Pub Date : 2014-01-01DOI: 10.1097/ASA.0000000000000013
R. Fink, J. Mark
Learning Objectives: As a result of completing this activity, the participant will be able to Explain the evidence base (or lack thereof) for pulmonary artery catheter use Discuss complications and risks associated with pulmonary artery catheters Describe the various waveform components on central venous pressure and pulmonary artery catheter tracings and describe their physiological basis Measure intracardiac pressure and understand how the interpretation of waveforms and pressures may assist with diagnostic and therapeutic decisions
{"title":"The Pulmonary Artery Catheter in 2014: Past, Present, and Is There a Future?","authors":"R. Fink, J. Mark","doi":"10.1097/ASA.0000000000000013","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000013","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Explain the evidence base (or lack thereof) for pulmonary artery catheter use Discuss complications and risks associated with pulmonary artery catheters Describe the various waveform components on central venous pressure and pulmonary artery catheter tracings and describe their physiological basis Measure intracardiac pressure and understand how the interpretation of waveforms and pressures may assist with diagnostic and therapeutic decisions","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"42 1","pages":"55–64"},"PeriodicalIF":0.0,"publicationDate":"2014-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000013","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62016334","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 : 2014-01-01DOI: 10.1097/ASA.0000000000000010
I. Bentov
In a recent editorial in Anesthesiology 1 the authors stated that ‘‘education in genomics will be essential for practitioners to translate genomic discoveries into clinical practice.’’ The Refresher Course lecture on which this chapter is based was designed to be part of that effort. First, basic concepts and nomenclature of genetics are reviewed. We will then discuss examples of the influence of genetic information and genetic research strategies upon patient care in anesthesia. Envision that you are reviewing the laboratory results for your next patient and you find that the blood counts and serum chemistries are all within normal limits. However, you notice that your patient has had genetic testing and is carrying the allele A290G (*1b) for the gene CYP3A4, homozygous for butyrylcholinesterase Asp70Gly polymorphism, and has an alarming single nucleotide polymorphism (SNP) analysis of natriuretic peptide receptor C/guanylate cyclase C (atrionatriuretic peptide receptor C), also known as NPR3, and natriuretic peptide precursor A (NPPA) and B (NPPB) genes (Supplemental Digital Content 1, http://links.lww.com/ASA/ A459). As she comes into your office, you see that she has flaming red hair. During the interview she claims that she requires large doses of local anesthetics when she visits the dentist. Would this information alter your anesthetic plan?
{"title":"Anesthetic Implications of Pharmacogenetics","authors":"I. Bentov","doi":"10.1097/ASA.0000000000000010","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000010","url":null,"abstract":"In a recent editorial in Anesthesiology 1 the authors stated that ‘‘education in genomics will be essential for practitioners to translate genomic discoveries into clinical practice.’’ The Refresher Course lecture on which this chapter is based was designed to be part of that effort. First, basic concepts and nomenclature of genetics are reviewed. We will then discuss examples of the influence of genetic information and genetic research strategies upon patient care in anesthesia. Envision that you are reviewing the laboratory results for your next patient and you find that the blood counts and serum chemistries are all within normal limits. However, you notice that your patient has had genetic testing and is carrying the allele A290G (*1b) for the gene CYP3A4, homozygous for butyrylcholinesterase Asp70Gly polymorphism, and has an alarming single nucleotide polymorphism (SNP) analysis of natriuretic peptide receptor C/guanylate cyclase C (atrionatriuretic peptide receptor C), also known as NPR3, and natriuretic peptide precursor A (NPPA) and B (NPPB) genes (Supplemental Digital Content 1, http://links.lww.com/ASA/ A459). As she comes into your office, you see that she has flaming red hair. During the interview she claims that she requires large doses of local anesthetics when she visits the dentist. Would this information alter your anesthetic plan?","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"42 1","pages":"18–22"},"PeriodicalIF":0.0,"publicationDate":"2014-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000010","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62015530","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 : 2014-01-01DOI: 10.1097/ASA.0000000000000014
R. Holzman
Learning Objectives: As a result of completing this activity, the participant will be able to Incorporate principles of mindfulness into a portfolio of vigilance, clinical decision making, and error reduction in the practice of anesthesiology Apply enhanced mindfulness techniques in the context of clinical anesthesiology practice Contrast mindfulness challenges and opportunities in the setting of multitasked dynamic perioperative care Recognize that mindfulness learned well in one area is an available competency that diffuses to other areas and transfers from professional to personal life
{"title":"Mindfulness and Anesthesiology","authors":"R. Holzman","doi":"10.1097/ASA.0000000000000014","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000014","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Incorporate principles of mindfulness into a portfolio of vigilance, clinical decision making, and error reduction in the practice of anesthesiology Apply enhanced mindfulness techniques in the context of clinical anesthesiology practice Contrast mindfulness challenges and opportunities in the setting of multitasked dynamic perioperative care Recognize that mindfulness learned well in one area is an available competency that diffuses to other areas and transfers from professional to personal life","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"42 1","pages":"75–82"},"PeriodicalIF":0.0,"publicationDate":"2014-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000014","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62015966","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 : 2014-01-01DOI: 10.1097/ASA.0000000000000017
B. Sweitzer
Learning Objectives: As a result of completing this activity, the participant will be able to Describe medical conditions that predict patients at risk for a poor outcome Evaluate screening tools and algorithms to identify and manage high-risk patients preoperatively Implement key preoperative practices to improve outcomes for patients in American Society of Anesthesiologists Physical Status 3 or 4
{"title":"Preoperative Identification, Evaluation, and Optimization of the Highest Risk Patients","authors":"B. Sweitzer","doi":"10.1097/ASA.0000000000000017","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000017","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Describe medical conditions that predict patients at risk for a poor outcome Evaluate screening tools and algorithms to identify and manage high-risk patients preoperatively Implement key preoperative practices to improve outcomes for patients in American Society of Anesthesiologists Physical Status 3 or 4","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"42 1","pages":"144-153"},"PeriodicalIF":0.0,"publicationDate":"2014-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000017","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62016593","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 : 2014-01-01DOI: 10.1097/ASA.0000000000000015
L. Moore, A. Gelb
Learning Objectives: As a result of completing this activity, the participant will be able to Describe patient comorbidities and surgical procedures that may place surgical patients at particular risk for perioperative stroke Recognize perioperative events that may be associated with stroke Explain initial management steps and potential interventions for postoperative patients with evidence of acute ischemic stroke
{"title":"Perioperative Stroke","authors":"L. Moore, A. Gelb","doi":"10.1097/ASA.0000000000000015","DOIUrl":"https://doi.org/10.1097/ASA.0000000000000015","url":null,"abstract":"Learning Objectives: As a result of completing this activity, the participant will be able to Describe patient comorbidities and surgical procedures that may place surgical patients at particular risk for perioperative stroke Recognize perioperative events that may be associated with stroke Explain initial management steps and potential interventions for postoperative patients with evidence of acute ischemic stroke","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"42 1","pages":"100–107"},"PeriodicalIF":0.0,"publicationDate":"2014-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0000000000000015","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62016756","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 : 2013-01-01DOI: 10.1097/ASA.0b013e318299f9a3
K. Baker
The Expert Pathway is an approach to professional development aimed at improving teaching, learning and performance in the domain of medicine. The approach is derived from the study of actual experts from a variety of different domains. Results from cognitive science are also applied as they relate to performance improvement. The ultimate goal is not simply to become competent (i.e. sufficient or adequate but not exceptional) rather the goal of the expert pathway is to reach towards expert performance. Performance in the domain of medicine has a great many contributing factors. These include motivation, environment, native ability or talent, employed strategies, self-regulation, costs and goal orientation. The expert pathway focuses on aspects of performance that are under an individual’s control such as employing selected strategies and persisting in the face of a setback.
{"title":"The Expert Pathway: What You Can Do to Improve Your Performance","authors":"K. Baker","doi":"10.1097/ASA.0b013e318299f9a3","DOIUrl":"https://doi.org/10.1097/ASA.0b013e318299f9a3","url":null,"abstract":"The Expert Pathway is an approach to professional development aimed at improving teaching, learning and performance in the domain of medicine. The approach is derived from the study of actual experts from a variety of different domains. Results from cognitive science are also applied as they relate to performance improvement. The ultimate goal is not simply to become competent (i.e. sufficient or adequate but not exceptional) rather the goal of the expert pathway is to reach towards expert performance. Performance in the domain of medicine has a great many contributing factors. These include motivation, environment, native ability or talent, employed strategies, self-regulation, costs and goal orientation. The expert pathway focuses on aspects of performance that are under an individual’s control such as employing selected strategies and persisting in the face of a setback.","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"41 1","pages":"15–21"},"PeriodicalIF":0.0,"publicationDate":"2013-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0b013e318299f9a3","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62021460","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 : 2013-01-01DOI: 10.1097/ASA.0b013e31829aea76
K. Ruskin
E ffective decision-making, risk management, and teamwork are essential components of patient safety. Anesthesiologists work as part of a multidisciplinary team in a complex, stressful environment that has multiple distractions and is intolerant of errors. Frequent interaction is required with sophisticated medical equipment and personnel who have varying backgrounds and levels of education. As part of an ongoing effort to improve patient safety, numerous techniques have been adopted from the aviation industry in order to decrease the frequency and severity of critical events caused by human error. Anesthesiologists were among the first to adopt human factors, industrial engineering, and operations research as part of clinical practice, but other specialties soon followed. A recent editorial highlighted the growing body of articles on human factors in the medical literature—more than 140 papers on crisis resource management— demonstrating the growing level of interest in this topic. Research in the fields of safety and human factors continues to evolve, and current interests include the early detection of error-producing situations and the design of error-resistant systems. Using these well-developed tools for risk assessment, judgment, and decision-making may help to make the operating room a safer place.
{"title":"Safety and Human Factors in the Operating Room","authors":"K. Ruskin","doi":"10.1097/ASA.0b013e31829aea76","DOIUrl":"https://doi.org/10.1097/ASA.0b013e31829aea76","url":null,"abstract":"E ffective decision-making, risk management, and teamwork are essential components of patient safety. Anesthesiologists work as part of a multidisciplinary team in a complex, stressful environment that has multiple distractions and is intolerant of errors. Frequent interaction is required with sophisticated medical equipment and personnel who have varying backgrounds and levels of education. As part of an ongoing effort to improve patient safety, numerous techniques have been adopted from the aviation industry in order to decrease the frequency and severity of critical events caused by human error. Anesthesiologists were among the first to adopt human factors, industrial engineering, and operations research as part of clinical practice, but other specialties soon followed. A recent editorial highlighted the growing body of articles on human factors in the medical literature—more than 140 papers on crisis resource management— demonstrating the growing level of interest in this topic. Research in the fields of safety and human factors continues to evolve, and current interests include the early detection of error-producing situations and the design of error-resistant systems. Using these well-developed tools for risk assessment, judgment, and decision-making may help to make the operating room a safer place.","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"41 1","pages":"103–108"},"PeriodicalIF":0.0,"publicationDate":"2013-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0b013e31829aea76","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62022332","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 : 2013-01-01DOI: 10.1097/ASA.0b013e318299fb18
A. Shander
Evidence has shown that the clinical practice of liberal use of allogeneic blood transfusion is in dire need of reassessment. Concerns regarding the safety and efficacy of allogeneic blood transfusions, their impact on patient outcomes, and the astounding costs and challenges associated with supply reserves of blood products have fueled the quest for alternative strategies to reduce blood use while meeting the needs of a growing (and increasingly aging) population (Supplemental Digital Content 1, http:// links.lww.com/ASA/A333). Blood has always been perceived as a ‘‘life saver’’ and, as such, is an emotional topic. The revisiting of transfusion practices has highlighted the potential risks associated with allogeneic blood (Table 1) and offers a lack of convincing evidence of its benefit in nonhemorrhaging and many transfusion-dependent patients. The evidence highlighting the association of allogeneic blood transfusion with worse outcomes—not just the known and relatively rare side effects of transfusion, but significant and substantial negative impact on mortality, morbidity, and length of hospital stay—is rapidly growing.
{"title":"Patient Blood Management From Blood Product to Patient-centered Care","authors":"A. Shander","doi":"10.1097/ASA.0b013e318299fb18","DOIUrl":"https://doi.org/10.1097/ASA.0b013e318299fb18","url":null,"abstract":"Evidence has shown that the clinical practice of liberal use of allogeneic blood transfusion is in dire need of reassessment. Concerns regarding the safety and efficacy of allogeneic blood transfusions, their impact on patient outcomes, and the astounding costs and challenges associated with supply reserves of blood products have fueled the quest for alternative strategies to reduce blood use while meeting the needs of a growing (and increasingly aging) population (Supplemental Digital Content 1, http:// links.lww.com/ASA/A333). Blood has always been perceived as a ‘‘life saver’’ and, as such, is an emotional topic. The revisiting of transfusion practices has highlighted the potential risks associated with allogeneic blood (Table 1) and offers a lack of convincing evidence of its benefit in nonhemorrhaging and many transfusion-dependent patients. The evidence highlighting the association of allogeneic blood transfusion with worse outcomes—not just the known and relatively rare side effects of transfusion, but significant and substantial negative impact on mortality, morbidity, and length of hospital stay—is rapidly growing.","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"41 1","pages":"109–114"},"PeriodicalIF":0.0,"publicationDate":"2013-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0b013e318299fb18","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62021582","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 : 2013-01-01DOI: 10.1097/ASA.0b013e31829a1e34
K. Nelson
Patient-controlled Epidural Analgesia and Programmed Intermittent Epidural Bolusing Once a catheter has been placed into the epidural space, several options are available to maintain analgesia (Supplemental Digital Content 1, http://links.lww.com/ ASA/A347). One of the first methods to be used was intermittent bolusing on patient request. Once the effect of the initial dose of local anesthetic would begin to subside, contraction pain would return and the patient would request more medication, at which time the anesthesiologist would provide analgesia using another bolus dose of local anesthetic. The obvious disadvantage to this technique is the relatively large amount of manpower required. Other disadvantages include noncontinuous pain relief and an intermittent increase in side effects such as hypotension and motor blockade. The natural progression in management of labor analgesia was, then, to use infusions to maintain analgesia; however, early infusion pumps were relatively primitive and sometimes unreliable, and data were lacking to guide infusion rates. A large body of research was eventually published to help rectify the problem, and it was during this time that the next step in the evolution of maintenance of labor analgesia occurred: patient-controlled epidural analgesia (PCEA). By this time, copious experience had accumulated with the use of intravenous patient-controlled analgesia, and the same principles were then applied to PCEA. However, it was soon discovered that there are some important differences between opioid-based intravenous patient-controlled analgesia for acute postoperative pain and local anesthetic–based PCEA for labor analgesia. Perhaps most important, a basal infusion was found to be very effective
{"title":"State-of-the-Art Labor Analgesia","authors":"K. Nelson","doi":"10.1097/ASA.0b013e31829a1e34","DOIUrl":"https://doi.org/10.1097/ASA.0b013e31829a1e34","url":null,"abstract":"Patient-controlled Epidural Analgesia and Programmed Intermittent Epidural Bolusing Once a catheter has been placed into the epidural space, several options are available to maintain analgesia (Supplemental Digital Content 1, http://links.lww.com/ ASA/A347). One of the first methods to be used was intermittent bolusing on patient request. Once the effect of the initial dose of local anesthetic would begin to subside, contraction pain would return and the patient would request more medication, at which time the anesthesiologist would provide analgesia using another bolus dose of local anesthetic. The obvious disadvantage to this technique is the relatively large amount of manpower required. Other disadvantages include noncontinuous pain relief and an intermittent increase in side effects such as hypotension and motor blockade. The natural progression in management of labor analgesia was, then, to use infusions to maintain analgesia; however, early infusion pumps were relatively primitive and sometimes unreliable, and data were lacking to guide infusion rates. A large body of research was eventually published to help rectify the problem, and it was during this time that the next step in the evolution of maintenance of labor analgesia occurred: patient-controlled epidural analgesia (PCEA). By this time, copious experience had accumulated with the use of intravenous patient-controlled analgesia, and the same principles were then applied to PCEA. However, it was soon discovered that there are some important differences between opioid-based intravenous patient-controlled analgesia for acute postoperative pain and local anesthetic–based PCEA for labor analgesia. Perhaps most important, a basal infusion was found to be very effective","PeriodicalId":91163,"journal":{"name":"Refresher courses in anesthesiology","volume":"19 1","pages":"88–94"},"PeriodicalIF":0.0,"publicationDate":"2013-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/ASA.0b013e31829a1e34","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"62021662","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 : 2013-01-01DOI: 10.1097/ASA.0b013e3182995629
Johann Strumpher, E. Jacobsohn
Learning Objectives: As a result of completing this activity, the participant will be able to Discuss pulmonary hypertension (PH) as a disease entity including its definition, pathogenesis, classification, diagnosis, and treatment options Describe the pathophysiology of acute perioperative right ventricular (RV) failure in patients with PH Explain the principles of treatment for acute perioperative RV failure
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