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.

UNLABELLED:We evaluated the spontaneous recovery characteristics of rapacuronium during desflurane-, sevoflurane-, or propofol-based anesthesia in 51 consenting women undergoing laparoscopic tubal ligation procedures. After the induction of the anesthesia with standardized doses of propofol and fentanyl, 1.5 mg/kg IV rapacuronium was administered to facilitate tracheal intubation. Patients were randomized to receive either 1 minimum alveolar anesthetic concentration of desflurane, 1 minimum alveolar concentration of sevoflurane, or 100 microg. kg(-1). min(-1) propofol infusion in combination with 66% nitrous oxide in oxygen for maintenance of anesthesia. Neuromuscular blockade was monitored at the wrist by using electromyography. The degree of maximum blockade and the times for first twitch recovery (T(1)) to 5%, 25%, 50%, 75%, and 90%, as well as the recovery index, were similar in all three anesthetic groups. However, recovery times for the train-of-four ratio to achieve 0.7 and 0.8 were significantly longer with desflurane (44.4 +/- 18.9 and 53.5 +/- 22.4 min) and sevoflurane (44.8 +/- 15.1 and 53.2 +/- 15.8 min) compared with propofol (31.8 +/- 5.3 and 36.5 +/- 6.5 min). Eight patients (16%) required a maintenance dose of 0.5 mg/kg rapacuronium and reversal of rapacuronium residual block occurred in three (6%) patients. We conclude that spontaneous recovery after an intubating dose of 1.5 mg/kg rapacuronium was significantly prolonged by both desflurane and sevoflurane compared with propofol-based anesthesia. Routine monitoring of neuromuscular activity is recommended even when a single bolus dose of rapacuronium is administered during ambulatory anesthesia. IMPLICATIONS:When administered for laparoscopic surgery, the duration of action of an intubating dose of rapacuronium was prolonged 40%-50% by desflurane and sevoflurane, respectively, (versus propofol). Monitoring recovery of neuromuscular blockade produced by rapacuronium is particularly important when desflurane or sevoflurane is administered to ensure that an adequate recovery (train-of-four > or = 0.8) is achieved by the end of anesthesia.

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.