acupuncture for Pain Relief after Ambulatory Knee Arthroscopy—A Pilot Study 
Auricular acupuncture (AA) is effective in treating various pain conditions, but there have been no analyses of AA for the treatment of pain after ambulatory knee surgery. We assessed the range of analgesic requirements under AA after ambulatory knee arthroscopy. Twenty patients randomly received a true AA procedure (Lung, Shenmen and Knee points) or sham procedure (three non-acupuncture points on the auricular helix) before ambulatory knee arthroscopy. Permanent press AA needles were retained in situ for one day after surgery. Post-operative pain was treated with non-steroidal anti-inflammatory ibuprofen, and weak oral opioid tramadol was used for rescue analgesic medication. The quantity of post-operative analgesics and pain intensity were used to assess the effect of AA. The incidence of analgesia-related side effects, time to discharge from the anesthesia recovery room, heart rate and blood pressure were also recorded. Ibuprofen consumption after surgery in the AA group was lower than in the control group: median 500 versus 800 mg, P = 0.043. Pain intensity on a 100 mm visual analogue scale for pain measurement and other parameters were similar in both groups. Thus AA might be useful in reducing the post-operative analgesic requirement after ambulatory knee arthroscopy.
doi:10.1093/ecam/neh097
PMCID: PMC1142209  PMID: 15937559
ambulatory surgery; auricular acupuncture; post-operative pain
10.  Takotsubo cardiomyopathy during ambulatory anesthesia for bladder hydrodistension therapy -A case report- 
Korean Journal of Anesthesiology  2012;62(5):484-487.
Stress-induced cardiomyopathy, also referred to Takotsubo cardiomyopathy or apical ballooning syndrome presents in perioperative period. We demonstrated a case of Takotsubo cardiomyopathy recognized after general anesthesia for bladder hydrodistension therapy as ambulatory surgery, which we surmise was due to inadequate blockage of surgical stress and sympathetic discharge against noxious stimulus during ambulatory anesthesia.
doi:10.4097/kjae.2012.62.5.484
PMCID: PMC3366318  PMID: 22679548
Ambulatory surgery; Apical ballooning syndrome; Hydrodistension of bladder; Takotsubo cardiomyopathy
11.  PONV in Ambulatory surgery: A comparison between Ramosetron and Ondansetron: a prospective, double-blinded, and randomized controlled study 
Saudi Journal of Anaesthesia  2014;8(1):25-29.
Background:
postoperative nausea and vomiting (PONV) frequently hampers implementation of ambulatory surgery in spite of so many antiemetic drugs and regimens.
Aims:
the study was carried out to compare the efficacy of Ramosetron and Ondansetron in preventing PONV after ambulatory surgery.
Setting and Design:
it was a prospective, double blinded, and randomized controlled study.
Methods:
124 adult patients of either sex, aged 25-55, of ASA physical status I and II, scheduled for day care surgery, were randomly allocated into Group A [(n=62) receiving (IV) Ondansetron (4 mg)] and Group B [(n=62) receiving IV Ramosetron (0.3 mg)] prior to the induction of general anesthesia in a double-blind manner. Episodes of PONV were noted at 0.5, 1, 2, 4 h, 6, 12, and 18 h postoperatively.
Statistical Analysis and Results:
statistically significant difference between Groups A and B (P <0.05) was found showing that Ramosetron was superior to Ondansetron as antiemetic both regarding frequency and severity.
Conclusion:
it was evident that preoperative prophylactic administration of single dose IV Ramosetron (0.3 mg) has better efficacy than single dose IV Ondansetron (4 mg) in reducing the episodes of PONV over 18 h postoperatively in patients undergoing day-care surgery under general anesthesia.
doi:10.4103/1658-354X.125917
PMCID: PMC3950448  PMID: 24665236
Ambulatory (day care) surgery; American Society of Anaesthesiologists; Ondansetron; postoperative nausea and vomiting; Ramosetron; visual analogue score
12.  Effect of Dexmedetomidine on Sevoflurane Requirements and Emergence Agitation in Children Undergoing Ambulatory Surgery 
Yonsei Medical Journal  2013;55(1):209-215.
Purpose
Dexmedetomidine, a potent selective α2-adrenergic agonist, produces sedation and analgesia. This study was conducted to assess the effect of dexmedetomidine infusion on sevoflurane requirements, recovery profiles, and emergence agitation in children undergoing ambulatory surgery.
Materials and Methods
Forty children undergoing ambulatory hernioplasty or orchiopexy were randomized into two groups. The dexmedetomidine group (Group D, n=20) received dexmedetomidine 1 µg/kg, followed by 0.1 µg/kg/h until the end of surgery, whereas the saline group (Group S, n=20) received volume-matched normal saline. Sevoflurane was used for induction and maintenance of anesthesia and caudal block was performed in all children. End-tidal sevoflurane concentration (ET-sevo), the incidence of emergence agitation, pain scores, and sedation scores were recorded. Hemodynamic changes and other adverse effects were assessed in the perioperative period.
Results
ET-sevo of Group D was significantly reduced in 23.8-67% compared to Group S during surgery. The incidence of emergence agitation was lower in Group D than in Group S (5% vs. 55%, p=0.001). Postoperative pain was comparable, and discharge time was not different between the groups. Mean arterial pressure and heart rate were significantly lower in Group D during surgery.
Conclusion
Intraoperative infusion of dexmedetomidine reduced sevoflurane requirements and decreased emergence agitation without delaying discharge in children undergoing ambulatory surgery. However, caution should be taken in regard to bradycardia and hypotension.
doi:10.3349/ymj.2014.55.1.209
PMCID: PMC3874907  PMID: 24339309
Agitation; ambulatory surgery; dexmedetomidine; emergence; sevoflurane
13.  Volume and acidity of residual gastric fluid after oral fluid ingestion before elective ambulatory surgery. 
We studied 211 unselected, healthy, adult patients scheduled to undergo elective ambulatory surgery to determine whether the volume or pH of gastric fluid at induction of anesthesia is correlated with the duration of the preoperative fluid fast. Patients were instructed that they must not eat any solid food after midnight but that they were permitted to drink 150 ml of tea, coffee, apple juice or water until 3 hours before their scheduled time of surgery. Patients with gastric disorders and those taking medications that affect gastric motility or secretion were excluded. No premedicant drugs were given. Following induction of general anesthesia the gastric fluid was aspirated through an orogastric tube, its volume recorded and its pH measured with a calibrated pH meter. The patients were retrospectively assigned to one of four groups according to the interval from last fluid ingestion until induction of anesthesia (less than 3 hours, 3 to 4.9 hours, 5 to 8 hours and nothing after midnight). The mean values and extremes for gastric fluid volume and pH were similar in the four groups. We conclude that healthy patients should be allowed to ingest fluid until 3 hours before elective ambulatory surgery.
PMCID: PMC1451262  PMID: 2819633
14.  External fixation of “intertrochanteric” fractures 
Orthopedic Reviews  2009;1(2):e18.
In developing countries, due to limited availability of modern anesthesia and overcrowding of the hospitals with patients who need surgery, high-risk patients with “intertrochanteric” fractures remain unsuita ble for open reduction and internal fixation.
The aim of this study was to analyze the results of external fixation of “intertrochanteric” fractures in high-risk geriatric patients in a developing country.
The results of 62 ambulatory high-risk geriatric patients with a mean age of 70 years (range 58–90 years) with “intertrochanteric” fractures, in whom external fixation was performed, are reported.
Eight patients died during follow-up due to medical causes unrelated to the surgical procedure. So only 54 patients were available for final assessment. Procedure is simple, performed under local anesthesia, requires less time for surgery and is associated with less blood loss. Good fixation and early ambulation was achieved in most of the patients. Average time to union was 14 weeks. Thirty-one patients developed superficial pin tract infection and 28 patients had average shortening of 15 mm due to impaction and varus angulation. Functional outcome was assessed using Judet's point system. Good to excellent results were achieved in 44 patients.
This study demonstrated that external fixation of “intertrochantric” fractures performed under local anesthesia offers significant advantage in ambulatory high-risk geriatric patients especially in a developing country.
doi:10.4081/or.2009.e18
PMCID: PMC3143994  PMID: 21808680
15.  Caffeine for the prevention of postoperative nausea and vomiting 
Context:
Postoperative nausea and vomiting (PONV) is common after ambulatory surgery performed under general anesthesia. Anecdotal evidence suggests that caffeine may be useful in preventing PONV.
Aims:
The aim of the study was to determine efficacy of intravenous (IV) caffeine given prior to surgery is effective prophylaxis against PONV.
Settings and Design:
We conducted a prospective, randomized, double-blind, placebo-controlled study.
Subject and Methods:
Patients at moderate or high risk of PONV were randomized to receive IV caffeine (500 mg) or saline placebo during general anesthesia; all patients received dexamethasone and dolasetron.
Statistical analysis:
Statistical comparisons were tested using bivariable linear and logistic regression for each outcome and then adjusted for high/low risk.
Results:
Nausea in the postanesthesia care unit (PACU) was more common in the caffeine (16 of 62 patients) than the placebo group (seven of 69; P = 0.02). There were no significant differences in the use of rescue antiemetics in the PACU, in the incidence of nausea or vomiting over 24 h postoperatively, nor in other outcomes (headache, fatigue, or overall satisfaction) either in the PACU or at 24 h; time-to-discharge was similar for both groups.
Conclusion:
Caffeine was not effective in the prevention of PONV or headache, and did not improve time-to-discharge or patient satisfaction.
doi:10.4103/0970-9185.119170
PMCID: PMC3819849  PMID: 24249992
Antiemetic prophylaxis; caffeine; postoperative nausea; postoperative vomiting
16.  Anesthesiologists' practice patterns for treatment of postoperative nausea and vomiting in the ambulatory Post Anesthesia Care Unit 
BMC Anesthesiology  2006;6:6.
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 for PONV treatment.
Conclusion
5-HT3-antagonists are the most common choice for treatment of established PONV for outpatients when no prophylaxis is used, and also following prophylactic regimens that include a 5HT3 antagonist, regardless of the number of prophylactic antiemetics given. Whereas 3% – 7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% of practitioners would re-dose the 5-HT3-antagonist for PONV treatment.
doi:10.1186/1471-2253-6-6
PMCID: PMC1525160  PMID: 16740165
17.  Dynamics of Elective Case Cancellation for Inpatient and Outpatient in an Academic Center 
Background
Unexpected surgical cancellation is common and can have significant adverse effects. Cancellation rates vary because of a lack of a standard definition, different patient populations and study methodology. We hypothesized that case cancellation has a different pattern in a dedicated ambulatory surgical center compared to a general operating room (OR) setting in a large academic center without an anesthesia preoperative evaluation center necessitating evaluation by the various surgeons.
Methods
Elective cases in general OR and in the ambulatory surgical center were included in this study. Elective cases are defined as the non-emergent cases scheduled before 8:00 am on the day of surgery. A cancelled case was defined as a scheduled procedure which is not performed on the scheduled procedure day. Case cancellation was monitored in real time using an electronic patient flow system (Navicare). As soon as the case is cancelled, the reason for the cancellation was obtained from the surgeon, the anesthesiologist, the OR coordinated nurses and/or the floor nurse. In the day surgical center, the cancelled cases were followed to determine whether/when they were rescheduled.
Results
4261 elective cases were included in this investigation, including 2751 cases in the general OR and 1510 cases in the ambulatory surgical center. A total of 283 cases (6.6%) were cancelled which include 206 cases from the general OR and 77 from the ambulatory surgical center. The cancellation rate in the general OR was 7.5%, among which inpatients have the highest cancellation rate of 18.1%, followed by outpatients at 4.6%, and same day admission at the lowest cancellation rate of 2.0%. The top 3 reasons for cancellation in general OR werein adequate preoperative preparation 29.4 ± 4.5%, medical condition change 28.5 ± 10.2%; and scheduling issue 20.2 ± 7.1%. Most (59.2 ± 8.9%) of the cancellations was considered preventable, 12.3 ± 5.9% was considered potentially preventable, and 28.5 ± 10.2% were not preventable (such as patient condition changes). The cancellation rate in the ambulatory surgical center was 5.1%. The major reason for cancellation was patient no show 75.8 ± 5.2 %, 61% of those no show patients were rescheduled and the mean delay in surgery was 18 days (range from 1 day to 84 days).
Conclusions
Case cancellation is not un-common in a large academic center without a preoperative evaluation clinic. The dynamics of case cancellation are different in an ambulatory surgical center as compared to the general OR. Inpatients have the highest cancellation rate associated with inadequate preoperative preparation and scheduling, this should be preventable via adopting proper systems of evaluation and preparation. Most of the case cancellations in the ambulatory surgical center are from patient no show, suggesting that administrative strategies to reduce this issue should be implemented. The patients admitted on the same day of surgery had the lowest cancellation rate requiring minimal intervention.
PMCID: PMC3839960  PMID: 24286019
18.  The impact of local anesthetic distribution on block onset in Ultrasound-guided interscalene block 
Acta anaesthesiologica Scandinavica  2012;56(9):1146-1151.
Background
Recent investigations of local anesthetic distribution in the lower extremity have revealed that completely surrounding the sciatic nerve with local anesthetic provides the advantage of more rapid and complete anesthesia in the territory served by the nerve. We hypothesized that a pattern of distribution which entirely envelops the targeted nerve roots during interscalene block would provide similar benefits of more rapid anesthesia onset.
Methods
During interscalene block guided by ultrasound with nerve-stimulator confirmation, the pattern of local anesthetic distribution was recorded and later classified as complete or incomplete envelopment of the visible nerve elements in 50 patients undergoing ambulatory shoulder arthroscopic surgery. The pattern was then compared to the extent of block set-up at predetermined intervals, as well as to postoperative pain levels and block duration.
Results
22 patients (44%) had complete envelopment of the nerves in the plane of injection during ultrasound imaging of the interscalene block. There was no difference in the fraction of blocks that were fully set-up at 10 minutes with regards to complete or incomplete envelopment of the nerves by local anesthetic. All of the patients had complete set-up of the block by 20 minutes. In addition, the postoperative pain levels and duration of block did not vary among the two groups with complete versus incomplete local anesthetic distribution around the nerves.
Conclusion
The presence or absence of complete envelopment of the nerve elements in the interscalene groove by local anesthetic did not determine the likelihood of complete block effect at predetermined time intervals after the procedure.
doi:10.1111/j.1399-6576.2012.02745.x
PMCID: PMC3653130  PMID: 22845687
19.  Wide-Awake Wrist Arthroscopy and Open TFCC Repair 
Journal of Wrist Surgery  2012;1(1):55-60.
The wide-awake approach to hand surgery entails the use of local infiltration anesthesia using lidocaine with epinephrine and no tourniquet. The technique provides practitioners with an option to perform advanced hand surgical care in an ambulatory setting, without the need for general or regional anesthetics. We present our results using wide-awake approach in wrist surgery, both open and arthroscopic. Between June and August 2011, the wide-awake approach was used in nine elective wrist surgery cases; three arthroscopic procedures, four open triangular fibrocartilage complex (TFCC) repairs, and two combined arthroscopy/open surgery (eight men/one woman). The arthroscopic patients were anesthetized using dorsal infiltration of lidocaine with epinephrine (20 mL) with an additional intra-articular 5 mL injection 30 minutes before surgery. The open surgery patients received 40 mL of lidocaine with epinephrine around the ulnar aspect of the forearm, from 8-cm proximal to 3-cm distal to the distal radioulnar joint. Standard diagnostic radio- and midcarpal arthroscopies were performed, where one patient had a loose body removed and two patients underwent TFCC debridements due to central TFCC tears. The six open cases were all due to TFCC foveal disruptions, which were reinserted using osteosutures in the distal ulna. Following placement of the ligament sutures, a preliminary knot allowed active and passive motion testing of pronosupination, to determine the adequate amount of tension in the ligaments. The wide-awake approach to wrist surgery is a plausible and reliable technique that eliminates the need for general anesthesia, removes the need of a tourniquet, and provides a cost-efficient and safe approach to wrist surgery. The ability to control ligament reconstructions using active motion may additionally enhance the rehabilitation of these patients, both through early proprioceptive awareness and adequate tensioning of soft tissues.
doi:10.1055/s-0032-1312045
PMCID: PMC3658674  PMID: 23904980
arthroscopy; local anesthesia; proprioception; TFCC; wide-awake surgery; wrist
20.  Outpatient Cataract and Intraocular Lens Surgery 
Outpatient ophthalmic surgery has arrived, and ambulatory surgical centers are cropping up all across the country. Government and third-party payers have produced significant financial incentives for performing outpatient surgery, but there are, perhaps, more compelling reasons for allowing this option for patients. Advantages accrue to both the patient and the ophthalmic surgeon. Disadvantages can be minimized and the prospects for success can be maximized through proper preoperative workup, anesthesia management, and postoperative follow-up.
In the experience of one of the authors with outpatient cataract and intraocular lens surgery, 66.7 percent of outpatients achieved visual acuity of 20/40 or better and 33.3 percent of inpatients achieved visual acuity of 20/40 or better. All patients had significant improvement in vision, and failure to achieve a 20/40 level of vision was caused by preoperative pathology. Because of these considerations, the authors believe that it is not only reasonable but prudent to direct the development of skills and techniques toward even safer and more efficient outpatient ophthalmic surgery.
PMCID: PMC2561803  PMID: 6512877
21.  Tramadol/paracetamol combination tablet for postoperative pain following ambulatory hand surgery: a double-blind, double-dummy, randomized, parallel-group trial 
Journal of Pain Research  2011;4:103-110.
This randomized, double-blind, double-dummy, multicenter trial compared efficacy and safety of tramadol HCL 37.5 mg/paracetamol 325 mg combination tablet with tramadol HCL 50 mg capsule in the treatment of postoperative pain following ambulatory hand surgery with iv regional anesthesia. Patients received trial medication at admission, immediately after surgery, and every 6 hours after discharge until midnight of the first postoperative day. Analgesic efficacy was assessed by patients (n = 128 in each group, full analysis set) and recorded in a diary on the evening of surgery day and of the first postoperative day. They also documented the occurrence of adverse events. By the end of the first postoperative day, the proportion of treatment responders based on treatment satisfaction (primary efficacy variable) was comparable between the groups (78.1% combination, 71.9% tramadol; P = 0.24) and mean pain intensity (rated on a numerical scale from 0 = no pain to 10 = worst imaginable pain) had been reduced to 1.7 ± 2.0 for both groups. Under both treatments, twice as many patients experienced no pain (score = 0) on the first postoperative day compared to the day of surgery (35.9% vs 16.4% for tramadol/paracetamol and 36.7% vs 18% for tramadol treatment). Rescue medication leading to withdrawal (diclofenac 50 mg) was required by 17.2% patients with tramadol/paracetamol and 13.3% with tramadol. Adverse events (mainly nausea, dizziness, somnolence, vomiting, and increased sweating) occurred less frequently in patients under combination treatment (P = 0.004). Tramadol/paracetamol combination tablets provided comparable analgesic efficacy with a better safety profile to tramadol capsules in patients experiencing postoperative pain following ambulatory hand surgery.
doi:10.2147/JPR.S16760
PMCID: PMC3085269  PMID: 21559356
ambulatory hand surgery; analgesia; combination therapy; paracetamol; postoperative pain; tramadol
22.  Anesthetic implications of laparoscopic surgery. 
Minimally invasive therapy aims to minimize the trauma of any interventional process but still achieve a satisfactory therapeutic result. The development of "critical pathways," rapid mobilization and early feeding have contributed towards the goal of shorter hospital stay. This concept has been extended to include laparoscopic cholecystectomy and hernia repair. Reports have been published confirming the safety of same day discharge for the majority of patients. However, we would caution against overenthusiastic ambulatory laparoscopic cholecystectomy on the rational but unproven assumption that early discharge will lead to occasional delays in diagnosis and management of postoperative complications. Intraoperative complications of laparoscopic surgery are mostly due to traumatic injuries sustained during blind trocar insertion and physiologic changes associated with patient positioning and pneumoperitoneum creation. General anesthesia and controlled ventilation comprise the accepted anesthetic technique to reduce the increase in PaCO2. Investigators have recently documented the cardiorespiratory compromise associated with upper abdominal laparoscopic surgery, and particular emphasis is placed on careful perioperative monitoring of ASA III-IV patients during insufflation. Setting limits on the inflationary pressure is advised in these patients. Anesthesiologists must maintain a high index of suspicion for complications such as gas embolism, extraperitoneal insufflation and surgical emphysema, pneumothorax and pneumomediastinum. Postoperative nausea and vomiting are among the most common and distressing symptoms after laparoscopic surgery. A highly potent and selective 5-HT3 receptor antagonist, ondansetron, has proven to be an effective oral and IV prophylaxis against postoperative emesis in preliminary studies. Opioids remain an important component of the anesthesia technique, although the introduction of newer potent NSAIDs may diminish their use. A preoperative multimodal analgesic regimen involving skin infiltration with local anesthesia. NSAIDs to attenuate peripheral pain and opioids for central pain may reduce postoperative discomfort and expedite patient recovery/discharge. There is no conclusive evidence to demonstrate clinically significant effects of nitrous oxide on surgical conditions during laparoscopic cholecystectomy or on the incidence of postoperative emesis. Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gallbladder disease.
PMCID: PMC2578944  PMID: 10604786
23.  Nitrous Oxide and the Inhalation Anesthetics 
Anesthesia Progress  2008;55(4):124-131.
Nitrous oxide is the most commonly used inhalation anesthetic in dentistry and is commonly used in emergency centers and ambulatory surgery centers as well. When used alone, it is incapable of producing general anesthesia reliably, but it may be combined with other inhalation and/or intravenous agents in deep sedative/general anesthestic techniques. However, as a single agent, it has impressive safety and is excellent for providing minimal and moderate sedation for apprehensive dental patients. To gain a full appreciation of the pharmacology, physiologic influences, and proper use of nitrous oxide, one must compare it with other inhalation anesthetics. The purpose of this CE article is to provide an overview of inhalation anesthetics in general and to address nitrous oxide more specifically in comparison.
doi:10.2344/0003-3006-55.4.124
PMCID: PMC2614651  PMID: 19108597
General anesthesia; Inhalation anesthetics; Nitrous oxide; Conscious sedation; Moderate sedation
24.  Reducing Nasopharyngeal Trauma: The Urethral Catheter–Assisted Nasotracheal Intubation Technique 
Anesthesia Progress  2011;58(1):26-30.
Nasal intubation is an advantageous approach for dental procedures performed in the hospital, ambulatory surgery center, or dental office, when possible. Although many who provide anesthesia services are familiar and comfortable with nasal intubation techniques, some are reluctant and uncomfortable because of lack of experience or fear of nasopharyngeal bleeding and trauma. It has been observed from experiences in various settings that many approaches may be adapted to the technique of achieving nasal intubation. The technique that is described in this paper suggests a minimally invasive approach that introduces the nasoendotracheal tube through the nasopharyngeal pathway to the oropharynx in an expedient manner while preserving the nasopharyngeal structures, thus lessening nasal bleeding and trauma to soft tissues. The technique uses a common urethral catheter and can be incorporated along with current intubation armamentaria. As with all techniques, some limitations to the approach have been identified and are described in this paper. Cases with limited mouth opening, neck injury, and difficult airways may necessitate alternative methods. However, the short learning curve along with the many benefits of this technique offers the anesthesia professional additional options for excellent patient care.
doi:10.2344/0003-3006-58.1.26
PMCID: PMC3262400  PMID: 21410362
Nasotracheal tube; Nasopharyngeal; Intubation; Special needs; Urethral catheter; Epistaxis
25.  Can bilateral bronchospasm be a sign of unilateral phrenic nerve palsy after supraclavicular brachial plexus block? 
Ultrasound-guided peripheral nerve blocks facilitate ambulatory anesthesia for upper limb surgeries. Unilateral phrenic nerve blockade is a common complication after interscalene brachial plexus block, rather than the supraclavicular block. We report a case of severe respiratory distress and bilateral bronchospasm following ultrasound-guided supraclavicular brachial plexus block. Patient did not have clinical features of pneumothorax or drug allergy and was managed with oxygen therapy and salbutamol nebulization. Chest X-ray revealed elevated right hemidiaphragm confirming unilateral phrenic nerve paresis.
doi:10.4103/0970-9185.94912
PMCID: PMC3339737  PMID: 22557755
Bronchospasm; phrenic nerve blockade; supraclavicular block; ultrasound guided

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