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Fast Tracking in Ambulatory Surgery

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. Outline. Anesthetic techniques Effective management of PONV Pain NMB

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Fast Tracking in Ambulatory Surgery

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  1. Fast Tracking in Ambulatory 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

  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 min * p<0.05 * * * 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

  9. TIVA (Prop/Remi) versus Desflurane in Children ENT Procedures Grundmann et al. Acta Anesth Scndinavica 1998;42:845-50

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

  11. 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

  12. 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

  13. General Anesthesiavs.Regional Anesthesia

  14. 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

  15. Chan et al. Anesth Analg 2001;93:1181-4

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

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

  18. 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

  19. Hadzic A et al. Anesthesiology 2005;102:1001-7

  20. Management of PONV

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

  22. 100 80 60 40 20 0 PONV Occurring in the PACU* and/or Within 48 Hours After PACU Discharge 78% Patients Who Experienced PONV, % 36% 36% Initial PONV in the PACU and/or Within 48 Hours After PACU Discharge(45/58) Initial PONV in the PACU (21/58) • Nearly 65% of patients did not experience PONV symptoms until after discharge from the PACU. * PACU=postanesthesia care unit. Carroll NV et al. Anesth Analg. 1995;80:903–909.

  23. PONV Risk Scores % Apfel C, et al. Acta Anaesthesiol Scand 1998;42:495-501.

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

  25. Factorial Designed Trial: 6 Interventions for PONV Prevention High-Risk PONV Patients (N=4,123) • Results: PONV risk reduction • Ondansetron 26% • Dexamethasone 26% • Droperidol 26% • Propofol 19% • Nitrogen 12% (nitrous oxide exclusion) • Remifentanil not significant Apfel CC, et al. N Engl J Med. 2004;350:2441-2451.

  26. 0 1 2 3 Factorial Designed Trial: Ondansetron, Dexamethasone, and Droperidol Antiemetic Drug Combination Outcomes (N=5,161) 60 50 * † ‡ 40 *† *‡ †‡ Incidence of PostoperativeNausea and Vomiting (%) 30 20 10 0 No. of Antiemetics Incidence for each antiemetic or combination Average value for each number of antiemetics *Ondansetron; †dexamethasone; ‡ droperidol. Apfel CC, et al. N Engl J Med. 2004;350:2441-2451. Adapted with permission.

  27. Low Moderate High No prophylaxis unless thereis medical risk ofsequelae from vomiting Consider regionalanesthesia Not Indicated If general anesthesia is used, reduce baseline risk factors when clinically practical & consider using nonpharmacologic therapies Patients at moderate risk Patients at high risk Consider antiemetic prophylaxiswith monotherapy (adults) or combination therapy (children & adults) Initiate combination therapy with2 or 3 prophylactic agentsfrom different classes Algorithm for PONV Prophylaxis Evaluate risk of PONV in surgical patient and patient’s concerns • 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

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

  29. Management of Pain

  30. Postoperative Pain: All Patients (in Hospital up to 2 Weeks) 1 2 Patients’ worst pain Any pain Slightpain Moderatepain Severepain Extremepain 1Apfelbaum, Gan et al. Anesth Analg. 2003;97:534-40; 2Warfield et al. Anesthesiology. 1993

  31. 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

  32. Structural Remodeling Sensitization CNS Neuroplasticity Hyperactivity Peripheral Nociceptive Fibers Peripheral Nociceptive Fibers Sustained currents Transient Activation Sustained Activation Long-Term Consequences of Acute Pain: Potential for Progression to Chronic Pain Surgeryorinjurycausesinflammation CHRONIC PAIN 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.

  33. Acute Postoperative Pain Has Been Associated With Chronic Pain After Common Procedures • Factors correlated with thedevelopment of post-surgical chronic pain1: • Nerve injury • Inflammation • Intense acute postoperative pain 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.

  34. Multimodal or balanced analgesia Opioid •  doses of each analgesic • Improved anti-nociception due to synergistic/additive effects • May  severity of side effects of each drug Potentiation Conventional NSAIDs/coxibs, paracetamol, nerve blocks Kehlet H, et al. Anesth Analg 1993;77:1048–56Playford RJ, et al. Digestion 1991;49:198–203

  35. AdjunctiveAnalgesics • NSAIDs and COX-2 selective inhibitors (coxibs) • Acetaminophen • Local anesthetics • Ketamine • Gabapentin / pregabalin • Clonidine / dexmedetomidine • Steroids • Non pharmacological techniques

  36. 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%

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

  38. 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

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

  40. Ambulatory Infusion Pump

  41. Management of Neuromuscular Blockade

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

  43. Cisatracurium vs. Rocuronium Cammu et al. Eu J Anaesth 2002;19:129-34

  44. Residual Paralysis Time between the administration of a single dose of NMB and the arrival in the PACU. Debaene et al. Anesthesiology 2003;98:1042-8

  45. Sugammadex Angewandte Chemie 2002:41:266 -270

  46. 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.

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

  48. Depth of Anesthesia Monitoring

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