A 49-year-old woman presents for bilateral breast reduction. The patient has a history of significant severe post-operative nausea and vomiting requiring overnight hospitalization. In this case, however, the goal is to discharge her the same day.

Once the patient is in the OR and the requisite cardiac and respiratory monitors are attached, an additional monitor is placed on her forehead, which allows the anesthesiologist to measure depth of anesthesia and more accurately titrate drugs. He also places a small watch-like device on her wrist, which will help combat post-op nausea and vomiting. Throughout the procedure the surgeon administers local anesthetic at the surgical site, and at the end he inserts a pain pump, which will continue administering anesthetic medication for up to three days post-op.

After the surgery, the patient awakens in the OR and is assisted into a wheeled recliner, where she recovers uneventfully. She does not require any additional narcotics in the PACU, and she has no nausea. After one hour, she is discharged, having had an optimal surgical experience.

Whether this story seems routine or exceptional, it wouldn't have been possible five years ago. A combination of techniques and devices including depth of anesthesia monitors, pain pumps, non-pharmacologic treatment of post operative nausea and vomiting, and fast-tracking has made it possible for clinicians to help patients recover faster and have minimal pain and nausea after both simple and complex procedures. We've been using these methods for a few years now as part of our office-based anesthesia practice. In this article, I'll share how they've changed and improved the way we administer anesthesia.

1. Depth-of-anesthesia monitoring
Neurophysiologic monitors have stirred up a fair amount of controversy since Aspect Medical Systems introduced the bispectral index monitor (BIS) in 1996; some anesthesia providers feel they're indispensable, some doubt they work at all. There are currently two brands of monitors on the market-Physiometrix introduced its monitor, the PSA 4000, at last year's ASA meeting. Both devices work by analyzing EEG activity to monitor the patient's level of consciousness. Aspect recently received FDA approval for an upgrade to the BIS, which promises to give an enhanced signal in deep anesthetic states and minimize interference from electrocautery and motion.

We adopted BIS monitoring in March 1998. Since then, we have performed more than 4,000 anesthetics with it and have observed the following:

• We've decreased our overall propofol consumption by about 15 percent. Before BIS, an average induction dose of propofol was 1.5-2.0 mg/kg; but by titrating the dose following BIS, we've decreased this to 1.0-1.5 mg/kg. Our maintenance doses tend to run 10 to 15 percent lower when targeting BIS ranges of 55-65 (a BIS level of 98 indicates complete consciousness, 70-80 indicates a light hypnotic state, and 60 and below indicates unconsciousness). With one vial of propofol costing anywhere between $8 and $12, this translates into significant savings on drugs alone.1
• When we use the BIS, our patients wake up and meet discharge criteria significantly faster. We're therefore able to care for more patients with limited space and staff, which translates into cost and time savings.

The BIS does come with a significant price tag of up to $6,000, plus $12 to $20 for the single-use probes. However, the cost of the monitor can be defrayed by entering into a commitment to buy probes. The ultimate cost of probes under this arrangement will depend on their volume of use. We simply add the probe cost to the facility fee. We feel that the decreased drug costs, increased facility and staff efficiency, and patient and surgeon satisfaction make depth of anesthesia monitoring indispensable technology for our practice.

2. Local anesthetics and pain pumps
To provide patients with a pain-free surgical and post-operative experience, many anesthesia providers have adopted and/or encouraged surgeons to use local anesthetic infiltration. When we inject local anesthesia into or around the surgical area, we need less anesthesia for maintenance, we use fewer narcotics, and our patients wake up with little or no pain. Some practitioners have been so successful in convincing the surgeons they work with to use local anesthetics that they have been able to eliminate narcotics all together and enjoy a near-zero PONV rate.

Local anesthetic infiltration has its limitations, however. It typically wears off a few hours after surgery, requiring the patient to take opioids, such as Vicodin or Darvocet. These drugs cause side effects, such as nausea and vomiting.

Now, however, we can extend the benefits of local anesthesia for up to five days post-op by using pain pumps. These devices consist of a reservoir loaded with local anesthetic attached to an epidural catheter, which is placed into the surgical site. Initially developed for use after orthopedic procedures such as shoulder and knee surgeries, their use is now spreading to other surgical venues. In our practice, a plastic surgeon (Steven Bloch, MD, Highland Park Ill.) has been using pain pumps on patients undergoing breast augmentations, breast reductions and abdominoplasties. He uses Stryker pumps that hold 120cc of dilute bupivicaine and infuse at 2cc/hr (dj Orthopedics and Ethicon, as well as many other manufacturers, also make these devices). He's been doing this for over a year, and the results have been very impressive. Patients have been waking up virtually pain-free, requiring little to no medication in PACU and going home within one hour of their procedures. During the first three post-operative days, patients require little to no additional pain medication. Patient satisfaction is through the roof, and Dr. Bloch is rapidly developing a reputation for using this technique.

Because these are elective procedures, the surgeon is able pass the cost of the pump (which can be anywhere from $150 to $250 depending on manufacturer and volume of use) directly on to the patient. However, as more surgeons are adopting this technology, insurers are realizing that these devices can make it possible to turn procedures that were once only inpatient into outpatient procedures. Once insurers realize that pain pumps offer increased efficiency and reduced costs, obtaining reimbursement should be less of an issue.