[Clonidine compared to midazolam for intravenous premedication for ambulatory procedures. A controlled double blind study in ASA 1 patients]. Midazolam premedication increases sedation but does not prolong discharge times after brief outpatient general anesthesia for laparoscopic tubal sterilization. A comparison of propranolol and diazepam for preoperative anxiolysis. Intravenous versus epidural administration of hydromorphone. Effects on analgesia and recovery after radical retropubic prostatectomy. Temazepam and recovery in day surgery. The perioperative effects of oral premedication in children. A pharmacy discharge plan for hospitalized elderly patients--a randomized controlled trial. The effect of cerebral monitoring on recovery after general anesthesia: a comparison of the auditory evoked potential and bispectral index devices with standard clinical practice. Comparison of postoperative analgesic effects of preemptively used epidural ketamine and neostigmine.
Midazolam is frequently used for premedication in day-case surgical patients whereas clonidine is rarely administered for this indication. However, clonidine has several useful effects that make the drug an interesting alternative to conventional premedicants. Thus, in this randomised, double-blind, and controlled study the anxiolytic effect of midazolam was compared to that of clonidine. Furthermore, effects on postoperative complaints and minor complications, and readiness for discharge were investigated.
                100 ASA-1 patients undergoing wisdom teeth extraction on a day-case basis were included into the analysis. A further 50 patients who received no premedication served as a control group. General anaesthesia was standardised (propofol-fentanyl-isoflurane in N2O/O2). The anxiolytic effect of the premedication was assessed using the Erlanger anxiety- and tension scale (EAS). The test was applied before and after intravenous premedication with 1.5 micrograms/kg clonidine or 50 micrograms/kg midazolam and repeated once postoperatively. During recovery the incidence and severity of pain, nausea and vomiting, and shivering were recorded. The readiness for discharge was assessed using standardised discharge criteria. The recording of data was completed by a telephone interview on the day after surgery.
                The demographic data of the groups did not differ. In the two treatment groups there was a time-dependent decrease of anxiety and tension. However, postoperatively there was no difference between the levels of anxiety and inner tension between the premedicated patients and the untreated control group. Furthermore there was no difference in the incidence and severity of any postoperative complications. Time until the patients were ready for discharge did not differ between the three groups.
                The effects of an intravenous premedication with 1.5 micrograms/kg clonidine or 50 micrograms/kg midazolam, respectively in young ASA-1 patients undergoing minor surgical procedures on a day-case basis are restricted to decrease of anxiety and inner tension before surgery. No beneficial effects were found during the postoperative period compared with untreated control patients. Preoperatively administered midazolam may contribute to postoperative sedation and delayed recovery from brief outpatient general anesthesia, particularly in patients who receive significant postoperative opioid analgesics. We evaluated the effects of midazolam premedication (0.04 mg/kg) on postoperative sedation and recovery times after laparoscopic tubal sterilization (Falope rings) in 30 healthy women in a randomized, double-blind, placebo-controlled study. Patients received midazolam or saline-placebo intravenously 10 min before anesthesia. General anesthesia was induced with fentanyl, propofol, and mivacurium and was maintained with N2O and isoflurane. Sedation was quantified before and after premedication and 15, 30, and 60 min after emergence from anesthesia, using the digit-symbol substitution (DSST) and Trieger dot (TDT) tests. Management of postoperative pain and nausea and discharge criteria were standardized. Groups were similar with respect to age, weight, and duration of surgery and anesthesia. Midazolam was associated with impairment of performance on the TDT and DSST after premedication administration and 15 (TDT and DSST) and 30 (DSST) min after postanesthesia care unit (PACU) arrival. There were no differences in PACU time and time to discharge-readiness. In conclusion, midazolam premedication augments postoperative sedation in this population but does not prolong recovery times. The effectiveness of propranolol, a nonsedating anxiolytic premedication, was studied by monitoring preoperative anxiety and postoperative recovery of cognitive function in 92 healthy ASA physical status I females aged 15-42 yr undergoing outpatient dilatation and curettage (D&C) for therapeutic abortion. In a randomized double-blind design, patients received one of the following oral medications 1-1.5 hr preoperatively: (1) diazepam 10 mg (n = 31); (2) propranolol 80 mg (n = 31); (3) placebo (n = 30). Anxiety throughout the hospital stay was monitored using the State-Trait Anxiety Inventory (STAI). Postoperative cognitive recovery was assessed using the digit span and Trieger tests. STAI anxiety levels were recorded on admission to hospital, immediately before entering the operating room, and two hours postoperatively. There was no difference among the anxiolytic properties of the three medications and all three patient groups showed a significant decrease in anxiety levels after administration of the medication. Tests of cognitive function after anaesthesia showed the fastest return to baseline status in patients receiving propranolol, possibly because beta adrenergic blockade blunted the autonomic signs of light anaesthesia and less anaesthetic was administered. None of the study premedications was demonstrated to have an anxiolytic advantage, but propranolol did offer a faster return of cognitive function in the postoperative period. It remains unclear whether epidural administration of hydromorphone results in spinal analgesia or clinical benefit when compared with intravenous administration. Therefore, we undertook this study to determine whether epidural administration of hydromorphone resulted in decreased opioid requirement, improved analgesia, reduced side effects, more rapid return of gastrointestinal function, or shorter duration of hospital stay than intravenous administration.
                Sixteen patients undergoing radical retropubic prostatectomy were randomized in a double-blind manner to receive either intravenous or epidural hydromorphone via patient-controlled analgesia (PCA) for postoperative analgesia. All patients underwent a standardized combined epidural and general anesthetic and all received ketorolac for 72 h postoperatively. To decrease variability, patients were cared for according to a standardized protocol and were deemed ready for discharge according to prospectively defined criteria.
                Patients in the intravenous PCA group required approximately twice as much opioid than the epidural PCA group (P < 0.008), but there were no differences between groups in pain scores or patient satisfaction. Epidural administration resulted in a greater incidence of pruritus (P = 0.02). Gastrointestinal function recovered quickly in all patients with little variation, and there were no differences between groups. All patients were deemed ready for discharge by the third postoperative day, and removal of surgical drains was the last discharge criterion reached in all patients.
                Our results indicate that epidural administration of hydromorphone results in spinally mediated analgesia. However, epidural administration did not provide significant benefits in terms of postoperative analgesia, recovery of gastrointestinal function, or duration of hospitalization. Furthermore, we suggest that radical retropubic prostatectomy no longer be used as a model to assess the effects of analgesic technique on postoperative recovery, because control of discharge criteria revealed that hospital discharge was primarily dependent on removal of surgical drains. A double-blind trial of temazepam premedication for day cases was undertaken. Effective anxiolysis was recorded in the groups that received temazepam 10 or 20 mg and there was no prolongation of delayed recovery times as measured by memory test cards. All patients were discharged from the day unit 3 hours after the administration of general anaesthesia. The pre- and postoperative effects of oral diazepam (0.5 mg/kg), trimeprazine (4 mg/kg), pentobarbitone (3 mg/kg) and a placebo were compared in a randomized double-blind clinical trial in 149 children, aged one to ten years, undergoing adenotonsillectomy. The anaesthetic was standardised and each patient received intraoperative intramuscular papaveretum (0.3 mg/kg). Preoperative sedation was assessed in the ward before transfer onto the theatre trolley, on leaving the ward, on arrival on the theatre floor, on arrival in the induction room and on induction of anaesthesia. There was no significant difference in sedation between the four drug groups except for the placebo group which had a significantly greater unsatisfactory rating at the stage of induction of anaesthesia (P = 0.001). There were no differences in waking times between the diazepam, pentobarbitone and placebo groups, but the trimeprazine group's waking times were significantly prolonged (P less than 0.001). However, the trimeprazine group exhibited significantly less distress in the recovery unit (P = 0.02) and had half the incidence of vomiting (P less than 0.001) than did the other premedication groups. to investigate the effectiveness of a pharmacy discharge plan in elderly hospitalized patients.
                randomized controlled trial.
                we randomized patients aged 75 years and older on four or more medicines who had been discharged from three acute general and one long-stay hospital to a pharmacy intervention or usual care.
                the hospital pharmacist developed discharge plans which gave details of medication and support required by the patient. A copy was given to the patient and to all relevant professionals and carers. This was followed by a domiciliary assessment by a community pharmacist. In the control group, patients were discharged from hospital following standard procedures that included a discharge letter to the general practitioner listing current medications.
                the primary outcome was re-admission to hospital within 6 months. Secondary outcomes included the number of deaths, attendance at hospital outpatient clinics and general practice and proportion of days in hospital over the follow-up period, together with patients' general well-being, satisfaction with the service and knowledge of and adherence to prescribed medication.
                we recruited 362 patients, of whom 181 were randomized to each group. We collected hospital and general practice data on at least 91 and 72% of patients respectively at each follow-up point and interviewed between 43 and 90% of the study subjects. There were no significant differences between the groups in the proportion of patients re-admitted to hospital between baseline and 3 months or 3 and 6 months. There were no significant differences in any of the secondary outcomes.
                we found no evidence to suggest that the co-ordinated hospital and community pharmacy care discharge plans in elderly patients in this study influence outcomes. The use of cerebral monitoring may improve the ability of anesthesiologists to titrate anesthetic drugs. However, there is controversy regarding the impact of the alleged anesthetic-sparing effects of cerebral monitoring on the recovery process and patient outcome. We designed this prospective double-blinded, sham-controlled study to evaluate the impact of intraoperative monitoring with the electroencephalogram bispectral index (BIS) or auditory evoked potential (AEP) device on the usage of desflurane and the time to discharge from the recovery room, as well as on patient satisfaction with their anesthetic experience and recovery. Ninety healthy patients undergoing laparoscopic general surgery procedures using a standardized anesthetic technique were randomly assigned to one of three monitoring groups: standard clinical practice (control), BIS-guided, or AEP-guided. Both the BIS and AEP monitors were connected to all patients before induction of general anesthesia. In the control group, the anesthesiologists were not permitted to observe the BIS or AEP index values during the intraoperative period. In the BIS-guided group, the volatile anesthetic was titrated to maintain a BIS value in the range of 45-55. In the AEP-guided group, the targeted AEP index range was 15-20. The BIS and AEP indices, as well as end-tidal desflurane concentration, were recorded at 3-5 min intervals. Recovery times to awakening, tracheal extubation, fast-track score >or=12, and postanesthesia care unit (PACU) discharge criteria were recorded at 1-10 min intervals. In addition, patient satisfaction with anesthesia and quality of recovery were evaluated on 100- and 18-point scales, respectively, at 24 h after surgery. The AEP- and BIS-guided groups were administered significantly smaller average end-tidal desflurane concentrations than the control group (3.8 +/- 0.9 and 3.9 +/- 0.6 versus 4.7 +/- 1.7, respectively) (P < 0.01). Although the emergence times to eye opening, tracheal extubation, and obeying commands were consistently shorter in the AEP and BIS groups (6 +/- 4 and 6 +/- 5 versus 8 +/- 8 min; 6 +/- 5 and 6 +/- 4 versus 11 +/- 10 min; and 8 +/- 4 and 7 +/- 4 versus 12 +/- 9 min, respectively), only the extubation times were significantly different from the control group (P < 0.05). More importantly, the length of the PACU stay was significantly shorter in both the AEP- and BIS-guided groups (79 +/- 43 and 80 +/- 47 versus 108 +/- 58 min, respectively) (P < 0.05). The patients' quality of recovery was also significantly higher in the two monitored groups (15 +/- 2 versus 13 +/- 3 in the control group, P < 0.05). We concluded that cerebral monitoring with either the BIS or AEP devices reduced the maintenance anesthetic (desflurane) requirement, resulting in a shorter length of stay in the PACU and improved quality of recovery after laparoscopic surgery. However, there were no significant outcome differences between the two cerebral monitored groups.
                Compared with standard monitoring practices, use of an auditory evoked potential or bispectral index monitor to titrate the volatile anesthetic led to a significant reduction in the anesthetic requirement. The anesthetic-sparing effect of cerebral monitoring resulted in a shorter postanesthesia care unit stay and improved quality of recovery from the patient's perspective. To compare the analgesic and side effects of preemptively used epidural ketamine +bupivacaine, neostigmine +bupivacaine, and bupivacaine alone on postoperative analgesia after major abdominal surgery.
                Randomized, controlled study.
                Inpatient anesthesia at the department of surgery of a metropolitan hospital.
                30 ASA physical status I, II, and III patients scheduled for abdominal surgery.
                Group K received 1 mL (50 mg) ketamine and 5 mL (25 mg) bupivacaine epidurally, Group N received 1 mL (0.5 mg) neostigmine and 5 mL (25 mg) bupivacaine epidurally, and Group B received 1 mL saline and 5 mL (25 mg) bupivacaine epidurally 30 minutes before operation. All patients underwent anesthesia induction with thiopental and vecuronium; anesthesia was maintained with isoflorane and vecuronium. For postoperative analgesia, all patients received epidural morphine for 48 hours postoperatively.
                Standard monitoring included: 48 hours of analgesic requirement, visual analog scale (VAS), mean arterial pressure (MAP), and heart rate (HR) in the 1st, 2nd, 6th, 12th, 24th, and 48th hours. Data were analyzed using Kruskall-Wallis and Mann Whitney U tests, with a p < 0.05 considered statistically significant. No significant differences were observed regarding MAP and HR among the groups during the study period. In Group N, VAS was significantly lower than Group K and Group B. The total opioid consumption in Group N was significantly lower than in Groups K and B in the first 48 hours after the operation.
                Preemptive neostigmine can be a good choice for postoperative analgesia.
We found no evidence of a difference in time to discharge from hospital, assessed by clinical criteria, in patients who received anxiolytic premedication. However, in view of the age and variety of anaesthetic techniques used and clinical heterogeneity between studies, inferences for current day case practice should be made with caution.