PLAN NOW TO ATTEND THE SAMBA MID YEAR MEETING! - TOP

2008 Mid Year Meeting Friday, October 17, 2008 Rosen Centre Hotel Orlando, Florida Program Information

SUGGESTIONS NEEDED: ASA 2009 AMBULATORY TRACK - TOP

Please help us to plan the Ambulatory Track for the 2009 ASA Annual Meeting in New Orleans by submitting suggestions for topics, speakers, and format.  The Ambulatory Track will include refresher course lectures, point-counterpoint, panels, luncheon panels, and clinical forum sessions. 

ASA members can submit suggestions via the members-only section of the ASA website at: www.asawebapps.org. 

Open Session Submissions for the ASA 2009 Annual Meeting

If possible, please submit suggestions BEFORE this year’s ASA meeting to allow us to review the track content at that time.  Submissions must be received by November 30, 2008

Thanks
Lucy Everett MD
Chair, Ambulatory Track Subcommittee

Click to find out what Activities for Ambulatory Anesthesia are available at the upcoming 2008 ASA Meeting!

WEB SITE OF THE MONTH- TOP

Malignant hyperthermia made front page news in March as the cause of death of a teenage girl undergoing surgery in a Boca Raton plastic surgeon’s office. A tragic reminder of this rare disease prompts this month’s featured web-site, www.mhaus.org.

The Malignant Hyperthermia Association of the United States (MHAUS) was founded in 1981 with the mission: “to reduce death and injury from MH by improving medical care related to MH, provide support information for patients, and improve the scientific understanding of MH through ongoing research.”

The web-site features information for patients and families as well as health care professionals. There is a recently updated printable poster for emergency therapy that includes sections for diagnosis, acute phase treatment and post acute phase treatment. The poster also has the MH Hotline number to contact consultants 24/7: 1-800-MH-HYPER begin_of_the_skype_highlighting              1-800-MH-HYPER      end_of_the_skype_highlighting

The web-site has easily accessible information on a variety of information including a list of consultants, safe and unsafe anesthetic agents, and FAQs about dantrolene and concerns such as the perioperative care of the MH patient, including outpatients and the pregnant patient

Two PowerPoint presentations delivered by Dr. Harry Rosenberg “MH Syndrome 2006” and “Rhabdomyolysis in the Perioperiative Period ‘’ are available. Other educational materials include 2 exams for CME credit and a “case of the month” which are also archived. Links to podcasts of expert speakers are provided as well as Dr. Rosenberg’s blog.

Feedback

Please feel free to give us your feedback about this web-site and this new section (VSMOOT@anes.umm.edu).  Furthermore, if you have a web-site that you have found to be informative for the practice of anesthesiology, please let us know. Thanks.

Victoria Smoot, MD

SAMBA 2009 ANNUAL MEETING: SCOTTSDALE, AZ - TOP


As the days of fall begin we can start to get excited about what spring may yield. We hope as part of your spring you are planning to attend the SAMBA annual meeting in Scottsdale, Arizona. The program is beginning to take shape.

The preconvention meeting on Thursday May 14th is titled 'Preoperative Decision Making'. It will kick off with an overview by Dr Tom Cutter on patient selection, followed by several panels. The first will be on Obstructive Sleep Apnea and the 2nd on drugs patients are on that provide challenges for their anesthetic management. The first panel will be a brief overview of the topic followed by a case presentation in the format of an oral board stem.

After lunch the 3rd panel titled ' If I had to do it again" focuses on case presentations. The panelists will present cases where they have made decisions that they subsequently would have altered. Audience participation will be encouraged so that we can all share such experiences and hopefully learn how to minimize them. This will be followed by several workshops on cardiac evaluation, use of ultrasound for regional anesthesia, use of catheters for ambulatory regional anesthesia, and airway devices for use in an ASC. This year we will also provide a course on ACLS certification on Thursday.

The Main program begins on Friday May 15th with the day devoted to topics on Office Based Anesthesia (OBA). The morning session covers OBA for dentistry, plastics, developmentally delayed children, regional anesthesia for OBA and then ends with the question 'Is OBA a short lived specialty.' The afternoon consists of multiple workshops on regional anesthesia techniques, OBA and ASC administration and on how to prepare for emergencies in an office.

Saturday kicks off with the debate 'Should We Be the Preoperative Physicians or Just Leave it to the Internists?' followed by the SAMBA Frontiers lecture and an update on the ASA. The afternoon consists of the ever popular 'Cases from the real world', followed by several parallel PBLD sessions.
 
Sunday starts with a session on post operative analgesia concentrating on regional anesthesia for adults followed by pain management in children. Next are the presentations of the Award winning abstracts. Sunday ends with Journal club which reviews pertinent new literature in Ambulatory Anesthesia.

We certainly hope that we will see many of you in Scottsdale for our Annual Meeting

Peter Glass and Tom Cutter

RESIDENTS SECTION: INTERVIEW WITH DR. GEORGE NEUMAN - TOP

Leadership in Anesthesiology

An interview with Dr. George Neuman
Jennifer Wu, CA-2 Resident at St. Vincent’s Hospital in Manhattan

Dr. George Neuman is the Chairman of the Department of Anesthesiology and the Chief Medical Officer of St. Vincent’s Hospital in Manhattan.  Dr. Neuman and I spoke about leadership, goals, and the role of anesthesiologists.

What do you like about Anesthesiology?

First and foremost, I like the work that we do as anesthesiologists. In addition, you have the ability to reinvent yourself as you go through your career.  You can pursue academia or private practice. There are administrative opportunities both within and outside of the perioperative environment. Over the past 10-15 years, anesthesiologists have increasingly taken on new roles including: medical director, dean, and CEO.

What are your responsibilities as Chairman?

My primary responsibility is to assure that a high standard of patient care is consistently achieved. I optimize the use of resources, both human and facility, in the department.  I work to ensure that we maintain our reputation by recruiting the best physicians and by creating an environment that assures their success. Successfully balancing individuals’ wants and needs is a challenge that confronts all chairs.

What is your favorite activity as Chairman?

Mentoring.  I enjoying sharing my experience with others, providing people with what they need to meet their goals, and ultimately, seeing them succeed.

Why does anesthesiology go hand in hand with leadership?

The administrative goals of an anesthesia department should be in sync with the goals of the hospital.  As anesthesiologists, we are focused on customer service, quality care, and resource conservation.  If the department and perioperative services run well, the reputation and financial position of the institution will be enhanced.  Anesthesiologists are at the forefront of quality improvement and evidence based care, having made incredible contributions to patient safety. We are key members of the perioperative team, not only responsible for the wellbeing of the patient but for the maintaining high standards of compliance and efficiency in the OR.

What advice do you give to physicians who want to move ahead in their careers?

You must be a self-starter and a skilled physician.  Enjoy what you do and look for opportunities.  If you take on new opportunities as they arise, you will continue to advance.  Be proactive and do a good job, you’ll be noticed.

SAMBA Talks is Produced by: Editor: Ali Jahan MD Literature Review: Suhas Kalhatgi MD, Brian Parker MD, M Denise Daley MD, Kumar Belani MD Discussion Section: Ashu Wali MD, Ali Jahan MD Committee Members:Gareth S. Kantor MD, Ali Jahan MD, Ashu Wali MD, Brian Parker MD, Suhas Kalghatgi MD, Melinda L. Mingus MD, Beverly K. Philip MD, Adam F. Dorin MD, Denise Daley MD, Daniel T. Goulson MD, Kumar Belani MD, Victoria Smoot MD, and Robert Helfand MD Webmaster: Jim McGreal

Need advice about a problem case in ambulatory anesthesia? Suggestions about a difficult situation in your ambulatory surgery center? A reply to questions others have raised about ambulatory anesthesia issues?

If you answered "yes" to any of these questions, or would like to share with other professionals a comment or opinion on a topic related to ambulatory anesthesia then please "Join the Discussion".

Your question, reply or comment will be published in the next available issue of SAMBA TALKS. Include your name (or initials), email address, city, and state, if you would like these published. Please note that because of the high volume of questions we receive, there is often a delay of 1 to 2 months before publication.

SAMBA Talks will include all discussion questions we receive considered of interest to the membership at large. We will endeavor to publish a response to at least one of these questions. The response will be from experts in the field, and from those willing to express a view on a particular topic, backed by experience and/or published evidence. Where email addresses are published, those individuals have indicated their interest in discussing the published questions.

Questions and responses from previous months are now available at the eNewsletter Discussion Archive. If you have any comments regarding the previous questions, please submit them to SAMBA Discussion, and they will be published here next month.

Please note: The information presented in the replies below does not represent SAMBA policy. The replies are solely the opinions of the individuals who wrote them.

?? - LAST MONTH'S QUESTIONS WITH REPLIES - ?? - TOP

Question 1:

We perform anesthesia for colonoscopies using propofol and regard this as general anesthesia.  However, ASA guidelines seem to indicate that end-tidal CO2 monitoring is a standard of care for general anesthesia.  Do you regard end-tidal CO2 monitoring a standard of care for colonoscopy with propofol?

-- From: John Booth, Richmond, VA (booth006@mac.com)

Reply 1

We believe it is absolutely the standard of care to monitor end-tidal CO2 during a colonoscopy using propofol or any deep sedation. Anesthesia vigilance should be the same whether a procedure is done in the operating room or out of the operating room and whether general anesthesia or MAC is performed. Monitoring for any anesthetic should include EKG, blood pressure, pulse oximetry, and capnography. There are several companies making low-priced portable pulse oximeters and capnographs. To not use these monitors is indefensible.

-- From: David S. Rapkin, M.D., Richmond Hts, OH

Reply 2

It is correct to call patients who are asleep with propofol for colonoscopies as having general anesthesia- that's what most folk are doing.   It is not sedation, since the patients are not "responding purposefully to painful stimuli  {ASA Continuum of Depth of Sedation:  Definition of General Anesthesia and  Levels of Sedation/Analgesia, 2004}.  Also, "If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required."  {ASA Position on Monitored Anesthesia Care, 2005}.

This definition is not dependent on which drug/s are used, or what the procedure is, but only on the state that the patient reaches.  Calling this state "sedation” also does not change the fact that it is general anesthesia

If the patient is under general anesthesia, all relevant ASA guidelines apply. In the ASA Standards for Basic Anesthesia Monitoring (2005), under Ventilation: we find:

"Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated.  Qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds are useful.  Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment."

So the requirement is “shall"  (have to) unless it's 'not possible'.
However, it would be tough to defend that it was impossible to monitor CO2 should you need to defend a bad outcome, since there are now MULTIPLE technical possibilities for measuring CO2 during a colonoscopy.

I do regard end-tidal CO2 monitoring as the standard of care for colonoscopy with propofol, and for all such GAs with propofol, anywhere we give it.

-- From: Beverly K. Philip, M.D., Boston, Massachusetts

Reply 3

I agree and would like to add that sedation to the point of GA is not needed for patient comfort & safe conduct of colonoscopy/EGD. Whether it stems from our end, by telling the gastroenterologist that their patient will be completely asleep for the procedure or from their end where they have guaranteed to their patient that they will be asleep - whichever - it has created a potentially unsafe environment. Maybe it's a NYC paranoia, but both of the gastroenterologists that I work with and I tell our patients that they will NOT be asleep, they will hear us talking but they will be comfortable. Patients tell me afterwards that they were more awake this time but that it was fine.  I would advise offices that perform endoscopy with sedation and do not choose to use ETCO2 monitoring to provide only light sedation.

-- From: Melinda Mingus, M.D., Manhattan, NY

Question 2:

What guidelines are ASCs following regarding sleep apnea patients?  Specifically for mild and moderate sleep apnea patients having peripheral surgery, how long post surgery do they remain in the ASC?

-- From: Richard F. Gargiulo, M.D. (Rgargiulo@virtua.org)

Reply

I would refer you to the ASA practice guidelines on this topic for which I have attached the link below. Hope this helps.

www.asahq.org/publicationsAndServices/sleepapnea103105.pdf

?? -- THIS MONTH'S QUESTIONS -- ?? - TOP

Question 1:

What is the general consensus for fluid replacement during tumescent liposuction on healthy individuals?

-- From: Jean White, M.D., Atlanta, GA (jeanwhite@mac.com)

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

Extra-1 Acupressure for Children Undergoing Anesthesia.[Miscellaneous Article]
Wang, Shu-Ming MD *; Escalera, Sandra MD +; Lin, Eric C. BS *; Maranets, Inna MD *; Kain, Zeev N. MD *+++[S][P]
Anesthesia & Analgesia. 107(3):811-816, September 2008.

BACKGROUND: Acupuncture and related techniques have been used as adjuncts for perioperative anesthesia management. We examined whether acupressure in the Extra-1 (Yin-Tang) point would result in decreased preprocedural anxiety and reduced intraprocedural propofol requirements in a group of children undergoing endoscopic procedures.
METHODS: Fifty-two children were randomized to receive acupressure bead intervention either at the Extra-1 acupuncture point or at a sham point. A Bispectral Index (BIS) monitor was applied to all children before the onset of the intervention. Anxiety was assessed at baseline and before entrance to the operating room. Anesthetic techniques were standardized and maintained with IV propofol infusion titrated to keep BIS values of 40-60.
RESULTS: We found that after the intervention, children in the Extra-1 group experienced reduced anxiety whereas children in the sham group experienced increased anxiety (-9% [-3 to -15] vs 2% [-6 to 7.4], P = 0.012). In contrast, no significant changes in BIS values were observed in the preprocedural waiting period between groups (P = ns). We also found that total intraprocedural propofol requirements did not differ between the two study groups (214 +/- 76 [mu]g [middle dot] kg-1 [middle dot] min-1 vs 229 +/- 95 [mu]g [middle dot] kg-1 [middle dot] min-1, P = 0.52).
CONCLUSIONS: We conclude that acupressure bead intervention at Extra-1 acupoint reduces preprocedural anxiety in children undergoing endoscopic procedures. This intervention, however, has no impact on BIS values or intraprocedural propofol requirements.

The Dose-Response of Nitrous Oxide in Postoperative Nausea in Patients Undergoing Gynecologic Laparoscopic Surgery: A Preliminary Study. [Miscellaneous]
Mraovic, Boris MD *; Simurina, Tatjana MD, MSc +; Sonicki, Zdenko MD, PhD ++; Skitarelic, Neven MD, PhD [S]; Gan, Tong J. MD [//]
Anesthesia & Analgesia. 107(3):818-823, September 2008.

BACKGROUND: Whether nitrous oxide (N2O) increases the incidence of postoperative nausea and vomiting (PONV) after laparoscopic gynecologic surgery is still controversial, which may be due to the administration of different concentrations of inspired N2O. We investigated whether N2O results in a dose-response increase in PONV.
METHODS: Patients undergoing gynecologic laparoscopic surgery were randomized to receive 30% oxygen with air (G0, n = 46), 50% N2O with oxygen (G50, n = 46), or 70% N2O with oxygen (G70, n = 45). A standardized general anesthetic was used with no PONV prophylaxis. Known risk factors for PONV were controlled. Metoclopramide was used as a rescue antiemetic. The incidence of nausea, vomiting, use of rescue antiemetic, and pain visual analog scale (VAS) score was measured at 2 and 24 h postoperatively.
RESULTS: Patient demographics were comparable, and there were no differences among groups regarding factors that may influence PONV. The incidence of PONV at 24 h was 33% (15 of 46) in the G0 group, 46% (21 of 46) in the G50 group, and 62% (28 of 45) in the G70 group (P = 0.018). Subgroup analysis revealed a difference between G0 versus G70 groups (P = 0.018), but no significant difference between G0 versus G50 groups and G50 versus G70 groups. The incidence of nausea showed a similar difference (G0 = 26%, G50 = 35%, and G70 = 56%; P = 0.012), but the incidence of vomiting was not different among the groups although there was a trend (G0 = 28%, G50 = 35%, and G70 = 42%; P = 0.377). The severity of nausea (measured by VAS 100 mm) was significantly increased with increasing N2O concentration (G0 = 10.9, G50 = 12.7, and G70 = 20.5; P = 0.027). The highest VAS score during 24 h was used for the analysis. There was no difference in the use of a rescue antiemetic among groups. Pain VAS scores and opioids consumption were not different among groups (at 2 and 24 h after surgery).
CONCLUSIONS: N2O increases the incidence of postoperative nausea after gynecologic laparoscopic surgery. This preliminary finding indicates that N2O may increase PONV in a dose-dependent fashion. A study with a sample size of >400 patients in each group would be necessary to demonstrate a statistically significant difference among each of these three groups. We do not recommend using a high concentration of N2O in this clinical setting.

The Duration of Intrathecal Bupivacaine Mixed with Lidocaine. [Miscellaneous]
Lee, Sung-Jin MD, PhD; Bai, Sun-Joon MD, PhD; Lee, Jong-Seok MD; Kim, Won-Ok MD; Shin, Yang-Sik MD, PhD; Lee, Ki-Young MD, PhD
Anesthesia & Analgesia. 107(3):824-827, September 2008.

BACKGROUND: Although spinal bupivacaine may have too long duration to be useful in the ambulatory setting, recent animal data suggest that lidocaine added to spinal bupivacaine may reduce the duration of bupivacaine spinal anesthesia. We explored whether lidocaine added to spinal bupivacaine could shorten the duration of bupivacaine spinal anesthesia in humans similarly to what has been reported in animals.
METHODS: Ninety patients presenting for transurethral resection of bladder tumor or prostate were assigned to one of three groups by double blind randomization to receive intrathecal 1.5 mL of hyperbaric 0.5% bupivacaine, plus 0.6 mL of one of three solutions: saline (Group I, n = 30, control), 1% lidocaine (Group II, n = 30), and 2% lidocaine (Group III, n = 30). Peak sensory block level, time to peak sensory block, times to two-segment, L1, and S2 regressions from peak sensory block, motor blocks at peak sensory block, L1, and S2 regressions, and postanesthesia care unit stay time (PACU time) were measured.
RESULTS: Times to peak sensory block were similar in all three groups. Times to two-segment, L1, and S2 regressions from peak sensory block, and PACU time were significantly reduced in Group II compared to Group I. Times to L1, S2 regressions, and PACU times in Group III were significantly prolonged.
CONCLUSIONS: We conclude that lidocaine (6 mg) mixed to spinal bupivacaine (7.5 mg) can shorten the duration of bupivacaine spinal anesthesia, therefore provide more rapid recovery from the spinal anesthesia compared to the same dose of bupivacaine (7.5 mg) alone.

An In-Vivo Metabolic Test for Detecting Malignant Hyperthermia Susceptibility in Humans: A Pilot Study. [Miscellaneous Article]
Schuster, Frank MD *; Metterlein, Thomas MD *; Negele, Sabrina MS *; Kranke, Peter MD *; Muellenbach, Ralf M. MD *; Schwemmer, Ulrich MD *; Roewer, Norbert MD *; Anetseder, Martin MD +
Anesthesia & Analgesia. 107(3):909-914, September 2008.

INTRODUCTION: In vitro contracture testing to diagnose malignant hyperthermia (MH) susceptibility requires a muscle biopsy, which may be associated with severe side effects for the patient. After investigation of several different protocols, we present a less invasive metabolic test that involves IM injection of caffeine and halothane, and subsequent measurement of interstitial lactate to differentiate between MH susceptible (MHS) and MH non-susceptible (MHN) individuals.
METHODS: Two microdialysis probes with attached microtubing for trigger injection were inserted into the lateral vastus muscle of eight previously diagnosed MHS patients (representing three genetic variants Gly2434Arg, Thr2206Met, and Arg614Cys), seven MHN patients, and seven control individuals. After equilibration and lactate baseline recording, a single bolus of 200 [mu]L caffeine 80 mM and a suspension of 200 [mu]L halothane 4%V/V in soy bean oil (triggers) were injected locally. Lactate was measured spectrophotometrically. Data are presented as medians and interquartile ranges.
RESULTS: Although baseline lactate values were similar in the investigated groups before trigger injection, caffeine increased local lactate in MHS patients significantly more (2.0 [1.8-2.6] mM) than in MHN (0.8 [0.6-1.1] mM) or in control individuals (0.8 [0.6-0.8 mM]). Similarly, halothane lead to a significant lactate increase in MHS compared to MHN and control individuals (8.6 [3.7-8.9] mM vs 0.9 [0.5-1.1] mM and 1.7 [0.9-2.3] mM, respectively). However, a relevant increase of lactate was observed in one MHN and in two control individuals. Systemic hemodynamic and metabolic variables did not differ between the investigated groups.
DISCUSSION: Metabolic monitoring of IM lactate after local caffeine and halothane injection may allow less invasive testing to detect MH susceptibility, without systemic side effects.

A Comparison Between Ultrasound-Guided Infraclavicular Block Using the "Double Bubble" Sign and Neurostimulation-Guided Axillary Block.[Report]
Tran, De Q. H. MD, FRCPC; Clemente, Antonio MD; Tran, Don Q. MD; Finlayson, Roderick J. MD, FRCPC
Anesthesia & Analgesia. 107(3):1075-1078, September 2008.

BACKGROUND: Ultrasound-guided infraclavicular block can be performed using the double bubble sign. Previously described, the double bubble sign consists superiorly of the axillary artery (in short axis) superimposed on an inferior bubble created by local anesthetic injection. In this study, we compared this new method of brachial plexus anesthesia to the traditional triple-nerve stimulation axillary block.
METHODS: Seventy patients were randomized to receive a single-injection, ultrasound-guided infraclavicular block using the double bubble sign or a triple-stimulation axillary block.
RESULTS: Both methods produced similar success rates (89%-91%). However, infraclavicular blocks were associated with a shorter performance time (3.90 +/- 2.27 vs 8.03 +/- 3.92 min; P < 0.001) and lower block-related pain scores (2.70 +/- 2.02 vs 4.17 +/- 2.57 on a 0-10 scale; P = 0.01).
CONCLUSION: Compared to triple-stimulation axillary block, ultrasound-guided infraclavicular block using the double bubble sign provided a similar efficacy, a shorter performance time and lower procedural pain scores.

ANESTHESIOLOGY - TOP

Intraoperative Acceleromyographic Monitoring Reduces the Risk of Residual Neuromuscular Blockade and Adverse Respiratory Events in the Postanesthesia Care Unit.
Murphy, Glenn S. M.D. ; Szokol, Joseph W. M.D. ; Marymont, Jesse H. M.D. ; Greenberg, Steven B. M.D. ; Avram, Michael J. Ph.D. ; Vender, Jeffery S. M.D.; Nisman, Margarita B.A. 
Anesthesiology. 109(3):389-398, September 2008.

Abstract:
Background: Incomplete recovery from neuromuscular blockade in the postanesthesia care unit (PACU) may contribute to adverse postoperative respiratory events. This study determined the incidence and degree of residual neuromuscular blockade in patients randomized to conventional qualitative train-of-four (TOF) monitoring or quantitative acceleromyographic monitoring. The incidence of adverse respiratory events in the PACU was also evaluated.
Methods: One hundred eighty-five patients were randomized to intraoperative acceleromyographic monitoring (acceleromyography group) or qualitative TOF monitoring (TOF group). Anesthetic management was standardized. TOF patients were extubated when standard criteria were met and no fade was observed during TOF stimulation. Acceleromyography patients had a TOF ratio of greater than 0.80 as an additional extubation criterion. Upon arrival in the PACU, TOF ratios of both groups were measured with acceleromyography. Adverse respiratory events during transport to the PACU and during the first 30 min of PACU admission were also recorded.
Results: A lower frequency of residual neuromuscular blockade in the PACU (TOF ratio <= 0.9) was observed in the acceleromyography group (4.5%) compared with the conventional TOF group (30.0%; P < 0.0001). During transport to the PACU, fewer acceleromyography patients developed arterial oxygen saturation values, measured by pulse oximetry, of less than 90% (0%) or airway obstruction (0%) compared with TOF patients (21.1% and 11.1%, respectively; P < 0.002). The incidence, severity, and duration of hypoxemic events during the first 30 min of PACU admission were less in the acceleromyography group (all P < 0.0001).
Conclusions: Incomplete neuromuscular recovery can be minimized with acceleromyographic monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intraoperative acceleromyography use.

Transmission of Pathogenic Bacterial Organisms in the Anesthesia Work Area.
Loftus, Randy W. M.D. ; Koff, Matthew D. M.D. ; Burchman, Corey C. M.D. ; Schwartzman, Joseph D. M.D. ; Thorum, Valerie M.T. (A.S.C.P.) ; Read, Megan E. M.T. (A.S.C.P.) ; Wood, Tammara A. M.T., (A.M.T.) ; Beach, Michael L. M.D., Ph.D.
Anesthesiology. 109(3):399-407, September 2008.

Abstract:
Background: The current prevalence of hospital-acquired infections and evolving amplification of bacterial resistance are major public health concerns. A heightened awareness of intraoperative transmission of potentially pathogenic bacterial organisms may lead to implementation of effective preventative measures.
Methods: Sixty-one operative suites were randomly selected for analysis. Sterile intravenous stopcock sets and two sites on the anesthesia machine were decontaminated and cultured aseptically at baseline and at case completion. The primary outcome was the presence of a positive culture on the previously sterile patient stopcock set. Secondary outcomes were the number of colonies per surface area sampled on the anesthesia machine, species identification, and antibiotic susceptibility of isolated organisms.
Results: Bacterial contamination of the anesthesia work area increased significantly at the case conclusion, with a mean difference of 115 colonies per surface area sampled (95% confidence interval [CI], 62-169; P < 0.001). Transmission of bacterial organisms, including vancomycin-resistant enterococcus, to intravenous stopcock sets occurred in 32% (95% CI, 20.6-44.9%) of cases. Highly contaminated work areas increased the odds of stopcock contamination by 4.7 (95% CI, 1.42-15.42; P = 0.011). Contaminated intravenous tubing was associated with a trend toward increased nosocomial infection rates (odds ratio, 3.08; 95% CI, 0.56-17.5; P = 0.11) and with an increase in mortality (95% CI odds ratio, 1.11-[infinity]; P = 0.0395).
Conclusions: Potentially pathogenic, multidrug-resistant bacterial organisms are transmitted during the practice of general anesthesia to both the anesthesia work area and intravenous stopcock sets. Implementation of infection control measures in this area may help to reduce both the evolving problem of increasing bacterial resistance and the development of life-threatening infectious complications.

Observations on Surgical Demand Time Series: Detection and Resolution of Holiday Variance.
Moore, Ian C. M.A.Sc. ; Strum, David P. M.D. ; Vargas, Luis G. Ph.D. ; Thomson, David J. Ph.D., P.Stat., C.Stat., P.Eng.
Anesthesiology. 109(3):408-416, September 2008.

Abstract:
Background: Surgical scheduling is complicated by both naturally occurring and human-induced variability in the demand for surgical services. Surgical demand time series are decomposed into periodic, lagged, and linear trends with frequent occurrences of nonconstant variations in mean and variance. The authors used time series methods to model surgical demand time series in order to improve the scheduling of scarce surgical resources.
Methods: With institutional approval, the authors studied 47,752 surgeries undertaken at a large academic medical center. They initially extracted periodic information from the time series using two frequency domain techniques: the harmonic F test and the multitaper test. They subsequently extracted lagged (correlated) behavior using a seasonal autoregressive integrated moving average model. Finally, they used moving variance filters on the residuals to identify variance in the time series that coincided with major US holidays.
Results: Linear terms such as periodic cycles, trends, and daily and weekly lags explained 80% of the variance in the raw time series. In the residuals, the authors used moving variance filters to detect nonlinear variance artifacts that correlated with surgical activities on specific US holidays.
Conclusions: After extracting linear terms, the remaining variance was attributable to a combination of nonlinear and unexplained random events. The authors used the term holiday variance to describe a specific nonlinear disturbance in surgical demand attributable to statutory US holidays. Resolving these holiday variances may assist in management and scheduling of scarce surgical personnel and resources.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Are women more sensitive to a pre-curarization dose of rocuronium than men?
T. Mencke , S. Soltesz , M. Sauer  , A. Menzebach , M. Silomon and G. Nöldge-Schomburg
Acta Anaesthesiologica Scandinavica 2008 Volume 52 Issue 8, Pages 1051 - 1055

Background: There is increasing evidence that there are gender-related differences in the pharmacodynamics of neuromuscular blocking drugs. However, it is not known whether gender influences the pharmacodynamics of a pre-curarizing dose.
Methods: In the first part, we measured the neuromuscular blockade after administration of rocuronium 0.03 mg/kg (10% of ED95) after induction of anaesthesia in 20 patients (10 female and 10 male patients) by electromyography. In the second part, 40 female and 40 male patients were observed for signs and symptoms of muscle weakness 2.5 min after injection of rocuronium 0.03 mg/kg before loss of consciousness. Succinylcholine-associated post-operative myalgia (POM) was also assessed.
Results: Median twitch heights were comparable between the two groups: 95.5 (range: 85–97; female) vs. 96.0 (range: 85–99; male), (NS). Train-of-four ratios were 97.5 (range: 64–100; female) vs. 99.0 (range: 52–100; male) (NS). Signs and symptoms of muscle weakness were observed in 64 (80%) patients, but there were no gender-related differences. The incidence and severity of POM did not differ significantly between the study groups.
Conclusions: Pre-curarization with rocuronium 0.03 mg/kg affected men and women equally. Nor was the incidence and the severity of muscle weakness affected by gender.

Effect of oral gabapentin on the intraocular pressure and haemodynamic responses induced by tracheal intubation
F. N. Kaya , B. Yavascaoglu , M. Baykara , G. T. Altun  , N. Gülhan  and F. Ata 
Acta Anaesthesiologica Scandinavica 2008 Volume 52 Issue 8, Pages 1076 - 1080

Background: Laryngoscopy and tracheal intubation may cause undesirable increases in blood pressure, heart rate (HR) and intraocular pressure (IOP). Gabapentin has been used effectively to attenuate the pressor response to laryngoscopy and tracheal intubation. We investigated whether the pre-treatment with gabapentin attenuates the IOP in addition to a haemodynamic response to tracheal intubation.
Methods: Sixty ASA I–II patients were randomly allocated into two groups who received either gabapentin (800 mg) or placebo 2 h before surgery. IOP, mean arterial pressure (MAP) and HR were measured before and after the induction of anaesthesia as well as at 0, 1, 3, 5, 10 and 15 min following intubation.
Results: IOP and MAP increased from baseline immediately after intubation in the placebo group (P=0.001 and 0.002, respectively). When compared with the placebo group, IOP values of the gabapentin group were significantly lower for the first 15 min after tracheal intubation (P=0.002 at 0 min, P=0.006 at 1 min, P<0.001 at 3 min, P<0.001 at 5 min, P<0.001 at 10 min and P=0.003 at 15 min) while MAP was lower in the first 10 min (P=0.001 at 0 min, P=0.002 at 1 min, P<0.001 at 3 min, P<0.001 at 5 min and P=0.028 at 10 min). These results showed that gabapentin effectively suppresses the increase in IOP secondary to endotracheal intubation and attenuates the increases in MAP.
Conclusion: It is suggested that gabapentin is a useful adjuvant in order to prevent an increase in the IOP in response to laryngoscopy and tracheal intubation.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room
A. F. Smith, C. Pope, D. Goodwin and M. Mort
British Journal of Anaesthesia 2008 101(3):332-337

Background: We aimed to describe how anaesthetists hand over information and professional responsibility to nurses in the operating theatre recovery room.
Methods: We carried out non-participant practice observation and in-depth interviews with practitioners working in the recovery room of an English hospital and used qualitative methods to analyse the resulting transcripts.
Results: We observed 45 handovers taking place between 17 anaesthetists and 15 nurses in the recovery room of the operating theatre suite. These took place in an environment that is event-driven, time-pressured, and prone to concurrent distractions. Anaesthetists and nurses often had differing expectations of the content and timing of information transfer. The point at which transfer of responsibility for the patient occurred during the handover process was variable and depended not only on the condition of the patient but also on the professional relationship between the nurse and doctor concerned. Handover also provided an ‘audit point’ in care where the patient’s intraoperative progress was reviewed and plans were made for further management. Here, as in the transfer of responsibility, we found evidence that nurses play a greater role in defining the limits of anaesthetists’ practice than might be expected.
Conclusions: Patient handovers in the recovery room are largely informal, but nevertheless show many inherent tensions, both professional and organizational. Although formalized handover procedures are often advocated for the promotion of safety, we suggest that they are likely to work best when the informal elements, and the cultural factors underlying them, are acknowledged.

Comparison of three scores to screen for delirium in the recovery room
F. M. Radtke, M. Franck, M. Schneider, A. Luetz, M. Seeling, A. Heinz, K. D. Wernecke and C. D. Spies
British Journal of Anaesthesia 2008 101(3):338-343

Background: Delirium is often seen in the recovery room and is a predictor for postoperative delirium on the ward. However, monitoring to detect delirium in the recovery room as a basic prerequisite for early intervention is rarely used. The aim of this study was to identify a valid and easy-to-use test for early screening of delirium in the recovery room.
Methods: One hundred and fifty-four adult patients admitted to the recovery room during regular working hours were included. A screening assessment for delirium was performed in the recovery room by a trained research team at the time when the patient was judged to be ‘ready for discharge’. Delirium monitoring was performed with the Confusion Assessment Method (CAM), the Delirium Detection Score (DDS), and the Nursing Delirium Screening Scale (Nu-DESC). The Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria were used as the gold standard.
Results: Delirium in the recovery room was seen in 21 patients (14%) with the DSM-IV criteria, in 11 patients (7%) with the CAM, in four patients (3%) with the DDS, and in 37 patients (24%) with the Nu-DESC. Sensitivity and specificity were 0.43 and 0.98 for the CAM, 0.14 and 0.99 for the DDS, and 0.95 and 0.87 for the Nu-DESC, respectively.
Conclusions: All scores used were very specific, but the CAM and the DDS were less sensitive compared with the gold standard. Overall, the Nu-DESC was the most sensitive test in the recovery room to detect delirium.

Effect of intra-articular dexmedetomidine on postoperative analgesia after arthroscopic knee surgery
R. R. Al-Metwalli, H. A. Mowafi, S. A. Ismail, A. K. Siddiqui, A. M. Al-Ghamdi, M. A. Shafi and A.-R. El-Saleh
British Journal of Anaesthesia 2008 101(3):395-399

Background: Alpha-2-adrenergic agonists have peripheral analgesic effects. We have assessed the potential analgesic effect of dexmedetomidine after intra-articular administration in arthroscopic knee surgery.
Methods: Sixty patients undergoing arthroscopic knee surgery were randomly assigned into three groups in a double-blind placebo controlled study. The control group received i.v. and intra-articular saline, the intra-articular group received i.v. saline and intra-articular dexmedetomidine, and the i.v. group received i.v. dexmedetomidine and intra-articular saline. Haemodynamic changes, pain visual analogue scale (VAS), sedation score, the time to first postoperative analgesic request, and the total postoperative analgesic use during the first 24 h were evaluated.
Results: Dexmedetomidine administration resulted in a significant reduction in pain scores for 6 h after operation in the intra-articular group but only for 1 h in the i.v. group. The time to first postoperative analgesic request was longer in the intra-articular group [312.0 (SD 120.7) min] compared with the control group [71.0 (50.1) min] and the i.v. group [102.1 (54.4) min] (P<0.001). Total diclofenac requirement was significantly lower in the intra-articular group [90.0 (46.2) mg] than in the control group [165.0 (52.2) mg] and in the i.v. group [129.3 (54.3) mg] (P<0.05).
Conclusions: Intra-articular dexmedetomidine enhanced postoperative analgesia after arthroscopic knee surgery, with an increased time to first analgesic request and a decreased need for postoperative analgesia.

Avoiding propofol injection pain in children: a prospective, randomized, double-blinded, placebo-controlled study
A. Rochette, A. F. Hocquet, C. Dadure, D. Boufroukh, O. Raux, J. F. Lubrano, S. Bringuier and X. Capdevila
British Journal of Anaesthesia 2008 101(3):390-394

Background: Pain on injection limits the use of propofol in children. The combination of lidocaine and propofol is widely used to reduce pain. A new solvent [medium-chain triglyceride (mct)/long-chain triglyceride (lct)] has been advocated to be less painful than standard (lct) propofol in adults, but no information is available of its usefulness in pre-school children. We designed a prospective, randomized, double-blinded, placebo-controlled study to assess injection pain with two different propofol emulsions, each given with or without lidocaine in children <7 yr.
Methods: A total of 160 ASA I–III children were randomly assigned to receive lct–propofol or mct/lct–propofol, 5 mg kg–1, with lidocaine 10 mg ml–1 or saline. The site and size of venous cannulation and restlessness before injection were recorded in each patient. A pain score graded 0–6 was established based on spontaneous verbal and motor reaction during injection, each graded 0–3. Kruskall–Wallis and Mann–Whitney tests were used for statistical analysis.
Results: Median pain scores decreased in all groups compared with lct–propofol–saline (P<0.001) and were least in the lct/mct–propofol–lidocaine group (P<0.001). Painless injection (score, 0–2) occurred in 92.5% of patients in the mct/lct–propofol–lidocaine group compared with 41–77% in the others (P<0.001).
Conclusions: Mct/lct–propofol caused significantly less pain than lct–propofol in preschool children. Mixing of lidocaine with mct/lct–propofol resulted in a further significant decrease, virtually eliminating the pain on injection.

CANADIAN JOURNAL OF ANESTHESIA - TOP

TrachlightTM management of succinylcholine-induced subluxation of the Temporo-mandibular joint: a case report and review of the literature
Amanda Roze des Ordons, MD and Derek R. Townsend, MD FRCPC
Canadian Journal of Anesthesia 55:616-621 (2008)

Purpose: We present a case of spontaneous subluxation of the Temporo-mandibular joint (TMJ) induced by succinylcholine, to compare our experience with previous cases reported in the literature, and to review the pathophysiology, preoperative screening, and intraoperative management of TMJ instability.
Clinical features: A 39-yr-old female with primary hyperparathyroidism and a normal airway examination presented for elective parathyroidectomy. Following induction of anesthesia and the administration of succinylcholine prior to jaw manipulation, her mouth could not be opened, and we suspected spontaneous subluxation of the TMJ. We secured the airway with the use of a TrachlightTM and, subsequently, reduced the joint. Postoperatively, a history of mild TMJ-related symptoms was elicited.
Conclusion: Instability of the TMJ is not uncommon, and has several implications for airway management, highlighting the importance of preoperative screening. Limited mouth opening, due to spontaneous subluxation of the TMJ following succinylcholine-induced muscle relaxation in the absence of airway manipulation, has only twice been reported in the literature. This report highlights how tracheal intubation may be accomplished using the TrachlightTM, in order to secure the airway prior to reduction of the subluxed joint.

PUB MED - TOP

Desynchronization of Daily Rest-Activity Rhythm in the Days Following Light Propofol Anesthesia for Colonoscopy.
Dispersyn G, Touitou Y, Coste O, Jouffroy L, Lleu J, Challet E, Pain L.
Clin Pharmacol Ther. 2008 Sep 17. [Epub ahead of print]

[1] 1Faculté de Médecine Pierre et Marie Curie, Service de biochimie médicale et biologie moléculaire, Paris, France [2] 2Institut de Médecine Aérospatiale du Service de Santé des Armées, Bretigny-sur-Orge, France [3] 3Institut National de la Santé et de la Recherche Médicale U666 (GRERCA), Centre de Recherche en Biomédecine de Strasbourg, Faculté de Médecine, Université de Strasbourg, and Centre Hospitalier Régional Universitaire de Strasbourg, Strasbourg, France.

Anesthesia and surgery are associated with fatigue and sleep disorders, suggestive of disturbance of the circadian rest-activity rhythm. Previous studies on circadian rhythm disturbance were focused on patients undergoing general anesthesia associated with surgery. This does not permit one to draw valid conclusions about the effects of general anesthesia per se on circadian rhythms. Our study was set up to determine the impact of a hypnotic dose of propofol on the circadian rest-activity rhythm in humans under real-life conditions. Seventeen healthy subjects scheduled to receive light propofol anesthesia for ambulatory colonoscopy were investigated. Their rest-activity rhythms were assessed using actigraphic monitoring. Diurnal rest was increased, whereas nocturnal sleep was unchanged in the days following anesthesia. Nonparametric analyses showed a decrease in the strength of coupling of the rhythm to stable environmental zeitgebers and increase of fragmentation of the rhythm after anesthesia. Light general anesthesia itself impairs synchronization of the circadian rest-activity rhythm to local time in patients by acting directly on the circadian clock.Clinical Pharmacology &#38; Therapeutics (2008); doi:10.1038/clpt.2008.179.

Continuous peripheral nerve blocks in clinical practice.
Capdevila X, Ponrouch M, Choquet O.
Curr Opin Anaesthesiol. 2008 Oct;21(5):619-23.

PURPOSE OF REVIEW: The present review highlights new insights into indications and guidance during procedures for continuous peripheral nerve blocks.
RECENT FINDINGS: Continuous peripheral nerve blocks consistently provide better analgesia than traditional systemic opioid-based analgesia. The literature shows that continuous peripheral nerve blocks prolong site-specific local anesthetic delivery in the outpatient setting, allow optimal analgesia, have minimal side effects, and avoid premature regression of an analgesic block. Furthermore, an improvement in patients' health-related quality of life or outcome benefits has been demonstrated. It appears that continuous peripheral nerve blocks are generally superior to intraarticular local anesthetic infusion for immediate postoperative pain, but new data demonstrate that, apart from a multimodal analgesia regimen, periarticular and intraarticular application of local anesthetics can improve early postoperative analgesia and mobilization. Finally, it seems that, only for interscalene and popliteal sciatic nerve blocks, the use of stimulating catheters slightly decreases visual analog scale scores for postoperative pain and intravenous opioid rescue analgesia. Ultrasound guidance offers the potential advantage to confirm catheter tip location.
SUMMARY: Continuous peripheral nerve blocks are essential in the perioperative anesthetic management of in-hospital or ambulatory patients. Ultrasound guidance and stimulating catheters can help anesthetists during the procedure.

Fasting times in caregivers of children presenting for ambulatory surgery.
Farooq M, Tan , Crowe S.
Paediatr Anaesth. 2008 Sep;18(9):820-2.

BACKGROUND: It has been the anecdotal experience in this unit that many parents and guardians of children presenting for day-case surgery also fast along with their child for prolonged periods of time. There have been several episodes of parents feeling dizzy or nauseated on leaving the anesthetic room after induction of anesthesia, and many incidents of fainting in recovery when collecting their child. Our purpose was to investigate this theme further, by auditing the fasting times of caregivers coming to the induction room over a 3-month period. This information has not been previously described in the literature.
METHODS: We carried out a prospective audit of current practice. Data were collected by questionnaire, which caregivers were requested to complete in the holding area, after the child was checked in for theatre.
RESULTS: Two hundred and fifty-seven caregivers fasted for 0-6 h and 223 fasted for >6 h. One hundred and fourteen caregivers fasted for 7-12 h and 109 caregivers fasted between 13 and 19 h.
CONCLUSIONS: A large proportion of parents choose to fast with their children. Some caregivers fast for long periods. In general, this does not cause any ill effects, although some parents missed routine medications while fasting.

Factors associated with delayed postsurgical voiding interval in ambulatory spinal anesthesia patients: a prospective cohort study in 3 types of surgery.
Gil MJ, Gómez AE, Vargas DB, Garcia EM, Daros FN, Tugas EI, Paises AA, Pi-Siques
Am J Surg. 2008 Aug 22. [Epub ahead of print]

BACKGROUND: Spinal anesthesia has been considered inappropriate for ambulatory surgery patients because of concern about voiding dysfunction. The purpose of this study was to analyze the relationship between voiding interval and type of surgery under spinal anesthesia with lidocaine and to identify other nonanesthetic risk factors for delayed voiding.
PATIENTS AND METHODS: A prospective study of 406 patients undergoing to ambulatory surgery under spinal anesthesia with lidocaine was performed. Voiding interval was defined as the time in minutes from the injection of local anesthetic to the patient's first spontaneous voiding. Univariate and multivariate linear regression models were constructed to identify risk factors associated with length of voiding interval.
RESULTS: A total of 187 patients underwent herniorrhaphy; 187 patients underwent lower limb surgery; and 32 patients went benign anorectal surgery. The mean +/- sd voiding interval was 230 +/- 50.5 minutes. Factors associated with length of voiding interval in the univariate analysis were sex, body mass index (BMI), type and duration of surgery, lidocaine dose, and volume of fluid administered. Factors that remained significant in the multivariate model were sex, BMI, lidocaine dose and type of surgery: spontaneous voiding came later after inguinal herniorrhaphy surgery than after lower-limb surgery (regression coefficient 20 minutes; 95% confidence interval 11.5-29.8). Multivariate models performed for each type of surgery separately identified sex and lidocaine dose as factors related to length of voiding interval in all types of surgery.
CONCLUSIONS: A longer voiding interval was associated with inguinal herniorrhaphy, spinal lidocaine dose, and male sex.

Pain Relief by Continuous Intraperitoneal Nebulization of Ropivacaine during Gynecologic Laparoscopic Surgery-A Randomized Study and Review of the Literature.
Kaufman Y, Hirsch I, Ostrovsky L, Klein O, Shnaider I, Khoury E, Pizov R, Lissak A.
J Minim Invasive Gynecol. 2008 Sep-Oct;15(5):554-8.

STUDY OBJECTIVE: To evaluate the efficacy of intraperitoneal nebulization of ropivacaine on pain relief during and after gynecologic laparoscopic procedures including a review of the literature. DESIGN: Double-blinded, randomized, controlled, clinical trial (Canadian Task Force classification I).
SETTING: University hospital ambulatory gynecoendoscopic department.
PATIENTS: Forty patients (20 patients in each arm) undergoing elective gynecologic same-day outpatient laparoscopic surgery including unilateral/bilateral salpingo-oophorectomy or unilateral/bilateral ovarian cystectomy.
INTERVENTIONS: The study group received 10 mL of 1% ropivacaine and the control group received 10 mL of sterile water by intraperitoneal nebulization. During surgery, vital signs were recorded and summarized. Postoperatively patients were followed up for 24 hours including visual analog scale scores and analgesic use.
MEASUREMENTS AND MAIN RESULTS: No significant differences existed between the groups during surgery and at the recovery department in terms of arterial blood pressure (p = .42) or heart rate (p = .60). Regarding postoperative analgesia, no difference existed between the groups in terms of morphine consumption (p = .52) or other analgesics (p = .53). No significant difference existed between the groups in postoperative visual analog scale scores including visceral, abdominal wall, and shoulder pain during rest and during cough at the different time frames (30, 60, and 120 minutes and 6 and 24 hours after surgery).
CONCLUSION: Our study is the first to examine the effects of intraperitoneal nebulization of ropivacaine throughout laparoscopic gynecologic procedures on patients undergoing general anesthesia. Nebulization of 100 mg of ropivacaine under our specific regimen of anesthesia does not improve patients' outcome in terms of intraoperative and postoperative pain along with consumption of analgesics. Further research with other regimens is required.

Obesity as a risk factor for unanticipated admissions after ambulatory surgery.
Hofer RE, Kai T, Decker PA, Warner DO.
Mayo Clin Proc. 2008 Aug;83(8):908-16.

OBJECTIVE: To test the hypothesis that obesity is an independent risk factor for unplanned hospital admission or readmission among patients scheduled for ambulatory surgery in a tertiary medical center.
PATIENTS AND METHODS: Existing databases were used to identify 235 obese patients (body mass index [BMI] >40) scheduled for ambulatory surgery from January 2, 2002, through December 31, 2003, at Mayo Clinic's site in Rochester, MN. Each patient was matched to a normal-weight control (BMI <25) by age, sex, surgical procedure, type of anesthesia, and date of surgery, and the medical records of all patients were reviewed. Conditional logistic regression analysis was performed to assess whether obesity is an independent risk factor for unplanned postoperative hospital admission. In all cases, 2-sided tests were performed. P<.05 was considered statistically significant.
RESULTS: Obese patients (mean +/- SD BMI, 44+/-4) were matched with control patients (mean +/- SD BMI, 23+/-2). Comorbidity was more frequent in the obese cohort. The frequency of unplanned hospital admission did not differ between groups: 61 obese patients (26.0%) and 52 control patients (22.1%) were admitted (odds ratio, 1.3; 95% confidence interval, 0.8-2.0; P=.30).
CONCLUSION: Obesity is not a significant independent risk factor for unplanned admission after ambulatory surgery, suggesting that obesity per se should not prevent ambulatory surgery from being scheduled.

Anesthesia outside the operating room in the office-based setting.
Perrott DH.
Curr Opin Anaesthesiol. 2008 Aug;21(4):480-5.

PURPOSE OF REVIEW: The majority of anesthesia services provided outside the operating room or ambulatory surgery center is in the office-based setting. This review will focus on three areas that are critical to office-based anesthesia: safety, quality of care and patient satisfaction.
RECENT FINDINGS: Data obtained from the State of Florida office-based surgery adverse event data repository indicate that, even with The American Society of Anesthesiology I patients, there remains opportunity to improve outcomes. Careful patient selection remains critical, especially the patient with a history of sleep apnea. While general anesthesia remains the gold standard, expanded use of local anesthesia, regional blocks and variation on sedation techniques offer alternatives that may reduce risks but still maintain a high quality of care. While there is limited office-based anesthesia satisfaction data, limiting postoperative nausea and vomiting remains a major patient satisfier of which an occurrence rate of zero may be possible.
SUMMARY: There is rapid growth for the need of safe and high quality office-based anesthesia. To meet these needs, a special set of skills is required, which may require expanded exposure and experience during training. An office-based anesthesia central data repository is needed for benchmarking and identifying areas for improvement. Finally, with advances in surgical technology, there is a need for focused research in office-based anesthetic techniques and modalities and patient satisfaction.

WS FOR PATIENTS - TOP

To find answers to Frequently Asked Questions, go to our Patient Information Page on the SAMBA Web site. Our Patient Information Page includes a large variety of frequently asked questions about ambulatory anesthesia, with replies written especially for patients. On this page, patients can also ask their own questions.

SPONSORS - TOP


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