To the Editor:—

With all due respect to the excellent discussion by Ebert et al.  1of recovery from sevoflurane versus  isoflurane and propofol, I believe we are continuing to split hairs over aspects of patients’ early (i.e. , in-hospital) recovery period while neglecting meaningful and unanswered questions about the recovery process once patients are at home. The article by Ebert et al.  adds to an already very large body of literature focusing on the early postoperative period. To our patients, what happens at home would seem to be of more interest, yet it is still an unproven and barely tested assumption that better recovery parameters while patients are in the hospital might actually reflect advantages later in the recovery process.

We still do not have an understanding of many basic questions regarding at-home recovery. What is the natural course of recovery from anesthesia for most outpatient procedures? When does a patient resume their usual at-home activities? How soon are they able to sustain these activities over the course of the entire day? When is cognitive function good enough to allow return to work, and when is it fully restored to baseline? When is a child able to play and eat normally or to return to the usual school or child-care setting so that a parent might return to either work or customary at-home routines? How frequent is postoperative confusion in the elderly outpatient and how long does it last? Are the answers to these questions different for various intravenous and inhaled anesthetic agents?

I am aware of only one study that investigated some of these questions. In 1991, Sung et al.  2noted that patients who underwent general anesthesia for breast biopsies resumed normal activities sooner (7 h vs.  17 h) and returned to work sooner (1.5 days vs.  2 days) after a propofol infusion and nitrous oxide anesthetic versus  a pentothal induction and maintenance with isoflurane and nitrous oxide.

From the perspective of the needs of our patients, their families, and their employers, the aforementioned questions would seem to be at least as relevant as the excellent database available to us on times to emergence, orientation, and recovery room and hospital discharge. Moreover, such data should be of great interest to the manufacturers of the new and expensive anesthetic agents, given the pressures so many of us are facing to prove that we are providing “cost-effective care.” In fact, after investigation of at-home recovery, we might find that we have a new and more compelling rationale to support even more widespread use of the short-acting agents; at the very least, this seems plausible enough to deserve further investigation.

Ebert TJ, Robinson BJ, Uhrich TD, Mackenthun A, Pichotta PJ: Recovery from sevoflurane anesthesia: A comparison to isoflurane and propofol anesthesia. A NESTHESIOLOGY 1998; 89: 1524–31
Sung YF, Reiss N, Tillette T: The differential cost of anesthesia and recovery with propofol–nitrous oxide versus thiopental sodium–isoflurane–nitrous oxide anesthesia. J Clin Anesth 1991; 3: 391–4