Pub Date : 2015-01-01DOI: 10.1097/ASA.0000000000000033
Arthur Atchabahian, Michael Andreae
population-based average effects or biomarkers as evidence of meaningful improvement in care are unconvincing in this day and age. Outcomes suitable as arguments for the sustained value of regional anesthesia should instead be patient centered. Patient preferences, shared decision-making, and individualized tailored care are the hallmarks of this new paradigm in outcomes research, differentiating it from previous concepts of comparative effectiveness research. Much needs to be done to define and investigate patient-centered outcomes in anesthesiology and pain medicine, especially long-term outcomes. Pay for performance is another emerging concept, forcing us to emphasize our unique contribution to the quality of patient outcomes. What is the added value that anesthesiologists providing patients regional anesthesia contribute in the long run in the perioperative surgical home, where these anesthesiology subspecialists serve as the shepherds guiding the individualized perioperative recovery process? Outcomes suitable as arguments for the sustained value of regional anesthesia should be patient centered. Pain, Function, and Cognition as Cornerstones of Meaningful Long-term Recovery In this chapter, we examine the clinical evidence suggesting that regional anesthesia has meaningful benefits for our patients and society beyond the immediate perioperative period. Although there are several other outcomes of interest, such as morbidity and mortality or cancer recurrence, we focus on three long-term outcomes after elective surgery based on their particular importance: (1) Persistent pain (2) Joint function (3) Cognitive outcomes We also selected these outcomes because their impact and significance are easy to convey to any interlocutor—surgical colleague, lay person, hospital administrator, or politician— regardless of their previous training or experience. FOCUS 1: REGIONAL ANESTHESIA FOR THE PREVENTION OF PERSISTENT PAIN AFTER SURGERY
{"title":"Long-term Functional Outcomes after Regional Anesthesia: A Summary of the Published Evidence and a Recent Cochrane Review.","authors":"Arthur Atchabahian, Michael Andreae","doi":"10.1097/ASA.0000000000000033","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000033","url":null,"abstract":"population-based average effects or biomarkers as evidence of meaningful improvement in care are unconvincing in this day and age. Outcomes suitable as arguments for the sustained value of regional anesthesia should instead be patient centered. Patient preferences, shared decision-making, and individualized tailored care are the hallmarks of this new paradigm in outcomes research, differentiating it from previous concepts of comparative effectiveness research. Much needs to be done to define and investigate patient-centered outcomes in anesthesiology and pain medicine, especially long-term outcomes. Pay for performance is another emerging concept, forcing us to emphasize our unique contribution to the quality of patient outcomes. What is the added value that anesthesiologists providing patients regional anesthesia contribute in the long run in the perioperative surgical home, where these anesthesiology subspecialists serve as the shepherds guiding the individualized perioperative recovery process? Outcomes suitable as arguments for the sustained value of regional anesthesia should be patient centered. Pain, Function, and Cognition as Cornerstones of Meaningful Long-term Recovery In this chapter, we examine the clinical evidence suggesting that regional anesthesia has meaningful benefits for our patients and society beyond the immediate perioperative period. Although there are several other outcomes of interest, such as morbidity and mortality or cancer recurrence, we focus on three long-term outcomes after elective surgery based on their particular importance: (1) Persistent pain (2) Joint function (3) Cognitive outcomes We also selected these outcomes because their impact and significance are easy to convey to any interlocutor—surgical colleague, lay person, hospital administrator, or politician— regardless of their previous training or experience. FOCUS 1: REGIONAL ANESTHESIA FOR THE PREVENTION OF PERSISTENT PAIN AFTER SURGERY","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"43 1","pages":"15-26"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000033","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34078770","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-01-01DOI: 10.1097/ASA.0000000000000032
N. Weitzel
Learning Objectives: As a result of completing this activity, the participant will be able to Describe preoperative risk factors in patients presenting for interventional procedures, including transcatheter aortic valve replacement List critical management options for transfemoral and transapical approaches to transcatheter aortic valve replacement Differentiate among critical monitoring techniques on the basis of the type of interventional procedure Explain the challenges in caring for patients having lead extractions, percutaneous mitral valve repair, or atrial exclusions
{"title":"Catheter-based Cardiac Surgery: Anesthesia in the Hybrid Suite and Cath Lab","authors":"N. Weitzel","doi":"10.1097/ASA.0000000000000032","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000032","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Describe preoperative risk factors in patients presenting for interventional procedures, including transcatheter aortic valve replacement List critical management options for transfemoral and transapical approaches to transcatheter aortic valve replacement Differentiate among critical monitoring techniques on the basis of the type of interventional procedure Explain the challenges in caring for patients having lead extractions, percutaneous mitral valve repair, or atrial exclusions","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"43 1","pages":"120–127"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000032","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62017342","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 : 2015-01-01DOI: 10.1097/ASA.0000000000000035
George W Williams
S troke is the third-leading cause of death in the United States and has been well characterized as a highly morbid disease. The goal of this chapter is to review the epidemiological and clinical scope of perioperative stroke, the mechanisms by which such strokes occur, and how perioperative management can serve to optimize the clinical outcome of these patients. In line with the American Society of Anesthesiologists’ goal of implementing the perioperative surgical home, the concepts discussed here are highly applicable to the daily practice of anesthesiology. Although several of the concepts discussed are not yet monitored from a Medicare quality metric perspective, the prevention and management of perioperative stroke is likely to rise to the forefront of anesthetic quality measurement in the near future.
{"title":"Different Strokes for Operative Folks: Prevention of the Perioperative Cerebrovascular Accident","authors":"George W Williams","doi":"10.1097/ASA.0000000000000035","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000035","url":null,"abstract":"S troke is the third-leading cause of death in the United States and has been well characterized as a highly morbid disease. The goal of this chapter is to review the epidemiological and clinical scope of perioperative stroke, the mechanisms by which such strokes occur, and how perioperative management can serve to optimize the clinical outcome of these patients. In line with the American Society of Anesthesiologists’ goal of implementing the perioperative surgical home, the concepts discussed here are highly applicable to the daily practice of anesthesiology. Although several of the concepts discussed are not yet monitored from a Medicare quality metric perspective, the prevention and management of perioperative stroke is likely to rise to the forefront of anesthetic quality measurement in the near future.","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"43 1","pages":"128-134"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000035","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62017360","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 : 2015-01-01DOI: 10.1097/ASA.0000000000000037
M. Brzezinski, J. Mitchell
Learning Objectives: As a result of completing this activity, the participant will be able to: Describe the current and relevant teaching theories, including the adult learning theory and the Dreyfus and Dreyfus model Explain the development of clinical decisionmaking by residents Identify potential obstacles to teaching in the fastpaced, high-pressure environment of the operating room Describe simple approaches to optimize the curriculum, as well as effective techniques to improve teaching, while not compromising quality of care Explain the impact of milestones on resident education
{"title":"Advanced Teaching Skills for the Fast-paced OR: How to Educate Successfully When Faced With High Clinical Workload, Lack of Protected Time, and Limited Funding","authors":"M. Brzezinski, J. Mitchell","doi":"10.1097/ASA.0000000000000037","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000037","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to: Describe the current and relevant teaching theories, including the adult learning theory and the Dreyfus and Dreyfus model Explain the development of clinical decisionmaking by residents Identify potential obstacles to teaching in the fastpaced, high-pressure environment of the operating room Describe simple approaches to optimize the curriculum, as well as effective techniques to improve teaching, while not compromising quality of care Explain the impact of milestones on resident education","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"43 1","pages":"49–57"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000037","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62017632","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 : 2015-01-01DOI: 10.1097/ASA.0000000000000022
G. Murphy
Learning Objectives: As a result of completing this activity, the participant will be able to Discuss neuromuscular monitoring and its impact on postoperative outcomes Describe the effect of reversal of neuromuscular blocking agents on the incidence of postoperative residual neuromuscular blockade Explain principles of neuromuscular management that may beneficially impact postoperative recovery in surgical patients
{"title":"Neuromuscular Management and Patient Outcomes","authors":"G. Murphy","doi":"10.1097/ASA.0000000000000022","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000022","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Discuss neuromuscular monitoring and its impact on postoperative outcomes Describe the effect of reversal of neuromuscular blocking agents on the incidence of postoperative residual neuromuscular blockade Explain principles of neuromuscular management that may beneficially impact postoperative recovery in surgical patients","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"43 1","pages":"80–86"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000022","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62016980","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 : 2015-01-01DOI: 10.1097/ASA.0000000000000036
A. Sinha
Learning Objectives: As a result of completing this activity, the participant will be able to Articulate the epidemiology of morbid obesity and its associated cost to society Recognize that morbid obesity and airway challenges can but do not always coexist Develop an understanding on ventilating obese patients Appreciate difficult intubating options in obese patients Describe how to extubate the challenging intubations
{"title":"Obesity and Anesthesia: Crossroads of a Challenge","authors":"A. Sinha","doi":"10.1097/ASA.0000000000000036","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000036","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Articulate the epidemiology of morbid obesity and its associated cost to society Recognize that morbid obesity and airway challenges can but do not always coexist Develop an understanding on ventilating obese patients Appreciate difficult intubating options in obese patients Describe how to extubate the challenging intubations","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"13 1","pages":"87–92"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000036","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62017461","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 : 2015-01-01DOI: 10.1097/ASA.0000000000000028
P. Birmingham
Anesthesiologists have expertise and experience with both analgesics and regional anesthetic techniques that enable them to optimize perioperative pain relief. This has always been of value to patients and their families. It is particularly so in the modern era of the ‘‘perioperative surgical home,’’ where what anesthesiologists do in the operating room and beyond may improve time to discharge and decrease unplanned returns to the hospital. Much of the discussion in this chapter includes ‘‘offlabel’’ or ‘‘unapproved’’ use of drugs, as this practice remains common in children despite recent laws promoting the need for more study and inclusive labeling for infants and children. Unapproved use does not imply improper or illegal use of such drugs. An in-depth review of developmental pharmacokinetics and pharmacodynamics in newborns and infants is beyond the scope of this discussion, but is available to the interested reader in any of several pediatric anesthesia textbooks.
{"title":"Acute Postoperative Pain Management in Infants and Children: Size and Age Do Matter","authors":"P. Birmingham","doi":"10.1097/ASA.0000000000000028","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000028","url":null,"abstract":"Anesthesiologists have expertise and experience with both analgesics and regional anesthetic techniques that enable them to optimize perioperative pain relief. This has always been of value to patients and their families. It is particularly so in the modern era of the ‘‘perioperative surgical home,’’ where what anesthesiologists do in the operating room and beyond may improve time to discharge and decrease unplanned returns to the hospital. Much of the discussion in this chapter includes ‘‘offlabel’’ or ‘‘unapproved’’ use of drugs, as this practice remains common in children despite recent laws promoting the need for more study and inclusive labeling for infants and children. Unapproved use does not imply improper or illegal use of such drugs. An in-depth review of developmental pharmacokinetics and pharmacodynamics in newborns and infants is beyond the scope of this discussion, but is available to the interested reader in any of several pediatric anesthesia textbooks.","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"43 1","pages":"42–48"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000028","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62016930","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 : 2015-01-01DOI: 10.1097/ASA.0000000000000030
E. Baird, M. Hutchens
Acute kidney injury (AKI) is surprisingly common in the perioperative period and, perhaps even more surprisingly, significantly affects patient outcomes, including death. AKI occurs in 1% of all noncardiac surgical patients—270,000 cases per year in the United States. Even mild AKI raises the death rate by a factor of 6 to 8, also increasing cost and length of hospital stay. Fundamentally, AKI is a source of suffering for our patients, and deserves the attention of anesthesiologists. UNIVERSAL DEFINITION OF ACUTE KIDNEY INJURY
{"title":"Perioperative Renoprotection","authors":"E. Baird, M. Hutchens","doi":"10.1097/ASA.0000000000000030","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000030","url":null,"abstract":"Acute kidney injury (AKI) is surprisingly common in the perioperative period and, perhaps even more surprisingly, significantly affects patient outcomes, including death. AKI occurs in 1% of all noncardiac surgical patients—270,000 cases per year in the United States. Even mild AKI raises the death rate by a factor of 6 to 8, also increasing cost and length of hospital stay. Fundamentally, AKI is a source of suffering for our patients, and deserves the attention of anesthesiologists. UNIVERSAL DEFINITION OF ACUTE KIDNEY INJURY","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"43 1","pages":"34–41"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000030","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62017170","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 : 2015-01-01DOI: 10.1097/ASA.0000000000000027
G. Ackland
Over the next 10 years, it is estimated that more than 20% of the US population will be older than 65 years. Globally, older patients comprise an ever-expanding proportion of more than 234 million surgical procedures performed each year. This demographic group is overrepresented in major surgery, particularly for malignancy. With increasing age, cardiac reserve and function decline. The overall prevalence of heart failure in patients older than 45 years is estimated at 2.2%. However, with age, this picture changes dramatically. The Framingham Heart Study found a prevalence of heart failure in men of 8 per 1,000 between the ages of 50 and 59 years, which subsequently increased eight-fold by the ninth decade. Broadly similar increases in prevalence have been reported in women. The prevalence in African Americans is around 25% higher than in whites. The American Heart Association estimated that there were 5.1 million people with heart failure in the United States in 2006, and this estimate has certainly risen, given predicted increases in life expectancy. In addition to the increasingly elderly population exhibiting overt cardiac failure, it has become apparent that many patients present for surgery with poor cardiopulmonary reserve that physiologically resembles many features of heart failure, albeit without the formal recognition of this syndrome. Recent epidemiological data demonstrate that for patients with an established diagnosis of heart failure, perioperative morbidity and mortality are increased. Most importantly, the risk conferred by heart failure appears to outweigh other preoperative morbidities that have attracted more academic and clinical attention (Supplemental Digital Content 1, http://links.lww. com/ASA/A537). Heart failure encompasses a complex multiorgan syndrome, and its cardiac and extracardiac pathophysiological features present many perioperative challenges.
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Pub Date : 2015-01-01DOI: 10.1097/ASA.0000000000000024
P. Slinger
Learning Objectives: As a result of completing this activity, the participant will be able to Identify patients at increased risk for perioperative lung injury Develop an evidence-based intraoperative ventilation strategy to improve postoperative outcomes Apply recent knowledge of perioperative fluid management and inflammation to decrease the incidence of postoperative respiratory complications in thoracic and nonthoracic surgery
{"title":"Perioperative Lung Protection Strategies in One-lung and Two-lung Ventilation","authors":"P. Slinger","doi":"10.1097/ASA.0000000000000024","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000024","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Identify patients at increased risk for perioperative lung injury Develop an evidence-based intraoperative ventilation strategy to improve postoperative outcomes Apply recent knowledge of perioperative fluid management and inflammation to decrease the incidence of postoperative respiratory complications in thoracic and nonthoracic surgery","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"43 1","pages":"93-103"},"PeriodicalIF":0.0,"publicationDate":"2015-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000024","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62017096","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}
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