Search

BACKGROUND Middle ear surgeries done under local anaesthesia require adequate patient sedation and analgesia to prevent patient anxiety and movement during surgical procedures. This study was undertaken to compare dexmedetomidine and propofol for their sedative and analgesic properties, safety profile, adverse events and recovery profile in patients undergoing middle ear surgery under monitored anaesthesia care. METHODS This is a prospective observational study. 96 patients of both sexes, of American society of anaesthesiologist (ASA) grade I or II, between 18 - 60 years of age were randomly divided into two groups; group D and group P consisting of 48 patients each. Patients in group D received a loading dose of injection dexmedetomidine 1 µg / kg I.V. over 10 minutes followed by an infusion at a rate of 0.5 µg / kg / hr. Patients in group P received a loading dose of injection propofol 75 µg / kg / min. I.V. over 10 min followed by an infusion at a rate of 50 µg / kg / min. Time taken to achieve the modified Aldrete score of 10 was compared between both the groups. Before discharge from post anaesthesia care unit (PACU), patient’s satisfaction with sedation & surgeon satisfaction was recorded on Likert scale. Time to rescue analgesia was compared. RESULTS The Bi-Spectral Index values in intra-operative period were on the lower side in the group D as compared to the corresponding values in the group P, but P values were statistically insignificant suggesting that both dexmedetomidine and propofol produced similar sedation. Time to rescue analgesia was greater for group D. CONCLUSIONS Having similar sedation effect, dexmedetomidine was better than propofol for sedation in patients undergoing middle ear surgery under monitored anaesthesia care. KEYWORDS Dexmedetomidine, Propofol, Monitored Anaesthesia Care, Bi-spectral Index

Background: Monitored anaesthesia care (MAC) has become increasingly used for middle ear surgeries. Midazolam is most commonly used for sedation in MAC; likewise, dexmedetomidine has gained popularity for intravenous sedation for the procedures to be done under MAC. The present study was undertaken to evaluate and compare the perioperativeeffects of inj. dexmedetomidine and midazolam with respect to sedation, analgesia and hemodynamic stability. Method: Study was approved by the Institutional Medical Ethics Committee and written informed consent was obtained from all patients participating in the study. Total 60 patients of ASA Grade I and II, aged 18 - 60 years, undergoing tympanoplasty surgery under local anaesthesia with 2% Lignocaine plus adrenaline 1:200000 and sedation with infusion of either dexmedetomidine or midazolam drug. Patients were divided in two groups of 30 patients in each group by chit block method. Group D received Dexmedetomidine 1 mcg/kg IV bolus over 10 min followed by continuous IV infusion at 0.5 mcg/kg/hr. Group M received midazolam 40 mcg/kg IV over 10 min followed by continuous IV infusion at 20 mcg/kg/hr. Results: Perioperatively, sedative effects of dexmedetomidine and midazolam were almost comparable, analgesic effects of dexmedetomidine was better than midazolam IV infusion. The significant reduction in haemodynamic variables was noted with dexmedetomidine (p=0.001) provided better hemodynamic stability than midazolam. Oxygen saturation and respiratory rate were maintained within normal limits in both the groups. 80% of surgeons in either group showed significant satisfaction but the difference was not statistically significant between two groups. Conclusion: Dexmedetomidine is a safe agent as sedative in patients undergoing tympanoplasty surgery under local anaesthesia with MAC.

ObjectivesThis clinical trial is registered at ClinicalTrials.gov. (NCT02476981) This randomized, prospective double-blind study compared remifentanil with dexmedetomidine for monitored anaesthesia care during minimally invasive corrections of vertebral compression fractures (vertebroplasty or kyphoplasty).MethodsPatients > 65 years of age with American Society of Anesthesiologists (ASA) classification I–III, scheduled for vertebroplasty or kyphoplasty under monitored anaesthesia care, received remifentanil (i.v. infusion 1–5 µg/kg/h) or dexmedetomidine (loading dose 0.3–0.4 µg/kg followed by i.v. infusion 0.2–1 µg/kg/h) to maintain observer's assessment of alertness/sedation (OAA/S) scale ResultsThere were no statistically significant differences in demographic data between the remifentanil ( n = 37) and dexmedetomidine groups ( n = 38). Patients on dexmedetomidine experienced lower mean arterial pressure (MAP) and heart rate (HR), and higher SpO2values, than patients on remifentanil. Compared with dexmedetomidine, remifentanil produced more respiratory depression, oxygen desaturation, and reduced the need for additional intraoperative opioids. There were no significant between-group differences in terms of recovery time, investigators’ satisfaction scores, or patients’ overall pain experiences.ConclusionsDuring monitored anaesthesia care, dexmedetomidine provides less respiratory depression, lower MAP and HR, but also less analgesic effect than remifentanil in elderly patients undergoing vertebroplasty or kyphoplasty.

Background and Aims: Monitored anaesthesia care (MAC) is meant for procedures under local anaesthesia. Various drugs have been used for this purpose. The recently introduced alpha2 agonist, dexmedetomidine provides "conscious sedation" with adequate analgesia and minimal respiratory depression. Hence, the safety and efficacy of two doses of dexmedetomidine for sedation and analgesia were evaluated. Methods: A total of 90 patients were distributed in three groups of 30 each: Dexmedetomidine 0.5 μg/kg (DL), dexmedetomidine 1.0 μg/kg (DH) and normal saline (C). The initial loading dose was followed by maintenance infusion of 0.2-0.7 μg/kg/h of dexmedetomidine or equivalent volume of saline. Study drug was started at least 15 min before placement of local anaesthesia. Drugs were titrated to a target level of sedation (=3 on Ramsay sedation scale [RSS]). Midazolam 0.02 mg/kg for RSS < 3 and fentanyl 0.5 μg/kg were supplemented as required. The statistical analysis was performed using Chi-square test and mean and anova analysis. Results: In groups DL and DH fewer patients required supplemental midazolam, 56.7% (17/30) and 40% (12/30), compared with control, where 86.7% (26/30)needed midazolam supplements. P = 0.000. Both groups DL and DH required significantly less fentanyl (84.8 and 83.9 μg) versus control (144.2 μg). There was significantly increased ease of achieving and maintaining targeted sedation and analgesia in both dexmedetomidine groups when compared with placebo (P = 0.001). Adverse events observed with dexmedetomidine were bradycardia and hypotension. Conclusions: Dexmedetomidine in the doses studied was considered safe and effective sedative and analgesic for patients undergoing procedures under MAC.

Backgraound: Transcatheter aortic valve implantation (TAVI), with its improved valve technologies will also be an option for patients in the near future and improved operator experience. Cerebrovascular events are among the most feared complications of TAVI, since they cause high morbidity and mortality. Case: After the patient with EuroSCORE II = 8.6% was considered to be at high risk in terms of surgery, the decision to perform TAVI was taken. The valve (Medtronic 26 mm) was successfully placed during the 110 min procedure. Blood loss was 140 mL, no red blood cell (RBC) transfusion and catecholamines requirements were present, no VF (ventricular fibrillation) and cardiac tamponade were observed and post procedure left ventricular ejection fraction (LVEF) was 60%. At the end of the procedure, the BIS value of the patient was 70, regression in the Glasgow Coma Score (GCS = 12), anisocoria in the pupils (R = 2 mm < L = 4 mm) and motor loss in the right arm (3/5) and right leg (3/5) were detected. Modified Rankin scale (mRS) was evaluated as 4. Conclusions: The neurological complication rate of up to 80% during and in the days following the procedure, the long recovery period after embolism, the possibility of being a nursing patient and even the risk of death, remind us that the TAVI procedure and the sedation given during the procedure should never be underestimated. Keywords: Transcatheter aortic valve implantation, cerebral embolism, complications, neuroradiology, monitorized anaesthesia care, aort stenosis.

Background and Aims: Middle ear surgeries (MESs) are usually performed under sedation with local anaesthesia and can be well tolerated by the patient with minimal discomfort. In the present study, we compare the effect of nalbuphine/dexmedetomidine combination with nalbuphine/propofol on sedation and analgesia in monitored anaesthesia care. Methods: One hundred adult patients undergoing MESs under monitored anaesthesia care (MAC) were randomly allocated into two groups. All patients in both groups received injection nalbuphine 50 μg/kg intravenously (IV). Group D received a bolus dose of injection dexmedetomidine 1 μg/kg IV over 10 min followed by an infusion started at 0.4 μg/kg/h IV. Group P received a bolus dose of injection propofol 0.75 mg/kg followed by an infusion started at 0.025 mg/kg/min IV. Sedation was titrated to Ramsay Sedation Score (RSS) of 3. Patient's mean arterial pressure, heart rate, saturation peripheral pulse and need for intraoperative rescue sedation/analgesia were recorded and compared. The data analysis was carried out with Z test and Chi-square test. Results: Mean RSS was significantly more in Group D (4.24 ± 1.54) as compared to Group P (2.58 ± 0.95). Overall VAS score was also significantly less in Group D (3.5 ± 1.7) than in Group P (5.4 ± 1.8). In total, 16 patients (32%) in Group D had hypotension whereas 7 patients (14%) only in Group P had hypotension. Conclusion: Nalbuphine/dexmedetomidine combination is superior to nalbuphine/propofol in producing sedation and decreasing VAS in patients undergoing MESs under MAC. Better surgeon and patient satisfaction were observed with nalbuphine/dexmedetomidine. Haemodynamics need to be closely monitored.

INTRODUCTION Monitored anaesthesia care involves administering a combination of drugs for anxiolytic, hypnotic, amnestic and analgesic effect. Ideally it should result in less physiological disturbance and allow for more rapid recovery than general anaesthesia. It typically involves administration of local anaesthesia in combination with IV sedatives, anxiolytic and analgesic drugs which is a common practice during various ENT surgical procedures. AIM OF STUDY Is to “Compare Dexmedetomidine with Fentanyl for sedation in tympanoplasty (ENT Surgeries)”. The objective of the study is to evaluate the efficacy of dexmedetomidine and fentanyl as an appropriate sedative drug for Monitored Anaesthesia Care in Tympanoplasty (ENT surgeries) METHODS & MATERIALS A total of 60 patients are being recruited into this study with regards to assess, Pain, Discomfort, Sedation, Peripheral Oxygen Saturation (SPO2) & Systolic Blood Pressure (SBP), Diastolic blood pressure (DBP), Mean arterial blood pressure(MAP) & Heart rate This study was undertaken at Govt. ENT Hospital Hyderabad. Sixty (60) patients undergoing Tympanoplasty surgery were taken for study. Thus the study contains 30 patients in Dexmedetomidine group-(Group D) and 30 patients in Fentanyl group (Group F) RESULT Dexmedetomidine provides less discomfort, better sedation, and analgesia when compared with fentanyl under monitored anaesthesia care (Conscious sedation). However, the risk of adverse effects requires monitoring for ready intervention. It provides a unique type of sedation, “conscious sedation” in which patients appear to be sleepy but are easily arousable, cooperative and communicative when stimulated. It is sedative and analgesic agent, with opioid-sparing properties and minimal respiratory depression.

Objective Chronic subdural haematoma (CSDH) is a common neurosurgical problem, and treatment includes evacuation of the haematoma by burr hole drainage. Commonly, these procedures are performed under local anaesthesia, general anaesthesia or, recently, with monitored anaesthesia care (MAC). We compared dexmedetomidine- and propofol-based sedation along with scalp nerve block for burr hole evacuation of CSDH. Methods In this prospective randomised study, 62 patients were divided into the following two groups of 31 patients each: Group D and Group P. Group D received dexmedetomidine 1 μg kg-1 over 10 minutes as a loading dose, followed by 0.2-0.7 μg kg-1 hr-1. Group P received propofol 1 mg kg-1 over 10 minutes as a loading dose, followed by 1-3 mg kg-1 hr-1. The heart rate (HR) and blood pressure were measured at different intervals. The recovery parameter and satisfaction score were also recorded. Results There were no significant differences noted in the demographic profile. A significant decrease in HR compared to preoperative value was seen in Group D compared to Group P. Blood pressure values were statistically significantly lower in both study groups, compared to preoperative values during the whole procedure and after surgery (p

Background: In elderly patients for some diagnostic, therapeutic and surgical procedure, Monitored anaesthesia care (MAC) may be an anaesthetic option for them. Aim and objective: This prospective study was designed to assess the efficacy, safety, and tolerability of MAC in elderly patients. Method: This study was performed on elderly patients of both sex, age from 50 years and above, scheduled to undergo different therapeutic, diagnostic and surgical procedures. The patient’s characteristics, pre-anaesthetic problems, anaesthetic techniques, anaesthetic agents, anesthetic time, MAC procedure and complications were assessed. Result: They involved mainly hypertension (26.49%) and diabetes mellitus (21.78%). Almost all procedure was done under sedation (70.38%), local anaesthesia (22.71%) and under only monitoring without sedation or local anaesthesia (6.90%). There were no serious adverse events reported in any patients during MAC. The common complications were arrhythmia (9.60%), vomiting (7.36%) and desaturation (4.56%), hypertension (5.64%). Complications were minor, transient and promptly managed and corrected. MAC duration was ranged from 15 to180 minutes. The mean procedure time was 35.1 + 12.5 minutes. Majority of cases were completed within 30 minutes (51.21%). Conclusion: In properly selected elderly patients, MAC is a safe and effective method of providing intraoperative care for some common diagnostic, therapeutic, and operative procedures. DOI: http://dx.doi.org/10.3329/jbsa.v23i1.18154 Journal of BSA, 2010; 23(1): 19-24

BACKGROUND: This study aimed to compare remifentanil and ketamine-propofol in terms of hemodynamic response, duration of recovery and patient satisfaction in operative hysteroscopy cases who underwent monitored anaesthesia care in combination with paracervical block. METHODS: Monitored anaesthesia care was used in 60 ASA I-II female patients. The patients were divided into two groups as remifentanil (Group R) and ketamine-propofol (Group K-P). The hemodynamic effects of remifentanil and ketamine-propofol, and duration of recovery were recorded and compared. The patient satisfaction was also recorded and the two groups were compared. RESULTS: Age, body mass, ASA status, duration of anaesthesia and type of surgery were found to be similar between groups. The time of the Aldrete score reaching ≥ 9 was found to be shorter in Group R when compared with Group KP (Group R: 4.1 ± 1.9 min, Group K-P: 6.1 ± 2.6 min) ( P < 0.05). The incidence of postoperative nausea and vomiting was found to be significantly higher in the remifentanil group ( P ≤ 0.05). When the groups were compared in terms of patient satisfaction, in both groups this was found to be similar. CONCLUSION: Sedation with remifentanil combined with a paracervical block during monitored anaesthesia care provides early recovery with effective sedation and analgesia in hysteroscopy procedures.

As the number of elderly patients undergoing surgery continues to rise, it is important to consider anaesthetic options that minimize physiological stress in these patients. Monitored anaesthesia care (MAC), or sedation and monitoring during surgery, is an attractive option for certain common procedures. However, those administering MAC must consider the normal decline in functional reserve in patients aged >70 years. This includes loss of normal compensation for the stress of hypovolaemia, decreased peripheral vascular resistance, altered mental status and reduced response to hypoxia and hypercarbia associated with the perioperative and sedated state in this population. In addition, vigilance is necessary to identify co-morbid states, which increase in incidence with age and often present atypically. Elderly patients have increased sensitivity to all sedatives and opioids (doubled by age 80 years, quadrupled by age 90 years with benzodiazepines). As a result of changes in body composition, as well as senescence of renal and hepatic function, the time to onset and offset of even short-acting sedatives will be prolonged. There is also extreme variability in the response to sedatives among these patients. Anaesthetic dosing should be in smaller increments in the elderly, boluses reduced by half and infusions reduced by as much as two-thirds. Caution must be exercised through full monitoring of intra-operative and postoperative mental status, oxygenation and perfusion states. Pain is best treated using smaller doses in a multimodal regimen, the aim being to reduce adverse effects while ensuring adequate pain relief. In this way, a huge range of procedures can be safely performed in our aging population with expectations for a full and early return to baseline functional status.

BACKGROUND AND OBJECTIVE We conducted an open, prospective, randomized study to compare the efficacy, safety and recovery characteristics of remifentanil or propofol during monitored anaesthesia care in patients undergoing colonoscopy. METHODS Forty patients were randomly assigned to receive either propofol (1 mg kg(-1) followed by 10 mg kg (-1) h(-1), n = 20) or remifentanil (0.5 microg kg(-1) followed by 0.2 microg kg(-1) min(-1), n = 20). The infusion rate was subsequently adapted to clinical needs. RESULTS In the propofol group, arterial pressure and heart rate decreased significantly from the baseline. These variables remained unchanged in the remifentanil group, but hypoventilation occurred in 55% of patients. Early recovery was delayed in the propofol group (P < 0.002). Recovery of cognitive and psychomotor functions was faster in the remifentanil group. Fifteen minutes after anaesthesia, the Digit Symbol Substitution Test score was 28.6 +/- 12.8 versus 36.2 +/- 9.4 and the Trieger Dot Test score was 25.6 +/- 8.1 versus 18.7 +/- 4.1 in the propofol and remifentanil groups, respectively (both P < 0.05). Patient satisfaction, using a visual analogue scale, was higher in the propofol group (96 +/- 7 versus 77 +/- 21, P < 0.001). CONCLUSIONS Remifentanil proved efficient in reducing pain during colonoscopy. Emergence times were shorter and the recovery of cognitive function was faster with remifentanil compared with propofol. Remifentanil provided a smoother haemodynamic profile than propofol; however, the frequent occurrence of remifentanil-induced hypoventilation requires the cautious administration of this agent.

The use of monitored anaesthesia care (MAC) is increasing with the discovery of newer, more effective and appropriate drugs and techniques. MAC is intended to achieve patient comfort with safety and optimal clinical outcome and is being extensively used worldwide for cataract and other ophthalmic surgeries. This article briefly reviews the conceptual basis of MAC, its use in ophthalmic surgeries, sedative-analgesic drugs commonly used during MAC in eye surgeries, monitoring during MAC in eye surgery and the role of anaesthesia practitioners during MAC. Key words: anaesthesia; cataract; eye; monitored anaesthesia care (MAC); sedation; surgery DOI: 10.3126/nepjoph.v1i1.3674 Nep J Oph 2009;1(1):60-65

Local anaesthetic with monitored anaesthetic care (MAC) is a very good technique for unilateral-inguinal herniorraphy. We looked at the analgesia produced by the infiltration with local anaesthetic, the intensity of pain in the immediate postsurgery period; the efficiency of oral analgesics and the satisfaction of the patients. Between January and July 1997, 63 patients underwent unilateral-inguinal herniorraphy (Shouldice type) using local anaesthetic (300 mg of mepivacain 1% and 50 mg of bupivacain 0.25%) and MAC (fentanyl, mydazolan and propofol). The intensity of pain was measured using two evaluation scales: visual analogue scale (EV) and verbal scale (Eve). When the patients asked for an analgesic they were given magnesic metamizol (Nolotil), every 6 h. Five patients (8%) felt no pain and 58 felt pain 4 h 36 min after local anaesthetic infiltration (EV=2.5; Eve=1.45) of these 58 patients, 49 took a first dose of ‘Nolotil’ 6 h 40 min after local anaesthetic induction (EV=4; Eve=1.97), 43 received a second dose of ‘Nolotil’ at 13 h 40 min (EV=3; Eve=1.49) and 22 a third dose at 17 h 40 min (EV=3.2; Eve=1.7). Every patient that was very satisfied with the anaesthetic technique, said that the postsurgery pain was bearable and they would be happy to be operated on again with the same anaesthetic-surgery technique. The efficacy of the anaesthetic technique (local anaesthetic with conscious sedation) was very good, 8% of the patients never felt pain and 21% never received any analgesic. The time passed until the first analgesic dose was 6 h 40 min, and the tolerance of the pain was excellent.

Comparison of entropy (state entropy [SE] and response entropy [RE]) with the bispectral index (BIS) during propofol sedation in monitored anaesthesia care (MAC) was carried out in patients undergoing hand surgery. Thirty candidates for elective hand surgery were pre-medicated with midazolam 0.06 mg/kg and atropine 0.01 mg/kg. Sedation was induced with intravenous propofol and fentanyl was also administered. The Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) was used to determine sedation level and pain was maintained at < 4 on a 0-10 verbal rating scale. The BIS, entropy, MOAA/S and pain values were recorded before initiation of sedation (control), during initiation of sedation, during surgery, and for 30 min after the end of surgery and anaesthesia. On initiation of sedation, entropy decreased more rapidly than BIS. At 10 min after initiation of sedation, the mean ± SD values for MOAA/S, BIS, RE and SE were 3.00 ± 0.36, 85.45 ± 0.15, 74.00 ± 0.60 and 72.02 ± 0.12, respectively. During recovery, BIS and RE and SE increased in parallel with MOAA/S. It is concluded that entropy monitoring is as reliable as BIS monitoring in MAC.

Introduction: Monitored Anesthesia Care (MAC) is proposed to be a suitable technique for middle ear surgery. Aim: In present study we compared the efficiency of dexmedetomidine and propofol as an adjunct to local anesthesia for in producing analgesia, sedation, variation in respiratory and hemodynamic responses, along with patients and surgeons satisfaction. Materials and Methods: Fifty patients were enrolled in this prospective, single blinded, randomized study. The patients were allotted randomly into two groups: dexmedetomidine (Group D) or propofol (Group D). Sedation was assessed with Ramsay Sedation Scale (RSS) value of 3. Different parameters observed included changes in hemodynamic and respiratory values, post-surgical recovery time, sedation analgesia, surgeons’ and patients’ satisfaction about quality of anaesthesia. Results: Both the drugs i.e. dexmedetomidine and propofol were found to be providing adequate sedation but propofol was related with increased need for rescue analgesia and less patient satisfaction. These results propose that dexmedetomidine provide sufficient sedation with analgesia with good surgeon and patient ease without any adverse effect for patients being operated for middle ear surgery under local anesthesia. Keywords: Dexmedetomidine, Propofol, Fentanyl, Sedation, Middle ear surgery

Monitored Anaesthesia Care (MAC) refers to the provision of sedation and/or analgesia during diagnostic and therapeutic procedures in the presence or absence of regional anaesthesia. Monitored anaesthesia care has developed as a key component of modern ambulatory surgery and offers patients the benefits of regional anaesthesia with sufficient sedation to permit the patient to tolerate the procedure. Sedation is not the exclusive province of the anaesthetist. Sedative techniques are practised by other clinicians using a wide variety of agents. Used appropriately, monitored anaesthesia care extends the repertoire of surgical procedures that can be considered for ambulatory patients and may also permit day surgery in patient groups who would traditionally be considered unsuitable for outpatient general anaesthesia. Monitored anaesthesia care spans the continuum between conscious sedation and general anaesthesia. It is recognised that in such cases, the level of sedation may vary widely during a single case and the potential jeopardy to the cardiovascular and respiratory systems justifies the continuous presence of an anaesthetist and the deployment of additional monitoring techniques.

Although moderate (conscious) sedation is intended during elective gastrointestinal endoscopy, unintended levels of deep sedation occur resulting in respiratory and cardiac compromise. We present here use of Ayre’s T-piece circuit along with nasopharyngeal airway for Endoscopic Retrograde CholangioPancreatography (ERCP) procedure under sedation which negates all the above problems, ensuring safety of the patient. DOI: http://dx.doi.org/10.4038/slja.v23i1.7043

Cataract surgery is commonly performed under local anaesthesia with midazolam sedation. Dexmedetomidine, a sedative-analgesic, is devoid of respiratory depressant effects, and its use in cataract surgery has not been reported. This double-blind study compared the use of dexmedetomidine and midazolam in patients undergoing cataract surgery.Forty-four patients undergoing cataract surgery under peribulbar anaesthesia randomly received either i.v. dexmedetomidine 1 microg kg(-1) over 10 min; followed by 0.1-0.7 microg kg(-1) h(-1) i.v. infusion (Group D), or midazolam 20 microg kg(-1) i.v.; followed by 0.5 mg i.v. boluses as required (Group M). Sedation was titrated to a Ramsay sedation score of 3. Mean arterial pressure (MAP), heart rate (HR), readiness for recovery room discharge (time to Aldrete score of 10), and patients' and surgeons' satisfaction (on a scale of 1-7) were determined.MAP and HR were lower in Group D compared with Group M [86 (se 3) vs 102 (3) mm Hg and 65 (2) vs 72 (2) beats min(-1), respectively] (P0.05). Group D patients had slightly higher satisfaction with sedation [median (IQR): 6 (6-7) vs 6 (5-7), P0.05], but delayed readiness for discharge [45 (36-54) vs 21 (10-32) min, P0.01] compared with patients in Group M. Surgeons' satisfaction was comparable in both groups [5 (4-6) vs 5 (4-6)].Compared with midazolam, dexmedetomidine does not appear to be suitable for sedation in patients undergoing cataract surgery. While there was a slightly better subjective patient satisfaction, it was accompanied by relative cardiovascular depression and delayed recovery room discharge.

The objective of this study was to evaluate the effect of an ilioinguinal-hypogastric nerve block (IHNB) with bupivacaine 0.25% on the postoperative analgesic requirement and recovery profile in outpatients undergoing inguinal herniorrhaphy with local anaesthetic infiltration. Thirty consenting healthy men undergoing elective unilateral inguinal herniorrhaphy procedures were randomly assigned to receive an IHNB with either saline or bupivacaine according to a double-blind, IRB-approved protocol. All patients received midazolam, 2 mg iv, and fentanyl 25 microgram iv, prior to injection of 30 ml of either bupivacaine 0.25% or saline through the oblique muscle approximately 1.5 cm medial to the anterior superior iliac spine. Subsequently, the surgeon infiltrated the incision site with a lidocaine 1% solution. Sedation was maintained during the operation with a variable-rate propofol infusion, 25-140 micrograms.kg-1.min-1. No significant differences were noted in the intraoperative doses of lidocaine, propofol and fentanyl in the two treatment groups. However, the pain visual analogue score at 30 min after entering the PACU was lower in the bupivacaine (versus saline) group (P0.05). Although the times to ambulation (86 +/- 18 vs 99 +/- 27 min) and being judged "fit for discharge" (112 +/- 49 vs 126 +/- 30 min) were similar in the two groups, the bupivacaine-treated (vs saline) patients required less oral analgesic medication after discharge (46% vs 85%). We concluded that the use of an ilioinguinal-hypogastric nerve block with bupivacaine 0.25% as an adjuvant during inguinal herniorrhaphy under monitored anaesthesia care decreased pain in the PACU and oral analgesic requirements after discharge from the day-surgery unit.

International audience; Endovascular therapy (EVT) is now standard of care for eligible patients with acute ischaemic stroke caused by large vessel occlusion in the anterior circulation. EVT can be performed with general anaesthesia (GA) or with monitored anaesthesia care, involving local anaesthesia with or without conscious sedation (LA/CS). Controversies remain regarding the optimal choice of anaesthetic strategy and observational studies suggested poorer functional outcome and higher mortality in patients treated under GA, essentially because of its haemodynamic consequences and the delay to put patients under GA. However, these studies are limited by selection bias, the most severe patients being more likely to receive GA and recent randomised trials and meta-analysis showed that protocol-based GA compared with LA/CS is significantly associated with less disability at 3 months. Unlike for intravenous thrombolysis, few data exist to guide management of blood pressure (BP) before and during EVT, but arterial hypotension should be avoided as long as the occlusion persists. BP targets following EVT should probably be adapted to the degree of recanalisation and the extent of ischaemia. Lower BP levels may be warranted to prevent reperfusion injuries even if prospective haemodynamic management evaluations after EVT are lacking.

Background Endoscopic lung volume reduction using one or more endobronchial valves is a treatment option for a select group of patients with severe emphysema. Patients presenting for this procedure pose various challenges to the anaesthetist; in addition to their lung condition, they are often elderly with multiple comorbidities. The procedure is usually performed outside the operating room. Monitored anaesthesia care with intravenous sedation, and general anaesthesia with an endotracheal tube have both been described for these procedures, aiming for adequate ventilation and haemodynamic stability. Methods We present our experience on 20 of these procedures in relation to the anaesthetic techniques employed and discuss the perioperative challenges involved in managing these cases. Results Twenty one planned endobronchial valve insertion procedures were identified on 18 patients. There were ten cases of monitored anaesthesia care with sedation and 10 cases which used general anaesthesia with an endotracheal tube. Two have been excluded; one had features of anaphylaxis and the procedure was abandoned, and the other required conversion from monitored anaesthesia care to general anaesthesia with endotracheal tube. Conclusions Both monitored anaesthesia care with sedation and general anaesthesia with endotracheal tube were well tolerated during endobronchial valve insertion procedures. General anaesthesia with endotracheal tube may offer better interventional conditions, patient comfort and reduced anaesthetic time.

Summary Background Propofol-mediated sedation for endoscopy is popular because of its rapid onset and recovery profile. Aim To examine procedure-specific occurrence and risk factors for cardiopulmonary events during propofol-mediated upper endoscopy (EGD) and colonoscopy. Design A cohort study using the Clinical Outcomes Research Initiative database was used to determine the frequency of cardiopulmonary events. Clinical Outcomes Research Initiative consisted of 69 practice sites comprising 593 US endoscopists. Multivariate logistic regression analysis used variables, such as age, ASA classification and propofol administration by monitored anaesthesia care or gastroenterologist-administered propofol to determine the risk of cardiopulmonary events. Results The overall cardiopulmonary event rate for 5928 EGDs and 11 683 colonoscopies was 11.7/1000 cases. For colonoscopy, ascending ASA classification was associated with an increased risk. Monitored anaesthesia care was associated with a decreased adjusted relative risk (0.5, 95% CI: 0.36–0.72). ASA I and II patients receiving monitored anaesthesia care for EGD exhibited a significantly lower relative risk (ARR 0.29, 95% CI: 0.14–0.64). For subjects with ASA class III or greater, there was no difference in the risk between monitored anaesthesia care and gastroenterologist-administered propofol. Conclusions There are procedure-specific risk factors for cardiopulmonary events during propofol-mediated EGD and colonoscopy. These should be taken into account during future prospective comparative trials.

The second phase of the 5th National Audit Project of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland, concerning accidental awareness during general anaesthesia, consisted of a survey of anaesthetic activity in Ireland. A network of consultant anaesthetists co-ordinated data collection from the anaesthetic departments of 46 public and 20 independent hospitals over seven days. Data on patients' characteristics, anaesthetic techniques, staffing, and admission and discharge arrangements were collected on all cases for which anaesthetic care (general, regional or local anaesthesia, sedation or monitored anaesthesia care) was provided. A total of 8049 cases were reported during the survey, giving an annual estimate of 426 600 cases for which anaesthetic care is provided. General anaesthesia constituted 5621 (70%), regional anaesthesia 1404 (17%), local anaesthesia 290 (4%), sedation 618 (8%) and monitored anaesthesia care 116 (1%) of the total number of cases. This survey provides unique data regarding anaesthesia services in public and independent hospitals in Ireland.