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STUDY OBJECTIVE: To evaluate the effect of propofol (two mg/kg)/remifentanil (4 µg/kg) on intraocular pressure (IOP) when used for rapid-sequence induction. DESIGN: Randomized, double-blinded trial. SETTING: Ambulatory surgery center. PATIENTS: 47 adult, ASA physical status I and II patients (ages 18-75 yrs), undergoing outpatient, elective, nonophthalmologic surgery. INTERVENTIONS: After premedication with midazolam (two mg) and glycopyrrolate (0.2 mg), standard monitors and a bispectral index (BIS) monitor were applied. Patients underwent rapid-sequence induction with intravenous (IV) propofol two mg/kg and either remifentanil 4 µg/kg IV or succinylcholine 1.5 mg/kg IV. An experienced anesthesiologist, blinded to patient group assignment, performed intubation after 60 seconds. MEASUREMENTS: IOP, heart rate (HR), blood pressure, BIS scores, intubating conditions, and response to intubation (coughing or moving) were recorded at baseline, immediately after completion of induction, one minute after intubation, and three minutes after intubation. Time to return of spontaneous ventilation was also measured. MAIN RESULTS: Remifentanil produced a 39% decrease in IOP immediately after induction, which remained unchanged by laryngoscopy and intubation (P < 0.001). IOP remained below baseline even in patients who coughed or moved in response to intubation. Remifentanil caused a significant decrease in mean arterial pressure of 24% to 31% but no significant change in HR, and it blocked the hemodynamic response to laryngoscopy and intubation while providing intubating conditions comparable to those of succinylcholine. CONCLUSIONS: Propofol/remifentanil induction provides adequate intubating conditions, prevents an increase in IOP, and controls the hemodynamic stress response to laryngoscopy and intubation.

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STUDY OBJECTIVE: To determine whether a set of predetermined discharge criteria, used by nurses, shortens the length of patient stay in the postanesthesia care unit (PACU) without compromising safety. STUDY DESIGN: Prospective clinical study. SETTING: Postoperative recovery area of a large, tertiary-care, academic hospital. PATIENTS: 1,198 adult, ASA physical status I, II, and III patients, 18 years or older, requiring general anesthesia. INTERVENTIONS: Two groups of inpatients were followed. In the first group, over a 90 day period, all inpatients meeting study inclusion criteria were discharged by a physician (traditional discharge group [TDG]). This period was followed by a subsequent 90 day period in which a second group of patients were discharged by a PACU nurse using predetermined discharge criteria (discharge criteria group [DCG]). MEASUREMENTS: Demographic and discharge variables, including the time when the physician was called for an order, the time a discharge order was written, and the actual discharge time, were recorded. Other comparisons of various discharge variables included the time that discharge criteria were met, the actual discharge time, and the difference between these times. The frequency of PACU stays longer than 60 minutes, PACU discharge delays, and the time discharge criteria were met longer than 60 minutes were also compared between groups. Floor nurse satisfaction with patient status and any related morbidities noted were also measured. MAIN RESULTS: Length of PACU stay was significantly shorter (133.1 +/- 91.4 vs 101.7 +/- 53.7 min; P < 0.05) for inpatients in the DCG group. Discharge delays were higher with physician discharge. The DCG had a lower number of patients with multiple delays. There was no significant difference in the occurrence of adverse events between the two groups. CONCLUSIONS: Predetermined discharge criteria resulted in a 24% decrease in PACU time.

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STUDY DESIGN: Prospective randomized study of patients undergoing spine surgery. OBJECTIVE: To compare changes in hemodynamic and cardiac function after prone positioning using different prone positioners. SUMMARY OF BACKGROUND DATA: Prone positioning decreases blood pressure and cardiac function. Several studies have evaluated changes in cardiac function after prone positioning, and linked them to reduced venous return and ventricular compliance. This study compares different prone positioners using transesophageal echocardiography, and determines their effect on cardiac function and hemodynamics. METHODS: After correction of fluid deficits with the patient under stable anesthesia, hemodynamic and cardiac performance was measured using transesophageal echocardiography. After prone positioning, repeat measurements were performed, and comparisons were made between prone and supine positions. RESULTS: No intergroup differences in demographics, fluid deficit, baseline hemodynamics, or differences from supine to prone position were noted. Cardiac output decreased with the Wilson (Union City, CA) and Siemens AG (Munich, Germany) frames, while cardiac index and stroke volume decreased with the Andrews (Hollywood, CA), Wilson, and Siemens systems. Cardiac preload decreased using the Andrews frame. The Jackson spine table (Hollywood, CA) and bolsters had the least effect on cardiac performance. CONCLUSION: Adequate fluid replacement reduced hypotension and hemodynamic instability after prone positioning. The Jackson spine table and longitudinal bolsters had minimal effects on cardiac function, and should be considered in patients with limited cardiac reserve.

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We report the case of a 72-year-old male who underwent primary angioplasty for an acute myocardial infarction and developed a coronary stent infection with Staphylococcus aureus. The patient was treated with a prolonged course of IV antibiotics and underwent debridement and partial stent extraction successfully.

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BACKGROUND: Diaphragmatic excursion during spontaneous ventilation (SV) in normal supine volunteers is greatest in the dependent regions (bottom). During positive pressure ventilation (PPV) after anesthesia and neuromuscular blockade and depending on tidal volume, the nondependent region (top) undergoes the greatest excursion, or the diaphragm moves uniformly. The purpose of this study was to compare diaphragmatic excursion (during SV and PPV) in patients with chronic obstructive pulmonary disease (COPD) with patients having normal pulmonary function. METHODS: Twelve COPD patients and 12 normal control subjects were compared. Cross-table diaphragmatic fluoroscopy was performed while patients breathed spontaneously. After anesthetic induction and pharmacologic paralysis and during PPV, diaphragmatic fluoroscopy was repeated. For analytic purposes, the diaphragm was divided into three segments: top, middle, and bottom. Percentage of excursion of each segment during SV and PPV in normal subjects was compared with the percentage of excursion of each segment in patients with COPD. RESULTS: There was no significant difference in the pattern of regional diaphragmatic excursion (as a percentage of total excursion)-top, middle, bottom-when comparing COPD patients with control subjects during SV and PPV. In the control subjects, regional diaphragmatic excursion was 16 +/- (5), 33 +/- (5), 51 +/- (4) during SV and 49 +/- (13), 32 +/- (6), 19 +/- (9) during PPV. In COPD patients, regional diaphragmatic excursion was 18 +/- (7), 34 +/- (5), 49 +/- (7) during SV and 47 +/- (10), 32 +/- (6), 21 +/- (9) during PPV. CONCLUSION: Regional diaphragmatic excursion in patients with COPD during SV and PPV is similar to that in persons with normal pulmonary function.

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Bleeding into the upper airway can cause airway obstruction and death if not recognized promptly. Anesthesiologists are quite familiar with potential airway obstruction from acute epiglottitis, but they may be less familiar with the potential for airway obstruction from epiglottic hematoma. We report what we believe is the second case of epiglottic hematoma after anesthesia and surgery that led to an acute upper airway obstruction. Our case was unique in that there was no excessive airway trauma during tracheal intubation. Most important, this case emphasizes that patients receiving multiple anticoagulants--as our patient was--are at risk for airway bleeding, epiglottic hematoma formation, and airway obstruction.

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