Title: The Opioid-Free/Sparing Revolution

Abstract:

The maximum duration of pediatric outpatient anesthetics has been previously limited to 4 hours. Advances in anesthesia care now make pediatric ambulatory surgery of over 7 hours duration medically feasible. A retrospective analysis was conducted of 585 consecutive successful combined atresia/microtia reconstruction surgeries performed in the years 2008 to 2022 on an outpatient basis. These anesthetics, exceeding 7 hours in length, expanded the scope of ambulatory pediatric anesthetics to a duration previously deemed unwise or unsafe. Each surgical procedure was a combined cosmetic external ear reconstruction, otologic external auditory canal, and middle ear reconstruction. The general endotracheal anesthetic and surgery were followed by patient discharge to a home or hotel setting. Anesthetic challenges included: 1) appropriate preoperative evaluation and medical clearance of each patient; 2) intraoperative care designed for both safety and quick recovery; and 3) postoperative care designed for both safety and quick recovery. Ear reconstruction surgery is ideal for freestanding ambulatory centers because it involves limited surgical trauma, blood loss, perioperative fluid shifts, postoperative pain, or need for complex postoperative care. Patient disqualifiers included age under 3 years, significant cardiac or pulmonary disease, morbid obesity, sleep apnea, or the presence of dyspnea, productive cough, or fever. The anesthetic technique included sevoflurane, propofol, and fentanyl. The surgical team contributed to the anesthetic management by infiltrating surgical fields with lidocaine and bupivacaine throughout the procedure. Patients had minimal recovery room pain. Narcotics in the recovery room were rarely required. Post-anesthesia care unit stays averaged less than one hour. Only one patient required inpatient admission, due to an anaphylactic reaction to an intravenous antibiotic. This series of 7-hour-plus general endotracheal anesthetics for pediatric ambulatory surgery shows evidence that a lengthy duration of pediatric general anesthesia is both medically feasible and safe for healthy children, providing the surgical procedure causes limited surgical trauma, blood loss, perioperative fluid shifts, postoperative pain, or need for complex postoperative care.

Biography:

Richard Novak MD is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University. Dr. Novak is board-certified in anesthesiology and internal medicine, and is also the Medical Director at Waverley Surgery Center in Palo Alto, California and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.