Anesth Analg 2000;91:1049-1055
© 2000 International Anesthesia Research Society
AMBULATORY ANESTHESIA
Is There a Learning Curve Associated with the Use of Remifentanil?
Girish P. Joshi, MB, BS, MD, FFARCSI*,
Brenda D. Jamerson, PharmD ,
Michael F. Roizen, MD ,
Lee Fleisher, MD§,
Rebecca S. Twersky, MD||,
David S. Warner, MD¶, and
Michael Colopy, PhD
*Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas;
GlaxoWellcome Inc., Research Triangle Park, North Carolina;
Department of Anesthesia and Critical Care, University of Chicago Hospital, Chicago, Illinois;
§Department of Anesthesiology, Johns Hopkins University, Baltimore, Maryland;
||Department of Anesthesiology, State University of New York Health Science Center, Brooklyn, New York; and
¶Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
Address correspondence and reprint requests to Girish P. Joshi, MB, BS, MD, FFARCSI, Associate Professor of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, Texas 75235-9068. Address e-mail to girish.joshi{at}email.swmed.edu
This study prospectively determined whether there was a learning curve with the use of remifentanil, as indicated by decreased hemodynamic variability, improved recovery profile, and decreased incidence of opioid-related adverse events with increasing experience. Patients undergoing diverse surgical procedures (outpatient [n = 1340] and inpatient [n = 560]) were enrolled by investigators (n = 190) who had no previous experience with remifentanil use. Each investigator enrolled 10 patients. A standardized protocol for administration of remifentanil was used. Data were analyzed to determine differences between the first three patients and the last three patients enrolled for each anesthesiologist in the study. There were no differences in hemodynamic variables between the first triad and the last triad in either outpatients or inpatients. Requirements for hypnotic drugs and the doses of remifentanil used were also similar between groups. Analgesic medications administered at the end of surgery and in the postanesthesia care unit (PACU) were similar between groups, except that the last triad in the outpatient group received smaller doses of fentanyl compared with the first triad. Times to response to verbal command, tracheal extubation, and operating room discharge did not differ between groups. However, patients in the last triad undergoing outpatient surgery had shorter times to eligibility for PACU discharge, but times to eligibility for discharge home did not differ. The overall incidence of all adverse events (i.e., hypotension, hypertension, muscle rigidity, respiratory depression, apnea, nausea, and vomiting) was less in the last triad as compared with the first triad. When analyzed separately, only the incidence of vomiting (in the outpatient group) was decreased in the last triad as compared with the first triad. This study suggests that there is a learning curve that aids reduction of minor adverse effects associated with the use of analgesic medications administered at the end of surgery in outpatients, which might have reduced the incidence of postoperative vomiting and the duration of PACU stay.
Implications: This study demonstrated that anesthesiologists rapidly acquire the ability to use remifentanil with limited experience. However, there is a learning curve that aids reduction of minor adverse effects associated with the use of analgesic medications administered at the end of surgery in outpatients, which might have reduced the incidence of postoperative vomiting and the duration of postanesthesia care unit stay.
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J. G. Reves
Lessons on Learning About Learning Curves
Anesth. Analg.,
November 1, 2000;
91(5):
1047 - 1048.
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