Post anesthesia recovery rate evaluated by using White fast tracking scoring system

Introduction : Postponed recuperation from anesthesia can lead to different complications such as ap-noea, aspiration of gastric content whit consequent development of aspiration pneumonia, laryngospasm, bradycardia, and hypoxia. Aim of this research was to determine in ﬂ uence of propofol, sevo ﬂ urane and iso ﬂ urane anesthesia on post anesthesia recovery rate. Methods : This was a prospective study; it included 90 patients hospitalized in period form October 2011 to may 2012 year, all patients included in the study underwent lumbar microdiscectomy surgery. Patients were randomly allocated to one of three groups: group 1: propofol maintained anesthesia, group 2: sevoﬂ urane and group 3: iso ﬂ urane maintained anesthesia. Assessments of recovery rate were done 1, 5 and 10 minutes post extubation using White fast tracking scoring system. Results : Signi ﬁ cant difference was observed only 1 minute after extubation (p=0,025) ﬁ nding recovery rate to be superior in propofol group. Propofol group compared to inhaled anesthesia with sevo ﬂ urane group, shows signi ﬁ cantly faster recovery from anesthesia only one minute after extubation (p=0,046). In comparison of propofol group and iso ﬂ urane anesthesia group, statistical signi ﬁ cance was noticed one minute following extubation (p=0,008). Comparison of propofol group and inhaled anesthesia groups recovery rates were not signi ﬁ cantly different at all times measured. When we were comparing sevo ﬂ urane and iso ﬂ urane anesthesia, recovery rates shoved no signi ﬁ cant statistical difference. Conclusions : Recovery rate evaluated by using White fast tracking scoring system was superior and with fewer complications in propofol maintained in comparison to sevo ﬂ urane and iso ﬂ urane maintained anesthesia only one minute post extubation, while after ﬁ fth and tenth minute difference was lost.


INTRODUCTION
Delayed post anesthesia recovery is often multifactorial and it might be infl uenced by pharmacological and organic causes as well as metabolic abnormalities. Postponed recuperation from anesthesia can lead to diff erent complications such as apnoea, as-piration of gastric content whit consequent development of aspiration pneumonia, laryngospasm, bradycardia, and hypoxia. Because of the fact that these complications can appear, it is very important to ensure that the patient is fully awake, adequately breathing, with completely recovered cough and swallowing refl exes (1). Choice of anesthetic is infl uenced by diff erent factors; knowledge and experience of anaesthesiologist, available equipment, patient related indications, and economic circumstances. Propofol is most widely used intravenous anesthetic today, it is used to induce and maintain anesthesia. Main advantage of propofol in clinical practice is rapid recovery of consciousness and full awareness when bolus doses are used to induce anesthesia. No signifi cant cumulation of propofol in the tissues occurs even after prolonged continuous infusion (1,3). Propofol is one of the mostly suitable anesthetics for total intravenous anesthesia (4). Inhaled anesthetics are among most rapidly acting drugs today, they have high safety ratio. Isofl urane, a halogenated methyl ethyl ether, it is a clear, non-fl ammable liquid at room temperature and has a high degree of pungency (5). Isofl urane is relatively insoluble and has a low blood-gas partition coeffi cient 1, 4 that combined with a high potency, permits rapid onset and recovery from anesthesia using isofl urane alone or in combination with nitrous oxide or injected drugs, such as opioids (2,3). Sevofl urane is relatively insoluble in blood and has a low blood-gas partition coeffi cient which allows rapid induction and recovery from anesthesia (2). Sevofl urane is approximately half as potent as isofl urane, has minimal odour, no pungency, and is a potent bronchodilator. Th ese attributes make sevofl urane an excellent candidate for administration via the facemask on induction of anesthesia in both children and adults (5). Aim of this research was to determine emergence quality after anesthesia with propofol, sevofl urane and isofl urane in order to assure safe discharge of the patient from operating room in every day practice

METHODS
Th is was a prospective study; conducted at University Clinical Centre Tuzla, Department of neurosur-gery. It included 90 patients hospitalized in period form October 2011 to May 2012 year. All patients included in the study undergone lumbar microdiscectomy surgery due to herniated lumbar disc, and were assessed as ASA I (American Society of Anesthesiologists) physical status. Written consent was obtained from all the patients included in the study and they were randomly allocated to one of three groups, each group consisting of thirty patients: group 1: propofol maintained anesthesia, group 2: sevofl urane maintained anesthesia and group 3: isofl urane maintained anesthesia. In all three groups, patients where premedicated using either diazepam 5 mg or 2.5 mg midazolam plus fentanyl 0.10 mg. Following induction with propofol 1.5 to 2.5 mg/kg, tracheal intubation was facilitated with atracurium, which was also used in maintaining muscular relaxation in a doze 0. 3 -0. 6 mg. All patients were ventilated to maintain normocapnia with oxygen (O 2 )/nitrous oxide (N 2 O) mixture in ratio 60:40, in all three groups, and in group 1 with continuous propofol infusion 8 to 10 mg/ kg/h were used to maintain anesthesia. In group 2 to N 2 O: O 2 mixture, 1. 0 volume percentage of sevofl urane was added for maintaining anesthesia and in group 3, 1.0 volume percentage of isofl urane. In all three groups, analgesia was provided with fentanyl boluses ranging form 0.05 to 0.10 mg per dose. Assessments of recovery rate were done 1, 5 and 10 minutes post extubation using White fast tracking scoring system (6) (appendix 1). Th is scoring system is based on evaluation of pain, nausea, vomiting, awakens of the patient, physical activity and hemodynamic and respiratory stability. Maximal score is 14 points and score of 12 points is considered sufficient (as long as there are no scores less then one) in order to sent the patient from operating ward (post anesthesia care unit) to hospital room.

Statistical analysis
Results are displayed in numeric-percentual form, as well as mean value with standard deviation (SD). Signifi cance was evaluated using Chi square test and Student test, statistical analysis was performed with a confi dence interval of 95%, a value of p <0.05 was considered statistically signifi cant.

Study was conducted in University Clinical Centre
Tuzla, Department of Neurosurgery; it enrolled 90 patients allocated to three groups each consisting of 30 patients. Based on White fast tracking scoring system infl uence of anesthetic on speed and quality of post anesthesia recovery was evaluated. In order to test quality and rate of recovery from anesthesia we used White fast tracking scoring system. Based on this test in fi rst group one minute after extubation score was 12. 4 (SD±2. 78), in second group 10. 90 (SD ± 2. 92) and in third group 10. 67 (SD ± 2. 07) ( Table 1.) Comparing results between the groups, signifi cant diff erence was established (p=0.025) fi nding recovery rate to be superior in propofol group 1 minute post extubation. Estimate carried out fi ve minutes post extubation showed following results; in group 1 score were 12. 93 (SD ± 2. 64), in group 2 score was 12. 37 (SD ± 2. 65) and in group 3 score 12. 53 (SD ± 1. 25), without statistical signifi cance (p=0. 61). Ten minutes after extubation assessment using fast tracking scoring system was repeated again and next results were obtained; in group 1 score 12. 53 (SD ± 3. 54), in group 2 score 12. 73 (SD ± 2. 60) and in group 3 score 13. 27 (SD ± 1. 01). Comparison of these results showed no signifi cant diff erence (p=0. 61). Depending on anesthetic used to maintain anesthesia important diff erence in recovery rate, was observed only one minute after extubation, while fi ve and ten minutes post extubation signifi cance was lost ( Table 1). As seen in table 2, propofol group compared to inhaled anesthesia with sevofl urane, group 1 shows   signifi cantly faster recovery from anesthesia only one minute after extubation (p=0. 046), while at second and third measurements diff erence was not established (p=0. 4 after 5 minutes and p=0. 8 ten minutes post extubation).
In comparison of propofol group and isofl urane anesthesia group, statistical signifi cance was noticed one minute following extubation (p=0. 008), while after fi fth and tenth minute no considerable diff erence was found (p=0. 46 after 5 minutes and p=0. 28 after 10) ( Table 3). As seen from table 4, when we were comparing sevofl urane and isofl urane anesthesia, recovery rates shoved no signifi cant statistical diff erence at all times measured (p=0. 72 after 1 minute; p=0. 756 after 5 minutes; p=0.299 after 10 minutes). White fast tracking scoring system evaluated recovery quality and rate ten minutes post extubation, test examined level of awakens, physical activity, hemodynamic stability, respiratory stability, percentage of oxygen saturation, pain intensity in post-operative period and presence of nausea and vomiting. Assessment of these parameters ten minutes after extubation showed no signifi cant diff erence in relation to anesthetic used ( Table 5). Analysis of the results established that although some diff erence in recovery speed was noticed oneminute post extubation it was not signifi cant and it was not observed after fi ve and ten minutes.

White and Song in there study examined 216 women who underwent laparoscopic hysterectomy and fallopian tube ligation in Medical Centre Dallas Texas
University. From the study are excluded all patients that are not evaluated using modifi ed Aldrete's score for discharge, as well as the patients that declined preventive preoperative analgesia and anti-emetic pre-treatment. Demographic characteristics of patients in all three groups were similar, average age was 33 years in desfl urane group, 34 years in sevofl urane and 31 year in propofol group. Th eir study investigated recovery speed, following anesthesia with propofol, sevofl urane and desfl urane; they measured time to extubation, awaking time and determined how well the patient is orientated in early postoperative period. Th ey concluded that recovery time is signifi cantly shorter in desfl urane and sevofl urane group in comparison to propofol group. Estimate is performed using modifi ed Aldrete's score, and authors proved that recovery is faster after propofol anesthesia in comparison to desfl urane and sevofl urane (p<0, 05) (7). While in our study, propofol was superior to inhaled anesthesia concerning speed and quality of recovery measured in early postoperative period. Larsen et alt. also examined quality of recovery form anesthesia in early postoperative period in patients who underwent elective surgical procedures using propofol, desfl urane and isofl urane, all patients   are assessed as ASA I and II physical status. Exclusion criteria in this study matched these criteria in our study, and examines showed no signifi cance regarding demographic characteristics. Propofol maintained anesthesia proved superior in terms of recovery sped, compared to desfl urane and sevofl urane anesthesia. Signifi cance is found in early post extubation period, they also concluded that there is no signifi cance concerning hemodynamic parameters, side eff ects, pain level, and nausea and vomiting among compared groups (4). In our study, we compared characteristics of post anesthesia recovery depending on anesthetic used to maintain anesthesia (propofol, sevofl urane, isofl urane) one, fi ve and ten minutes post extubation. Our inspection was based on test that is modifi cation of Aldrete's score same as it is done in study conducted by Larsen and associates (4). Fredman et alt. compared sevofl urane to propofol in outpatient anesthesia, forty six ASA I and II physical status undergoing either gynaecological or otolaryngology procedures participated in there study. Emergence times from discontinuation of the primary maintenance anesthetics to spontaneous eye opening, response to verbal commands, extubation, and to correctly stating name, age, and date of birth were similar in all treatment groups (8). Bharti et alt. conducted study to compare hemodynamic changes and emergence characteristics of sevofl urane versus propofol anesthesia for microlaryngeal surgery. Th ey fi nd that emergence time, extubation times and recovery time were similar in both groups (9). In our study comparison of recovery rate after propofol vs. sevofl urane anesthesia one minute post extubation proved propofol anesthesia superior to sevofl urane, fi ve and ten minutes post extubation recovery was similar in both groups.
In there systematic review Gupta et alt. focused on postoperative recovery and complications using four diff erent anesthetic techniques. Th ey searched database MEDLINE via PubMed (1966 to June 2002) using the search words "anesthesia" and with ambulatory surgical procedures limited to randomized controlled trials in adults (>19 yr), in the English language, and in humans. A second search strategy was used combining two of the words "propofol," "isofl urane," "sevofl urane," or "desfl urane". No difference was found between propofol and isofl urane in early recovery of cognitive function, incidence of side eff ects, specifi cally postoperative nausea and vomiting, was less frequent with propofol (10). In our study recovery rate one minute post extubation in comparison propofol versus isofl urane anesthesia proved that faster recovery after propofol maintained anesthesia when measured one minute post extubation, while after fi fth and tenth minute superiority of propofol to isofl urane was lost. We found no signifi cant diff erence in inhaled anesthesia groups (sevofl urane versus isofl urane) at all times measured.

CONCLUSIONS
Evaluation of emergence quality after anesthesia regarding diff erent types of anesthetics is important in order to assure safe discharge of the patient from operating room in every day practice. Recovery rate evaluated by using White fast tracking scoring system was superior and with fewer complications in propofol maintained in comparison to sevofl urane and isofl urane maintained anesthesia only one minute post extubation, while after fi fth and tenth minute diff erence was lost.