Letter to the editorThe post-anesthesia recovery score revisited
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A postanesthetic recovery score
Anesth Analg
(1970)
Cited by (1076)
Comparing preoperative and postoperative dexamethasone effects on analgesia duration in shoulder surgery
2024, iScienceDexamethasone is commonly used as an adjuvant to prolong peripheral nerve block analgesia, but the optimal timing is unclear. This randomized equivalence trial tested whether preoperative versus postoperative intravenous dexamethasone have equivalent analgesic effects when combined with interscalene brachial plexus block for shoulder surgery. 168 patients were randomized to receive 5 mg dexamethasone either preoperatively or postoperatively. The primary outcome was duration of analgesia, analyzed for equivalence with a 2-h margin. The mean durations were equivalent between groups (11.5 h preoperative versus 10.7 h postoperative). The confidence intervals fell within the equivalence margin. There were no other clinically significant differences in secondary outcomes like time to first analgesia, motor recovery, opioid consumption, blood glucose, or complications. In conclusion, as an adjuvant for nerve block, preoperative and postoperative intravenous dexamethasone provide equivalent analgesic duration, allowing for flexibility in clinical use. This addresses previous uncertainty about timing while demonstrating equivalent efficacy.
Remimazolam: A Retrospective Study of Initial Safety and Recovery Data in Diverse Procedural Sedation
2024, Clinical TherapeuticsThe new ultra-short-acting benzodiazepine, remimazolam, offers a pharmacokinetic and pharmacodynamic advantage over commonly used procedural sedation medication. This retrospective study explored the real-world utilization of remimazolam during procedural sedation to support the development of a nurse sedation protocol. The primary outcome was to identify associations between recovery time, adverse reactions, and dose-response in expanded patient populations.
This study reviewed charts of 292 adult patients from 3 hospitals within one institution who received remimazolam during procedural sedation between June 1, 2021 and December 31, 2021. Data were analyzed using logistic and linear regression.
The median time to alert in patients receiving remimazolam alone was 12 minutes (interquartile range 10, 17) and increased when additional sedation medications were utilized. Receiving additional sedative medication significantly increased the odds of hypoxia (OR 2.77, 95% CI 1.30–5.91, P = 0.008) after adjusting for body mass index (BMI), American Society of Anesthesiologists physical status (ASA-PS), and total remimazolam dose. There was a 25% increase in odds of experiencing hypoxia for every 5 kg/m2 increase in BMI (95% CI 1.01–1.54, P = 0.037).
Remimazolam presents as a promising option for nurse procedural sedation, offering minimal impact on hemodynamics and respirations, quick recovery, and no residual sedative effects.
Sleep Apnea is Not an Obstacle for Outpatient Hip and Knee Arthroplasty
2024, Journal of ArthroplastyUp to 25% of patients requiring hip or knee arthroplasty have sleep apnea (SA), and these patients have historically been excluded from outpatient programs. The objectives of this study were to evaluate same-day discharge failure as well as 30-day complications, readmissions, and unexpected visits.
A retrospective case-control study comparing patients who have and do not have SA matched for age, sex and arthroplasty type (total hip arthroplasty, total knee arthroplasty, unicompartimental knee arthroplasty) who underwent primary outpatient surgery between February 2019 and December 2022 in 2 academic hospitals was conducted. Cases with mild SA, moderate SA with a body mass index (BMI) <35, and SA of all severity treated by continuous positive airway pressure machines were eligible. There were 156 patients included (78 cases). Complications were assessed according to the Clavien-Dindo Classification and the Comprehensive Complication Index. Continuous variables were evaluated by Student's T or Mann-Whitney tests, while categorical data were analyzed by Chi-square or Fisher tests. Univariate analyses were performed to determine discharge failure risk factors.
There were 6 cases (7.7%) and 5 controls (6.4%) who failed to be discharged on surgery day (P = .754), with postoperative hypoxemia (6, [3.8%]) and apnea periods (3, [1.9%]) being the most common causes. Higher BMI (odds ratio = 1.19, P = .013) and general anesthesia (odds ratio = 11.97, P = .004) were found to be risk factors for discharge failure. No difference was observed on 30-day readmissions (P = .497), unexpected visits (P = 1.000), and complications on the Clavien-Dindo Classification (P > .269) and Comprehensive Complication Index (P > .334) scales.
Selected patients who have SA can safely undergo outpatient hip or knee arthroplasty. Higher BMI and general anesthesia increased the odds of same-day discharge failure.
Level III, Case-control Study.
Improving Postanesthesia Care Unit (PACU) Delays: A Quality Improvement Project
2024, Journal of Perianesthesia NursingDelays within the postanesthesia care unit (PACU) are a major cause of complications and inefficiency. In this project, we investigated the factors associated with delays in the PACU and implemented policies to mitigate these factors.
A quality improvement project.
Data were collected for 10 months and included 1,134 surgical patients in a tertiary Obstetrics and Gynecology hospital in Kuwait. Several meetings were held with stakeholders to identify and overcome the reasons contributing to delays within the PACU.
Among the top reasons for PACU delay were manpower shortage and lack of bed availability in the surgical wards due to improper admission and discharge policies. Policies were implemented to improve admission policy, hasten patient discharge, and improve patient flow through the operating theater (OT). These policies lead to a significant reduction (25 minutes) in the average time patients spend in the OT, mainly by reducing the stay in the PACU by 19 minutes.
PACU delays were mostly due to reasons outside the OT. Further, follow-up is needed to assess the sustainability of these improvements and identify any new challenges that may arise.
Effect of intubation in lateral position on placement of a double-lumen tube in patients undergoing unilateral video-assisted thoracic surgery: a randomied clinical trial
2024, eClinicalMedicineApproximately one-third of patients who undergo double-lumen tube (DLT) intubation in the conventional supine position experience DLT malposition. No randomized study investigates the effect of DLT intubation in the lateral position. We therefore aimed to evaluate the effect of intubation in lateral position on placement of a DLT compared to supine intubation, and to test primary hypothesis that lateral DLT intubation could reduce the incidence of DLT malposition.
We randomly allocated 108 patients undergoing video-assisted thoracic surgery to receive DLT intubation in the comfortable and surgically required lateral position (lateral group) or in the supine position (supine group) from October to December 2022. The primary outcome was the incidence of DLT malposition defined as movement >1.0 cm to correct the DLT position. The secondary outcomes included intubation time, the frequency and duration of fibreoptic bronchoscopy, the need for re-intubation, intra-operative vital signs, and post-operative recovery. This trial is registered with the Chinese Clinical Trial Registry (ChiCTR2200060794).
The incidence of DLT malposition was significantly lower in the lateral group (1/53 [2%]) than that in the supine group (16/53 [30%]; RR [95% confidence interval] of 0.06 [0.01–0.46]; P < 0.001). Lateral DLT intubation decreased the intubation time, the frequency and duration of fibreoptic bronchoscopy. The incidence of hypotension, post-operative sore throat, and upper-arm discomfort was lower in the lateral group. Other secondary outcomes were similar between groups.
Lateral DLT intubation reduced the incidence of DLT malposition for patients undergoing video-assisted thoracic surgery. These results support that lateral DLT intubation offers more benefits and may be a superior option compared to conventional supine intubation.
National Natural Science Foundation of China and of Zhejiang Province.
Discharge From the Postanesthesia Care Unit With Motor Blockade After Spinal Anesthesia Safely Optimizes Fast Track Recovery in Primary Total Hip and Knee Arthroplasty
2024, Journal of ArthroplastyPost anesthesia care units (PACU) await return of motor function in lower extremities, prior to discharge for patients undergoing spinal anesthesia. The purpose of this study was to assess the impact of a newly utilized recovery protocol that facilitated early discharges of patients undergoing total hip and knee arthroplasties (THA/TKA) to the floor before full motor recovery from spinal anesthesia is achieved.
A total of 647 patients undergoing spinal anesthesia for primary THA (n = 190) and TKA (n = 457) were divided into 2 groups: (1) Early PACU discharge group: patients with partial or full motor blockade at discharge. (2) Control PACU discharge group: patients with full motor recovery at discharge. Readiness for discharge was assessed using a modified Aldrete Score system. The primary outcome was incidences of hypotension or rapid responses post-operatively.
There was no significant difference in the incidence of hypotension between the two groups (1.4 versus 1.39%, P = 1.0) and zero rapid responses were noted. Early discharge shortened mean PACU LOS time from 86.50 minutes to 70.27 minutes (P < .01). There was no difference in the incidence of nausea (0.55 versus 0%; P = .51) ordizziness (2.22 versus 0.35%; P = .09).
In this retrospective observational study, we found that early PACU discharge did not result in an increase in hemodynamic consequences on the surgical floor. Thus, discharge from PACU can be safely and more expeditiously performed without waiting for return of motor function in patients receiving spinal anesthesia for THA/TKA using a modified Aldrete Score recovery protocol.