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Fast Tracking in Ambulatory Surgery T. J. Gan, M.D., F.R.C.A. FFARCS(I) Professor and Vice Chairman Director of Clinical Research Department of Anesthesiology.

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Presentation on theme: "Fast Tracking in Ambulatory Surgery T. J. Gan, M.D., F.R.C.A. FFARCS(I) Professor and Vice Chairman Director of Clinical Research Department of Anesthesiology."— Presentation transcript:

1 Fast Tracking in Ambulatory Surgery T. J. Gan, M.D., F.R.C.A. FFARCS(I) Professor and Vice Chairman Director of Clinical Research Department of Anesthesiology Duke University Medical Center

2 Outline Anesthetic techniques Effective management of –PONV –Pain –NMB Monitoring depth of anesthesia PACU fast track and discharge scoring systems

3 Freestanding ASCs in the United States 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

4 Should you use intravenous of inhalational anesthesia?

5 Inhalational vs. Intravenous Anesthetic – Recovery Profile * * p<0.05 ** min Tang et al. Anesthesiology 1999;91:253-61

6 Inhalational vs. Intravenous Anesthetic – Recovery Profile * * p<0.05 * * min Tang et al. Anesthesiology 1999;91:253-61

7 Choice of Anesthetic Agents in 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

8 Propofol vs. Sevo vs. Des Coloma et al. Anesth Analg 2001;93:112-5

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10 TIVA (Prop/Remi) versus Desflurane in Children ENT Procedures RemifentanilPropofolDesfluraneNitrous Spon Ventilation 11 ± 4 min 7 ± 3 min Eye Opening 11 ± 4 min 14 ± 7 min Aldrete Score 9 17± 7 min Agitation44%80% Grundmann et al. Acta Anesth Scndinavica 1998;42:845-50

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12 Larsen B et al. Anesth Analg 2000;90:168-74

13 Compared propofol, Isoflurane, Sevoflurane and Desflurane Propofol vs. Isoflurane18 studies Propofol vs. Desflurane13 studies Propofol vs. Sevoflurane11 studies Isoflurane vs. Sevoflurane6 studies Isoflurane vs. Desflurrane4 studies Sevoflurane vs. Desflurane6 studies Gupta et al. Anesth Analg 2004;98:632-41

14 Systematic 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

15 General Anesthesia vs. Regional Anesthesia

16 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

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18 Spinal vs. GA - Outcomes Korhonen et al. anesth Analg 2004;99:1668-73

19 Spinal Anethesia vs. Desflurane GA Korhonen et al. anesth Analg 2004;99:1668-73

20 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

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22 Management of PONV

23 Functional Interference Due to Nausea and/or Vomiting Emesis NauseaFunctional Interference White et al. Anesth Analg 2008;107:452-8

24 PONV Occurring in the PACU* and/or Within 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% Patients Who Experienced PONV, % 0 20 40 60 80 100

25 Wengritzky et al. BJA 2010;104:158-66

26 Leslie et al. BJA 2009;101:498-505

27 PONV Risk Scores Risk Factors Points Female1 History of PONV/motion sickness 1 Postop Opioid1 Non-Smoker1 % Apfel C, et al. Acta Anaesthesiol Scand 1998;42:495-501.

28 % of Patients ODT – Post Discharge Incidence of Nausea and Emesis * * p<0.05 Gan et al. Anesth Analg 2002;94:1199-1200

29 Cumulative Incidence of PONV TDS + Ondansetron vs. Ondansetron P<0.05 Gan et al. Anesth Analg 2009;108:1498 –504

30 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: 6 Interventions for PONV Prevention Apfel CC, et al. N Engl J Med. 2004;350:2441-2451.

31 *Ondansetron; dexamethasone; droperidol. Apfel CC, et al. N Engl J Med. 2004;350:2441-2451. Adapted with permission. Factorial Designed Trial: Ondansetron, Dexamethasone, and Droperidol Antiemetic Drug Combination Outcomes (N=5,161) Average value for each number of antiemetics Incidence for each antiemetic or combination Incidence of Postoperative Nausea and Vomiting (%) 60 50 40 30 20 10 0 No. of Antiemetics 03 21 * * *

32 Algorithm for PONV Prophylaxis Evaluate risk of PONV in surgical patient and patients concerns ModerateHigh Consider regional anesthesia Low No prophylaxis unless there is medical risk of sequelae from vomiting Not Indicated If general anesthesia is used, reduce baseline risk factors when clinically practical & consider using nonpharmacologic therapies Patients at moderate risk Consider antiemetic prophylaxis with monotherapy (adults) or combination therapy (children & adults) Patients at high risk Initiate combination therapy with 2 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

33 Gan et al. A&A 2007;105:1615-28

34 Management of Pain

35 Postoperative Pain: All Patients (in Hospital up to 2 Weeks) Any painSlight pain Moderate pain Severe pain Extreme pain 1 Apfelbaum, Gan et al. Anesth Analg. 2003;97:534-40 ; 2 Warfield et al. Anesthesiology. 1993 1 2 Patients worst pain

36 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

37 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. Surgery or injury causes inflammation Long-Term Consequences of Acute Pain: Potential for Progression to Chronic Pain Sustained Activation Peripheral Nociceptive Fibers Sensitization CHRONIC PAIN CNS Neuroplasticity Hyperactivity Structural Remodeling

38 Acute Postoperative Pain Has Been Associated With Chronic Pain After Common Procedures Incidence of Chronic Post-Surgical Pain US Surgical Volumes (1000s) 1 Amputation57-62% 2 159 Breast surgery27-48% 3,4 479 Thoracotomy52-61% 5,6 Unknown Inguinal hernia repair19-40% 7,8 609 Coronary artery bypass23-39% 9-11 598 Caesarean section12% 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. ODwyer 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 pain 1 : 1.Nerve injury 2.Inflammation 3.Intense acute postoperative pain

39 Kehlet H, et al. Anesth Analg 1993;77:1048–56 Playford RJ, et al. Digestion 1991;49:198–203 Multimodal or balanced analgesia 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

40 Adjunctive Analgesics NSAIDs and COX-2 selective inhibitors (coxibs) Acetaminophen Local anesthetics Ketamine Gabapentin / pregabalin Clonidine / dexmedetomidine Steroids Non pharmacological techniques

41 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%

42 Morphine Consumption – 24 hours Elia et al. Anesthesiology 2005;103:1296-1304

43 Regional Anesthesia in Ambulatory 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

44 Hadzic et al Anesth Analg 2005;100:976–81

45 Hadzic et al. Anesthesiology 2004;101:127-32

46 Ambulatory Infusion Pump

47 Management of Neuromuscular Blockade

48 Reversal of Rocuronium 0.45 mg/kg Bevan JC et al. Anesth Analg 1999;89:333–339

49 Cisatracurium vs. Rocuronium CisatracuriumRocuronium TOF 0.9 at EOS 27%7% TOF at reversal 63 7%40 19% EOS to TOF = 0.9 10 9 min18 13 min Cammu et al. Eu J Anaesth 2002;19:129-34

50 Assessment of NMB Recovery Positive Predictive Value % (95 CI) Negative Predictive Value % (95 CI) TOF<0.7TOF<0.9TOF<0.7TOF<0.9 Head lift19 (15-23) 53 (47-58) 85 (81-89) 58 (52-63) Tongue depressor 28 (23-33) 54 (48-59) 86 (83-90) 56 (51-62) TOF79 (75-82) 93 (91-94) 87 (84-90) 57 (53-61) DBS83 (78-86) 97 (95-98) 88 (85-90) 58 (54-62) Debaene et al. Anesthesiology 2003;98:1042-8

51 Residual 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.

52 Sugammadex Angewandte Chemie 2002:41:266 -270

53 First Human Exposure to ORG25969 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.

54 Phase 1 Gijsenbergh, Francois Anesthesiology. 103(4):695-703, 2005.

55 Depth of Anesthesia Monitoring

56 * p < 0.001 CLINICAL UTILITY TRIAL: EMERGENCE TIMES Gan TJ, et al. Anesthesiology, Oct. 1997. minutes

57 CLINICAL UTILITY TRIAL: PACU DISCHARGE TIME BIS Patients 16% Faster than Standard Practice Gan TJ, et al. Anesthesiology, Oct. 1997.

58 23% Less Propofol Used CLINICAL UTILITY TRIAL: DRUG USAGE Gan TJ, et al. Anesthesiology, Oct. 1997. mg * p <0.001

59 Excellent Oriented on Arrival Good Fast Recovery Fair Slow Recovery * p < 0.001 CLINICAL UTILITY TRIAL: BLINDED PACU ASSESSMENTS Gan TJ, et al. Anesthesiology, Oct. 1997.

60 PACU Discharge Criteria

61 PACU Discharge Max 10 Score 9 Aldrete JA. J Clin Anesth 1995;7:89-91

62 PADS Max 10 Score 9 Fit for discharge Chung et al. J Clin Anesth 1995;80:896-902

63 Eligible for fast- track Score of 12 No score < 1 in any category White et al. Anesth Analg 1999;88:1069-72

64 Factors Delaying Discharge Preoperative –Female –Increasing age –CHF Intraoperative –Long duration of surgery –GA –Spinal anesthesia Postoperative –Pain –PONB –Drowsiness –No escort

65 Factors 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

66 Summary 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

67 Questions


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