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Anesth Analg 2001;92:95-99
© 2001 International Anesthesia Research Society

AMBULATORY ANESTHESIA

Fast-Track Office-Based Anesthesia: A Comparison of Propofol Versus Desflurane with Antiemetic Prophylaxis In Spontaneously Breathing Patients

Jun Tang, MD*, Paul F. White, PhD, MD, FANZCA*, Ronald H. Wender, MD{dagger}, Robert Naruse, MD{dagger}, Robert Kariger, MD{dagger}, Alexander Sloninsky, MD{dagger}, Mitchell S. Karlan, MD{ddagger}, Robert Y. Uyeda, MD{ddagger}, Scott R. Karlan, MD{ddagger}, Carol Reichman, RN{ddagger}, and Brian Whetstone, ORT{ddagger}

*Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas, {dagger}Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California, and {ddagger}Bedford Surgical Center, Beverly Hills, California

Address correspondence to Paul F. White, PhD, MD, Professor and McDermott Chair of Anesthesiology, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, F2.208, Dallas, Texas 75390-9068. Address e-mail to paul.white{at}utsouthwestern.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 

Implications: Compared to propofol, maintenance of anesthesia with desflurane provided significantly better intraoperative conditions during office-based surgery. In addition, desflurane with routine antiemetic prophylaxis was associated with a faster early recovery and similar incidence of postoperative side effects.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Office-based surgery is expected to account for up to 25% of all elective surgery procedures performed in the United States within the next decade (1). The popularity of office-based surgery is related primarily to costs savings and enhanced convenience for patients and surgeons. For general anesthesia to be successfully used in the office-based setting, it is important that the technique provides for adequate spontaneous ventilation, good operating conditions, and a rapid recovery without side effects (2).

As a result of their favorable recovery profiles, the anesthetics propofol, sevoflurane, and desflurane are all widely used in the ambulatory setting (3,4). However, a recent study found that the use of sevoflurane for maintenance of general anesthesia during office-based surgery was associated with an increased incidence of postoperative nausea and vomiting (PONV) and delayed patient discharge compared to propofol (5). White and Watcha (6) have recommended routine antiemetic prophylaxis of all outpatients "at risk" of developing PONV, and Scuderi et al. (7) reported that triple antiemetic prophylaxis was highly effective in minimizing PONV after ambulatory surgery.

Therefore, we designed this prospective randomized study to test the hypothesis that the use of a combination of antiemetic drugs with desflurane could minimize the incidence of PONV symptoms in the office setting. In addition, the intraoperative anesthetic conditions and postoperative recovery profiles were compared when office-based general anesthesia was maintained with either desflurane or propofol in combination with nitrous oxide (N2O) in spontaneously breathing patients.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
After obtaining IRB approval and written, informed consent, 75 ASA physical status I-III outpatients scheduled to undergo superficial surgical procedures lasting 20–40 min in the office setting were enrolled in this single-blind study. This study was performed at an office-based surgical center (Bedford Surgical Center, Beverly Hills, CA) with a single operating room (OR), one Phase II recovery bed (with a noninvasive blood pressure monitor and pulse oximeter), and one nurse who assisted the anesthesiologist and surgeon during the surgical procedure and cared for the patient in the recovery area. Patients were randomly assigned to one of two anesthetic treatment groups according to a computer-generated random numbers table. Exclusion criteria included pregnancy, a history of alcohol or drug abuse, a history of allergic reactions to any of the study medications, severe cardiovascular, respiratory, metabolic, endocrine diseases, as well as use of prophylactic antiemetic drugs within 24 h before surgery.

Before entering the OR, patients completed baseline visual analog scales for sedation, fatigue, comfort, pain and nausea, using a 100-mm scale, with 0 = none to 100 = maximum. On arrival in the OR, standard monitoring devices were used in addition to the electroencephalographic (EEG) bispectral index (BIS) monitor. These unpremedicated patients received 100% oxygen via a face mask for 2–3 min before the induction of general anesthesia. Anesthesia was induced with propofol, 2.0 mg · kg-1 IV, and a laryngeal mask airway was placed for airway management. Anesthesia was maintained with either a variable-rate propofol infusion, 75–150 µg · kg-1 · min-1 IV (Group 1) or desflurane 2–4% end-tidal (Group 2) in combination with N2O 67% in oxygen at 3 L · min-1. The mean arterial pressure, heart rate, hemoglobin oxygen saturation, and respiratory rate values were recorded at 5-min intervals during the operation. The inspired and end-tidal concentrations of oxygen, carbon dioxide, desflurane, and N2O were measured continuously using a calibrated infrared gas analyzer.

All patients were allowed to breathe spontaneously during the operation. A local anesthetic mixture consisting of 2% lidocaine and 0.5% bupivacaine was infiltrated by the surgeon before the skin incision, and supplemental injections were performed as necessary to maintain adequate analgesia during the operation. The absence of purposeful movements and tachypnea (respiratory rate >20 bpm) was considered "optimal" intraoperative analgesia. The propofol maintenance infusion rate and the inspired desflurane concentration were adjusted to maintain an EEG-BIS index value between 55 and 65. Before the end of surgery, all patients received ketorolac 30 mg IV. In the desflurane group, ondansetron 4 mg IV, droperidol 0.625 mg IV, and metoclopramide 10 mg IV were administered before the end of surgery to minimize emetic symptoms. The maintenance anesthetic drugs were discontinued and the laryngeal mask airway was removed at the start of skin closure. On awakening from anesthesia, all patients were evaluated at 1-min intervals with respect to their ability to meet specific fast-track discharge criteria (8). Patients achieving a score of 12 or more were asked to sit up on the OR table and, after standing, they were allowed to walk to the recovery area with assistance.

One of the investigators recorded anesthetic time (from induction to discontinuation of the anesthetic drugs), surgical time (from incision to placement of the dressing), and the times from discontinuation of the maintenance anesthetics until the patients were able to open their eyes, to follow commands (e.g., to squeeze the investigator’s hand), and were oriented to their name, place and date of birth. In addition, the times to sitting up, standing up, tolerating oral fluid, ambulating without assistance were recorded, as well as the duration of the recovery room stay and the actual time to discharge. Recovery was also assessed at 10-min intervals using the modified Aldrete postanesthetic recovery scoring system (9). "Home readiness" was considered to be the time that the patient was discharged from the recovery area.

The visual analog scale assessments were repeated at 30 min after the end of anesthesia and at the time of discharge home. Side effects during the perioperative period (e.g., movement, coughing, dizziness, postoperative nausea, vomiting, and pain) were also noted. Rescue medications (e.g., metoclopramide, hydrocodone/acetaminophen) were administered in the recovery area if patients vomited (or retched), or if they requested treatment for persistent nausea or pain. A trained interviewer who was "blinded" to the study group contacted all the patients by telephone at home 24 h after discharge to inquire about postdischarge side effects, and the need for any therapeutic interventions. The patients were asked to rate their overall satisfaction with the anesthetic experience on a three-point scale: 2 = very satisfied, 1 = satisfied, or 0 = dissatisfied.

An a priori power analysis suggested that group sizes of 35 should be adequate to detect a significant difference (50%) in the incidence of PONV based on an expected incidence in the desflurane group of 20–40% (5), with an {alpha} = 0.05 and ß = 0.80. The statistical analysis consisted of Students’ t-test to compare the continuous variables between the two anesthetic treatment groups, and a {chi}2 test or Fisher’s exact test, as appropriate, to analyze proportions among the categorical variables. A P value <0.05 was considered statistically significant. Data are presented as mean values ± SD, numbers, or percentages.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
The two anesthetic treatment groups were comparable with respect to demographic characteristics ( Table 1). The durations of anesthesia and surgery, amount of local anesthetic solution injected during the operative period, and the number of oral analgesics administered in the recovery area were also similar between the two groups.


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  		Table 1. Demographic Characteristics, Types of Procedures, Durations of Anesthesia and Surgery, and Anesthetic Drug Dosages in the Two Treatment Groups
 
Significantly more patients in the propofol group (40% vs 5% in the desflurane group) had one or more transient movements in response to the surgical stimulus during the procedure ( Table 2). However, coughing and/or respiratory irritation (which occurred in only 9–10% of the patients) did not differ between the two groups. Similarly, the vital signs did not differ between the two groups during the maintenance period (data not reported).


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  		Table 2. Incidence of Postoperative Side Effects During the First 24-h Period after Surgery and Patient Satisfaction with Anesthesia in the Two Groups
 
The early recovery times (including eye opening and following verbal commands) were significantly shorter in the desflurane group ( Table 3). Fast-track criteria were achieved earlier (11 ± 4 vs 13 ± 5 min) in the desflurane (versus propofol) group (P < 0.05). Use of desflurane also significantly reduced the time to standing up and ambulating. Even though the length of the recovery room stay ("home readiness") and actual discharge were reduced by 14% and 10%, respectively, in the desflurane group, these differences did not achieve statistical significance.


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  		Table 3. Postanesthesia Recovery Times in the Two Treatment Groups
 
The incidence of PONV before discharge was also similar in the propofol and desflurane groups (Table 2). Only one patient complained of nausea in the propofol group and three patients experienced nausea in the desflurane group. Similarly, the number of patients requesting a rescue antiemetic did not differ between the two groups (0 and 2 in the propofol and desflurane groups, respectively). During the 24-h follow-up period, the incidence of PONV was not significantly different between the two groups, with one patient in the propofol and four in the desflurane group complaining of symptoms of PONV. Only one patient in the desflurane group experienced vomiting or retching. Of importance, over 95% of the patients in both groups reported being "highly satisfied" with their anesthetic experience (Table 2).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
The practice of office-based surgery is expected to continue to grow because of the reduced costs associated with surgical care in this setting compared to a hospital-based or freestanding ambulatory surgery center (10). A wide variety of surgical procedures have been performed in the office-based setting (11,12) using general anesthesia (13), local sedation (14), and sedation-analgesic (15) techniques. The ideal anesthetic technique for office-based surgery should be capable of producing a rapid and smooth onset of its clinical effects, intraoperative amnesia and analgesia (spontaneous ventilation), and optimal surgical conditions while facilitating a short recovery period that allows patients to predictably achieve fast-track eligibility in the OR without side effects (16).

Propofol, sevoflurane, and desflurane all possess a rapid and smooth onset of action, provide satisfactory anesthetic and surgical conditions, and have been associated with a fast recovery of cognitive and psychomotor skills after ambulatory surgery (3,4,17,18). However, the increased incidence of PONV after sevoflurane (4,5) and desflurane (4,19,20) compared to propofol is a particular concern when these volatile anesthetics are used in the office setting because of the limited recovery facilities. Because PONV can lead to prolonged times to discharge and unanticipated hospital admissions after ambulatory surgery (21), special considerations must be given to preventing these uncomfortable side effects (6). Although use of sevoflurane for maintenance of office-based anesthesia is associated with a frequent incidence of postoperative emesis (15–40%), which may contribute to decreased patient satisfaction (5), the addition of a multimodal antiemetic prophylaxis regimen can minimize these untoward outcomes in the office setting (22). Analogous to the recent findings of Scuderi et al. (7), we have also found that the use of "triple" antiemetic prophylaxis (22) is significantly more effective than a single drug alone (5) in preventing emetic sequelae after volatile anesthesia in this patient population.

In the present study, variables that are known to influence the incidence of PONV (i.e., gender, type and duration of operation, history of PONV and motion sickness) were similar in both anesthetic treatment groups. Although there was only one patient who experienced nausea after propofol, there were three patients who had transient nausea in the recovery area after desflurane anesthesia. None of the patients in the propofol group experienced vomiting, retching or required rescue antiemetics compared to one case of vomiting and two patients who required a rescue antiemetic in the desflurane group. Because none of the patients received either opioid analgesics or muscle relaxants during the perioperative period, analgesia was provided by the local anesthetics and ketorolac. Avoiding opioid analgesics and neuromuscular reversal drugs reduces the risk of PONV after ambulatory surgery (23).

Analogous to the findings of Ashworth and Smith (24), use of desflurane as an alternative to propofol for maintenance of anesthesia in spontaneously breathing patients significantly improved the surgical conditions (e.g., fewer movements) without increasing respiratory complications. In addition, desflurane facilitated a faster emergence from anesthesia compared to propofol. However, later recovery end points, including "home readiness" and actual discharge, were similar in the two groups. Of importance, all patients in this study achieved the fast-tracking criteria while still in the OR and were able to be discharged home from the office surgery center within one hour after the operation. During the 24-hour follow-up evaluation, there was only a small incidence of minor side effects in both groups. Overall patient satisfaction with their anesthetic experience was equally high in both the desflurane and propofol groups.

Office-based anesthesia with either propofol-N2O or propofol-desflurane-N2O can provide safe and effective conditions for superficial surgical procedures with a high degree of patient satisfaction. Although this investigation can be criticized because the anesthesiologist caring for the patient was not blinded as to the maintenance drug, both anesthetics were titrated to similar EEG-BIS values. In addition, the types of surgical procedures were similar in both groups, and all operations were performed by the same group of surgeons and anesthesiologists. Of interest, these data suggest that the BIS monitor is not very useful in "predicting" purposeful movements during surgery. Further studies are needed to assess the cost-effectiveness and cost-benefit of using desflurane (combined with antiemetic prophylaxis) as an alternative to propofol for maintenance of anesthesia in the office-based setting.

In conclusion, desflurane provided significantly better intraoperative conditions than propofol during the maintenance period. With triple antiemetic prophylaxis consisting of ondansetron (4 mg), droperidol (0.625 mg), and metoclopramide (10 mg) administered before the end of surgery, PONV after desflurane anesthesia was reduced to a level comparable to propofol after office-based surgery.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Laurito CE. Proceedings of the Annual Meeting of the Society for Office-Based Anesthesia. J Clin Anesth 1998; 10: 445–8.[Medline]
  2. White PF. Practical issues in outpatient anaesthesia: management of postoperative pain and emesis. Can J Clin Anesth 1995; 42: 1053–5.
  3. Smith I, White PF, Nathanson M, Gouidson R. Propofol: an update on its clinical use. Anesthesiology 1994; 81: 1005–43.[Web of Science][Medline]
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  5. Tang J, Chen L, White PF, et al. Recovery profile, costs, and patient satisfaction with propofol and sevoflurane for fast-track office-based anesthesia. Anesthesiology 1999; 91: 253–61.[Web of Science][Medline]
  6. White PF, Watcha MF. Postoperative nausea and vomiting: prophylaxis versus treatment. Anesth Analg 1999; 89: 1337–9.[Free Full Text]
  7. Scuderi P, James R, Harris L, Mims III GR. Multimodal management eliminates postoperative nausea and vomiting (PONV) following outpatient laparoscopy [abstract]. Anesthesiology 1999; 91: A6.
  8. White PF. Criteria for fast-tracking after ambulatory anesthesia. J Clin Anesth 1999; 11: 78–9.[Web of Science][Medline]
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  10. Schultz LS. Cost analysis of office surgery clinic with comparison to hospital outpatient facilities for laparoscopic procedures. Int Surg 1994; 79: 273–7.[Web of Science][Medline]
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  15. Tobin HA. Low-dose ketamine and diazepam. Use as an adjunct to local anesthesia in an office operating room. Arch Otolaryngol 1982; 108: 439–40.[Abstract/Free Full Text]
  16. White PF. Ambulatory anesthesia advances into the new millennium. Anesth Analg 2000; 90: 1234–5.[Free Full Text]
  17. Smith I, Nathanson MH, White PF. The role of sevoflurane in outpatient anesthesia. Anesth Analg 1995;81:S67–72 .
  18. Song D, Joshi GP, White PF. Fast-track eligibility after ambulatory anesthesia: a comparison of desflurane, sevoflurane, and propofol. Anesth Analg 1998; 86: 267–73.[Abstract]
  19. Hough MB, Sweeney B. Postoperative nausea and vomiting in arthroscopic day-case surgery: a comparison between desflurane and isoflurane. Anaesthesia 1998; 53: 910–24.[Web of Science][Medline]
  20. Raeder JC, Mjaland O, Aasbo V, et al. Desflurane verses propofol maintenance for outpatient laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1998; 42: 106–10.[Web of Science][Medline]
  21. Watcha MF, White PF. Postoperative nausea and vomiting: its etiology, treatment, and prevention. Anesthesiology 1992; 77: 162–84.[Web of Science][Medline]
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  24. Ashworth J, Smith I. Comparison of desflurane with isoflurane or propofol in spontaneously breathing ambulatory patients. Anesth Analg 1998; 87: 312–8.[Abstract/Free Full Text]
Accepted for publication September 25, 2000.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins and Stanford University Libraries' HighWire Press®. Copyright 2001 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press