is one anesthetic technique associated with faster recovery? trey bates, md “time equals money”...
TRANSCRIPT
Is One Anesthetic Technique Associated with Faster Recovery?
Trey Bates, MD
“Time Equals Money”
Or
The Case
• 60 year-old Woman
• HTN (controlled on beta blocker)
• Tobacco (17 pack-year history)
• Right Inguinal Hernia Repair
• Allergic to Amide and Ester Local Anesthetics
The Catch
• You work at a busy surgical center
• Prefer to bypass PACU and take patients directly to outpatient surgery.
• Is that possible in this case?
• How would you accomplish this?
The Article
• Emphasis on rapid postoperative recovery and early discharge
• PACU stay is questioned• There is evidence that the choice of general
anesthetic technique is associated with faster recovery
• The most important aspect of an anesthetic technique is its ability to consistently achieve rapid recovery after termination of surgery
Premedication
Your Thoughts?
Premedication
• Benzodiazepines often used to provide anxiolysis and reduce incidence of intraoperative awareness
• Recent evidence suggests that recovery, particularly in the elderly, may be prolonged
Premedication
• However, significant reduction in stress hormone levels after diazepam premedication found by Duggan (2002) using Diazepam 0.1 mg/kg 60 or 90 minutes preoperatively)
• Benzodiazepine premedication only in high-risk (e.g., cardiac patients) undergoing ambulatory surgery
Induction
Your Thoughts?
Induction
• Propofol versus Sevoflurane– Thwaites, 1997– Induction with Propofol then 2% Sevo
Maintenance– Induction with 8% Sevo then 2% Sevo
Maintenance
Induction
• Time to emergence (eye opening to command) was shorter in patients with Sevoflurane induction (5.2 minutes versus 7 minutes)
• However, incidence of PONV was higher after Sevoflurane induction
• Significantly more patients rated induction with Sevoflurane as unpleasant
• Since Propofol induction is associated with higher perioperative patient satisfaction, Sevoflurane ahould be reserved for selected patients
Maintenance
Your Thoughts?
Maintenance
• Ease of titratability and a rapid emergence from anesthesia favor inhaled anesthetic techniques
• In addition, inhaled anesthetics potentiate neuromuscular blockade, thereby reducing the requirements of muscle relaxants
• Desflurane and Sevoflurane allow for more rapid emergence than Isoflurane
Maintenance
• Desflurane versus Sevoflurane versus Propofol– Song, 1998– Inhaled anesthetic resulted in shorter times to
awakening, tracheal extubation, and orientation compared to Propofol TIVA
– 90% of Desflurane patients were considered fast-track eligible (Sevo – 75%, Propofol – 26%)
Maintenance
• However, there was no difference between the groups with respect to the times to oral intake and home-readiness.
• Faster emergence does not translate into an earlier discharge from the PACU
Maintenance
• Propofol TIVA is consistently associated with a lower incidence of PONV as compared with inhaled anesthetic technique
• However, PONV incidence is equivalent when prophylactic antiemetics are used with inhalation anesthesia and Nitrous Oxide
• Propofol TIVA is preferable in high risk PONV patients
Nitrous Oxide
Your Thoughts?
Nitrous Oxide
• Amnestic and Analgesic Properties
• Lower the requirement of costly anesthetic drugs
• Some studies report a higher incidence of PONV with Nitrous Oxide
• A meta-analysis of randomized controlled trials found that the emetic effect of Nitrous Oxide was not significant
Nitrous Oxide
• Arellano, 2000– 740 women– Outpatient gynecologic surgery– Incidence of PONV and time to home-
readiness– Propofol-Nitrous Oxide versus Propofol alone– Nitrous Oxide reduced propofol requirements
20% to 25% without increasing adverse events
Nitrous Oxide
• Most studies assessing the feasibility of fast-tracking have used nitrous oxide as part of their technique
• Overall, there is no convincing evidence to avoid Nitrous Oxide
Supralaryngeal Airway Devices
Your Thoughts?
Supralaryngeal Airway Devices
• Do not require NMB
• Generally tolerated at lower anesthetic levels than a tracheal tube
• Opiod requirements can be based on respiratory rate
• Desflurane has irritant properties but can be safely used in patients breathing spontaneously through an LMA
Opiods
Your Thoughts?
Opioids
• Nausea, vomiting, and sedation contribute to delayed recover and discharge home
• Use sparingly in ambulatory surgery• Remifentanil
– Rapidly Metabolized = Very short duration of action– Independent of duration of infusion– Reliable and Rapid emergence – Because of its short duration of action, plan for
longer-acting analgesics before discontinuation
Areas of Uncertainty
• Does the use of a small dose (2 mg)of midazolam protect against awareness or delay recovery from anesthesia?
• Does the use of nitrous oxide reduce intraoperative and/or postoperative opioid requirements?
• Are longer-acting opioids (morphine and hydromorphone) suitable for anesthesia practice?
Author’s Recommendations
• Intravenous induction is preferable
• Maintenance with Sevo or Des
• Des may be associated with faster emergence
• Optimal Technique = intravenous propofol induction, inhalation anesthesia with Nitrous Oxide for maintenance, and an LMA