Fast Tracking in
Ambulatory 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
Outline
• Anesthetic techniques
• Effective management of
– PONV
– Pain
– NMB
• Monitoring depth of anesthesia
• PACU fast track and discharge scoring systems
Freestanding ASCs in the United States
5000
4000
The number of
freestanding ASCs
jumped to 5,068 during
2005
3000
2000
1000
0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2005
Source: Verispan and William Blair & Co., LLC Estimates
RS Daniels, Outpatient Surgery;Jan 2006:108-111
Should you use intravenous of
inhalational anesthesia?
Inhalational vs. Intravenous
Anesthetic – Recovery Profile
min
* p<0.05
*
*
*
Tang et al. Anesthesiology 1999;91:253-61
Inhalational vs. Intravenous
Anesthetic – Recovery Profile
min
*
*
* p<0.05
*
Tang et al. Anesthesiology 1999;91:253-61
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
Propofol vs. Sevo vs. Des
Coloma et al. Anesth Analg 2001;93:112-5
TIVA (Prop/Remi) versus Desflurane
in Children ENT Procedures
Spon
Ventilation
Eye Opening
Aldrete Score
9
Agitation
Remifentanil
Propofol
11 ± 4 min
Desflurane
Nitrous
7 ± 3 min
11 ± 4 min
14 ± 7 min
17± 7 min
17 ± 7 min
44%
80%
Grundmann et al. Acta Anesth Scndinavica 1998;42:845-50
Larsen B et al. Anesth Analg 2000;90:168-74
• 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
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
General Anesthesia
vs.
Regional Anesthesia
• Outpatient hand surgery
• Randomized to
– GA – Propofol/Isoflurane/Fentanyl
– IVRA – 0.5% lidocaine
– Axillary Block – lidocaine/chlorrprocaine
• Regional groups received sedation with
propofol
Chan et al. Anesth Analg 2001;93:1181-4
Chan et al. Anesth Analg 2001;93:1181-4
Spinal vs. GA - Outcomes
Korhonen et al. anesth Analg 2004;99:1668-73
Spinal Anethesia vs.
Desflurane GA
Korhonen et al. anesth Analg 2004;99:1668-73
• 50 outpatients for open rotator cuff repair
• Randomized to
– Fast track GA with LA infiltration (bupivacaine
0.25%)
– 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
Hadzic A et al. Anesthesiology 2005;102:1001-7
Management of PONV
Functional Interference
Due to Nausea and/or Vomiting
White et al. Anesth Analg 2008;107:452-8
Emesis
Nausea
Functional Interference
Patients Who Experienced PONV, %
PONV Occurring in the PACU* and/or
Within 48 Hours After PACU Discharge
100
78%
80
60
40
20
36%
36%
0
Initial PONV in the PACU
(21/58)

Initial PONV in the PACU and/or
Within 48 Hours After PACU Discharge
(45/58)
Nearly 65% of patients did not experience PONV symptoms until after
discharge from the PACU.
* PACU=postanesthesia care unit.
Carroll NV et al. Anesth Analg. 1995;80:903–909.
PONV Risk Scores
%
Risk Factors
Points
Female
1
History of
PONV/motion
sickness
Postop Opioid
1
Non-Smoker
1
1
Apfel C, et al. Acta Anaesthesiol Scand 1998;42:495-501.
Cumulative Incidence of PONV
TDS + Ondansetron vs. Ondansetron
P<0.05
Gan et al. Anesth Analg 2009;108:1498 –504
Factorial Designed Trial:
6 Interventions for PONV Prevention
High-Risk PONV Patients (N=4,123)
• Results: PONV risk reduction
–
–
–
–
–
–
Ondansetron 26%
Dexamethasone 26%
Droperidol 26%
Propofol 19%
Nitrogen 12% (nitrous oxide exclusion)
Remifentanil not significant
Apfel CC, et al. N Engl J Med. 2004;350:2441-2451.
Factorial Designed Trial: Ondansetron,
Dexamethasone, and Droperidol
Incidence of Postoperative
Nausea and Vomiting (%)
Antiemetic Drug Combination Outcomes (N=5,161)
60
50
*
†
‡
40
*† *‡ †‡
30
20
10
0
0
1
2
No. of Antiemetics
3
Incidence for each
Average value for each
antiemetic or combination
number of antiemetics
*Ondansetron; †dexamethasone; ‡ droperidol.
Apfel CC, et al. N Engl J Med. 2004;350:2441-2451. Adapted with permission.
Algorithm for PONV Prophylaxis
Evaluate risk of PONV in surgical patient and patient’s concerns
Low
Moderate
No prophylaxis unless there
is medical risk of
sequelae from vomiting
High
Consider regional
anesthesia
Not Indicated
If general anesthesia is used, reduce baseline
risk factors when clinically practical &
•Avoid opioids (IIIA)
consider using nonpharmacologic therapies
•Avoid N2O (IIA)
Patients
at moderate
risk
•Avoid high dose
reversal
agent (IIA)
•Adequate
hydration
(IIIA)
Consider
antiemetic
prophylaxis
with monotherapy (adults) or
•Propofol anesthetic (IA)
combination therapy (children & adults)
Patients at high risk
Initiate combination therapy with
2 or 3 prophylactic agents
from different classes
Gan et al. Anesth Analg 2003;97:62-71Gan JAMA 2002;287:1233-6
Gan et al. A&A 2007;105:1615-28
Management of Pain
Postoperative Pain: All Patients
(in Hospital up to 2 Weeks)
100
1
90
2
83
% of patients
80
1999
1993
77
70
Patients’ worst pain
60
47 49
50
40
30
20
21 23
19
18
13
8
10
0
Any pain
1Apfelbaum,
Slight
pain
Moderate
pain
Severe
pain
Extreme
pain
Gan et al. Anesth Analg. 2003;97:534-40; 2Warfield et al. Anesthesiology. 1993
• 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
Long-Term Consequences of Acute Pain:
Potential for Progression to Chronic Pain
Sensitization
Surgery
or
injury
causes
inflammation
Structural
Remodeling
CNS
Peripheral
Peripheral
Nociceptive
Nociceptive
Fibers
Sustained
Fibers
currents
Transient
Activation
Neuroplasticity
Hyperactivity
Sustained
Activation
ACUTE
CHRONIC
PAIN
PAIN
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.
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
12%12
220
Caesarean section
Factors correlated with the development of post-surgical chronic pain1:
1. Nerve injury
2. Inflammation
3. Intense acute postoperative pain
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. O’Dwyer 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;131:12741280; 11. Bruce et al. Pain. 2003;104:265-273; 12. Nikolajsen et al. Acta Anaesthesiol Scand. 2004;48:111-116.
Multimodal or balanced
analgesia
Opioid
Potentiation
Conventional
NSAIDs/coxibs,
paracetamol,
 doses of each analgesic
Improved antinociception due to
synergistic/
additive effects
May  severity of side
effects of each drug
nerve blocks
Kehlet H, et al. Anesth Analg 1993;77:1048–56
Playford RJ, et al. Digestion 1991;49:198–203
Adjunctive Analgesics
• NSAIDs and COX-2 selective inhibitors (coxibs)
• Acetaminophen
• Local anesthetics
• Ketamine
• Gabapentin / pregabalin
• Clonidine / dexmedetomidine
• Steroids
• Non pharmacological techniques
•
•
•
•
•
•
52 RPCTs (~5000 patients)
Acetaminophen, NSAIDs or COX-2 inhibitors
Average morphine consumption – 49 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%
Morphine Consumption – 24 hours
Elia et al. Anesthesiology 2005;103:1296-1304
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 PACU – 89% to 92%
• Require opioid up to 7 days – 21% to 27%
• Persistent parasthesia 0.25%, resolved within 3 months
Klein et al. Anesth Analg 2002;94:65–70
Hadzic et al. Anesthesiology 2004;101:127-32
Ambulatory Infusion Pump
Management of
Neuromuscular
Blockade
Reversal of Rocuronium 0.45 mg/kg
Bevan JC et al. Anesth Analg 1999;89:333–339
Cisatracurium vs. Rocuronium
Cisatracurium Rocuronium
TOF  0.9 at
EOS
TOF at
reversal
EOS to
TOF = 0.9
27%
7%
63  7%
40 19%
10  9 min
18  13 min
Cammu et al. Eu J Anaesth 2002;19:129-34
Residual Paralysis
Time between the administration of a single dose of
NMB and the arrival in the PACU.
Debaene et al. Anesthesiology 2003;98:1042-8
Sugammadex
Angewandte Chemie 2002:41:266 -270
First Human Exposure to
ORG25969
• Gijsenbergh et al.
– 29 healthy men
– Anesthesia: propofol target-controlled infusion and
remifentanil
– Rocuronium 0.6mg/kg
– Placebo or sugammadex ranging from 0.1 to 8.0
mg/kg
Gijsenbergh, Francois Anesthesiology. 103(4):695-703, 2005.
Phase 1
Gijsenbergh, Francois Anesthesiology. 103(4):695-703, 2005.
Depth of Anesthesia Monitoring
CLINICAL UTILITY TRIAL:
EMERGENCE TIMES
Emergence Times
12
9
Standard
Practice
BIS
10
9
6
6
6
3
0
OPEN EYES
Gan TJ, et al. Anesthesiology, Oct. 1997.
RESPOND TO
COMMAND
* p < 0.001
CLINICAL UTILITY TRIAL:
PACU DISCHARGE TIME
Eligible for Discharge from PACU
40
Minutes
BIS
Patients
16%
Faster
than
Standard
Practice
35
30
25
20
Gan TJ, et al. Anesthesiology, Oct. 1997.
Standard Practice
BIS
37
31
CLINICAL UTILITY TRIAL:
DRUG USAGE
Total Propofol Used Per Case
1500
1250
1000
1252
964
750
Standard
Practice
BIS
500
250
* p <0.001
0
23% Less Propofol Used
Gan TJ, et al. Anesthesiology, Oct. 1997.
Average Score
CLINICAL UTILITY TRIAL:
BLINDED PACU ASSESSMENTS
Standard
Practice
1.7
2.1
* p < 0.001
1
Excellent
Oriented on Arrival
2
Good
Fast Recovery
Gan TJ, et al. Anesthesiology, Oct. 1997.
3
Fair
Slow Recovery
BIS
PACU Discharge Criteria
• PACU
Discharge
• Max 10
• Score ≥ 9
Aldrete JA. J Clin Anesth 1995;7:89-91
•
•
•
•
PADS
Max 10
Score ≥ 9
Fit for
discharge
Chung et al. J Clin Anesth 1995;80:896-902
• Eligible for fasttrack
• Score of ≥12
• No score < 1 in
any category
White et al. Anesth Analg 1999;88:1069-72
Factors Delaying Discharge
• Preoperative
– Female
– Increasing age
– CHF
• Intraoperative
– Long duration of surgery
– GA
– Spinal anesthesia
• Postoperative
–
–
–
–
Pain
PONB
Drowsiness
No escort
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 sex
– Spinal/epidural
– Duration of surgery > 60 min
– Intraoperative fluid > 750 mL
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
Questions