Factors affecting recovery profile

TIVA’s recovery profile

• Associated with a pleasant and smooth nature of emergence from general anaesthesia
• Multifactorial anaesthetic plan needs to be both patient and procedure specific
  • Procedure specific
    • Neurosurgery: prevention of coughing might be one of the most important considerations
    • Tonsillectomy: return of airway reflexes and timing of extubation
    • Day surgery: TIVA is associated with shorter time to home readiness
    • Longer surgery: consider a shorter-acting sedative
  • Patient-specific
    • Age and cognitive function
    • High risk of PND
    • Baseline anxiety and fears
• Elements of a smooth recovery
  • Reasonable fast recovery
  • Patient comfort:
    • Adequate postoperative analgesia
    • Absence of PONV
    • Avoidance of agitation
  • Cardiovascular stability
  • Return of airway reflexes
• To provide us with the highest chance of providing a smooth recovery from anaesthesia knowledge of the following is required
  • Pharmacokinetic characteristics and decrement times
  • Pharmacodynamic interactions between different drugs
  • Prevention of PONV
  • Adjuncts for postoperative analgesia
  • Optimal timing of emergence from anaesthesia
    • May be difficult to predict we should use all available information
    • Depth-of- anaesthesia (DoA) monitoring
      • Prevent excessive depth of anaesthesia
      • Improve the speed and quality of recovery from anaesthesia
      • Guidance states BIS range between 40-60 for general anaesthesia towards the end of the surgery this range can be narrowed to BIS between 50-60
• Know your pump: Decrement function
• Know your patient: The target effect site level that corresponds to loss of response to verbal stimlus when titrated slowly at induction corresponds well to return conciousness
• Know your surgery: Noxious stimuli during the last part of surgery may result in the patient waking too soon if the dose of anaesthetic is turned off or reduced too soon
• Know your surgeon: Consider reducing the target concentrations when wound closure begins.
  • Who will be closing the patient and how long will it take?
  • Stopping all drug infusions when the last sutures are being inserted