Propofol ketamine technique for rapid turnover

1. Propofol-Ketamine Technique
for Rapid Turnover Outpatient
Anesthesia

2. Disclosure Statement

3. What is P-K Anesthesia?
 P-K anesthesia is the use of a propofol and
ketamine based technique to attain a level of deep
sedation. This is a sedation/MAC technique with
brief intermittent periods of general anesthesia.
 P-K anesthesia relies heavily on surgeon
participation. The majority of analgesia provided is
done so by the surgeon with liberal and strategic
application of an appropriate LA

4. Types of Procedures Appropriate
for P-K Technique
 Cosmetic procedures (breast augmentation,
abdominoplasty, facelift/neck lift/brow lift,
brachioplasty, liposuction, otoplasty, rhinoplasty)
 Minor GYN procedures (hysteroscopy,
colposcopy, LEEP, Novasure, Essure)
 Minor urology procedures (bladder scope, prostate
biopsy, lithotripsy, circumcision, stone extraction,
vasectomy and reversal
 Interventional radiology procedures (arteriograms,
fibroid embolizations, varicose vein procedures,
AV fistula placements

5. Sample Daily Schedule
01/11/2016
 8:30 a.m.
 D.B.
 Bilateral breast augmentation
 9:45
 M.M.
 Bilateral breast augmentation
 11:00 a.m.
 S.S.
 Bilateral implant exchange & mastopexy revision
 12:45 p.m.
 R.W.
 Neck lift and perioral dermabrasion
 3:00 p.m.
 J.W.
 Bilateral implant exchange with capsulectomy

6. Serving Two Masters: Goals for
Patients/Goals for Facilities
 Patient Goals
 -feel confident in the
surgeon, anesthesia
provider, facility and
process
 -patient who understands
the pre-op, operative,
discharge and post
anesthesia process
 -relative comfort during
and after procedure
 -meeting discharge criteria
30-45 minutes post
procedure
 Facility Goals
 -patient safety
 -patient satisfaction and
referrals
 -surgeon satisfaction
 -provide high quality care
at a max profit
 -quiet surgical field
 -efficient turnover allowing
for more cases

7. The Pre-Anesthesia Process:
Setting the Stage for Success
 Set admission criteria, surgery types and lengths
(policy created in conjunction with facility)
 Pre-anesthesia phone call
 -health history
 -NPO/medication instructions
 -describe day or procedure process
 Day of surgery pre-anesthesia interview
 -review health history
 -ensure NPO status
 -manage post operative pain expectations
 -family member/driver education

8. NPO Guidelines
 Clear liquids 2hrs
 Dry toast 6hrs
 Regular meal 8hrs
(no dairy on surgery day)
Adhere to these
guidelines and
administer routine
fluids.
QuickTime™ and a
decompressor
are needed to see this picture.

9. Pre-Meds
 Tylenol 1000mg po
 Clonidine 0.1-0.2mg po**
 Have patient take all routine meds am of
procedure (consider restricting lisinopril)

10. IV Size Selection
Items to consider:
-length of procedure
-time of day
-hours NPO

11. Intraoperative Process

12. Anesthesia Set Up

13. Anesthesia Administration
Routine (Start)
 Versed 2mg IV/Morphine 5mg IV**
 Ketamine 25-50mg
 Ancef start infusion
 Propofol 50-70mg IVP
 Propofol Infusion 250mcg/kg/min
 90mm OA
 Morphine 5mg IM**
 Toradol 30mg IV/30mg IM**
 Zofran & Decadron up front

14. Anesthesia Administration
Routine (maintenance)
 Titrate Propofol to sedation, ventilation & BP
 Give ketamine 25-50mg q45-60min or before stimulating
portions of any procedure.
 Generally the maintenance infusion of Propofol is in the
range of 140-180mcg/kg/min
 Begin to decrease Propofol infusion 20 minutes prior to end
of procedure
 Rules for Ketamine:
 - no ketamine within 30 minutes of end of procedure
 - do not exceed 200mg total dose for ketamine

15. Surgical Analgesia
 The majority of analgesia is supplied by the surgeon
through LA injection, field coverage and tumescent fluid
(plastics).
 Anesthesia provider/operating physician partnership
requires encouragement, education and communication.
 Encourage maximum amounts of LA, give surgeon a
ballpark figure at the beginning of the case.
 Plane of anesthesia can effect surgical administration of
adequate LA
 Surgeon understanding of LA injection importance is vital
to quick recovery, discharge and patient satisfaction.
 Exparel, adequately administered, is AWESOME!!

16. Recovery Process
 Expected time to discharge is 30-45 minutes.
 Assess pain on awakening, at 15 minute intervals,
treat early with IV fentanyl.
 Encourage assisted ambulation to restroom at 15
minutes.
 Instruct driver to have patient eat substantial solid
foods ASAP after d/c and begin oral pain
medication with first meal.
 Treat PONV with fluid bolus, additonal IV Zofran or
PO Zofran. Alcohol sniff is effective as well.

17. Discharge Goals
 Pain score 4 out of 10 or less.
 Minimal to absence of nausea and vomiting
 Stable vital signs
 Ambulation with assistance

18. Keys to Achieving D/C Goals
 Manage expectations
 - describe expected level and quality of pain
 - explain discharge goals
 - set expectation of time to discharge post
procedure
 - include family member/driver in discussion of
discharge goals
 - explain the process for alleviating hindrances to
achieving discharge goals

19. Measuring Patient Outcomes
Measure post op analgesia scores
- emergence and discharge (average 3/10)
Measure rate of PONV (roughly 10%)
- separate PONV related to anesthesia from
PONV related to oral pain medications
Ask:
- when the nausea occurred
- what was oral intake prior to oral meds
Measure time from end of procedure to d/c home

20. Time Management
On to the next case:
- set staff expectations for
timely turnover
- measure and document
turnover times
- review at regular intervals
reasons for delays (patient
arrival, staff arrival,
equipment not ready,
surgeon not ready)
- routinely discuss turnover
times and any reasons for
trends in delay

21. Special Scenarios:
- Starting cases in prone position**
- Turning during cases
- IV’s for upper extremity procedures
- Surgical fire prevention

22. My Favorite Special Scenario

23. Managing Facility Profitability
 Continuous review of process as it relates to
profitability
 Continuous consideration of medications and
supplies used on a routine basis
 Discover the costs of your anesthetic
 - breast augmentation - roughly $22.00
 - abdominoplasty - roughly $32.00
 - AVF - roughly $28.00
 Don’t be shy about advertising your attention to
detail and profitability.

24. Review of Pearls
 Manage patient expectations throughout the
process.
 Develop a repeatable routine that works with your
procedure type and facility
 Keep everyone on the same page with time
management.
 Frequently communicate with your surgeons
regarding LA administration. Let them know that
better LA coverage = less Propofol used which =
more profit!!
 Set your metrics and measure your outcomes at
regular intervals.

25. Resources

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27. Resources