Pub Date : 2016-05-01DOI: 10.1213/XAA.0000000000000293
E. Sun, T. R. Miller, Nicholas M. Halzack
In the United States, anesthesia care can be provided by anesthesiologists or nurse anesthetists. Since 2001, 17 states have exercised their right to "opt-out" of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist, with the majority citing increased access to anesthesia care as the rationale for their decision. By using Medicare data, we found that most (4 of 5) cohorts of "opt-out" states likely experienced smaller growth in anesthesia utilization rates compared with non-"opt-out" states, suggesting that opt-out was not associated with an increase in access to anesthesia care.
{"title":"In the United States, \"Opt-Out\" States Show No Increase in Access to Anesthesia Services for Medicare Beneficiaries Compared with Non-\"Opt-Out\" States.","authors":"E. Sun, T. R. Miller, Nicholas M. Halzack","doi":"10.1213/XAA.0000000000000293","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000293","url":null,"abstract":"In the United States, anesthesia care can be provided by anesthesiologists or nurse anesthetists. Since 2001, 17 states have exercised their right to \"opt-out\" of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist, with the majority citing increased access to anesthesia care as the rationale for their decision. By using Medicare data, we found that most (4 of 5) cohorts of \"opt-out\" states likely experienced smaller growth in anesthesia utilization rates compared with non-\"opt-out\" states, suggesting that opt-out was not associated with an increase in access to anesthesia care.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"24 1","pages":"283-5"},"PeriodicalIF":0.0,"publicationDate":"2016-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76163031","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2016-04-15DOI: 10.1213/XAA.0000000000000283
Zihui Tan, K. T. Tan, R. Poopalalingam
Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by the deposition of lipoproteinaceous materials in the bronchoalveolar tree. Whole lung lavage was introduced in the 1960s and remains a treatment of choice for PAP. The main anesthetic challenge of whole lung lavage is maintaining adequate oxygenation during the procedure. We describe 2 interesting patients with PAP, the anesthetic challenges faced during the lung lavage, and discuss the management strategies adopted in each case.
{"title":"Anesthetic Management for Whole Lung Lavage in Patients with Pulmonary Alveolar Proteinosis.","authors":"Zihui Tan, K. T. Tan, R. Poopalalingam","doi":"10.1213/XAA.0000000000000283","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000283","url":null,"abstract":"Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by the deposition of lipoproteinaceous materials in the bronchoalveolar tree. Whole lung lavage was introduced in the 1960s and remains a treatment of choice for PAP. The main anesthetic challenge of whole lung lavage is maintaining adequate oxygenation during the procedure. We describe 2 interesting patients with PAP, the anesthetic challenges faced during the lung lavage, and discuss the management strategies adopted in each case.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"56 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85881918","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2016-04-15DOI: 10.1213/XAA.0000000000000274
Olivia Nelson, T. Quinn, Alexander F. Arriaga, D. Hepner, S. Lipsitz, Zara Cooper, A. Gawande, A. Bader
Previous literature on preoperative evaluation focuses on the impact on the day of surgery cancellations and delays; however, the framework of cancellations and delays at the time of the elective outpatient preoperative anesthesia visit has not been categorized. We describe the current model in the preoperative clinic at Brigham and Women's Hospital, examining the pattern of cancellations at the time of this preoperative visit and the framework used for categorizing the issues involved. Looking at this broader framework is important in an era of patient-centered care; we seek to identify targets to modify the preoperative assessment and adequately assess and capture the spectrum of issues involved. Elective cases evaluated in the preoperative clinic were reviewed over 10 months. Characteristics of cancelled and noncancelled cases were compared. In-depth analysis of issues related to cancellation was done; 1-year follow-up was completed. Cancellation patterns included categories encompassing clinical, financial, alignment with patient values and goals, compliance, and social issues. The period of preoperative assessment can therefore be leveraged to review a number of domains that can adversely affect surgical outcomes and improve patient-centered care. Also, our framework allows the institution to benchmark these patterns over time; increases in cancellations at the time of the preoperative anesthesia clinic visit for specific categories can prompt an opportunity to examine and improve preoperative workflow.
先前关于术前评估的文献主要关注对手术取消和延迟的影响;然而，取消和延迟的框架，在时间的选择性门诊术前麻醉访问尚未分类。我们描述了布里格姆妇女医院(Brigham and Women's Hospital)术前诊所的当前模式，检查了术前就诊时的取消模式，以及用于对所涉及问题进行分类的框架。在一个以患者为中心的医疗时代，审视这个更广泛的框架是很重要的;我们寻求确定目标，以修改术前评估，并充分评估和捕获所涉及的问题范围。在术前诊所评估的选择性病例在10个月内进行回顾。比较取消和未取消病例的特点。对取消相关问题进行了深入分析;随访1年。取消模式包括临床、财务、与患者价值观和目标的一致性、依从性和社会问题等类别。因此，术前评估期间可以用来审查一些可能对手术结果产生不利影响的领域，并改善以患者为中心的护理。此外，我们的框架允许机构对这些模式进行基准测试;在特定类别的术前麻醉门诊就诊时取消的增加可以提示检查和改进术前工作流程的机会。
{"title":"A Model for Better Leveraging the Point of Preoperative Assessment: Patients and Providers Look Beyond Operative Indications When Making Decisions.","authors":"Olivia Nelson, T. Quinn, Alexander F. Arriaga, D. Hepner, S. Lipsitz, Zara Cooper, A. Gawande, A. Bader","doi":"10.1213/XAA.0000000000000274","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000274","url":null,"abstract":"Previous literature on preoperative evaluation focuses on the impact on the day of surgery cancellations and delays; however, the framework of cancellations and delays at the time of the elective outpatient preoperative anesthesia visit has not been categorized. We describe the current model in the preoperative clinic at Brigham and Women's Hospital, examining the pattern of cancellations at the time of this preoperative visit and the framework used for categorizing the issues involved. Looking at this broader framework is important in an era of patient-centered care; we seek to identify targets to modify the preoperative assessment and adequately assess and capture the spectrum of issues involved. Elective cases evaluated in the preoperative clinic were reviewed over 10 months. Characteristics of cancelled and noncancelled cases were compared. In-depth analysis of issues related to cancellation was done; 1-year follow-up was completed. Cancellation patterns included categories encompassing clinical, financial, alignment with patient values and goals, compliance, and social issues. The period of preoperative assessment can therefore be leveraged to review a number of domains that can adversely affect surgical outcomes and improve patient-centered care. Also, our framework allows the institution to benchmark these patterns over time; increases in cancellations at the time of the preoperative anesthesia clinic visit for specific categories can prompt an opportunity to examine and improve preoperative workflow.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"54 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78814520","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2016-04-15DOI: 10.1213/XAA.0000000000000286
Peter E Shapiro, Hedwig Schroeck
We present the case of an otherwise healthy 12-month-old girl undergoing repair of a giant omphalocele, who experienced a postoperative seizure attributed to accumulation of bupivacaine from an epidural infusion. Whereas a standard dose was used, this patient experienced temporary liver dysfunction postoperatively, presumably from elevated intra-abdominal pressures, predisposing her to toxicity after a prolonged infusion. This case illustrates how the type of surgery can influence the margin of safety of routinely used neuraxial local anesthetic doses in infants and young children.
{"title":"Seizure After Abdominal Surgery in an Infant Receiving a Standard-Dose Postoperative Epidural Bupivacaine Infusion.","authors":"Peter E Shapiro, Hedwig Schroeck","doi":"10.1213/XAA.0000000000000286","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000286","url":null,"abstract":"We present the case of an otherwise healthy 12-month-old girl undergoing repair of a giant omphalocele, who experienced a postoperative seizure attributed to accumulation of bupivacaine from an epidural infusion. Whereas a standard dose was used, this patient experienced temporary liver dysfunction postoperatively, presumably from elevated intra-abdominal pressures, predisposing her to toxicity after a prolonged infusion. This case illustrates how the type of surgery can influence the margin of safety of routinely used neuraxial local anesthetic doses in infants and young children.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"7 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81765516","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2016-04-15DOI: 10.1213/XAA.0000000000000287
Joe C. Hong, Emilio Ramos, Curtis C Copeland, K. Ziv
We present 2 patients with Moyamoya disease undergoing revascularization surgery who developed transient intraoperative central diabetes insipidus with spontaneous resolution in the immediate postoperative period. We speculate that patients with Moyamoya disease may be predisposed to a transient acute-on-chronic insult to the arginine vasopressin-producing portion of their hypothalamus mediated by anesthetic agents. We describe our management, discuss pertinent literature, and offer possible mechanisms of this transient insult. We hope to improve patient safety by raising awareness of this potentially catastrophic complication.
{"title":"Transient Intraoperative Central Diabetes Insipidus in Moyamoya Patients Undergoing Revascularization Surgery: A Mere Coincidence?","authors":"Joe C. Hong, Emilio Ramos, Curtis C Copeland, K. Ziv","doi":"10.1213/XAA.0000000000000287","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000287","url":null,"abstract":"We present 2 patients with Moyamoya disease undergoing revascularization surgery who developed transient intraoperative central diabetes insipidus with spontaneous resolution in the immediate postoperative period. We speculate that patients with Moyamoya disease may be predisposed to a transient acute-on-chronic insult to the arginine vasopressin-producing portion of their hypothalamus mediated by anesthetic agents. We describe our management, discuss pertinent literature, and offer possible mechanisms of this transient insult. We hope to improve patient safety by raising awareness of this potentially catastrophic complication.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"49 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84951946","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2016-04-15DOI: 10.1213/XAA.0000000000000290
Bradford L. Cardonell, Barry A Marks, M. Entrup
The development of acute abdominal pain in a laboring parturient after a previous cesarean delivery is of concern and may be the result of a potentially life-threatening condition such as uterine rupture. We present a case of a parturient with type II diabetes mellitus, who had undergone 2 previous cesarean deliveries and now presented in labor with increasing abdominal pain. An emergency cesarean delivery was performed for probable uterine rupture. Intraoperatively, the patient was noted to be severely hypocarbic with significant metabolic acidosis, and the diagnosis of diabetic ketoacidosis was established.
{"title":"Normoglycemic Diabetic Ketoacidosis in a Pregnant Patient with Type II Diabetes Mellitus Presenting for Emergent Cesarean Delivery.","authors":"Bradford L. Cardonell, Barry A Marks, M. Entrup","doi":"10.1213/XAA.0000000000000290","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000290","url":null,"abstract":"The development of acute abdominal pain in a laboring parturient after a previous cesarean delivery is of concern and may be the result of a potentially life-threatening condition such as uterine rupture. We present a case of a parturient with type II diabetes mellitus, who had undergone 2 previous cesarean deliveries and now presented in labor with increasing abdominal pain. An emergency cesarean delivery was performed for probable uterine rupture. Intraoperatively, the patient was noted to be severely hypocarbic with significant metabolic acidosis, and the diagnosis of diabetic ketoacidosis was established.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"16 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78947966","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2016-04-15DOI: 10.1213/XAA.0000000000000255
Ankeet D. Udani, Daniel Moyse, C. A. Peery, J. Taekman
Social media is a nascent medical educational technology. The benefits of Twitter include (1) easy adoption; (2) access to experts, peers, and patients across the globe; (3) 24/7 connectivity; (4) creation of virtual, education-based communities using hashtags; and (5) crowdsourcing information using retweets. We report on a novel Twitter-augmented journal club for anesthesia residents: its design, implementation, and impact. Our inaugural anesthesia Twitter-augmented journal club succeeded in engaging the anesthesia community and increasing residents' professional use of Twitter. Notably, our experience suggests that anesthesia residents are willing to use social media for their education.
{"title":"Twitter-Augmented Journal Club: Educational Engagement and Experience So Far.","authors":"Ankeet D. Udani, Daniel Moyse, C. A. Peery, J. Taekman","doi":"10.1213/XAA.0000000000000255","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000255","url":null,"abstract":"Social media is a nascent medical educational technology. The benefits of Twitter include (1) easy adoption; (2) access to experts, peers, and patients across the globe; (3) 24/7 connectivity; (4) creation of virtual, education-based communities using hashtags; and (5) crowdsourcing information using retweets. We report on a novel Twitter-augmented journal club for anesthesia residents: its design, implementation, and impact. Our inaugural anesthesia Twitter-augmented journal club succeeded in engaging the anesthesia community and increasing residents' professional use of Twitter. Notably, our experience suggests that anesthesia residents are willing to use social media for their education.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"15 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83725113","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2016-04-15DOI: 10.1213/XAA.0000000000000289
N. B. Greilich, I. Gasanova, B. Farrell, G. Joshi
Development of subcutaneous emphysema after gastrointestinal endoscopy with general anesthesia presents a diagnostic conundrum. We discuss the management of a patient who experienced significant vomiting followed by neck and facial swelling with crepitus and shortness of breath after the endoscopic retrograde cholangiopancreatography. The presence of respiratory distress usually suggests that head and neck subcutaneous emphysema is most likely associated with pneumothorax and/or pneumomediastinum. We discuss the prevention, differential diagnosis, and current management of tracheal tears including subcutaneous emphysema.
{"title":"The Diagnosis and Management of Patient with Delayed Symptoms from a Tracheal Tear.","authors":"N. B. Greilich, I. Gasanova, B. Farrell, G. Joshi","doi":"10.1213/XAA.0000000000000289","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000289","url":null,"abstract":"Development of subcutaneous emphysema after gastrointestinal endoscopy with general anesthesia presents a diagnostic conundrum. We discuss the management of a patient who experienced significant vomiting followed by neck and facial swelling with crepitus and shortness of breath after the endoscopic retrograde cholangiopancreatography. The presence of respiratory distress usually suggests that head and neck subcutaneous emphysema is most likely associated with pneumothorax and/or pneumomediastinum. We discuss the prevention, differential diagnosis, and current management of tracheal tears including subcutaneous emphysema.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"50 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86179604","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2016-04-01DOI: 10.1213/XAA.0000000000000269
R. Hadler, M. Neuman, S. Raper, L. Fleisher
Anesthesiologists and surgeons are frequently called on to perform procedures on critically ill patients with advanced directives. We assessed the attitudes of attending and resident surgeons and anesthesiologists at our institution regarding their understanding of and practice around the application of consenting critically ill patients with advance directives in the operating room. To do so, we deployed a survey after interdepartmental grand rounds, featuring a panel discussion of ethically complex cases featuring end-of-life issues.
{"title":"Advance Directives and Operating: Room for Improvement?","authors":"R. Hadler, M. Neuman, S. Raper, L. Fleisher","doi":"10.1213/XAA.0000000000000269","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000269","url":null,"abstract":"Anesthesiologists and surgeons are frequently called on to perform procedures on critically ill patients with advanced directives. We assessed the attitudes of attending and resident surgeons and anesthesiologists at our institution regarding their understanding of and practice around the application of consenting critically ill patients with advance directives in the operating room. To do so, we deployed a survey after interdepartmental grand rounds, featuring a panel discussion of ethically complex cases featuring end-of-life issues.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"23 ","pages":"204-7"},"PeriodicalIF":0.0,"publicationDate":"2016-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91463108","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：