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com/viewarticle/846151_print

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EffectsofChangesinIntraoperativeManagementon
RecoveryFromAnesthesia
AReviewofPracticeImprovementInitiative
TobyNWeingartenTammySBerganBradlyJNarrDarrellRSchroederJurajSprung
BMCAnesthesiol.201515(54)

Abstract
BackgroundOuranestheticpracticewashinderedbyinadequatepostanesthesiacareunitspaceresultinginoperatingroom
inefficiencies.Inresponse,ananestheticprotocoldesignedtoreducethedurationofpostanesthesiastaybydecreasing
residualanestheticsedationandpostoperativenauseaandvomiting(PONV)wasintroduced.Heretheimpactofthispractice
changeisanalyzed.

MethodsTheprotocolencourageddesfluraneuseinsteadofisoflurane,tripleantiemeticprophylaxis,anddiscouraged
midazolam.Recordsofpatientsundergoinggeneralanesthesiafromcalendarmatchedepochswerereviewed.EpochIincluded
a6monthperiodpriortoimplementationofthepracticechange(October1,2009,toMarch31,2010)andEpochIIincluded6
monthsfollowingthepracticechange(October1,2010,toMarch31,2011).

ResultsGeneralanesthesiawasadministeredto2,936and3,137patientsduringEpochsIandII,respectively.Midazolam
decreasedfrom57.4%to24.0%,isofluranefrom50.8%to5.7%,desfluraneincreasedfrom25.6%to77.0%,andantiemetic
prophylaxisfrom6.5%to50.8%.Median[IQR]recoverytimedecreasedfrom72[50,102]to62[44,90]minutes,P<0.001.
SupplementalanalysesfoundantiemeticprophylaxiswasassociatedwithPONVreduction(OR=0.47,95%CI0.380.58,P
<0.001).Whencomparedtoisoflurane,desfluranewasassociatedwithadecreasedrateofrespiratorydepression(OR=0.72,
95%CI0.550.93,P=0.013).Patientsadministeredmidazolamtrendedtowardshigherrateofrespiratorydepression(OR=
1.27,95%CI1.001.60,P=0.050).

ConclusionsIntroductionofananestheticprotocolthatwasdesignedtoattenuateadverseanestheticeffectswasassociated
withareductionofanestheticrecoverytime.

Background
Efficientsurgicalpracticesrelyoninteractionbetweenperioperativeandpostoperativecareareastofacilitatepatient
throughput. [1]Postoperativecareiscomplexandcomprisedofmultipleclinicalareas.Thelynchpinofthissystemisthe
PostanesthesiaCareUnit(PACU)wherepatientsundergoimmediaterecoveryfromanesthesia(PhaseIrecovery)priorto
dischargetoambulatorysettings,postoperativewards,andadvancedmonitoringwards(PhaseIIrecovery).Whenpatient
volumesurpassesPACUcapacity,abottleneckofpatientflowiscreateddelayingdischargefromtheoperatingroom. [2]Slow
anestheticemergence,excessiverespiratorydepression,andpostoperativenauseaandvomiting(PONV)canprolongPACU
stays. [24]

Ourpracticeinyear2009almostdailyoutstrippedPACUcapacitywhichresultedinpatienttransferdelaysfromtheoperating
roomtoPACU.Inresponse,apracticeimprovementinitiativeforadultpatientsundergoinggeneralendotrachealanesthesia
(GETA)designedtofacilitatePhaseIrecoverywasformulated.Thisprotocolconsistedofelementsdesignedtoreducetimeto
emergencefromanesthesiaandoccurrenceofrespiratorydepression(reducingroutinemidazolamadministration,substituting
desfluraneforisofluraneastheprimaryinhalationalanesthetic)andmeasurestoreducePONV(tripleantiemeticprophylaxis
regardlessofPONVrisk).TheprimaryhypothesisofthisstudywasthatthispracticechangewasassociatedwithfasterPhase
Irecovery.

Methods
ThisstudywasapprovedbytheMayoClinic,RochesterMN,InstitutionalReviewBoard(IDnumber13000171,approved
February5,2013).ConsistentwithMinnesotaStatute144.295,allpatientsprovidedauthorizationforresearchuseoftheir
medicalrecords.

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StudyDesign

OnAugust1,2010,ananesthesiaprotocoldesignedtohastenPhaseIanesthesiarecoveryofpatientsundergoingGETAwas
instituted.Toassesswhetherrecoveryshortened,aretrospectiveanalysisofclinicaloutcomesbeforeandafterprotocol
implementationwasperformed.Toallowtimeforacceptanceoftheprotocola2monthtransitionperiodfromprotocolinstitution
tothestartofdatacollectionwasallowed.Therefore,datawereobtainedduringthe6monthperiodfromOctober1,2010,
throughMarch31,2011[EpochII]).Inordertoensurethatsimilarcalendarperiodswerecomparedpreimplementationdata
wereobtainedfromOctober1,2009,throughMarch31,2010[EpochI].

PatientSelection

IncludedwereadultpatientswhounderwentGETA,transferredtothePACU,andextubatedpriortoPACUdischarge.Patients
wereexcludediftheybypassedthePACUhadsurgerywhenPACUstaffingwasnotstandard(i.e.,weekends)orhadsurgery
performedundermonitoredanesthesiacareorregionalanesthesia.

StudySetting

Thisstudywasofthepracticeofasingleanesthesiadivisionwithinalargeanesthesiadepartment.Thisdivisionprovidedcare
for27operatingroomswhichtypicallyservegeneral,urological,plastic,otolaryngologic,andophthalmologicspecialtiesaswell
asendoscopicprocedurestoocomplextobeperformedinthegastrointestinalproceduralsuites.Followingsurgery,patients
weretransferredtoPACU.

Anesthesia

PreimplementationPractice.Theanesthesiapracticewasconductedaccordingtotheattendinganesthesiologist's
discretion,buttypicallyconsistedofanintravenousinductionwithmidazolam,fentanyl,andpropofolmaintenancewith
isofluraneandantiemeticprophylaxiswithondansetronwithorwithoutdexamethasone.

PracticeImprovementProtocol.Theanesthesiaprotocolconsistedofthreepracticechanges.Twoweredesignedtohasten
anestheticrecovery(midazolamwasnolongerroutinelyusedwithinductionanddesfluranebecamethedefaultvolatile
anesthetic)whilethethirdchangewasaimedtoreducePONV(byusing0.625mgdroperidol,and4mgofdexamethasoneat
thebeginningofanesthesia,and4mgofondansetronattheendofanesthesia).Becauseoftheheterogeneityofthispractice,
therewerenorecommendationsregardingtheanalgesicregimen.Compliancewasnotmandatoryandanesthesiologistscould
deviateforindividualcircumstances.

PACUClinicalPractice

ThePACUintheclinicalpracticeservesthisdivisionaswellasotherclinicalareas(i.e.,thoracic,vascular,orthopedic,spine,
neurosurgery,andradiologyperformedundergeneralanesthesia).ThePACUdoesnotacceptpediatricoutpatientsnordoesit
serveasanoverflowfortheintensivecareunit.ThePACUisstaffedbyregisterednursesaswellasananesthesiaresident.
Theattendinganesthesiologistwasalsoimmediatelyavailable.

DischargecriteriaforPhaseIrecoverywereprimarilybasedonstandarddischargecriteria,goalpainscoresandcontrolof
postoperativenausea,aswellasforrespiratorydepressionasdefinedbyfourrespiratoryspecificevents,see. [58]

Table1.DischargecriteriaforPhaseIrecoveryfollowinggeneralanesthesia

Primary Points
Discharge
Criteria*[5] 0 1 2

Motoractivity Nomotion Weakmotion Activemotion

Respiration Requiredairwaymaintenance Maintainsairwaywithoutsupport Coughsoncommand

Systolicbloodpressure50 Systolicbloodpressure2050 Systolicbloodpressure20

Bloodpressure
mmHgpreanestheticvalue mmHgpreanestheticvalue mmHgpreanestheticvalue

Consciousness Noresponseorabsentprotective Respondstostimulus Fullyawakeoreasilyaroused

reflexes

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Oxyhemoglobin <93%orpreoperativevaluewith 93%orpreoperativevaluewith 93%orpreoperativevalue

saturation supplementaloxygen supplementaloxygen withoutsupplementaloxygen

RespiratorySpecificEvents[7,8]

Hypoventilation 3episodesof<8respirations/minute

Apnea Episodeofapnea10seconds

3episodesofoxyhemoglobindesaturationsasmeasuredbypulseoximetry(<90%withorwithoutnasal
Hypoxemia
cannula)

Pain/sedation
RichmondAgitationSedationScore[6]=3to5andanumericpainscore>5,fromascale0to10
mismatch

AdditionalDischargeCriteria

NumericPain
Score4
Score

Postoperative
Mildtonone
nausea

*Tomeetdischargecriteriathecompositescoreneedstobe8withabsenceof0scoreinanyofthe5subcategories Any
patientwhodevelopsarespiratoryspecificeventmusthaveasubsequent60minuteperiodfreeoffurthereventsinordertobe
transferredtoanonmonitoredward.Patientswhohadrepeatedrespiratoryspecificeventsaredischargedtoanadvanced
monitoredsettingorcontinuouslymonitoredforoxyhemoglobindesaturationviapulseoximetry.

DataAbstraction

Electronicmedicalrecordswereabstractedusingproprietarysoftware. [9,10]Presurgicalvariablesincludedpatientage,sex,
bodymassindex,andAmericanSocietyofAnesthesiologistPhysicalStatus.Perioperativevariablesincludedproceduretype
surgicaldurationmedicationsuseofregionaltechniqueforpostoperativeanalgesiaandPhaseIrecoverycourseincluding
duration,medications,andrespiratorydepression. [7,8]

Perioperativedysrhythmiawasdefinedastheuseofantiarrhythmicagentorcardioversion,hypertensionbytheadministration
ofantihypertensiveagents,andbronchospasmbyalbuteroladministration.Intraoperativehypotensionwasassessedfromthe
recordsofadministrationofepinephrine,dopamine,calciumchloride,vasopressin,orphenylephrineinfusion.Hypotension
duringPhaseIrecoverywasassessedfromtheadministrationofephedrineorphenylephrine.Antiemeticprophylaxiswas
determinedfromtheadministrationofdroperidol,dexamethasone,ondansetronorgranisetron.PONVwasidentifiedfromthe
useofrescueantiemeticmedicationinthePACU.Perioperativeopioidswereconvertedtointravenousmorphineequivalents
usingpublishedguidelines. [11,12]Theultrashortactingremifentanilwasnotincludedinmorphineequivalentcalculations.

ThedurationofPhaseIrecoverywasdefinedasthetimeofPACUadmissiontothetimethatPhaseIdischargecriteriawas
met.ThistimewasnotaffectedbynonclinicaldelaysinpatienttransferfromthePACUtoPhaseIIrecovery(i.e.,patient
transportorpostsurgicalbedavailability). [13]

StatisticalAnalysis

Dataarepresentedasmeanstandarddeviationormedian[25%,75%]forcontinuousvariables,andnumber(percentage)for
categoricalvariables.TheprimaryendpointwasaPhaseIrecoverytime,withsecondaryendpointbeingtherateofPONV,and
respiratoryspecificevents.Outcomeswerecomparedbetweenepochsusingtheranksumtestforcontinuousvariablesand
thechisquaretestforcategoricalvariables.Postoperativeeventswhichcouldprolonganesthesiarecovery(e.g.,respiratory
depression,PONV,hemodynamicinstability,orincreasedopioidanalgesicadministration)werecharacterizedwithdescriptive
statistics.Becausethisstudyanalyzedacomplexpracticechange,aseriesofhypothesisgeneratingsecondaryanalyses
wereperformedusingmultivariablelogisticregressiontoexaminetheassociationofthethreeprotocolelementswith
postoperativePONVandrespiratorydepression.TwotailedPvalueslessthan0.05wereconsideredstatisticallysignificant.
StatisticalanalyseswereperformedwithJMPPro9.0.1.(SASSoftware,Inc.,Cary,NC,USA).

Results
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Generalendotrachealanesthesiawasadministeredto2,936and3,137patientsduringEpochsIandII,respectively.Figure1
showsthecontributionofthesepatientstotheoverallPACUpopulation.Patient,surgicalandanestheticcharacteristicsare
presentedin.ChangesinanestheticmanagementbetweenepochsaresummarizedinFigure2.Midazolamusedecreased
57.4%to24.0%,desfluraneincreasedfrom25.6%to77.0%,isofluranedecreasedfrom50.8%to5.7%,andtripleantiemetic
prophylaxisincreasedfrom6.5%to50.8%inEpochII.

Table2.Demographics,surgicalandanestheticcharacteristics

EpochI*N=2,936 EpochII*N=3,137 P

Age,years 54.816.8 54.916.8 0.765

Malesex 1,539(52.5) 1,689(53.8) 0.291

ASAPS 0.008

I 267(9.1) 313(10.0)

II 1,686(57.4) 1,731(55.2)

III 945(32.2) 1,019(32.5)

IV 38(1.3) 74(2.4)

BMI,kg/m2 29.77.7 29.47.6 0.234

Surgicaltype 0.054

General 1,070(36.4) 1,034(33.0)

Head/Neck 674(23.0) 811(25.8)

Urology 613(20.9) 642(20.5)

Ophthalmology 180(6.1) 174(5.5)

Plastics 168(5.7) 205(6.5)

Gastrointestinal 157(5.4) 190(6.1)

Orthopedics 50(1.7) 53(1.7)

Neurosurgical 13(0.4) 12(0.4)

Thoracic 11(0.4) 16(0.5)

Surgeryduration,minutes 12997 12593.1 0.131

Intraoperativeopioids,ivME,mg 25[10,35] 25[15,35] <0.001

Intraoperativeketorolac 407(13.9) 516(16.5) 0.005

NDMRuse 1,594(54.3) 1,848(58.9) <0.001

Neuraxialanalgesiaused 88(3.0) 119(3.8) 0.090

Intraoperativeuse:

Bronchodilators 41(1.4) 64(2.0) 0.061

Antihypertensives 442(15.1) 481(15.3) 0.775

Antiarrhythmics 7(0.2) 4(0.1) 0.775

Vasopressors 41(1.4) 64(2.0) 0.061

*Allpatientsunderwentsurgery/proceduresundergeneralanesthesiaandfewhadsupplementalneuraxialanalgesia. NDMR
wasreversedwithneostigmine1,500(94.1%)casesduringEpochIand1,724(93.3%)duringEpochIIwhereNDMRwereused,
P=0.673.Datapresentedasmeanstandarddeviationnumber(percentage),ormedian[25%,75%].Abbreviations:ASA=

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AmericanSocietyofAnesthesiologistsPhysicalStatusBMI=bodymassindexivME=intravenousmorphineequivalents
NDMR=nondepolarizingmusclerelaxant

Figure1.

PostanesthesiaCareUnit(PACU)populationinstudiedhospital.Legend:*Othertechniquesincludeprimaryregional
anesthetics,monitoredanesthesiacare,generalanesthesiawiththeuseoflaryngealmaskairway,etc.

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Figure2.

AnestheticmanagementduringtwoEpochs.Legend:*Mixedanestheticmanagementincludedpatientswhohadmultiple
anesthetic.

PhaseIrecoverytimedecreasedby13.9%(72[50,102]vs.62[44,90]minutesinEpochIandII,respectively,P<0.001)().
TheratesofPONV,respiratoryspecificevents,andadministrationofantihypertensivemedicationsdeclined().Supplemental
analysesfoundtripleantiemeticprophylaxiswasassociatedwithPONVreduction(oddsratio0.47,95%CI0.380.58,P<
0.001).Whencomparedtoisoflurane,desfluranewasassociatedwithadecreasedrateofrespiratorydepression(oddsratio
0.72,95%CI0.550.93,P=0.013).Midazolamusetrendedtowardsassociationtohigherratesofrespiratorydepression(odds
ratio1.27,95%CI1.001.60,P=0.050).

Table3.DurationofPhaseIrecoveryfromgeneralanesthesiaandclinicaloutcomes

EpochIN=2,936 EpochIIN=3,137 P

PhaseI,minutes 72[50,102] 62[44,90] <0.001

PONVrequiringtreatment 399(13.6) 261(8.3) <0.001

Respiratoryevents* 229(7.8) 161(5.1) <0.001

Apnea 76 45

Hypoventilation 107 82

Oxyhemoglobindesaturation 85 63

Pain/sedationmismatch 74 48

Bronchospasm 17(0.6) 30(1.0) 0.107

PACUmedications

Antihypertensives 266(9.1) 188(6.0) <0.001

Antiarrhythmicmedication 7(0.2) 3(0.1) 0.213

Vasoactivemedication 40(1.4) 37(1.2) 0.567

Opioidsmedication 1.5[0,10] 0[0,9] 0.011

*Therateofrespiratoryeventsamongpatientsadministerednondepolarizingmusclerelaxantmedicationsdidnotdifferbetween
patientswhoweresubsequentlyreversedwithneostigmine(204of3,180patients[7.7%])orwerenotreversed(14of218
patients[6.4%]),P=0.597. WhenexcludingpatientswhodidnotreceiveopioidsinthePACU,thedoseofopioidbetween
epochsdidnotdiffer(10[5,15]ivMEmgvs.10[5,15]ivMEmg,P=0.253.Datapresentedasnumber(percentage)ormedian
[25%,75%].Abbreviations:PONV=postoperativenauseaorvomitingivME=intravenousmorphineequivalents.

Table3.DurationofPhaseIrecoveryfromgeneralanesthesiaandclinicaloutcomes

EpochIN=2,936 EpochIIN=3,137 P

PhaseI,minutes 72[50,102] 62[44,90] <0.001

PONVrequiringtreatment 399(13.6) 261(8.3) <0.001

Respiratoryevents* 229(7.8) 161(5.1) <0.001

Apnea 76 45

Hypoventilation 107 82

Oxyhemoglobindesaturation 85 63

Pain/sedationmismatch 74 48
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Bronchospasm 17(0.6) 30(1.0) 0.107

PACUmedications

Antihypertensives 266(9.1) 188(6.0) <0.001

Antiarrhythmicmedication 7(0.2) 3(0.1) 0.213

Vasoactivemedication 40(1.4) 37(1.2) 0.567

Opioidsmedication 1.5[0,10] 0[0,9] 0.011

*Therateofrespiratoryeventsamongpatientsadministerednondepolarizingmusclerelaxantmedicationsdidnotdifferbetween
patientswhoweresubsequentlyreversedwithneostigmine(204of3,180patients[7.7%])orwerenotreversed(14of218
patients[6.4%]),P=0.597. WhenexcludingpatientswhodidnotreceiveopioidsinthePACU,thedoseofopioidbetween
epochsdidnotdiffer(10[5,15]ivMEmgvs.10[5,15]ivMEmg,P=0.253.Datapresentedasnumber(percentage)ormedian
[25%,75%].Abbreviations:PONV=postoperativenauseaorvomitingivME=intravenousmorphineequivalents.

Discussion
Themainfindingisthatintroductionofaprotocoldesignedtoreducetherateofresidualanestheticeffectswasassociatedwith
fasterPhaseIrecovery.Specifically,therewasareductionofoversedationasevidencedbyfewerepisodesofrespiratory
depression,andreductioninPONVasevidencedbyfeweradministrationsofantiemetics.Secondaryanalysessupportthe
notionthattheuseofdesfluranecoupledwiththeavoidanceofmidazolamwasassociatedwithreducedoversedationwhile
antiemeticprophylaxisreducedPONV,andalltheseeffectsmayhavecontributedtoshorterPACUstay.

Desfluranehasarapiddecreaseinalveolarconcentrationaftercessation,andinthatregardissuperiortoisofluraneduring
anestheticrecovery [14]. [19]Fasterrecoverywithdesfluraneoverisofluranehavebeenobservedinmorbidlyobese[19]and
elderlypatients, [17,18]asubstantialfractionofthesurgicalpopulation.Whileoneconcernwithdesfluranehasbeenairway
irritability, [20]albuterolusedidnotdifferbetweenepochs,suggestingtherewasnotincreasesofbronchospasm.However,
selectionbiasforsevofluraneinpatientswithreactiveairwaydiseasecannotbeexcluded.

BecausemidazolamisassociatedwithincreasedPhaseIrecovery,theprotocolnarroweditsindicationtopatientsundergoing
invasiveawakeproceduresorexperiencingnotableanxiety.TheeffectsofmidazolamonPhaseIrecoveryhavenotbeen
extensivelystudied.Oneprospectivestudyof90elderlypatientsundergoingtransurethralproceduresunderdesflurane
anesthesiafoundmidazolamprolongedPACUdischargetimeandincreasedincidenceofoxyhemoglobindesaturations. [21]
Anotherprospectivestudyof30womenundergoinglaparoscopictubalsterilizationundernitrousoxideandisofluranefound
increasesedationduringPhaseIrecovery. [22]Anotherprospectivestudyof88nonobeseadultambulatorypatientsfoundthat
midazolamdidnotaffectPACUstay. [14]Asupplementalanalysesfoundanassociationbetweenrespiratorydepressionand
isofluraneandatrendwithmidazolamsuggestingthatbothcomponentscanadverselyimpactanesthesiarecovery.

TripleantiemeticprophylaxisregimensreducePONV, [23](anassociationobservedinthisstudysupplementalanalyses),which
contributestofasterPhaseIrecovery.Nopatientsinthisstudywhoreceiveddroperidolexperiencedadversecardiaceffects
(dysrhythmiasassociatedwithlongQTinterval,aconcernthattriggeredFDAtoissuea"blackbox"warning). [24]A
confoundingobservationisthedecreaseduseofopioidsinthePACUduringEpochIIwhichmaybeexplainedbythemodest
increaseofintraoperativeopioidadministration.ThisdeclineinadministrationcouldhavecontributedtothedeclineinPONV
andrespiratorydepression.AnotherunexplainedobservationwasdecreaseduseofantihypertensivesinEpochII.

Limitations

Thisstudyhastheinherentlimitationsofaretrospectivestudydesign.ThoughtheanesthesiaprotocolinEpochIIwaswidely
adopted,itwasnotuniversallyso.Reasonsforvariancemayincluderesidualpracticebiasandclinicalfactorswhichcould
introduceatreatmentbiaswhereanesthetictechniquecouldbealteredtoaccountforspecificpatientriskfactors.Althoughthe
formalpracticechangewasimplementedonAugust1,2010,informaladoptionofprotocolcomponentsmayhaveoccurredprior
tothatdate.Becausethepracticeprotocolwasmultifacetedassessingtheimpactofindividualcomponentsisdifficult,buta
seriesofhypothesisgeneratingsupplementalanalysessupportthespeculationthatindividualcomponentscontributedto
clinicalimprovements.However,otherfactorscouldcontributetoclinicaloutcomessuchasinadequatereversalof
neuromuscularblockingdrugsandrespiratorydepression.UnaccountedmanagementchangescouldhaveimpactedPACU

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efficiencyhowevernochangesinstaffingordischargeprotocolweremadeduringthestudytimeframe.Finally,thoughthe
PhaseIrecoveryauditwasperformedretrospectively,wecannotexcludeapotentialHawthorneeffectbyhealthcarestaffin
anticipationofpracticeevaluationfollowingprotocolimplementation.

Conclusions
Theintroductionofananestheticprotocolthataimedtoreduceadverseeffectsofanestheticswasassociatedwithareduction
ofPhaseIrecoverytimeinadultpatientsundergoinggeneralendotrachealanesthesia.Theseanestheticmanagementchanges
wereprimarilyassociatedwithdecreasedrateofpostoperativerespiratorydepressionandnauseaandvomiting.

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Abbreviations
PONV:Postoperativenauseaandvomiting,PACU:PostanesthesiaCareUnit,GETA:Generalendotrachealanesthesia,BMI:
Bodymassindex

Aknowledgement
WewishtothankMr.GregoryAWilson,RT,forhisassistanceindataabstraction.

BMCAnesthesiol.201515(54)2015BioMedCentral,Ltd.

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