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Fast Tracking in Fast Tracking in Ambulatory SurgeryAmbulatory Surgery
T. J. Gan, M.D., F.R.C.A. FFARCS(I)
Professor and Vice Chairman
Director of Clinical ResearchDepartment of Anesthesiology
Duke University Medical Center
OutlineOutline
• Anesthetic techniques
• Effective management of – PONV– Pain– NMB
• Monitoring depth of anesthesia
• PACU fast track and discharge scoring systems
Freestanding ASCs in the United StatesFreestanding ASCs in the United States
0
1000
2000
3000
4000
5000
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2005
The number of freestanding ASCs
jumped to 5,068 during 2005
Source: Verispan and William Blair & Co., LLC Estimates
RS Daniels, Outpatient Surgery;Jan 2006:108-111
Should you use intravenous of Should you use intravenous of inhalational anesthesia?inhalational anesthesia?
Inhalational vs. Intravenous Inhalational vs. Intravenous Anesthetic – Recovery ProfileAnesthetic – Recovery Profile
** p<0.05
**
min
Tang et al. Anesthesiology 1999;91:253-61
Inhalational vs. Intravenous Inhalational vs. Intravenous Anesthetic – Recovery ProfileAnesthetic – Recovery Profile
*
* p<0.05*
*
min
Tang et al. Anesthesiology 1999;91:253-61
Choice of Anesthetic Agents Choice of Anesthetic Agents in Fast-Trackingin Fast-Tracking
• 51 women undergoing GYN laparoscopy
• Propofol for induction
• Randomized to – Propofol, sevoflurane and desflurane
• BIS monitored to keep at 60
• Triple antiemetic prophylaxis
• Local anesthetic infiltration
Coloma et al. Anesth Analg 2001;93:112-5
Propofol vs. Sevo vs. DesPropofol vs. Sevo vs. Des
Coloma et al. Anesth Analg 2001;93:112-5
TIVA (Prop/Remi) versus Desflurane TIVA (Prop/Remi) versus Desflurane in Children ENT Proceduresin Children ENT Procedures
RemifentanilRemifentanil
PropofolPropofol
DesfluraneDesflurane
NitrousNitrous
Spon Spon VentilationVentilation
11 11 ± 4 min± 4 min 7 7 ± 3 min± 3 min
Eye OpeningEye Opening 11 11 ± 4 min± 4 min 14 14 ± 7 min± 7 min
Aldrete Score Aldrete Score 99
1717± 7 min± 7 min 17 17 ± 7 min± 7 min
AgitationAgitation 44%44% 80%80%
Grundmann et al. Acta Anesth Scndinavica 1998;42:845-50
Larsen B et al. Anesth Analg 2000;90:168-74
• Compared propofol, Isoflurane, Sevoflurane and Desflurane
• Propofol vs. Isoflurane 18 studies
• Propofol vs. Desflurane 13 studies
• Propofol vs. Sevoflurane 11 studies
• Isoflurane vs. Sevoflurane 6 studies
• Isoflurane vs. Desflurrane 4 studies
• Sevoflurane vs. Desflurane 6 studies
Gupta et al. Anesth Analg 2004;98:632-41
Systematic Analysis - ResultsSystematic Analysis - Results
• Early recovery– Faster with desflurane than propofol and isoflurane– Faster with Sevoflurane than isoflurane
• Intermediate recovery (Home readiness)– Sevoflurane faster than isoflurane (5 min)
• PONV, PDNV, rescue antiemetic and headache– Propofol better than inhalational agents
Gupta et al. Anesth Analg 2004;98:632-41
General AnesthesiaGeneral Anesthesia
vs.vs.
Regional AnesthesiaRegional Anesthesia
• Outpatient hand surgery
• Randomized to– GA – Propofol/Isoflurane/Fentanyl– IVRA – 0.5% lidocaine– Axillary Block – lidocaine/chlorrprocaine
• Regional groups received sedation with propofol
Chan et al. Anesth Analg 2001;93:1181-4
Chan et al. Anesth Analg 2001;93:1181-4
Spinal vs. GA - OutcomesSpinal vs. GA - Outcomes
Korhonen et al. anesth Analg 2004;99:1668-73
Spinal Anethesia vs. Spinal Anethesia vs. Desflurane GADesflurane GA
Korhonen et al. anesth Analg 2004;99:1668-73
• 50 outpatients for open rotator cuff repair
• Randomized to– Fast track GA with LA infiltration (bupivacaine
0.25%)– Interscalene block (ropivavaine 0.75%)– Outcomes:
• Phase I and II recovery• Daily activities up to 2 weeks.• Patient satisfaction
Hadzic A et al. Anesthesiology 2005;102:1001-7
Hadzic A et al. Anesthesiology 2005;102:1001-7
Management of PONVManagement of PONV
Functional Interference Functional Interference Due to Nausea and/or Vomiting Due to Nausea and/or Vomiting
Emesis Nausea Functional Interference
White et al. Anesth Analg 2008;107:452-8
PONV Occurring in the PACU* and/or PONV Occurring in the PACU* and/or Within 48 Hours After PACU DischargeWithin 48 Hours After PACU Discharge
* PACU=postanesthesia care unit.
Carroll NV et al. Anesth Analg. 1995;80:903–909.
36%
Nearly 65% of patients did not experience PONV symptoms until after discharge from the PACU.
36%
Initial PONV in the PACU and/or Within 48 Hours After PACU Discharge
(45/58)
Initial PONV in the PACU
(21/58)
78%
Pat
ien
ts W
ho
Exp
erie
nce
d P
ON
V,
%
0
20
40
60
80
100
PONV Risk ScoresPONV Risk Scores
Risk FactorsRisk Factors PointsPoints
Female 1
History of PONV/motion sickness
1
Postop Opioid 1
Non-Smoker 1
%
Apfel C, et al. Acta Anaesthesiol Scand 1998;42:495-501.Apfel C, et al. Acta Anaesthesiol Scand 1998;42:495-501.
Cumulative Incidence of PONVTDS + Ondansetron vs. Ondansetron
P<0.05
Gan et al. Anesth Analg 2009;108:1498 –504
• Results: PONV risk reduction– Ondansetron 26%
– Dexamethasone 26%
– Droperidol 26%
– Propofol 19%
– Nitrogen 12% (nitrous oxide exclusion)
– Remifentanil not significant
High-Risk PONV Patients (N=4,123)
Factorial Designed Trial: Factorial Designed Trial: 6 Interventions for PONV Prevention6 Interventions for PONV Prevention
Apfel CC, et al. N Engl J Med. 2004;350:2441-2451.
*Ondansetron; †dexamethasone; ‡ droperidol. Apfel CC, et al. N Engl J Med.
2004;350:2441-2451. Adapted with permission.
Factorial Designed Trial: Ondansetron, Factorial Designed Trial: Ondansetron, Dexamethasone, and DroperidolDexamethasone, and Droperidol
Antiemetic Drug Combination Outcomes (N=5,161)
Average value for each number of antiemetics
Incidence for each antiemetic or combination
Inci
den
ce o
f P
ost
op
erat
ive
Nau
sea
and
Vo
mit
ing
(%
)
†
60
50
40
30
20
10
0
No. of Antiemetics
0 3 21
* ‡
*‡*† †‡
Algorithm for PONV ProphylaxisAlgorithm for PONV ProphylaxisEvaluate risk of PONV in surgical patient and patient’s concerns
Moderate High
Consider regionalanesthesia
Low
No prophylaxis unless thereis medical risk of
sequelae from vomitingNot Indicated
If general anesthesia is used, reduce baseline risk factors when clinically practical &
consider using nonpharmacologic therapies
Patients at moderate risk
Consider antiemetic prophylaxiswith monotherapy (adults) or
combination therapy (children & adults)
Patients at high risk
Initiate combination therapy with2 or 3 prophylactic agents
from different classes
•Avoid opioids (IIIA)
•Avoid N2O (IIA)
•Avoid high dose reversal agent (IIA)
•Adequate hydration (IIIA)
•Propofol anesthetic (IA)
Gan et al. Anesth Analg 2003;97:62-71Gan JAMA 2002;287:1233-6
Gan et al. A&A 2007;105:1615-28
Management of PainManagement of Pain
Postoperative Pain: All Patients Postoperative Pain: All Patients (in Hospital up to 2 Weeks)(in Hospital up to 2 Weeks)
Any pain Slightpain
Moderatepain
Severepain
Extremepain
1Apfelbaum, Gan et al. Anesth Analg. 2003;97:534-40; 2Warfield et al. Anesthesiology. 1993
1
2
Patients’ worst pain
• 24% had pain score ≥ 7
• 24% delayed PACU
discharge by pain
• Maximum pain score
predictive of total recovery
• Lower pain score (by 25%)
if LA or NASID were used
Pavlin et al. Anesth Analg 2002;95:627-34
Sustained
currents
Peripheral
Nociceptive
Fibers
Transient Activation
ACUTE
PAIN
Woolf. Ann Intern Med. 2004;140:441; Petersen-Felix. Swiss Med Weekly. 2002;132:273-278; Woolf. Nature.1983;306:686-688; Woolf et al. Nature. 1992;355:75-8.
Surgeryor
injurycauses
inflammation
Long-Term Consequences of Acute Pain: Long-Term Consequences of Acute Pain: Potential for Progression to Chronic PainPotential for Progression to Chronic Pain
Sustained
Activation
Peripheral
Nociceptive
Fibers
Sensitization
CHRONIC
PAIN
CNS
Neuroplasticity
Hyperactivity
Structural Remodeling
Acute Postoperative Pain Has Been Associated With Acute Postoperative Pain Has Been Associated With Chronic Pain After Common ProceduresChronic Pain After Common Procedures
Incidence of Chronic Post-Surgical Pain
US Surgical Volumes(1000s)1
Amputation 57-62%2 159
Breast surgery 27-48%3,4 479
Thoracotomy 52-61%5,6 Unknown
Inguinal hernia repair 19-40%7,8 609
Coronary artery bypass 23-39%9-11 598
Caesarean section 12%12 220
1. Kehlet et al. Lancet. 2006;367:1618-1625; 2. Hanley et al. J Pain. 2007;8:102-10; 3. Carpenter et al. Cancer Prac. 1999;7:66-70; 4. Poleschuk et al. J Pain. 2006;7:626-634; 5. Katz et al. Clin J Pain. 1996;12:50-55; 6. Perttunen et al. Acta Anaesthesiol Scand. 1999;43:563-567; 7.Massaron et al. Hernia. 2007;11:517-525; 8. O’Dwyer et al. Br J Surg.
2005;92:166-170; 9. Steegers et al. J Pain. 2007;8:667-673; 10. Taillefer et al. J Thorac Cardiovasc Surg. 2006;131:1274-1280; 11. Bruce et al. Pain. 2003;104:265-273; 12. Nikolajsen et al. Acta Anaesthesiol Scand. 2004;48:111-116.
Factors correlated with the development of post-surgical chronic pain1:1. Nerve injury2. Inflammation
3. Intense acute postoperative pain
Kehlet H, et al. Anesth Analg 1993;77:1048–56Playford RJ, et al. Digestion 1991;49:198–203
Multimodal or balanced Multimodal or balanced analgesiaanalgesia
doses of each analgesic
Improved anti-nociception due to synergistic/additive effects
May severity of side effects of each drug
Potentiation
Opioid
Conventional NSAIDs/coxibs,
paracetamol,
nerve blocks
Adjunctive AnalgesicsAdjunctive Analgesics
• NSAIDs and COX-2 selective inhibitors (coxibs)
• Acetaminophen
• Local anesthetics
• Ketamine
• Gabapentin / pregabalin
• Clonidine / dexmedetomidine
• Steroids
• Non pharmacological techniques
• 52 RPCTs (~5000 patients)
• Acetaminophen, NSAIDs or COX-2 inhibitors
• Average morphine consumption – 49 mg/24hrs
• 15-55 % decrease in morphine consumption
• VAS pain decreased by 1 cm
• NSAIDs / COX-2 Specific inhibitors– ↓ nausea from 28.8% to 22%
– ↓ Sedation 15.4% to 12.7%
– ↑ Renal failure 0% to 1.7%
Morphine Consumption – 24 hoursMorphine Consumption – 24 hours
Elia et al. Anesthesiology 2005;103:1296-1304
Regional Anesthesia in Regional Anesthesia in Ambulatory SurgeryAmbulatory Surgery
• 1800 patients receiving upper or lower extremity block with 0.5% ropivacaine
• Interscelene, supraclavicular, axillary, lumbar plexus, emoral and sciatic block
• Discharged on the day of surgery
• Conversion to GA 1-6%
• No opioid in PACU – 89% to 92%
• Require opioid up to 7 days – 21% to 27%
• Persistent parasthesia 0.25%, resolved within 3 months
Klein et al. Anesth Analg 2002;94:65–70
Hadzic et al. Anesthesiology 2004;101:127-32
Ambulatory Infusion PumpAmbulatory Infusion Pump
Management of Management of Neuromuscular Neuromuscular
BlockadeBlockade
Reversal of Rocuronium 0.45 mg/kgReversal of Rocuronium 0.45 mg/kg
Bevan JC et al. Anesth Analg 1999;89:333–339
Cisatracurium vs. RocuroniumCisatracurium vs. Rocuronium
Cisatracurium Rocuronium
TOF 0.9 at EOS
27% 7%
TOF at reversal
63 7% 40 19%
EOS to TOF = 0.9
10 9 min 18 13 min
Cammu et al. Eu J Anaesth 2002;19:129-34
Residual ParalysisResidual Paralysis
Debaene et al. Anesthesiology 2003;98:1042-8
Time between the administration of a single dose of
NMB and the arrival in the PACU.
SugammadexSugammadex
Angewandte Chemie 2002:41:266 -270
First Human Exposure to First Human Exposure to ORG25969ORG25969
• Gijsenbergh et al.– 29 healthy men– Anesthesia: propofol target-controlled infusion and
remifentanil – Rocuronium 0.6mg/kg– Placebo or sugammadex ranging from 0.1 to 8.0
mg/kg
Gijsenbergh, Francois Anesthesiology. 103(4):695-703, 2005.
Phase 1Phase 1
Gijsenbergh, Francois Anesthesiology. 103(4):695-703, 2005.
Depth of Anesthesia MonitoringDepth of Anesthesia Monitoring
Emergence Times
109
66
0
3
6
9
12
OPEN EYES RESPOND TOCOMMAND
StandardPracticeBIS
* p < 0.001
CLINICAL UTILITY TRIAL:CLINICAL UTILITY TRIAL:EMERGENCE TIMESEMERGENCE TIMES
Gan TJ, et al. Anesthesiology, Oct. 1997.
min
ute
s
CLINICAL UTILITY TRIAL: CLINICAL UTILITY TRIAL: PACU DISCHARGE TIMEPACU DISCHARGE TIME
Eligible for Discharge from PACU
37
31
20
25
30
35
40M
inu
tes
Standard Practice
BIS
BIS Patients 16% Faster than Standard Practice
Gan TJ, et al. Anesthesiology, Oct. 1997.
Total Propofol Used Per Case
1252
964
0
250
500
750
1000
1250
1500
StandardPracticeBIS
23% Less Propofol Used
CLINICAL UTILITY TRIAL:CLINICAL UTILITY TRIAL:DRUG USAGEDRUG USAGE
Gan TJ, et al. Anesthesiology, Oct. 1997.
mg
* p <0.001
2.1
1.7
1 2 3
Av
era
ge
Sc
ore Standard
PracticeBIS
ExcellentOriented on Arrival
GoodFast Recovery
FairSlow Recovery
* p < 0.001
CLINICAL UTILITY TRIAL: CLINICAL UTILITY TRIAL: BLINDED PACU ASSESSMENTSBLINDED PACU ASSESSMENTS
Gan TJ, et al. Anesthesiology, Oct. 1997.
PACU Discharge CriteriaPACU Discharge Criteria
• PACU Discharge
• Max 10
• Score ≥ 9
Aldrete JA. J Clin Anesth 1995;7:89-91
• PADS
• Max 10
• Score ≥ 9
• Fit for discharge
Chung et al. J Clin Anesth 1995;80:896-902
• Eligible for fast-track
• Score of ≥12
• No score < 1 in any category
White et al. Anesth Analg 1999;88:1069-72
Factors Delaying DischargeFactors Delaying Discharge
• Preoperative– Female– Increasing age– CHF
• Intraoperative– Long duration of surgery– GA– Spinal anesthesia
• Postoperative– Pain– PONB– Drowsiness– No escort
Factors delaying dischargeFactors delaying discharge• Mandatory oral fluid intake• Mandatory voiding• Risk factors for postop urinary retention
– Type of surgery (anorectal, hernia, vaginal/pelvic gynecological surgery)
– Old age– Male sex– Spinal/epidural– Duration of surgery > 60 min– Intraoperative fluid > 750 mL
SummarySummary• Use short acting drugs
• IV or inhalational anesthetic are recommended
• Regional anesthesia can have postdischarge advantages
• Optimal antiemetic prophylaxis
• Comprehensive perioperative analgesic regimen
• Beware of residual paralysis
• Aggressively adopt bypass and discharge criteria
QuestionsQuestions