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© 2001 International Anesthesia Research Society
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Abstract |
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Implications: In this study, although 41%–94% of the patients were fast-track eligibleafter laparoscopic surgery, only 35%–53% of the patients actuallybypassed the postanesthesia care unit (PACU) because of anesthetic-relatedfactors and surgical complications. Residual sedation was the most commonanesthetic-related cause of failure to bypass thePACU.
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Introduction |
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In the ambulatory setting, fast-tracking refers to bypassing the postanesthesia care unit (PACU) by transferring patients directly from the operating room (OR) to the step-down (phase II) recovery area (1). Although fast-tracking can be reliably accomplished after procedures performed under monitored anesthesia care, the use of general anesthesia represents a greater challenge because of the residual anesthetic effects and more frequent incidence of side effects (2,3). The use of a laryngeal mask airway and supplementation with nonopioid analgesics facilitates the fast-tracking process after general anesthesia, thereby allowing outpatients undergoing superficial operative procedures to be fast-tracked and discharged within 1 h after surgery (4–6).
For outpatients undergoing ambulatory procedures requiring tracheal intubation, fast-tracking raises additional concerns regarding airway complications and adequacy of neuromuscular reversal. In a preliminary study (7), we evaluated the effects of different maintenance anesthetics on the time to achieve fast-track eligibility after gynecologic laparoscopy. However, there was no attempt to actually bypass the PACU in that study. Therefore, we designed a follow-up study to evaluate the feasibility of actually fast-tracking outpatients undergoing gynecologic laparoscopy and to determine both the anesthetic and nonanesthetic factors that precluded bypassing of the PACU.
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Methods |
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After we obtained IRB approval and written informed consent, 51 healthy female outpatients scheduled for laparoscopic tubal ligation procedures were randomly assigned to one of three anesthetic treatment groups on the basis of a computer-generated random numbers table. Patients were excluded from the study if they had a serious preexisting medical condition, a body weight >50% above the ideal, or a history of alcohol or drug abuse. All anesthetics were administered by a care team consisting of a small group of attending anesthesiologists working with nurse anesthetists, all of whom were familiar with the anesthetics used in the study.
Upon arrival in the OR, noninvasive monitors were used to record heart rate, mean arterial pressure, and oxygen saturation. In addition, the electroencephalogram Bispectral index (BIS) value was obtained by using a single-channel sensor in a frontal temporal montage (A-1050 EEG Monitor; Aspect Medical Systems, Inc., Natick, MA). After we obtained baseline values, midazolam 2 mg IV was administered as preoperative medication.
Anesthesia was induced with propofol 2 mg/kg IV and fentanyl 1 µg/kg IV. Tracheal intubation was performed after administering rapacuronium 1.5 mg/kg IV and topical lidocaine 4% intratracheally (4 mL). For maintenance of anesthesia, patients were randomized to receive an infusion of propofol 100 µg · kg-1 · min-1 (Propofol group), sevoflurane 1.2% (Sevoflurane group), or desflurane 3% (Desflurane group), in combination with nitrous oxide (N2O) 65% in oxygen. The primary maintenance anesthetic was subsequently titrated to maintain a target BIS value of 60 during the operation. The inspired sevoflurane or desflurane concentration and the propofol infusion rate were changed by 50%–100% if the BIS value was >70 or <50 for 60 s or longer. All patients were mechanically ventilated to maintain an end-tidal CO2 concentration of 32–36 mm Hg. A supplemental dose of rapacuronium 0.5 mg/kg IV was administered only if the postintubation peak inspiratory pressure increased by >50% or coughing ("bucking") occurred. Supplemental doses of fentanyl 25–50 µg IV were given to treat persistent increases in heart rate (>100 bpm) or mean arterial pressure (>20% of the preanesthesia baseline) that failed to respond to increases in the maintenance anesthetic. Surgeons instilled a mixture of lidocaine 1% and bupivacaine 0.25% (5 mL) on the surface of each fallopian tube before ligation and also injected this local anesthetic mixture at the fascial level of each surgical portal. All patients received a combination of prophylactic antiemetics consisting of droperidol 0.625 mg IV, dexamethasone 4 mg IV, and ondansetron 4 mg IV. In addition, acetaminophen (1.3 g per rectum) and ketorolac (30 mg IV) were administered to minimize postoperative pain. The primary maintenance anesthetic was discontinued when the laparoscope was withdrawn from the abdominal cavity, and N2O was discontinued after the last skin suture was placed.
A blinded observer assessed recovery times to awakening (i.e., opening eyes in response to a verbal command) and orientation to person and place, as well as the time to achieve a modified Aldrete score of 10 (8) at 1-min intervals after discontinuation of the maintenance anesthetics. Upon leaving the OR, patients who satisfied a standardized fast-tracking criteria (9) were eligible to be transported directly from the OR to the phase II recovery unit (bypassing the PACU). If the patient was admitted to the PACU, the reasons for the anesthesiologist’s decision were also recorded. Postoperative side effects, requirements for rescue analgesics and antiemetic therapy, and unanticipated hospital admissions were recorded upon discharge from the phase II recovery unit.
The criteria for home readiness required that the patient be awake and alert, have stable vital signs upon standing, be able to walk without assistance, and not be experiencing intractable side effects. Finally, follow-up evaluations were performed via a telephone interview at 24 and 72 h (or 96 h) after surgery to assess patient satisfaction with the quality of the recovery from anesthesia (by using a 100-point verbal rating scale [0 = poor recovery to 100 = excellent recovery]) (10), postdischarge side effects, and time to resume normal activities.
An a priori power analysis based on earlier studies involving a similar patient population (7,9) suggested that a group size of 15 would be adequate to determine a difference of 45% or more in the time to achieve fast-track eligibility with a power of 0.80 and 
= 0.05. Data were analyzed with the Number Cruncher Statistical System (NCSS, Kaysville, UT) version 6.0. A one-way analysis of variance was used for all continuous variables, with the Bonferroni test performed for post hoc intergroup comparisons. Categorical data were analyzed by using the 
2 test. Data were presented as mean values ± SD, numbers, or percentages, with P values <0.05 considered statistically significant.
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Results |
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The three treatment groups were similar with respect to their demographic characteristics (Table 1). Patients maintained with sevoflurane or desflurane emerged more rapidly from anesthesia than those receiving propofol. Not surprisingly, a larger percentage of patients in the volatile anesthetic groups was judged to be fast-track eligible (77% and 94% for Sevoflurane and Desflurane, respectively, compared with 41% for Propofol [P < 0.05]). However, the percentages of patients who actually bypassed the PACU were similar in the three anesthetic groups (35% to 53%) (Table 1). The overall incidences of side effects were also comparable, except that fewer patients in the Desflurane group complained of pain before discharge. Patient satisfaction with their quality of recovery was equally high in all three groups (Table 1).
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Reasons for failure to bypass the PACU included residual sedation, nonspecific factors (e.g., weakness, shivering), and surgical complications (Table 2). In the Propofol group, residual sedation (sleepiness) was the primary factor preventing fast-tracking, whereas nonspecific factors were more important in the volatile anesthetic groups. No patient was admitted to the hospital because of an anesthesia-related complication, although one bypassed patient experienced the onset of pulmonary edema in the step-down (phase II) unit. The times to home readiness were similar in all three anesthetic groups. Moreover, the times to home readiness and actual discharge for the bypassed patients (113 ± 44 and 172 ± 51 min, respectively) were not significantly shorter than for the nonbypassed group (132 ± 53 and 191 ± 61 min, respectively). Finally, patient satisfaction scores with the quality of their recovery from anesthesia were similar in the bypassed (94 ± 10) and nonbypassed (96 ± 5) patients.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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With a standardized anesthetic technique involving the use of a new short-acting nondepolarizing muscle relaxant (rapacuronium), 35% to 53% of outpatients undergoing laparoscopic gynecologic surgery were able to successfully bypass the PACU at our University teaching hospital. Although anesthetic-related factors (e.g., residual sedation and weakness) were the most common reasons for admitting the patient to the PACU, nonanesthetic factors (e.g., surgical complications) also contributed to the failure of patients to be fast-tracked. In some cases, the attending anesthesiologist’s decision to take a fast-track eligible patient to the PACU was apparently influenced by the use of rapacuronium, an investigational muscle relaxant at the time this study was performed.
In a recently published study involving a similar gynecologic laparoscopy population (11), we were able to fast-track 78%–81% of the patients by using desflurane and N2O for maintenance of anesthesia. The only significant difference between the two protocols related to the adjunctive IV drugs (e.g., analgesics and muscle relaxants). Because succinylcholine and mivacurium were used for muscle relaxation in the previous study (11), the decision to use rapacuronium may have been a confounding factor in this study. Of interest, the times to home readiness and actual discharge were significantly reduced in the subgroup of patients who bypassed the PACU in this earlier study.
Apfelbaum (12) reported that, one month after an educational program describing the potential benefits of the PACU bypass paradigm, bypass rates after general anesthesia increased from 0%–2% to 14%–42% at five ambulatory surgery centers. Patients who bypassed the PACU were alleged to have reduced total recovery times, and there were no differences in any other patient outcome measures. Patel et al. (13) also reported that children admitted directly to the phase II recovery unit from the OR were discharged home earlier. It is interesting to note that fewer children in the fast-tracked group required pain medication after surgery.
The failure to demonstrate significant differences in times to home readiness and actual discharge in our study may have been related to the fact that several fast-track-eligible patients were admitted to the PACU because of the anesthesiologist’s concerns regarding the use of an investigational muscle relaxant or because of surgical complications. Because the study was probably underpowered with respect to the later recovery end points, we combined these fast-track recovery data with our earlier findings in an identical patient population (11). By using the combined data, overall times to home readiness (112 ± 45 minutes) and actual discharge (167 ± 63 minutes) in the bypassed patients (n = 63) were significantly reduced compared with the nonbypassed group (n = 29) (139 ± 41 and 196 ± 56 minutes, respectively).
Analogous to an earlier study (7), maintenance of anesthesia with desflurane was associated with the most rapid emergence and shortest time to achieving fast-track eligibility. However, in terms of the overall number of patients who bypassed the PACU, there were no significant differences among the three anesthetic groups. Although residual sedation was less likely to interfere with fast-tracking when desflurane (versus propofol) was used for maintenance of anesthesia, nonspecific factors on emergence from anesthesia were more frequent in patients receiving desflurane. Nonanesthetic factors included surgical complications (e.g., uterine perforations, intraabdominal hemorrhage, or the need for open laparotomy) and nonspecific concerns of the attending anesthesiologist. In one patient who was initially fast-tracked, the onset of pulmonary edema in the step-down unit necessitated overnight hospitalization. This complication has been reported previously after laparoscopic surgery (14).
This study can be criticized because of the use of rapacuronium rather than more traditional muscle relaxant drugs, prolonged surgery times and a high surgical complication rate because of the lack of experience on the part of the operating surgeons at our public teaching hospital, and relatively small group sizes because we were using an investigational new drug (rapacuronium). Although the use of rapacuronium was a potential confounding factor in this fast-tracking study, it was administered to all patients enrolled in this study.
In conclusion, 35% to 53% of outpatients undergoing gynecologic laparoscopy were able to bypass the PACU. Both anesthetic and nonanesthetic factors were found to interfere with the fast-tracking process at this teaching institution.
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Acknowledgments |
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Supported in part by the Ambulatory Anesthesia Research Foundation in Dallas, TX, and the White Mountain Institute in Los Altos, CA.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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- White PF. Bypassing (fast-tracking) of the recovery room after ambulatory surgery. Acta Anaesthesiol Scand 1998; 42: 189–91.[Web of Science][Medline]
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Song D, Greilich NB, White PF, et al. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000; 91: 876–81.
[Abstract/Free Full Text] - Li S, Coloma M, White PF, et al. Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. Anesthesiology 2000; 93: 1225–30.[Web of Science][Medline]
- Tang J, Chen L, White PF, et al. Use of propofol for office-based anesthesia: effect of nitrous oxide on recovery profile. J Clin Anesth 1999; 11: 226–30.[Web of Science][Medline]
- 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]
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Tang J, White PF, Wender RH, et al. Fast-track office-based anesthesia: a comparison of propofol versus desflurane with antiemetic prophylaxis in spontaneously breathing patients. Anesth Analg 2001; 92: 95–9.
[Abstract/Free Full Text] - 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]
- Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995; 7: 89–91.[Web of Science][Medline]
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White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the Aldrete’s scoring system. Anesth Analg 1999; 88: 1069–72.
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Myles PS, Hunt JO, Nightingale CE, et al. Development and psychometric testing of recovery score after general anesthesia and surgery in adults. Anesth Analg 1999; 88: 83–90.
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Coloma M, Chiu JW, White PF, et al. Use of esmolol as an alternative to remifentanil during desflurane anesthesia for outpatient gynecologic laparoscopy surgery. Anesth Analg 2001; 92: 362–7.
[Abstract/Free Full Text] - Apfelbaum JL. Bypassing PACU : a cost effective measure. Can J Anaesth 1998; 45: R91–2.[Web of Science][Medline]
- Patel R, Hannallah R, Verghese S, et al. Fast-tracking (bypassing phase I recovery unit) in children undergoing short surgical procedures [abstract]. Anesthesiology 1998; 89: A53.
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Healzer JM, Nezhat C, Brodsky JB, et al. Pulmonary edema after absorbing crystalloid irrigating fluid during laparoscopy [letter]. Anesth Analg 1994; 78: 1207.
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