The Outpatient Anesthetic

I Want You to Give Me

ORANA Fall ConferenceORANA Fall Conference

Oct. 24, 2009Oct. 24, 2009

L. Scott Letourneau, M.D.

Bend Surgery Center

Bend, OR

Disclosure

The Outpatient Anesthetic I Want You to Give Me

Introduction/Background/ObjectivesIntroduction/Background/ObjectivesMultimodal ApproachMultimodal ApproachDrawbacks/ComplicationsDrawbacks/ComplicationsSummarySummary

The Outpatient Anesthetic I Want You to Give Me

Introduction/Background/Objectives

Who is this person??

Why should I be listening to anything he has to say??

The Outpatient Anesthetic I Want You to Give Me

Introduction/Background/ObjectivesIntroduction/Background/ObjectivesMultimodal ApproachDrawbacks/ComplicationsDrawbacks/ComplicationsSummarySummary

Multimodal ElementsPre-Op Phone CallPre-Op Phone CallOral Pre-medsOral Pre-meds IV Pre-medsIV Pre-medsPONV ProphylaxisPONV ProphylaxisLocal/Regional/Nerve BlockLocal/Regional/Nerve BlockMaintenance AspectsMaintenance Aspects

Multimodal ElementsPre-Op Phone CallOral Pre-meds IV Pre-medsPONV ProphylaxisLocal/Regional/Nerve BlockMaintenance Aspects

Pre-Op Phone Call

Pediatric PatientsPediatric Patients Identify Pts at high risk or with PONV Identify Pts at high risk or with PONV

history history Identify Pts who need labs, tests, etc.Identify Pts who need labs, tests, etc.Agree on a plan and answer questionsAgree on a plan and answer questionsGive medication instructionsGive medication instructionsTalk about regional/PARQTalk about regional/PARQ Identify other problemsIdentify other problems

Multimodal ElementsPre-Op Phone CallOral Pre-meds IV Pre-medsPONV ProphylaxisLocal/Regional/Nerve BlockMaintenance Aspects

Oral Pre-meds

Clonidine .05 – 0.1 mg POClonidine .05 – 0.1 mg PO

Centrally acting ACentrally acting A22 antagonist antagonist

Mild pre-op sedationMild pre-op sedation

Narcotic and/or Vapor-sparing effectNarcotic and/or Vapor-sparing effect

Moderates hemodynamic responsesModerates hemodynamic responses

Less than $.05 per doseLess than $.05 per dose

Hypotension and/or bradycardiaHypotension and/or bradycardia

Oral Pre-meds

Celebrex(Celecoxib) 400 mg. POCelebrex(Celecoxib) 400 mg. PO

COX-2 inhibitorCOX-2 inhibitor

Anti-inflammatory effectAnti-inflammatory effect

Narcotic-sparing analgesic effectNarcotic-sparing analgesic effect

About $7 per dose (2 x 200mg caps)

Sulfa allergy concern

Multimodal ElementsPre-Op Phone CallOral Pre-meds IV Pre-medsPONV ProphylaxisLocal/Regional/Nerve BlockMaintenance Aspects

IV Pre-meds

Versed and FentanylVersed and Fentanyl

Why Bother???

Multimodal ElementsPre-Op Phone CallOral Pre-meds IV Pre-medsPONV ProphylaxisLocal/Regional/Nerve BlockMaintenance Aspects

PONV ProphylaxisMultimodal approachMultimodal approach

Ondansetron Ondansetron 5 HT-35 HT-3 $.25/dose$.25/doseScopolamine (IV)Scopolamine (IV) AnticholinergicAnticholinergic $1/dose$1/doseScopolamine (TD)Scopolamine (TD) AnticholinergicAnticholinergic $8-$9/dose$8-$9/doseDroperidolDroperidol ButyrophenoneButyrophenone $.40/dose$.40/dosePromethazine (IV)Promethazine (IV) H1 antagonistH1 antagonist $.50/dose$.50/dosePromethazine (Supp)Promethazine (Supp) H1 antagonistH1 antagonist $.50/dose$.50/doseMetoclopramideMetoclopramide Dopa antagonistDopa antagonist $.50/dose$.50/doseDexamethasoneDexamethasone CorticosteroidCorticosteroid $.12/dose$.12/doseSupplemental OSupplemental O22 ?????? PenniesPenniesDiprivanDiprivan ?????? $.20/dose$.20/dose

Transderm Scop

PONV ProphylaxisConsider no vapor: TIVA w/ Diprivan/UltivaConsider no vapor: TIVA w/ Diprivan/Ultiva

or Diprivan/fentanyl +/- Ketamineor Diprivan/fentanyl +/- Ketamine

Multimodal ElementsPre-Op Phone CallOral Pre-meds IV Pre-medsPONV ProphylaxisLocal/Regional/Nerve BlockMaintenance Aspects

Local/Regional/Nerve Block

Bier blockBier block Ilioinguinal nerve block (Inguinal Hernia)Ilioinguinal nerve block (Inguinal Hernia)Lumbar plexus block (ACL)Lumbar plexus block (ACL)Ankle block (Podiatry cases)Ankle block (Podiatry cases)Popliteal sciatic block (continuous?)Popliteal sciatic block (continuous?)Brachial plexus block (continuous?)Brachial plexus block (continuous?)Pain pump/catheterPain pump/catheterDon’t fear the outpatient spinalDon’t fear the outpatient spinal

Local/Regional/Nerve Block

Check out New York School of Regional Check out New York School of Regional Anesthesia at:Anesthesia at:

http://www.nysora.com/http://www.nysora.com/

Multimodal ElementsPre-Op Phone CallOral Pre-meds IV Pre-medsPONV ProphylaxisLocal/Regional/Nerve BlockMaintenance Aspects

Maintenance Aspects Suprane (Desflurane)Suprane (Desflurane) Ultiva (Remifentanyl)Ultiva (Remifentanyl)

Maintenance Aspects Both used at Both used at very low dosevery low dose::

~2–3% End tidal concentration for ~2–3% End tidal concentration for DesfluraneDesflurane

MAC Faceplate and low MAC dose for MAC Faceplate and low MAC dose for UltivaUltiva

But It Costs Too Much!!Remifentanly using MAC infusion plate:Remifentanly using MAC infusion plate:

70kg pt at 0.05 mcg/kg/min = 210mcg/hr70kg pt at 0.05 mcg/kg/min = 210mcg/hr

4+ hours per 1 mg vial4+ hours per 1 mg vial

1mg vial~ $32, so $8 - $10/hour1mg vial~ $32, so $8 - $10/hour

But It Costs Too Much!!Bottle acquisition cost comparison Bottle acquisition cost comparison

very misleadingvery misleading

Consider cost of lost time in OR Consider cost of lost time in OR and/or PACUand/or PACU

Desflurane at low flows and low dose is Desflurane at low flows and low dose is extremely cost effectiveextremely cost effective

Cost DeterminationSimplistic (and erroneous) approach:Simplistic (and erroneous) approach:

Suprane 240 ML’s Sevoflurane 250ML’sMAC = >6% MAC = 2%

Since Suprane’s MAC is 3X that of Ultane, it takes 3 bottles of Suprane toSince Suprane’s MAC is 3X that of Ultane, it takes 3 bottles of Suprane to

deliver the same number of anesthetic hours as a single bottle of Ultane. deliver the same number of anesthetic hours as a single bottle of Ultane.

==Suprane Price: $152.00 Ultane Price: $195.003 X $152.00 = $456.00 1 X $195.00 = $195.00

Cost DeterminationBottle cost/MAC comparison Bottle cost/MAC comparison

misleading for multiple reasons:misleading for multiple reasons:1. The agents are delivered as a gas, not a

liquid

15% more gas per ml of Suprane liquid

2. Ignores metabolism

5+% for Sevoflurane vs. 0.02% for Suprane

Cost Determination3. Ignores Solubility; Absorption by tissues

Tissue Desflurane Sevoflurane Difference

Blood/Gas .42 .65 55%

Brain/Gas 0.55 1.1 2x

Heart/Gas 0.55 1.1 2x

Liver/Gas 0.67 1.3 2x

Muscle/Gas 0.78 1.7 2x

Fat/Gas 13 37 3x

Cost Determination

4. Ignores Flow RatesFlow Rates can have a 10-fold

impact on the cost of delivering

modern inhaled anesthetics.

$$$$

Flow RatesYou really aren’t supposed to use flow You really aren’t supposed to use flow

rates less than 2liters/min with rates less than 2liters/min with Sevoflurane Sevoflurane

4, 3, 2, and even 1liters/min flow rates 4, 3, 2, and even 1liters/min flow rates waste money with Desfluranewaste money with Desflurane

Running low-flow, low-dose Desflurane Running low-flow, low-dose Desflurane forces you to forces you to pay attention in order to keep in order to keep

the patient the patient just deep enough

Airway Irritation with Desflurane

Airway Irritation with Desflurane

“Unlike Sevoflurane, Desflurane is pungent… Indeed, the pungency of Desflurane produces airway irritation and an appreciable incidence of salivation, breath-holding, coughing, or laryngospasm when >6% inspired Desflurane is administered to an awake patient.”

Eger, EI; 1994(from Stoelting)

Airway Irritation with Desflurane

“Desflurane does not cause (airway) irritation at concentrations below 6%... Administration of 1.8% to 5.4% desflurane for 30 min. to 10 young, healthy nonsmoking male volunteers was tolerated by all subjects and there was no breath-holding, coughing, salivation, laryngospasm, or bronchospasm….”

Eger, EI; 2002

DesfluraneAirway irritation/coughing/laryngospasmAirway irritation/coughing/laryngospasm

Not a Problem

Sample Case10/20/09

50 yo Female for bil. breast implant 50 yo Female for bil. breast implant removal/replacement with capsulectomiesremoval/replacement with capsulectomies

Scheduled for 120 minScheduled for 120 minPre- op phone call:Pre- op phone call:

PMH: 1ppd smokerPMH: 1ppd smokerPSH: Hyst, Breast biopsy x 3, Lapscope, PSH: Hyst, Breast biopsy x 3, Lapscope,

breast augmentation/mastopexy; no PONVbreast augmentation/mastopexy; no PONVMeds: Oxybutinin, topical metronidazoleMeds: Oxybutinin, topical metronidazoleAll: DarvocetAll: Darvocet

Sample Case PlanNo history of PONV or high risk surgeryNo history of PONV or high risk surgeryDexamethasone and Ondansetron for Dexamethasone and Ondansetron for

PONV prophylaxisPONV prophylaxisCan’t use regional or nerve block, but…Can’t use regional or nerve block, but…Field block and bil. catheter/pain pumpField block and bil. catheter/pain pumpOral pre-meds: Clonidine and CelebrexOral pre-meds: Clonidine and CelebrexNo IV pre-medsNo IV pre-medsGA w/ LMAGA w/ LMAMaintenance w/ Desflurane and UltivaMaintenance w/ Desflurane and Ultiva

Emergence and PACU

09:4009:40 D/C Ultiva and Desflurane, 10 l/minD/C Ultiva and Desflurane, 10 l/min

09:43 (3min)09:43 (3min) Eye opening and extubateEye opening and extubate

09:46 (6min)09:46 (6min) Moves self to stretcher, conversantMoves self to stretcher, conversant

09:52 (12 min)09:52 (12 min) Telling stories in PACU, denies painTelling stories in PACU, denies pain

10:02 (22 min)10:02 (22 min) Ambulates to BR, returns to reclinerAmbulates to BR, returns to recliner

10:10 (30 min)10:10 (30 min) Eating and drinkingEating and drinking

10:20 (40 min)10:20 (40 min) 50mcg Fentanyl, 1 Percocet for 4/10 pain50mcg Fentanyl, 1 Percocet for 4/10 pain

10:40 (60min)10:40 (60min) Coffee, dressed, dischargedCoffee, dressed, discharged

No Nausea, 1-2/10 pain on dischargeNo Nausea, 1-2/10 pain on discharge

PACU stay ~ 50 minPACU stay ~ 50 min

Sample Case 2 Inguinal Hernia with mesh

Celebrex and Clonidine PO pre-medsCelebrex and Clonidine PO pre-meds Ilioinguinal nerve block Ilioinguinal nerve block

(10 ml ¼% (10 ml ¼% Marcaine w/Epi)Marcaine w/Epi)

LMA General anesthesia LMA General anesthesia

w/ Ultiva and Desfluranew/ Ultiva and DesfluraneField block and supplemental local by Field block and supplemental local by

surgeonsurgeonDecadron and Ondansetron for PONVDecadron and Ondansetron for PONV

AgeAge FentanylFentanylOROR

OROR

TimeTimeFentanyl Fentanyl PACUPACU

DilauduidDilauduid

PACUPACU

VicodinVicodin

PACUPACUPACU PACU TimeTime

OR OR LocalLocal PONVPONV

6262 150150 3636 100100 11 22 6969 3030 NoNo

4545 7575 4545 5050 00 11 6464 3030 NoNo

8686 7575 6767 2525 00 11 6767 2525 NoNo

7070BB 7575 9898 00 00 11 8080 4040 NoNo

6262 5050 6666 00 00 11 7070 1515 NoNo

22 1*1* 6161 1*1* 00 00 5353 1010 NoNo

7272 100100 5555 100100 00 00 9191 3535 NoNo

AveAve 7575 6161 3535 7070 NoneNone

Last 7 consecutive cases; 7/6/09 – 10/16/09

The Outpatient Anesthetic I want You to Give Me

Introduction/Background/ObjectivesMultimodal ApproachDrawbacks/ComplicationsSummary

Drawbacks/Complications

More work, more energy, more timeMore work, more energy, more timeHypotension and/or bradycardiaHypotension and/or bradycardiaLight anesthesia/Awareness?Light anesthesia/Awareness? ‘‘Abrupt’ wake-up: Prepare to possibly Abrupt’ wake-up: Prepare to possibly

treat hypertension/tachycardiatreat hypertension/tachycardia

The Outpatient Anesthetic I want You to Give Me

Introduction/Background/ObjectivesMultimodal ApproachDrawbacks/ComplicationsSummary

Summary Invest the time: Call pts. and make a planInvest the time: Call pts. and make a planMinimize/avoid opioids and vapor if you canMinimize/avoid opioids and vapor if you can

(Local, Regional, Nerve Block, (Local, Regional, Nerve Block, Oral Premeds)Oral Premeds)PONV: Don’t wait to reactPONV: Don’t wait to reactConsider Desflurane and UltivaConsider Desflurane and Ultiva

Thank You!!!