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In 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.

In 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 medical plans.

While 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 al found 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.

The 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.

Criticisms 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.

References:

  1. Serdiuk AA, 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. 2018; 50:76-77.
  2. Beverly A et al. Enhanced Recovery After Surgery: Evidence for Delivering Value-based Care. Int Anesthesiol Clin. 2017;55(4):78-89.
  3. 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.
  4. Kolarczyk LM, et al. Defining Value-Based Care in Cardiac and Vascular Anesthesiology: The Past, Present, and Future of Perioperative Cardiovascular Care. J Cardiothorac Vasc Anesth. 2018;32(1):512-521.

The post Updates on Value Based Care appeared first on Ambulatory Anesthesia Services | OBS Anesthesia Management Groups .

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Medical 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 responsibilities increased.

There 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 anesthesia residency.

A 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.

Alongside 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.

Further 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 care.

The post Virtual Reality as a Tool for Surgical and Anesthesia Training appeared first on Ambulatory Anesthesia Services | OBS Anesthesia Management Groups .

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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.

The post Double-Booked Surgeries: Policy and Practice for Anesthesiologists appeared first on Ambulatory Anesthesia Services | OBS Anesthesia Management Groups .

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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 acceptable.

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 [1]. 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.

The post Electrosurgical Interference with ICDs appeared first on Ambulatory Anesthesia Services | OBS Anesthesia Management Groups .

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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.

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Introduction 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.

Patients 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 reactivation.

The 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 [1]. Numerous case reports describe epidural abscess formation even in the absence of known immunodeficiency [2]. Other specific case reports have been described for herpes zoster. One report describes herpes esophagitis following a cervical epidural steroid injection [3]. Another describes cutaneous herpes zoster eruption following serial lumbar epidural steroid injections [4]. As such, providers should seriously consider the higher risk of infection in this patient population.

In 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.

Pain 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.

References:

  1. Moudgal V, et al. Spinal and paraspinal fungal infections associated with contaminated methylprednisolone injections. Open Forum Infect Dis. 2014 May 14;1(1)
  2. Kraeutler MJ, et al. Spinal subdural abscess following epidural steroid injection. J Neurosurg Spine. 2015; 22(1):90-3.
  3. Davis K, et al. A difficult case to swallow: herpes esophagitis after epidural steroid injection. Am J Ther. 2014; 21(1):e9-14.
  4. Parsons SJ, Hawboldt GS. Herpes zoster: a previously unrecognized complication of epidural steroids in the treatment of complex regional pain syndrome. J Pain Symptom Manage. 2003; 25(3):198-9.
  5. Maviki M, et al. Injecting epidural and intra-articular triamcinolone in HIV-positive patients on ritonavir: beware of iatrogenic Cushing’s syndrome. Skeletal Radiol. 2013; 42(2):313-5.
  6. Albert NE, et al. Ritonavir and epidural triamcinolone as a cause of iatrogenic Cushing’s syndrome. Am J Med Sci. 2012; 344(1):72-4.

The post Spinal Injections in Immunosuppressed Patients appeared first on Ambulatory Anesthesia Services | OBS Anesthesia Management Groups .

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In 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.

Cost 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.

However, 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.

Referencing 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 patients.

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 for all.

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.

2. Centers for Medicare & Medicaid Services. “2018ASPFiles.” CMS.gov, 30 Nov. 2018, www.cms.gov/medicare/medicare-fee-for-service-part-b-drugs/mcrpartbdrugavgsalesprice/2018aspfiles.html.

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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.

References:

  1. Desai N, Schofield N, Richards T. Perioperative patient blood management to improve outcomes. Anesth  Analg. 2018;127(5):1211-1220.
  2. 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.
  3. 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.
  4. Richman JM, Rowlingson AJ, Maine DN, Courpas GE, Weller JF, Wu CL. Does Neuraxial Anesthesia Reduce Intraoperative Blood Loss? A Meta-Analysis. J Clin Anesth. 2006;18(6):427-435.
  5. Gupta PB, DeMario VM, Amin RM, et al. Patient Blood Management Program Improves Blood Use and Clinical Outcomes in Orthopedic Surgery. Anesthesiology. 2018;129(6):1082-1091.
  6. Padhi S, Kemmis-Betty S, Rajesh S, Hill J, Murphy MF. Blood Transfusion: Summary of NICE guidance. BMJ. 2015;351:h5832.

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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.

References:

  1. Love S. Neuropathological investigation of dementia: a guide for neurologists. J Neurol Neurosurg Psychiatry. 2005 Dec;76 Suppl 5:v8-14.
  2. 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.
  3. Whitlock et al. Association Between Persistent Pain and Memory Decline and Dementia in a Longitudinal Cohort of Elders. JAMA Intern Med. 2017;177(8):1146-1153.
  4. Paladini et al. Chronic Pain in the Elderly: The Case for New Therapeutic Strategies. Pain Physician. 2015;18(5):E863-76.
  5. 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 Res. 2017;14(5):512-522.
  6. Dublin et al. Prescription Opioids and Risk of Dementia or Cognitive Decline: A Prospective Cohort Study. J Am Geriatr Soc. 2015;63(8):1519-26.

The post Chronic Pain Linked with a Greater Probability of Memory Decline & Dementia appeared first on Ambulatory Anesthesia Services | OBS Anesthesia Management Groups .

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Atrial 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 cardiologists.

Initial assessment 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.

Stable patients 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.

References:

  1. Vaporciyan AA, et al. Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients. J Thorac Cardiovasc Surg. 2004;127(3):779
  2. 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
  3. 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 Jan;33(1):12-26.
  4. Mathew JP, et al. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA. 2004;291(14):1720
  5. Arsenault KA, et al. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev. 2013

The post Managing Postoperative Atrial Fibrillation appeared first on Ambulatory Anesthesia Services | OBS Anesthesia Management Groups .

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