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T
he modified Aldretes scoring system (1) is com- Methods
monly used for determining when patients can
Recovery data from 216 consenting female outpatients
be safely discharged from the postanesthesia
undergoing either laparoscopic tubal ligation (LT) or
care unit (PACU) to either the postsurgical ward or to
cholecystectomy (LC) procedures at the University of
the second stage (Phase II) recovery area. Recently, Texas Southwestern Medical Center at Dallas from
these discharge criteria have also been used in the January 1997 through July 1998 were analyzed. Pa-
operating room (OR) to determine the fast-track eligi- tients without an evaluation of the modified Aldrete
bility of outpatients undergoing ambulatory surgery score and objective assessments of pain, nausea, and
(2,3). Because fast-tracking in the ambulatory setting vomiting at 1-min intervals after discontinuation of
implies taking a patient from the OR directly to the the maintenance anesthetics, as well as those who
less extensively monitored Phase II step-down unit, failed to receive both preventative analgesic and pro-
this scoring system may not be adequate after ambu- phylactic antiemetic medications, were excluded from
latory procedures requiring general anesthesia be- the data analysis.
cause it fails to consider common side effects that All patients were premedicated with midazolam
have traditionally been treated in the PACU (e.g., 2 mg IV. Anesthesia was induced with propofol
pain, nausea, and vomiting). Therefore, a new fast- 2 mg/kg IV and remifentanil 1 mg/kg IV (for LT) or
track scoring system that incorporates the essential with fentanyl 2 mg/kg IV (for LC). Laryngoscopy and
elements of the modified Aldrete system, as well as tracheal intubation were facilitated with either succi-
an assessment of pain and emesis, has been proposed nylcholine 1 mg/kg IV (for LT) or with rocuronium
(4). 0.6 mg/kg IV (for LC). After tracheal intubation, an-
We hypothesized that using this new scoring sys- esthesia was maintained with one of the three anes-
tem to determine a patients fast-track eligibility thetics: desflurane 2% 8% (inspired), sevoflurane
would reduce the need for nursing interventions to 0.6%2.4% (inspired), or propofol 50 200 mg z kg21 z
administer parenteral medications in the Phase II re- min21, in combination with nitrous oxide 67% in ox-
ygen. Supplemental bolus doses of fentanyl 2550 mg
covery area. The times to fast-track eligibility were
IV were administered for persistent hypertension or/
compared using the modified Aldrete and new fast-
and tachycardia that did not respond to increases in
track criteria in outpatients undergoing laparoscopic
the dose of the maintenance anesthetic. Muscle relax-
surgery with one of three standardized general anes- ation was maintained with bolus doses of either mi-
thetic techniques. vacurium 0.04 mg/kg (for LT) or rocuronium
0.15 mg/kg IV (for LC). All patients received both
analgesic and antiemetic prophylaxis with ketorolac
30 (for LT) to 60 (for LC) mg IV and droperidol
0.625 mg IV 1530 min before the end of surgery.
This work was supported by Ambulatory Anesthesia Research
Foundation, Dallas, TX. Early recovery status was evaluated at 1-min inter-
Accepted for publication January 20, 1999. vals after discontinuation of the maintenance anes-
Address correspondence and reprint requests to Dr. Paul F. thetics using both the modified Aldrete scoring system
White, Department of Anesthesiology and Pain Management, Uni- (1) and the new fast-track scoring system (Appendix 1)
versity of Texas Southwestern Medical Center at Dallas, 5161 Harry
Hines Boulevard, CS 2. 282, Dallas, TX 75235-9068. Address e-mail (4). In calculating the fast-track score, the recorded
to pwhite@mednet.swmed.edu. visual analog scale (VAS) scores for pain, nausea, and
vomiting (0 5 none to 10 5 maximal) were assigned a anesthesia to fast-track eligibility was significantly
descriptive term. A VAS score #3 was considered longer in patients receiving propofol (versus desflu-
mild, 4 7 represented moderate, and $8 was clas- rane or sevoflurane) anesthesia, whereas there were
sified as severe. Patients were considered fast-track no differences among the three anesthetic techniques
eligible if they achieved a score of 10 using the mod- when using the fast-track scoring system. On arrival in
ified Aldrete scoring system or a score of $12 (with no the PACU, the percentage of patients judged fast-
score ,1 in any individual category) using the new track eligible using the new criteria was also signifi-
scoring system. Times from discontinuation of the cantly lower in the desflurane and sevoflurane groups,
maintenance anesthetics to fast-track eligibility using but not in the propofol group, compared with using
the two scoring systems were recorded at 1-min inter- the modified Aldrete criteria (Table 2). A significantly
vals until 5 min after arrival in the PACU, and subse- higher percentage of patients judged fast-trackeligible
quently at 5-min intervals until the patient achieved using the modified Aldrete criteria subsequently re-
fast-track eligibility using both scoring systems. quired IV analgesics and antiemetics compared with that
Data were analyzed using one-way analysis of vari- after fast-track eligibility was achieved using the new
ance for continuous variables and x2 test for discrete criteria (Fig. 1). None of the patients in any anesthetic
variables. These data are expressed as means 6 sd or group received parenteral medications other than IV
percentages, with P values ,0.05 considered statisti- analgesics and antiemetics after surgery.
cally significant.
Discussion
Results Fast-tracking outpatients after general anesthesia has
The patient demographic data and distribution of assumed increased importance in ambulatory anes-
cases were similar in the three general anesthetic thesia because of the cost-savings potential when pa-
groups (Table 1). Compared with the modified Al- tients are transferred directly from the OR to the less
drete criteria, use of the new criteria required a sig- labor-intensive Phase II recovery area (5,6). Given the
nificantly longer time period to achieve fast-track inherent risks of complications associated with by-
eligibility with both desflurane and sevoflurane, but passing the PACU, effective and reliable fast-track
not with propofol (Table 2). When using Aldretes
scoring system, the times from discontinuation of
Table 2. Time from Discontinuation of Anesthesia to Achieving Fast-Track Eligibility and the Number of Patients Being
Judged Fast-TrackEligible on Arrival in the Phase I Postanesthesia Care Unit
Desflurane Sevoflurane Propofol
a
Time (min) from discontinuation of anesthesia to fast-track eligibility
Aldretes criteria 10.2 6 4.2 12.0 6 5.7 16.3 6 6.4*
Fast-track criteria 15.6 6 6.2 16.4 6 6.9 17.5 6 7.9
Fast-trackeligible on arrival in the Phase I postanesthesia care unit
Aldretes criteria 56 (90) 64 (74) 22 (32)*
Fast-track criteria 41 (66) 48 (56) 18 (26)*
Values are mean 6 sd or n (%).
Aldrete score (1) of 10 or a fast-track score (4) of $12.
* P , 0.05 compared with the desflurane and sevoflurane groups.
P , 0.05 compared with Aldretes criteria.
ANESTH ANALG BRIEF COMMUNICATION WHITE AND SONG 1071
1999;88:1069 72 CRITERIA FOR FAST-TRACKING
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surgery. J Clin Anesth. In press. tory surgery. Anesth Analg 1995;80:896 902.
5. Lubarsky DA. Fast-track in the postanesthesia care unit: unlim-
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