EP1094 - Propofol-free monitored anesthesia care for prone jack-knife anorectal procedures: single-center case series.

Purpose/Background: Patient positioning for anorectal cases is an ongoing point of discussion among colorectal surgeons and anesthesiologists. The two most common positions are lithotomy and prone jack-knife. Prior studies suggest the prone jack-knife position can provide better operative exposure, shorter operative time, less blood loss, and improved ergonomics for proctologic cases . However, the prone jack-knife position may present challenges in patients with higher BMI and/or difficult airway. Prone positioning can affect hemodynamics by compressing the IVC, decreasing cardiac output and SVR, and causing hypotension . In addition, propofol, the most common anesthetic for these cases, may further depress ventilation and affect hemodynamics. If respiratory depression occurs, securing the airway is more challenging because prone positioning limits airway access. To the best of our knowledge, no standardized protocol exists to reduce airway complications in the prone jack-knife position. With these considerations, we present a prospective analysis of patients who received the listed medication cocktail without propofol.

Methods/Interventions: We report a multimodal regimen tailored to these patients with the goal of providing a framework for safe monitored anesthesia care (MAC) without propofol and with the aim of decreasing potential respiratory compromise necessitating urgent or emergent intubation. We selected patients scheduled for elective anorectal surgery at NYU Langone Brooklyn from 9/2025-10/2025 for standard hemorrhoidectomy, fistulectomy, pilonidal cyst excision, perianal abscess drainage, and rectal polyp excision. These patients underwent propofol-free anesthesia; they received MAC with IV dexmedetomidine, prophylactic IV glycopyrrolate to reduce secretions and mitigate bradycardia from dexmedetomidine, IV fentanyl for sedation, IV ketorolac, IV midazolam, IV dexamethasone, diphenhydramine, ondansetron, and ketamine as needed for pain, in addition to local anesthetic for all cases. Patients were monitored intra- and postoperatively for pain, bradycardia, and respiratory secretions by the anesthesia team. Median BMI was calculated, and ASA classification was assigned by the anesthesia team.

Results/Outcomes: A total of 16 patients underwent anorectal surgery in the 4-week period. Of these, 81% (n=13) were male, with a median BMI of 26.4. ASA classification of 2 in 69% (n=11). Of the 15 patients who underwent propofol-free sedation, no patients had events of hypoxia or desaturations, bradycardia, or respiratory secretions requiring airway manipulation. Median intraoperative time was 42.5 minutes. Patients were monitored in recovery post-procedure; median recovery time was 2-3 hours.

This study is limited by the small sample size. We did not account for patients who had propofol-free sedation in lithotomy position, so position-based differences were not assessed.

Conclusion/Discussion: A propofol-free, multimodal MAC regimen was feasible for anorectal procedures performed in the prone jack-knife position in this series and was not associated with hypoxia/desaturation, bradycardia, or airway interventions. These preliminary findings suggest the approach may be suitable for selected patients at higher risk for respiratory depression based on BMI, comorbidities, or ASA class; and may support operating-room efficiency. Further work in collaboration with anesthesia should evaluate respiratory and recovery outcomes comparatively across anesthetic regimens and positions, including lithotomy.