A 52 year-old patient with CAD, with a history of an MI 2 years ago is now being prepared for a hip replacement and asks you if certain techniques are better for her heart than others. Of course you plan to provide a hemodynamically stable anesthetic.

Do regional versus general anesthetic techniques make a difference in patients with myocardial ischemia risk? Go to this Anesthesiology question at TheAnswerPage

Epidural Anesthesia and Analgesia Decrease the Postoperative Incidence of Insulin Resistance in Preoperative Insulin-Resistant Subjects Only

(Anesthesia & Analgesia 2007; 104(6): 1587-93)

SOURCE: Ivanhoe interview with Zhongcong Xie, M.D., Ph.D.; The Journal of Neuroscience, 2007;27:1247- 1254

Do patients profit from physostigmine in recovery from desflurane anaesthesia?

Background: Physostigmine is the drug of choice in the central anticholinergic syndrome, but has also been used in post-operative mental derangement secondary to sedatives and volatile anaesthetics. The aim of this double-blind, randomized, prospective study was to determine whether physostigmine alters recovery after desflurane anaesthesia.

Methods: One hundred patients undergoing urologic or surgical procedures were enrolled to receive either NaCl 0.9% (n = 50) or 2 mg of physostigmine (n = 50) at the end of general anaesthesia with propofol, fentanyl, cisatracurium and desflurane. Times to extubation, stating name, birthday and place of residence, and obeying commands such as eye opening and hand squeezing were noted. Haemodynamics, Aldrete and pain scores, the analgesic requirements, and any adverse side-effects were documented until the 1st post-operative day.

Results: Demographic, peri-operative data including duration of anaesthesia, surgery and postanaesthetic care unit (PACU) stay, and consumption of anaesthetics were comparable in both groups. No significant difference between the groups was found for extubation time or other emergence parameters. Patients undergoing anaesthesia >150 min showed after receiving physostigmine significantly (P < 0.05) faster spontaneous breathing (2.6 ± 3.1 vs. placebo 5.0 ± 4.2 min) and extubation time (6.2 ± 3.7 vs. placebo 8.8 ± 5.0 min). Women showed significantly shorter extubation times (5.5 ± 3.4 min) and eye opening (5.5 ± 2.6 min) with physostigmine than placebo (7.7 ± 4.5 and 7.8 ± 4.0 min). The incidence of post-operative nausea and vomiting (PONV) was significantly higher after physostigmine than placebo, whereas shivering occurred more often after placebo.

Conclusion: Physostigmine does not alter desflurane-based anaesthesia compared with placebo. An option is to use physostigmine in patients with a duration of anaesthesia >150 min who profit in earlier return to spontaneous breathing and shorter extubation time.

OR efficiency boosted by pre-op clinic visits

Anethesiology 2006; 105: 1254–1259

Pre-operative consultations can significantly increase efficiency in the operating room (OR) by allowing medical issues to be identified and resolved before surgery, according to the results of a retrospective study.

This is the view of surgeons at Brigham and Women’s Hospital in Boston, Massachusetts, USA, where all patients undergoing elective procedures are evaluated in a pre-operative clinic. To assess the economic impact of these visits, Darin Correll and colleagues retrospectively studied the charts of 5083 patients seen at the Hospital over a 3-month period.

Medical issues requiring further action were identified in 647 patients, Correll et al report in the journal Anesthesiology. The vast majority (87%) of issues were cardiac in origin, followed by pulmonary, anesthetic, and hematologic problems.

Many of the issues related to pre-existing problems and simply required the retrieval of information from other centers.

However, in 115 cases a new medical problem was identified at the pre-operative visit. The most common findings were electrocardiographic abnormalities or new cardiac symptoms that required an additional test or consultation.

Importantly, around one in 10 patients in whom new medical issues were identified had their operation delayed or canceled, a finding with implications for costs and resource use, say the authors.

“It is difficult to calculate the financial impact if the missing information results in a delay rather than a cancellation,” they write.

“However, should case delay result in the overall lengthening of the operating room day, resulting in increased overtime as well as shift differential payments, the variable costs of running the operating room would increase.”

Correll et al conclude that pre-operative clinic visits streamline assessment, allow implementation of protocols that may improve outcomes, and increase OR efficiency.