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Anesthetic techniques for ambulatory surgery �� Discuss optimal general, regional and local anesthetic techniques for fast-tracking patients after surgery, �� Describe benefits of fast-track recovery programs, �� Review techniques for minimizing postoperative nausea and vomiting, �� Review the concept of multimodal (“balanced”) analgesia for the management of postoperative pain, �� Describe the side effects of opioid analgesics, �� Describe the side effects of non-steroidal anti-inflammatory drugs, �� Describe the side effects of antiemetic drugs, �� Discuss the benefits of “complementary” non-pharmacologic therapies in the prevention of pain and emesis, �� Explain how postoperative pain and nausea and vomiting can interfere with the fast-tracking process, �� Describe the benefits of propofol (vs. thiopental) and desflurane (vs. isoflurane and sevoflurane). Introduction
Values are means ± SD or numbers (n) or percentages (%) Table 2: Comparison of propofol and desflurane when used in combination with nitrous oxide for maintenance of anesthesia for fast-track, office-based ambulatory surgery (Tang et al12). Propofol Desflurane 57 ± 18 53 ± 17 66 ± 14 70 ± 14 36 ± 14 40 ± 20 34 ± 14 37 ± 19 319 ± 98 146 ± 137 N/A 2.3 ± 0.6 14 (40) 2 (5)* 3 (9) 4 (10) 4 (11) 1 (3) 1 (3) 3 (8) 0 (0) 1 (3) 0 (0) 2 (5) 5 (14) 3 (8) 1 (3) 6 (15) 0 (0) 1 (3) 6 ± 2 4 ± 2* 23 ± 15 14 ± 5* 51 ± 14 46 ± 10 1 (3) 4 (10) 0 (0) 1 (3) 0 (0) 0 (0)
* p<0.05 compared to Propofol and/or Isoflurane groups
Claims regarding cost-effectiveness of anesthetic drugs should be subjected to close scrutiny, with studies specifically designed to evaluate the impact of a given technique on healthcare personnel costs, the ability of the surgical team to complete additional surgical procedures in the same operating room session, and/or the ability of the patient and their caretakers to resume their normal activities.33 It will be necessary to alter work patterns (e.g., discharge policies) to obtain the full benefits of the newer drugs and techniques in the outpatient setting. For example, eliminating the minimum lengths of stay in recovery areas, and allowing patients who achieve fast-track criteria in the OR to bypass the more laborintensive postanesthesia care unit (PACU).34,35 It is clear that greater cost savings in the operating room can be achieved by increasing efficiency in resource utilization (e.g., personnel) than by limiting the availability of new anesthetic drugs and techniques.35 The use of newer monitoring devices that can improve the titration of anesthetic drugs can also facilitate the fast-tracking process.36 The bispectral (BIS) index is derived from the electroencephalograph (EEG) and has been correlated with the hypnotic component of the anesthetic state. EEG-BIS monitoring provides practitioners with information regarding the degree of sedation or hypnosis produced by centrally-acting anesthetic drugs. The BIS monitor has been found to be useful in predicting recovery of consciousness from general anesthesia when using either IV or inhaled anesthetic drugs.36,37 For example, titrating desflurane or sevoflurane to maintain a BIS index value of 60 during general anesthesia decreased the amount of the volatile anesthetic administered during the maintenance period compared to “standard practices,” resulting in a faster emergence. Similarly, the use of a BIS titration protocol also resulted in a more rapid emergence and shorter times to extubation after propofol-based anesthesia.37 The BIS value at the end of surgery correlates with the time required to meet fast-track and PACU discharge criteria.38 Analogous to earlier studies with the BIS monitor, recent studies with the auditory evoked potential (AEP) monitor have found that it can also be used to facilitate the fast-tracking process, leading to earlier PACU and hospital discharge.39 In the present healthcare environment, it is also important to consider the increased costs associated with cerebral function monitoring (e.g., the cost of the monitor and its disposable accessories). Therefore, performance of a cost-benefit analysis is useful before introduction of this technology into “routine” anesthesia practice. An important step in this process is to document that these monitors actually improve the anesthesia provider’s ability to administer anesthetic drugs (e.g., decreasing emergence, turnover, and recovery times) and improve patient outcome (e.g., reducing postoperative side effects). By improving the titration of propofol, desflurane and sevoflurane with these cerebral monitors, it should be possible to fast-track the vast majority of patients receiving general anesthesia for ambulatory surgery. While cost analysis of new medical devices is complex and the benefits are difficult to measure with any accuracy,40 the potential benefits of improved monitoring and titration of anesthetic drugs are obvious in a fast-tracking environment. Finally, adjunctive drugs that can minimize the anesthetic and analgesic requirements (e.g., ketamine, α- 2 agonists, β-blockers, adenosine, local anesthetics) are helpful in ensuring a rapid and smooth emergence from anesthesia.41-44 Premedication with small doses of sedative-anxiolytic drugs,45 μ-blockers,46 steroids,47 and non-opioid analgesics48 can improve patient outcome and facilitate the fasttracking process. Fast-Tracking Procedures Ambulatory anesthesia is administered with the goal of rapidly and safely establishing satisfactory conditions for the performance of a given surgical or diagnostic procedure. Not surprisingly, anesthesiologists utilize anesthetic drugs with fast, smooth onset, predictable recovery profiles, and no postoperative sequelae. If the careful titration of short-acting drugs permits a safe transfer of patientsdirectly from the OR suites to the less labor-intensive Phase II (step-down) recovery area,11,34,35,44 significant cost savings to the institution could be achieved.40 Although bypassing of Phase I (PACU) recovery is the most common type of “fast tracking” in ambulatory surgery, PACU fast-tracking is an alternative to PACU bypassing for facilitating the recovery process.9,10,12,49 Specific fast-tracking criteria have been developed for outpatients undergoing general, regional and local anesthesia (Figure 1).50,51 Figure 1: Criteria used to determine fast-track eligibility after anesthesia (from White50). Score I. Level of consciousness • awake and oriented 2 • arousable with minimal stimulation 1 • responsive only to tactile stimulation 0 II. Physical activity • able to move all extremities on command 2 • some weakness in movement of extremities 1 • unable to voluntarily move extremities 0 III. Hemodynamic stability • blood pressure <15% of baseline MAP value 2 • blood pressure between 15-30% of baseline MAP value 1 • blood pressure >30% below baseline MAP value 0 IV. Respiratory stability • able to breathe deeply 2 • tachypnea with good cough 1 • dyspneic with weak cough 0 V. Oxygen saturation status • maintains value >90% on room air 2 • requires supplemental oxygen (nasal prongs) 1 • saturation less than 90% with supplemental oxygen 0 VI. Postoperative pain assessment • none or mild discomfort 2 • moderate-to-severe pain controlled with IV analgesics 1 • persistent severe pain 0 VII. Postoperative emetic symptoms • none or mild nausea with no active vomiting 2 • transient vomiting or retching 1 • persistent moderate-severe nausea and vomiting 0 Total score 14 Decreases in OR and PACU labor costs resulting from faster emergence and PACU bypassing (or PACU fast-tracking) vary depending on overtime, personnel requirements, the system used to compensate the nursing staff, and how efficiently the OR suites are utilized.39 Figure 2: Non-opioid analgesic drugs and techniques for ambulatory surgery (from White59) Local anesthetics· lidocaine, 0.5-2% SQ/IV · bupivacaine, 0.125-0.5% SQ · ropivacaine, 0.125-0.5% SQ · levobupivacaine, 0.125-0.5% SQ Nonsteroidal antiinflammatory drugs· ketorolac, 15-30 mg PO/IM,/IV · diclofenac, 50-100 mg PO/IM/IV · ibuprofen, 300-800 mg · indomethacin, 25-50 mg PO/PR/IM · naproxen, 250-500 mg · celecoxib, 100-200 mg · rofecoxib, 25-50 mg Miscellaneous analgesic compounds · acetaminophen, 0.5- · Propacetamol, 0.5- · ketamine, 10-20 mg PO, IM/IV · clonidine, 0.15-0.3 mg PO, IM/IV Non-pharmacologic therapies· transcutaneous electrical nerve stimulation (TENS) · transcutaneous acupoint electrical stimulation (TAES) · acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) The anesthetic and analgesic-sparing effects of local anesthetics when administered before the surgical incision allow patients to be maintained at a “lighter” plane of anesthesia (or sedation) during surgery, contributing to a faster, smoother emergence and more rapid return to a functional status.64 For many superficial surgical procedures, general and regional anesthesia can be avoided by using a combination of local anesthetics and intravenous sedative-analgesic drugs as part of a MAC technique.17 These local anesthetic-based techniques decrease the incidence and severity of postoperative pain, reducing the need for both parenteral and oral opioid-containing analgesics in the recovery period, decreasing PONV and other opioid-related side effects, thereby enabling earlier ambulation and discharge from the ambulatory surgical facility.12,13 The simple infiltration of the surgical wound with local anesthetic can reduce pain and postoperative analgesic requirements, thereby facilitating earlier ambulation and discharge after outpatient surgery.65 Although subcutaneous infiltration of local anesthetics may not improve postoperative pain scores after surgical incisions, administration at the fascial (or subfacial) level improved pain at rest and with movement.66 Compared to spinal or general anesthesia alone, the use of general anesthesia with local anesthetic infiltration significantly reduced postoperative pain and increased the length of time until the patient first requested analgesic medication after undergoing inguinal hernia repair.63 Patients undergoing vein stripping procedures also recovered faster, with less pain and fewer complications when the surgery was performed using a combined femoral and genitofemoral nerve block compared to spinal anesthesia.22 Ilioinguinal and iliohypogastric nerve blocks with bupivacaine 0.25% (30 ml) after inguinal hernia repair also reduced pain in the PACU and decreased the need for oral analgesics after discharge.64 In children, the subfascial instillation of bupivacaine 0.25% provided comparable analgesia after inguinal herniorrhaphy to that obtained with an ilioinguinal/iliohypogastric nerve block.67 The effectiveness of local anesthetics in preventing pain after laparoscopic procedures remains controversial.68-70 Infiltration of the mesosalpinx with bupivacaine has been shown to reduce postoperative pain and cramping after laparoscopic tubal ligations with the “banding” technique, but not when the electrocautery was used. Studies have suggested that bupivacaine sprayed on the lower surface of the liver and in the right subdiaphragmatic space adjacent to the gall bladder reduces postoperative pain and the need for analgesics after laparoscopic cholecystectomy.53 It is still controversial whether the timing of the local anesthetic administration (i.e., pre- vs. post-incision) affects the intensity of pain after surgery.70 Since orthopedic surgery is associated with a high incidence of moderate-to-severe pain, a variety of local anesthetic techniques have been studied in an effort to reduce the postoperative opioid analgesic requirement. For example, ankle blocks have been used to facilitate ambulation and decrease pain after podiatric surgery71 and femoral nerve blocks have reduced opioid usage after anterior cruciate ligament repairs.72 The use of continuous peripheral nerve block techniques for painful orthopedic ambulatory surgery procedures involving the shoulder, knee and foot are becoming increasingly popular.73-75 Local anesthetics are commonly injected into joints to provide analgesia following arthroscopic surgery and studies suggest that they allow for earlier mobilization.65 The addition of ketorolac, either intravenously76 or intra-articularly,77 may further enhance patient comfort in the early postoperative period after arthroscopic procedures. Similarly, intra-articular morphine, clonidine and triamcinolone have all been alleged to provide prolonged analgesia after arthroscopic knee surgery.78-80 The suprascapular nerve block has also been advocated as a simple peripheral block for postoperative pain relief after arthroscopic shoulder surgery.81 The major benefit of using peripheral nerve blocks (or instillation) techniques is that the risk of complications is reduced compared to more complex major nerve block procedures. Nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs have long been used for treating pain syndromes because of their well known anti-inflammatory, antipyretic and analgesic properties. However, with the introduction of parenteral preparations (e.g., ketorolac, diclofenac), these drugs have become more popular in the management of pain associated with ambulatory surgery.59 NSAIDs are known to block the synthesis of prostaglandins by inhibiting theenzyme cyclooxygenase (COX), thereby reducing the production of mediators of the acute inflammatory response. By decreasing the inflammatory response to surgical trauma, NSAIDs have also been alleged to reduce peripheral nociception. Studies suggest that administration of ketorolac at the surgical incision site may enhance its analgesic properties.82 Early reports suggested that NSAIDs possessed analgesic properties comparable to opioid analgesics without opioid-related side effects.83 Outpatients receiving ketorolac experienced a lower incidence of PONV, tolerated oral fluids, and were judged "fit for discharge" earlier than those receiving opioid compounds.84 In children, ketorolac (1 mg/kg IV) was comparable to morphine (0.2 mg/kg IV) in preventing postoperative pain and was associated with less PONV.85 In laparoscopic cholecystectomy patients, ketorolac provided an opioid-sparing effect that resulted in less nausea, somnolence, and respiratory depression.86 For anorectal procedures, use of ketorolac (30 mg) to supplement local anesthesia at the incision site resulted in significantly less postoperative pain, a better quality of recovery,and earlier discharge compared to local anesthesia alone.82 When administered preoperatively to pediatric patients, both the incidence of restlessness and crying, as well as the postoperative opioid requirements, were lower in the NSAID (vs. acetaminophen) treated children.87 Oral ketorolac (1 mg/kg) compared favorably to low-dose acetaminophen (10 mg/kg) for bilateral myringotomy procedures in children, with the ketorolac treated patients recording lower pain scores and requiring less analgesic medication in the early postoperative period.88 In children undergoing inguinal hernia repair, ketorolac (1 mg/kg IV) compared favorably to caudal bupivacaine 0.2% with respect to pain control and postoperative side effects.89 In fact, the ketorolac treated patients had an improved recovery profile, including less vomiting, shorter times to voiding and ambulation, and earlier discharge home. Oral NSAIDs are assuming a more important role as alternatives to the opioid- (hydrocodone or oxycodone)-containing oral analgesics, VicodinTM and LortabTM in the postdischarge period. In an outpatient study involving the use of a multi-modal analgesic technique consisting of alfentanil, lidocaine, ketorolac and paracetamol,62 oral ibuprofen (800 mg q 8h) was equi-analgesic to paracetamol 800 mg plus codeine 60 mg (q 8h) when administered during the first 72 h after discharge, and resulted in better global patient satisfaction and less constipation than the opioid-containing oral analgesic. To achieve the optimal benefit of using NSAIDs in the perioperative period, these compounds should be continued for “preventative” pain management in the early postdischarge period. COX-2 inhibitors In an effort to minimize the potential for operative site bleeding complications, as well as gastrointestinal and renal damage, associated with the traditional NSAIDs,90 the more specific COX-2 inhibitors are being increasingly utilized as non-opioid adjuvants for minimizing pain during the perioperative period (Table 5).
Premedication with rofecoxib also facilitated the recovery process by reducing postoperative pain and improving the quality of recovery from the patient’s perspective (Table 6).
* p<0.05 vs Placebo group PACU = Postoperative Care Unit DSU = Day-Surgery Unit. More recently, a parenterally-active COX-2 inhibitor, parecoxib (20-40 mg IV), has been investigated as an alternative to the classical non-selective parenteral NSAID. Parecoxib is a prodrug with an active metabolite (valdecoxib), and appears to be similar to celecoxib both pharmacokinetically and pharmacodynamically. Both preoperative93 and postoperative94 administration of this investigational COX-2 drug appears to exert significant opioid sparing effects, and these preliminary studies suggest that it may lead to an improvement in the quality of recovery and patient satisfaction with their postoperative pain management. However, cost-efficacy studies will be needed to define the role of the parenteral (vs. oral) COX-2 inhibitors in the ambulatory setting. Non-pharmacological techniques Transcutaneous electrical nerve stimulation (TENS) or acupuncture-like transcutaneous electrical nerve stimulation (ALTENS), as well as percutaneous neuromodulation therapy (PNT), have all been used in the treatment of acute and chronic pain in the ambulatory setting.95 Given the inherent side effects produced by both opioid and non-opioid analgesics, non-pharmacological approaches to the management of acute postoperative pain may become increasingly popular in the future. The mechanisms by which these non-pharmacologic techniques exert their analgesic action have not been completely elucidated. However, possible mechanisms for electroanalgesia include: (1) stimulation of descending pain inhibitory pathways, (2) inhibition of substance-P release in the central nervous system, and (3) the release of endogenous opioid-like substances. Prevention of postoperative nausea and vomiting (PONV) Despite the many recent advances in ambulatory anesthetic and surgical techniques, postoperative nausea and vomiting remain a “big little problem” after ambulatory surgery. PONV is not only distressing to patients, it is also a leading cause for delayed discharge and unanticipated hospital admission after ambulatory surgery.57 A recent survey reported that more than 35% of outpatients experienced PONV severe enough to delay their resumption of normal activities.96 Interestingly, more than 50% of these patients had not complained of nausea nor had they vomited prior to discharge from the ambulatory surgical facility. It is well accepted that anesthetic agents, the type of surgical procedure, and use of opioid analgesics influence the incidence of PONV.97 More recently, additional factors that increase the risk of PONV have been identified. These include age, gender, smoking history, phase of the menstrual cycle, history of motion sickness or postoperative nausea, pain, anxiety, and hydration status. While anesthesiologists have little control over most of these predisposing factors, there are some relatively simple measures (e.g., adequate hydration, avoidance of nitrous oxide and reversal drugs, avoiding large doses of opioid analgesics) that can be useful in reducing the incidence of PONV. For example, outpatients hydrated with 20 ml/kg of intravenous fluid had less postoperative morbidity (including nausea) than those receiving only 2 ml/kg prior to induction of anesthesia.56 The choice of induction agent may also contribute to the reduction of PONV.8,9 Even when propofol was used as an alternative to thiopental for induction of anesthesia, there was an 18% decrease in the number of patients experiencing nausea.98 Propofol administered to induce and maintain general anesthesia was even more effective than ondansetron in reducing PONV and was associated with fewer requests for rescue antiemetics and a faster early recovery.99 The prophylactic administration of antiemetics has been shown to be particularly useful in the prevention of PONV in the ambulatory setting.57 With the introduction of more expensive antiemetic agents (i.e., 5-HT3 receptor antagonists), it is important to consider the cost-effectiveness of these drugs. Droperidol, 0.625 mg IV, was found to be more cost-effective in preventing PONV than ondansetron, 4 mg IV, in outpatients undergoing gynecologic procedures.100,101 Prophylactic antiemetic therapy improves patient outcome for operations associated with a high frequency of emesis (e.g., laparoscopic surgery, ENT, plastics, ophthalmology). Furthermore, the efficacy of prophylactic antiemetics is affected by the timing of their administration. When ondansetron, 4 mg IV, was given at the end of otolaryngologic or gynecologic surgery rather than prior to induction, it produced a greater reduction in the incidence of PONV and the need for rescue antiemetics.102,103 The beneficial effects of ondansetron in improving recovery were clearly evident in the post-discharge period. Ondansetron has also been successfully used for the treatment of established PONV and is superior to metoclopramide, 10 mg IV, in the treatment of PONV.104 The use of combinations of antiemetic agents may be more cost-effective than a single agent for routine prophylaxis.105 Droperidol, 0.625 mg IV, plus metoclopramide, 10 mg IV, was more effective in preventing postoperative nausea after laparoscopic cholecystectomy than ondansetron, 4 mg IV.106 Combining lowdose droperidol and the 5-HT3 antagonists with dexamethasone (4-8 mg IV) may be the “optimal” combination for prophylaxis in high-risk outpatient populations.107 Finally, the use of acupressure and acustimulation at the P6 acupoint has also been investigated for the treatment and prevention of PONV in the ambulatory setting.108,109 Recent studies would suggest that non-pharmacological techniques may compare favorably to antiemetics drugs (e.g., ondansetron) for the prevention of PONV.110 However, acustimulation appears to be less effective for the treatment of established PONV.111 Clearly, the most effective approach to minimizing PONV is one that uses a combination of modalities.55 Notwithstanding the FDA concerns regarding its possible adverse cardiovascular side effects,112 droperidol (0.625-1.25 mg) remains an extremely useful drug for antiemetic prophylaxis when combined with dexamethasone (4-8 mg), a 5-HT3 antagonist [e.g., ondansetron (4 mg), or dolasetron (12.5 mg)],107 and/or acustimulation (e.g., ReliefBandTM).110 Summary The use of rapid, short-acting, fast emergence anesthetic drugs and improved titration techniques can clearly facilitate the recovery process after ambulatory surgical procedures. Local anesthesia combined with either IV sedation (i.e., MAC) or general anesthetic techniques minimizes recovery times and postoperative side effects. However, unless outpatients can be discharged home earlier, or additional cases performed with the same personnel costs, it will be difficult to realize actual cost savings from the use of the more expensive anesthetic drugs and monitoring devices for fast-tracking. The ability to fast-track patients allows them to bypass the labor-intensive recovery areas and be discharged home 20-60 min earlier without compromising either patient satisfaction or safety. 32,35,113,114 A major limitation to the fast-track process has been the inability to reliably prevent postoperative pain and nausea. Therefore, the use of adjuvant drugs and techniques (e.g., local anesthetics, NSAIDs, ketamine, sympatholytics, steroids, and non-pharmacological devices) that minimize the requirements for anesthetic and opioid analgesic medications, as well as the cost-effective usage of prophylactic antiemetic drugs, will enable even more outpatients to be fast-tracked in the future. The use of fast-tracking anesthetic techniques is economically justified if improvements in recovery and work patterns can be demonstrated. From an institutional perspective, earlier achievement of discharge criteria may be meaningless unless it is accompanied by earlier actual discharge times. If the use of the newer anesthetic drugs is associated with decreased recovery times, reduced payments for skilled nursing care or an earlier return to work by the patient, their preferential use can be easily justified. However, anesthetic practices have advanced to the point where cost savings from variations in drug use are only apparent when system-wide improvements are made in the efficiency of resource utilization (including personnel, space, time, consumables and capital investments). In conclusion, there is no ideal anesthetic agent or technique for all outpatient surgery procedures. However, there is an impressive array of pharmacologic drugs which, when combined in a rational manner and carefully titrated, can produce the desired anesthetic conditions and still permit a fast-track recovery. With the available pharmacologic armamentarium and enhanced monitoring capabilities, the anesthesiologist should be able to provide all ambulatory surgery patients with a relaxed and comfortable perioperative experience. 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Cost-efficacy of rofecoxib versus acetaminophen for preventing pain after ambulatory surgery. Anesthesiology 2002;97:931-7 49. Watkins AC, White PF. Fast-tracking after ambulatory surgery. J Perianesth Nurs 2001;16:379-87. 50. White PF. Criteria for fast-tracking outpatients after ambulatory surgery. J Clin Anesth 1999; 11:78-9. 51. White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete’s scoring system. Anesth Analg 1999; 88: 1069-72. 52. Enlund M, Kobosko P, Rhodin A. A cost-benefit evaluation of using propofol and alfentanil for a short gynecological procedure. Acta Anesth Scand 1996, 40:416-20. 53. Michaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996, 82:44-51. 54. Eriksson H, Tenhunen, Korttila K. Balanced analgesia improves recovery and outcome after outpatient tubal ligation. Acta Anaesth Scand 1996;40:151-5. 55. Scuderi PE, James RL, Harris L, et al. Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy. Anesth Analg 2000;91:1408-1414. 56. Yogendran S, Asokumar B, Cheng D, Chung F. A prospective, randomized double-blind study of the effect of intravenous fluid therapy on adverse outcomes after outpatient surgery. Anesth Analg 1995;80:682-6. 57. White PF, Watcha MF. Postoperative nausea and vomiting: Prophylaxis versus treatment. Anesth Analg 1999;89:1337-9. 58. Pavlin DJ, Chen C, Penaloza DA, et al. Pain as a factor complicating recovery and discharge after ambulatory surgery. Anesth Analg 2002;95:627-34. 59. White PF. The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. Anesth Analg 2002;94:577-85. 60. Gesztesi Z, Sá Ręgo MM, White PF. The comparative effectiveness of fentanyl and its newer analogs during extracorporeal shock wave lithotripsy under monitored anesthesia care. 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Subcutaneously versus subfascially administered lidocaine in pain treatment after inguinal herniotomy. Anesth Analg 1994;79:324-7. 67. Casey WF, Rice LJ, Hannallah RS, et al. A comparison between bupivacaine instillation versus ilioinguinal/iliohypogastric nerve block for postoperative analgesia following inguinal herniorrhaphy in children. Anesthesiology 1990;72:637-9. 68. Narchi P, Benhamou D, Fernandez H. Intraperitoneal local anaesthetic for shoulder pain after day-case laparoscopy. Lancet 1991;338:1569-70. 69. Saff GN, Marks RA, Kuroda M, et al. Analgesic effect of bupivacaine on extraperitoneal laparoscopic hernia repair. Anesth Analg 1998; 87:377-81. 70. Pasqualucci A, de Angelis V, Contardo R, et al. Preemptive analgesia: Intraperitoneal local anesthetic in laparoscopic cholecystectomy. A randomized, double-blind, placebo-controlled study. Anesthesiology 1996;85:11-20. 71. Needoff M, Radford P, Costigan P. Local anesthesia for postoperative pain relief after foot surgery: a prospective clinical trial. Foot Ankle Int 1995;16:11-13. 72. Edkin BS, Spindler KP, Flanagan JF. Femoral nerve block as an alternative to parenteral narcotics for pain control after anterior cruciate ligament reconstruction. Arthroscopy 1995;11:404-409. 73. Klein SM, Greengrass RA, Steele SM, et al. A comparison of 0.5% bupivacaine, 0.5% ropivacaine, and 0.75% ropivacaine for interscalene brachial plexus block. Anesth Analg 1998; 87:1316-9. 74. Mulroy MF, Larkin KL, Batra MS, et al. Femoral nerve block with 0.25% or 0.5% bupivacaine improves postoperative analgesia following outpatient arthroscopic anterior cruciate ligament repair. Reg Anesth Pain Med 2001; 26:24-9. 75. Singelyn FJ, Aye F, Gouverneur JM. Continuous popliteal sciatic nerve block: An original technique to provide postoperative analgesia after foot surgery. Anesth Analg 1997;84:383-6. 76. Smith I, Shively RA, White PF. Effects of ketorolac and bupivacaine on recovery after outpatient arthroscopy. Anesth Analg 1992;75:208-12. 77. Reuben S, Connelly NR. Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular bupivacaine and ketorolac. Anesth Analg 1995; 80: 1154-7. 78. Stein C, Comisel K, Haimerl E, et al. Analgesic effect of intraarticular morphine after arthroscopic knee surgery. N Engl J Med 1991;325:1123-6. 79. Reuben SS, Connelly NR. Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular clonidine. Anesth Analg 1999; 88: 729-33. 80. Wang JJ, Ho ST, Lee SC, et al. Intraarticular triamcinolone acetonide for pain control after arthroscopic knee surgery. Anesth Analg 1998: 87: 1113-6. 81. Ritchie ED, Tong D, Chung F, et al. Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: a new modality?. Anesth Analg 1997;84:1306-1312. 82. Coloma M, White PF, Huber PJ, et al. The effect of ketorolac on recovery after anorectal surgery: IV versus local administration. Anesth Analg 2000; 90:1107-10. 83. O'Hara DA, Fragen RJ, Kinzer M, et al. Ketorolac tromethamine as compared with morphine sulfate for the treatment of postoperative pain. Clin Pharmacol Ther 1987;41:556-61. 84. Ding Y, White PF. Comparative effects of ketorolac, dezocine and fentanyl as adjuvants during outpatient anesthesia. Anesth Analg 1992;75:566-71. 85. Watcha MF, Jones MB, Lagueruela RG, et al. Comparison of ketorolac and morphine as adjuvants during pediatric surgery. Anesthesiology 1992;76:368-72. 86. Liu J, Ding Y, White PF, et al. Effects of ketorolac on postoperative analgesia and ventilatory function after laparoscopic cholecystectomy. Anesth Analg 1993;76:1061-6. 87. Baer GA, Rorarius MGF, Kolehmainen S, Seliu S. The effect of paracetamol or diclofenac administered before operation on postoperative pain and behavior after adenoidectomy in small children. Anaesthesia 1992;47:1078- 80. 88. Watcha MF, Ramirez-Ruiz M, White PF, et al. Perioperative effects of oral ketorolac and acetaminophen in children undergoing bilateral myringotomy. Can J Anaesth 1992;39:649-54. 89. Splinter WM, Reid CW, Roberts DJ, Bass J: Reducing pain after inguinal hernia repair in children: caudal anesthesia versus ketorolac tromethamine. Anesthesiology 1997;87:542-6. 90. Souter AJ, Fredman B, White PF. Controversies in the perioperative use of nonsteroidal antiinflammatory drugs. Anesth Analg 1994;79:1178-1190. 91. Reuben SS, Connelly NR. Postoperative analgesic effects of celecoxib or rofecoxib after spinal fusion surgery. Anesth Analg 2000; 91: 1221-5. 92. Issioui T, Klein KW, White PF, et al. The efficacy of premedication with celecoxib and acetaminophen in preventing pain after otolaryngologic surgery. Anesth Analg 2002;94:1188-93. 93. Desjardins PJ, Grossman EH, Kuss ME, et al. The injectable cyclooxygenase-2-specific inhibitor parecoxib sodium has analgesic efficacy when administered preoperatively. Anesth Analg 2001; 93:721-7. 94. Tang J, Li S, White PF, et al. Effect of parecoxib, a novel intravenous cyclooxygenase type-2 inhibitor, on the postoperative opioid requirement and quality of pain control. Anesthesiology 2002;96:1305-9. 95. White PF, Li S, Chiu JW. Electroanalgesia: its role in acute and chronic pain management. Anesth Analg 2001; 92: 505-13. 96. Carroll NV, Miederhoff P, Cox FM, Hirsch JD. Postoperative nausea and vomiting after discharge from outpatient surgery centers. Anesth Analg 1995;80:903-909. 97. Watcha MF, White PF. Postoperative nausea and vomiting: Its etiology, treatment, and prevention. Anesthesiology 1992; 77: 162-84. 98. Myles PS, Hendrata M, Bennett AM, et al. Postoperative nausea and vomiting. Propofol or thiopentone: does choice of induction agent affect outcome?. Anaesth Intensive Care 1996;24:355-359. 99. 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The use of transcutaneous acupoint electrical stimulation for preventing nausea and vomiting after laparoscopic surgery. Anesth Analg 2001;92:629-35. 110. White PF, Issioui T, Hu J, et al. Comparative efficacy of acustimulation (ReliefBand ) versus ondansetron (Zofran ) in combination with droperidol for preventing nausea and vomiting. Anesthesiology 2002; 97:1075-81. 111. Coloma M, White PF, Ogunnaike BO, et al. Comparison of acustimulation and ondansetron for the treatment of established postoperative nausea and vomiting. Anesthesiology 2002 (December). 112. White PF. Droperidol: A cost-effective antiemetic for over thirty years. Anesth Analg 2002;95:789-90. 113. Patel RI, Verghese ST, Hannallah RS, et al. Fast-tracking children after ambulatory surgery. Anesth Analg 2001; 92: 918-22. 114. Coloma M, Greilich N, White PF. Recovery after inguinal herniorraphy: Effect of a multimodal prophylaxis regimen on outcome. Anesthesiology 2000; 93: A38. Fast-tracking concepts for ambulatory surgery Multiple-choice questions 1. Ondansetron is most effective for prophylaxis when administered:
2. The most cost-effective antiemetic drug for routine antiemetic prophylaxis is:
3. Which of the following factors is least important in preventing post-operative nausea and vomiting:
4. The most cost-effective anesthetic technique for ambulatory surgery is:
5. The minimal fasting period for taking oral medication prior to elective surgery is:
6. The disadvantages of central neuroaxial blockade include all of the following except:
7. The opioid of choice for the management of moderate/severe pain immediately after ambulatory surgery is:
8. Local anesthetics are most effective in preventing postoperative pain when injected:
9. For preventing pain after discharge, which NSAID is the most effective?
10. Which of the following non-opioid drugs is most commonly used as an adjuvant to oral opioid analgesics?
11. Which of the following non-pharmacologic pain therapies is most appropriate for use in the postoperative period?
12. Which anesthetic technique is associated with the earliest discharge after superficial ambulatory surgery procedures?
13. The “optimal” approach to postoperative pain management involves:
14. Which factor is probably of least importance in facilitating the fast-tracking process?
15. The most important benefit of fast-tracking relates to:
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