Presentation on theme: "Fast Tracking in Ambulatory Surgery"— Presentation transcript:
1Fast Tracking in Ambulatory Surgery Prevention and Management of Anesthesia AwarenessOctober 2004Fast Tracking in Ambulatory SurgeryT. J. Gan, M.D., F.R.C.A. FFARCS(I)Professor and Vice ChairmanDirector of Clinical Research Department of AnesthesiologyDuke University Medical CenterADVANCED AWARENESS TRAINING MODULE
2Prevention and Management of Anesthesia Awareness OutlineOctober 2004Anesthetic techniquesEffective management ofPONVPainNMBMonitoring depth of anesthesiaPACU fast track and discharge scoring systemsADVANCED AWARENESS TRAINING MODULE
3Freestanding ASCs in the United States The number of freestanding ASCs jumped to 5,068 during 2005Source: Verispan and William Blair & Co., LLC EstimatesRS Daniels, Outpatient Surgery;Jan 2006:
4Should you use intravenous of inhalational anesthesia?
5Inhalational vs. Intravenous Anesthetic – Recovery Profile min* p<0.05***Tang et al. Anesthesiology 1999;91:253-61
6Inhalational vs. Intravenous Anesthetic – Recovery Profile min** p<0.05**Tang et al. Anesthesiology 1999;91:253-61
7Choice of Anesthetic Agents in Fast-Tracking 51 women undergoing GYN laparoscopyPropofol for inductionRandomized toPropofol, sevoflurane and desfluraneBIS monitored to keep at 60Triple antiemetic prophylaxisLocal anesthetic infiltrationColoma et al. Anesth Analg 2001;93:112-5
8Coloma et al. Anesth Analg 2001;93:112-5 Propofol vs. Sevo vs. DesColoma et al. Anesth Analg 2001;93:112-5
13Gupta et al. Anesth Analg 2004;98:632-41 Compared propofol, Isoflurane, Sevoflurane and DesfluranePropofol vs. Isoflurane 18 studiesPropofol vs. Desflurane 13 studiesPropofol vs. Sevoflurane 11 studiesIsoflurane vs. Sevoflurane 6 studiesIsoflurane vs. Desflurrane 4 studiesSevoflurane vs. Desflurane 6 studiesGupta et al. Anesth Analg 2004;98:632-41
14Systematic Analysis - Results Early recoveryFaster with desflurane than propofol and isofluraneFaster with Sevoflurane than isofluraneIntermediate recovery (Home readiness)Sevoflurane faster than isoflurane (5 min)PONV, PDNV, rescue antiemetic and headachePropofol better than inhalational agentsGupta et al. Anesth Analg 2004;98:632-41
16Chan et al. Anesth Analg 2001;93:1181-4 Outpatient hand surgeryRandomized toGA – Propofol/Isoflurane/FentanylIVRA – 0.5% lidocaineAxillary Block – lidocaine/chlorrprocaineRegional groups received sedation with propofolChan et al. Anesth Analg 2001;93:1181-4
18Korhonen et al. anesth Analg 2004;99:1668-73 Spinal vs. GA - OutcomesKorhonen et al. anesth Analg 2004;99:
19Spinal Anethesia vs. Desflurane GA Korhonen et al. anesth Analg 2004;99:
20Hadzic A et al. Anesthesiology 2005;102:1001-7 50 outpatients for open rotator cuff repairRandomized toFast track GA with LA infiltration (bupivacaine 0.25%)Interscalene block (ropivavaine 0.75%)Outcomes:Phase I and II recoveryDaily activities up to 2 weeks.Patient satisfactionHadzic A et al. Anesthesiology 2005;102:1001-7
23Functional Interference Due to Nausea and/or Vomiting White et al. Anesth Analg 2008;107:452-8EmesisNauseaFunctional InterferencePatients who reported emesis experienced a median of at least 2 episodes. Patients experienced more frequent nausea than vomiting across all study intervals. Forty-four percent of the study population experienced interference with postoperative functioning due to nausea and/or vomiting during the 3-day post-surgical study period. This interference occurred for 29% of patients in the 0-6 h interval and for 35% in the 6 ‑ 72 h study interval.
24PONV Occurring in the PACU* and/or Within 48 Hours After PACU Discharge Carroll p905/T6/A=58 patients w/ PONV=45 45/58=78%7+14=21 21/58=36%2040608010078%Patients Who Experienced PONV, %36%Carroll p905/T6/A=58 patients w/ PONV13+24=37 37/58=64%36%A study designed to evaluate PONV in patients receiving care at outpatient surgery centers provides valuable insight regarding the incidence of PONV. In this study, the incidence of PONV was measured in the recovery room, by telephone the day after discharge, and by a questionnaire patients were instructed to complete 5 days after discharge. The study enrolled adult patients (≥18 years of age) who were scheduled to receive general anesthesia and undergo 1 of 4 selected surgeries: laparoscopy, dilation and curettage (D&C), arthroscopy, or hernia repair. Among the 143 outpatients with complete data, the overall incidence of PONV was 41%.1As shown in this figure, among patients who experienced PONV, the majority of PONV occurred initially within the first 48 hours after discharge from the postanesthesia care unit (PACU). In fact, only 36% of patients who experienced PONV did so initially in the PACU, whereas 78% of patients who experienced PONV did so initially in the PACU and/or within 48 hours after PACU discharge.1 Some patients who initially experienced PONV within 48 hours after PACU discharge continued to experience PONV for up to 5 days after PACU discharge.1Also of interest is the emergence of PONV in patients who did not experience PONV in the recovery room. Nearly 65% of patients (37/58) with PONV did not experience symptoms until after discharge from the PACU.1Carroll p903/A,C; p904/B,CInitial PONV in the PACU(21/58)Initial PONV in the PACU and/or Within 48 Hours After PACU Discharge (45/58)Carroll p903/C; p904/ACarroll p905/T6/A=58 patients w/ PONV58/143=41%Carroll p905/T6/A=58 patients w/ PONV=45 45/58=78%7+14=21 21/58=36%Nearly 65% of patients did not experience PONV symptoms until after discharge from the PACU.Carroll p905/T6/A=58 patients w/ PONV13+24=37 37/58=64%* PACU=postanesthesia care unit.Carroll NV et al. Anesth Analg. 1995;80:903–909.Reference:1. Carroll NV, Miederhoff P, Cox FM, Hirsch JD. Postoperative nausea and vomiting after discharge from outpatient surgery centers. Anesth Analg. 1995;80:903–909.
27Apfel C, et al. Acta Anaesthesiol Scand 1998;42:495-501. PONV Risk Scores%Risk FactorsPointsFemale1History of PONV/motion sicknessPostop OpioidNon-SmokerApfel C, et al. Acta Anaesthesiol Scand 1998;42:
28ODT – Post Discharge Incidence of Nausea and Emesis % of Patients*Gan et al. Anesth Analg 2002;94:
29Cumulative Incidence of PONV TDS + Ondansetron vs. Ondansetron 1. Transderm Scop Phase IV Clinical Study ReportPage TableGan et al. Anesth Analg 2009;108:1498 –504
30Factorial Designed Trial: 6 Interventions for PONV Prevention High-Risk PONV Patients (N=4,123)Results: PONV risk reductionOndansetron 26%Dexamethasone 26%Droperidol 26%Propofol 19%Nitrogen 12% (nitrous oxide exclusion)Remifentanil not significantApfel CC, et al. N Engl J Med. 2004;350:
31Factorial Designed Trial: Ondansetron, Dexamethasone, and Droperidol Antiemetic Drug Combination Outcomes (N=5,161)6050*†‡40*†*‡†‡Incidence of Postoperative Nausea and Vomiting (%)302010321No. of AntiemeticsIncidence for each antiemetic or combinationAverage value for each number of antiemetics*Ondansetron; †dexamethasone; ‡ droperidol Apfel CC, et al. N Engl J Med. 2004;350: Adapted with permission.
32Algorithm for PONV Prophylaxis Evaluate risk of PONV in surgical patient and patient’s concernsLowNo prophylaxis unless there is medical risk of sequelae from vomitingModerateHighConsider regional anesthesiaNot IndicatedIf general anesthesia is used, reduce baseline risk factors when clinically practical & consider using nonpharmacologic therapiesAvoid opioids (IIIA)Avoid N2O (IIA)Avoid high dose reversal agent (IIA)Adequate hydration (IIIA)Propofol anesthetic (IA)Patients at moderate riskConsider antiemetic prophylaxis with monotherapy (adults) or combination therapy (children & adults)Patients at high riskInitiate combination therapy with 2 or 3 prophylactic agents from different classesGan et al. Anesth Analg 2003;97:62-71Gan JAMA 2002;287:1233-6
35Postoperative Pain: All Patients (in Hospital up to 2 Weeks) 12Patients’ worst painAny painSlight painModerate painSevere painExtreme pain1Apfelbaum, Gan et al. Anesth Analg. 2003;97:534-40; 2Warfield et al. Anesthesiology. 1993
36Pavlin et al. Anesth Analg 2002;95:627-34 24% had pain score ≥ 724% delayed PACUdischarge by painMaximum pain scorepredictive of total recoveryLower pain score (by 25%)if LA or NASID were usedPavlin et al. Anesth Analg 2002;95:627-34
37Structural Remodeling Long-Term Consequences of Acute Pain: Potential for Progression to Chronic PainCNSNeuroplasticityHyperactivityStructural RemodelingSustainedActivationPeripheralNociceptiveFibersSensitizationSurgery or injury causes inflammationPeripheralNociceptiveFibersTransient ActivationSustainedcurrentsChanges in neuronal function following injury can take place at the level of the periphery, the spinal cord, and the brain, and may increase the magnitude of perceived pain and contribute to the development of chronic pain.1Peripheral nociceptors can become more sensitive following repeated exposure to noxious stimuli due to release of chemical mediators from damaged cells following injury and inflammation, and alteration of sodium channel activity in the nociceptor membrane.2Plastic changes in the spinal dorsal horn due to increased afferent input can also play a role in neuronal sensitization.1,2High-frequency action potentials result in release of neuropeptides from the nociceptor central terminals in the spinal cord and subsequent modification of neuronal membrane excitability.2The more intense the peripheral noxious stimulus, the higher the frequency and the longer the duration of the train of action potentials activated in the nociceptors.2During the acute phase of central sensitization, release of transmitters from nociceptor central terminals in the dorsal horn causes changes in synaptic receptor density, as well as changes in the threshold and kinetics of neuronal activation. Together, these changes dramatically increase the efficiency of pain transmission.2It should be noted that most of the available information regarding modulation of pain perception at the peripheral, spinal, and supraspinal levels is based on animal research. However, the few published human studies indicate that peripheral sensitization and central hyperexcitability may also be important determinants for acute and chronic pain in humans.1CHRONICPAINACUTEPAINWoolf. Ann Intern Med. 2004;140:441; Petersen-Felix. Swiss Med Weekly. 2002;132: ; Woolf. Nature.1983;306: ; Woolf et al. Nature. 1992;355:75-8.Petersen-Felix S, Curatolo M. Neuroplasticity--an important factor in acute and chronic pain. Swiss Med Wkly. 2002;132(21-22):Woolf CJ. Pain: moving from symptom control toward mechanism-specific pharmacologic management. Ann Intern Med. 2004;140(6):
38Acute Postoperative Pain Has Been Associated With Chronic Pain After Common Procedures Incidence of Chronic Post-Surgical PainUS Surgical Volumes(1000s)1Amputation57-62%2159Breast surgery27-48%3,4479Thoracotomy52-61%5,6UnknownInguinal hernia repair19-40%7,8609Coronary artery bypass23-39%9-11598Caesarean section12%12220Acute postoperative pain is followed by chronic pain after common procedures, the rate of which varies based on type of surgery.Intensity of acute postsurgical pain has been correlated with the development of chronic postsurgical pain, as have other factors such as nerve injury and inflammation.Factors correlated with the development of post-surgical chronic pain1:Nerve injuryInflammationIntense acute postoperative painKehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:Hanley MA, Jensen MP, Smith DG, et al. Preamputation pain and acute pain predict chronic pain after lower extremity amputation. J Pain Feb;8:Carpenter JS, Andrykowski MA, Sloan P, et al. Postmastectomy/postlumpectomy pain in breast cancer survivors. J Clin Epidemiol. 1998;51:Poleshuck EL, Katz J, Andrus CH, et al. Risk factors for chronic pain following breast cancer surgery: a prospective study. J Pain Sep;7:Katz J, Jackson M, Kavanagh BP, et al. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12:50-55.Perttunen K, Tasmuth T, Kalso E. Chronic pain after thoracic surgery: a follow-up study. Acta Anaesthesiol Scand. 1999;43:Massaron S, Bona S, Fumagalli U, et al. Analysis of post-surgical pain after inguinal hernia repair: a prospective study of 1,440 operations. Hernia. 2007;11:O'Dwyer PJ, Kingsnorth AN, Molloy RG, et al. Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair. Br J Surg Feb;92(2):Steegers MA, van de Luijtgaarden A, Noyez L, et al. The role of angina pectoris in chronic pain after coronary artery bypass graft surgery. J Pain. 2007;8:Taillefer MC, Carrier M, Bélisle S, et al. Prevalence, characteristics, and predictors of chronic nonanginal postoperative pain after a cardiac operation: a cross-sectional study. J Thorac Cardiovasc Surg. 2006;131:Bruce J, Drury N, Poobalan AS, et al. The prevalence of chronic chest and leg pain following cardiac surgery: a historical cohort study. Pain. 2003;104:Nikolajsen L, Sørensen HC, Jensen TS, Kehlet H. Chronic pain following Caesarean section. Acta Anaesthesiol Scand. 2004;48:1. Kehlet et al. Lancet. 2006;367: ; 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: ; 5. Katz et al. Clin J Pain. 1996;12:50-55; 6. Perttunen et al. Acta Anaesthesiol Scand. 1999;43: ; 7.Massaron et al. Hernia. 2007;11: ; 8. O’Dwyer et al. Br J Surg. 2005;92: ; 9. Steegers et al. J Pain. 2007;8: ; 10. Taillefer et al. J Thorac Cardiovasc Surg. 2006;131: ; 11. Bruce et al. Pain. 2003;104: ; 12. Nikolajsen et al. Acta Anaesthesiol Scand. 2004;48:
39Multimodal or balanced analgesia Opioid doses of each analgesicImproved anti- nociception due to synergistic/ additive effectsMay severity of side effects of each drugPotentiationConventional NSAIDs/coxibs,paracetamol,nerve blocksKehlet H, et al. Anesth Analg 1993;77:1048–56 Playford RJ, et al. Digestion 1991;49:198–203
41Acetaminophen, NSAIDs or COX-2 inhibitors 52 RPCTs (~5000 patients)Acetaminophen, NSAIDs or COX-2 inhibitorsAverage morphine consumption – 49 mg/24hrs15-55 % decrease in morphine consumptionVAS pain decreased by 1 cmNSAIDs / COX-2 Specific inhibitors↓ nausea from 28.8% to 22%↓ Sedation 15.4% to 12.7%↑ Renal failure 0% to 1.7%
42Morphine Consumption – 24 hours Elia et al. Anesthesiology 2005;103:
43Regional Anesthesia in Ambulatory Surgery 1800 patients receiving upper or lower extremity block with 0.5% ropivacaineInterscelene, supraclavicular, axillary, lumbar plexus, emoral and sciatic blockDischarged on the day of surgeryConversion 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 monthsKlein et al. Anesth Analg 2002;94:65–70
48Reversal of Rocuronium 0.45 mg/kg 3/25/2017Recovery times after administration of a single dose of 0.45 mg/kg (1.5 × ED95) rocuronium. In one group (Spont), spontaneous recovery is allowed. In the remaining groups, 70 µg/kg neostigmine is administered 5 minutes after rocuronium or at 1%, 10%, and 25% recovery of the first twitch (T1) from its control value. *P < 0.01 versus spontaneous recovery. Note that times to attain a train-of-four ratio of 0.9 are significantly shorter when neostigmine is administered at T1 = 10% or 25% of control tension. (Figure constructed based on data redrawn from Bevan JC, Collins L, Fowler C, et al: Early and late reversal of rocuronium and vecuronium with neostigmine in adults and children. Anesth Analg 89:333–339, 1999.)Bevan JC et al. Anesth Analg 1999;89:333–339
49Cisatracurium vs. Rocuronium TOF 0.9 at EOS27%7%TOF at reversal63 7%40 19%EOS toTOF = 0.910 9 min18 13 minCammu et al. Eu J Anaesth 2002;19:129-34
50Assessment of NMB Recovery Positive Predictive Value % (95 CI)Negative Predictive Value % (95 CI)TOF<0.7TOF<0.9Head lift19(15-23)53(47-58)85(81-89)58(52-63)Tongue depressor28(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)(54-62)Debaene et al. Anesthesiology 2003;98:1042-8
51Residual Paralysis Debaene et al. Anesthesiology 2003;98:1042-8 Time between the administration of a single dose ofNMB and the arrival in the PACU.Debaene et al. Anesthesiology 2003;98:1042-8
53First Human Exposure to ORG25969 Gijsenbergh et al.29 healthy menAnesthesia: propofol target-controlled infusion and remifentanilRocuronium 0.6mg/kgPlacebo or sugammadex ranging from 0.1 to 8.0 mg/kgGijsenbergh, Francois Anesthesiology. 103(4): , 2005.
54Phase 1 Gijsenbergh, Francois Anesthesiology. 103(4):695-703, 2005. 3/25/2017Train-of-four tracing from one volunteer who participated during part 2 of the study. The blue line represents the height of the twitch, and the dashed red line is the value of the train-of-four ratio. The volunteer received 0.6 mg/kg rocuronium (Roc) followed by placebo at 3 min (A) in one treatment period, followed by 8 mg/kg Org in another treatment period (B). No recurarization was observed in the 90 min during which the neuromuscular block was monitored.Gijsenbergh, Francois Anesthesiology. 103(4): , 2005.
56CLINICAL UTILITY TRIAL: EMERGENCE TIMES Prevention and Management of Anesthesia AwarenessCLINICAL UTILITY TRIAL: EMERGENCE TIMESOctober 2004minutes* p < 0.001As a result of decreased drug usage, patients woke up faster, they opened their eyes faster and they responded to verbal command faster. On average, emergence from anesthesia dropped from 10 minutes in the standard practice group to only 6 minutes in the BIS monitored group.A common question is often asked, “what difference does 3 or 4 minutes make in emergence times”? This trial demonstrated that there were benefits beyond shaving a couple minutes off at the end of surgery. The more significant improvements result from reducing the outliers -- those patients that take an unusually long time to wake upGan TJ, et al. Anesthesiology, OctADVANCED AWARENESS TRAINING MODULE
57CLINICAL UTILITY TRIAL: PACU DISCHARGE TIME Prevention and Management of Anesthesia AwarenessCLINICAL UTILITY TRIAL: PACU DISCHARGE TIMEOctober 2004BIS Patients 16% Faster than Standard PracticeAs a result of reduced drugs administered, faster emergence times and better global assessment scores in recovery, patients were eligible to leave the PACU 16% faster.Gan TJ, et al. Anesthesiology, OctADVANCED AWARENESS TRAINING MODULE
58CLINICAL UTILITY TRIAL: DRUG USAGE Prevention and Management of Anesthesia AwarenessCLINICAL UTILITY TRIAL: DRUG USAGEOctober 2004mgIn each of the next several slides, the yellow bar represents patients treated using the BIS monitor. The pink bar represents the standard practice group. Looking first at drug usage, the BIS patients, on average, received 23% less propofol.* p <0.00123% Less Propofol UsedGan TJ, et al. Anesthesiology, OctADVANCED AWARENESS TRAINING MODULE
59CLINICAL UTILITY TRIAL: BLINDED PACU ASSESSMENTS Prevention and Management of Anesthesia AwarenessOctober 2004* p < 0.001The patients that were monitored with the BIS during surgery in the multicenter clinical utility trial received a much better overall assessment score from the nurses in the recovery room. Many more BIS patients were rated “excellent to good” compared to “good to fair” in the standard practice group.ExcellentOriented on ArrivalGoodFast RecoveryFairSlow RecoveryGan TJ, et al. Anesthesiology, OctADVANCED AWARENESS TRAINING MODULE
62Chung et al. J Clin Anesth 1995;80:896-902 PADSMax 10Score ≥ 9Fit for dischargeChung et al. J Clin Anesth 1995;80:
63White et al. Anesth Analg 1999;88:1069-72 Eligible for fast-trackScore of ≥12No score < 1 in any categoryWhite et al. Anesth Analg 1999;88:
64Factors Delaying Discharge PreoperativeFemaleIncreasing ageCHFIntraoperativeLong duration of surgeryGASpinal anesthesiaPostoperativePainPONBDrowsinessNo escort
65Factors delaying discharge Mandatory oral fluid intakeMandatory voidingRisk factors for postop urinary retentionType of surgery (anorectal, hernia, vaginal/pelvic gynecological surgery)Old ageMale sexSpinal/epiduralDuration of surgery > 60 minIntraoperative fluid > 750 mL
66Summary Use short acting drugs IV or inhalational anesthetic are recommendedRegional anesthesia can have postdischarge advantagesOptimal antiemetic prophylaxisComprehensive perioperative analgesic regimenBeware of residual paralysisAggressively adopt bypass and discharge criteria
67Prevention and Management of Anesthesia Awareness October 2004QuestionsADVANCED AWARENESS TRAINING MODULE