The effect of variable‐dose diazepam on dreaming and emergence phenomena in 400 cases of ketamine‐fentanyl anaesthesia

Abstract

SummaryWe developed a screening questionnaire to be used by nurses to decide which patients should see an anaesthetist for further evaluation before the day of surgery. Our objective was to measure the accuracy of responses to the questionnaire. Agreement between questionnaire responses and the anaesthetist's assessment was assessed. For questions with a prevalence of 5 to 95%, the Kappa coefficient was used; percentage agreement was used for all other questions. Criterion validity was excellent ⁄ good for all questions with a prevalence between 5 and 95%, except for the question 'Do you have kidney disease?' For questions with prevalence < 5%, all demonstrated adequate criterion validity except the questions 'Has anyone in your family had a problem following an anaesthetic?' and 'If you have been put to sleep for an operation were there any anaesthetic problems?' Therefore, it is reasonable for nurses to use this questionnaire to determine which patients an anaesthetist should see before the day of surgery.Keywords Anaesthesia; pre-operative, assessment, questionnaire. Recent advances in anaesthetic and surgical practice have facilitated the growth of 'fast track' surgery [1, 2]. Careful outpatient assessment is fundamental to the success of this type of surgery and the Association of Anaesthetists of Great Britain and Ireland now recommends assessment at a pre-operative assessment (POA) clinic [3].The provision of a pre-operative screening and assessment service at POA clinics supplies background information about patient's general medical status and fitness for anaesthesia. POA clinics improve patient care by allowing careful pre-operative evaluation and optimisation of coexisting disease [4], reduce costs [5, 6], improve efficiency [7], and lower surgical cancellation rates [8, 9].In POA clinics, nurses increasingly carry out preoperative screening [10]. Although they are not qualified to decide if a patient is fit for anaesthesia, they play a valuable role in identifying patients who are at risk and require further evaluation and optimisation before the day of surgery [11]. Nurses screen patients for risk factors for fitness for anaesthesia and surgery using questionnaires [12]. These can be self-administered by the patient [9], or used during structured interviews [13], or computer programs [14]. Although many locally developed questionnaires exist, few have been formally assessed.We have developed a multi-tiered screening questionnaire to be used by nurses to decide which patients should be seen at a POA clinic by an anaesthetist for further evaluation and optimisation. Using Delphi consensus methods, we have already evaluated content validity for each question [15] to ensure that the questions are relevant to concept being measured.Our objective was to perform item analysis of the screening questionnaire and measure criterion validity [16], that is, is it a true measure of what it is designed to measure?By testing individual questions beyond basic content validity, we were able to put them together in a...

Greater vulnerability to the amnestic effects of ketamine in males

“…However, controlled laboratory studies of subanesthetic doses of ketamine in healthy volunteers failed to find gender differences in response to ketamine on measures of cognition and psychosis (Krystal et al 1998b, although greater prolactin response to ketamine was observed in men in the latter study. More recently, no gender differences were reported in the rate of dreaming after ketamine anesthesia administration (Krystal et al 1998bGrace 2003). However, the relative absence of gender effects in the published literature could be due to limited power, given the small number of women in each study.…”

The incidence of unpleasant dreams after sub-anaesthetic ketamine

“…The co-use of other drugs during anaesthesia [e.g. benzodiazepines (Grace 2003), clonidine (Handa et al 2000), diazepam and midazolam (Hersack 1994)] can reduce the incidence of unpleasant dreams such that this prediction is in those circumstances not necessary, but prediction of the incidence of unpleasant dreams should be considered where ketamine is the sole agent used, such as in analgesia and minor surgery.…”

“…Krissel et al 1994;Ellingson et al 1977;Handa et al 2000), that 'terrifying dreams are infrequent' (Khorramzadeh and Lofty 1976;Lofty et al 1970) or that there are predominantly pleasant dreams (e.g. Grace 2003;Hejja and Galloon 1975;Hersack 1994;Sklar et al 1981;Sechzer 1984;Fine and Finestone 1973;Downing et al 1976;White et al 1980White et al , 1982. There is no systematic difference in ketamine dose between these acute studies, despite the large differences in dream characteristics.…”

“…Dream recall is chosen in this study as an index of any prolonged effect of ketamine because increased dream recall has been found to result during ketamine anaesthesia (e.g. Grace 2003), in a dose-dependent manner (Edwards et al 1993), and lasting for at least 24 h post-operation (Klausen et al 1983). Also, there are significant associations between dream recall frequency and dissociation and schizotypy in the normal population (Watson 2001).…”

Fatores de risco para o despertar intraoperatório

“…Patients who make use of antihypertensive drugs and beta blockers are susceptible to experience awareness episodes if exposed to low doses of general anesthetic agents in the attempt to avoid episodes of systemic blood hypotension. The preoperative use of benzodiazepines reduces the incidence of awareness 21,22 .…”