1. Fast Tracking in Ambulatory Surgery
Prevention and Management of Anesthesia Awareness
October 2004
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
ADVANCED AWARENESS TRAINING MODULE

2. Prevention and Management of Anesthesia Awareness
Outline
October 2004
Anesthetic techniques
Effective management of
PONV
Pain
NMB
Monitoring depth of anesthesia
PACU fast track and discharge scoring systems
ADVANCED AWARENESS TRAINING MODULE

3. Freestanding ASCs in the United States
The number of freestanding ASCs jumped to 5,068 during 2005
Source: Verispan and William Blair & Co., LLC Estimates
RS Daniels, Outpatient Surgery;Jan 2006:

4. Should you use intravenous of inhalational anesthesia?

5. Inhalational vs. Intravenous Anesthetic – Recovery Profile
min
* p<0.05 * * *
Tang et al. Anesthesiology 1999;91:253-61

6. Inhalational vs. Intravenous Anesthetic – Recovery Profile
min *
* p<0.05 * *
Tang et al. Anesthesiology 1999;91:253-61

7. 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

8. Coloma et al. Anesth Analg 2001;93:112-5
Propofol vs. Sevo vs. Des
Coloma et al. Anesth Analg 2001;93:112-5

10. TIVA (Prop/Remi) versus Desflurane in Children ENT Procedures
Remifentanil
Propofol
Desflurane
Nitrous
Spon Ventilation
11 ± 4 min
7 ± 3 min
Eye Opening
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

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

13. Gupta et al. Anesth Analg 2004;98:632-41
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

14. 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

15. General Anesthesia vs. Regional Anesthesia

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

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

18. Korhonen et al. anesth Analg 2004;99:1668-73
Spinal vs. GA - Outcomes
Korhonen et al. anesth Analg 2004;99:

19. Spinal Anethesia vs. Desflurane GA
Korhonen et al. anesth Analg 2004;99:

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

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

22. Management of PONV

23. Functional Interference Due to Nausea and/or Vomiting
White et al. Anesth Analg 2008;107:452-8
Emesis
Nausea
Functional Interference
Patients who reported emesis experienced a median of at least 2 episodes. Patients experienced more frequent nausea than vomiting across all study intervals. Forty-four percent of the study population experienced interference with postoperative functioning due to nausea and/or vomiting during the 3-day post-surgical study period. This interference occurred for 29% of patients in the 0-6 h interval and for 35% in the 6 ‑ 72 h study interval.

24. PONV Occurring in the PACU* and/or Within 48 Hours After PACU Discharge
Carroll p905/T6/A
=58 patients w/ PONV
=45 45/58=78%
7+14=21 21/58=36% 20 40 60 80
100
78%
Patients Who Experienced PONV, %
36%
Carroll p905/T6/A
=58 patients w/ PONV
13+24=37 37/58=64%
36%
A study designed to evaluate PONV in patients receiving care at outpatient surgery centers provides valuable insight regarding the incidence of PONV. In this study, the incidence of PONV was measured in the recovery room, by telephone the day after discharge, and by a questionnaire patients were instructed to complete 5 days after discharge. The study enrolled adult patients (≥18 years of age) who were scheduled to receive general anesthesia and undergo 1 of 4 selected surgeries: laparoscopy, dilation and curettage (D&C), arthroscopy, or hernia repair. Among the 143 outpatients with complete data, the overall incidence of PONV was 41%.1
As shown in this figure, among patients who experienced PONV, the majority of PONV occurred initially within the first 48 hours after discharge from the postanesthesia care unit (PACU). In fact, only 36% of patients who experienced PONV did so initially in the PACU, whereas 78% of patients who experienced PONV did so initially in the PACU and/or within 48 hours after PACU discharge.1 Some patients who initially experienced PONV within 48 hours after PACU discharge continued to experience PONV for up to 5 days after PACU discharge.1
Also of interest is the emergence of PONV in patients who did not experience PONV in the recovery room. Nearly 65% of patients (37/58) with PONV did not experience symptoms until after discharge from the PACU.1
Carroll p903/A,C; p904/B,C
Initial PONV in the PACU
(21/58)
Initial PONV in the PACU and/or Within 48 Hours After PACU Discharge (45/58)
Carroll p903/C; p904/A
Carroll p905/T6/A
=58 patients w/ PONV
58/143=41%
Carroll p905/T6/A
=58 patients w/ PONV
=45 45/58=78%
7+14=21 21/58=36%
Nearly 65% of patients did not experience PONV symptoms until after discharge from the PACU.
Carroll p905/T6/A
=58 patients w/ PONV
13+24=37 37/58=64%
* PACU=postanesthesia care unit.
Carroll NV et al. Anesth Analg. 1995;80:903–909.
Reference:
1. Carroll NV, Miederhoff P, Cox FM, Hirsch JD. Postoperative nausea and vomiting after discharge from outpatient surgery centers. Anesth Analg. 1995;80:903–909.

25. Wengritzky et al. BJA 2010;104:158-66

26. Leslie et al. BJA 2009;101:

27. Apfel C, et al. Acta Anaesthesiol Scand 1998;42:495-501.
PONV Risk Scores %
Risk Factors
Points
Female 1
History of PONV/motion sickness
Postop Opioid
Non-Smoker
Apfel C, et al. Acta Anaesthesiol Scand 1998;42:

28. ODT – Post Discharge Incidence of Nausea and Emesis
% of Patients *
Gan et al. Anesth Analg 2002;94:

29. Cumulative Incidence of PONV TDS + Ondansetron vs. Ondansetron
1. Transderm Scop Phase IV Clinical Study Report
Page Table
Gan et al. Anesth Analg 2009;108:1498 –504

30. 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:

31. Factorial Designed Trial: Ondansetron, Dexamethasone, and Droperidol
Antiemetic Drug Combination Outcomes (N=5,161) 60 50 * † ‡ 40 *† *‡ †‡
Incidence of Postoperative Nausea and Vomiting (%) 30 20 10 3 2 1
No. of Antiemetics
Incidence for each antiemetic or combination
Average value for each number of antiemetics
*Ondansetron; †dexamethasone; ‡ droperidol Apfel CC, et al. N Engl J Med. 2004;350: Adapted with permission.

32. Algorithm for PONV Prophylaxis
Evaluate risk of PONV in surgical patient and patient’s concerns
Low
No prophylaxis unless there is medical risk of sequelae from vomiting
Moderate
High
Consider regional anesthesia
Not Indicated
If general anesthesia is used, reduce baseline risk factors when clinically practical & consider using nonpharmacologic therapies
Avoid opioids (IIIA)
Avoid N2O (IIA)
Avoid high dose reversal agent (IIA)
Adequate hydration (IIIA)
Propofol anesthetic (IA)
Patients at moderate risk
Consider antiemetic prophylaxis with monotherapy (adults) or 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

33. Gan et al. A&A 2007;105:

34. Management of Pain

35. Postoperative Pain: All Patients (in Hospital up to 2 Weeks)1 2
Patients’ worst pain
Any pain
Slight pain
Moderate pain
Severe pain
Extreme pain
1Apfelbaum, Gan et al. Anesth Analg. 2003;97:534-40; 2Warfield et al. Anesthesiology. 1993

36. Pavlin et al. Anesth Analg 2002;95:627-34
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

37. Structural Remodeling
Long-Term Consequences of Acute Pain: Potential for Progression to Chronic Pain
CNS
Neuroplasticity
Hyperactivity
Structural Remodeling
Sustained
Activation
Peripheral
Nociceptive
Fibers
Sensitization
Surgery or injury causes inflammation
Peripheral
Nociceptive
Fibers
Transient Activation
Sustained
currents
Changes in neuronal function following injury can take place at the level of the periphery, the spinal cord, and the brain, and may increase the magnitude of perceived pain and contribute to the development of chronic pain.1
Peripheral nociceptors can become more sensitive following repeated exposure to noxious stimuli due to release of chemical mediators from damaged cells following injury and inflammation, and alteration of sodium channel activity in the nociceptor membrane.2
Plastic changes in the spinal dorsal horn due to increased afferent input can also play a role in neuronal sensitization.1,2
High-frequency action potentials result in release of neuropeptides from the nociceptor central terminals in the spinal cord and subsequent modification of neuronal membrane excitability.2
The more intense the peripheral noxious stimulus, the higher the frequency and the longer the duration of the train of action potentials activated in the nociceptors.2
During the acute phase of central sensitization, release of transmitters from nociceptor central terminals in the dorsal horn causes changes in synaptic receptor density, as well as changes in the threshold and kinetics of neuronal activation. Together, these changes dramatically increase the efficiency of pain transmission.2
It should be noted that most of the available information regarding modulation of pain perception at the peripheral, spinal, and supraspinal levels is based on animal research. However, the few published human studies indicate that peripheral sensitization and central hyperexcitability may also be important determinants for acute and chronic pain in humans.1
CHRONIC
PAIN
ACUTE
PAIN
Woolf. Ann Intern Med. 2004;140:441; Petersen-Felix. Swiss Med Weekly. 2002;132: ; Woolf. Nature.1983;306: ; Woolf et al. Nature. 1992;355:75-8.
Petersen-Felix S, Curatolo M. Neuroplasticity--an important factor in acute and chronic pain. Swiss Med Wkly. 2002;132(21-22):
Woolf CJ. Pain: moving from symptom control toward mechanism-specific pharmacologic management. Ann Intern Med. 2004;140(6):

38. 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
Acute postoperative pain is followed by chronic pain after common procedures, the rate of which varies based on type of surgery.
Intensity of acute postsurgical pain has been correlated with the development of chronic postsurgical pain, as have other factors such as nerve injury and inflammation.
Factors correlated with the development of post-surgical chronic pain1:
Nerve injury
Inflammation
Intense acute postoperative pain
Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:
Hanley MA, Jensen MP, Smith DG, et al. Preamputation pain and acute pain predict chronic pain after lower extremity amputation. J Pain Feb;8:
Carpenter JS, Andrykowski MA, Sloan P, et al. Postmastectomy/postlumpectomy pain in breast cancer survivors. J Clin Epidemiol. 1998;51:
Poleshuck EL, Katz J, Andrus CH, et al. Risk factors for chronic pain following breast cancer surgery: a prospective study. J Pain Sep;7:
Katz J, Jackson M, Kavanagh BP, et al. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12:50-55.
Perttunen K, Tasmuth T, Kalso E. Chronic pain after thoracic surgery: a follow-up study. Acta Anaesthesiol Scand. 1999;43:
Massaron S, Bona S, Fumagalli U, et al. Analysis of post-surgical pain after inguinal hernia repair: a prospective study of 1,440 operations. Hernia. 2007;11:
O'Dwyer PJ, Kingsnorth AN, Molloy RG, et al. Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair. Br J Surg Feb;92(2):
Steegers MA, van de Luijtgaarden A, Noyez L, et al. The role of angina pectoris in chronic pain after coronary artery bypass graft surgery. J Pain. 2007;8:
Taillefer MC, Carrier M, Bélisle S, et al. Prevalence, characteristics, and predictors of chronic nonanginal postoperative pain after a cardiac operation: a cross-sectional study. J Thorac Cardiovasc Surg. 2006;131:
Bruce J, Drury N, Poobalan AS, et al. The prevalence of chronic chest and leg pain following cardiac surgery: a historical cohort study. Pain. 2003;104:
Nikolajsen L, Sørensen HC, Jensen TS, Kehlet H. Chronic pain following Caesarean section. Acta Anaesthesiol Scand. 2004;48:
1. Kehlet et al. Lancet. 2006;367: ; 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: ; 5. Katz et al. Clin J Pain. 1996;12:50-55; 6. Perttunen et al. Acta Anaesthesiol Scand. 1999;43: ; 7.Massaron et al. Hernia. 2007;11: ; 8. O’Dwyer et al. Br J Surg. 2005;92: ; 9. Steegers et al. J Pain. 2007;8: ; 10. Taillefer et al. J Thorac Cardiovasc Surg. 2006;131: ; 11. Bruce et al. Pain. 2003;104: ; 12. Nikolajsen et al. Acta Anaesthesiol Scand. 2004;48:

39. Multimodal or balanced analgesia
Opioid
 doses of each analgesic
Improved anti- nociception due to synergistic/ additive effects
May  severity of side effects of each drug
Potentiation
Conventional NSAIDs/coxibs,
paracetamol,
nerve blocks
Kehlet H, et al. Anesth Analg 1993;77:1048–56 Playford RJ, et al. Digestion 1991;49:198–203

40. Adjunctive Analgesics
NSAIDs and COX-2 selective inhibitors (coxibs)
Acetaminophen
Local anesthetics
Ketamine
Gabapentin / pregabalin
Clonidine / dexmedetomidine
Steroids
Non pharmacological techniques

41. Acetaminophen, NSAIDs or COX-2 inhibitors
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%

42. Morphine Consumption – 24 hours
Elia et al. Anesthesiology 2005;103:

43. 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

44. Hadzic et al Anesth Analg 2005;100:976–81

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

46. Ambulatory Infusion Pump

47. Management of Neuromuscular Blockade

48. Reversal of Rocuronium 0.45 mg/kg
3/25/2017
Recovery times after administration of a single dose of 0.45 mg/kg (1.5 × ED95) rocuronium. In one group (Spont), spontaneous recovery is allowed. In the remaining groups, 70 µg/kg neostigmine is administered 5 minutes after rocuronium or at 1%, 10%, and 25% recovery of the first twitch (T1) from its control value. *P < 0.01 versus spontaneous recovery. Note that times to attain a train-of-four ratio of 0.9 are significantly shorter when neostigmine is administered at T1 = 10% or 25% of control tension. (Figure constructed based on data redrawn from Bevan JC, Collins L, Fowler C, et al: Early and late reversal of rocuronium and vecuronium with neostigmine in adults and children. Anesth Analg 89:333–339, 1999.)
Bevan JC et al. Anesth Analg 1999;89:333–339

49. Cisatracurium vs. Rocuronium
TOF  0.9 at EOS
27% 7%
TOF at reversal
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

50. Assessment of NMB Recovery
Positive Predictive Value % (95 CI)
Negative Predictive Value % (95 CI)
TOF<0.7
TOF<0.9
Head lift 19
(15-23) 53
(47-58) 85
(81-89) 58
(52-63)
Tongue depressor 28
(23-33) 54
(48-59) 86
(83-90) 56
(51-62)
TOF 79
(75-82) 93
(91-94) 87
(84-90) 57
(53-61)
DBS 83
(78-86) 97
(95-98) 88
(85-90)
(54-62)
Debaene et al. Anesthesiology 2003;98:1042-8

51. 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.
Debaene et al. Anesthesiology 2003;98:1042-8

52. Sugammadex
Angewandte Chemie 2002:41:

53. 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): , 2005.

54. Phase 1 Gijsenbergh, Francois Anesthesiology. 103(4):695-703, 2005.
3/25/2017
Train-of-four tracing from one volunteer who participated during part 2 of the study. The blue line represents the height of the twitch, and the dashed red line is the value of the train-of-four ratio. The volunteer received 0.6 mg/kg rocuronium (Roc) followed by placebo at 3 min (A) in one treatment period, followed by 8 mg/kg Org in another treatment period (B). No recurarization was observed in the 90 min during which the neuromuscular block was monitored.
Gijsenbergh, Francois Anesthesiology. 103(4): , 2005.

55. Depth of Anesthesia Monitoring

56. CLINICAL UTILITY TRIAL: EMERGENCE TIMES
Prevention and Management of Anesthesia Awareness
CLINICAL UTILITY TRIAL: EMERGENCE TIMES
October 2004
minutes
* p < 0.001
As a result of decreased drug usage, patients woke up faster, they opened their eyes faster and they responded to verbal command faster. On average, emergence from anesthesia dropped from 10 minutes in the standard practice group to only 6 minutes in the BIS monitored group.
A common question is often asked, “what difference does 3 or 4 minutes make in emergence times”? This trial demonstrated that there were benefits beyond shaving a couple minutes off at the end of surgery. The more significant improvements result from reducing the outliers -- those patients that take an unusually long time to wake up
Gan TJ, et al. Anesthesiology, Oct
ADVANCED AWARENESS TRAINING MODULE

57. CLINICAL UTILITY TRIAL: PACU DISCHARGE TIME
Prevention and Management of Anesthesia Awareness
CLINICAL UTILITY TRIAL: PACU DISCHARGE TIME
October 2004
BIS Patients 16% Faster than Standard Practice
As a result of reduced drugs administered, faster emergence times and better global assessment scores in recovery, patients were eligible to leave the PACU 16% faster.
Gan TJ, et al. Anesthesiology, Oct
ADVANCED AWARENESS TRAINING MODULE

58. CLINICAL UTILITY TRIAL: DRUG USAGE
Prevention and Management of Anesthesia Awareness
CLINICAL UTILITY TRIAL: DRUG USAGE
October 2004 mg
In each of the next several slides, the yellow bar represents patients treated using the BIS monitor. The pink bar represents the standard practice group. Looking first at drug usage, the BIS patients, on average, received 23% less propofol.
* p <0.001
23% Less Propofol Used
Gan TJ, et al. Anesthesiology, Oct
ADVANCED AWARENESS TRAINING MODULE

59. CLINICAL UTILITY TRIAL: BLINDED PACU ASSESSMENTS
Prevention and Management of Anesthesia Awareness
October 2004
* p < 0.001
The patients that were monitored with the BIS during surgery in the multicenter clinical utility trial received a much better overall assessment score from the nurses in the recovery room. Many more BIS patients were rated “excellent to good” compared to “good to fair” in the standard practice group.
Excellent
Oriented on Arrival
Good
Fast Recovery
Fair
Slow Recovery
Gan TJ, et al. Anesthesiology, Oct
ADVANCED AWARENESS TRAINING MODULE

60. PACU Discharge Criteria

61. Aldrete JA. J Clin Anesth 1995;7:89-91
PACU Discharge
Max 10
Score ≥ 9
Aldrete JA. J Clin Anesth 1995;7:89-91

62. Chung et al. J Clin Anesth 1995;80:896-902
PADS
Max 10
Score ≥ 9
Fit for discharge
Chung et al. J Clin Anesth 1995;80:

63. White et al. Anesth Analg 1999;88:1069-72
Eligible for fast-track
Score of ≥12
No score < 1 in any category
White et al. Anesth Analg 1999;88:

64. Factors Delaying Discharge
Preoperative
Female
Increasing age
CHF
Intraoperative
Long duration of surgery GA
Spinal anesthesia
Postoperative
Pain
PONB
Drowsiness
No escort

65. 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

66. 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

67. Prevention and Management of Anesthesia Awareness
October 2004
Questions
ADVANCED AWARENESS TRAINING MODULE