Fast Track in Ambulatory Surgery-5!22!2010

7/30/2019 Fast Track in Ambulatory Surgery-5!22!2010

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Fast Tracking inAmbulatory 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


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Outline

Anesthetic techniques

Effective management of

PONV

Pain

NMB

Monitoring depth of anesthesia

PACU fast track and discharge scoring systems


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Freestanding 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 offreestanding ASCs

jumped to 5,068 during2005

Source: Verispan and William Blair & Co., LLC Estimates

RS Daniels, Outpatient Surgery;Jan 2006:108-111


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Inhalational vs. Intravenous

AnestheticRecovery Profile

** p


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Inhalational vs. Intravenous

AnestheticRecovery Profile

*

* p


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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


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Propofol vs. Sevo vs. Des

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


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TIVA (Prop/Remi) versus Desflurane

in Children ENT Procedures

Remifentanil

Propofol

Desflurane

Nitrous

SponVentilation

11 4 min 7 3 min

Eye Opening 11 4 min 14 7 min

Aldrete Score

9

17 7 min 17 7 min

Agitation 44% 80%

Grundmann et al. Acta Anesth Scndinavica 1998;42:845-50


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12/62Larsen B et al. Anesth Analg 2000;90:168-74


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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


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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


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General Anesthesia

vs.

Regional Anesthesia


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Outpatient hand surgery

Randomized to

GAPropofol/Isoflurane/Fentanyl

IVRA0.5% lidocaine

Axillary Blocklidocaine/chlorrprocaine

Regional groups received sedation with

propofol

Chan et al. Anesth Analg 2001;93:1181-4


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Chan et al. Anesth Analg 2001;93:1181-4


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Spinal vs. GA - Outcomes

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


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Spinal Anethesia vs.

Desflurane GA

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


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50 outpatients for open rotator cuff repair

Randomized to

Fast track GA with LA infiltration (bupivacaine0.25%)

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


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Hadzic A et al. Anesthesiology 2005;102:1001-7


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Management of PONV


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Functional Interference

Due to Nausea and/or Vomiting

Emesis Nausea Functional Interference

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


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PONV Occurring in the PACU* and/or

Within 48 Hours After PACU Discharge

* PACU=postanesthesia care unit.

Carroll NV et al. Anesth Analg. 1995;80:903909.

36%

Nearly 65% of patients did not experience PONV symptoms until afterdischarge from the PACU.

36%

Initial PONV in the PACU and/orWithin 48 Hours After PACU Discharge

(45/58)

Initial PONV in the PACU

(21/58)

78%

PatientsWhoExperiencedPONV,%

0

20

40

60

80

100


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PONV Risk Scores

Risk Factors Points

Female 1

History of

PONV/motion

sickness

1

Postop Opioid 1

Non-Smoker 1

%

Apfel C, et al. Acta Anaesthesiol Scand1998;42:495-501.


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Cumulative Incidence of PONV

TDS + Ondansetron vs. Ondansetron

P


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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:

6 Interventions for PONV Prevention

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


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*Ondansetron;

dexamethasone;

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

Factorial Designed Trial: Ondansetron,

Dexamethasone, and DroperidolAntiemetic Drug Combination Outcomes (N=5,161)

Average value for eachnumber of antiemetics

Incidence for eachantiemetic or combination

In

cidenceofPostoperative

NauseaandVomiting(%)

60

50

40

30

20

10

0

No. of Antiemetics

0 321

*

**

Al ith f PONV P h l i


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Algorithm for PONV Prophylaxis

Evaluate risk of PONV in surgical patient and patients concerns

Moderate High

Consider regionalanesthesia

Low

No prophylaxis unless thereis medical risk of

sequelae from vomiting Not Indicated

If general anesthesia is used, reduce baselinerisk 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


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


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Management of Pain


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Postoperative Pain: All Patients

(in Hospital up to 2 Weeks)

83

13

47

2118

77

19

49

23

8

0

10

20

30

40

50

60

70

80

90

100

%

ofpatie

nts

1999 1993

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


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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


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Sustained

currents

Peripheral

Nociceptive

Fibers

TransientActivation

ACUTEPAIN

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

injury

causesinflammation

Long-Term Consequences of Acute Pain:

Potential for Progression to Chronic Pain

Sustained

Activation

Peripheral

Nociceptive

Fibers

Sensitization

CHRONICPAIN

CNS

Neuroplasticity

Hyperactivity

StructuralRemodeling


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Acute Postoperative Pain Has Been Associated With

Chronic 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. 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;131:1274-1280; 11. Bruce et al. Pain. 2003;104:265-273; 12. Nikolajsen et al. Acta Anaesthesiol Scand. 2004;48:111-116.

Factors correlated with thedevelopment of post-surgical chronic pain1:

1. Nerve injury2. Inflammation

3. Intense acute postoperative pain

M lti d l b l d


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Kehlet H, et al. Anesth Analg 1993;77:104856

Playford RJ, et al. Digestion 1991;49:198203

Multimodal or balanced

analgesia

doses of each analgesic

Improved anti-

nociception due tosynergistic/

additive effects

May severity of sideeffects of each drug

Potentiation

Opioid

ConventionalNSAIDs/coxibs,

paracetamol,

nerve blocks


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Adjunctive Analgesics

NSAIDs and COX-2 selective inhibitors (coxibs)

Acetaminophen

Local anesthetics

Ketamine

Gabapentin / pregabalin

Clonidine / dexmedetomidine

Steroids

Non pharmacological techniques


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52 RPCTs (~5000 patients)

Acetaminophen, NSAIDs or COX-2 inhibitors

Average morphine consumption49 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%


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Morphine Consumption 24 hours

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

R i l A th i i


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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 PACU89% to 92%

Require opioid up to 7 days21% to 27%

Persistent parasthesia 0.25%, resolved within 3 months

Klein et al. Anesth Analg 2002;94:65

70


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


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Ambulatory Infusion Pump


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Management ofNeuromuscular

Blockade


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Reversal of Rocuronium 0.45 mg/kg

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

339


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Cisatracurium vs. Rocuronium

Cisatracurium Rocuronium

TOF 0.9 atEOS

27% 7%

TOF atreversal

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

R id l P l i


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Residual 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.


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Sugammadex

Angewandte Chemie 2002:41:266 -270


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First Human Exposure to

ORG25969

Gijsenbergh et al.

29 healthy men

Anesthesia: propofol target-controlled infusion andremifentanil

Rocuronium 0.6mg/kg

Placebo or sugammadex ranging from 0.1 to 8.0

mg/kg

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


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Phase 1

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


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Depth of Anesthesia Monitoring

CLINICAL UTILITY TRIAL


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Emergence Times

109

66

0

3

6

9

12

OPEN EYES RESPOND TO

COMMAND

Standard

PracticeBIS

* p < 0.001

CLINICAL UTILITY TRIAL:

EMERGENCE TIMES

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



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PACU DISCHARGE TIME

Eligible for Discharge from PACU

37

31

20

25

30

35

40

Minutes

Standard Practic

BIS

BIS

Patients16%Faster

thanStandardPractice




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Total Propofol Used Per Case

1252

964

0

250

500

750

1000

1250

1500

StandardPractice

BIS

23% Less Propofol Used


DRUG USAGE


* p


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2.1

1.7

1 2 3

Average

Score

StandardPractice

BIS

ExcellentOriented on Arrival

Good

Fast Recovery

Fair

Slow Recovery

* p < 0.001


BLINDED PACU ASSESSMENTS



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PACU Discharge Criteria


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PACU

Discharge

Max 10

Score 9

Aldrete JA. J Clin Anesth 1995;7:89-91


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PADS

Max 10

Score 9

Fit for

discharge

Chung et al. J Clin Anesth 1995;80:896-902


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Eligible for fast-

track

Score of 12

No score < 1 in

any category

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


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Factors Delaying Discharge

Preoperative

Female

Increasing ageCHF

Intraoperative

Long duration of surgeryGA

Spinal anesthesia

Postoperative

Pain

PONB

Drowsiness

No escort


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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 sexSpinal/epidural

Duration of surgery > 60 min

Intraoperative fluid > 750 mL


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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


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Questions

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Fast Track in Ambulatory Surgery-5!22!2010