Patient selection in ambulatory surgery.

Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.

Intraoperative Kounis Syndrome and Fixation Errors: A Case Report.

Postinduction hypotension, though frequently due to anesthetic medications, has a variety of causes. We present a case of presumed intraoperative Kounis syndrome, or anaphylaxis-induced coronary vasospasm, in which the patient's perioperative course was initially attributed to anesthesia-induced hypotension and iatrogenic rebound hypertension leading to Takotsubo cardiomyopathy. A second anesthetic event with immediate recurrence of hypotension after the patient received levetiracetam appears to confirm the diagnosis of Kounis syndrome. In this report, we discuss the fixation error that led to this patient's original misdiagnosis.

Endo-anesthesia: a primer.

Gastrointestinal (GI) endoscopy has witnessed a Cambrian explosion of techniques, indications, and expanding target populations. GI endoscopy encompasses traditional domains that include preventive measures, palliation, as alternative therapies in patients with prohibitive risks of more invasive procedures, and indicated primary treatments. But, it has expanded to include therapeutic and diagnostic interventional endosonography, luminal endoscopic resection, third space endotherapy, endohepatology, and endobariatrics. The lines between surgery and endoscopy are blurred on many occasions within this paradigm. Moreover, patients with high degrees of co-morbidity and complex physiology require more nuanced peri-endoscopic management. The rising demand for endoscopy services has resulted in the development of endoscopy referral centers that offer these invasive procedures as directly booked referrals for regional and rural patients. This further necessitates specialized programs to ensure appropriate evaluation, risk stratification, and optimization for safe sedation and general anesthesia if needed. This landscape is conducive to the organic evolution of endo-anesthesia to meet the needs of these focused and evolving practices. In this primer, we delineate important aspects of endo-anesthesia care and provide relevant clinical and logistical considerations pertaining to the breadth of procedures.

Perioperative Care of the Patient with Eye Pathologies Undergoing Nonocular Surgery.

The authors reviewed perioperative ocular complications and implications of ocular diseases during nonocular surgeries. Exposure keratopathy, the most common perioperative eye injury, is preventable. Ischemic optic neuropathy, the leading cause of perioperative blindness, has well-defined risk factors. The incidence of ischemic optic neuropathy after spine fusion, but not cardiac surgery, has been decreasing. Central retinal artery occlusion during spine fusion surgery can be prevented by protecting eyes from compression. Perioperative acute angle closure glaucoma is a vision-threatening emergency that can be successfully treated by rapid reduction of elevated intraocular pressure. Differential diagnoses of visual dysfunction in the perioperative period and treatments are detailed. Although glaucoma is increasingly prevalent and often questions arise concerning perioperative anesthetic management, evidence-based recommendations to guide safe anesthesia care in patients with glaucoma are currently lacking. Patients with low vision present challenges to the anesthesia provider that are becoming more common as the population ages.

Preoperative Management of Cardiovascular Medications: A Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

Cardiovascular conditions such as hypertension, arrhythmias, and heart failure are common in patients undergoing anesthesia for surgical or other procedures. Numerous guidelines from various specialty societies offer variable recommendations for the perioperative management of these medications. The Society for Perioperative Assessment and Quality Improvement identified a need to provide multidisciplinary evidence-based recommendations for preoperative medication management. The society convened a group of 13 members with expertise in perioperative medicine and training in anesthesiology or internal medicine. The aim of this consensus effort is to provide perioperative clinicians with guidance on the management of cardiovascular medications commonly encountered during the preoperative evaluation. We used a modified Delphi process to establish consensus. Twenty-one classes of medications were identified: α-adrenergic receptor antagonists, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, angiotensin receptor-neprilysin inhibitors, ß-adrenoceptor blockers, calcium-channel blockers, centrally acting sympatholytic medications, direct-acting vasodilators, loop diuretics, thiazide diuretics, potassium-sparing diuretics, endothelin receptor antagonists, cardiac glycosides, nitrodilators, phosphodiesterase-5 inhibitors, class III antiarrhythmic agents, potassium-channel openers, renin inhibitors, class I antiarrhythmic agents, sodium-channel blockers, and sodium glucose cotransportor-2 inhibitors. We provide recommendations for the management of these medications preoperatively.

White Cane Approach to Teaching Spinal Anesthesia.

With aging-associated obesity and osteoarthritis, anesthesiology trainees and their instructors face difficulties in identifying the surface anatomy and landmarks for spinal anesthesia, and successfully advancing the needle into the intrathecal space. Through a series of illustrations and instructions, this teaching tool suggests that using a spinal needle in the same way that a blind person uses a white cane may improve a trainee's ability to successfully perform a lumbar puncture. Reviewing the technique and instructions with the trainee before approaching the patient can minimize verbal instructions in the patient's presence and may lead to improved efficiency and trainee success.

Preoperative Anemia and Risk for Perioperative Neurocognitive Dysfunction in Cardiac Surgery Patients: A Retrospective Analysis.

OBJECTIVES: To evaluate whether there is a relationship between preoperative anemia and domain-specific cognitive performance in patients undergoing cardiac surgery. DESIGN: Retrospective analysis of data collected from a randomized study. SETTING: Tertiary care university hospital. PARTICIPANTS: A total of 436 patients age ≥55 years undergoing cardiac surgery. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Neuropsychological testing was performed before and one month after surgery, using a standard battery. Individual Z-scores calculated from the mean and standard deviation of tests at baseline were combined into domain-specific scores. Anemia (hemoglobin <130 g/L for men, <120 g/L for women) was present in 41% of patients. Preoperative anemia had little impact on preoperative cognition. There were no differences in the change in cognitive performance one month after surgery from baseline between patients with and without preoperative anemia. However, in a sensitivity analysis using multiple imputation for missing cognitive test scores, significant associations were observed between preoperative anemia and change in postoperative processing speed (p = 0.016), change in executive function (p = 0.049), and change in fine motor speed (p = 0.016). Nadir hemoglobin during cardiopulmonary bypass, which was lower in anemic than nonanemic patients, was associated with decrements in performance on tests of verbal fluency (p = 0.007), processing speed (p = 0.042), and executive function (p = 0.10) one month after surgery but not delayed neurocognitive recovery (p = 0.06). CONCLUSIONS: Preoperative anemia may be associated with impairment of selective cognitive domains after surgery. Any effect of preoperative anemia may have on cognition after surgery might be related to lower nadir hemoglobin during cardiopulmonary bypass.

Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement.

Cataract surgeries are among the most common procedures requiring anesthesia care. Cataracts are a common cause of blindness. Surgery remains the only effective treatment of cataracts. Patients are often elderly with comorbidities. Most cataracts can be treated using topical or regional anesthesia with minimum or no sedation. There is minimal risk of adverse outcomes. There is general consensus that cataract surgery is extremely low risk, and the benefits of sight restoration and preservation are enormous. We present the Society for Ambulatory Anesthesia (SAMBA) position statement for preoperative care for cataract surgery.

Risk assessment and risk stratification for perioperative complications and mitigation: Where should the focus be? How are we doing?

Various risk stratification tools are used to predict patients' risk of adverse outcomes. Most of these tools are based on type of surgery and patient comorbidities. Accuracy of risk prediction is improved when additional factors such as functional capacity are included. However, these tools are limited because data are obtained from specific patient populations, are simplified to aid ease of use, and do not account for improved treatment modalities that occur over time. Risk estimation allows for shared decision-making among the perioperative care team and the patient, for perioperative planning, and for opportunity for risk mitigation. Technological advancement in data collection will likely improve existing risk assessment and allow development of new options. Future research should focus on establishing and standardizing perioperative outcomes that include meaningful patient-centric considerations such as quality of life. We review available stratification tools and important risk assessment biomarkers that address the most common causes of adverse outcomes.

Preoperative Intravenous Iron and Erythropoietin to Treat Severe Anemia in Patient With Stage 4 Kidney Disease Before Oncologic Surgery: A Case Report.

Preoperative treatment of anemia with intravenous iron is inconsistent despite known risks of anemia and allogeneic blood transfusions. Limited research exists on the effectiveness of preoperative intravenous iron for chronic kidney disease (CKD) patients. We discuss a patient with severe anemia from advanced CKD, endometrial cancer, and menometrorrhagia. Her hemoglobin increased more than 2 g/dL after erythropoietin and two 750-mg ferric carboxymaltose infusions 5 weeks before a total abdominal hysterectomy and avoided blood transfusions perioperatively. By raising hemoglobin, preoperative intravenous iron and erythropoietin reduce blood transfusions and consequent risk of future allograft rejection and alloimmunization in potential transplant recipients.

Intraoperative Diagnosis of Coronavirus Disease 2019 in an Asymptomatic Patient: A Case Report.

Patients with coronavirus disease 2019 (COVID-19) with variable clinical presentations are encountered in the perioperative setting. While some have already been diagnosed and are symptomatic, others have undiagnosed, asymptomatic COVID-19. The latter group poses the greatest risk of transmission. Given limited capacities in most health care systems, diagnostic testing is mainly performed in symptomatic patients or those with relevant exposure. We report an intraoperative diagnosis of COVID-19 in an asymptomatic patient, prompted by clinical signs. To control a pandemic such as COVID-19, a high index of suspicion is pivotal when caring for asymptomatic patients in the perioperative setting.

Preoperative considerations for Jehovah's Witness patients: a clinical guide.

PURPOSE OF REVIEW: Jehovah's Witnesses have religious beliefs that preclude transfusion of blood products and certain medical interventions. This presents a unique dilemma and ethical challenge to healthcare providers, especially in a surgical setting. RECENT FINDINGS: The growing number of followers of this faith warrants a deeper look at the ethical, legal, and clinical implications of their beliefs. Advances in patient blood management now allow timely optimization before surgery. SUMMARY: Anticipating the challenges associated with managing and optimizing patients who refuse blood products allows for more favorable outcomes in the preoperative period.

Special Considerations Related to Race, Sex, Gender, and Socioeconomic Status in the Preoperative Evaluation: Part 1: Race, History of Incarceration, and Health Literacy.

Patients anticipating surgery and anesthesia often need preoperative care to reduce risk and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges is vital to reducing disparities in health and health care.

Special Considerations Related to Race, Sex, Gender, and Socioeconomic Status in the Preoperative Evaluation: Part 2: Sex Considerations and Homeless Patients.

Patients anticipating surgery and anesthesia often need preoperative care to lower risk and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges are vital to reducing disparities in health and health care.