1. Is One Anesthetic Technique Associated with Faster Recovery? Trey Bates, MD “Time Equals Money” Or

2. 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

3. 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?

4. 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

5. Premedication Your Thoughts?

6. 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

7. 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

8. Induction Your Thoughts?

9. Induction Propofol versus Sevoflurane –Thwaites, 1997 –Induction with Propofol then 2% Sevo Maintenance –Induction with 8% Sevo then 2% Sevo Maintenance

10. 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

11. Maintenance Your Thoughts?

12. 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

13. 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%)

14. 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

15. 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

16. Nitrous Oxide Your Thoughts?

17. 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

18. 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

19. 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

20. Supralaryngeal Airway Devices Your Thoughts?

21. 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

22. Opiods Your Thoughts?

23. 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

24. 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?

25. 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