Short-acting Anesthetic Drugs Research Articles

Continued Growth and Advances in Ambulatory Anesthesiology

Article| February 2021 Continued Growth and Advances in Ambulatory Anesthesiology Catlin Nalley Catlin Nalley Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor February 2021, Vol. 85, 27. https://doi.org/10.1097/01.ASM.0000733860.08295.6c Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Catlin Nalley; Continued Growth and Advances in Ambulatory Anesthesiology. ASA Monitor 2021; 85:27 doi: https://doi.org/10.1097/01.ASM.0000733860.08295.6c Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: ambulatory care facilities, anesthesia, ambulatory, pain management, surgical procedures, operative Decades ago, sending a patient home the same day he or she underwent surgery was unheard of. However, ongoing advancements in surgical practices as well as improvements in postoperative care have made this the norm. Since it was first proposed in the mid-19th century, ambulatory anesthesia has become an integral component of the surgical experience. The discovery of more effective short-acting anesthetic drugs as well as a tailored approach to care has made it possible for the specialty to support a growing demand for safe and efficient ambulatory procedures. During an interview with the ASA Monitor, Tong Joo (TJ) Gan, MD, MHS, FRCA, MBA, Professor and Distinguished Endowed Chair, Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, shared his perspective on the growth of ambulatory anesthesiology and what the future may hold. ASA Monitor: How has the field of ambulatory anesthesiology evolved? Dr. Gan: Ambulatory anesthesia... You do not currently have access to this content.

Fast Tracking in Off Pump CABG with Supraglottic Airway and TIVA

AbstractThe standard goals of anesthetic management for an off pump coronary artery bypass (OPCAB) surgery are that it should be safe, provide cardiac and other organ protection and stability, preserve neurocognitive integrity, maintain hemodynamics, allow early emergence and ambulation, and offer pain relief in the postoperative period. The cardiac surgical team should collaborate and plan the best preoperative strategy, so as to provide optimal care and a rapid and expeditious recovery of these patients. Scientific evidence and practical experience make total intravenous anesthesia (TIVA) the recommended choice for cardiac surgery. Use of endotracheal tube (ETT) is associated with certain drawbacks which can be overcome with judicious use of ProSeal laryngeal mask airway (PLMA) for cardiac surgeries too. The core principles of ultrafast track anesthetic (UFTA) technique are choice and titration of short-acting anesthetic drugs, postoperative normothermia, multimodal analgesia, early extubation, ambulation, and discharge. Fast tracking with use of TIVA and PLMA in patients undergoing OPCAB at our center offers certain advantages over other techniques in terms of reduced airway and lung trauma, improved cardiac output and renal perfusion with spontaneous respiration, decreased stress and discomfort of ETT suctioning and weaning from ventilation, substantially reduced requirement of dosages of analgesics, anesthetics and opioids, resulting in better patient hemodynamics, alert and pain-free patient that are more amenable and cooperative for early feeds, postoperative chest physiotherapy and lung recruitment strategies, and early ambulation and discharge.

An HPLC tandem mass spectrometry for quantification of ET-26-HCl and its major metabolite in plasma and application to a pharmacokinetic study in rats

ET-26-HCl is a new analog of etomidate, a short-acting anesthetic drug, with less adrenal cortex inhibition. The pharmacokinetics of ET-26-HCl in rats needs to be determined for future clinical trials in human subjects. In order to facilitate the pharmacokinetic study, a liquid chromatography based tandem mass spectrometric (HPLC–MS/MS) method was developed and validated for quantification of ET-26-HCl and its major metabolite, ET-26-acid. These two compounds and gabapentin (internal standard) were extracted using a protein precipitation method with methanol and detected by Multiple Reaction Monitoring of m/z transition of 275.6–170.9, 217.7–113.1, and 172.5–154.3 for ET-26-HCl, ET-26-acid, and gabapentin respectively. This method was validated in terms of sensitivity, linearity, reproducibility, and stability. The HPLC–MS/MS method was found linear over the concentration ranges of 21.76–4352ng/mL, and 18.62–3724ng/mL with LLOQ of 21.76 and 18.62ng/mL for ET-26-HCl and ET-26-acid respectively. The mean intra-day and inter-day accuracy was between 94.11–107.78%, while the precision was within the limit of 15.0% for all the quality control samples. A pharmacokinetic study was then conducted in rats following intravenous injection of 2.1, 4.2, and 8.4mg/kg. The linear pharmacokinetics of ET-26-HCl was observed over the dose range of 2.1–8.4mg/kg. The average terminal phase elimination half-lives were 0.87 and 1.03h for ET-26-HCl and ET-26-acid respectively. In summary, an HPLC–MS/MS method for quantification of ET-26-HCl in rat plasma has been developed and successfully applied to a pharmacokinetic study.

Driving impairment due to propofol at effect-site concentrations relevant after short propofol-only sedation.

Australian guidelines state "Following brief surgery or procedures with short acting anaesthetic drugs, the patient may be fit to drive after a normal night's sleep. After long surgery or procedures requiring longer lasting anaesthesia, it may not be safe to drive for 24 hours or more". The increasing use of the short-acting anaesthetic drug propofol as a solitary sedative medication for simple endoscopy procedures suggests a need to review this blanket policy. Thirty patients presenting for elective day surgery were recruited as volunteers for a pre-procedure driving simulation study and randomised to propofol or placebo arms. Driving ability was assessed at baseline and then, in the propofol group, at three effect-site concentrations. Driving impairment at these concentrations of propofol was compared to that of a third group of volunteers with a blood alcohol concentration of 0.05% (g/100 ml). Driving impairment at 0.2 µg/ml propofol effect-site concentration was not statistically different to placebo. Impairment increased with propofol effect-site concentration (P=0.002) and at 0.4 µg/ml it was similar to that found with a blood alcohol concentration of 50 mg/100 ml (0.05%). Plasma propofol concentrations of 0.2 µg/ml, as might be found approximately an hour after short (<1 hour duration) propofol-only sedation for endoscopy, were not associated with driving impairment in our young cohort of volunteers.

It May be Unsafe for Patients with Untreated Severe OSA Requiring Postoperative Narcotic to Undergo Ambulatory Surgery

The recent article published in October 2010 by T.L. Stierer concluded that patients with OSA can be safely treated in an ambulatory care center with subsequent discharge to home.1 With the advancement of anesthetic techniques, use of short-acting anesthetic drugs and development of noninvasive surgery, anesthesia is becoming safer and the incidence of major adverse outcomes is very low. The incidence of unanticipated admission in ambulatory surgery is approximately 1-2%.2 A study of major adverse events in OSA patients undergoing inpatient or outpatient surgery will require huge numbers of OSA patients. A failure to show that there was an increase in major adverse events such as unanticipated admission in 103 patients might be related to the small sample size. The questionnaire tool in this study provided a prevalence of 4.8% in these patients with a > 70% likelihood of OSA. We agree with Gay’s comment that the prevalence level in the Stierer paper seemed to be small compared to those reported in the literature.3 In 1993, an epidemiologic study showed that 24% of males and 9% of females had AHI > 5.4 In three studies using screening questionnaires to determine the frequency of patients at risk of OSA in the general surgical population, 24%, 27.5% and 23.7% were identified preoperatively at high risk for OSA using the Berlin questionnaire, the STOP questionnaire, and the Apnea Risk Evaluating System OSA screening questionnaire.5–7 The low incidence in this study might indicate that the Maislin questionnaire is less sensitive in identifying the OSA at risk patient.1 Of the 103 OSA at risk patients, 29 patients gave a self-reported diagnosis of OSA and 74 were not diagnosed. However, the authors also reported that 94 patients gave a self-reported diagnosis of OSA in 2139 patients. This means that 65 patients with a self-reported diagnosis of OSA were not identified by the questionnaire. These patients might increase the risk of adverse events in the 70% propensity group might have received CPAP resulting in a reduction in the adverse events. Another important point is that there are a wide range of ambulatory surgical procedures and a wide variety of pain medications. For some procedures, pain can be relieved by acetaminophen and nonsteroidal agents and postoperative narcotics are not required. However, there may be potential safety concerns to discharge the untreated OSA patients with high AHI and who require postoperative narcotics after ambulatory surgery.8 We need to do more studies on a larger number of OSA patients to understand the peri-operative risk and define the particular thresholds of OSA severity that are of concern. Would a higher AHI or a lower nocturnal O2 saturation predict worse outcomes? Do we need to be concerned only in surgical procedures requiring postoperative narcotics? Further studies need to be done to make a final recommendation and we urge caution on this topic, as one death is too many.9

Propofol and remifentanil total intravenous anesthesia for a patient with Huntington disease

Huntington disease presents many challenges for the anesthetist. Of primary importance is that these patients are at increased risk of pulmonary aspiration. The use of short-acting anesthetic drugs should, therefore, be advantageous in promoting the rapid return of protective airway reflexes. We report the first documented use, to date, of propofol and remifentanil total intravenous anesthesia in a patient with Huntington disease and demonstrate its efficacy and safety.

Early extubation after single-lung transplantation: Analysis of the first 106 cases

Objective: To determine if a modern anesthetic approach permits extubation immediately after surgery for single-lung transplantation. Design: A retrospective study of all patients undergoing single-lung transplantation from June 1993 to December 1999 in Denmark. Setting: Rigshospitalet, Copenhagen University hospital. Participants: One hundred six consecutive patients scheduled for single-lung transplantation. Interventions: From July 1997, the anesthetic approach was changed to facilitate early extubation. The changes included epidural analgesia and short-acting anesthetic drugs. Measurements and Main Results: One hundred six patients were anesthetized for single-lung transplantation. The first 33 patients were moved to the intensive care unit for postoperative mechanical ventilation. After the change of anesthesia technique, 53 of 73 patients were extubated in the operating room. Eleven patients needed reintubation within the first 24 hours because of respiratory insufficiency, pulmonary edema, hemorrhage, or pneumothorax. The need for reintubation increased the length of stay in the intensive care unit by 1 day from 2 to 3 days (NS). The possibility of early extubation or the need for reintubation was not related to age, weight, sex, preoperative condition, mode of transport of the graft, duration of graft ischemia, or side of transplantation. Conclusion: This study has shown that it is possible to extubate patients in the operating room immediately after single-lung transplantation in the majority of cases. Copyright 2003, Elsevier Science (USA). All rights reserved.

Is very early extubation after lung transplantation feasible?

Objective: To evaluate donor graft function, intraoperative blood consumption, and oxygenation and hemodynamic stability in patients undergoing lung transplantation. Design: Prospective pilot study. Setting: University hospital. Participants: Forty-three patients undergoing lung transplantation from January 1999 to June 2001. Interventions: Hemodynamic monitoring, early extubation, and noninvasive ventilation criteria. Measurements and Main Results: The 31 nonearly extubated patients showed a lower PaO2/fraction of inspired oxygen (FIO2), a higher mean pulmonary arterial pressure, extravascular lung-water index (EVLWI) and vasoactive drug support (norepinephrine), and more blood products consumption than 12 early extubated patients at the end of surgery. Seven of 12 early extubated patients did not show any signs of respiratory failure after tracheal extubation; they were alert and able to perform deep breathing exercise and coughing. In the other 5 patients, hypoxemia, hypercapnia, and an increase of respiratory rate >30 breaths/min were observed. The intermittent application of noninvasive pressure ventilation by face mask avoided endotracheal intubation. Conclusion: The use of a short-acting anesthetic drug, appropriate intraoperative extubation criteria, epidural analgesia, and postoperative noninvasive ventilation make early extubation of lung-transplanted patients possible and effective. Copyright 2003, Elsevier Science (USA). All rights reserved.

REVIEW: Fast-Tracking Cardiac Surgery.

A "fast track" approach to cardiac surgery can be defined as a perioperative process involving rapid progress from preoperative preparation through surgery and discharge from the hospital. Although highly individualized among the various heart surgery centers, the fast-track process is a team activity. It requires a team of health care providers to interact with the patient at various phases, from admission to discharge. The necessary elements of the fast-track program are choice and the titration of short-acting anesthetic drugs, standardized surgical procedures, early extubation, rewarming and sustained postoperative normothermia, postoperative pain control, early ambulation, alimentation and discharge, and follow-up after discharge. We review the current approaches to some of these aspects of patient care.

Éviter la salle de réveil, l’étude pilote d’un “protocole accéléré” dans un hôpital communautaire

To evaluate the effectiveness of short-acting anesthetic drugs and techniques to achieve recovery room bypass criteria after minor surgery in a community hospital environment. After agreement by a multidisciplinary committee, a pilot project was undertaken to assess the usefulness of ultra- short acting anesthetic drugs and pre-emptive analgesia to facilitate rapid recovery from general anesthesia. A cohort of 100 ASA I-II patients aged 18-65 yr undergoing simple knee arthroscopy or minor peripheral orthopedic procedures was compared to a similar cohort treated in the three months prior to the study period. Outcomes of interest included patient morbidity, success in achieving post-anesthesia care unit (PACU) bypass criteria, impact upon nursing resources, duration of operating room (OR) and hospital stay, and pharmaceutical costs before and after implementation. No patient morbidity was demonstrated prior to discharge home, and successful PACU bypass occurred in 83% of cases. Achievement of PACU discharge criteria while in the OR did not prolong the OR time, and discharge from hospital occurred earlier in the patients who did not require PACU care (P=0.0006 all "fast-track cases" vs all "controls"). Nursing complaints were more numerous when the day surgery personnel did not normally participate in PACU care. The cost of anesthetic care was significantly more using ultra-short acting drugs (CDN $14.17 vs CDN $20.57), but closer adherence to protocol could reduce this differential (CDN $18.84). Not all patients who receive a general anesthetic require admission to a phase I recovery facility. However, the justification for use of more expensive pharmaceuticals to achieve PACU bypass requires extensive changes in operating systems and voluntary professional behaviours.

Pharmacokinetic concepts for TCI anaesthesia.

The development of new short-acting anaesthetic drugs, improved drug assay techniques and the availability of reliable infusion systems opened the field of clinical pharmacokinetics and pharmacodynamics. The tri-exponential drug concentration decay complicates the definition of therapeutic dosage regiments and prevents straightforward prediction of recovery from drug effects. The context-sensitive half-time, the time required for drug blood concentration to decrease to half its value, provides a useful comparative predictor of drug concentration decline after infusion. The effect-site equilibration time contributes to the delay of drug effect and intensifies the disequilibrium between drug blood concentrations and obtained effect following incremental dosage. The rationale for drug infusion is reduction of fluctuating drug concentrations and drug effects. A variability similar to that observed with the use of inhalation agents, must be achieved by the choice of an appropriate pharmacokinetic model. The use of a target controlled infusion device, delivering proportional changes based on pharmacokinetic principles, allows titration of the concentration against clinical effect in individual patients.

Anesthesia for Bedside Procedures

Within the past 10 years, numerous short-acting anesthetic drugs have been introduced for use in the operating room. This review article will discuss the role of these agents in critically ill patients undergoing bedside procedures. After a brief historical update, the first part of the review will focus on issues related to the pathophysiology and pharmacology of critically ill patients in general, and of specific organ dysfunction in particular. In-appropriate dosing and improper selection of agents will be highlighted. The second part of the article will discuss specific classes of drugs, with reference to their advantages and disadvantages in the ICU population. The article will conclude by emphasizing the potency, safety, and efficacy of these drugs in significantly reducing the pain and suffering experienced by patients with critical illness.