Demands of Integrated Care Delivery in Interventional Medicine and Anesthesiology: Interdisciplinary Teamwork and Strategy.

Evolving financial and medical constraints fueled by the increasing repertoire of nonoperating room cases and widening scope of patient comorbidities are discussed. The need to integrate finances and care approaches is detailed, and strategic suggestions for broader collaborative practice are suggested.

Value-Based Care and Strategic Priorities.

The anesthesia market continues to undergo disruption. Financial margins are shrinking, and buyers are demanding that anesthesia services be provided in an efficient, low-cost manner. To help anesthesiologists analyze their market, Drucker and Porter's framework of buyers, suppliers, quality, barriers to entry, substitution, and strategic priorities allows for a structured analysis. Once this analysis is completed, anesthesiologists must articulate their value to other medical professionals and to hospitals. Anesthesiologists can survive and thrive in a value-based health care environment if they are capable of providing services differently and able to deliver cost-effective care.

Life-threatening perioperative anesthetic complications: major issues surrounding perioperative morbidity and mortality.

Perioperative morbidity and mortality related to anesthesia involves multiple factors. Patient characteristics and comorbidities play a role in many of these events, highlighting the importance of preoperative screening. While optimization of patient comorbidities is not always possible, having data regarding those comorbidities can prove life-saving. Equipment and medication considerations also enter into untoward outcomes such as anesthetic interventions outside of the traditional operating room where resources are sometimes lacking and haste creates errors. Ultimately, when surgeons and anesthesiologists cooperate in patient care, communicating concisely but thoroughly, patients are more likely to do well. The language of surgeons is that of diagnosis requiring a surgical intervention, while anesthesiologists are discussing patient comorbidities impacted by anesthetic medications, positive pressure ventilation, neuraxial techniques, ramifications of patient positioning, effects of opiates and so on. Because all of the considerations combine in determining outcomes, it is incumbent on both surgeons and anesthesiologists to understand those elements leading to severe morbid events as well as death. This review touches on many of the most important factors.

Changes in cerebral oxygen saturation during transcatheter aortic valve replacement.

Cerebral oxygen saturation (rSO2) is a non-invasive monitor used to monitor cerebral oxygen balance and perfusion. Decreases in rSO2 >20 % from baseline have been associated with cerebral ischemia and increased perioperative morbidity. During transcatheter aortic valve replacement (TAVR), hemodynamic manipulation with ventricular pacing up to 180 beats per minute is necessary for valve deployment. The magnitude and duration of rSO2 change during this manipulation is unclear. In this small case series, changes in rSO2 in patients undergoing TAVR are investigated. Ten ASA IV patients undergoing TAVR with general anesthesia at a university hospital were prospectively observed. Cerebral oximetry values were analyzed at four points: pre-procedure (baseline), after tracheal intubation, during valve deployment, and at procedure end. Baseline rSO2 values were 54.5 ± 6.9 %. After induction of general anesthesia, rSO2 increased to a mean of 66.0 ± 6.7 %. During valve deployment, the mean rSO2 decreased <20 % below baseline to 48.5 ± 13.4 %. In two patients, rSO2 decreased >20 % of baseline. Cerebral oxygenation returned to post-induction values in all patients 13 ± 10 min after valve deployment. At procedure end, the mean rSO2 was 67.6 ± 8.1 %. As expected, rapid ventricular pacing resulting in the desired decrease in cardiac output during valve deployment was associated with a significant decrease in rSO2 compared to post-induction values. However, despite increased post-induction values in all patients, whether related to increased inspired oxygen fraction or reduced cerebral oxygen consumption under anesthesia, two patients experienced a significant decrease in rSO2 compared to baseline. Recovery to baseline was not immediate, and took up to 20 min in three patients. Furthermore, baseline rSO2 in this population was at the lower limit of the published normal range. Significant cerebral desaturation during valve deployment may potentially be limited by maximizing rSO2 after anesthetic induction. Future studies should attempt to correlate recovery in rSO2 with recovery of hemodynamics and cardiac function, provide detailed neurological assessments pre and post procedure, determine the most effective method of maximizing rSO2 prior to hemodynamic manipulation, and provide the most rapid method of recovery of rSO2 following valve deployment.

A matter of life or limb? A review of traumatic injury patterns and anesthesia techniques for disaster relief after major earthquakes.

BACKGROUND: All modalities of anesthetic care, including conscious sedation, general, and regional anesthesia, have been used to manage earthquake survivors who require urgent surgical intervention during the acute phase of medical relief. Consequently, we felt that a review of epidemiologic data from major earthquakes in the context of urgent intraoperative management was warranted to optimize anesthesia disaster preparedness for future medical relief operations. The primary outcome measure of this study was to identify the predominant preoperative injury pattern (anatomic location and pathology) of survivors presenting for surgical care immediately after major earthquakes during the acute phase of medical relief (0-15 days after disaster). The injury pattern is of significant relevance because it closely relates to the anesthetic techniques available for patient management. We discuss our findings in the context of evidence-based strategies for anesthetic management during the acute phase of medical relief after major earthquakes and the associated obstacles of devastated medical infrastructure. METHODS: To identify reports on acute medical care in the aftermath of natural disasters, a query was conducted using MEDLINE/PubMed, Embase, CINAHL, as well as an online search engine (Google Scholar). The search terms were "disaster" and "earthquake" in combination with "injury," "trauma," "surgery," "anesthesia," and "wounds." Our investigation focused only on studies of acute traumatic injury that specified surgical intervention among survivors in the acute phase of medical relief. RESULTS: A total of 31 articles reporting on 15 major earthquakes (between 1980 and 2010) and the treatment of more than 33,410 patients met our specific inclusion criteria. The mean incidence of traumatic limb injury per major earthquake was 68.0%. The global incidence of traumatic limb injury was 54.3% (18,144/33,410 patients). The pooled estimate of the proportion of limb injuries was calculated to be 67.95%, with a 95% confidence interval of 62.32% to 73.58%. CONCLUSIONS: Based on this analysis, early disaster surgical intervention will focus on surviving patients with limb injury. All anesthetic techniques have been safely used for medical relief. While regional anesthesia may be an intuitive choice based on these findings, in the context of collapsed medical infrastructure, provider experience may dictate the available anesthetic techniques for earthquake survivors requiring urgent surgery.

Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel.

PURPOSE: Consensus recommendations to help ensure safe insulin use in hospitalized patients are presented. SUMMARY: Insulin products are frequently involved in medication errors in hospitals, and insulin is classified as a high-alert medication when used in inpatient settings. In an initiative to promote safer insulin use, the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation convened a 21-member panel representing the fields of pharmacy, medicine, and nursing and consumer advocacy groups for a three-stage consensus-building initiative. The panel's consensus recommendations include the following: development of protocol-driven insulin order sets, elimination of the routine use of correction/sliding-scale insulin doses for management of hyperglycemia, restrictions on the types of insulin products stored in patient care areas, and policies to restrict the preparation of insulin bolus doses and i.v. infusions to the pharmacy department. In addition, the panelists recommended that hospitals better coordinate insulin use with meal intake and glucose testing, prospectively monitor the coordination of insulin delivery and rates of hypoglycemia and hyperglycemia, and provide standardized education and competency assessment for all hospital-based health care professionals responsible for insulin use. CONCLUSION: A 21-member expert panel convened by the ASHP Foundation identified 10 recommendations for enhancing insulin-use safety across the medication-use process in hospitals. Professional organizations, accrediting bodies, and consumer groups can play a critical role in the translation of these recommendations into practice. Rigorous research studies and program evaluations are needed to study the impact of implementation of these recommendations.

Review article: the evolving role of information technology in perioperative patient safety.

PURPOSE: The adoption of new technologies in medicine is frequently met with both enthusiasm and resistance. The universal adoption of health information technology (IT) and anesthesia information management systems (AIMS) remains low despite the potential benefits. Electronic medical records, and hence AIMS, are at the intersection of patient safety. This article highlights advantages and barriers to adoption and implementation of IT in general and AIMS in particular, with a focus on clinical decision support systems (CDSS) and computerized physician order entry (CPOE) as hallmarks that may lead to improvement in patient safety and quality in the perioperative setting. PRINCIPAL FINDINGS: The advantages of health IT and AIMS include improved legibility of documentation; the ability to integrate new scientific evidence into practice; enhanced management and exchange of complex health information; the ability to standardize order sets, incorporate computerized physician order entry, and provide clinical decision support; and the ability to capture data for management, research, and quality monitoring and reporting. While not foolproof, AIMS have been shown to improve safety, quality, and patient outcomes. Barriers to the adoption of health IT and AIMS include costs, lack of truly interoperable AIMS components in health-system IT solutions, and lack of clinician involvement in implementation, planning, design, and installation of many IT or AIMS products. CONCLUSIONS: Health IT and AIMS are at the intersection of patient safety and technology. Anesthesiologists are perfectly positioned to be the physician leaders of adoption, design, implementation, and integration, not only for AIMS but also for health-system IT solutions in general.

Influences observed on incidence and reporting of medication errors in anesthesia.

BACKGROUND: Medication errors are a common occurrence during the conduct of anesthesia (one in 133-450 [corrected] patients). Several factors contribute to medication errors in anesthesia, including experience of the anesthesia provider, severity of comorbidities, and type of procedure. The inexperience of anesthesia providers-in-training also leads to increased error rates. This prospective observational study repeats and extends previous work by Webster et al. and Llewellyn et al. examining the role of comorbidities, type of case, and level of provider experience on the incidence of medication errors. METHODS: After Institutional Review Board review and exemption from informed consent, medication error reporting forms were attached to every anesthetic record during a six-month period. All providers were asked to return the forms for every anesthetic, on a strictly voluntary and anonymous basis, and to record the occurrence of medication errors. If providers indicated that a medication error had occurred, additional details about the event were obtained anonymously. RESULTS: There were 8,777 (83%) responses obtained in a review of 10,574 case forms. A medication error was reported in 35 forms, with an additional 17 forms indicating a medication pre-error or near miss, resulting in 52 (0.49%) errors/pre-errors or a reported incidence of 1:203 anesthetics. Most case types were observed to have a statistically significant increase in reported medication errors. Reported errors by type of anesthesia provider were categorized into anesthesia provider-in-training group and the experienced provider group. The anesthesia provider-in-training group reported a twofold increase in the rate of errors, with the most frequently reported errors being incorrect dose and substitution. CONCLUSION: This study suggests that case type, American Society of Anesthesiologists' classification, and level of provider experience play a role on the rate of medication errors. The results of this study are in agreement with previously reported error rates.

Outpatient regional anesthesia for upper extremity surgery update (2005 to present) distal to shoulder.

Multiple different approaches to the brachial plexus are available for the regional anesthesiologist to provide successful anesthesia and analgesia for ambulatory surgery of the upper extremity. Although supraclavicular and infraclavicular blocks are faster to perform than axillary blocks, the operator needs to keep in mind that blocks performed around the clavicle carry the risk for specific side effects and complications, no matter whether ultrasound or nerve stimulation is the chosen modality for neurolocation. Owing to the ambulatory nature of the planned surgical intervention, even significant side effects may not become clinically symptomatic until the patient is discharged from the facility. For example, due to pneumothorax risks, axillary or mid-humeral blocks remain the most logical approaches for ambulatory surgical procedures at and below the elbow, while reserving infra-clavicularor supraclavicular approaches for surgery from the proximal humerus to above the elbow. Smaller interventions such as carpal tunnel release or trigger finger release can be performed under elbow, wrist, or digital blocks. The regional anesthesiologist should strive to develop a tailored plan for each individual case to provide the most effective and safest nerve block technique for their patients.

A randomized, controlled trial on dexmedetomidine for providing adequate sedation and hemodynamic control for awake, diagnostic transesophageal echocardiography.

OBJECTIVE: Transesophageal echocardiography (TEE) has become established as a sensitive and accurate diagnostic method for the rapid assessment of myocardial function. It was theorized that dexmedetomidine (Precedex; Hospira, Inc, Lake Forest, IL) might prove to be useful for sedating patients while undergoing TEE. DESIGN: A prospective, randomized trial was designed comparing dexmedetomidine versus standard therapy (eg, midazolam and opioids) for sedation. SETTING: This trial was performed in a tertiary care, single-institution university hospital. PARTICIPANTS: Males and females, American Society of Anesthesiologists I to IV, ages 18 to 65 years, requiring diagnostic TEE. Patients were excluded if pregnant, if they had taken benzodiazepines or opioids within 24 hours, or if they were deemed to be too unstable to receive any kind of sedation. INTERVENTIONS: Patients were randomized to standard therapy or dexmedetomidine infusion groups. Sedation was assessed at 6 time points. Pulse oximetry, electrocardiogram, heart rate, noninvasive blood pressure, and respiratory rate were monitored. Additional variables measured were the amount of each drug given, the time of the TEE procedure, and the time to recovery. MEASUREMENTS AND MAIN RESULTS: A survey about the quality of sedation, the level of comfort, and whether or not they would accept this type of sedation again was administered after recovery from sedation. Demographic data and patient questionnaire responses were reported as means and standard errors or percents and were analyzed with the t test and chi-square test. Twenty-two patients were enrolled. Hemodynamics were statistically different between the two groups at several time points. Both systolic and diastolic blood pressures (BP) were elevated in the standard therapy group, whereas the dexmedetomidine group had a lower BP. Heart rate was elevated significantly in the standard therapy group compared with the dexmedetomidine group. There was no statistical or clinical difference between the groups in terms of oxygenation or respiratory rate. CONCLUSIONS: The authors concluded that dexmedetomidine appears equivalent in achieving adequate levels of sedation without increasing the rate of respiratory depression or decreasing oxygen saturation compared with standard therapy, and it may be better in achieving desired hemodynamic results.

Postoperative complications after thoracic surgery in the morbidly obese patient.

Little has been recently published about specific postoperative complications following thoracic surgery in the morbidly obese patient. Greater numbers of patients who are obese, morbidly obese, or supermorbidly obese are undergoing surgical procedures. Postoperative complications after thoracic surgery in these patients that can lead to increased morbidity and mortality, prolonged hospital stay, and increased cost of care are considered. Complications include difficulties with mask ventilation and securing the airway, obstructive sleep apnea with risk of oversedation, pulmonary complications related to reduced total lung capacity, reduced functional residual capacity, and reduced vital capacity, risks of aspiration pneumonitis and ventilator-associated pneumonia, cardiomyopathies, and atrial fibrillation, inadequate diabetes management, positioning injuries, increased risk of venous thrombosis, and pulmonary embolism. The type of thoracic surgical procedure may also pose other problems to consider during the postoperative period. Obese patients undergoing thoracic surgery pose a challenge to those caring for them. Those working with these patients must understand how to recognize, prevent, and manage these postoperative complications.

Surgery under extreme conditions in the aftermath of the 2010 Haiti earthquake: the importance of regional anesthesia.

The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thousands of injuries requiring immediate surgical interventions, and 1.5 million internally displaced survivors. The earthquake destroyed or disabled most medical facilities in the city, seriously hampering the ability to deliver immediate life- and limb-saving surgical care. A Project Medishare/University of Miami Miller School of Medicine trauma team deployed to Haiti from Miami within 24 hours of the earthquake. The team began work at a pre-existing tent facility in the United Nations (UN) compound based at the airport, where they encountered 225 critically injured patients. However, non-sterile conditions, no means to administer oxygen, the lack of surgical equipment and supplies, and no anesthetics precluded the immediate delivery of general anesthesia. Despite these limitations, resuscitative care was administered, and during the first 72 hours following the event, some amputations were performed with local anesthesia. Because of these austere conditions, an anesthesiologist, experienced and equipped to administer regional block anesthesia, was dispatched three days later to perform anesthesia for limb amputations, debridements, and wound care using single shot block anesthesia until a better equipped tent facility was established. After four weeks, the relief effort evolved into a 250-bed, multi-specialty trauma/intensive care center staffed with >200 medical, nursing, and administrative staff. Within that timeframe, the facility and its staff completed 1,000 surgeries, including spine and pediatric neurological procedures, without major complications. This experience suggests that when local emergency medical resources are completely destroyed or seriously disabled, a surgical team staffed and equipped to provide regional nerve block anesthesia and acute pain management can be dispatched rapidly to serve as a bridge to more advanced field surgical and intensive care, which takes longer to deploy and set up.