Post on 21-Jan-2016
description
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