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Remifentanil and Day Surgery

Remifentanil and Day Surgery. Lawrence Rowe Norfolk and Norwich University Hospital. Day Surgery Procedures. Baskets Shopping Trolley BADS Directory of Procedures 2006 www.bads.co.uk 160 procedures 4 options 18 week pathways. Norfolk & Norwich University Hospital. www.nnuh.nhs.uk.

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Remifentanil and Day Surgery

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  1. Remifentanil and Day Surgery Lawrence Rowe Norfolk and Norwich University Hospital

  2. Day Surgery Procedures • Baskets • Shopping Trolley • BADS Directory of Procedures 2006www.bads.co.uk • 160 procedures • 4 options • 18 week pathways

  3. Norfolk & Norwich University Hospital www.nnuh.nhs.uk

  4. Norwich Case Mix No of Cases 3000 100.0% 90.0% 2500 80.0% 70.0% 2000 60.0% 1500 50.0% 40.0% 1000 30.0% 20.0% 500 10.0% 0 0.0% 10 20 30 40 50 60 70 80 90 100 110 120 operation time (min)

  5. UK General Anaesthesia costs in perspective, Churnside RJ et al, Br Jnl of Medical Economics 1996; 10: 83-98 day case hernia day case varicose veins inpatient hernia inpatient major abdominal surgery

  6. Day Surgery Advantages • Cheaper • Less risk of cancellation • Patients prefer it • Lower infection risk

  7. Pre-requisites: • Dedicated unit • Well organised processes • High quality surgery and anaesthesia • Motivated nursing staff • Audit

  8. Operation Times for Inguinal Hernia Repair (n=103) ANOVA: p<0.001 50 Operation time (min) 40 30 20 10 0 Consultant Senior Reg Reg SHO

  9. Anaesthetic choices • Volatile vs Propofol

  10. “Time to discharge” in ambulatory surgery studies Valanne Pandit et al Wetchler et al Siler et al Volatile Killian et al Propofol Korttila et al Marais et al Sung et al 0 50 100 150 200 250 Time (min)

  11. Anaesthetic agents in adult day case surgeryBJ Pollard et al EJA 2003;20: 1-9 • Review of all comparative published studies of adult day case anaesthesia up to Dec 2000 • “With respect to the maintenance of anaesthesia, isoflurane and halothane were the worst.” • “Propofol is the induction agent of choice” • “The use of Propofol and avoidance of nitrous oxide may help to reduce the incidence of postoperative nausea and vomiting”

  12. Is PONV important in day case anaesthesia? Reasons for admission from Norwich DPU 1993 = 56 cases

  13. Volatile versus Total Intravenous Anaesthesia. An 11 year study of outcomes following Day Case Surgery at Torbay Hospital. P G Margetts, M E Stocker (submitted BADS ASM 2007) • 41350 patients over 11yrs • TIVA 25% fewer admissions for anaesthetic reasons: • nausea, vomiting, dizziness and feeling faint • 24hr follow-up significantly fewer side effects with TIVA • Earlier discharge but not practically significant • Encouraging the use of TIVA and antiemetic guidelines has reduced stay in rate from 2% to 0.3% • TIVA now 80% cases

  14. Why Remifentanil? • Quality anaesthesia • High opiate low hypnotic technique • The cardiac technique but for short duration • Hypnotic sparing effect • Part of the TIVA technique • Problems with inadequate analgesia

  15. Esterase Metabolism • flexibility........ • rapid onset/offset, allows opioid concentration to be increased and decreased almost without restriction • Hypnotic sparing due to ability to achieve high opioid concentrations

  16. Hypnotic Technique H O ‘Hypnotic’ (inhaled or IV) + adjunctive opioid analgesic

  17. Hypnotic Technique ‘Opioid’ Technique H O H O ‘Opioid’ for basis of anaesthesia + adjunctive hypnotic (inhaled or IV) ‘Hypnotic’ (inhaled or IV) + adjunctive opioid analgesic

  18. The Pharmacodynamic Interaction of Propofol and Alfentanil during Lower Abdominal Surgery in Women. Vuyk, J et al, Anesthesiology. 83(1):8-22, July 1995

  19. Vuyk J et al. Anesthesiology 1997;87:1549-1562, & Anesthesiology 1995:83:8-22

  20. Propofol Reduces Perioperative Remifentanil Requirements in a Synergistic Manner Mertens et al Anesthesiology, 99(2) 2003, 347-359

  21. 19 min • 14 min • 19 min Interaction for Alfentanil

  22. 8 min • 6 min • 12 min Interaction for Remifentanil

  23. Context Sensitive Half Time fentanyl thiopentone CT half time (min) alfentanil propofol remifentanil Infusion duration (hr)

  24. Comparison Alfentanil vs Remifentanil

  25. Why Remifentanil? • High opiate low hypnotic technique • Hypnotic sparing effect • CVS stability • Cost benefits • Anaesthetic sparing • Rapid recovery • Less need for NMB

  26. Practical points • IV access secure • Visible, Connections • Proper giving sets for IVA • Concentrations • Not too concentrated • 2mg in 40ml = 50 g / ml

  27. h

  28. Which cases? • Laparoscopies • ENT • Anal surgery • Varicose veins • Hernias

  29. Induction • Midazolam 2mg • Propofol TCI 3 – 4 g / ml • Remifentanil 0.25 - 0.5 g/kg/min • Intubation or LMA • Remifentanil 0.1 - 0.25 g/kg/min

  30. Effect of Age and BMI

  31. TCI or Manual Remifentanil? • Minto model: • Age adjusted • BMI adjusted • Pumps available?

  32. Fresenius Base Primea

  33. Alaris Asena PK

  34. IV Sedation Technique • Eg Gynae TVT procedures • Oxygen • +/- TCI propofol • 0.2 to 1.0 g/ml target • Remifentanil • 0.02 g/kg/min to 1 g/kg/min • Verbal contact

  35. Postop Analgesia • Paracetamol (IV or PR) • NSAID’s (Preop, IV or PR) • LA ++ • IV Fentanyl in recovery room

  36. PONV Strategy • Have a strategy • Avoid N2O and Volatiles • Avoid Morphine • Dexamethasone 4mg iv • 5HT antagonist • +/- Cyclizine 50mg

  37. Thank you lawrence.rowe@nnuh.nhs.uk

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