Characteristics Associated With Prolonged Time to Awakening After Propofol Maintenance Anesthesia – Initial Experiences of 1,819 Physicians

Apfelbaum, Jeffrey L.; Grasela, Thaddeus H.; Hug, Carl C.; McLeskey, Charles H.; Nahrwold, Michael L.; Roizen, M.F.; Stanley, Thwdore H.; Thisted, Ronald A.; Walawander, Cynthia A.; White, Paul F.

doi:10.1097/00000542-199209001-00001

Cited by 5 publications

(19 citation statements)

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“…Anesthesiologists rate times longer than 15 min as poor quality extubation. 19 There were 39% of cases at the US hospital that were prolonged (303 of 785), greater than the 6% at the Japanese hospital (42 of 685). CI indicates confidence interval; OR, operating room.…”

Section: Discussionmentioning

confidence: 92%

“…We studied prolonged times to tracheal extubation. [7][8][9][10]19,20 The incidence was 6.4-fold greater at the US hospital, because of vastly greater variability in times to extubation. Patient and case characteristics did not account for the difference.…”

Section: Anesthesia and Analgesiamentioning

confidence: 99%

“…This criteria is not arbitrary, in that during observational study, it was at 15 minutes when all other clinicians in the OR had completed whatever care they had to do (ie, everyone was waiting for the patient to awaken). Anesthesiologists rate times longer than 15 min as poor quality extubation 19. There were 39% of cases at the US hospital that were prolonged (303 of 785), greater than the 6% at the Japanese hospital (42 of 685).…”

mentioning

confidence: 95%

“…10 Anesthesiologists rate prolonged extubation as inferior quality of recovery. 19 They are not prevented by more than minimal skill of the anesthesia provider (eg, anesthesiology resident) caring for the patient at the time of tracheal extubation. 8,20 Finally, timely extubation is a factor important to surgeons when assessing anesthesiologists' performance.…”

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confidence: 99%

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Comparison of Percentage Prolonged Times to Tracheal Extubation Between a Japanese Teaching Hospital and One in the United States, Without and With a Phase I Postanesthesia Care Unit

Sugiyama

Dexter

Thenuwara

et al. 2020

Anesthesia &Amp; Analgesia

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BACKGROUND: Prolonged times to tracheal extubation are those from end of surgery (dressing on the patient) to extubation 15 minutes or longer. They are so long that others in the operating room (OR) generally have exhausted whatever activities can be done. They cause delays in the starts of surgeons’ to-follow cases and are associated with longer duration workdays. Anesthesiologists rate them as being inferior quality. We compare prolonged times to extubation between a teaching hospital in the United States with a phase I postanesthesia care unit (PACU) and a teaching hospital in Japan without a PACU. Our report is especially important during the coronavirus disease 2019 (COVID-19) pandemic. Anesthesiologists with some patients undergoing general anesthetics and having initial PACU recovery in the ORs where they had surgery can learn from the Japanese anesthesiologists with all patients recovering in ORs. METHODS: The historical cohort study included all patients undergoing gynecological surgery at a US hospital (N = 785) or Japanese hospital (N = 699), with the time from OR entrance to end of surgery of at least 4 hours. RESULTS: The mean times from end of surgery to OR exit were slightly longer at the US hospital than at the Japanese hospital (mean difference 1.9 minutes, P < .0001). The mean from end of surgery to discharge to surgical ward at the US hospital also was longer (P < .0001), mean difference 2.2 hours. The sample standard deviations of times from end of surgery until tracheal extubation was 40 minutes for the US hospital versus 4 minutes at the Japanese hospital (P < .0001). Prolonged times to tracheal extubation were 39% of cases at the US hospital versus 6% at the Japanese hospital; relative risk 6.40, 99% confidence interval (CI), 4.28–9.56. Neither patient demographics, case characteristics, surgeon, anesthesiologist, nor anesthesia provider significantly revised the risk ratio. There were 39% of times to extubation that were prolonged among the patients receiving neither remifentanil nor desflurane (all such patients at the US hospital) versus 6% among the patients receiving both remifentanil and desflurane (all at the Japanese hospital). The relative risk 7.12 (99% CI, 4.59–11.05) was similar to that for the hospital groups. CONCLUSIONS: Differences in anesthetic practice can facilitate major differences in patient recovery soon after anesthesia, useful when the patient will recover initially in the OR or if the phase I PACU is expected to be unable to admit the patient.

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Section: Discussionmentioning

confidence: 92%

Section: Anesthesia and Analgesiamentioning

confidence: 99%

mentioning

confidence: 95%

mentioning

confidence: 99%

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Comparison of Percentage Prolonged Times to Tracheal Extubation Between a Japanese Teaching Hospital and One in the United States, Without and With a Phase I Postanesthesia Care Unit

Sugiyama

Dexter

Thenuwara

et al. 2020

Anesthesia &Amp; Analgesia

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“…In Korean patients, median (25%-75%) time to LOBR in women of 16 seconds (10-22 seconds) was significantly shorter than the 20 seconds (14-24 seconds) in men [22]. Apfelbaum et al [7] postulated an interesting premise that female sex hormones can cause functional changes in the γ-aminobutyric acid (GABA) receptors, site of action of most intravenous anesthetic drugs [7]. The plausible explanation of our results in Han-Chinese women is a pharmacodynamic assertion of putative biologic increase in intrinsic propofol brain sensitivity in women.…”

Section: Propofol Pharmacokinetics and Pharmacodynamicsmentioning

confidence: 96%

Location matters: Overlooked ethnic‐geographic effect in China and Austria on propofol/cisatracurium sex differences among a population pharmacokinetic/pharmacodynamic (PopPK/PD) covariate analysis in men, women, and one transgender subject

Dahaba

Xiao

Zhu

et al. 2021

Fundamemntal Clinical Pharma

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A quick literature search using “sex/gender” vs. the commonly used hypnotic propofol or neuromuscular‐blocking agent cisatracurium will reveal numerous contradictory sex difference publications depending on the ethnic‐geographic location of where these studies were conducted. We induced anesthesia with cisatracurium besylate (GlaxoSmithKline) 100 μg kg−1 administered exactly 1 minute following propofol (AstraZeneca) 2 mg kg−1. In 20 male and 20 female ethnic Han‐Chinese test set patients (Xi'an China), and in similar ethnic white Austrian validation set patients (Graz Austria), we quantified propofol/cisatracurium pharmacodynamic parameters namely propofol onset time, lag time, plasma concentrations (Cp) at loss‐of‐behavioral response (LOBR) using bispectral index (BIS); cisatracurium onset time, lag time, and Cp at T1% (first twitch of train‐of‐four) complete twitch suppression using mechanomyography (MMG). Serial arterial blood samples were collected for population pharmacokinetic (PopPK) analysis of all demographic and biological covariates (region, sex, age, weight, and height) versus volumes of distribution and clearances pharmacokinetic parameters. In Chinese women (but not in white women), propofol Cp at LOBR was 33.60% lower than men and cisatracurium Cp at T1% complete twitch suppression was 21.49% lower than men, a clear pharmacodynamic assertion. Region and weight were significant PopPK covariates. We demonstrated that sex differences are influenced by ethnic‐geographic location as only in Chinese women (but not in white women) propofol Cp at LOBR and cisatracurium Cp at T1% complete twitch suppression were lower than in men. When defining sex differences, ethnic‐geographic location should be taken into consideration as a predictive factor for optimizing propofol/cisatracurium initial loading recommended dosages.

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Narrative Review of Prolonged Times to Tracheal Extubation After General Anesthesia With Intubation and Extubation in the Operating Room

Dexter,

Hindman

2023

Anesthesia &Amp; Analgesia

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This narrative review summarizes research about prolonged times to tracheal extubation after general anesthesia with both intubation and extubation occurring in the operating room or other anesthetizing location where the anesthetic was performed. The literature search was current through May 2023 and included prolonged extubations defined either as >15 minutes or at least 15 minutes. The studies showed that prolonged times to extubation can be measured accurately, are associated with reintubations and respiratory treatments, are rated poorly by anesthesiologists, are treated with flumazenil and naloxone, are associated with impaired operating room workflow, are associated with longer operating room times, are associated with tardiness of starts of to-follow cases and surgeons, and are associated with longer duration workdays. When observing prolonged extubations among all patients receiving general anesthesia, covariates accounting for most prolonged extubations are characteristics of the surgery, positioning, and anesthesia provider’s familiarity with the surgeon. Anesthetic drugs and delivery systems routinely achieve substantial differences in the incidences of prolonged extubations. Occasional claims made that anesthesia drugs have unimportant differences in recovery times, based on medians and means of extubation times, are misleading, because benefits of different anesthetics are achieved principally by reducing the variability in extubation times, specifically by decreasing the incidence of extubation times sufficiently long to have economic impact (ie, the prolonged extubations). Collectively, the results show that when investigators in anesthesia pharmacology quantify the rate of patient recovery from general anesthesia, the incidence of prolonged times to tracheal extubation should be included as a study end point.

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Characteristics Associated With Prolonged Time to Awakening After Propofol Maintenance Anesthesia – Initial Experiences of 1,819 Physicians

Cited by 5 publications

References 0 publications

Comparison of Percentage Prolonged Times to Tracheal Extubation Between a Japanese Teaching Hospital and One in the United States, Without and With a Phase I Postanesthesia Care Unit

Comparison of Percentage Prolonged Times to Tracheal Extubation Between a Japanese Teaching Hospital and One in the United States, Without and With a Phase I Postanesthesia Care Unit

Location matters: Overlooked ethnic‐geographic effect in China and Austria on propofol/cisatracurium sex differences among a population pharmacokinetic/pharmacodynamic (PopPK/PD) covariate analysis in men, women, and one transgender subject

Narrative Review of Prolonged Times to Tracheal Extubation After General Anesthesia With Intubation and Extubation in the Operating Room

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