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