method/technique would you choose to provide anesthesia?
All types of anesthesia ranging from monitored
anes-thesia care (MAC) through regional and general anesthesia have been safely
performed in the office. Both general anes-thesia and MAC have benefited from
the introduction of newer faster-acting anesthetic agents, such as sevoflurane,
desflurane, and remifentanil. These new agents provide rapid onset and offset
that are perfect for the office setting.
Remifentanil is an ultra-short-acting opioid
that can be easily titrated to various levels of surgical stimulation. It is a
selective mu opioid agonist with potency similar to that of fentanyl. It is
distinguished from fentanyl by its unique ester linkage. It has a rapid onset
and offset making it ideal for use in the office setting. Remifentanil,
0.05–0.10 μg/kg/min, in combination with midazolam provides effective
analgesia and sedation during MAC. Remifentanil can be titrated to provide deep
levels of analgesia, if necessary; however, it does not provide long-term
analgesia. Thus, it will be necessary to provide for postoperative analgesia
for painful procedures.
Sevoflurane and desflurane are newer inhalation
agents which have the distinction of rapid uptake and distribu-tion, thereby
allowing for a faster recovery from general anesthesia and short time to
Propofol, while not a new anesthetic agent, is
widely used in office-based surgery because of its rapid onset and recovery
times. A propofol infusion in combination with midazolam also provides good
sedation during MAC, but does not provide analgesia.
Ketamine has recently gained popularity in the
office-based arena. Ketamine is a phencyclidine derivative and provides intense
analgesia without decreasing ventilation. In contrast to opioids, it is not
associated with nausea and vomiting. However, ketamine is a dissociative
anesthetic and has been linked to hallucinations. This effect can be attenuated
or eliminated by the use of midazolam or propofol. Additionally, since ketamine
can increase secre-tions, one should administer an antisialogogue, such as
glycopyrrolate, when ketamine is used.