Does small-dose fentanyl improve perioperative outcomes in the ambulatory setting? A randomized, double-blind, placebo-controlled study.

BACKGROUND: Despite its widespread use, the beneficial effect of low-dose fentanyl administered at induction of anesthesia on perioperative outcomes has not been studied in the ambulatory setting. Therefore, this study was designed to test the hypothesis that administration of small-dose fentanyl vs. saline during induction reduces coughing and movements without adversely affecting recovery after day-surgery. METHODS: One hundred consenting outpatients scheduled to undergo superficial surgical procedures under general anesthesia with a laryngeal mask airway (LMA) device for airway management were randomly assigned to one of two treatment groups: control (n = 50) or fentanyl (n = 50). After administration of 2 ml of the unlabelled study medication containing either fentanyl (100 µg) or saline, anesthesia was induced with lidocaine 30-50 mg and propofol 2 mg/kg IV followed by the insertion of an LMA device. General anesthesia was maintained using a propofol infusion, 75 µg/kg/min, and desflurane (2-5% end-tidal) in 100% oxygen. RESULTS: Coughing was observed in six (12%) and ten (20%) in the fentanyl and control group, respectively (P = 0.41). The incidence of movements during surgery was lower in the fentanyl group (18% vs. 31%, P < 0001). There were no significant differences in early and late recovery times or pain scores between the two groups. CONCLUSION: Administration of a small-dose of fentanyl at induction of anesthesia significantly reduced purposeful movements during day-surgery under propofol-desflurane anesthesia. No significant difference was found in coughing or recovery times.

Association of increased postoperative opioid administration with non-small-cell lung cancer recurrence: a retrospective analysis.

BACKGROUND: Evidence suggests that opioid-sparing anaesthetic techniques might be associated with increased cancer-free postoperative survival. This could be related to suppression of natural killer cells by opioid analgesics in the perioperative period. This retrospective analysis tested the hypothesis that greater opioid use in the postoperative period is associated with a higher incidence of recurrences after surgery for lung cancer. METHODS: The medical records of 99 consecutive patients who underwent video-assisted thoracoscopic surgery with lobectomy for Stage I or IIa biopsy-proven non-small-cell lung cancer (NSCLC) were reviewed. Perioperative information including patient characteristics, laboratory data, and surgical, anaesthetic, nursing, and pharmacy reports were collected. Doses of opioids administered intra-operatively and for the first 96 h after operation were converted into equianalgesic doses of oral morphine using a standard conversion table. Data were then compared with the National Cancer Registry's incidence of disease-free survival for 5 yr. RESULTS: A total of 99 patients with similar characteristics were included in the final analysis, 73 of whom were NSCLC recurrence-free at 5 yr and 26 had NSCLC recurrence within 5 yr. Total opioid dose during the 96 h postoperative period was 124 (101) mg of morphine equivalents in the cancer-free group and 232 mg (355) mg in the recurrence group (P=0.02). CONCLUSIONS: This retrospective analysis suggests an association between increased doses of opioids during the initial 96 h postoperative period with a higher recurrence rate of NSCLC within 5 yr.

Awake insertion of the fibreoptic intubating LMA CTrach in three morbidly obese patients with potentially difficult airways.

The Intubating Laryngeal Mask Airway (ILMA) is a supraglottic airway that facilitates ventilation and blind tracheal intubation. The LMA CTrach is functionally identical to the ILMA, but has an integrated fibreoptic bundle that provides a view of the larynx. This enables visualisation of tracheal intubation while delivering 100% oxygen, with or without an inhalational anaesthetic. We report awake insertion of the CTrach in three morbidly obese patients (BMI 60-63) with known or anticipated difficult airways. Pre-operatively, patients were given midazolam and glycopyrrolate intravenously, and then in the operating theatre the airway was anaesthetised with topical lidocaine 4%. The CTrach was inserted into the oropharynx of the still-awake patient, the vocal cords were visualised, and anaesthetic induction was commenced with sevoflurane and spontaneous ventilation. Neuromuscular blockers were not used and we were able to see the vocal cords during the entire anaesthetic induction and intubation.

The recovery of cognitive function after general anesthesia in elderly patients: a comparison of desflurane and sevoflurane.

UNLABELLED: We evaluated the cognitive recovery profiles in elderly patients after general anesthesia with desflurane or sevoflurane. After IRB approval, 70 ASA physical status I-III consenting elderly patients (> or =65 yr old) undergoing total knee or hip replacement procedures were randomly assigned to one of two general anesthetic groups. Propofol and fentanyl were administered for induction of anesthesia, followed by either desflurane 2%-4% or sevoflurane 1%-1.5% with nitrous oxide 65% in oxygen. The desflurane (2.5 +/- 0.6 MAC. h) and sevoflurane (2.7 +/- 0.5 MAC. h) concentrations were adjusted to maintain comparable depths of hypnosis using the electroencephalogram bispectral index monitor. The Mini-Mental State (MMS) test was used to assess cognitive function preoperatively and postoperatively at 1, 3, 6, and 24-h intervals. The use of desflurane was associated with a more rapid emergence from anesthesia (6.3 +/- 2.4 min versus 8.0 +/- 2.8 min) and a shorter length of stay in the postanesthesia care unit (213 +/- 66 min versus 241 +/- 87 min). However, there were no significant differences between the Desflurane and the Sevoflurane groups when the MMS scores were compared preoperatively, and postoperatively at 1, 3, 6, and 24 h. Compared with the preoperative (baseline) MMS scores, the values were significantly decreased at 1 h postoperatively (27.8 +/- 1.7 versus 29.5 +/- 0.5 in the Desflurane group, and 27.4 +/- 1.7 versus 29.2 +/- 1.0 in the Sevoflurane group, respectively). However, the MMS scores returned to preoperative baseline levels within 6 h after surgery. At 1 h and 3 h after surgery, 51% and 11% (versus 57% and 9%) of patients in the Desflurane (versus Sevoflurane) Group experienced cognitive impairment. In conclusion, desflurane is associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar after desflurane and sevoflurane-based anesthesia. IMPLICATIONS: Desflurane was associated with a faster early recovery than sevoflurane after general anesthesia in elderly patients. However, recovery of cognitive function was similar with both volatile anesthetics.

Metabolic substrates other than glucose support axon function in central white matter.

We tested the hypothesis that non-glucose energy sources can support axon function in the rat optic nerve. Axon function was assessed by monitoring the stimulus-evoked compound action potential (CAP). CAP was maintained at full amplitude for 2 hr in 10 mM glucose. 20 mM lactate, 20 mM pyruvate, 10 mM fructose, or 10 mM mannose supported axon function as effectively as did glucose, and 10 mM glutamine provided partial support, but beta-hydroxybutyrate, octanoate, sorbitol, alanine, aspartate, and glutamate failed to support axon function. Our results indicated that a variety of compounds can sustain function in CNS myelinated axons. Axons probably use lactate, pyruvate, and glutamine directly as energy substrates, whereas mannose and fructose could be shuttled through astrocytes to lactate, which is then exported to axons.

American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. Also: update 2001--testing for early lung cancer detection.

Updates to the American Cancer Society (ACS) guidelines regarding screening for the early detection of prostate, colorectal, and endometrial cancers, based on the recommendations of recent ACS workshops, are presented. Additionally, the authors review the "cancer-related check-up," clinical encounters that provide case-finding and health counseling opportunities. Finally, the ACS is issuing an updated narrative related to testing for early lung cancer detection for clinicians and individuals at high risk of lung cancer in light of emerging data on new imaging technologies. Although it is likely that current screening protocols will be supplanted in the future by newer, more effective technologies, the establishment of an organized and systematic approach to early cancer detection would lead to greater utilization of existing technology and greater progress in cancer control.

The effect of timing of dolasetron administration on its efficacy as a prophylactic antiemetic in the ambulatory setting.

UNLABELLED: Dolasetron (12.5 mg IV) is effective in both preventing and treating postoperative nausea and vomiting (PONV) after ambulatory surgery. However, the optimal timing of dolasetron administration and its effect on the patient's quality of life after discharge have not been established. One-hundred-five healthy, consenting women undergoing gynecologic laparoscopic procedures with a standardized general anesthetic technique were enrolled in this randomized, double-blinded study. Group 1 received dolasetron 12.5 mg IV 10-15 min before the induction of anesthesia; Group 2 received dolasetron 12.5 mg IV at the end of the laparoscopy (79 +/- 48 min later than Group 1); and Group 3 received dolasetron 12.5 mg IV at the end of anesthesia (93 +/- 52 min later than Group 1). The incidence of PONV, complete responses (defined as no emetic episodes and no rescue medication within the 24-h period after anesthesia), recovery profiles, and patient satisfaction were recorded. In the postanesthesia care unit and during the 24-h follow-up period, the incidence of nausea and vomiting, as well as the need for rescue antiemetics, did not differ significantly among the three groups. The percentages of patients with complete responses to the study drug within the first postoperative 24 h were also similar in all three groups (55%, 59%, and 52% for Groups 1, 2, and 3, respectively). The early and intermediate recovery profiles, including resumption of a normal diet and patient satisfaction with the control of PONV, were not different among the three study groups. Dolasetron 12.5 mg IV administered before the induction of anesthesia is as effective as dolasetron given at the end of laparoscopy or at the end of anesthesia in preventing PONV after outpatient laparoscopy. IMPLICATIONS: The timing of dolasetron administration appears to have little effect on its efficacy when administered as a prophylactic antiemetic in the ambulatory setting.

Ionic mechanisms of aglycemic axon injury in mammalian central white matter.

The authors investigated ionic mechanisms underlying aglycemic axon injury in adult rat optic nerve, a central white matter tract. Axon function was assessed using evoked compound action potentials (CAPs). Glucose withdrawal led to delayed CAP failure, an alkaline extracellular pH shift, and an increase in extracellular [K(+)]. Sixty minutes of glucose withdrawal led to irreversible axon injury. Aglycemic axon injury required extracellular calcium; the extent of injury progressively declined as bath [Ca(2+)] was decreased. To evaluate Ca(2+) movements during aglycemia, the authors recorded extracellular [Ca(2+)] ([Ca(2+)](o)) using Ca(2+)-sensitive microelectrodes. Under control conditions, [Ca(2+)](o) fell with a similar time course to CAP failure, indicating extracellular Ca(2+) moved to an intracellular position during aglycemia. The authors quantified the magnitude of [Ca(2+)]o decrease as the area below baseline [Ca(2+)]o during aglycemia and used this as a qualitative measure of Ca(2+) influx. The authors studied the mechanisms of Ca(2+) influx. Blockade of Na(+) influx reduced Ca(2+) influx and improved CAP recovery, suggesting Na(+)-Ca(2+) exchanger involvement. Consistent with this hypothesis, bepridil reduced axon injury. In addition, diltiazem or nifedipine decreased Ca(2+) influx and increased CAP recovery. The authors conclude aglycemic central white matter injury is caused by Ca(2+) influx into intracellular compartments through reverse Na(+)-Ca(2+) exchange and L-type Ca(2+) channels.

Evaluation of documentation before and after implementation of a nursing information system in an acute care hospital.

Economic pressures on healthcare systems have intensified the necessity of demonstrating the unique contribution of nursing care to patient outcomes. The use of nursing information systems (NIS) has increased completeness of some nursing documentation elements. This study's purpose was to evaluate differences in documentation completeness of nurse assessments of patient outcomes (NASSESS), achievement of patient outcomes (NGOAL), nursing interventions done (NQUAL), and routine assessments before and after implementation of an NIS in a 100-bed urban university hospital in west Tennessee and before and after retraining in NIS use and care planning. NIS implementation did not improve documentation within the first six months. However, retraining and continued NIS use did significantly improve NASSESS, NGOAL, NQUAL, and blood pressure documentation 18 months postimplementation. Nurses must evaluate documentation completeness before and periodically after NIS implementation, using results to improve patient record data validity for patient care decisions, quality improvement, and research.

Fast-track office-based anesthesia: a comparison of propofol versus desflurane with antiemetic prophylaxis in spontaneously breathing patients.

IMPLICATIONS: Compared to propofol, maintenance of anesthesia with desflurane provided significantly better intraoperative conditions during office-based surgery. In addition, desflurane with routine antiemetic prophylaxis was associated with a faster early recovery and similar incidence of postoperative side effects.

Substance P (Neurokinin-1) antagonist prevents postoperative vomiting after abdominal hysterectomy procedures.

BACKGROUND: The safety and antiemetic efficacy of CP-122,721, a novel neurokinin-1 antagonist, was evaluated when administered alone or in combination with ondansetron. METHODS: Using a randomized, double-blind, placebo-controlled study design, CP-122,721 was initially compared with placebo and subsequently to ondansetron alone and in combination for prophylaxis against postoperative nausea and vomiting in 243 women undergoing abdominal hysterectomy. In the dose-ranging studies (n = 86), patients received either CP-122,721 100 mg (vs. placebo) or 200 mg (vs. placebo) orally 60-90 min before induction of anesthesia. In the interaction study (n = 157), patients received CP-122,721 200 mg or placebo 60-90 min before induction of anesthesia, and ondansetron 4 mg or saline 2 ml intravenously 15-30 min before the end of surgery. Patients assessed their level of nausea and pain on arrival in the postanesthesia care unit and at 0.5-, 1-, 1.5-, 2-, 4-, 8-, 12-, and 24-h intervals postoperatively. Emetic episodes, need for rescue antiemetic-antinausea medication, postoperative complications, and patient satisfaction were recorded. RESULTS: In the initial dose-ranging study, only 10% of the patients experienced emesis within the first 8 h after surgery with CP-122,721 200 mg compared with 50% in the placebo group. CP-122,721 200 mg also decreased the need for rescue medication (25% vs. 48%). CP-122,721 100 mg was less effective than 200 mg in decreasing the incidence of repeated episodes of emesis. In the interaction study, 6% of the patients receiving CP-122,721 200 mg orally experienced emesis less than 2 h after surgery compared with 17% with ondansetron alone. With combined therapy, only 2% experienced emesis. In addition, the median times for 75% of patients to remain free from postoperative nausea and vomiting were 82, 75, and 362 min in the ondansetron, CP-122,721, and combination groups, respectively. CONCLUSIONS: Oral CP-122,721 200 mg decreased emetic episodes compared with ondansetron (4 mg intravenously) during the first 24 h after gynecologic surgery; however, there was no difference in patient satisfaction.

Astrocytic glycogen influences axon function and survival during glucose deprivation in central white matter.

We tested the hypothesis that astrocytic glycogen sustains axon function during and enhances axon survival after 60 min of glucose deprivation. Axon function in the rat optic nerve (RON), a CNS white matter tract, was monitored by measuring the area of the stimulus-evoked compound action potential (CAP). Switching to glucose-free artificial CSF (aCSF) had no effect on the CAP area for approximately 30 min, after which the CAP rapidly failed. Exposure to glucose-free aCSF for 60 min caused irreversible injury, which was measured as incomplete recovery of the CAP. Glycogen content of the RON fell to a low stable level 30 min after glucose withdrawal, compatible with rapid use in the absence of glucose. An increase of glycogen content induced by high-glucose pretreatment increased the latency to CAP failure and improved CAP recovery. Conversely, a decrease of glycogen content induced by norepinephrine pretreatment decreased the latency to CAP failure and reduced CAP recovery. To determine whether lactate represented the fuel derived from glycogen and shuttled to axons, we used the lactate transport blockers quercetin, alpha-cyano-4-hydroxycinnamic acid (4-CIN), and p-chloromercuribenzene sulfonic acid (pCMBS). All transport blockers, when applied during glucose withdrawal, decreased latency to CAP failure and decreased CAP recovery. The inhibitors 4-CIN and pCMBS, but not quercetin, blocked lactate uptake by axons. These results indicated that, in the absence of glucose, astrocytic glycogen was broken down to lactate, which was transferred to axons for fuel.

Reversal of rapacuronium block during propofol versus sevoflurane anesthesia.

UNLABELLED: We studied the antagonism of rapacuronium with edrophonium-atropine during propofol- or sevoflurane- based anesthesia in 60 healthy outpatients. After the induction of anesthesia with standardized doses of propofol and fentanyl, rapacuronium 1.5 mg/kg was administered to facilitate tracheal intubation. Patients were randomized to receive either a propofol infusion (100 microg. kg(-1). min(-1)) or sevoflurane (1.0%, end-tidal) in combination with nitrous oxide 66% for maintenance of anesthesia. Neuromuscular block was monitored by using electromyography at the wrist and reversed with edrophonium 1.0 mg/kg and atropine 0.015 mg/kg when the first twitch (T(1)) response of the train-of-four (TOF) stimulation recovered to 25% of the baseline value. The clinical duration of action (i.e., time to 25% T(1) recovery) was similar during both propofol (13.1 +/- 3.6 min) and sevoflu-rane (13.7 +/- 4.4 min) anesthesia. The time from 25% T(1) recovery to TOF ratio of 0.8 was also similar with propofol (3.4 +/- 2.1 min) and sevoflurane (5.9 +/- 8.7 min) (P > 0.05). Although none of the patients in the propofol group required more than 9 min to achieve a TOF ratio of 0. 8, two patients receiving sevoflurane required 31 min and 37 min. Adequate antagonism of rapacuronium block with edrophonium can be achieved within 10 min during propofol anesthesia. However, more prolonged recovery may occur in the presence of sevoflurane. IMPLICATIONS: We studied the reversal of rapacuronium-induced block with edrophonium and found that the residual rapacuronium block can be readily antagonized during propofol-based anesthesia. However, reversal of rapacuronium appears to be less predictable during sevoflurane-based anesthesia.

Defining responsibility for screening.

Patients commonly receive medical care from multiple providers and confusion as to who is responsible for cancer screening undoubtedly contributes to inadequate recommendations. Effective screening requires successful implementation of a series of steps that begin with the initial discussion of a screening test and proceed through obtaining results and instituting appropriate follow-up. Clear definition of generalist and specialist physician roles are necessary to optimally screen the public. This article explores the differences in how generalists and specialists approach screening, describes models of care that facilitate shared responsibility for screening, and suggests strategies on how to improve communication between physicians to maximize screening performance.

Use of propofol for office-based anesthesia: effect of nitrous oxide on recovery profile.

STUDY OBJECTIVE: To evaluate the effect of nitrous oxide (N2O) on the recovery profile and the incidence of postoperative nausea and vomiting (PONV) after office-based surgery performed under propofol anesthesia. DESIGN: Prospective, randomized, single-blind study. SETTING: Office-based surgical center. PATIENTS: 69 ASA physical status I, II, and III healthy, consenting outpatients undergoing superficial surgical procedures lasting 15 to 45 minutes. INTERVENTIONS: After a standard propofol induction (1.5 mg.kg-1 i.v.), anesthesia was initially maintained with propofol, 100 micrograms.kg-1.min-1 i.v., in combination with either air or N2O 65% in oxygen. The propofol infusion rate was subsequently varied to maintain an adequate depth of anesthesia. All patients received local anesthetic infiltration prior to the surgical incision, as well as during the operation. No prophylactic antiemetics were administered. MEASUREMENTS AND MAIN RESULTS: Recovery times and the incidences of PONV were recorded during the first 24 hours after surgery. Early and late recovery variables were similar in the two treatment groups; however, 65% N2O produced a 19% decrease in the propofol maintenance dosage requirement. One patient (3%) experienced nausea prior to discharge in the propofol-N2O group, and two patients (6%) experienced nausea at home in the propofol alone group. None of the patients vomited or received antiemetic medication during the 24 hours postdischarge period. Ninety-seven percent of patients receiving propofol alone and all of the patients in the propofol-N2O group were "very satisfied" with their anesthetic experience. CONCLUSIONS: In outpatients undergoing office-based surgical procedures with propofol anesthesia, administration of 65% N2O decreased the anesthetic requirement without increasing PONV. Therefore, use of a propofol-N2O combination may be a cost-effective alternative to propofol alone for office-based anesthesia.

Recovery profile, costs, and patient satisfaction with propofol and sevoflurane for fast-track office-based anesthesia.

BACKGROUND: Office-based surgery is becoming increasingly popular because of its cost-saving potential Both propofol and sevoflurane are commonly used in the ambulatory setting because of their favorable recovery profiles. This clinical investigation was designed to compare the clinical effects, recovery characteristics, and cost-effectiveness of propofol and sevoflurane when used alone or in combination for office-based anesthesia. METHODS: One hundred four outpatients undergoing superficial surgical procedures at an office-based surgical center were randomly assigned to one of three general anesthetic groups. In groups I and II, propofol 2 mg/kg was administered for induction followed by propofol 75-150 microg x kg(-1) x min(-1) (group I) or sevoflurane 1-2% (group II) with N2O 67% in oxygen for maintenance of anesthesia In group m, anesthesia was induced and maintained with sevoflurane in combination with N2O 67% in oxygen. Local anesthetics were injected at the incision site before skin incision and during the surgical procedure. The recovery profiles, costs of drugs, and resources used, as well as patient satisfaction, were compared among the three treatment groups. RESULTS: Although early recovery variables (e.g., eye opening, response to commands, and sitting up) were similar in all three groups, the times to standing up and to be "home ready" were significantly prolonged when sevoflurane-N2O was used for both induction and maintenance of anesthesia. The time to tolerating fluids, recovery room stay, and discharge times were significantly decreased when propofol was used for both induction and maintenance of anesthesia. Similarly, the incidence of postoperative nausea and vomiting and the need for rescue antiemetics were also significantly reduced after propofol anesthesia. Finally, the total costs and patient satisfaction were more favorable when propofol was used for induction and maintenance of office-based anesthesia CONCLUSION: Compared with sevoflurane-N2O, use of propofol-N2O for office-based anesthesia was associated with an improved recovery profile, greater patient satisfaction, and lower costs. There were significantly more patients who were dissatisfied with the sevoflurane anesthetic technique.

The effect of location of transcutaneous electrical nerve stimulation on postoperative opioid analgesic requirement: acupoint versus nonacupoint stimulation.

UNLABELLED: Transcutaneous electrical nerve stimulation (TENS) has been used as a complementary (supplemental) therapy to opioid analgesics for pain relief after surgery. Simultaneous stimulation at a classical Chinese acupoint site and periincisional dermatomes significantly decreases the postoperative analgesic requirement. This sham-controlled study was designed to assess the relative effectiveness of acupoint versus nonacupoint stimulation on the postoperative hydromorphone (HM) requirement, the incidence of opioid-related side effects, and the overall recovery profile. One hundred women undergoing total abdominal hysterectomy or myomectomy procedures with a standardized general anesthesia were randomly assigned to one of four postoperative analgesic treatment regimens (n = 25 each): Group I = sham-TENS (no electrical current) at the Zusanli (ST36) acupoints, Group II = nonacupoint-TENS at the shoulders, Group III = dermatomal-TENS at the level of the surgical incision, and Group IV = acupoint-TENS at the Zusanli acupoints. The frequency of TENS was set in the standard dense-and-disperse mode of 2/100 Hz. The intensity of stimulation was set at 0 mA for patients in Group I and at 9-12 mA for patients in Groups II, III, and IV. A patient-controlled analgesia (PCA) device programmed to deliver bolus doses of HM 0.2-0.4 mg IV on demand with a minimal lockout interval of 10 min was used to quantify the postoperative opioid analgesic requirement. Standard 100-mm visual analog scales were used to assess pain, as well as sedation, fatigue, and nausea, at specific intervals after surgery. The numbers of PCA demands and delivered bolus doses, requirements for supplemental medication, and any opioid-related side effects were recorded. In the first 24 h postoperatively, the opioid requirements in Groups III and IV were decreased by 37% and 39%, respectively, compared with the control (sham) group and 35% and 38%, respectively, compared with Group II. The duration of PCA usage and the incidences of nausea and dizziness were also significantly decreased in Groups III and IV compared with Groups I and II. We conclude that periincisional dermatomal and Zusanli acupoint stimulation were equally effective in decreasing the postoperative opioid analgesic requirement and in reducing opioid-related side effects. Both of these positions were more effective than the nonacupoint (shoulder) location. IMPLICATIONS: The location of the stimulating electrodes seems to be an important determinant of the efficacy of transcutaneous electrical nerve stimulation in decreasing the need for opioid analgesics in the postoperative period. This study demonstrates that transcutaneous electrical nerve stimulation applied at the dermatomal level of the skin incision is as effective as Zusanli acupoint stimulation, and both were more effective than stimulation at a nonacupoint (shoulder) location.

The effect of timing of ondansetron administration on its efficacy, cost-effectiveness, and cost-benefit as a prophylactic antiemetic in the ambulatory setting.

UNLABELLED: Although ondansetron (4 mg I.V.) is effective in the prevention and treatment of postoperative nausea and vomiting (PONV) after ambulatory surgery, the optimal timing of its administration, the cost-effectiveness, the cost-benefits, and the effect on the patient's quality of life after discharge have not been established. In this placebo-controlled, double-blind study, 164 healthy women undergoing outpatient gynecological laparoscopic procedures with a standardized anesthetic were randomized to receive placebo (Group A), ondansetron 2 mg at the start of and 2 mg after surgery (Group B), ondansetron 4 mg before induction (Group C), or ondansetron 4 mg after surgery (Group D). The effects of these regimens on the incidence, severity, and costs associated with PONV and discharge characteristics were determined, along with the patient's willingness to pay for antiemetics. Compared with ondansetron given before induction of anesthesia, the administration of ondansetron after surgery was associated with lower nausea scores, earlier intake of normal food, decreased incidence of frequent emesis (more than two episodes), and increased times until 25% of patients failed prophylactic antiemetic therapy (i.e., had an emetic episode or received rescue antiemetics for severe nausea) during the first 24 h postoperatively. This prophylactic regimen was also associated with the highest patient satisfaction and lowest cost-effectiveness ratios. Compared with the placebo group, ondansetron administered after surgery significantly reduced the incidence of PONV in the postanesthesia care unit and during the 24-h follow-up period and facilitated the recovery process by reducing the time to oral intake, ambulation, discharge readiness, resuming regular fluid intake and a normal diet. When ondansetron was given as a "split dose," its prophylactic antiemetic efficacy was not significantly different from that of the placebo group. In conclusion, the prophylactic administration of ondansetron after surgery, rather than before induction, may be associated with increased patient benefits. IMPLICATIONS: Ondansetron 4 mg I.V. administered immediately before the end of surgery was the most efficacious in preventing postoperative nausea and vomiting, facilitating both early and late recovery, and improving patient satisfaction after outpatient laparoscopy.

Eltanolone as an alternative to propofol for ambulatory anesthesia.

UNLABELLED: The intravenous (i.v.) steroid anesthetic, eltanolone, compares favorably to propofol with respect to its induction characteristics. This double-blind investigation was designed to compare the induction and recovery profile of eltanolone (versus propofol) when it was used for both induction and maintenance of ambulatory anesthesia. Eighty-three consenting ASA physical status I-III outpatients undergoing minor gynecologic or urologic procedures lasting 10-40 min were randomly assigned to one of three anesthetic treatment groups. All patients received midazolam, 2 mg i.v., and fentanyl, 50 micrograms i.v., before induction of anesthesia. The control group (Group 1) was induced with propofol, 2.4 mg/kg i.v. (18-60 yr or ASA physical status I or II) or 1.6 mg/kg i.v. (61-80 yr and/or ASA physical status III), followed by intermittent bolus doses of 0.6 mg/kg i.v. in combination with N2O 67% for maintenance of anesthesia. In Group 2, anesthesia was induced with eltanolone, 0.75 mg/kg i.v., (18-60 yr and/or ASA physical status I or II) or 0.5 mg/kg i.v. (61-80 yr and/or ASA physical status III), and maintained with intermittent bolus injections of 0.2 mg/kg i.v. and N2O 67%. Group 3 received eltanolone, 1.0 mg/kg i.v. (18-60 yr and/or ASA physical status I or II), or 0.75 mg/kg i.v. (61-80 yr and/or ASA physical status III), followed by intermittent bolus injections of 0.2 mg/kg i.v. and N2O 67%. In addition to recording the induction and recovery times and side effects, psychomotor testing was performed before and at 30-min intervals after anesthesia. Induction times (57 +/- 23, 67 +/- 26, and 61 +/- 22s, respectively) were similar in all three groups. Although eltanolone produced no pain on injection (versus 52% in the propofol group), 10% of the eltanolone-treated patients (versus none in the propofol group) developed transient cutaneous (rash-like) reactions. The total dose of study medication used during the anesthetic period was 9.2 +/- 3.7 mg.kg-1.h-1 in the propofol group compared with 3.3 +/- 1.4 mg.kg-1.h-1 and 3.3 +/- 1.9 mg.kg-1.h-1 in Groups 2 and 3, respectively. Early recovery times were significantly shorter after propofol anesthesia. However, times to ambulation, micturition, and being judged "fit for discharge," as well as recovery of cognitive function, were similar in all three groups. Although ethanolone seems to be a safe and effective i.v. anesthetic, these data suggest that it is unlikely to replace propofol in the ambulatory setting. IMPLICATIONS: Eltanolone is an investigational steroid anesthetic that causes less pain on injection and less cardiovascular depression than propofol (the most widely used intravenous anesthetic in the outpatient setting). Unfortunately, emergence from anesthesia after ambulatory surgery is slower with eltanolone compared with propofol. Therefore, it is unlikely that eltanolone will replace propofol for outpatient anesthesia.