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.

Fast Tracking in Fast Tracking in Ambulatory SurgeryAmbulatory 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

OutlineOutline

• Anesthetic techniques

• Effective management of – PONV– Pain– NMB

• Monitoring depth of anesthesia

• PACU fast track and discharge scoring systems

Freestanding ASCs in the United StatesFreestanding ASCs in the United States

0

1000

2000

3000

4000

5000

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2005

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

Should you use intravenous of Should you use intravenous of inhalational anesthesia?inhalational anesthesia?

Inhalational vs. Intravenous Inhalational vs. Intravenous Anesthetic – Recovery ProfileAnesthetic – Recovery Profile

** p<0.05

**

min

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

Inhalational vs. Intravenous Inhalational vs. Intravenous Anesthetic – Recovery ProfileAnesthetic – Recovery Profile

*

* p<0.05*

*

min

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

Choice of Anesthetic Agents Choice of Anesthetic Agents in Fast-Trackingin 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. DesPropofol vs. Sevo vs. Des

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

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

RemifentanilRemifentanil

PropofolPropofol

DesfluraneDesflurane

NitrousNitrous

Spon Spon VentilationVentilation

11 11 ± 4 min± 4 min 7 7 ± 3 min± 3 min

Eye OpeningEye Opening 11 11 ± 4 min± 4 min 14 14 ± 7 min± 7 min

Aldrete Score Aldrete Score 99

1717± 7 min± 7 min 17 17 ± 7 min± 7 min

AgitationAgitation 44%44% 80%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 - ResultsSystematic 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 AnesthesiaGeneral Anesthesia

vs.vs.

Regional AnesthesiaRegional 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 - OutcomesSpinal vs. GA - Outcomes

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

Spinal Anethesia vs. Spinal Anethesia vs. Desflurane GADesflurane 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 PONVManagement of PONV

Functional Interference Functional Interference Due to Nausea and/or Vomiting Due to Nausea and/or Vomiting

Emesis Nausea Functional Interference

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

PONV Occurring in the PACU* and/or PONV Occurring in the PACU* and/or Within 48 Hours After PACU DischargeWithin 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%

Pat

ien

ts W

ho

Exp

erie

nce

d P

ON

V,

%

0

20

40

60

80

100

PONV Risk ScoresPONV Risk Scores

Risk FactorsRisk Factors PointsPoints

Female 1

History of PONV/motion sickness

1

Postop Opioid 1

Non-Smoker 1

%

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

Cumulative Incidence of PONVTDS + Ondansetron vs. Ondansetron

P<0.05

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

• 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: Factorial Designed Trial: 6 Interventions for PONV Prevention6 Interventions for PONV Prevention

Apfel CC, et al. N Engl J Med. 2004;350:2441-2451.

*Ondansetron; †dexamethasone; ‡ droperidol. Apfel CC, et al. N Engl J Med.

2004;350:2441-2451. Adapted with permission.

Factorial Designed Trial: Ondansetron, Factorial Designed Trial: Ondansetron, Dexamethasone, and DroperidolDexamethasone, and Droperidol

Antiemetic Drug Combination Outcomes (N=5,161)

Average value for each number of antiemetics

Incidence for each antiemetic or combination

Inci

den

ce o

f P

ost

op

erat

ive

Nau

sea

and

Vo

mit

ing

(%

)

†

60

50

40

30

20

10

0

No. of Antiemetics

0 3 21

* ‡

*‡*† †‡

Algorithm for PONV ProphylaxisAlgorithm for PONV ProphylaxisEvaluate risk of PONV in surgical patient and patient’s concerns

Moderate High

Consider regionalanesthesia

Low

No prophylaxis unless thereis medical risk of

sequelae from vomitingNot Indicated

If general anesthesia is used, reduce baseline risk factors when clinically practical &

consider using nonpharmacologic therapies

Patients at moderate risk

Consider antiemetic prophylaxiswith monotherapy (adults) or

combination therapy (children & adults)

Patients at high risk

Initiate combination therapy with2 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

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

Management of PainManagement of Pain

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

Any pain Slightpain

Moderatepain

Severepain

Extremepain

1Apfelbaum, Gan et al. Anesth Analg. 2003;97:534-40; 2Warfield et al. Anesthesiology. 1993

1

2

Patients’ worst pain

• 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

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.

Surgeryor

injurycauses

inflammation

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

Sustained

Activation

Peripheral

Nociceptive

Fibers

Sensitization

CHRONIC

PAIN

CNS

Neuroplasticity

Hyperactivity

Structural Remodeling

Acute Postoperative Pain Has Been Associated With Acute Postoperative Pain Has Been Associated With Chronic Pain After Common ProceduresChronic Pain After Common Procedures

Incidence of Chronic Post-Surgical Pain

US Surgical Volumes(1000s)1

Amputation 57-62%2 159

Breast surgery 27-48%3,4 479

Thoracotomy 52-61%5,6 Unknown

Inguinal hernia repair 19-40%7,8 609

Coronary artery bypass 23-39%9-11 598

Caesarean section 12%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. 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.

Factors correlated with the development of post-surgical chronic pain1:1. Nerve injury2. Inflammation

3. Intense acute postoperative pain

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

Multimodal or balanced Multimodal or balanced analgesiaanalgesia

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

Adjunctive AnalgesicsAdjunctive 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 hoursMorphine Consumption – 24 hours

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

Regional Anesthesia in Regional Anesthesia in Ambulatory SurgeryAmbulatory 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

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

Ambulatory Infusion PumpAmbulatory Infusion Pump

Management of Management of Neuromuscular Neuromuscular

BlockadeBlockade

Reversal of Rocuronium 0.45 mg/kgReversal of Rocuronium 0.45 mg/kg

Bevan JC et al. Anesth Analg 1999;89:333–339

Cisatracurium vs. RocuroniumCisatracurium vs. Rocuronium

Cisatracurium Rocuronium

TOF 0.9 at EOS

27% 7%

TOF at reversal

63 7% 40 19%

EOS to TOF = 0.9

10 9 min 18 13 min

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

Residual ParalysisResidual 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.

SugammadexSugammadex

Angewandte Chemie 2002:41:266 -270

First Human Exposure to First Human Exposure to ORG25969ORG25969

• 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 1Phase 1

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

Depth of Anesthesia MonitoringDepth of Anesthesia Monitoring

Emergence Times

109

66

0

3

6

9

12

OPEN EYES RESPOND TOCOMMAND

StandardPracticeBIS

* p < 0.001

CLINICAL UTILITY TRIAL:CLINICAL UTILITY TRIAL:EMERGENCE TIMESEMERGENCE TIMES

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

min

ute

s

CLINICAL UTILITY TRIAL: CLINICAL UTILITY TRIAL: PACU DISCHARGE TIMEPACU DISCHARGE TIME

Eligible for Discharge from PACU

37

31

20

25

30

35

40M

inu

tes

Standard Practice

BIS

BIS Patients 16% Faster than Standard Practice

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

Total Propofol Used Per Case

1252

964

0

250

500

750

1000

1250

1500

StandardPracticeBIS

23% Less Propofol Used

CLINICAL UTILITY TRIAL:CLINICAL UTILITY TRIAL:DRUG USAGEDRUG USAGE

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

mg

* p <0.001

2.1

1.7

1 2 3

Av

era

ge

Sc

ore Standard

PracticeBIS

ExcellentOriented on Arrival

GoodFast Recovery

FairSlow Recovery

* p < 0.001

CLINICAL UTILITY TRIAL: CLINICAL UTILITY TRIAL: BLINDED PACU ASSESSMENTSBLINDED PACU ASSESSMENTS

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

PACU Discharge CriteriaPACU 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 fast-track

• Score of ≥12

• No score < 1 in any category

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

Factors Delaying DischargeFactors Delaying Discharge

• Preoperative– Female– Increasing age– CHF

• Intraoperative– Long duration of surgery– GA– Spinal anesthesia

• Postoperative– Pain– PONB– Drowsiness– No escort

Factors delaying dischargeFactors 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

SummarySummary• 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

QuestionsQuestions