Practical considerations in the management of sedation for colonoscopy.

PURPOSE OF REVIEW: The purpose of this review is to discuss the unique elements of providing anesthesia services for colonoscopy including the practical issues within an endoscopy suite, nothing by mouth status for colonoscopy, chronic medication instructions, appropriate anesthesia equipment, informed consent, pharmacology of agents for sedation, anesthetic techniques, and issues related to postprocedural care. RECENT FINDINGS: The national trend is toward increasing number and complexity of colonoscopy procedures using anesthesia services. Providing anesthesia services in a dedicated endoscopy suite has unique elements related to open scheduling and the rapid turnover environment. Agents for sedation and general anesthesia for colonoscopy are chosen for rapid onset, amnestic properties, and raid emergence/recovery. SUMMARY: Sedation for colonoscopy is a rapidly expanding subspecialty with special needs created by the increasing medical complexity of the patients, the demands of the endoscopy procedures, the challenges of the endoscopy suite, and the rapid turnover of the outpatient environment.

Time to Loosen the Apron Strings: Cohort-based Evaluation of a Learner-driven Remediation Model at One Medical School.

BACKGROUND: Remediation in the era of competency-based assessment demands a model that empowers students to improve performance. AIM: To examine a remediation model where students, rather than faculty, develop remedial plans to improve performance. SETTING/PARTICIPANTS: Private medical school, 177 medical students. PROGRAM DESCRIPTION: A promotion committee uses student-generated portfolios and faculty referrals to identify struggling students, and has them develop formal remediation plans with personal reflections, improvement strategies, and performance evidence. Students submit reports to document progress until formally released from remediation by the promotion committee. PROGRAM EVALUATION: Participants included 177 students from six classes (2009-2014). Twenty-six were placed in remediation, with more referrals occurring during Years 1 or 2 (n = 20, 76 %). Unprofessional behavior represented the most common reason for referral in Years 3-5. Remedial students did not differ from classmates (n = 151) on baseline characteristics (Age, Gender, US citizenship, MCAT) or willingness to recommend their medical school to future students (p < 0.05). Two remedial students did not graduate and three did not pass USLME licensure exams on first attempt. Most remedial students (92 %) generated appropriate plans to address performance deficits. DISCUSSION: Students can successfully design remedial interventions. This learner-driven remediation model promotes greater autonomy and reinforces self-regulated learning.

Assessment of competence in anesthesiology.

PURPOSE OF REVIEW: This review is designed to evaluate various aspects of the teaching, demonstration and assessment of competence in anesthesiology. RECENT FINDINGS: The approach to evaluation of competence has evolved from global impressions to an understanding of the elements of performance that determine competence. This assessment of performance to measure competence has been applied to cognitive performance, technical skills, and behavior. There is increasing consensus that assessment of competence is more effective when more than one tool is used, and when the tool selected actually measures the element of competence it was selected to measure. SUMMARY: The traditional evaluation of clinical competence in anesthesiology has focused on written examinations and global evaluation of skill. Limits to this approach have become obvious. Assessment has evolved to specific competencies with performance and behavior-based standards and criteria for mastery of each competency. As standards for competency are better understood, multimedia tools, such as simulation and electronic portfolio, will further advance this evolution.

Microdiscectomy: spinal anesthesia offers optimal results in general patient population.

Spinal anesthesia provides a safe and highly satisfactory alternative to general anesthesia in patients undergoing limited lumbar surgery. Nevertheless, it is not commonly used for spinal surgery, and in some centers it is not even considered as an option for spinal procedures. This study presents the current anesthetic technique for patients undergoing microdiscectomy and compares the peri- and postoperative outcomes in 76 patients drawn from a case-controlled study group. Patients underwent microdiscectomy for herniated nucleus pulposus under spinal (43 patients) or general anesthesia (33 patients). Patients ranged from 18 to 40 years, and all were anesthesia class 1. Surgical and anesthesia times were longer for the general anesthetic group, as was total anesthetic time. Urinary retention was more common in the general anesthesia group (p = .035). Postanesthetic care unit admission times were significantly shorter among general anesthetic patients compared with spinal anesthetic patients (p < .001). Spinal anesthesia patients required less pain medication and experienced less nausea and emesis. Even among young, medically fit patients, spinal anesthesia provided specific advantages over general anesthesia, including decreased anesthesia time, decreased nausea and antiemetic requirements, reduced analgesic requirements, and a trend toward lower complication rates and shorter hospital stay. Both surgeon and patient satisfaction with this anesthetic approach is high.

Anesthetic management of a patient with stiff person syndrome.

We describe the successful anesthetic management of a patient with stiff-person syndrome (SPS) undergoing a right inguinal hernia repair, using a somatic paravertebral block supplemented with conscious sedation. We also present the implications of general anesthesia in patients with SPS. The use of regional anesthetic techniques in patients with SPS has the advantage of avoiding exposure to muscle relaxants. The use of general anesthesia in patients with SPS carries the risk of postoperative hypotonia due to enhancement of gamma-aminobutyric acid action on synaptic transmission by drugs that have a gamma-aminobutyric acid agonistic action.

Teaching and evaluating professionalism for anesthesiology residents.

The Accreditation Council for Graduate Medical Education Outcome Project requires teaching and evaluation of 6 core competencies, one of which is professionalism. Because of this initiative, anesthesiology residency programs are obliged to teach and evaluate professionalism for anesthesiology residents. We decided to create a system that would allow the teaching and evaluation of professionalism in the specific context of anesthesiology.

Inadvertent dural puncture during attempted thoracic epidural catheter placement complicated by cerebral and spinal subdural hematoma.

Minor complications of inadvertent dural puncture during attempted epidural anesthesia are common, related to the size of the needle and the incidence of postdural puncture headache. Serious complications are much less common. We report a case where inadvertent dural puncture with an 18-gauge epidural needle was associated with the creation of intracranial and spinal subdural hematoma.

Preprocedural Assessment for Sedation in Gastrointestinal Endoscopy.

The role of the anesthesia service in sedation for gastrointestinal endoscopy (GIE) has been steadily increasing. The goals of preprocedural assessment are determined by the specific details of the procedure, the issues related to the illness that requires the endoscopy, comorbidities, the goals for sedation, and the risk of complications from the sedation and the endoscopic procedure. Rather than consider these issues as separate entities, they should be considered as part of a continuum of preparation for GIE. This is told from the perspective of an anesthesiologist who regularly participates in the full range of sedation for GIE.

Comparison of spinal and general anesthesia in lumbar laminectomy surgery: a case-controlled analysis of 400 patients.

OBJECT: Despite a history of safety and efficacy, spinal anesthesia is rarely used in lumbar surgery. Application of regional anesthetics is widely preferred for lower-extremity surgery, but general anesthesia is used almost exclusively in spine surgery, despite evidence that spinal anesthesia is as safe and may offer some advantages. METHODS: In this case-controlled study the authors analyzed outcomes obtained in 400 patients in whom either spinal anesthesia or general anesthesia was induced to perform a lumbar decompression. Patients were matched for anesthesia-related class, preoperative diagnosis, surgical procedure, and perioperative protocols. All aspects of surgery, recovery, postanesthesia care, and pain management were uniform irrespective of the anesthetic type. Case complexity was equivalent. An independent observer performed analysis of the data. Data from the intraoperative period through hospital discharge were collected and compared. Two hundred consecutive patients meeting inclusion criteria were included in each group. Patients were treated for either lumbar stenosis or herniated nucleus pulposus. Demographically, both groups were well matched. Anesthetic and operative times were longer for patients receiving a general anesthetic (p < 0.05), in whom more nausea and greater requirements for antiemetics and pain medication were also present during recovery (p < 0.05). Overall complication rates and, specifically, the incidences of urinary retention were significantly lower in spinal anesthesia--induced patients (p < 0.05). There were no neural injuries in either group, and the incidence of spinal headache was lower in patients receiving a spinal anesthetic (1.5% compared with 3%). CONCLUSIONS: Spinal anesthesia was as safe and effective as general anethesia for patients undergoing lumbar laminectomy. Potential advantages of spinal anesthsia include a shorter anesthesia duration, decreased nausea, antiemetic and analgesic requirements, and fewer complications. Successful surgery can be performed using either anesthesia type.

Epidural analgesia improves early rehabilitation after total knee replacement.

STUDY OBJECTIVE: To compare epidural anesthesia and analgesia with spinal anesthesia with intravenous morphine analgesia for its effect on range of motion (ROM) and early rehabilitation after total knee replacement. DESIGN: Randomized prospective study. SETTING: Tertiary care, academic medical center. PATIENTS: Thirty-eight patients scheduled for total knee replacement. INTERVENTIONS: Patients were randomized into 2 groups. One group received spinal anesthesia with 0.5% bupivacaine and analgesia with intravenous patient-controlled analgesia morphine, demand mode only. The other group was given epidural anesthesia with 1.0% ropivacaine with 1:200,000 epinephrine and analgesia with 0.2% ropivacaine at 8 mL/h, maintained for 7 days. Both groups had compression stocking for deep venous thrombosis (DVT) prophylaxis, urinary catheter for the first 24 hours, and duplex scanning at days 3 and 10. The spinal group received low molecular-weight heparin for DVT prophylaxis. MEASUREMENTS: Data collected included pain scores at rest, and with ROM, frequency of DVT, and patient satisfaction. Data were evaluated with Wilcoxon rank sum test for continuous variables and Fisher exact test for categorical variables. Data were considered significant at P < .05. MAIN RESULTS: All 38 patients finished the study, 22 in the spinal group and 16 in the epidural group. There was no difference in demographics between groups. The pain sores at rest and with ROM were significantly less in the epidural group. ROM was better in the epidural group compared with the spinal group after day 1. No DVT was detected on day 3 or 10 in either group. No patient in either group required reinsertion of bladder catheter for urinary retention. CONCLUSION: By using epidural analgesia in the first 7 days postoperatively, we achieved improved early rehabilitation due to excellent pain relief effect and an antithrombotic effect with an efficacy comparable to low molecular-weight heparin.

Changing of an anesthesiology clinical base year to create an integrated 48-month curriculum: experience of one program.

To allow for growth in our anesthesiology residency, we assumed control of the clinical base year (postgraduate year 1[PGY-1]) and adjusted the curriculum to accommodate the expanded size. With this opportunity to change the curriculum, we created a clinical base year to prepare PGY-1 for clinical anesthesia training in PGY-2 to PGY-4 using, for this purpose, the best resources of our clinical site. We describe the process and preliminary results of the change.

Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients.

BACKGROUND AND OBJECTIVES: The incidence of postdural puncture headache (PDPH) after epidural wet tap for obstetric patients may be as high as 75%. We have studied how subsequent placement of a subarachnoid catheter immediately after confirmation of a wet tap, and leaving the catheter in place for 24 hours affects the incidence of PDPH. METHODS: Over a 5-year interval, 115 consecutive patients who had unintentional dural puncture were divided into 3 groups by consecutive assignment. Group A had an epidural catheter placed at another interspace. Group B had a subarachnoid catheter placed for labor analgesia that was removed immediately after delivery. Group C had a subarachnoid catheter that was left in place for 24 hours after delivery. Data were collected retrospectively. The incidence of PDPH and blood patch was compared between groups. RESULTS: The overall incidence of PDPH was 46.9% and need for blood patch 36.5%, significantly less in both subarachnoid catheter groups, 31% in B and 3% in group C, compared with group A (PDPH 81%) (P <.001). CONCLUSION: Subarachnoid catheter placement after wet tap in obstetric patients reduces the PDPH rate and does so to a greater extent if left in place for 24 hours after delivery.

Anesthetic implications of thoracic endometriosis.

Endometriosis occurs in 5% to 10% of women of childbearing age and involves the proliferation of endometrial tissue outside the uterine cavity. Thoracic endometriosis is the most frequent extrapelvic manifestation of endometriosis, numbering some 100 reported cases. It may include spontaneous pneumothorax, hemoptysis, chest pain, bronchiectasis, pneumomediastinum, or mediastinal bleeding. Because the tissue is hormonally responsive, all of these manifestations are related to the menstrual cycle (catamenial) and are likeliest to occur during menses. We report the successful anesthetic management of a patient with thoracic endometriosis and recurring catamenial pneumothorax who presented for elective pelvic surgery.

Implementing ACC/AHA guidelines for the preoperative management of patients with coronary artery disease scheduled for noncardiac surgery: effect on perioperative outcome.

STUDY OBJECTIVE: To review the new consensus guidelines for cardiac testing for the patient with cardiac disease scheduled for elective, noncardiac surgery, and their impact on cardiac functional testing. DESIGN: Retrospective chart review study. SETTING: Tertiary care medical center. PATIENTS: 181 patients scheduled for elective, major surgery who met American College of Cardiology/American Heart Association (ACC/AHA) criteria for a preoperative stress test. INTERVENTIONS: A variety of tests were ordered, including treadmill stress testing, persantine-thallium imaging, dobutamine echocardiography, and exercise stress echocardiography. MEASUREMENTS: The numbers of and outcome of the stress tests and the cardiac outcome of the patients who underwent cardiac testing and surgery were recorded. MAIN RESULTS: Abnormal tests occurred in 27 patients. Two patients declined treatment, eight patients had primary medical management, and the remainder (17) had cardiac catheterization. Results included no lesion (2 patients), angioplasty (4 patients), angioplasty plus stenting (1 patient), coronary artery bypass grafting (CABG) (4 patients), and delineated lesions treated with medical optimization (6 patients). One patient had CABG and declined further surgery. One patient had myocardial infarction 6 months after surgery that was treated by medical management after cardiac catheterization. The other 23 patients had surgery without cardiac complication within 1 year of surgery. Only 15% (27/180) of the patients with indications for a stress test had a positive result. Even fewer patients had any alteration of the perioperative period. Despite this finding, cardiac morbidity was very low. CONCLUSIONS: The guidelines for stress test may be over-sensitive, and further prospective clinical studies are indicated.

Horner's syndrome and trigeminal nerve palsy after lumbar epidural analgesia for labor and delivery.

This report highlights transient Horner's syndrome and trigeminal nerve palsy following labor epidural analgesia. A 29-year-old primigravida had a lumbar epidural catheter placed for analgesia in labor. The analgesia was maintained by infusion of a dilute local anesthetic/opioid mixture and turned off after achieving complete cervical dilation. Approximately 1 hour after delivery she complained of heaviness in her left eyelid, and was noted to have left-sided ptosis and paresthesia within the distribution of the ophthalmic and maxillary divisions of the trigeminal nerve, which resolved over the next 2 hours. There were no other neurologic changes. Horner's syndrome and cranial nerve palsies can occur as a consequence of epidural analgesia for labor.

Anesthetic considerations of the herbal, kava.

The herbal remedy, kava, is reviewed, with special focus on the anesthetic management of the perioperative patient. Consumption of kava has potential cardiovascular consequences that could manifest in the perioperative period. Kava may act through inhibition of sodium and calcium channels to cause direct decreases in systemic vascular resistance and blood pressure. Kava inhibits cyclooxygenase to potentially cause a decrease in renal blood flow and to interfere with platelet aggregation. Kava may also cause adverse neurologic effects because of benzodiazepine and antidepressant activities on noradrenergic and/or serotoninergic pathways that may potentiate benzodiazepine and induction anesthetic potency and cause excessive perioperative sedation. Patients often do not disclose their use of herbal substances, and drug interaction can occur without being suspected as the cause for a change in patient homeostasis. A role for patient education about the potential adverse consequences of kava use in the perioperative period is suggested.

Leukocyte reduction during orthotopic liver transplantation and postoperative outcome: a pilot study.

STUDY OBJECTIVE: To investigate the effect of intraoperative leukocyte reduction of administered blood products on the incidence of acute cellular rejection and postoperative patient outcome. DESIGN: Prospective, nonrandomized, historical control study. SETTING: Academic tertiary medical center. PATIENTS: The study group (Group 1) consisted of 30 consecutive adult patients with end-stage liver disease scheduled to undergo orthotopic liver transplantation (OLT) between 1998 and 2000. The historical control group (Group 2) consisted of 30 adult patients with end-stage liver disease matched to study group patients as closely as possible for age, gender, and etiology of liver disease who underwent OLT between 1995 and 1999. INTERVENTIONS: Group 1 patients had all intraoperative allogeneic and cell salvaged blood products leukocyte reduced before administration. Group 2 patients underwent OLT without leukocyte filtration of any administered blood products. MEASUREMENTS: Demographic data were collected for both patient groups and included age, gender, etiology of liver disease, and both intraoperative and postoperative immunosuppression. Demographic allograft donor data for both patient groups were collected and included age, gender, use of vasopressors during procurement, and cold and warm donor organ ischemic times. Outcome variables measured included incidence of acute cellular rejection, length of intensive care unit (ICU) and length of hospital stay, incidence of both graft loss and retransplantation, and mortality. MAIN RESULTS: The incidence of acute cellular rejection was 40% in Group 1 and 66.7% in Group 2 (p = 0.037). Length of ICU stay was 3.0 (2.0, 5.0) days in Group 1 and 4.0 (3.0, 6.0) days in Group 2 (p = 0.16). Length of hospital stay was 14.0 (11.0, 18.0) days in Group 1 and 18.0 (14.0, 27.0) days in Group 2 (p = 0.035). One allograft was lost in Group 2 because of primary nonfunction requiring retransplantation (p = 0.31), and three postoperative deaths occurred in Group 1 as a result of multisystem organ failure (p = 0.08). CONCLUSIONS: Coincident with leukocyte reduction of all administered blood products during OLT, an improved outcome was observed in Group 1 patients as demonstrated by both a decreased incidence of acute cellular rejection and length of hospital stay.

Nonoperating room anesthesia for the gastrointestinal endoscopy suite.

Anesthesia services are increasingly being requested for gastrointestinal (GI) endoscopy procedures. The preparation of the patients is different from the traditional operating room practice. The responsibility to optimize comorbid conditions is also unclear. The anesthetic techniques are unique to the procedures, as are the likely events that require intervention by the anesthesia team. The postprocedure care is also unique. The future needs for anesthesia services in GI endoscopy suite are likely to expand with further developments of the technology.