anesthesia in day surgery ,presented to a course in Tirrenia,2002(???)

1. Anestesia generale in day
surgery
Anestesia generale in day
surgery
tecniche e farmacitecniche e farmaci
Claudio MelloniClaudio Melloni
Bologna-FaenzaBologna-Faenza

2. Requirements of GA for ambulatory surgeryRequirements of GA for ambulatory surgery
psychological and pharmacological preparationpsychological and pharmacological preparation
rapid and predic table induc tion of anes thes iarapid and predic table induc tion of anes thes ia
s mooth and reliable maintenanc es mooth and reliable maintenanc e
hypnosis,amnesia,surgical anesthesiahypnosis,amnesia,surgical anesthesia
c ardiov as c ular s tabilityc ardiov as c ular s tability
ex cellent s urgic al conditionsex cellent s urgic al conditions
prompt and c omplete recov ery of mentalfac ultiesprompt and c omplete recov ery of mentalfac ulties
phys ic al c apability to return home safelyphys ic al c apability to return home safely
mimimalpos top.s ide effectsmimimalpos top.s ide effects
PONV,dizziness,pain...PONV,dizziness,pain...
prompt return to normal ac tiv itiesprompt return to normal ac tiv ities

3. Essential intraoperative monitoringEssential intraoperative monitoring
guidelinesguidelines
continuous presence of trained anesthesia personnelcontinuous presence of trained anesthesia personnel
continual assessment of ofcontinual assessment of of
oxy genationoxy genation
v entilationv entilation
circulationcirculation
tem peraturetem perature
clinical asessment+ standards of careclinical asessment+ standards of care
puls e oxy m etrypuls e oxy m etry
capnographycapnography
NIBPNIBP
ECGECG
FiO2FiO2
dis connect alarmdis connect alarm
therm om etrytherm om etry

4. Choice of technique I
• surgical requirements
• anaesthetic considerations
• patient's physical status
• Patient preference.
• The goal is to anaesthetize the patient for the
shortest possible time with the lowest concentration
of anaesthetic.

5. Choice of technique II
• Intraop optimal conditions
• Fast recovery of consciousness
• Minimal,if any,sedative residual effects
• Minimal disturbance of cognitive
postop.functions
• No side effects during recovery;No ponv,
• Fast discharge with early ambulation(???)

6. DebateDebate
Gas vs TIVAGas vs TIVA
GasGas
advantagesadvantages
induction without
vein
induction without
vein
easy maintenanceeasy maintenance
easy recoveryeasy recovery
familiar...familiar...
disadvantagesdisadvantages
pollutionpollution
Ponv...Ponv...
Point threePoint three

7. DebateDebate
TIVATIVA
AdvantagesAdvantages
no pollutionno pollution
smooth
emergence...
smooth
emergence...
postop.analgesiapostop.analgesia
smooth induction
(after i.v...).
smooth induction
(after i.v...).
DisadvantagesDisadvantages
know ledge of
pk-pd
know ledge of
pk-pd
less easyless easy
less reversibleless reversible

8. Basic physico-chemical
properties of modern inhalational
agents:
• Low blood/ gas solubilities
»fast induction and emergence
• No active metabolites
• Recovery times not dependent from
anesthesia duration

9. Inhalation
induction
• Ideal characteristics for an inhaled agent
useful for induction:
• Low blood gas solubility
• Pleasant smell
• Nonirritating for the airway
• High potency
• sevoflurane ??

10. Characteristics of inhaled
anesthetics
Decomposesnone2,424150,20,75197,4haloth
Stablemoder
ate
1,917556.51,68184,5enflur
ane
Stablemoder
ate
1.423848.51.15184,5isoflur
ane
decomposesno0,6016058.52.0200sevofl
urane
stableno0,4739000
gas
-8810544N2O
stableyes0,4266323.56168desflu
rane
Soda limepungencyBlood/gas
partition
coeff.
Vapor
press.
Boling
point
MACmwagent

11. Rate of equilibration between alveolar concentration and
inspired concentration
NN
NN
NN
2O
N2O
sevofluran
e
Fa/Fi
0.4
0.6
0.8

12. The interaction between fentanyl and
isoflurane(BJA 1998,81,38-50)

13. Interaction between remifentanil and isofluraneIsoflurane
concentration reduction by increasing remifentanil whole blood
concentration
Anesthesiology
85:721-8, 1996

14. Sebel PS., Glass PSA,Fletcher JE,Murphy
M,Gallagher C,Quill T.Reduction of rhe Mac of
desflurane with fentanyl. Anesthesiology
76:52-59, 1992

15. Sevoflurane Mac awake reduction by fentanyl
Katoh T,Iked K. The Effects of Fentanyl on Sevoflurane Requirements for Loss of
Consciousness
and Skin Incision ANESTHESIOLOGY 1998; 88:5—6.

16. Context sensitive half time of opioids(influence of P450
3A4 on alfentanil)

17. Inhalational anesthesia vs TIVAInhalational anesthesia vs TIVA
similarities...similarities...
parameterparameter inhalation anesth.inhalation anesth. TIVATIVA
cont.adm.cont.adm. yesyes yesyes
methodmethod vaporizervaporizer syringe pumpsyringe pump
titrationtitration yesyes yesyes
how much?how much? MACMAC MIRMIR
transporttransport airwayairway i.v.i.v.
initinit overpressureoverpressure bolusbolus
basal analgbasal analg N2O/titrationN2O/titration analgesicsanalgesics
pre-intraop checkspre-intraop checksyesyes yesyes

18. Plasma alfentanil vs propofol blood concentrations for
95% probability of no response to surgical stimulation(Vuyk
et al.Propofol Anesthesia and Rational Opioid Selection: Determination of Optimal EC50-EC95 Propofol—
Opioid Concentrations that Assure Adequate Anesthesia and a Rapid Return of Consciousness
Anesthesiology
87:1549-62, 1997

19. PharmacodynamicsPharmacodynamics
assumptionsassumptions
MEACMEAC
fent:0.6
ng/ml
fent:0.6
ng/ml
Resp
depression
Resp
depression
>2 ng/ml>2 ng/ml
MAC
reduction
MAC
reduction CSHTCSHT
RecoveryRecovery
ED95 intraop for surgery/ED95 for recovery of consciousness & spont.resp.ED95 intraop for surgery/ED95 for recovery of consciousness & spont.resp.

20. Vuyk J,Mertens MJ,Olofsen E
Propofol Anesthesia and Rational Opioid
Selection: Determination of Optimal EC50-EC95
Propofol—Opioid Concentrations that Assure
Adequate Anesthesia and a Rapid Return of
Consciousness
Anesthesiology
87:1549-62, 1997

21. time
Propofol blood concOpioid blood concentration
Three dimensional planes in the
graphs from Vuyk et al.

27. manual opioid infusion schemesmanual opioid infusion schemes
from many sources...from many sources...
drugdrug plasma target
concentation(ngml)
plasma target
concentation(ngml) bolus(microgr/kg)bolus(microgr/kg)
infusion rate
(microgr/kg/min
infusion rate
(microgr/kg/min
fentanylfentanyl 11 33 0.0200.020
fentanylfentanyl 44 1010 0.0700.070
alfentanilalfentanil 4040 2020 0.250.25
alfentanilalfentanil 160160 8080 1.001.00
sufentanilsufentanil 0.150.15 0.150.15 0.0030.003
sufentanilsufentanil 0.500.50 0.500.50 0.0100.010
remifentanilremifentanil 66 11 0.020.02
remifentanilremifentanil 12-2012-20 1-21-2 0.4-1.00.4-1.0

28. Practical pharmacokinetics as applied to our
daily anesthesia practice
Fiset, Pierre.Can J Anesth 1999 / 46 / R122-R126

29. Bekke AY, Berklay P, Osborn I,Bloo M, Yarmush J,
Turndorf H. The Recovery of Cognitive Function After
Remifentanil- Nitrous Oxide Anesthesia Is Faster than
After an Isoflurane-Nitrous Oxide-Fentanyl Combination
in Elderly Patients Anesth Analg 2000; 91:117–22
• We tested the hypothesis that remifentanil-nitrous
oxide (N2O) anesthesia shortens postoperative
emergence and recovery compared with an
isoflurane-N2O-fentanyl combination in elderly
patients undergoing spinal surgery.
• 60 patients (>65 yr old) were randomly assigned
to one of two groups for maintenance of
anesthesia. After the induction with 3.6 ± 1.2
mg/kg IV thiopental and endotracheal intubation
facilitated with 1.4 ± 0.5 mg/kg succinylcholine,
patients were maintained with either 0.5%–1.5%
isoflurane, 70% N2O, and up to 7 mg/kg fentanyl

30. Bekke et al The Recovery of Cognitive Function After Remifentanil- Nitrous Oxide Anesthesia Is Faste
than After an Isoflurane-Nitrous Oxide-Fentanyl Combination in Elderly Patients Anesth Analg 2000;
Isofl/fen
Remif/N

31. Physiological Effects of Remifentanil and
Alfentanil in Healthy Volunteers
Anesthesiology
90:718-26, 1999
• Background: The subjective and psychomotor
effects of remifentanil have not been evaluated.
Accordingly, the authors used mood inventories
and psychomotor tests to characterize the effects
of remifentanil in healthy, non—drug-abusing
volunteers. Alfentanil was used as a comparator
drug.
• Methods: Ten healthy volunteers were enrolled
in a randomized, double-blinded, placebo-
controlled, crossover trial in which they received
an infusion of saline, remifentanil, or alfentanil for
120 min. The age- and weight-adjusted infusions

32. remi
alf
remi
alf

33. Beers R,Calimlim JR, Uddoh E,Esposito B,
Camporesi EM.A Comparison of the Cost-
Effectiveness of Remifentanil Versus Fentanyl as
an Adjuvant to General Anesthesia for
Outpatient Gynecologic Surgery Anesth Analg
2000; 91:1420
• The unique pharmacokinetic properties of remifentanil make it a potentially useful
adjuvant during general anesthesia for ambulatory surgery. Fentanyl, inexpensive
and easy to administer, is the most common opioid used for this purpose. As an
adjuvant to general anesthesia for outpatient gynecologic surgery, we questioned if
remifentanil was cost-effective as an alternative to fentanyl. Thirty-four patients
undergoing gynecologic laparoscopy or hysteroscopy were prospectively and
randomly assigned to a standard practice (n = 18) or a study (n = 16) group.
Standard practice patients received fentanyl(3 mg/kg) before induction; study
patients received remifentanil by continuous infusion (0.5 mg×kg×min-1 at
induction, then 0.2 mg×kg×min-1). Sevoflurane was titrated to a Bispectral index
value of 40–55.
• Fentanyl administered to studty pts for analgesia before
awakening! the We investigated recovery profiles, patient and health care
professional satisfaction, and drug costs . The incidence of rescue antiemetic
treatment (2 of 16 vs 8 of 18; P = 0.013) and the nausea visual analog scale scores
during second stage recovery (0.2 vs 0.6; P = 0.044) were more frequent in the study

35. Rosenberg et al.Cost comparison:a desflurane
versus a propofol based general anesthetic
technique.AA 1994;79:
0
20
40
60
80
100
120
140
cost/hr
cost
wastetot.cost/hrduration
totcost/hrt
Pacustay
prop/n2O
desf/O2
*
*
*
0.09

36. Chung F. Recovery pattern and home readiness
after ambulatory surgery. Anesth Analg 1995;
80:896-902
• Despite increased use of ambulatory surgery, few
data exist regarding patient recovery patterns and
home-readiness. We prospectively identified the
pattern of home-readiness, the persistent
symptoms after surgery, and the factors that delay
discharge after home-readiness criteria are
satisfied. Five hundred patients were scored by the
same investigator using the Postanesthetic
Discharge Scoring System (PADSS) every 30
min, commencing 30 min after surgery, until the
PADSS score was > or = 9. The same investigator
telephoned each patient 24 h after discharge to

37. Laparscopy,general surg,orthopedic surg

38. Anesthesia and factors
associated with PONV
Anesthesia and factors
associated with PONV
GA> regGA> reg
etomidate,ketamine,(neostigmine),(N2O)etomidate,ketamine,(neostigmine),(N2O)
PAINPAIN
Sudden mov ementSudden mov ement
Hy potensionHy potension
Gastric distentionGastric distention

39. PONVPONV
Categories at riskCategories at risk
FemalesFemales young,pregnantyoung,pregnant
kinetosiskinetosis
certain operationscertain operations strabismus, inner
ear,pelvic laparoscopic ...
strabismus, inner
ear,pelvic laparoscopic ...
diabeticsdiabetics

40. PONVPONV
we know the risk factorswe know the risk factors
Preventive strategyPreventive strategy non emetogenic drugs...non emetogenic drugs...
Antiemetic
Prophylaxis
Antiemetic
Prophylaxis
Selected at risk groupsSelected at risk groups
Immediate treatmentImmediate treatment
in case of
occurrence.....
in case of
occurrence.....

41. Propofol & PONV
YES,>ondanse
tron (preop..)
Induz vs
intraop
Tps/isof vs
prop/N2O
major breast
surgery
Gan 1996
Fem outpts
laparoscopic
surgery
Mayot gynecol
surg
thyroidectomy
Gynecol lap
procedure
YESintraopEnflur/N2O vs
propof/N2O
Ding 1993
YESPostop 0.1
ml/kg/h
enfluraneMontgomery
1996
YESPostop,0.1
ml/kg/h
Isof/N2OEwalenko 1996
NonepostopisoflCampbell 1991
effectsPropofol
adm.
Inh.agentAuthor

42. PONV prophylaxis and treatment
• Droperidol 10 microgr/kg ev/im++
• Ondansetron 4-8 mg ev(8 p.o.)++
• Dexamethasone 4 mg ev+
• Ephedrine 10 mg iv?
• Scopolamine 0.5 mg/62 hr patch ??
• Metoclopramide 10 mg iv +/-
• Propofol 10-20 mg ev??
• ―setrons‖++

43. How well do we manage pain?
• 77% of patients still experience pain
postoperatively:80% moderate-severe and
57% quote pain as a primary concern or
preop fear(Acute Pain Management: Programs in U.S. Hospitals
and Experiences and Attitudes among U.S. Adults
Anesthesiology,83:1090-1094, 1995)

44. Acute Pain Management: Programs in U.S.
Hospitals and Experiences and Attitudes among
U.S. Adults
Anesthesiology
83:1090-1094, 1995• Two telephone questionnaire surveys
• U.S. hospital participants: 100 teaching hospitals
(acute care hospitals with a residency program
and/or university affiliation), 100 nonteaching
(community) hospitals with fewer than 200 beds,
and 100 nonteaching (community) hospitals with
200 beds or more
• interview regarding current and future pain
management programs and related topics.
• Adult participants in 500 U.S. households were
interviewed on attitudes and experiences with
postoperative pain and its management.

45. Song et al.
Titration of Volatile Anesthetics Using Bispectral
Index Facilitates Recovery after Ambulatory
Anesthesia Anesthesiology
87:842-8, 1997
-4
-2
0
2
4
6
8
10
12
14
% or min
Gas % Mac/hr verb
resp
extub orient
SEVO BIS
sevocontr
DESFL BIS
desfl contr
diff bis-contr desf
diff bis-contr sevo

46. Song et al.
Titration of Volatile Anesthetics Using Bispectral Index
Facilitates Recovery after Ambulatory Anesthesia
Anesthesiology
87:842-8, 1997

47. Song D, van Vlymen J, White PF.Is the
Bispectral Index Useful in Predicting Fast-Track
Eligibility After Ambulatory Anesthesia with
Propofol and Desflurane?
Anesth Analg 1998; 87:1245

48. Dexter F, Tinker JH..
Comparison between desflurane and isoflurane
or propofol on time to following commands and
time to discharge:a metanalysis.
Anesthesiology 1995; 83,

49. Dexter F, Tinker JH..
Comparison between desflurane and isoflurane
or propofol on time to following commands and
time to discharge:a metanalysis.
Anesthesiology 1995; 83,

50. Dexter F, Tinker JH..
Comparison between desflurane and isoflurane
or propofol on time to following commands and
time to discharge:a metanalysis.
Anesthesiology 1995; 83,

51. Dexter F, Tinker JH..
Comparison between desflurane and isoflurane
or propofol on time to following commands and
time to discharge:a metanalysis.
Anesthesiology 1995; 83,

52. Dexter F, Tinker JH..
Comparison between desflurane and isoflurane
or propofol on time to following commands and
time to discharge:a metanalysis.
Anesthesiology 1995; 83,

53. Song et al.Remifentanil infusion facilitates early
recovery for obese outpatients undergoing
laparoscopic cholecystectomy.AA 2000,90:1111-3.
0
2
4
6
8
10
12
14
16
18
sevo% opioid
intraop
awake extub orient
sevo
remif
*
*
*
*
mg
min

54. Conclus from Song et al
• Variable rate infus of remif(0.09
microgr/kg/min) + sevo + N2O :
• 50% sevo %
• Contributed to a more rapid emergence
• Postop side effects not increased(PONV=)
• PACU stay and discharge times =

55. Joshi et al.Use of the Laryngeal Mask Airway as an
Alternative to the Tracheal Tube During
Ambulatory Anesthesia Anesth Analg 1997; 85:573
0
20
40
60
80
100
120
140
160
180
fent mant PACU-
stepdown
PACU-
ambul
sore throat nausea
LMA
IOT
microg
min
min
% %

56. Advantages of the LMA>TT
• increased speed and ease of placement by
inexperienced personnel;
• increased speed of placement by anaesthetists;
• improved haemodynamic stability at induction
and during emergence;
• minimal increase in intraocular pressure
following insertion;
• reduced anaesthetic requirements for airway
tolerance;
• lower frequency of coughing during emergence;
• improved oxygen saturation during emergence;

57. Advantages LMA>Face Mask
• easier placement by inexperienced
personnel;
• improved oxygen saturation;
• less hand fatigue;
• improved operating conditions during minor
paediatric otological surgery.

58. Disadvantages LMA> TT&FM
• lower seal pressures
• higher frequency of gastric insufflation.
• The only disadvantage compared with the
FM was that oesophageal reflux was more
likely.

59. In conclusionIn conclusion
for the success of day anesthesia & surgeryfor the success of day anesthesia & surgery
pk-pd
foundations
pk-pd
foundations
clinical
experience
clinical
experience
organizationorganization
continuous
improvement
continuous
improvement
pk/pd
foundations
pk/pd
foundations
technology?technology?