Preoperative Communication Between Anesthesia, Surgery, and Primary Care Providers for Older Surgical Patients.

BACKGROUND: Suboptimal communication between clinicians remains a frequent driver of preventable adverse health care-related events, increased costs, and patient and physician dissatisfaction. METHODS: Cross-sectional surveys on preoperative interspecialty communication, tailored by stakeholder type, were administered to (1) primary care providers in northern New England, (2) anesthesia providers working in the perioperative clinic of a tertiary rural academic medical center, (3) surgeons from the same center, and (4) older surgical patients who underwent preoperative assessment at the same center. RESULTS: In total, 107/249 (43.0%) providers and 103/265 (39.9%) patients completed the survey. Preoperative communication was perceived as logistically challenging (59.8%), particularly across health systems. More than 77% of anesthesia and surgery providers indicated that they communicate frequently or sometimes, but 92.5% of primary care providers indicated that they rarely or never communicate with anesthesia providers. Some of the most common reasons for preoperative communication were discussion of complex patients, perioperative medication management, and optimization of comorbidities. Although 96.1% of older surgical patients reported that preoperative communication between providers is important, only 40.4% felt that their providers communicate very or extremely well. Many patients emphasized the importance of preoperative communication between providers to ensure transfer of critical clinical information. CONCLUSION: Surgeons and anesthesiologists infrequently communicate with primary care providers in one rural tertiary center, in contrast to patient expectations and values. These study results will help identify priorities and potentially resolvable barriers to bridging the gap between the inpatient perioperative and outpatient primary care teams. Future studies should focus on strategies to improve communication between hospital and community providers to prevent complications and readmission.

The association of prescription opioid use with incident cancer: A Surveillance, Epidemiology, and End Results-Medicare population-based case-control study.

BACKGROUND: Cancer is the second leading cause of death globally, and researchers seek to identify modifiable risk factors Over the past several decades, there has been ongoing debate whether opioids are associated with cancer development, metastasis, or recurrence. Basic science, clinical, and observational studies have produced conflicting results. The authors examined the association between prescription opioids and incident cancers using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. A complex relation was observed between prescription opioids and incident cancer, and cancer site may be an important determinant. METHODS: By using linked SEER cancer registry and Medicare claims from 2008 through 2013, a case-control study was conducted examining the relation between cancer onset and prior opioid exposure. Logistic regression was used to account for differences between cases and controls for 10 cancer sites. RESULTS: Of the population studied (n = 348,319), 34% were prescribed opioids, 79.5% were white, 36.9% were dually eligible (for both Medicare and Medicaid), 13% lived in a rural area, 52.7% had ≥1 comorbidity, and 16% had a smoking-related diagnosis. Patients exposed to opioids had a lower odds ratio (OR) associated with breast cancer (adjusted OR, 0.96; 95% CI, 0.92-0.99) and colon cancer (adjusted OR, 0.90; 95% CI, 0.86-0.93) compared with controls. Higher ORs for kidney cancer, leukemia, liver cancer, lung cancer, and lymphoma, ranging from lung cancer (OR, 1.04; 95% CI, 1.01-1.07) to liver cancer (OR, 1.19; 95% CI, 1.08-1.31), were present in the exposed population. CONCLUSIONS: The current results suggest that an association exists between prescription opioids and incident cancer and that cancer site may play an important role. These findings can direct future research on specific patient populations that may benefit or be harmed by prescription opioid exposure.

Preterm Versus Term Children: Analysis of Sedation/Anesthesia Adverse Events and Longitudinal Risk.

BACKGROUND AND OBJECTIVES: Preterm and former preterm children frequently require sedation/anesthesia for diagnostic and therapeutic procedures. Our objective was to determine the age at which children who are born <37 weeks gestational age are no longer at increased risk for sedation/anesthesia adverse events. Our secondary objective was to describe the nature and incidence of adverse events. METHODS: This is a prospective observational study of children receiving sedation/anesthesia for diagnostic and/or therapeutic procedures outside of the operating room by the Pediatric Sedation Research Consortium. A total of 57,227 patients 0 to 22 years of age were eligible for this study. All adverse events and descriptive terms were predefined. Logistic regression and locally weighted scatterplot regression were used for analysis. RESULTS: Preterm and former preterm children had higher adverse event rates (14.7% vs 8.5%) compared with children born at term. Our analysis revealed a biphasic pattern for the development of adverse sedation/anesthesia events. Airway and respiratory adverse events were most commonly reported. MRI scans were the most commonly performed procedures in both categories of patients. CONCLUSIONS: Patients born preterm are nearly twice as likely to develop sedation/anesthesia adverse events, and this risk continues up to 23 years of age. We recommend obtaining birth history during the formulation of an anesthetic/sedation plan, with heightened awareness that preterm and former preterm children may be at increased risk. Further prospective studies focusing on the etiology and prevention of adverse events in former preterm patients are warranted.

The National Anesthesia Clinical Outcomes Registry.

The Anesthesia Quality Institute (AQI) was chartered in 2008 by the American Society of Anesthesiologists to develop the National Anesthesia Clinical Outcomes Registry (NACOR). In this Technical Communication, we will describe how data enter NACOR, how they are authenticated, and how they are analyzed and reported. NACOR accepts case-level administrative, clinical, and quality capture data from voluntarily participating anesthesia practices and health care facilities in the United States. All data are transmitted to the AQI in summary electronic files generated by billing, quality capture, and electronic health care record software, typically on a monthly basis. All data elements are mapped to fields in the NACOR schema in accordance with a publicly available data dictionary. Incoming data are loaded into NACOR by AQI technologists and are subject to both manual and automated review to identify systematically missing elements, miscoding, and inadvertent corruption. Data are deidentified in compliance with Health Insurance Portability and Accountability Act regulations. The database server of AQI, which houses the NACOR database, is protected by 2 firewalls within the American Society of Anesthesiologists' network infrastructure; this system has not been breached. The NACOR Participant User File, a deidentified case-level dataset of information from NACOR, is available to researchers at participating institutions. NACOR architecture and the nature of the Participant User File include both strengths and weaknesses.

The current status of procedural sedation for pediatric patients in out-of-operating room locations.

PURPOSE OF REVIEW: To illustrate the changes that are occurring in the rapidly growing field of pediatric sedation. In the USA and throughout the world, children receive sedation from a multitude of specialists with varying levels of training. The current pediatric sedation literature reflects a growing body of sedation literature by medical specialists other than anesthesiologists. This article will review the controversial use of propofol by nonanesthesiologists and the manner in which this varied group of providers along with government entities, regulatory agencies, and national organizations contribute to the continuing evolution of sedation practices. RECENT FINDINGS: The number of diagnostic and therapeutic procedures performed on children outside of the operating room continues to increase. The growing body of pediatric sedation literature suggests anesthesiologists are no longer at the forefront of pediatric sedation training, education, and research. Articles published by nonanesthesiologists describe pediatric sedation services, safety, and quality initiatives, drugs, and original sedation research. Medications that were considered under the realm of anesthesiologists are utilized by nonanesthesiologists to provide sedation to children. Regulating and government agencies, including the Joint Commission and the Center for Medicaid and Medicare Services have recently issued statements on the oversight and practice of sedation. SUMMARY: The direction of pediatric sedation is no longer solely under the leadership of anesthesiologists. The use of anesthetic agents, including propofol, have been administered by nonanesthesiologists and reported as safe and effective agents. Nonanesthesiologists and governmental and regulatory agencies influence the delivery of sedation services. The future direction of pediatric sedation will ultimately depend upon the ability of anesthesiologists to collaborate with specialists, hospital administrators, credentialing committees, and oversight agencies in order to provide high-quality efficient sedation services to children.

Pediatric sedation--evolution and revolution.

Pediatric sedation continues to change in terms of the professionals who provide this care, those who produce original research on this topic, guidelines and literature concerning risk, medications employed, and methods for training for new providers. Some of the changes could be categorized as 'evolutionary' or gradual in nature and predictable - such as the changing role of anesthesiologists in the field of pediatric sedation and the use of the well-established dissociative sedative, ketamine. Other changes in pediatric sedation are more radical or 'revolutionary'. They include reconsideration of what is defined as an 'adverse event' during sedation, the use of propofol or dexmedetomidine, and the application of human patient simulation for training. This review will highlight the ongoing changes in the dynamic field of pediatric sedation by focusing on some of the important progress (both evolutionary and revolutionary) that has occurred across the varied specialties that provide this care.

Non-anesthesiologist-provided pediatric procedural sedation: an update.

PURPOSE OF REVIEW: This review evaluates the past year's literature on the provision of pediatric procedural sedation outside of the operating room, especially as performed by non-anesthesiologist healthcare providers. RECENT FINDINGS: Research on pediatric procedural sedation practice continues to be limited by small case series and single institution study design. However, some exciting developments have occurred. Recent guideline revisions and safety initiatives are reported that impact positively on practice. Efforts to analyze the elements of sedation systems that result in greater safety, efficiency, and patient satisfaction are increasing, including evaluations of tiered systems utilizing the skills of various healthcare providers. Dexmedetomidine and etomidate are the subjects of investigation on their utility for procedural sedation. A multicentered study, adequately powered to provide meaningful evaluation of adverse events, has been completed and provides valuable insight on pediatric procedural sedation as practiced by a variety of healthcare providers. SUMMARY: Pediatric procedural sedation practice as performed by non-anesthesiologists continues to grow. Ongoing efforts to understand the elements of sedation systems that lead to best practice, with the subsequent development of uniform practice approaches, are essential. A collaborative relationship between anesthesiologists and non-anesthesiologist providers of procedural sedation is essential for meeting common goals.

Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium.

OBJECTIVE: We sought to use a large database of prospectively collected data on pediatric sedation and/or anesthesia for diagnostic and therapeutic procedures to delineate the nature and the frequency of adverse events that are associated with sedation/anesthesia care for procedures that are performed outside the operating room in children. METHODS: Data were collected by the Pediatric Sedation Research Consortium, a collaborative group of 35 institutions that are dedicated to improving sedation/anesthesia care for children internationally. Members prospectively enrolled consecutive patients who were receiving sedation or anesthesia for procedures. Data on demographics, primary illness, coexisting illness, procedure performed, medications used, outcomes, airway interventions, and adverse events were collected and reported on a Web-based data collection tool. RESULTS: A total of 26 institutions submitted data on 30,037 sedation/anesthesia encounters during the study period from July 1, 2004, to November 15, 2005. Serious adverse events were rare in the institutions involved in this study; there were no deaths. Cardiopulmonary resuscitation was required once. Less serious events were more common with O2 desaturation below 90% for > 30 seconds, occurring 157 times per 10000 sedations. Stridor and laryngospasm both occurred in 4.3 per 10,000 sedations. Unexpected apnea, excessive secretions, and vomiting had frequencies of 24, 41.6, and 47.2 per 10,000 encounters, respectively. CONCLUSIONS: Our data indicate that pediatric sedation/anesthesia for procedures outside the operating room is unlikely to yield serious adverse outcomes in a collection of institutions with highly motivated and organized sedation services. However, the safety of this practice depends on the systems' ability to manage less serious events.

The effect of lengthening anesthesiology residency on subspecialty education.

In this study, we sought to determine the long-term effect of the additional year of anesthesia residency (postgraduate year [PGY]-4) instituted in 1989 by the American Board of Anesthesiology on the number of individuals who pursued 12-mo subspecialty anesthesia training. We tested the hypothesis that extending education by a year would decrease the number of anesthesia subspecialty trainees. Surveys were collected from approved anesthesia residency training programs in the United States from 1989 to 2001. The questionnaires determined the number of individuals pursuing subspecialty training during PGY-4 and PGY-5. The subspecialties included cardiac anesthesia, pediatric anesthesia, pain management, obstetrical anesthesia, neuroanesthesia, outpatient anesthesia, intensive care medicine, and research. The number of anesthesiology residents (PGY-5) pursuing 12-mo subspecialty training increased over this period. The specific subspecialty distribution of fellows changed, with the largest increase in number and percentage occurring in pain management. The largest declines occurred in critical care medicine and research. Our data do not indicate a decrease in the number of anesthesiology subspecialists. Factors other than the duration of training appear responsible for the selection of subspecialty education.

Conscious sedation of children with propofol is anything but conscious.

OBJECTIVE: To determine the depth of sedation required for bone marrow aspiration and intrathecal injection of chemotherapeutic agents in children using a bispectral (BIS) index monitor and clinical assessment by an independent observer. METHODS: Sixteen children who were undergoing 19 intrathecal chemotherapy and bone marrow aspirations were enrolled in the study. Their ages ranged from 23 months to 190 months with a mean of 79 months. The BIS index was recorded every 5 minutes by an independent observer. The patients received only intravenous propofol for sedation. There were no complications during the procedures. RESULTS: The mean BIS score was 62.8+/- 9.6. The mean low BIS score was 29.7 +/- 13.7, indicating a level of deep sedation and/or general anesthesia was necessary to induce the desired stated of consciousness that would permit the practitioner to perform the procedure. The average dose of propofol was 166 +/- 47 microg/kg/min. Mean Aldrete score for level of consciousness was 0.9 +/- 0.4, indicating a depressed level of consciousness. The mean activity level was 1.0+/- 0.4, indicating impaired movement. CONCLUSIONS: Children who undergo conscious sedation with propofol for intrathecal chemotherapy and bone marrow aspiration demonstrate BIS values and clinical assessments consistent with deep sedation. Because of an increased risk of adverse events when children undergo deep sedation, appropriate parental informed consent, age-appropriate resuscitative equipment, and skilled anesthesia personnel should be present for rescue in the event of cardiovascular and respiratory complications from deep sedation.