What method/technique would you choose to provide anesthesia?

What 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 discharge.

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.