Corticosteroids can decrease pain and postoperative nausea and vomiting after ambulatory surgery. Therefore, we designed a study to evaluate if the routine use of dexamethasone would facilitate the early recovery process after anorectal surgery. A secondary aim of the study was to determine if dexamethasone would increase the incidence of postoperative wound complications. Eighty adult outpatients undergoing anorectal surgery with a standardized monitored anesthesia care technique were randomly assigned to receive either dexamethasone 4 mg IV or an equal volume of saline before the start of surgery. All patients were premedicated with midazolam 2 mg IV and received ketorolac 30 mg IV as a preemptive analgesic. A propofol infusion, 50 mug.kg(-1).min(-1) IV, was initiated and subsequently titrated to maintain an observer's assessment of alertness/sedation score of 2 or 3 (with 5 = awake/alert to 1 = asleep). Fentanyl 25 mug IV was administered 3-5 min before infiltrating the surgical field with a 30-mL local anesthetic mixture containing 15 mt of Lidocaine 1% and 15 mt of bupivacaine 0.25% (with epinephrine 1:200,000 and sodium bicarbonate 3 mt). All patients were fast-tracked directly from the operating room to the step-down recovery area. Even though the incidences of postoperative pain and postoperative nausea and vomiting were small in both treatment groups, the time to "home readiness" was significantly shorter in the dexamethasone group. Importantly, there was no increase in the incidence of wound infections (8% vs 12%) or hematoma formation (3% vs 5%) in the dexamethasone (versus saline) group. We conclude that the administration of dexamethasone, 4 mg IV, shortened the time to home readiness without increasing the incidence of postoperative wound infections in a high-risk outpatient population undergoing anorectal surgery.

UNLABELLED:Both monitored anesthesia care (MAC) and general anesthesia (GA) offer advantages over epidural anesthesia for immersion lithotripsy. We compared propofol-based MAC and desflurane-based GA techniques for outpatient lithotripsy. After receiving midazolam 2 mg IV, 100 subjects were randomly assigned to one of two anesthetic treatment groups. In the MAC group, propofol 50-100 microg. kg(-1). min(-1) IV was titrated to maintain an observer's assessment of alertness/sedation score of 2-3 (5 = awake/alert to 1 = asleep). Remifentanil 0.05 microg.kg(-1). min(-1) IV supplemented with 0.125 microg/kg IV boluses, was administered for pain control. In the GA group, anesthesia was induced with propofol 1.5 mg/kg IV and remifentanil 0.125 microg/kg IV and maintained with desflurane (2%-4% inspired) and nitrous oxide (60%). Tachypnea (respiratory rate >20 breaths/min) was treated with remifentanil 0.125 microg/kg IV boluses. In the GA group, droperidol (0.625 mg IV) was administered as a prophylactic antiemetic. Recovery times and postoperative side effects were assessed up to 24 h after the procedure. Compared with MAC, the use of GA reduced the opioid requirement and decreased movements and episodes of desaturation (<90%) during the procedure. Although the GA group took longer to return to an observer's assessment of alertness/sedation score of 5, discharge times were similar in both groups. We conclude that GA can provide better conditions for outpatient immersion lithotripsy than MAC sedation without delaying discharge. IMPLICATIONS:A desflurane-based general anesthetic technique using the cuffed oropharyngeal airway device was found to be a highly acceptable alternative to propofol-based monitored anesthesia care sedation for outpatient immersion lithotripsy.

We compared onset and offset of action and tracheal intubating conditions after rapacuronium and rocuronium in 60 patients in a randomized, assessor-blinded study. Following induction of anaesthesia with propofol 2.5 mg kg-1, either rapacuronium 1.5 mg kg-1 (n = 30) or rocuronium 0.6 mg kg-1 (n = 30) was administered to facilitate tracheal intubation. Anaesthesia was maintained with either a propofol infusion (100 micrograms kg-1 min-1) or sevoflurane (1% end-tidal) with 66% nitrous oxide (N2O), n = 15 in each subgroup. Neuromuscular monitoring was performed using an electromyographic (EMG) device (Datex Relaxograph). The lag times (mean 42 (SD 11) s and 44 (16) s), maximum block (99 (2)% and 98 (3)%) and intubating conditions at 60 s (good-to-excellent in 86% and 84% of patients) were similar for rapacuronium and rocuronium, respectively. The onset time of rapacuronium was shorter than rocuronium (87 (20) vs 141 (65) s, P < 0.001), and the degree of block at 60 s was greater (69 (26) vs 50 (27)%, P < 0.05). Twenty-five per cent recovery was shorter with rapacuronium than rocuronium during propofol (15.0 (3.2) vs 39.1 (14.2) min, P < 0.001) and sevoflurane (15.1 (4.2) vs 47.8 (19.0) min, P < 0.001) anaesthesia. We conclude that rapacuronium 1.5 mg kg-1 had a more rapid onset, similar intubating conditions, and shorter recovery times than rocuronium 0.6 mg kg-1.

Background The intubating laryngeal mask airway (ILMA) is designed to facilitate blind tracheal intubation. The effect of a muscle relaxant on the ability to perform tracheal intubation through the ILMA device has not been previously evaluated. This randomized, double-blind, placebo-controlled study was designed to evaluate rocuronium, 0.2 or 0.4 mg/kg administered intravenously, on the success rate and incidence of complications associated with ILMA-assisted tracheal intubation. Methods A total of 75 healthy patients were induced with propofol 2 mg/kg and fentanyl 1 microg/kg intravenously. After insertion of the ILMA device, patients were administered either saline, rocuronium 0.2 mg/kg, or rocuronium 0.4 mg/kg in a total volume of 5 ml. At 90 s after administration of the study drug, tracheal intubation was attempted using a disposable polyvinyl tube. If unsuccessful, a reusable silicone tube was tried. In addition to recording the time and number of attempts required to secure the airway, the incidence of complications during placement of the tracheal tube and removal of the ILMA were noted. Results Tracheal intubation was successful in 76-96% of the patients. The overall success rates and times required to secure the airway were similar in all three treatment groups. The high-dose rocuronium group experienced less patient movement (8 vs. 28 and 48%) and coughing (12 vs. 20 and 52%) than the low-dose rocuronium and saline groups, respectively. Use of rocuronium was also associated with a dose-related decrease in the requirement for supplemental bolus doses of propofol during intubation and removal of the ILMA device. Conclusions Use of rocuronium did not significantly improve the success rate in performing tracheal intubation through the ILMA. However, it produced dose-related decreases in coughing and movement after tracheal intubation and reduced difficulties associated with removal of the ILMA device.

The use of an ilioinguinal-hypogastric nerve block (IHNB) as part of a monitored anesthesia care (MAC) technique has been associated with a rapid recovery profile for outpatients undergoing inguinal herniorrhaphy procedures. This study was designed to compare the cost-effectiveness of an IHNB-MAC technique with standardized general and spinal anesthetics techniques for inguinal herniorrhaphy in the ambulatory setting. We randomly assigned 81 consenting outpatients to receive IHNB-MAC general anesthesia, or spinal anesthesia. We evaluated recovery times, 24-h postoperative side effects and associated incremental costs. Compared with general and spinal anesthesia, patients receiving IHNB-MAC had the shortest time-to-home readiness (133 +/- 68 min vs 171 +/- 40 and 280 +/- 83 min), lowest pain score at discharge (15 +/- 14 mm vs 39 +/- 28 and 34 +/- 32 mm), and highest satisfaction at 24-h follow-up (75% vs 36% and 64%). The total anesthetic costs were also the least in the IHNB-MAC group ($132.73 +/- 33.80 vs $172.67 +/- 29.82 and $164.97 +/- 31.03). We concluded that IHNB-MAC is the most cost-effective anesthetic technique for outpatients undergoing unilateral inguinal herniorrhaphy with respect to speed of recovery, patient comfort, and associated incremental costs.

There is an increasing trend toward performing craniotomy for primary brain tumor excision with local anesthesia. We report the use of the laryngeal mask airway as a part of an anesthetic technique designed for patients requiring awake cortical mapping during brain tumor excision.

The role of ketorolac in facilitating the recovery process after ambulatory surgery is controversial. Ketorolac, a nonsteroid antiinflammatory drug (NSAID), produces pain relief with less respiratory depression, nausea, and vomiting than opioid analgesics (1). When used as an alternative to fentanyl in outpatients undergoing laparoscopy (2), ketorolac was associated with comparable postoperative analgesia and shorter discharge times. Additionally, the combination of ketorolac and local anesthesia provided superior postoperative analgesia than either drug alone in patients undergoing knee arthroscopy procedures (3,4). Although IV ketorolac has well known opioid-sparing properties (2–4) and even possible anesthetic-sparing qualities (5), the injection of ketorolac at the surgical site has been reported to possess varying degrees of analgesic activity (6–8). When ketorolac was administered "locally" to patients undergoing hemorrhoidectomy (6) and inguinal hernia repair (7), it decreased the postoperative pain scores and enhanced patient comfort compared with systemic morphine and IV ketorolac, respectively. However, in patients undergoing breast surgery (8), the analgesic effect of ketorolac administered at the surgical site was no more effective than IV ketorolac. We hypothesized that the administration of ketorolac at the surgical site (local) would provide more effective postoperative analgesia than IV administration during surgery performed under local anesthesia with sedation as part of a monitored anesthesia care technique. Specifically, this study was designed to determine if a single dose of ketorolac could facilitate the recovery process after anorectal surgical procedures. Methods After obtaining institutional review board approval, 105 consenting, ASA physical status I and II outpatients scheduled for minor anorectal surgical procedures were randomly assigned to one of three study groups according to a double-blinded protocol. The three study groups consisted of Control (saline), IV ketorolac, and local ketorolac. Patients with a history of sensitivity to NSAIDs, gastrointestinal bleeding, or renal impairment were excluded. On arrival in the operating room (OR), patients were administered diazepam emulsion, 5–10 mg IV, and then positioned in either the prone or lithotomy position. Standard monitors were placed, and oxygen (2 L/min) was administered through nasal cannulae with a CO2 sampling port. Before the start of surgery, patients received: 1) Control group: 2 mL saline IV and 2 mL of saline mixed with the local anesthetic solution, 2) IV ketorolac group: 2 mL (60 mg) ketorolac IV and 2 mL saline mixed with the local anesthetic solution, and 3) Local ketorolac group: 2 mL saline IV and 2 mL of ketorolac (60 mg) mixed with the anesthetic solution. Propofol, 50–100 μg · kg−1 · min−1 IV, was administered to maintain an Observer's Assessment of Alertness/Sedation score (9) of 2 or 3 (with 5 = awake/alert to 1 = asleep). Lidocaine gel 2% was then topically applied to the anodermal area with a large cotton applicator. Fentanyl, 25 μg IV, was administered 3–5 min before infiltrating the surgical field with 35 mL of a mixture containing lidocaine 1% and bupivacaine 0.25% with epinephrine 1/200,000 and sodium bicarbonate 4.2% (3 mL). Patient discomfort during the surgical procedure was treated with boluses of fentanyl, 25 μg IV At the end of the surgical procedure, the propofol infusion was discontinued. If the patient achieved a fast-track score of 12 or more (i.e., awake, alert, oriented, able to purposely move extremities, with stable vital signs and minimal pain, and without intractable symptoms of nausea or vomiting) (10) on leaving the OR, they were transported directly to the day-surgery (Phase II) recovery area. The degree of postoperative pain was assessed on arrival in the recovery unit by using a descriptive scale (0=none to 3=severe) and a 10-cm linear visual analog scale (VAS), with 0 = no pain to 10 = worst pain imaginable. The postoperative analgesic requirement was assessed before discharge home. Recovery times were recorded from discontinuation of the propofol infusion until the patient was able to tolerate oral fluids, walk unassisted (ambulation time), and be discharged home. Discharge criteria required that the patient be awake, alert, with stable vital signs on sitting and standing, and be able to walk without assistance. Voiding was not a prerequisite for discharge home. A predischarge questionnaire was completed by each patient to assess their quality of recovery (QoR) score (11). Additionally, a global QoR score (11) was also obtained from each patient before discharge home by using a 10-cm linear VAS, with 0 = poor recovery and 10 = excellent recovery. Oral hydrocodone (2.5 mg) with acetaminophen (500 mg) was prescribed for pain control after discharge. Finally, a follow-up evaluation was performed via telephone at 24 h and in the Proctology Clinic 10 days after surgery. Data analysis consisted of Number Cruncher Statistical Systems (NCSS, Kaysville, UT) version 6.0, one-way analysis of variance for all continuous variables. When significant differences were noted, the Newman-Keuls test was performed for post hoc intergroup comparisons. The VAS scores were analyzed by using the Kruskal-Wallis test, and if a significant result was obtained, Wilcoxon's ranked sum test was performed. Categorical (discrete) variables were analyzed by using the χ2 test. Data were presented as mean values ± sd, numbers, or percentages, with P values < 0.05 considered statistically significant. Results The three study groups were comparable with respect to age, weight, height, sex, ASA physical status, and HIV status (Table 1). The types of surgical procedures (e.g., hemorrhoidectomy, pilonidal cyst excision, fistulotomy, anal condyloma fulguration, and sphincterotomy) were evenly distributed among the three study groups. There were also no differences in the durations of surgery and anesthesia, the intraoperative fentanyl and propofol dosage requirements, or in the volume of intraoperative IV fluids (Table 2).Table 1: Demographic Data for the Three Study GroupsTable 2: Surgery and Anesthesia Duration, Intraoperative Anesthetic, Analgesic, and IV Fluids RequirementsAll patients achieved an Observer's Assessment of Alertness/Sedation score of 5 and a fast-track score of 12 or more before leaving the OR. The Local ketorolac group had lower VAS pain scores than the Control group on arrival in the Phase II recovery unit (Table 3). There were no episodes of postoperative nausea and vomiting in any of the treatment groups. Compared with the Control group, fewer patients in the IV and Local ketorolac groups experienced pain (37% vs 6% and 6%, respectively) and required oral analgesics (20% vs 3% and 0%, respectively) before discharge home. No antiemetic medication or supplemental oxygen was required after surgery. Although the time required for oral intake and ambulation were comparable (Table 3), the time to discharge home was significantly shorter when ketorolac was infiltrated locally at the surgical site compared with the Control group (Table 3). Of importance, the patients in the Control group also had significantly lower QoR scores than the IV and Local ketorolac groups (Table 3).Table 3: Postoperative Pain and Recovery Scores, Recovery and Discharge Times, Analgesic Requirements, and Postdischarge Side EffectsCompared with the Control group, fewer patients in the two ketorolac groups required oral analgesic medication during the first 24 h after discharge (Table 3). However, the incidence of wound infections was similar in the three study groups at the 10-day follow-up visit. In addition, the incidences of hematoma formation, bleeding with bowel movements, and urinary difficulty were similar in all groups (Table 3). Discussion Some colorectal surgeons have been reluctant to embrace the concept of day surgery for anorectal procedures because of the perceived difficulty in providing adequate postoperative pain relief (12). Although ketorolac decreases the need for postoperative opioid analgesic medication after ambulatory surgery (2–4), some investigators have been unable to demonstrate an improvement in clinically meaningful outcome variables [e.g., time to discharge home and QoR (13,14)]. This study provides evidence to support the concept that the use of even a single dose of ketorolac during surgery can improve the recovery profile after anorectal procedures in the ambulatory setting. The controversy regarding the optimal route of administration of ketorolac resulted, in part, because of the differential effects of the drug on the central (spinal cord) and peripheral nervous systems (15). Reuben and Connelly (4), Reuben et al. (16), Reuben and Duprat (17), and Connelly et al. (7) have suggested that the effectiveness of ketorolac is enhanced when injected at the site of the surgical incision. For example, these investigators have reported that injecting ketorolac (60 mg) directly at the surgical site in patients undergoing inguinal hernia repair produces superior analgesia compared with the parenteral (IV) route of administration (7). Although no randomized, placebo-controlled studies using locally administered ketorolac during anorectal surgery have been published, our results suggest that injection of ketorolac at the surgical site may produce a slight advantage over systemic administration with respect to discharge time. Perhaps the slower absorption after local injection produces a more sustained analgesic effect in the postoperative period. When administered systemically during outpatient gynecologic surgery, ketorolac was not associated with an increase in side effects and facilitated an earlier discharge compared with opioid and partial opioid agonist drugs (2). This placebo-controlled, double-blinded study demonstrated a significant reduction in postoperative pain when ketorolac 60 mg was administered either IV or locally before anorectal surgery. However, with respect to the postoperative VAS pain scores and discharge times, the only statistically significant differences compared with the Control group were in the Local ketorolac group. The differences may have been minimized because all three study groups received local anesthesia at the surgical site. Although all patients achieved fast-track criteria (18) in the OR, the ketorolac-treated patients required significantly less oral analgesic medication both before and after discharge home. More importantly, ketorolac improved the QoR from the perspective of the patient without producing side effects or postdischarge complications. In conclusion, ketorolac (60 mg) administered either IV or locally as part of the local anesthetic mixture, improved postoperative pain control and the QoR after outpatient anorectal surgery.

S319 INTRODUCTION: Epidural anesthesia has been considered the anesthetic technique of choice for immersion lithotripsy. However, more recent studies have demonstrated that both intravenous sedation-analgesia [1] and general anesthesia [2] can offer advantages over epidural anesthesia with respect to an improved recovery profile. This study was designed to compare intravenous sedation-analgesic and volatile anesthetic-based techniques in outpatients undergoing immersion lithotripsy procedures. METHODS: 49 consenting adult outpatients undergoing extracorporeal shock wave lithotripsy (ESWL) were randomly assigned to one of two anesthetic treatment groups according to an IRB-approved protocol. All patients received midazolam 2 mg iv, and fentanyl, 0.5 [micro sign]g/kg iv, for premedication. In Group 1 received propofol, 50 [micro sign]g[center dot]kg-1[center dot]min-1, which was subsequently titrated to maintain an observer's assessment of alertness/sedation (OAA/S) score >3, with 1=awake/alert to 5=asleep. If the patient complained of pain during the procedure, fentanyl 12.5-25 [micro sign]g iv was administered. In Group 2, anesthesia was induced with propofol 1.5 mg[center dot]kg-1 iv, and following loss of consciousness, a cuffed oropharyngeal airway (COPA) device was inserted and connected to the airway circuit. Maintenance of anesthesia consisted of desflurane 2-4% and nitrous oxide (N2 O) 60% in oxygen. Tachypnea (respiratory rate >20 bpm) was treated with fentanyl 12.5-25 [micro sign]g iv. At the end of the procedure, the inhaled anesthetics were discontinued and droperidol 0.625 mg iv, was administered as a prophylactic antiemetic. Recovery times were recorded from discontinuation of the anesthetic drugs until the patient was awake and oriented. In addition, times to achieving an OAA/S score of 1 and to discharged home were noted. Postoperative side effects were assessed in the recovery area (Phase II step-down unit) and at 24 hr after the procedure. Data were analyzed using Students' t-test and Chi-square test, with a p-value <0.05 considered statistically significant (*). Values are means +/- SD. RESULTS: The two anesthetic treatment groups were similar demographically (Table 1). Although the general anesthetic group required a longer time interval to awaken, the time required for the patients to return to an OAA/S score of 1 and to be discharged home were similar in both anesthetic treatment groups. Finally, there were no significant differences in the incidences of perioperative side effects.Table 1DISCUSSION: General anesthesia with propofol-desflurane-N2 O was an acceptable alternative to an intravenous sedative-analgesic technique involving propofol and fentanyl for outpatient ESWL procedures. The ability to "bypass" the recovery room after general anesthesia was facilitated by using a COPA airway device and resulted in recovery times that were comparable to a sedation-analgesia technique for outpatient immersion lithotripsy.

S30 INTRODUCTION: Local anesthesia with sedation, spinal anesthesia, and general anesthesia are all acceptable anesthetic techniques for outpatients undergoing inguinal hernia repair. This study was designed to determine which of the three anesthetic techniques provides the fastest recovery while optimizing patient comfort and minimizing side effects after herniorrhaphy procedures. METHODS: Seventy-eight consenting outpatients undergoing unilateral inguinal hernia repair procedures were randomly assigned to receive one of three anesthetic techniques according to an IRB-approved protocol: (Gp 1) ilioinguinal-hypogastric nerve block (IHNB) with propofol sedation, [1] (Gp 2) general anesthesia with propofol, desflurane and nitrous oxide, and (Gp 3) spinal anesthesia with hyperbaric bupivacaine and fentanyl. All patients were premedicated with midazolam, 2 mg and fentanyl, 25 [micro sign]g iv. Patients in Gp 1 received an IHNB with 30 ml of bupivacaine 0.25% and lidocaine 1% injected between the fascial layers of the external and internal oblique muscles 1.5 cm medial to the anterior superior iliac spine. Sedation with propofol 50 [micro sign]g[center dot]kg-1[center dot]min-1 iv was started after the IHNB and varied to maintained a level of sedation in which the patients responded to verbal or light tactile stimulation. In Gp 2, patients were induced with propofol, 2.5 mg[center dot]kg-1 and a LMA device was placed for airway management. Anesthesia was maintained with desflurane 2-4% or sevoflurane 0.5-2% in combination with nitrous oxide 65% in oxygen. In Gp 3, patients were administered spinal anesthesia with bupivacaine 0.75% 1.2-1.5 ml and fentanyl 12.5-25 [micro sign]g using a 25-ga pencil-point needle at L2-3 or L3-4 in the sitting position. In both Gps 1 and 2, the surgeons administered 10 ml of bupivacaine 0.25% along the fascial incision at closure. Recovery times were recorded from the discontinuation of the anesthetic drugs (Gps 1 and 2) or the end of surgery (Gp 3) to awakening, orientation and home-readiness. Postoperative pain and emetic symptoms were determined using 100-mm VAS scale (0=none to 100=severe) at discharge. Post-discharge side effects, as well as patient satisfaction with the anesthetic technique, were assessed through a 24 h follow-up phone call. Data were analyzed using ANOVA and Chi-square tests, with p-values <0.05 considered statistically significant (* vs. spinal) (mean +/- SD). RESULTS: The three groups were similar with respect to demographic data and duration of surgery. Patients receiving the local-sedation technique (Gp 1) had the shortest time from discontinuation of anesthesia to home-readiness, the lowest postoperative pain scores at discharge, and the highest degree of patient satisfaction. (Table 1)Table 1DISCUSSION: Use of local anesthesia with propofol sedation appears to be the optimal anesthetic for outpatients undergoing unilateral inguinal herniorrhaphy with respect to speed of recovery and patient satisfaction.

Airway management in patients with unstable cervical spines remains a challenge for anesthesia providers. Because neurologic evaluations may be required following tracheal intubation and positioning for the surgical procedure, an awake intubation technique is desirable in this patient population. In this report, we describe the use of an intubating laryngeal mask airway (ILMA) to facilitate awake tracheal intubation in two patients with cervical spine disorders. After topical local analgesia, the ILMA was inserted easily, and a tracheal tube was passed through the glottic opening without complications. Thus, the ILMA may be an acceptable alternative to the fiberoptic bronchoscope for awake tracheal intubation.