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Radius Anesthesia Services PLLC was founded by an anesthesiologist with the objective of providing exceptional anesthesia care and peri-operative services to the patients of the Greater New York City area. We offer a comprehensive approach to anesthesia services that starts with exceptional recruiting. Our anesthesiologists are experienced, board-certified and have impeccable bedside manners.
medicine, reimbursement drives change in clinical practice faster
than evidence. Bundled payments from Medicare since the development
of Accountable Care Organizations (ACOs) epitomize a heightened value
of measurable outcomes. The Merit Based Incentive Payment System
(MIPS) directs physicians to report outcomes. Based on these data,
bundled payments to practices may be altered (1). Anesthesiologists
are uniquely situated to help reduce cost, improve efficiency, deploy
protocols for enhanced recovery, all while ensuring that patient
safety is held to the utmost importance.
healthcare economics, value is defined as quality divided by cost.
The unique challenge of computing and comparing value lies in the
subjective nature of quality. While variables like length of stay,
mortality after 30 postoperative days, reoperation, and surgical site
infections are measurable, attainable values, they fail to capture
all aspects of care. Furthermore, billing departments and clinical
administration are distinct entities, and only recently are
collaborative efforts attempting to bridge this historical artifact.
Moreover, physicians of earlier generations were raised in a
“cost-blind” pedagogy. Medical schools and residency programs are
now integrating economics and encouraging containment of cost into
increasing quality is desirable for patients and providers alike,
this hurdle often comes with greater cost in the form of new
technologists, training personnel, and clinical uncertainties.
Moreover, few novel strategies have shown improvement in the already
exceptional safety margin of the delivery of anesthesia care.
Instead, practices often focus on cost containment. Personnel
comprise the lion’s share of OR operating costs for most
institutions. French et
that nearly 80% of OR cost was from personnel. Thus, optimizing
staffing ratios is an obvious source for improvement in some
practices. However, some novel incentives have been developed. For
instance, some practices link provider bonuses to lean usage of
volatile anesthetics by encouraging lower gas flows (2). Providers
should be familiar with emerging strategies for cost containment.
most studied tactic to contain cost and improve value is represented
by Enhanced Recovery After Surgery (ERAS), which has shown promise
since its original implementation in colorectal surgery. These
pathways stress the importance of early ambulation, neuraxial and
regional anesthesia where appropriate, antiemetics, and decreased
postoperative fasting times as a bundled package. These concepts have
been similarly employed to other surgical populations, including
thoracic, pelvic, urologic, spine, and breast surgeries (3). While
the mechanisms why ERAS pathways expedite recovery are not
entirely understood, their implementation has become widespread. The
success of ERAS is due to the multidisciplinary effort in
modulating the perioperative trajectory for standard surgical
encounters. Yet, anesthesiologists and anesthesia providers should
continue to treat each patient and condition with consideration and
not blindly yield to pathways when extenuating circumstances arise.
of value-based care arise when groups or practices are unfairly
penalized for inevitable, uncontrollable complications. For instance,
the acute kidney injury (AKI) rate after cardiothoracic surgery is
approximately 30%. The multifactorial nature of AKI has been
investigated in many prospective studies. Patient, anesthetic, and
procedural factors all contribute (4). However, managing blood
glucose levels with intravenous or subcutaneous insulin is a
controllable outcome which is known to complicate cardiac surgery.
The core measures upon which reimbursement is based will continue to
drive improvements in anesthetic care for a multitude of patients.
et al. Aligning Anesthesiology and Perioperative Services
with Value-Based Care: Proceedings of the Annual Meeting of the
Association of Anesthesia Clinical Directors (AACD). J Clin Anesth.
Beverly A et
al. Enhanced Recovery After Surgery: Evidence for Delivering
Value-based Care. Int Anesthesiol Clin. 2017;55(4):78-89.
French KE, et
al. Value based care and bundled payments: Anesthesia care costs
for outpatient oncology surgery using time-driven activity-based
costing. Healthc (Amst). 2016;4(3):173-80.
et al. Defining Value-Based Care in Cardiac and Vascular
Anesthesiology: The Past, Present, and Future of Perioperative
Cardiovascular Care. J Cardiothorac Vasc Anesth.
education continues to develop year after year, and anesthesiology
continues to do so as well. In the conventional pathway of training
to become a physician, future anesthesiologists are required to pass
two years of a traditional pre-clinical academic program, in addition
to two years of clerkships, and then complete a residency and
possibly an advanced fellowship. Requisite clinical skills were
taught under the direction of a senior physician in the operating
room (OR), and students would learn more as their clinical
is now discussion in the literature on the advantages of preparation
prior to an anesthesia trainee entering the OR. This concept has
begun to take hold at the medical school level. To use an example,
many medical schools in the United States have now introduced
technology to teach anatomy. Virtual reality simulations provide an
arena for students to practice simulated dissections to learn anatomy
before they enter the actual laboratory course. These technologies
continue to improve yearly and have positive reviews from medical
students. In light of such successes, virtual reality is now more
frequently used as a tool for learning throughout training, including
recent study from the University of Toronto explored the efficacy of
virtual reality education compared to conventional clinical education
with regards to developing fiber optic intubation skills. Anesthesia
residents were separated randomly into a control group, which learned
and practiced intubation on a standard medical training mannequin,
and the exploratory group, which learned the same skills using a
virtual reality program. The virtual reality program was created by
an external manufacturer and was specific for anesthesiologists.
After receiving training, anesthesia residents from both groups were
then tasked with performing intubations on real patients, and scored
by an independent rater. Scores were recorded with respect to time, a
global rating scale, and a checklist of numerical verification. The
raters were blinded to the order and group designation of all
residents. After analyzing the data, the researchers discovered that
residents who learned using virtual reality reached their optimal
performance at a faster pace that is after less practice intubations,
compared to the control group. Moreover, the global rating scales
were higher, and time to completion faster, in the virtual reality
group. Given these results, the research team has advised that
teaching hospitals consider adding virtual reality into their
anesthesiology residency curricula if possible. Additionally, it is
recommended that further studies will investigate the long-term
retention of skills learned using virtual reality, along with
increasing the variety of procedures taught by virtual reality.
the tactical and surgical skills required of an anesthesiologist,
patient care performance is also important. Virtual reality is in
parallel entering the anesthesia training process, as evidenced by
recent developments, including an emphasis on managing post-operative
pain. A flagship research program from Stanford University has
explored the quality and success of a virtual reality application
that allows clinicians to engage with patients, in real-time, in
order to minimize pain and increase satisfaction. Using this
application, physicians were able to analyze the ways in which
certain actions can alter the relationship between patient and
provider. Moreover, this technology has been used by
anesthesiologists and other anesthesia providers to explore how
anxiety affects pain, which is related to post-operative outcomes and
the patient experience. When used intelligently, the program was
found to be connected to decreased patient anxiety, in line with
decreasing the patient’s perception of pain.
research will continue to study the advantages of virtual reality as
a tool for training, education, and skills acquisition in anesthesia.
Anesthesiologists, by using technology as a learning tool, can
position themselves as leaders in expanding and improving patient
Operations Management for clinics, hospitals, and surgical services represents multiple challenges with regards to managing patient flow and delivering services in a punctual, cost-sensitive manner. One important challenge that has gained interest in the press concerns the practice of double-booking surgeries. As the title indicates, double-booked surgeries relates to the practice in which an attending surgeon, and potentially an attending anesthesiologist, is assigned to multiple surgeries throughout the same time-slot. In this way, the senior surgeon will usually perform the major or most difficult parts of the surgery, leaving the routine portions to physicians-in-training, e.g. residents and/or fellows. Largely, the process of double-booking surgeries is treated as a means for education and training. Less experienced physicians are able to observe experts in the field, while also performing crucial surgical tasks that will be important for their later clinical responsibilities as full-time, attending physicians. Yet, there are also potential concerns with the practice as explored in the literature, predominantly that double-booked surgeries may incur a risk to the patient, in addition to the logistical difficulties of execution from the operations management view. This article will ascertain the challenges associated with double-booking surgeries for anesthesiologists and practice managers, while also detailing the impact to patient safety and patient populations.
The practice of double-booking surgeries, while frequent at many hospitals, can create a serious administrative challenge for managers. Double-booking surgeries necessitates a high degree of coordination at the micro level. Surgeons must identify which elements of the surgery are most complex to perform, and smoothly communicate these recommendations to operating room (OR) managers, who then slot the surgeries in certain OR rooms and with associated staff, including anesthesiologists. For attending anesthesiologists and anesthesia staff, the instance of a surgeon moving from room to room can create a distraction.
Specifically, one potential side effect of double-booking surgeries is the ability to induce tardiness. Tardiness can lead to OR delays,
result in anesthesiologists and anesthesia staff working additional hours, and causing an unnecessary economic burden to the hospital
Allen et al calculated the impact of tardiness on surgical service healthcare institutions in the Journal of Healthcare Management1. The researchers concluded that each lost minute in the OR was valued at approximately $9.56 in associated costs. In an intervention condition that addressed delayed surgical start times, many of which were associated with double-booked surgeries, cost savings resulted in over $700,000 to the hospital. Hence, if not executed carefully, double-booked surgeries may result in a significant economic burden for the hospital.
Along with the cost impact of double-booked surgeries, patient safety is a significant cause for concern. Given that double booking surgeries requires multiple transitions during the operation, in addition to the condition that surgeon trainees may then perform a majority of the surgery, several thought leaders have questioned whether there is a significant patient safety issue in play with double-booked surgeries. The literature in fact, denotes the opposite. In a recent JAMA article, Sun et al performed a population-based retrospective study to ascertain post-operative outcomes of patients who underwent surgery under double-booked conditions2. The cohort included over 60,000 adult patients, and patients were analyzed for in-hospital mortality, post-operative complications, and surgical features. It was concluded that patients who were in double-booked surgeries did not experience any increase in mortality or complication rates. Yet, the average length of time in surgery was larger for double-booked surgeries, which conforms to previously stated concerns. These research results were critical for providing data to mitigate existing patient safety concerns on double-booked surgeries.
To conclude, the practice of double-booking surgeries allows for benefits, as well as costs, to individual physicians along with hospitals and healthcare institutions on a large scale. Anesthesiologists and anesthesia staff, who are intricately involved in surgery coordination, will find importance in understanding the policies, research, and practice connected with this occurrence.
1. Allen, Robert W., et al. “First Case On-Time Starts Measured by Incision On-Time and No Grace Period.” Journal of Healthcare Management, vol. 64, no. 2, 2019, pp. 111–121., doi:10.1097/jhm-d-17-00203.
2. Sun, Eric, et al. “Association of Overlapping Surgery With Perioperative Outcomes.” Jama, vol. 321, no. 8, 2019, p. 762., doi:10.1001/jama.2019.0711.
Sudden cardiac death is
prevalent among patients with conduction abnormalities, New York Heart
Association Heart Failure of class 4, and other heart disorders. Large clinical
trials have shown that implantable technology can mitigate the risk of death in
these patients. Implantable Cardioverter Defibrillators (ICDs) are devices
which detect native malignant arrhythmias in such patients and deliver
electrical cardioversion. Over 300,000 patients in the US have ICDs, and the
technology surrounding these devices is changing at a rapid pace. With the
growing prevalence of patients with ICDs presenting for surgery and procedures
requiring anesthesia care, anesthesiologists must possess a comprehensive
knowledge of how to manage these devices for emergent and elective procedures.
The first distinction
anesthesiologists must make regarding implantable devices preoperatively is
their nature: does the patient have an ICD, a pacemaker, or another type of
implantable technology? The indication for the device, battery life, and
function when a magnet is applied should also be reviewed. Often, the most
expeditious way to illuminate this information is by contacting a manufacturer
representative. Patients may also have information cards about their
implantable device. Details regarding the device should be reviewed from the
managing cardiologist notes. For ICDs specifically, device interrogations
should be performed within six months of the presenting procedure. However,
physicians should defer to their hospital or practices written policies
regarding the acceptable time frame from where an interrogation report is
General recommendations regarding ICD management are aimed at reducing electromagnetic interference (EMI), most often from electrosurgical units (monopolar or bipolar energy). Avoidance of monopolar cautery is advised whenever possible, as the risk of EMI is higher . Grounding pads and the current path should be placed as far away from ICD and the heart as possible. The surgeon should be encouraged to apply energy in short, intermittent bursts at the lowest acceptable energy. Anesthesiologists should be aware that the risk of EMI in infraumbilical surgeries is low, supraumbilical is higher, and cardiac surgery is the highest. Other intraoperative sources of EMI include nerve stimulators, radiofrequency ablation, and lithotripsy.
Further details regarding the intraoperative management of patients with ICDs varies based on the governing body offering recommendations. For instance, the American Society of Anesthesiologists (ASA) recommend reprogramming the device to an asynchronous mode. Other governing bodies, mostly in Europe, suggestion placing a magnet on the device to prevent ICD discharge when “over sensing” a source of EMI as cardiac conduction. Most advisory groups agree that ICD devices should be interrogated at the conclusion of a procedure to ensure functionality when a patient is discharged home.
The technology of ICDs has advanced beyond the application of a defibrillation dose of energy for tachyarrhythmias. For instance, anti-tachycardia pacing (ATP) provides pacemaker activity from ICDs to “break” arrhythmias without expending energy for defibrillation. Anesthesia providers should be aware of this capability, as active ATP function may cause undesired intraoperative tachycardia with EMI. Magnets most often do not disable this feature of ICDs, thus reprogramming is required. As such, this undesirable setting should be deactivated by a device representative or cardiologist prior to surgery.
In 2017, the Department of Health and Human Services made a statement that the opioid crisis represented a nationwide public health emergency1. The recent recognition of widespread overuse of opioids from physicians and policy-makers alike supports this declaration. Opioid monotherapy may be considered conventional care at multiple healthcare institutions given its high aptitude for analgesia. Yet, as exemplified in the public health emergency statement, opioid monotherapy is associated with several severe side effects, from respiratory depression to delirium, that may mitigate post-operative recovery. Given this landscape, it is suggested that multi-modal pain regimens may affect post-operative pain control for patients, thus acting as a viable solution.
Multi-modal pain regimens, also referred to as multi-modal analgesia, are composed of two or more pain relief treatments prescribed in a single time period. The treatment algorithm may include pharmacologic agents, such as opioids, benzodiazepines, and anticonvulsants, alongside non-pharmacologic treatments such as application of heat or cold, therapeutic massage, or electroanalgesia2. Generally speaking, the appropriate multi-modal pain regimen is decided between anesthesiologists, post-acute care specialists, and the primary care physician, and may differ depending on the patient’s health history and the guidelines set by the surgery’s recovery period. Indeed, a multi-modal approach is supported by leaders in the anesthesiology and pain management fields. The American Pain Society released a set of guidelines for post-surgical pain management, including specific algorithms for a multi-modal analgesia approach3. The Society in part determined that acetaminophen and/or non-steroidal anti-inflammatory drugs should be considered as part of a multi-modal approach. This collection of guidelines was further endorsed by the American Society for Regional Anesthesia, a professional society for clinicians and scientists involved with anesthesiology. Multi-modal treatments will range with regards to the combinations of treatments, and efficacious algorithms continue to be researched.
In recent news, studies have suggested that a multi-modal analgesia approach administered to patients undergoing Cesarean section (C-section) has an impactful effect on patient post-operative opioid use, as well as length of stay. Maternal and pregnant populations are often understudied with respect to anesthesia and pain management. To address this population, researchers from the University of Illinois Hospital and Health Sciences System created a multi-modal approach for C-section mothers4. In the multi-modal experimental cohort, patients were prescribed a combination of ketorolac, gabapentin, and/or acetaminophen depending on the patient’s pain designation score. A small subset of patients who reported significantly higher pain scores were given an opioid in combination with other medications. The control was standard of care opioid treatment. In the trial, the multi-modal cohort reported a 52% decrease in the number of opioid tablets prescribed at discharge. In detail, 89% of control patients were prescribed opioids at discharge, compared to 32.5% of the multi-modal cohort patients. Moreover, the multi-modal cohort reported a decrease in length of stay. The long-term effects of a multi-modal approach on post-operative care will continue to be explored, however this trial provides optimistic evidence towards a non-opioid or minimized opioid multi-modal regimen for post-C-section patients.
Continuing the initiative for research-driven, updated treatment algorithms for patients will last as a priority for clinicians and scientists in anesthesia and pain management. Multi-modal pain regimens serve as an important lever to affect post-operative acute care, thus supporting broad clinical efficacy as well as population health.
1. U.S. Department of Health and Human Services. “HHS Acting Secretary Declares Public Health Emergency to Address National Opioid Crisis.” HHS.gov, US Department of Health and Human Services, 23 May 2018, www.hhs.gov/about/news/2017/10/26/hhs-acting-secretary-declares-public-health-emergency-address-national-opioid-crisis.html.
2. Helander, Erik M., et al. “Multi-modal Analgesia, Current Concepts, and Acute Pain Considerations.” Current Pain and Headache Reports, vol. 21, no. 1, 2017, doi:10.1007/s11916-017-0607-y.
3. Chou R, Gordon DB, de Leon-Casasola, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131-157.
4. Khudeira, Zahra. “Use of Multi-modal Analgesia in Women Post-Cesarean Section: From Innovation to Bedside.” ICHP: Journal of the Illinois Council of Health-System , vol. 44, no. 08, 2018.
of steroids into the epidural space are utilized for the treatment of
pain from a variety of causes. Steroids have glucocorticoid
properties which downregulate processes associated with inflammation
of the nerve root from compression or irritation. They also treat
conditions such as chronic regional pain syndrome. The mechanisms of
epidural corticosteroids are incompletely understood. Furthermore,
ongoing debate has characterized the literature regarding the
efficacy, ideal indications, and procedural conduct of epidural
steroid injections. This article will briefly review infectious and
endocrine complications of epidural steroid injections.
with cancer often require chemotherapy and/or radiation treatment.
These patients, in addition to those on chronic corticosteroid or
disease modifying antirheumatic drug therapy, and patients with
inborn or acquired immunodeficiencies are at higher risk of
infection. These infections can be opportunistic, such as fungal or
bacterial from usually innocuous pathogens. Laboratory values
suggestive of an immunosuppressed state include leukopenia and
pancytopenia. Steroids can potentiate immunosuppression, even if
relatively small amounts are injected into the epidural space.
Systemic effects of steroids may increase risk of infection or viral
risks of rare but serious infections must be weighed with the
expected benefits of pain relief and functional improvement from
epidural steroid injections. Case reports have emerged documenting
infectious complications following epidural steroid injections. The
root cause of a series of fungal infections following epidural
steroid injection was traced to contaminated vial batches of
methylprednisolone in the 2010’s . Numerous case reports
describe epidural abscess formation even in the absence of known
Other specific case reports have been described for herpes zoster.
One report describes herpes esophagitis following a cervical epidural
steroid injection . Another describes cutaneous herpes zoster
eruption following serial lumbar epidural steroid injections . As
such, providers should seriously consider the higher risk of
infection in this patient population.
addition to risks of infection, there are risks of cortisol excess
when patients are taking other medications. Several cases describing
excess serum corticosteroid, characterized by glucose intolerance,
diffuse adipose deposition, and immune dysregulation highlight the
interaction between corticosteroids and ritonavir, a protease
inhibitor used to treat Human Immunodeficiency Virus (HIV) [5, 6].
Cushing’s syndrome is the clinical manifestation of cortisol excess
from endogenous or exogenous causes. Downstream complications of
Cushing’s syndrome are serious: they range from myocardial
infarction and stroke to bone loss, hypertension, diabetes type 2,
and depression. Pain physicians should be aware of this drug-drug
interaction when pursuing epidural steroid injections.
physicians and anesthesia providers should be aware of the risks of
epidural steroid injections when counseling patients. While epidural
abscess formation is an appropriately cited complication, other
effects related to administration of steroids should be discussed,
including iatrogenic Cushing’s syndrome and immunosuppression.
Spinal and paraspinal fungal infections associated with contaminated
methylprednisolone injections. Open
Forum Infect Dis.
2014 May 14;1(1)
Spinal subdural abscess following epidural steroid injection. J
A difficult case to swallow: herpes esophagitis after epidural
steroid injection. Am
SJ, Hawboldt GS. Herpes zoster: a previously unrecognized
complication of epidural steroids in the treatment of complex
regional pain syndrome. J
Pain Symptom Manage.
Injecting epidural and intra-articular triamcinolone in HIV-positive
patients on ritonavir: beware of iatrogenic Cushing’s syndrome.
Ritonavir and epidural triamcinolone as a cause of iatrogenic
Cushing’s syndrome. Am
J Med Sci.
the United States healthcare system, price transparency is a complex
topic that has spurred countless debates. One critical sub-topic of
cost of care that is rarely discussed in mainstream sources, is the
difference between cost and charge. Particularly in the surgical and
anesthesia services setting, this distinction is crucial for
understanding how costs of care are calculated and subsequently
presented to patient populations.
of care indicates the specific expenses that a healthcare system
incurs in delivering care. Cost of care can either be calculated from
a top-down or bottom-up costing approach1.
In this sense, healthcare administrators essentially break up the
total cost of say, a procedure into the sum of its parts. Then, each
subsection can be calculated by resourcing the personnel and supplies
that are required for each step. For surgery, this is inclusive of
all stages of the perioperative cycle, including pre-operative
preparation of the patient, sterilization and decontamination of all
surgical instruments, and acquisition of the anesthesia necessary for
the specific procedure. Moreover, the cost for housing a patient in
the wards is also calculated on a per-bed basis, with allocations for
the floor space, accommodations, housekeeping, and meals service. The
surgery itself is comprised of many costs, such as all required
instruments, and the compensation of surgical staff, which may be
fixed or variable depending on the circumstances. Post-operative
costs will include the bed fee, as well as any recovery medications
or physical therapy that is mandated by the lead physician. Each of
these costs are summed into a global cost per procedure, which can
further be separated into the total cost per minute in the OR.
cost is very different from charge. Most patients will only see the
charge for their procedure, which is in many cases billed to a
third-party insurance provider. The charge is not necessarily equal
to the cost of the procedure. Rather, the charge has been computed by
leveraging a forecasting model that allows the hospital to recoup
their costs in a time-sensitive manner, given the potential for
administrative delays from the insurance side. Therefore, charges are
often an increase from the cost of a procedure, noting these factors.
the distinction between cost and charge, patient advocates have urged
the government to provide a pathway for hospitals to disclose charges
in a public forum. The Centers for Medicare and Medicaid Services
provided a solution. The 2019 Inpatient and Long-Term Care Hospital
Prospective Payment System Rule extends previous requirements of the
ACA, by requiring hospitals to publish lists of their standard
charges for all procedures and related pharmaceuticals online2.
This list, known as the charge master of the hospital, was previously
only shared internally among healthcare administrators. This
transition will require time on the parts of hospitals, but will
greatly expand healthcare price transparency between providers and
Healthcare policy in the U.S. will continue to refine how healthcare
is calculated, charged, and managed. In 2019, great strides shall be
made towards patients’ understanding their own healthcare
processes, contributing to a more transparent healthcare experience
1. Macario, Alex. “What Does One Minute of Operating Room Time Cost?” Journal of Clinical Anesthesia, vol. 22, no. 4, 2010, pp. 233–236., doi:10.1016/j.jclinane.2010.02.003.
Anemia is an independent risk factor associated with significant morbidity
and mortality. As such, managing and treating a patient’s anemia is critical to
reducing the associated risks of bleeding and transfusions.1 Patient
blood management is a multidisciplinary approach to managing anemia and is
based on three pillars: the detection and treatment of preoperative anemia,
reducing intraoperative blood loss, and optimizing a patient’s physiological
tolerance toward anemia.1,2
Blood management starts preoperatively to identify risk factors and treat preoperative anemia. Reviewing medical records and interviewing the patient before surgery can identify risk factors for transfusion and the need for adjuvant therapy. Preoperative labs should be ordered to diagnose preexisting anemia so that it can be treated early. The American Society of Anesthesiologists (ASA) recommends iron supplementation for patients with iron deficiency anemia and suggests erythropoietin in select populations.3 The preoperative appointment should also be used to educate patients of the potential risk associated with transfusions, instruct when to discontinue anticoagulants and antiplatelets, and discuss the option for autologous blood transfusion if needed.
The second pillar focuses on reducing the risk of intraoperative bleeding. For surgeons, this means using laparoscopic or minimally invasive surgeries when possible. For anesthesiologists, this means creating an appropriate anesthetic plan with specific pharmacologic interventions. For example, utilizing neuraxial techniques compared to general anesthesia has been shown to decrease blood loss likely due to the to lower blood pressures associated with a sympathetic blockade.4 As for pharmacologic interventions, prophylactic antifibrinolytics (e.g., tranexamic acid) can reduce bleeding and decrease the risk of transfusions.3 Other strategies that help optimize hemostasis are maintaining normothermia and preventing acidosis or hypocalcemia.1
The third objective of patient blood management involves optimizing a patient’s physiology to tolerate anemia better. This means ensuring adequate oxygenation, transportation, and utilization. For example, sepsis or pain can increase the metabolic demand for oxygen. As such treating infections and ensuring adequate analgesia can help decrease metabolic oxygen consumption.1 Additionally, ensuring proper ventilation, oxygenation, and organ perfusion intraoperatively all help optimize tolerance for anemia.
However, if a patient
does require a transfusion, utilizing a restrictive approach is has been shown to be safe with improved
outcomes compared to a liberal strategy.5,6 The National Institute
for Health and Care Excellence (NICE) recommends a hemoglobin concentration of
7 g/dl as a threshold to transfuse for
those without major hemorrhage or acute coronary syndrome (ACS). For those with
ACS, this threshold is increased to 8
g/dl.6 ASA recommends a wider range of 6 to 10 g/dl but to consider
other factors such as rate and magnitude of bleeding, volume status, signs of
organ ischemia, and cardiopulmonary reserve.3 Overall, the decision
of when to transfuse is based on clinical judgment and should take into account
more than lab values. It is important that physicians stay current on the
practice of blood management to help
reduce transfusion overuse while improving patient outcomes.
Desai N, Schofield N, Richards T.
Perioperative patient blood management to improve outcomes. Anesth
Muñoz M, Gómez-Ramírez S, Kozek-Langeneker S. Pre-operative haematological assessment in patients scheduled
for major surgery. Anaesthesia. 2016;71 Suppl 1:19-28.
Practice Guidelines for Perioperative
Blood Management, an Updated Report by the American
Society of Anesthesiologists Task Force on Perioperative Blood Management*. Anesthes. 2015;122(2):241-275.
Richman JM, Rowlingson AJ, Maine
DN, Courpas GE, Weller JF, Wu CL. Does Neuraxial Anesthesia Reduce Intraoperative
Blood Loss? A Meta-Analysis. J Clin
Gupta PB, DeMario VM, Amin RM, et
al. Patient Blood Management Program Improves Blood Use and Clinical Outcomes
in Orthopedic Surgery. Anesthesiology.
Padhi S, Kemmis-Betty S, Rajesh S,
Hill J, Murphy MF. Blood Transfusion: Summary of NICE guidance. BMJ. 2015;351:h5832.
The aging body is predisposed to developing pain. Osteoarthritis of the neck and lower back, chronic joint pain, and musculoskeletal pain are some of the most common complaints among the elderly. However, the complex links between chronic pain, opioid use, depression, dementia, and pseudodementia are decidedly difficult to study among advanced age patients. The following summary of recent literature outlines several interactions with which anesthesia providers should be familiar.
Age-related changes in the central nervous system, notably the presence of amyloid plaques, neurofibrillatory tangles, and amyloid angiopathy, can be seen in pathologic tissue findings in patients with dementia.1 The extent to which these developments are accelerated by chronic pain is uncertain. However, a past study found that patients with chronic pain demonstrate poor performance in several neuropsychological testing domains, suggesting that cognitive decline coincides with pain in the elderly.2 More recently, a longitudinal cohort study of over 10,000 patients aged over 62 years found that persistent pain hastens measurable impairments in everyday living.3 In fact, persistent pain accelerated memory decline, inability to manage personal finances, and the probability of developing dementia by roughly 10%.
Nociception undergoes age-related changes. Notably, the thresholds for low and high intensity pain become dampened. That is to say, sub-threshold nociceptive stimuli may not illicit a pain response from the elderly. However, once perceived, the response to noxious stimuli may be exaggerated and complicate pain control.4 This decay in pain tolerance may be due to alterations in the central inhibitory pathways and neuronal plasticity. Taken together, these altered mechanisms can work to increase and elderly person’s susceptibility to developing chronic pain after an injury.
Although the use of opioid medications may impart many risks to chronic users, deleterious cognitive effects with long-term use have not been observed in large studies. A meta-analysis of studies on opioid prescriptions for cognitively-intact versus cognitively-demented patients found evidence for undertreatment of pain in the cognitively impaired.5 With regard to the long-term risks of opioid use, one prospective cohort study of patients over 65 years of age found little to no association between total opioid consumption and development of dementia or Alzheimer’s in a ten-year follow-up.6 These data underscore the challenges of detecting and managing pain in patients who struggle to communicate and express their subjective experiences.
Anesthesia providers should be aware of the associations between chronic pain and dementia. Elderly patients, especially those with dementia, may be more prone to inadequate treatment with analgesics as outpatients. Regional anesthesia and multimodal analgesia models should serve as the cornerstone for perioperative pain control. Diminishing the propensity for developing chronic pain after surgery continues to be a burgeoning area of research.
Neuropathological investigation of dementia: a guide for neurologists. J Neurol Neurosurg Psychiatry. 2005
Dec;76 Suppl 5:v8-14.
Landrø et al. The extent of
neurocognitive dysfunction in a
multidisciplinary pain centre population. Is there a relation
between reported and tested neuropsychological functioning? Pain. 2013;154(7):972-7.
Whitlock et al. Association Between Persistent
Pain and Memory Decline and Dementia in a Longitudinal Cohort of Elders. JAMA Intern Med.
Paladini et al. Chronic Pain in the
Elderly: The Case for New Therapeutic Strategies. Pain Physician. 2015;18(5):E863-76.
Griffioen et al.
Prevalence of the Use of Opioids for Treatment of Pain in Persons with a
Cognitive Impairment Compared with Cognitively Intact Persons: A
Systematic Review. Curr Alzheimer
al. Prescription Opioids and Risk of Dementia or Cognitive Decline: A
Prospective Cohort Study. J Am
Geriatr Soc. 2015;63(8):1519-26.
fibrillation (A Fib) is the most common sustained arrhythmia among adults. A
Fib is characterized by disorganized cardiac conduction within the atria,
resulting in an irregularly irregular heart rhythm. The hallmark
electrocardiographic (EKG) finding associated with A Fib is the absence of
P-waves, representing disorganized atrial contraction. A Fib is concerning
because of its potentially fatal consequences, including cardiovascular
collapse associated with tachyarrhythmias and thromboembolic events.
While chronic A Fib develops from several secondary causes, surgery is a common and discrete precipitant of new-onset A Fib. One study found that 4% of adults develop A Fib after non-cardiac surgery.1 A more recent database study revealed that, in descending order of risk, intrathoracic, vascular, and intra-abdominal surgeries were associated with clinically-important AFib.2 In this study, age greater than 85 years was the strongest covariate associated with the development of postoperative A Fib.
A Fib develops more
commonly after cardiac surgery than after other surgeries, with an incidence of
30-50% in post-cardiac surgery patients.3 Among patients undergoing coronary artery bypass grafts, independent
risk factors for postoperative A Fib include the following: age over 80 years,
concurrent valvular surgery, off-pump procedures, withdrawal of beta blocker or
angiotensin converting enzyme inhibitors, and prior history of A Fib or chronic
obstructive pulmonary disease.4 Common perioperative prevention strategies include the use
of beta blockers, amiodarone, and intracardiac atrial pacing.5 Despite having several models for risk
stratification, no current standard exists for predicting whether a patient is
at high or low risk for developing postoperative AFib.3 Thus, individualized assessments
should be made by anesthesiologists, cardiothoracic surgeons, and
of new-onset (i.e., less than 48 hours since sinus rhythm) postoperative A Fib
should focus on the overall stability of the patient. Patients with EKG
findings of tachyarrhythmia (sustained heart rate >100 beats per minute)
require immediate bedside attention. Patient complaints of newly developed
lightheadedness, dizziness, chest pain, dyspnea, or diaphoresis should prompt
providers to arrange for emergent cardioversion (i.e., synchronized) at 100-200
joules. Administration of sedation or amnestic therapies (e.g.,
benzodiazepines) prior to cardioversion should be done at the anesthesiologist’s or cardiologist’s discretion. Stabilization of the
arrhythmia may require multiple shocks and intravenous therapies.
with new-onset A Fib should be medically managed prior to discharge from the
recovery room. Standard labs should be obtained, with particular attention to
values for hemoglobin, potassium, magnesium, and calcium levels. Intravenous
beta-1 selective beta blockers (e.g., metoprolol, esmolol) are first-line
therapies for A Fib. Second-line medications include intravenous
non-dihydropyridine calcium channel blockers (e.g., diltiazem, verapamil) and
amiodarone. Caution should be exercised with the loading dose of amiodarone, as
rapid administration may result in hypotension.
Vaporciyan AA, et al. Risk factors associated with atrial fibrillation after
noncardiac thoracic surgery: analysis of 2588 patients. J Thorac Cardiovasc Surg.
Alonso-Coello P, et al. Predictors, Prognosis, and Management of New Clinically Important
Atrial Fibrillation After Noncardiac Surgery: A Prospective Cohort Study. Anesth Analg. 2017;125(1):162-169
O’Brien B, et al. Society of
Cardiovascular Anesthesiologists/European Association of Cardiothoracic
Anaesthetists Practice Advisory for the Management of Perioperative Atrial
Fibrillation in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth. 2019
Mathew JP, et
multicenter risk index for atrial fibrillation after cardiac surgery. JAMA.
KA, et al. Interventions
for preventing post-operative atrial fibrillation in patients undergoing heart
surgery. Cochrane Database Syst Rev. 2013