.svg?sfvrsn=be606e78_3)
Fast-track anesthesia refers to the art and science of swiftly moving patients out of the OR and PACU and sending them home in increasingly shorter periods. But which anesthetic techniques and which induction agents are best suited for a fast-track regimen? And just how much more effective and efficient will getting patients in and out quicker make your surgical facility? We'll answer those questions and question a few answers as we separate fact from fiction when it comes to fast tracking outpatients.
Which techniques and agents?
Because of their rapid peak effect and metabolism, ultra-short-acting induction agents and narcotics let patients wake extremely clear-headed. Fast tracking allows quicker recovery and, with pre-emptive interventions, may result in less post-op pain and PONV. But there's a lack of consensus on the optimal anesthetic technique (general anesthesia, regional or local?) or choice of anesthetic agents (intravenous, volatile, muscle relaxant, local anesthetic or sympatholytic?).
Many outpatient surgical facilities prefer to use propofol for sedation and induction. Besides being easy to administer, propofol has a rapid onset and a short duration of action, low PONV and high patient acceptance. Inhalation anesthetics such as desflurane and sevoflurane are popular for maintenance of anesthesia, as they readily lend themselves to titration to achieve adequate depth of anesthesia. While propofol, desflurane and sevoflurane facilitate rapid emergence from anesthesia, there was no difference among these agents in later recovery end-points, including home-readiness or actual discharge time. [2-4]
Be aware that the rate-limiting steps of traditional PACU discharge protocols can easily negate the faster recovery conferred by these new drugs. Unless you modify your discharge protocols to let fast-track-qualified patients bypass phase I (PACU) recovery or undergo a shorter PACU stay, you won't fully enjoy the benefits of these newer and costlier agents.
Fast tracking could be especially important in the office-based setting, where there is usually significant streamlining of traditional recovery areas and personnel.[3] While it's common in the office setting to recover and discharge the patient in the OR, it's uncommon to have dedicated recovery personnel in the office. Recent studies suggest that improved titration using such EEG devices as BIS and PSA or other sedation-level and anesthesia-depth monitoring can facilitate the recovery process. Similarly, regional anesthesia techniques often are amenable to fast tracking. A recent study reports on the success of discharging patients with a pain pump supplying a continuous infusion of local anesthesia for up to two days after a peripheral nerve block.[5]
In addition to the anesthetic choice, clinicians (anesthesiologists and surgeons) are forced to think preemptively in the OR and address pain control and PONV prevention. Local infiltration has become an integral element in the fast-tracking process. That's because local anesthetic infiltrations at the surgical incision site reduces opioid consumption. This facilitates fast tracking by maintaining mental alertness, GI function and the patient's ability to ambulate. In addition, you should administer non-opioid analgesics for prevention of pain and antiemetic prophylaxis against PONV to patients you expect will undergo a fast-tracking recovery process.
Discharge criteria
To successfully fast track patients undergoing general anesthesia, you must modify your anesthetic techniques to let the patient rapidly achieve established PACU discharge criteria. Patients achieving Aldrete's score of 9 after emergence from anesthesia were considered bypass eligible,[6-7] but this scoring system was found to be too narrow because it failed to capture pain and emesis, side effects commonly seen and treated in the PACU.
In a study, White and colleagues developed an expanded fast-tracking scoring system, incorporating the essential elements of the modified Aldrete and means for assessing pain and emesis. Generally, you use the fast-tracking scoring tool 10 minutes after emergence and while the patient is still in the OR. An overall score of 12, with a minimum score of 1 in each category, is required for bypass.[8] While fast tracking is usually achieved by bypassing phase I (PACU) recovery, PACU fast tracking is emerging as a viable alternative, resolving bottleneck areas of the process.[9]
What Makes Fast Tracking Possible? |
For facility managers, chief among fast tracking's many benefits is eliminating unnecessary delays in discharge, and decreasing PACU nursing workload and costs. For patients, there's quicker recovery, and less post-op pain and PONV. Here are the advances that have made fast tracking possible:
|
Economic benefits?
You'd expect that significant economic benefits would accompany fast tracking's clinical advantages. But there's a wide disparity in financial benefits across institutions. Anesthesia-related costs comprise only a small fraction of the total costs of surgery and anesthesiologists have minimal impact on the more substantial PACU costs, the major component of which is personnel costs.[10-11]
Volume, personnel requirement, how you compensate your staff and efficiency in OR utilization will influence any decrease in the OR and PACU labor costs resulting from faster emergence and PACU bypassing. In a study, Dexter and colleagues showed that whether fast tracking lets a hospital reduce staffing costs depends heavily on the institutional labor payment structure.
Fast tracking can decrease your cost because less staffing time is required. Patients wake up more quickly and can leave the OR sooner. They might bypass, or stay in the PACU for a shorter time. If you pay staff an hourly rate and fast tracking reduces substantial overtime, the decrease in labor costs can be significant. If you pay staff a set salary, the timesavings may not translate into financial savings.[12] Even if you don't save much in costs, fast tracking will increase productivity.
Anesthesia monitors
You can prevent intraoperative awareness through a proper concentration of short-acting general anesthetics. Depths of anesthesia monitors can facilitate rapid-emergence PACU-bypass protocols. Use of BIS and PSA monitors seems to have enhanced practitioners' ability to accurately measure the levels of consciousness, resulting in significantly less drug use, faster emergence, faster post-anesthesia recovery times and improved PACU bypass rates.[13-14]
While BIS and PSA values have been correlated with the degree of sedation under IV hypnotics and inhalation agents, these EEG-based indices have been less useful in assessing the depth of anesthesia with opioid analgesics, ketamine and nitrous oxide.[15-16] Even with these monitors, residual sedation, weakness or shivering will prevent some fast-track-eligible patients from bypassing the PACU.[4]
Preventing post-operative complications is equally important to a successful ambulatory surgery fast-tracking program. Pain, nausea and vomiting are among the most common post-op complications that can impede the fast-tracking process. However, multimodal analgesic and antiemetic treatment regimens have proved useful in facilitating this process.[17-19]
The adjunctive use of such non-opioid analgesics as NSAIDs, COX-2 inhibitors and local anesthetics will minimize pain, opioid analgesic requirements and PONV.[20-23]
In addition, appropriate use of prophylactic antiemetic agents, along with adequate rehydration, will further improve recovery and patient outcome.[24-27]
|
10 Tips for Fast Tracking Outpatients |
Patients feel no pain, yet they respond to the surgeon's commands. And afterwards, they don't remember a thing. Welcome to the world of conscious sedation. Here are 10 pearls to fine-tune your regimen. 1. Eliminate benzodiazepines. Oral benzodiazepines were the mainstay of dental conscious sedation. IV Valium (diazepam) was replaced with IV Versed (midazolam) as part of the conscious sedation routine. The gastroenterologists, one of the highest volume providers of sedation, have relied upon traditional benzodiazepines with opioids for conscious sedation for endoscopic examinations. The GI docs now recognize that propofol, not benzodiazepine-opioid, is the most efficacious agent to speed patients through the system. In 1997, Oxorn, et. al, found that patients who received a 2mg midazolam premedication were three times more likely to request pain medication in the PACU. However, the midazolam-premedicated patient showed no propofol-sparing effect. It is a potentially dangerous practice to generously titrate benzodiazepines and subsequently rely on flumazenil, a benzodiazepine reversal agent, to offset overzealous benzodiazepine administration. The half-life of flumazenil is less than that of the benzodiazepines you seek to reverse. 2. C.O.Y.O.T.E. Call off your old tired ethos. Eliminate, not minimize, opioid administration. Five hundred years ago, it was an article of faith that the earth was flat. One observed the flat horizon and knew that if one sailed past it, one simply fell of the face of the earth. Today, we have a no less an absurd belief system perpetuating less-satisfactory PONV outcomes. Today's belief system states: 1) surgery is painful, 2) opioids are painkillers and 3) all surgery requires the use of some opioids. This syllogism is true only if PONV is not a concern. In 1999, Macario published a statistically validated survey that PONV is the No. 1 anesthesia outcome that patients most desire to avoid. 3. The answer to eliminating PONV is the elimination of opioids. Opioid-sensitive patients (female patients with previous PONV and/or motion sickness, for example) are the waiting bucket of gasoline. If you don't toss the match (opioids) into the bucket, you don't need to worry about which fire extinguisher (antiemetic) to administer. The point is, if you don't overmedicate, fast tracking takes care of itself. 4. Provide non-opioid, preemptive analgesia (NOPA) instead of opioids. Local analgesia in the form of lidocaine with epinephrine is far more effective than any systemic opioid for the prevention of pain. However, the injection itself is a very painful stimulus. Conscious sedation eschews general anesthesia as one means of suppressing the stimulus of the local anesthetic injection. Dissociative anesthesia is a well-published means of obviating the painful stimulus of the administration of local analgesia. 5. Post-operative pain management begins intra-operatively. Eliminating the noxious sensory input (the injection of local anesthesia) to the cortex while the patient is asleep is the first step to eliminating post-operative pain management issues. The brain cannot react to information it does not receive. Anesthesiologists and surgeons must think preemptively in the OR and address pain control and PONV prevention. 6. Ketamine is the only currently FDA-approved dissociative agent. Doesn't ketamine cause tachycardia, hypertension and hallucinations? Yes, but only if you administer ketamine as a sole agent or under circumstances insufficient to block these undesirable side effects. If you create the context of gradually titrated propofol hypnosis at BIS 70-75 before the administration of a 50mg dissociative dose of ketamine, you'll avoid all of the historically published side effects. Two minutes to three minutes after this dose of ketamine, the patient will remain immobile for the injection of local anesthesia for approximately 10 minutes to 20 minutes. 7. Monitor the organ you're trying to medicate. Traditionally, the anesthesia provider attempts to surmise how asleep the patient is by assessing the heart rate and blood pressure and their changes. Another archaic belief system was that changes in the patient's level of consciousness would be reflected in the heart rate and blood pressure. The work of Ira Rampil, MS, MD, shows that our best measure of comparative anesthetic potency (minimum alveolar concentration or MAC) is only a measure of comparative spinal cord activity. The brain is the anesthesiologist's target organ. The medications the professional anesthesia provider is administering aren't primarily designed to medicate the heart rate and blood pressure. Without measuring the level of consciousness, you can't differentiate patient movement originating from the spinal cord (meaning more local anesthesia) from patient movement originating in the brain (meaning more propofol). Level of consciousness monitoring is the only way to derive this information. 8. Differentiate the cause of patient movement. Medicate appropriately. All patients will exhibit movement with conscious sedation. Typically, the surgeon will exclaim, "The patient is too light." The anesthesiologist's rejoinder is typically, "He needs more local." Without the ability to measure either entity, you'll be trapped in a circular argument. If the BIS is 60-75 with an isoelectric EMG (adequate hypnosis), the patient needs more local while the anesthesiologist is giving a bit more propofol to suppress the patient's emergence. 9. Reinforce local analgesia. For the 3 Bs - brows, breasts and bellies - it is especially important for superior post-operative pain management to supplement intraoperative lidocaine with 0.25 percent bupivicaine.
In all three situations, it's imperative that no more than 50cc 0.25 percent (or 125mg) total bupivicaine be injected. If more is administered, cardiac toxicity may cause the demise of the patient. 10. Minimally invasive anesthesia (MIA) technique for minimally invasive surgery. The MIA technique or BIS-monitored propofol ketamine (PK) MAC has a proven record for safety, simplicity and satisfaction. By virtually eliminating the twin scourges of PONV and post-op pain management with non-opioid preemptive analgesia, the MIA technique has established an unprecedented record of superior outcomes. By speeding an uncomplicated emergence for ambulatory anesthesia, the MIA technique increases the efficiency of any facility. Increased facility efficiency translates into either shorter workdays or more cases per workday. Dr. Friedberg ([email protected]), founder of the Society for Office Anesthesiologists (SOFA), is currently writing McGraw-Hill's Anesthesia in Cosmetic Surgery, minimally invasive anesthesia (MIA) for minimally invasive surgery, due in the fall. |
Don't overlook risks
Implemented incorrectly, poorly planned or without clear-cut guidelines, fast tracking can backfire. Here are a few examples:
- There may be pressure to discharge patients to make room for incoming patients;
- PACU nurse ratios may be stretched beyond the limits of patient safety; and
- patients may go home feeling rushed or without a clear understanding of their post-op instructions.
Before you implement a fast-tracking program, your anesthesiologists should be educated on the use of the newer shorter-acting anesthetics, and you should have a mechanism in place for feedback for those times when patients don't progress as expected. If the PACU is becoming overloaded, be sure to keep the nursing ratios at a defined level. And finally, focus discharge criteria solely on the patient's status. Even if patients have met discharge criteria, routinely ask them whether they feel comfortable leaving the facility.
Experts agree that fast-track programs must establish well-defined criteria for both discharge and inclusion. Screen out those patients who are ineligible for fast-track care before the surgery is even scheduled. Examples include patients who lack coping skills, have complicated health problems or poor home-support systems.
You can minimize the risks associated with fast tracking, provided that all caregivers work together as a team. A free flow of information about the patients and the fast-tracking policies should begin from the pre-operative phase and continue through to discharge. Notwithstanding potential cost savings associated with fast tracking, clinicians must feel free to practice in an atmosphere without repercussions, with patient safety and comfort as paramount concerns.
References
1. White PF. Ambulatory anesthesia advances into the new millennium. Anesth Analg 2000;90:1234-5
2. Gupta A, et al. Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systemic review. Anesth Analg 2004;98(3):632-41
3. Tang J, Chen L, White PF, et al. Fast-track office-based anesthesia: a comparison of propofol versus desflurane with antiemetic prophylaxis in spontaneously breathing patients. Anesth Analg 2001;92:95-9
4. Coloma M, Zhou T, White PF, et al. Fast-tracking after outpatient laparoscopy: reasons for failure after propofol, sevoflurane, and desflurane anesthesia. Anesth Analg 2001;93:112-5
5. Hadzic A, Arliss J, Kerimoglu B, et al. A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries. Anesthesiology 2004;101:127-32
6. Aldrete JA. The post-anesthesia score revisited. J Clin Anesth 1995;7:89-91
7. Marshall SI, et al. Discharge criteria and complication after ambulatory surgery. Anesth Analg 1999;88:508-16
8. White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete"s scoring system. Anesth Analg 1999;88:1069-72
9. Watkins AC, White PF. Fast-tracking after ambulatory surgery. J Perianesth Nurs 2001;16:379-87
10. Macario A, Vitez TS, Dunn S, et al. Where are the costs in perioperative care? Analysis of hospital costs and charges for inpatient surgical care. Anesthesiology 1995;82:94-101
11. Dexter F, Tinker JH. Analysis of strategies to decrease postanesthesia care unit costs. Anesthesiology 1995;82:94-101
12. Dexter F, Macario A, Manberg PJ, et al. Computer simulation to determine how rapid anesthetic recovery protocols to decrease the time of emergence or increase phase I postanesthesia care unit bypass rate affect staffing of an ambulatory surgery center. Anesth Analg 1999;88:842-8
13. White PF, Ma H, Tang J, et al. Does the use of electroencephalographic bispectral index or auditory evoked potential index monitoring facilitate recovery after desflurane anesthesia in the ambulatory setting? Anesthesiology 2004;100(4):811-7
14. Pavlin DJ, et al. The effect of bispectral index monitoring on end-tidal gas concentration and recovery duration after outpatient anesthesia. Anesth Analg 2001;93:613-9
15. Kalkman CJ, et al. Monitors of depth of anesthesia, quo vadis? Anesthesiology 2002;96:784-7
16. Ahmad S, et al. Impact of bispectral index monitoring on fast-tracking of gynecologic patients undergoing laparoscopic surgery. Anesthesiology 2003;98:849-52
17. Michaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996; 82:44-51
18. Joshi GP. Pain management after ambulatory surgery. Ambulatory Surgery 1999;7:3-12
19. Scuderi PE, James RL, Harris L, et al. Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy. Anesth Analg 2000;91:1408-14
20. White PF. The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. Anesth Analg 2002;94:577-85
21. Ma H, et al. Perioperative rofecoxib improves early recovery after outpatient herniorrhaphy. Anesth Analg 2004;98:970-5
22. Recart A, et al. The efficacy of celecoxib premedication on postoperative pain and recovery times after ambulatory surgery: a dose-ranging study. Anesth Analg 2003;96:1631-5
23. Joshi GP, et al. Effective treatment of laparoscopic cholecystectomy pain with intravenous followed by oral COX-2 specific inhibitor. Anesth Analg 2003;98(2):336-42
24. Apfel C, Kortilla K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. NEJM 2004;350:2441-2451
25. White PF. Prevention of postoperative nausea and vomiting - a multimodal solution to a persistent problem Editorial). NEJM 2004;350(24):2511-2
26. Scuderi PE, et al. Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy. Anesth Analg 2000;91:1408-14
27. Yogendran S, Asokumar B, Cheng D, et al. A prospective, randomized double-blind study of the effect of intravenous fluid therapy on adverse outcomes after outpatient surgery. Anesth Analg 1995;80:682-6
.svg?sfvrsn=56b2f850_5)