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

Monitoring depth of anesthesia PACU fast track and discharge scoring systems

Freestanding ASCs in the United States

5000

4000

The number of freestanding ASCs jumped to 5,068 during 2005

3000

2000

1000

0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2005
Source: Verispan and William Blair & Co., LLC Estimates
RS Daniels, Outpatient Surgery;Jan 2006:108-111

Should you use intravenous of inhalational anesthesia?

Inhalational vs. Intravenous Anesthetic Recovery Profile

min

* p<0.05
* * *

Tang et al. Anesthesiology 1999;91:253-61

Inhalational vs. Intravenous Anesthetic Recovery Profile

min

* p<0.05

Tang et al. Anesthesiology 1999;91:253-61

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

Propofol vs. Sevo vs. Des

Coloma et al. Anesth Analg 2001;93:112-5

TIVA (Prop/Remi) versus Desflurane in Children ENT Procedures

Remifentanil Propofol 11 4 min
11 4 min 17 7 min

Spon Ventilation Eye Opening Aldrete Score 9 Agitation

Desflurane Nitrous 7 3 min

14 7 min 17 7 min

44%

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 - 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 Anesthesia vs. Regional 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 - Outcomes

Korhonen et al. anesth Analg 2004;99:1668-73

Spinal Anethesia vs. Desflurane 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 PONV

Functional Interference Due to Nausea and/or Vomiting

White et al. Anesth Analg 2008;107:452-8

Emesis

Nausea

Functional Interference

PONV Occurring in the PACU* and/or Within 48 Hours After PACU Discharge
Patients Who Experienced PONV, % 100 80 60 40 20 0
Initial PONV in the PACU (21/58) Initial PONV in the PACU and/or Within 48 Hours After PACU Discharge (45/58)

78%

36%

36%

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;80:903909.

PONV Risk Scores

%

Risk Factors Female History of PONV/motion sickness

Points 1 1

Postop Opioid
Non-Smoker

1
1

Apfel C, et al. Acta Anaesthesiol Scand 1998;42:495-501.

Cumulative Incidence of PONV

TDS + Ondansetron vs. Ondansetron

P<0.05

Gan et al. Anesth Analg 2009;108:1498 504

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.

Factorial Designed Trial: Ondansetron, Dexamethasone, and Droperidol

Antiemetic Drug Combination Outcomes (N=5,161)
Incidence of Postoperative Nausea and Vomiting (%) 60 50 40 30 20 10 0 0 1 2 No. of Antiemetics 3

* *

Incidence for each Average value for each antiemetic or combination number of antiemetics *Ondansetron; dexamethasone; droperidol. Apfel CC, et al. N Engl J Med. 2004;350:2441-2451. Adapted with permission.

Algorithm for PONV Prophylaxis

Evaluate risk of PONV in surgical patient and patients concerns Low No prophylaxis unless there is medical risk of sequelae from vomiting Moderate High Consider regional anesthesia
Not Indicated

If general anesthesia is used, reduce baseline risk factors when clinically practical & Avoid opioids (IIIA) consider using nonpharmacologic therapies Avoid N2O (IIA)
Patients at moderate risk Avoid high dose reversal agent (IIA) Patients at high risk Initiate combination therapy with 2 or 3 prophylactic agents from different classes

Adequate hydration (IIIA) Consider antiemetic prophylaxis with monotherapy (adults) or Propofol anesthetic (IA) combination therapy (children & adults)

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 Pain

Postoperative Pain: All Patients (in Hospital up to 2 Weeks)

100 90 80 83
1999 1993
1 2

77

% of patients

70 60 50 40 30 20 10 0

Patients worst pain

47 49

19 13

21 23

18 8

Any pain

Slight pain

Moderate pain

Severe pain

Extreme pain

1Apfelbaum,

Gan et al. Anesth Analg. 2003;97:534-40; 2Warfield et al. Anesthesiology. 1993

 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

Long-Term Consequences of Acute Pain: Potential for Progression to Chronic Pain

Sensitization Structural Remodeling CNS
Peripheral Nociceptive Fibers
Sustained currents

Surgery or injury causes inflammation

Peripheral Nociceptive Fibers

Neuroplasticity

Hyperactivity

Transient Activation

Sustained
Activation

ACUTE PAIN

CHRONIC 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.

Acute Postoperative Pain Has Been Associated With Chronic Pain After Common Procedures
Incidence of Chronic Post-Surgical Pain Amputation Breast surgery Thoracotomy Inguinal hernia repair 57-62%2 27-48%3,4 52-61%5,6 19-40%7,8 US Surgical Volumes (1000s)1 159 479 Unknown 609

Coronary artery bypass

Caesarean section

23-39%9-11
12%12

598
220

Factors correlated with the development of post-surgical chronic pain1: 1. Nerve injury 2. Inflammation 3. 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. 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;131:12741280; 11. Bruce et al. Pain. 2003;104:265-273; 12. Nikolajsen et al. Acta Anaesthesiol Scand. 2004;48:111-116.

Multimodal or balanced analgesia

Opioid

doses of each analgesic Improved antinociception 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;77:104856 Playford RJ, et al. Digestion 1991;49:198203

Adjunctive 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 hours

Elia et al. Anesthesiology 2005;103:1296-1304

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;94:6570

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

Ambulatory Infusion Pump

Management of Neuromuscular Blockade

Reversal of Rocuronium 0.45 mg/kg

Bevan JC et al. Anesth Analg 1999;89:333339

Cisatracurium vs. Rocuronium

Cisatracurium Rocuronium TOF 0.9 at EOS TOF at reversal EOS to TOF = 0.9 27% 63 7% 10 9 min 7% 40 19% 18 13 min

Cammu et al. Eu J Anaesth 2002;19:129-34

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

Sugammadex

Angewandte Chemie 2002:41:266 -270

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.

Phase 1

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

Depth of Anesthesia Monitoring

CLINICAL UTILITY TRIAL: EMERGENCE TIMES

12 9 9 6 6 3 0 OPEN EYES RESPOND TO COMMAND 6
* p < 0.001

Emergence Times
10

Standard Practice BIS

Gan TJ, et al. Anesthesiology, Oct. 1997.

CLINICAL UTILITY TRIAL: PACU DISCHARGE TIME

Eligible for Discharge from PACU

BIS Patients 16% Faster than Standard Practice

40 35 30 25 20

Minutes

37 31

Standard Practice BIS

Gan TJ, et al. Anesthesiology, Oct. 1997.

CLINICAL UTILITY TRIAL: DRUG USAGE

Total Propofol Used Per Case
1500 1250 1000 750 500 250

1252 964

Standard Practice BIS

* p <0.001
0

23% Less Propofol Used

Gan TJ, et al. Anesthesiology, Oct. 1997.

CLINICAL UTILITY TRIAL: BLINDED PACU ASSESSMENTS

Average Score
Standard Practice BIS

1.7 2.1
* p < 0.001

Excellent Oriented on Arrival

Good Fast Recovery

Fair Slow Recovery

Gan TJ, et al. Anesthesiology, Oct. 1997.

PACU 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 fasttrack Score of 12 No score < 1 in any category

White et al. Anesth Analg 1999;88:1069-72

Factors Delaying Discharge

Preoperative
Female Increasing age CHF

Postoperative
Pain PONB Drowsiness No escort

Intraoperative
Long duration of surgery GA Spinal anesthesia

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

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

Questions