The Outpatient Anesthetic I Want You to Give Me

1. The Outpatient Anesthetic I Want You to Give Me ORANA Fall Conference Oct. 24, 2009 L. Scott Letourneau, M.D. Bend Surgery Center Bend, OR

2. Disclosure

3. The Outpatient Anesthetic I Want You to Give Me • Introduction/Background/Objectives • Multimodal Approach • Drawbacks/Complications • Summary

4. The Outpatient Anesthetic I Want You to Give Me • Introduction/Background/Objectives

5. Who is this person?? Why should I be listening to anything he has to say??

6. The Outpatient Anesthetic I Want You to Give Me • Introduction/Background/Objectives • Multimodal Approach • Drawbacks/Complications • Summary

7. Multimodal Elements • Pre-Op Phone Call • Oral Pre-meds • IV Pre-meds • PONV Prophylaxis • Local/Regional/Nerve Block • Maintenance Aspects

8. Multimodal Elements • Pre-Op Phone Call • Oral Pre-meds • IV Pre-meds • PONV Prophylaxis • Local/Regional/Nerve Block • Maintenance Aspects

9. Pre-Op Phone Call • Pediatric Patients • Identify Pts at high risk or with PONV history • Identify Pts who need labs, tests, etc. • Agree on a plan and answer questions • Give medication instructions • Talk about regional/PARQ • Identify other problems

10. Multimodal Elements • Pre-Op Phone Call • Oral Pre-meds • IV Pre-meds • PONV Prophylaxis • Local/Regional/Nerve Block • Maintenance Aspects

11. Oral Pre-meds • Clonidine .05 – 0.1 mg PO Centrally acting A2 antagonist Mild pre-op sedation Narcotic and/or Vapor-sparing effect Moderates hemodynamic responses Less than $.05 per dose Hypotension and/or bradycardia

12. Oral Pre-meds • Celebrex(Celecoxib) 400 mg. PO COX-2 inhibitor Anti-inflammatory effect Narcotic-sparing analgesic effect About $7 per dose (2 x 200mg caps) Sulfa allergy concern

13. Multimodal Elements • Pre-Op Phone Call • Oral Pre-meds • IV Pre-meds • PONV Prophylaxis • Local/Regional/Nerve Block • Maintenance Aspects

14. IV Pre-meds • Versed and Fentanyl Why Bother???

15. Multimodal Elements • Pre-Op Phone Call • Oral Pre-meds • IV Pre-meds • PONV Prophylaxis • Local/Regional/Nerve Block • Maintenance Aspects

16. PONV Prophylaxis Multimodal approach Ondansetron 5 HT-3 $.25/dose Scopolamine (IV) Anticholinergic $1/dose Scopolamine (TD) Anticholinergic $8-$9/dose Droperidol Butyrophenone $.40/dose Promethazine (IV) H1 antagonist $.50/dose Promethazine (Supp) H1 antagonist $.50/dose Metoclopramide Dopa antagonist $.50/dose Dexamethasone Corticosteroid $.12/dose Supplemental O2 ??? Pennies Diprivan ??? $.20/dose

17. Transderm Scop

18. PONV Prophylaxis • Consider no vapor: TIVA w/ Diprivan/Ultiva or Diprivan/fentanyl +/- Ketamine

19. Multimodal Elements • Pre-Op Phone Call • Oral Pre-meds • IV Pre-meds • PONV Prophylaxis • Local/Regional/Nerve Block • Maintenance Aspects

20. Local/Regional/Nerve Block • Bier block • Ilioinguinal nerve block (Inguinal Hernia) • Lumbar plexus block (ACL) • Ankle block (Podiatry cases) • Popliteal sciatic block (continuous?) • Brachial plexus block (continuous?) • Pain pump/catheter • Don’t fear the outpatient spinal

21. Local/Regional/Nerve Block • Check out New York School of Regional Anesthesia at: http://www.nysora.com/

22. Multimodal Elements • Pre-Op Phone Call • Oral Pre-meds • IV Pre-meds • PONV Prophylaxis • Local/Regional/Nerve Block • Maintenance Aspects

23. Maintenance Aspects • Suprane (Desflurane) • Ultiva (Remifentanyl)

24. Maintenance Aspects • Both used at very low dose: ~2–3% End tidal concentration for Desflurane MAC Faceplate and low MAC dose for Ultiva

25. But It Costs Too Much!! Remifentanly using MAC infusion plate: 70kg pt at 0.05 mcg/kg/min = 210mcg/hr 4+ hours per 1 mg vial 1mg vial~ $32, so $8 - $10/hour

27. But It Costs Too Much!! Bottle acquisition cost comparison very misleading Consider cost of lost time in OR and/or PACU Desflurane at low flows and low dose is extremely cost effective

28. Cost Determination Simplistic (and erroneous) approach: Suprane 240 ML’s Sevoflurane 250ML’s MAC =>6%MAC =2% Since Suprane’s MAC is 3X that of Ultane, it takes 3 bottles of Suprane to deliver the same number of anesthetic hours as a single bottle of Ultane. = Suprane Price: $152.00Ultane Price: $195.00 3 X $152.00 =$456.001 X $195.00 = $195.00

29. Cost Determination Bottle cost/MAC comparison misleading for multiple reasons: • The agents are delivered as a gas, not a liquid 15% more gas per ml of Suprane liquid • Ignores metabolism 5+% for Sevoflurane vs. 0.02% for Suprane

30. Cost Determination 3.Ignores Solubility; Absorption by tissues

31. Cost Determination 4. Ignores Flow Rates Flow Rates can have a 10-fold impact on the cost of delivering modern inhaled anesthetics. $$$$

32. Flow Rates • You really aren’t supposed to use flow rates less than 2liters/min with Sevoflurane • 4, 3, 2, and even 1liters/min flow rates waste money with Desflurane Running low-flow, low-dose Desflurane forces you to pay attention in order to keep the patient just deep enough

33. Airway Irritation with Desflurane

34. Airway Irritation with Desflurane “Unlike Sevoflurane, Desflurane is pungent… Indeed, the pungency of Desflurane produces airway irritation and an appreciable incidence of salivation, breath-holding, coughing, or laryngospasm when >6% inspired Desflurane is administered to an awake patient.” Eger, EI; 1994(from Stoelting)

35. Airway Irritation with Desflurane “Desflurane does not cause (airway) irritation at concentrations below 6%... Administration of 1.8% to 5.4% desflurane for 30 min. to 10 young, healthy nonsmoking male volunteers was tolerated by all subjects and there was no breath-holding, coughing, salivation, laryngospasm, or bronchospasm….” Eger, EI; 2002

36. Desflurane Airway irritation/coughing/laryngospasm Not a Problem

37. Sample Case10/20/09 50 yo Female for bil. breast implant removal/replacement with capsulectomies Scheduled for 120 min Pre- op phone call: PMH: 1ppd smoker PSH: Hyst, Breast biopsy x 3, Lapscope, breast augmentation/mastopexy; no PONV Meds: Oxybutinin, topical metronidazole All: Darvocet

38. Sample Case Plan • No history of PONV or high risk surgery • Dexamethasone and Ondansetron for PONV prophylaxis • Can’t use regional or nerve block, but… • Field block and bil. catheter/pain pump • Oral pre-meds: Clonidine and Celebrex • No IV pre-meds • GA w/ LMA • Maintenance w/ Desflurane and Ultiva

40. Emergence and PACU 09:40 D/C Ultiva and Desflurane, 10 l/min 09:43 (3min) Eye opening and extubate 09:46 (6min) Moves self to stretcher, conversant 09:52 (12 min) Telling stories in PACU, denies pain 10:02 (22 min) Ambulates to BR, returns to recliner 10:10 (30 min) Eating and drinking 10:20 (40 min) 50mcg Fentanyl, 1 Percocet for 4/10 pain 10:40 (60min) Coffee, dressed, discharged No Nausea, 1-2/10 pain on discharge PACU stay ~ 50 min

41. Sample Case 2Inguinal Hernia with mesh • Celebrex and Clonidine PO pre-meds • Ilioinguinal nerve block (10 ml ¼% Marcaine w/Epi) • LMA General anesthesia w/ Ultiva and Desflurane • Field block and supplemental local by surgeon • Decadron and Ondansetron for PONV

42. Last 7 consecutive cases; 7/6/09 – 10/16/09

43. The Outpatient Anesthetic I want You to Give Me • Introduction/Background/Objectives • Multimodal Approach • Drawbacks/Complications • Summary

44. Drawbacks/Complications • More work, more energy, more time • Hypotension and/or bradycardia • Light anesthesia/Awareness? • ‘Abrupt’ wake-up: Prepare to possibly treat hypertension/tachycardia

45. The Outpatient Anesthetic I want You to Give Me • Introduction/Background/Objectives • Multimodal Approach • Drawbacks/Complications • Summary

46. Summary • Invest the time: Call pts. and make a plan • Minimize/avoid opioids and vapor if you can (Local, Regional, Nerve Block, Oral Premeds) • PONV: Don’t wait to react • Consider Desflurane and Ultiva

47. Thank You!!!