The Differential Cost of Anesthesia and Recovery with Propofol-Nitrous Oxide Anesthesia versus Thiopental SodiumIsoflurane-Nitrous Oxide Anesthesia Yung-Fong Sung, MD,* Nell Reiss, CRNA,Jr Twila Tillette, CRNAT Departments of Anesthesiology, Emory Clinic, Atlanta, GA.
J. Clin. Anesth. 3:391-394,
1991
*Associate Professor of Anesthesiology, Emory University School of Medicine; Director of Anesthesiology, Ambulatory Surgical Center, The Emory Clinic tcertified Registered The Emory Clinic
Nurse-Anesthetist,
Address reprint requests to Dr. Sung at the Anesthesiology Division/ASC, The Emory Clinic, 1327 Clifton Road NE, Atlanta, GA 30322, USA.
Study Objective:
Received for publication August 14, 1990; revised manuscript accepted for publication April 11, 1991.
0 1991 Butterworth-Heinemann
To assess the recovery room profile of propofol in outpatient
anesthesia and to compare it to the profile of a standard technique.
Design: A comparative, randomized, double-blind, third-party open .study. Setting: Ambulatory Surgery Center at The Emory Clinic. Patients: Ninety-nine ASA physical status I, II, or III nonpregnant,female patients who had been diagnosed as needing breast biopsies. Interventions: All patients were given I pglkg of fentanyl prior to induction. Those in the propofol group were induced with 2.0 to 2.5 mglkg of propofol and maintained with a 100 to 200 pglkglmin infusion of propofol with nitrous oxide (N,O) in oxygen (Od. In the thiopental sodium-isoflurane group, patients were induced with 4.0 to 5.0 mglkg of thiopental sodium and maintained with isoflurane and N,O in 0,.
Measurements evaluator
This study was supported in part by ICI Pharmaceuticals Group, Wilmington, DE, a business unit of ICI Americas, Inc., which includes Stuart Pharmaceuticals.
Emory University School of Medicine and The
and Main Results: Recovery from anesthesia was assessed by an
who was unaware
of the anesthetic technique used for
immediate recovery time was measured in terms of awakening,
each patient.
response to verbal
command, and orientation to time and place. A brief postoperative follow-up
ques-
tionnaire was completed to assess the patients’ subjective feelings regarding their ability to eat, concentrate, and resume normal activities. In the thiopental sodiumisoflurane group, 15 of 50 patients (30%) had nausea and vomiting, but in the propofol group, only 4 of 49 patients (8.1%) had nausea and vomiting (p < 0.01). The latter group resumed normal activity {i.e., reading and watching television) 7.93 + 0.76 hours postanesthesia, whereas the thiopental sodium-isoflurane group resumed normal activity 17.02 k 1.21 hours postanesthesia (p < J. Clin. Anesth., vol. 3, September/October
1991
391
0.001).
Patients
in the propofol
group
returned
an uzleruge of 1.5 k 0.09 duys, compared
to work in
with 2.0
2 0.09
daysfor the ttiiop en ta 1:w d’aum-tiofluranrgroup (p < 0.001). Conclusions: The propofol group needed less nursing cure and returned thiopental
to more productive
sodium-isoflurane
uctizlitv earlier group.
thun did the
_
Keywords: Propofol; thiopental sodium; isoflurane; nausea and vomiting; cost-benefit analysis.
Introduction A number of recent economic, political, and social changes have resulted in an increase in the number of surgical procedures performed on an outpatient basis.’ Overall, ambulatory surgical procedures now account for 40% to 50% of all surgical procedures performed, and this percentage is increasing. In the 199Os, it is estimated that as many as two-thirds of all surgical procedures performed in the United States may be done on an outpatient basis. Propofol has been shown in clinical studie+ to be associated with more rapid recovery and a lower frequency of nausea and vomiting than standard anesthetic regimens. Therefore, it is reasonable to assume that the use of propofol in the current practice of outpatient anesthesia may result in economic benefits to the institution and the patient. One purpose of this study was to provide comparative safety and efficacy information regarding the use of propofol in outpatient anesthesia. Another was to assess the recovery room profile of propofol in outpatient anesthesia and to demonstrate its benefit over a standard technique involving thiopental sodium for induction and isoflurane and N,O for maintenance. The Emory Clinic was one of two centers (the other was the Methodist Medical Center of Illinois) participating in a comparative, randomized, prospective study evaluating the safety, efficacy, and economic benefits associated with the use of propofol in outpatient anesthesia. Few studies, including retrospective ones,’ have focused on the potential economic benefits of a specific anesthetic regimen for decreasing nursing time and increasing patient productivity.
Materials and Methods The study was approved by the Human Investigations Committee of the Emory University School of Med392
J. Clin. Anesth.,
vol. 3, September/October
1991
icinc. and all patients ga\‘r written informed ~~)1tsc‘111. Ninety-nine nonpregnant .\SA physical status I. I I, or I II l’emale patients who had been diagnosed as needing breast biopsies consented to participate in thr study. The patients were interviewed from 011e to a few hays prior to surgery. Routine laboratory tests were performed at that time, including tests for pregnancy in females of childbearing age. Xr the time of the biopsy, patients were nionitortd wirh electrocardiogram (EXX;), automatic blood pressure (BP) cuff, 0, analyzer pulse oximeter, capnograph, and temperature probe, and all patients were administered I Fg/kg of fentanyl prior to induction. Those in the propofol group w&e induced with 2.0 to 2.5 mg/kg of propofol and maintained with a 100 to 200 kg/kg/min infusion of propofol with N,O in 0,. Those in the thiopental sodium-isoflurane group were induced with 4.0 to 5.0 mg/kg of thiopental sodium and then maintained with isoflurane and NJ) in 0,. Recovery from anesthesia was assessed by an evaluator who was unaware of the anesthetic technique used for each patient. Immediate recovery time, in terms of awakening, response to verbal command. and orientation to time and place, was measured in the operating room (OR) as well as in the recover)’ room. Assessments were made to determine when the patient was ready to be transferred from Phase I to Phase II (step-down area).’ After emergence, patients were initially transported on the recovery room bed from the OR to the postanesthesia care unit (PACU). ‘The), were closely monitored with routine monitoring equipment ordinarily found in the PACU until achieving an Aldrete score” of 10. ‘T‘his was called Phase I. Patients were then stepped down to an area with less monitoring equipment and fewer personnel, where they remained in the reclining position until their vital signs were stable and they were able to sit up. They were discharged when their vital signs were stable and they were able to drink and void. This was called Phase II. Assessments for nausea and vomiting, ability to tolerate fluids, ability to sit independently, and ability to ambulate were made as appropriate. Suitability for discharge frorn the Phase II recovery area also was assessed for each patient. A brief postoperative follow-up questionnaire was completed to assess the patients’ subjective feelings regarding their ability to eat, concentrate, and resume normal activities. Frequency data were analyzed with a chi-square test. Other data were analyzed with Student’s f-test. The latter are presented as means * standard error of the mean (SEM).
Differential cost of anesthesia and recovery: Sung et al.
Results The average height and weight of both groups were similar. The propofol group was older than the thiopental sodium-isoflurane group (49.12 2 1.49 years us 43.32 * 1.47 years, p < 0.01) and had a longer operating time (55.5 2 1.83 minutes US 50.7 * 1.20 minutes, p < 0.002) (F@uw I). The propofol group had a shorter time in Phase 1 recovery and a shorter total recovery time than did the thiopental sodiumisoflurane group (41.68 + 2.31 minutes US 56.08 2 3.70 minutes for Phase I recovery, p < 0.01; 115.22 -C 3.82 minutes US 134.42 + 5.13 minutes for total recovery, p < 0.01) (F@ure 2). In the thiopental sodium-isoflurane group, 15 of 50 patients (30%) had nausea and vomiting; in the propofol group, only 4 of 49 patients (8.1%) had nausea and vomiting (p < 0.0 1) (Figure 3). The propofol group resumed normal activity (i.e., reading and watching television) 7.93 2 0.76 hours postanesthesia, whereas the thiopental sodium-isoflurane group resumed normal activity 17.02 +- 1.2 1 hours postoperatively (p < 0.001) (Figure 4). Patients in the propofol group returned to work in an average of 1.5 +- 0.09 days, compared with 2.0 ? 0.09 days for the thiopental sodium-isoflurane group (p < 0.001) (Figure 5).
??Propofol 0 Thiopental-isoflutane p
J. Clin. Anesth. 3:391-394,
1991
*Associate Professor of Anesthesiology, Emory University School of Medicine; Director of Anesthesiology, Ambulatory Surgical Center, The Emory Clinic tcertified Registered The Emory Clinic
Nurse-Anesthetist,
Address reprint requests to Dr. Sung at the Anesthesiology Division/ASC, The Emory Clinic, 1327 Clifton Road NE, Atlanta, GA 30322, USA.
Study Objective:
Received for publication August 14, 1990; revised manuscript accepted for publication April 11, 1991.
0 1991 Butterworth-Heinemann
To assess the recovery room profile of propofol in outpatient
anesthesia and to compare it to the profile of a standard technique.
Design: A comparative, randomized, double-blind, third-party open .study. Setting: Ambulatory Surgery Center at The Emory Clinic. Patients: Ninety-nine ASA physical status I, II, or III nonpregnant,female patients who had been diagnosed as needing breast biopsies. Interventions: All patients were given I pglkg of fentanyl prior to induction. Those in the propofol group were induced with 2.0 to 2.5 mglkg of propofol and maintained with a 100 to 200 pglkglmin infusion of propofol with nitrous oxide (N,O) in oxygen (Od. In the thiopental sodium-isoflurane group, patients were induced with 4.0 to 5.0 mglkg of thiopental sodium and maintained with isoflurane and N,O in 0,.
Measurements evaluator
This study was supported in part by ICI Pharmaceuticals Group, Wilmington, DE, a business unit of ICI Americas, Inc., which includes Stuart Pharmaceuticals.
Emory University School of Medicine and The
and Main Results: Recovery from anesthesia was assessed by an
who was unaware
of the anesthetic technique used for
immediate recovery time was measured in terms of awakening,
each patient.
response to verbal
command, and orientation to time and place. A brief postoperative follow-up
ques-
tionnaire was completed to assess the patients’ subjective feelings regarding their ability to eat, concentrate, and resume normal activities. In the thiopental sodiumisoflurane group, 15 of 50 patients (30%) had nausea and vomiting, but in the propofol group, only 4 of 49 patients (8.1%) had nausea and vomiting (p < 0.01). The latter group resumed normal activity {i.e., reading and watching television) 7.93 + 0.76 hours postanesthesia, whereas the thiopental sodium-isoflurane group resumed normal activity 17.02 k 1.21 hours postanesthesia (p < J. Clin. Anesth., vol. 3, September/October
1991
391
0.001).
Patients
in the propofol
group
returned
an uzleruge of 1.5 k 0.09 duys, compared
to work in
with 2.0
2 0.09
daysfor the ttiiop en ta 1:w d’aum-tiofluranrgroup (p < 0.001). Conclusions: The propofol group needed less nursing cure and returned thiopental
to more productive
sodium-isoflurane
uctizlitv earlier group.
thun did the
_
Keywords: Propofol; thiopental sodium; isoflurane; nausea and vomiting; cost-benefit analysis.
Introduction A number of recent economic, political, and social changes have resulted in an increase in the number of surgical procedures performed on an outpatient basis.’ Overall, ambulatory surgical procedures now account for 40% to 50% of all surgical procedures performed, and this percentage is increasing. In the 199Os, it is estimated that as many as two-thirds of all surgical procedures performed in the United States may be done on an outpatient basis. Propofol has been shown in clinical studie+ to be associated with more rapid recovery and a lower frequency of nausea and vomiting than standard anesthetic regimens. Therefore, it is reasonable to assume that the use of propofol in the current practice of outpatient anesthesia may result in economic benefits to the institution and the patient. One purpose of this study was to provide comparative safety and efficacy information regarding the use of propofol in outpatient anesthesia. Another was to assess the recovery room profile of propofol in outpatient anesthesia and to demonstrate its benefit over a standard technique involving thiopental sodium for induction and isoflurane and N,O for maintenance. The Emory Clinic was one of two centers (the other was the Methodist Medical Center of Illinois) participating in a comparative, randomized, prospective study evaluating the safety, efficacy, and economic benefits associated with the use of propofol in outpatient anesthesia. Few studies, including retrospective ones,’ have focused on the potential economic benefits of a specific anesthetic regimen for decreasing nursing time and increasing patient productivity.
Materials and Methods The study was approved by the Human Investigations Committee of the Emory University School of Med392
J. Clin. Anesth.,
vol. 3, September/October
1991
icinc. and all patients ga\‘r written informed ~~)1tsc‘111. Ninety-nine nonpregnant .\SA physical status I. I I, or I II l’emale patients who had been diagnosed as needing breast biopsies consented to participate in thr study. The patients were interviewed from 011e to a few hays prior to surgery. Routine laboratory tests were performed at that time, including tests for pregnancy in females of childbearing age. Xr the time of the biopsy, patients were nionitortd wirh electrocardiogram (EXX;), automatic blood pressure (BP) cuff, 0, analyzer pulse oximeter, capnograph, and temperature probe, and all patients were administered I Fg/kg of fentanyl prior to induction. Those in the propofol group w&e induced with 2.0 to 2.5 mg/kg of propofol and maintained with a 100 to 200 kg/kg/min infusion of propofol with N,O in 0,. Those in the thiopental sodium-isoflurane group were induced with 4.0 to 5.0 mg/kg of thiopental sodium and then maintained with isoflurane and NJ) in 0,. Recovery from anesthesia was assessed by an evaluator who was unaware of the anesthetic technique used for each patient. Immediate recovery time, in terms of awakening, response to verbal command. and orientation to time and place, was measured in the operating room (OR) as well as in the recover)’ room. Assessments were made to determine when the patient was ready to be transferred from Phase I to Phase II (step-down area).’ After emergence, patients were initially transported on the recovery room bed from the OR to the postanesthesia care unit (PACU). ‘The), were closely monitored with routine monitoring equipment ordinarily found in the PACU until achieving an Aldrete score” of 10. ‘T‘his was called Phase I. Patients were then stepped down to an area with less monitoring equipment and fewer personnel, where they remained in the reclining position until their vital signs were stable and they were able to sit up. They were discharged when their vital signs were stable and they were able to drink and void. This was called Phase II. Assessments for nausea and vomiting, ability to tolerate fluids, ability to sit independently, and ability to ambulate were made as appropriate. Suitability for discharge frorn the Phase II recovery area also was assessed for each patient. A brief postoperative follow-up questionnaire was completed to assess the patients’ subjective feelings regarding their ability to eat, concentrate, and resume normal activities. Frequency data were analyzed with a chi-square test. Other data were analyzed with Student’s f-test. The latter are presented as means * standard error of the mean (SEM).
Differential cost of anesthesia and recovery: Sung et al.
Results The average height and weight of both groups were similar. The propofol group was older than the thiopental sodium-isoflurane group (49.12 2 1.49 years us 43.32 * 1.47 years, p < 0.01) and had a longer operating time (55.5 2 1.83 minutes US 50.7 * 1.20 minutes, p < 0.002) (F@uw I). The propofol group had a shorter time in Phase 1 recovery and a shorter total recovery time than did the thiopental sodiumisoflurane group (41.68 + 2.31 minutes US 56.08 2 3.70 minutes for Phase I recovery, p < 0.01; 115.22 -C 3.82 minutes US 134.42 + 5.13 minutes for total recovery, p < 0.01) (F@ure 2). In the thiopental sodium-isoflurane group, 15 of 50 patients (30%) had nausea and vomiting; in the propofol group, only 4 of 49 patients (8.1%) had nausea and vomiting (p < 0.0 1) (Figure 3). The propofol group resumed normal activity (i.e., reading and watching television) 7.93 2 0.76 hours postanesthesia, whereas the thiopental sodium-isoflurane group resumed normal activity 17.02 +- 1.2 1 hours postoperatively (p < 0.001) (Figure 4). Patients in the propofol group returned to work in an average of 1.5 +- 0.09 days, compared with 2.0 ? 0.09 days for the thiopental sodium-isoflurane group (p < 0.001) (Figure 5).
??Propofol 0 Thiopental-isoflutane p
