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Umberham B, Hedin R, Detweiler B, Kollmorgen L, Hicks C, Vassar M. Heterogeneity of studies in anesthesiology systematic reviews: a meta-epidemiological review and proposal for evidence mapping. Br J Anaesth 2017; 119:874-884. [DOI: 10.1093/bja/aex251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2017] [Indexed: 01/25/2023] Open
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Shapiro FE, Punwani N, Rosenberg NM, Valedon A, Twersky R, Urman RD. Office-based anesthesia: safety and outcomes. Anesth Analg 2014; 119:276-285. [PMID: 25046785 DOI: 10.1213/ane.0000000000000313] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.
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Affiliation(s)
- Fred E Shapiro
- From the Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia; Department of Family Medicine and Community Health, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts; First Colonies Anesthesia Associates, Frederick, Maryland; Department of Anesthesiology, SUNY Downstate Medical Center, Brooklyn, New York; and Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts
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Kumar G, Stendall C, Mistry R, Gurusamy K, Walker D. A comparison of total intravenous anaesthesia using propofol with sevoflurane or desflurane in ambulatory surgery: systematic review and meta-analysis. Anaesthesia 2014; 69:1138-50. [DOI: 10.1111/anae.12713] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2014] [Indexed: 11/30/2022]
Affiliation(s)
- G. Kumar
- Department of Anaesthesia and Intensive Care; University College London Hospitals NHS Foundation Trust; London UK
- Department of Peri-operative Medicine; University College London; London UK
| | - C. Stendall
- Department of Anaesthesia and Intensive Care; University College London Hospitals NHS Foundation Trust; London UK
| | - R. Mistry
- Department of Peri-operative Medicine; University College London; London UK
| | - K. Gurusamy
- Division of Surgery; University College London; London UK
| | - D. Walker
- Department of Anaesthesia and Intensive Care; University College London Hospitals NHS Foundation Trust; London UK
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Arora SS, Gooch JL, García PS. Postoperative cognitive dysfunction, Alzheimer's disease, and anesthesia. Int J Neurosci 2013; 124:236-42. [PMID: 23931049 DOI: 10.3109/00207454.2013.833919] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although aging itself is not a disease, there are many comorbidities that become more common with aging. Heart disease, cancer, and other chronic illnesses are either more common or more severe in aging patients. Approximately 5.5 million people in the United States have Alzheimer's disease (AD), with the principal risk factor being age. It is estimated that the incidence of AD diagnosis doubles every 5 years after the age of 65. Therefore, as the population ages, the impact of AD on the healthcare landscape will increase. Understanding how to manage patients with AD is critical as we begin to care for more elderly patients in the perioperative period. In addition to their other health considerations, aging surgical patients are increasingly more likely to have pre-existing AD or be at risk for developing AD. There is growing interest to determine how anesthesia affects the development or progression of AD. Similarly, a best practice for the anesthetic management of patients with AD is not yet defined. Finally, the relationship between AD and susceptibility to or exacerbation of postoperative cognitive dysfunction (POCD) is not well understood. In this review, we will discuss both the clinical and the preclinical data related to anesthesia and AD, describe the overlapping pathophysiology of neurodegeneration and provide some insight into the anesthetic care of patients with AD.
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Affiliation(s)
- Sona S Arora
- 1Department of Anesthesiology, Emory University School of Medicine , Atlanta, GA , USA
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Hausman LM, Dickstein EJ, Rosenblatt MA. Types of office-based anesthetics. THE MOUNT SINAI JOURNAL OF MEDICINE, NEW YORK 2012; 79:107-115. [PMID: 22238043 DOI: 10.1002/msj.21285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Over the past several decades, there have been evolutionary changes in both surgery and anesthesia. Newer anesthetics have excellent safety profiles and are associated with fewer hemodynamic side effects and rapid elimination from the body. Innovative surgical techniques are less invasive and cause less perioperative patient pain. These developments have fueled the growth of office-based surgery and anesthesia. All types of anesthesia, including local, monitored anesthesia care, general, and regional anesthesia, have been used safely within the private practitioner's office. Because of the remote nature of the private surgeon's office, the proper selection of both patient and procedure to be performed is of utmost importance. It is likewise imperative that the practitioner assures that the patient does not experience excessive postoperative pain and/or nausea and vomiting. It is of the utmost importance that the practicing anesthesiologist assure that every location in which procedures and surgeries are performed is a safe anesthetizing location.
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Wachtel RE, Dexter F, Epstein RH, Ledolter J. Meta-analysis of desflurane and propofol average times and variability in times to extubation and following commands. Can J Anaesth 2011; 58:714-24. [DOI: 10.1007/s12630-011-9519-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 05/12/2011] [Indexed: 11/28/2022] Open
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Al Todd N. Desflurane why this choice? BMC Geriatr 2010. [PMCID: PMC3290314 DOI: 10.1186/1471-2318-10-s1-l70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Comparison of paravertebral block versus fast-track general anesthesia via laryngeal mask airway in outpatient inguinal herniorrhaphy. J Anesth 2010; 24:687-93. [DOI: 10.1007/s00540-010-0966-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 04/28/2010] [Indexed: 01/08/2023]
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Abstract
PURPOSE OF REVIEW Improving perioperative efficiency and throughput has become increasingly important in facilitating the fast-track recovery process following ambulatory surgery. This review focuses on the important role played by the anesthesiologist as a perioperative physician in fast-track ambulatory surgery. RECENT FINDINGS A literature review of more than 200 peer-reviewed publications was used to develop evidence-based recommendations for optimizing recovery following ambulatory anesthesia. The choice of anesthetic technique should be tailored to the needs of the patient as well as the type of surgical procedure being performed in the ambulatory setting. The anesthetic decisions made by the anesthesiologist, as a key perioperative physician, are of critical importance in developing a successful fast-track ambulatory surgery program. SUMMARY The pivotal role played by the anesthesiologist as the key perioperative physician in facilitating the recovery process has assumed increased importance in the current outpatient fast-track recovery environment. The choice of premedication, anesthetic, analgesic and antiemetic drugs, as well as cardiovascular, hormonal and fluid therapies, can all influence the ability to fast-track outpatients after ambulatory surgery.
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. MEE, . MDR, . MSAK, . MSA. A Comparison of the Effects of Epidural Anesthesia, Lumbar Paravertebral Block and General Anesthesia in Percutaneous Nephrolithotomy. JOURNAL OF MEDICAL SCIENCES 2008. [DOI: 10.3923/jms.2008.170.176] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F. The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care. Anesth Analg 2007; 104:1380-96, table of contents. [PMID: 17513630 DOI: 10.1213/01.ane.0000263034.96885.e1] [Citation(s) in RCA: 247] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Improving perioperative efficiency and throughput has become increasingly important in the modern practice of anesthesiology. Fast-track surgery represents a multidisciplinary approach to improving perioperative efficiency by facilitating recovery after both minor (i.e., outpatient) and major (inpatient) surgery procedures. In this article we focus on the expanding role of the anesthesiologist in fast-track surgery. METHODS A multidisciplinary group of clinical investigators met at McGill University in the Fall of 2005 to discuss current anesthetic and surgical practices directed at improving the postoperative recovery process. A subgroup of the attendees at this conference was assigned the task of reviewing the peer-reviewed literature on this topic as it related to the role of the anesthesiologist as a perioperative physician. RESULTS Anesthesiologists as perioperative physicians play a key role in fast-track surgery through their choice of preoperative medication, anesthetics and techniques, use of prophylactic drugs to minimize side effects (e.g., pain, nausea and vomiting, dizziness), as well as the administration of adjunctive drugs to maintain major organ system function during and after surgery. CONCLUSION The decisions of the anesthesiologist as a key perioperative physician are of critical importance to the surgical care team in developing a successful fast-track surgery program.
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Affiliation(s)
- Paul F White
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas, USA.
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Camci E, Koltka K, Celenk Y, Tugrul M, Pembeci K. Bispectral index-guided desflurane and propofol anesthesia in ambulatory arthroscopy: comparison of recovery and discharge profiles. J Anesth 2006; 20:149-52. [PMID: 16633779 DOI: 10.1007/s00540-005-0376-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Accepted: 12/10/2005] [Indexed: 11/30/2022]
Abstract
In this prospective, randomized study we compared the recovery profiles of bispectral index (BIS)-guided anesthesia regimens with desflurane or propofol in ambulatory arthroscopy. Fifty ASA I-II adult patients who underwent knee arthroscopy were randomized to receive desflurane (D) or propofol (P) infusion accompanied by remifentanil and nitrous oxide during maintenance, titrated to maintain a bispectral index value between 50 and 60. Initial awakening, fast-track eligibility, and home readiness as well as intraoperative hemodynamics, were compared. The groups did not differ with respect to demographics, duration of operation, or intraoperative vital signs. Although the times for initial awakening parameters were shorter in group D, the differences between the groups were not significant. The time needed for the White fast-track score to reach 12 was shorter in group P than group D (9 +/- 3.5 min vs 12.5 +/- 5.3 min). However, home readiness did not differ significantly between the groups. Desflurane is an alternative to propofol for BIS-guided ambulatory anesthesia. Using desflurane in combination with opioid analgesics blunted its rapid emergence characteristics, and the higher frequency of emetic symptoms with desflurane diminished the success of its fast-track eligibility.
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Affiliation(s)
- Emre Camci
- Department of Anesthesiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Sivaci R, Orman A, Yilmazer M, Yilmaz S, Ellidokuz H, Polat C. The effect of low-flow sevoflurane and desflurane on pulmonary mechanics during laparoscopic surgery. J Laparoendosc Adv Surg Tech A 2005; 15:125-9. [PMID: 15898901 DOI: 10.1089/lap.2005.15.125] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This study was designed to investigate the effects of inhaled anesthetic agents on respiratory mechanics with low flow anesthesia in laparoscopic abdominal surgery. Two inhaled anesthetics, desflurane and sevoflurane, have a lower solubility in blood and tissues than all previous volatile anesthetics, and have become the preferred volatile anesthetics for routine surgical procedures. METHODS Twenty-six patients were examined. Patients were randomly assigned to two groups, to receive sevoflurane (n = 13) or desflurane (n = 13). Tidal volume and ventilation rate were kept unchanged throughout the operation. Intra-abdominal pressure was kept constant at the level of 12 mm Hg. Respiratory mechanics such as peak inspiratory pressure (PIP), respiratory resistance (Rr), and dynamic compliance (Cdyn) measurements were recorded by a Datex-Ohmeda respiratory device (Datex-Ohmeda, Finland) at four timepoints: 5 minutes after mechanical ventilation started (T1), after insufflation of the peritoneum (T2), in the 30-degree Trendelenburg position (T3), and after desufflation of the peritoneum (T4). RESULTS In our study, desflurane caused a statistically significant increase in PIP and Rr and decrease in C(dyn). When the two groups were compared, Rr values in the deslurane group showed significant increases at T2, T3, and T4 compared to the sevoflurane group (P < 0.05). These values did not change in the sevoflurane group, while PIP significantly increased at T2, T3, and T4 after desufflation in the desflurane group (P < 0.05). Cdyn values decreased significantly at all 4 timepoints in the desflurane group compared to the sevoflurane group (P < 0.05). CONCLUSION We concluded that respiratory mechanics were affected by desflurane with low flow anesthesia in patients undergoing laparoscopic abdominal surgery. No significant influence on respiratory mechanics was seen with sevoflurane anesthesia.
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Affiliation(s)
- Remziye Sivaci
- Department of Anesthesiology and Re-animation, Kocatepe University, Afyon, Turkey.
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Update on ambulatory anesthesia. Can J Anaesth 2005. [DOI: 10.1007/bf03023085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Hadzic A, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, Claudio R, Vloka JD, Santos AC, Thys DM. Peripheral Nerve Blocks Result in Superior Recovery Profile Compared with General Anesthesia in Outpatient Knee Arthroscopy. Anesth Analg 2005; 100:976-981. [PMID: 15781509 DOI: 10.1213/01.ane.0000150944.95158.b9] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It has been suggested that use of peripheral nerve blocks (PNBs) may have some potential benefits in the outpatient setting. There have been no studies specifically comparing PNBs performed with short-acting local anesthetics with general anesthesia (GA) in patients undergoing outpatient knee surgery. We hypothesized that a combination of lumbar plexus and sciatic blocks using a short-acting local anesthetic will result in shorter time-to-discharge-home as compared with GA. Patients scheduled to undergo knee arthroscopy were randomized to receive a GA (midazolam, fentanyl, propofol, N(2)O/O(2)/desflurane via laryngeal mask airway) or lumbar plexus/sciatic block (PNBs; 2-chloroprocaine). Patients given GA also received an intraarticular injection of 20 mL 0.25% bupivacaine for postoperative pain control. Patients in the PNB group were given midazolam (up to 4 mg) and alfentanil (500-750 microg) before block placement and propofol 30-50 microg . kg(-1) . min(-1) for intraoperative sedation. Relevant perioperative times, postanesthesia care unit bypass rate, severity of pain, and incidence of complications were compared between the two groups. Fifty patients were enrolled in the study; 25 patients each received GA or PNBs. Total operating room time did not differ significantly between the 2 groups (97 +/- 37 versus 91 +/- 42 min). Seventy-two percent of patients receiving PNB met criteria enabling them to bypass Phase I postanesthesia care unit compared with only 24% of those receiving GA (P < 0.002). Time to meet criteria for discharge home (home readiness) and time to actual discharge were significantly shorter for patients given PNBs than for patients given GA (131 +/- 62 versus 205 +/- 94 and 162 +/- 71 versus 226 +/- 96, respectively). Under the conditions of our study, the combination of lumbar plexus and sciatic blocks with 2-chloroprocaine 3% was associated with a superior recovery profile compared with GA in patients having outpatient knee arthroscopy.
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Affiliation(s)
- Admir Hadzic
- Department of Anesthesiology, St. Luke's-Roosevelt Hospital Center, College of Physicians and Surgeons of Columbia University, New York, New York
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Millar J. II. Fast-tracking in day surgery. Is your journey to the recovery room really necessary? Br J Anaesth 2004; 93:756-8. [PMID: 15533955 DOI: 10.1093/bja/aeh277] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Korhonen AM, Valanne JV, Jokela RM, Ravaska P, Korttila KT. A Comparison of Selective Spinal Anesthesia with Hyperbaric Bupivacaine and General Anesthesia with Desflurane for Outpatient Knee Arthroscopy. Anesth Analg 2004; 99:1668-1673. [PMID: 15562051 DOI: 10.1213/01.ane.0000139351.40608.05] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this randomized and controlled trial, 64 adult ambulatory knee arthroscopy patients received either selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane. We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities, a shorter stay in the postanesthesia care unit, and earlier discharge home compared with GA with desflurane. Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group. No difference was seen in the fast-tracking possibilities or time in the postanesthesia care unit between the groups. Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS) in the SSA and GA groups, respectively. In the hospital, the pain scores were significantly (P < 0.001) lower in the SSA group compared with the GA group and the need for postoperative opioids was significantly (P = 0.008) larger after GA. The incidence of postoperative nausea and vomiting was 0% versus 19% in the SSA and GA groups (P = 0.024), respectively. We conclude that for outpatients undergoing knee arthroscopy, SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane.
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Affiliation(s)
- Anna-Maija Korhonen
- *Department of Anaesthesia, Lapland Central Hospital, Rovaniemi, Finland; †Department of Anaesthesia and Intensive Care, University of Helsinki, Helsinki, Finland
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White PF. Prevention of postoperative nausea and vomiting--a multimodal solution to a persistent problem. N Engl J Med 2004; 350:2511-2. [PMID: 15190144 DOI: 10.1056/nejme048099] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Caloss R, Lard MD. Anesthesia for office-based facial cosmetic surgery. Atlas Oral Maxillofac Surg Clin North Am 2004; 12:163-77. [PMID: 15062341 DOI: 10.1016/j.cxom.2003.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Ron Caloss
- Baptist Memorial Hospital-Golden Triangle, 2520 5(th) Street, Columbus, MS 39701, USA.
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Gupta A, Stierer T, Zuckerman R, Sakima N, Parker SD, Fleisher LA. Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review. Anesth Analg 2004; 98:632-41, table of contents. [PMID: 14980911 DOI: 10.1213/01.ane.0000103187.70627.57] [Citation(s) in RCA: 215] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED In this systematic review we focused on postoperative recovery and complications using four different anesthetic techniques. The database MEDLINE was searched via PubMed (1966 to June 2002) using the search words "anesthesia" and with ambulatory surgical procedures limited to randomized controlled trials in adults (>19 yr), in the English language, and in humans. A second search strategy was used combining two of the words "propofol," "isoflurane," "sevoflurane," or "desflurane". Screening and data extraction produced 58 articles that were included in the final meta-analysis. No differences were found between propofol and isoflurane in early recovery. However, early recovery was faster with desflurane compared with propofol and isoflurane and with sevoflurane compared with isoflurane. A minor difference was found in home readiness between sevoflurane and isoflurane (5 min) but not among the other anesthetics. Nausea, vomiting, headache, and postdischarge nausea and vomiting incidence were in favor of propofol compared with isoflurane (P < 0.05). A larger number of patients in the inhaled anesthesia groups required antiemetics compared with the propofol group. We conclude that the differences in early recovery times among the different anesthetics were small and in favor of the inhaled anesthetics. The incidence of side effects, specifically postoperative nausea and vomiting, was less frequent with propofol. IMPLICATIONS A systematic analysis of the literature comparing postoperative recovery after propofol, isoflurane, desflurane, and sevoflurane-based anesthesia in adults demonstrated that early recovery was faster in the desflurane and sevoflurane groups. The incidence of nausea and vomiting were less frequent with propofol.
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Affiliation(s)
- Anil Gupta
- Department of Anesthesiology and Critical Care, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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Affiliation(s)
- Barry L Friedberg
- University of Southern California, Los Angeles, Corona del Mar, CA 92625, USA
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Bibliography Current World Literature. Curr Opin Anaesthesiol 2003. [DOI: 10.1097/01.aco.0000084472.59960.ce] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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White PF, Rawal S, Nguyen J, Watkins A. PACU fast-tracking: an alternative to "bypassing" the PACU for facilitating the recovery process after ambulatory surgery. J Perianesth Nurs 2003; 18:247-53. [PMID: 12923752 DOI: 10.1016/s1089-9472(03)00187-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This retrospective evaluation assessed the impact of discharging outpatients home directly from the PACU as an alternative to "PACU bypassing." A total of 1,380 outpatients who had undergone minor ambulatory procedures were evaluated. Nine hundred fifty-two outpatients were admitted to a designated PACU fast-tracking area to facilitate an earlier discharge. Of the outpatients admitted to the PACU fast-track area, 88% were discharged home within 60 minutes (mean time [+/- SD] of 58 +/- 8 minutes]. The remaining 12% were discharged home from the PACU in an average of 88 (+/- 12) minutes. The recovery times for the 428 outpatients who were initially considered for the PACU fact-tracking program but were admitted to the regular PACU and recovered according to the conventional (two-step) pathway were 38 +/- 25 minutes in the PACU, followed by 61 +/- 32 minutes in the day surgery step-down unit. We conclude that this pilot program demonstrates the feasibility of discharging patients home from the PACU. Only 12% of the outpatients who were admitted to the PACU fast-track area failed to be discharged within 60 minutes. The overall times to discharge from the PACU fast-track area compared favorably to discharge times for outpatients bypassing the PACU. This program provides nurses with an alternative recovery pathway for fast-tracking patients after ambulatory surgery.
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Affiliation(s)
- Paul F White
- Department of Anesthesiology and Pain Management at the University of Texas Southwestern Medical Center at Dallas, 75390-9068, USA.
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Joshi GP. Inhalational techniques in ambulatory anesthesia. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2003; 21:263-72. [PMID: 12812394 DOI: 10.1016/s0889-8537(02)00074-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In the current health care environment, anesthesia practitioners are frequently required to reevaluate their practice to be more efficient and cost-effective. Although IV induction with propofol and inhalational induction with sevoflurane are both suitable techniques for outpatients, patients prefer IV induction. Maintenance of anesthesia with the newer inhaled anesthetics (ie, desflurane and sevoflurane) provide for a rapid early recovery as compared with infusion of propofol (ie, TIVA), while allowing easy titratability of anesthetic depth. Titration of hypnotic sedatives using BIS monitoring may reduce the time to awakening and thereby may facilitate fast tracking (ie, bypassing the PACU) and reduce hospital stay. Inhalational anesthesia is associated with a higher incidence of PONV, but no differences have been demonstrated with respect to late recovery (eg, PACU stay and home readiness). Although clinical differences between desflurane and sevoflurane appear to be small, desflurane may be associated with faster emergence, particularly in elderly and morbidly obese patients. Balanced anesthesia with IV propofol induction and inhalation anesthesia with N2O for maintenance, and an LMA for airway management, may be an optimal technique for ambulatory surgery. Inhalational anesthesia may have an economic advantage over a TIVA technique.
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Affiliation(s)
- Girish P Joshi
- Perioperative Medicine and Ambulatory Anesthesia, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235-9068, USA.
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White PF, Eshima RW, Maurer A, King T, Lin BK, Heavner JE, Bogetz MS, Kaye AD. A comparison of airway responses during desflurane and sevoflurane administration via a laryngeal mask airway for maintenance of anesthesia. Anesth Analg 2003; 96:701-705. [PMID: 12598249 DOI: 10.1213/01.ane.0000048978.40522.ab] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPLICATIONS Although sevoflurane is less pungent than desflurane at larger concentrations, neither anesthetic seems to irritate the airway when administered at the smaller concentrations often used during maintenance of anesthesia. Both anesthetics may be delivered effectively via a laryngeal mask airway, with minimal evidence of airway irritation.
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Affiliation(s)
- Paul F White
- *Department of Anesthesia and Perioperative Care, University of California, San Francisco; and †Department of Anesthesiology, Texas Tech University Health Science Center, Lubbock
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Abstract
PURPOSE OF REVIEW Ambulatory surgery is now one of the major areas of surgical and anesthetic practice, with up to 70% of procedures performed in the ambulatory setting. This review focuses on some of the recent studies performed in day case anesthesia. RECENT FINDINGS Emphasizing the economic benefits of ambulatory surgery, investigators have studied the cost implications of various anesthetic techniques and their impact on patient recovery, discharge times and readmission rates. Quality anesthetic management measures such as mortality, morbidity, postoperative stay and patient satisfaction ensure that perioperative care and treatment are optimized. SUMMARY Careful patient selection can minimize perioperative events. The concept of multimodal analgesic and antiemetic therapy, in combination with newer anesthetic drugs, help expand the field of ambulatory surgery.
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Affiliation(s)
- Anne Marie Troy
- Department of Anaesthesia, Royal College of Surgeons in Ireland, Dublin, Ireland
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White PF. Fast-tracking in ambulatory anesthesia: a new concept? Not! Can J Anaesth 2002; 49:759; author reply 759-60. [PMID: 12193504 DOI: 10.1007/bf03017465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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White PF. The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. Anesth Analg 2002; 94:577-85. [PMID: 11867379 DOI: 10.1097/00000539-200203000-00019] [Citation(s) in RCA: 210] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Paul F White
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, 75390-9068, USA.
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32
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Abstract
The fast-tracking recovery concept examines different paradigms for streamlining the postoperative recovery process. Fast-tracking anesthetic techniques allow suitable outpatients to be discharged earlier after ambulatory surgery. Outpatients are normally transferred from the OR to the PACU, followed by transfer to the Phase II step-down (day-surgery unit) before discharge home. With conventional fast-tracking, it is possible to bypass the PACU and take patients directly from the OR to the step-down unit if they meet specific criteria before leaving the OR. Alternatively, if the step-down unit is already functioning at maximum capacity, the PACU can be restructured to include a fast-track area, where appropriate patients are treated as if they had been admitted directly to the step-down unit. For these PACU fast-track patients, less monitoring is performed, a family member is permitted to be with the patient, and the patient is allowed to ambulate, change into street clothes, and be discharged home directly from the PACU without any time restrictions. Preliminary studies have shown that outpatients who are fast-tracked can be discharged home earlier without any increase in complications or side effects. Importantly, fast-tracking after ambulatory surgery does not seem to compromise patient satisfaction with the surgical experience.
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Affiliation(s)
- A C Watkins
- Clinical Manager PACU at the Zale Lipshy University Hospital, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390-9068, USA
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33
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Abstract
Fast-tracking in outpatient surgery is a new paradigm that allows for rapid throughput and early discharge, thereby facilitating perioperative efficiency. Compared with the conventional recovery process, bypassing the postanesthesia care unit reduces the time to discharge home. An ideal anesthetic technique for fast-tracking would provide for rapid emergence and the prevention of common postoperative complications such as pain, nausea, and vomiting using a multimodal approach.
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Affiliation(s)
- G P Joshi
- University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA.
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Coloma M, Zhou T, White PF, Markowitz SD, Forestner JE. Fast-tracking after outpatient laparoscopy: reasons for failure after propofol, sevoflurane, and desflurane anesthesia. Anesth Analg 2001; 93:112-5. [PMID: 11429350 DOI: 10.1097/00000539-200107000-00024] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
IMPLICATIONS In this study, although 41%-94% of the patients were fast-track eligible after laparoscopic surgery, only 35%-53% of the patients actually bypassed the postanesthesia care unit (PACU) because of anesthetic-related factors and surgical complications. Residual sedation was the most common anesthetic-related cause of failure to bypass thePACU.
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Affiliation(s)
- M Coloma
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9068, USA
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