The February 2012 Digital Edition of Anesthesiology News by McMahon Group

A @ lways Ane Av sth aila esio ble log Onl yNe ine ws. com

The Independent Monthly Newspaper for Anesthesiologists AnesthesiologyNews.com • F e b r u a r y 2 0 1 2 • Volume 38 Number 2

Ultrasound May Add No Gain For Pain

he use of ultrasound in regional anesthesia does not translate into better pain outcomes when compared with traditional techniques, according to a review of 23 randomized controlled trials published in the September 2011 issue of Anesthesia & Analgesia (113:596-604).

Seeing the (Green) Light In the OR Researchers take on poor visibility during surgery

perating rooms that are too dark should go green, according to a new study that purposely sheds little light on a safety issue. The research, presented at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 1660), found that rather than shutting off the overhead fixtures in the OR—a common practice that gives surgeons the clearest view of monitors—bathing the room in a dim green light accomplishes the same goal more safely and without forcing others to feel as if they are working in a tomb.

see ultrasound page 8

see green page 16

Laughter, and Tears, on the Way To Safer Anesthesia (Part 1) Gerald Zeitlin, MD, graduated from the University of Cambridge in England, in 1954. After qualification as a physician in 1958, he became intrigued by the power of anesthesiologists in saving the lives of young patients dying of poliomyelitis. After practicing in England for six years, Dr. Zeitlin accepted a position at the Peter Bent Brigham Hospital in Boston. Dr. Zeitlin has served as president of the Massachusetts Society of Anesthesiologists, delegate to the House of Delegates of the American Society of Anesthesiologists and reviewer for the American Society of Anesthesiologists Closed Claims Project.

INside

The following is the first installment of an excerpt from his new book, “Laughing and Crying About Anesthesia: A Memoir of Risk and Safety” (Allandale Publishers, 2011). Dr. Zeitlin will donate half the proceeds of the sales of the book, which he wrote in part “for a non-medical audience to help them understand what we do,” to the Foundation for Anesthesia Education and Research.

et’s return to the Whittington Hospital on the high and leafy hills of North London. The Senior Consultant in Anaesthesia was

see laughing page 12

06 | COMMENTARY How hospital closings may affect the anesthesia job market.

10 | Pain Medicine A better approach to injections for back pain.

18 | CLinical Anesthesiology Licorice gargle eases post-intubation irritation.

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23 | CME—PreAnesthetic Assessment Lesson 296: PreAnesthetic Assessment Of the Elderly Patient With Coexisting Alcohol or Substance Use Disorder

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4 I AnesthesiologyNews.com

February 2012

Discuss these and other articles @ AnesthesiologyNews.com.

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February 2012

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substantial effect on a very real

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1. Survey Finds ‘Discouraging’ Injection Habits Among Anesthesiologists

complication. … So,

2. Bar-Code Scanning Can Fix ‘Black Hole’ Of OR Drug Safety 3. OR Itself May Promote Bacteria 4. Is QT Prolongation a Valid Reason To Abandon Zofran?

use it?

5. Electronic Distraction: An Unmeasured Variable In Modern Medicine

See article on page 18.

Alan Kaye, PhD, MD, New Orleans, LA

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February 2012

AnesthesiologyNews.com I 5

IN BRIEF Supraglottic Airways Prove Super Easy To Use

or anesthesiologists, handling a supraglottic airway (SGA) is second nature. But what about clinicians with no training in airway care? Even in the hands of the “airway naive,” SGAs are remarkably effective, according to new findings from researchers in Europe and the United States. For the study, Kurt Rützler, MD, of the Medical University of Vienna, Austria, and colleagues asked 50 medical laypeople with no previous training in airway management to perform simulated intubations using six SGAs, as well as with mouth-to-mouth ventilation (Table). They then repeated the tests three months later. At both time points, participants achieved 100% success rates with the six SGAs compared with 86% and 84% for mouth-to-mouth and 74% and 64% for endotracheal intubation. Ventilation with the SGAs also proved markedly faster than either mouth-to-mouth or endotracheal intubation. “The [SGAs] were much more effective than endotracheal intubation, which often failed, and were even superior to mouth-to-mouth ventilation,” the researchers reported. SGAs “may thus be an appropriate firstline approach to field ventilation.” The researchers presented their findings at the 2011 PostGraduate Assembly in Anesthesiology (abstract P-9028).

Table. Levels of Significance Comparing Time-to-ventilation for Various Airway Devices

Endotracheal Intubation

Mouth-to-mouth

<0.001

Combitube (Covidien)

<0.001

EasyTube (Teleflex)

<0.001

0.31

0.698

Fastrach (LMA)

<0.001

0.441

<0.001

Supreme (LMA)

<0.001

0.937

0.001

0.002

0.02

Laryngeal Tube (King Systems)

<0.001

0.073

<0.001

i-Gel (Intersurgical)

<0.001

0.073

<0.001

0.003

<0.001

Mouth-to-Mouth

Combitube

EasyTube

Fastrach

Supreme

Laryngeal Tube

0.319

0.449

P-values significant if ≤0.002.

JEFFREY 1 HOUR 15 MINUTES EDWARD 2 HOURS ANNA 50 MINUTES

JUDY 30 MINUTES

EVA 1 HOUR 30 MINUTES ALEX 1 HOUR

Who should be

warmed?

Characteristic Patterns Of General Anesthesia Induced Hypothermia

—AN Staff

}

Core Temp (°C)

0 -1

The answer is simple—Everyone. Anesthetized patients can’t regulate their temperature. Research shows that core body temperature drops rapidly following the induction of general anesthesia,

-1.6 °C drop in core temperature

increasing the risk for unintended hypothermia—an all-too common and costly complication associated with higher mortality rates, longer hospital stays and an increased rate of wound infection.

-2

Forced-air warming has been used to safely warm over 135 million patients and is a simple, cost-effective method to prevent unintended hypothermia and its

-3

complications. Maintaining perioperative normothermia also is cited by healthcare

1 hr

Elapsed Time (hr) Adapted from: Sessler DI, Perioperative Heat Balance. Anesthesiology, V92, No. 2, February 2000.

initiatives as a key factor in reducing the rate of surgical site infections. Now proudly part of 3M Infection Prevention. For information contact a 3M Patient Warming representative, call 1-800-733-7775 or visit www.bairhugger.com.

3M is a trademark of 3M Company, used under license in Canada. BAIR HUGGER, and the BAIR HUGGER logo are trademarks of Arizant Healthcare Inc., used under license in Canada. ©2012 Arizant Healthcare Inc. All rights reserved. 602014N 1/12

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February 2012

C OMM E NT A R Y

Hospital Closings Helping Reshape Anesthesia Job Market

ooking for a more exciting, parttime, slower-paced or higherpaying anesthesia position? Good luck, and move quickly, because the market for desirable anesthesia jobs is tightening. Groups generally are reducing their benefits, such as retirement contributions and payments for interviews, while pushing for more operating room efficiency. Salaries in some areas, such as Florida, are decreasing. Hospital consolidations and closings seem to be the cause of these trends. Until something changes, anyone with a good position might want to sit tight, while those looking might want to improve their skills, broaden their search or change their expectations. We have gotten used to an everincreasing need for anesthesia providers—anesthesiologists, nurse anesthetists and anesthesiologist assistants. This need has grown for 15 years or more as the number of surgical procedures has increased. The trend has accelerated in the past decade, as procedures requiring anesthesia have

moved to sites remote from which could also spread to the surgical suite, where anesthesiologists. they demand extra workers. Of course, the market for The need to recruit professional anesthesia serenough clinicians to provices is large, diverse and vide all these anesthetics has nuanced. Trends are never boosted anesthesia incomes, clear until viewed historiand secondarily the number cally. But something seems of anesthesia trainees. The to be pressuring anesthesia relative shortage of anestheincomes and benefits downsia clinicians during the past Robert E. Johnstone, MD ward. Among the multiple decade has allowed many to causes are fewer hospitals, negotiate part-time and flexible work more nurse anesthetists, the economic schedules, further increasing the total recession, the relentless pressure of number of clinicians needed. health care reform to reduce costs and Recently, however, the demand for new attitudes among anesthesia clinianesthesia clinicians seems to have cians about work. slowed while their numbers conAlthough some drivers of more surtinue to grow, reversing the growth in gery persist—an aging population and salaries. When the number of anes- more office-based procedures—a conthesia clinicians starts to exceed the tinuation of the growth in open anesnumber of openings for them, some thesia jobs and incomes seems unlikely. clinicians will accept reduced incomes For many anesthesia clinicians today, for the most desired positions, driving a reduced income for more personal down salaries. An emerging trend of time is acceptable, but positions with fewer available jobs and reduced sala- flexible scheduling are the ones that ries is now hitting nurse anesthetists, seem most threatened. The large integrated institutions that are favored under health care reform must provide anesthesia services efficiently and around the clock, and they primarily need clinicians who can work full-time and take call.

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Fewer ORs Especially important for determining the need for anesthesia clinicians is the number of operating rooms and anesthetizing sites to be staffed each day. This number is tied to the total pool of hospitals in the United States, which is now shrinking. The first to go have been small and rural facilities. Approximately 1,300 hospitals—more than one-fourth of the acute care hospitals in the United States—have 25 or fewer beds, and nearly 40% of them are losing money. Many have closed and will do so, despite receiving extra payments under a special support program. This program pays these “critical access” hospitals 101% of their allowable expenses, instead of the fixed, diagnosis-related payments that other hospitals receive. These small hospitals often have limited-schedule surgical suites staffed by nurse anesthetists, who are paid by hospital pass-through cost reimbursements. Critical access hospitals cannot pass through payments for anesthesiologists. As these small hospitals close, nurse anesthetists and surgical cases are

pushed into the marketplace. Larger regional hospitals often can handle the additional surgeries and anesthetics without opening more operating rooms or hiring additional nurse anesthetists. Large hospitals aim to keep their operating rooms full 85% of the time and their anesthesia clinicians busy, whereas most small hospitals run theirs part-time. Southwest Alabama Medical Center in Thomasville, for instance, closed last August due to financial difficulties. This facility had 27 beds, and its physicians performed more than 400 surgical operations per year. No anesthesiologists were on staff. These surgical procedures have now moved to other small hospitals and large ones in Mobile. The growth of ambulatory surgery centers (ASCs) and offices performing surgery may also be slowing. Health care reform will bring value-based purchasing to ASCs and global payments to providers, perhaps limiting the economics driving their past growth. Performance measure reporting and other administrative burdens may increase their costs, and other reforms may limit anesthesia payments for these surgeries. Health care reform may reduce or eliminate the special payments that critical access hospitals have enjoyed, accelerating their closure. Gail Wilensky, former administrator of Medicare and Medicaid, recently said, “What started out as a reasonable concept has morphed into a program that is providing funds to a financially stressed group of hospitals that are not, in any reasonable sense of the term, critically needed.” Recent studies also have found lower-quality care and higher mortality rates in critical access hospitals than in larger hospitals, further motivating reformers to reduce the special payments.3 The closing of these hospitals generally means fewer operating rooms in a community and the availability of more clinicians, especially nurse anesthetists, for the existing ones. It also means fewer part-time anesthesia positions. Compounding the effect of fewer opportunities for nurse anesthetists at critical access hospitals is an increase in the number of nurses graduating from anesthesia training programs. Over the past decade, the number of graduates increased from approximately 1,000 per year to 2,500 per year. The number

February 2012

AnesthesiologyNews.com I 7

COMME N TA R Y of graduating anesthesiologists also has increased, from approximately 1,000 to 1,500. Nurses pay tuition to attend anesthesia training programs. They help perform clinical anesthetics for which the sponsoring department or institution receives payments, thus perversely incentivizing an increase in the number of nurse trainees to maintain the professional incomes of the sponsors. Memberships in the American Association of Nurse Anesthetists and the American Society of Anesthesiologists (ASA) are at all-time highs. ASA membership should reach 50,000 next year, from roughly 36,000 in 2000— evidence of the growth of practicing anesthesiologists. Looming Pay Cuts Incomes for anesthesiologists and nurse anesthetists are at historic highs, so reductions could be viewed as inevitable. Because incomes of nurse anesthetists have risen proportionally more than those of anesthesiologists over the past decade, perhaps it is logical that they would decrease the most. But it’s too soon to panic. Many open anesthesia positions exist and competent anesthesiologists and nurse anesthetists are finding places to work—and for good wages. The largest Internet anesthesia posting site, Gaswork.com, recently listed 668 positions for anesthesiologists and 369 for nurse anesthetists, including full-time and locums positions. Many of these posts, however, were for vacation relief and difficult-to-fill positions. Many unknowns exist in calculating the needs of the future anesthesia workforce. For instance, many senior anesthesiologists and nurse anesthetists now practicing may have deferred their retirements due to the effects of the recession on their retirement funds. When they will leave the workforce is unclear. Whether anesthesia clinicians will continue to provide deep sedation to patients in endoscopy or procedure suites is unknown. Even basic information is murky, such as how many operating rooms are in daily use in the United States. What is needed is the gathering and dissemination of more, and better, information about the anesthesia workforce. If well informed, nurses and medical students will individually decide what is in their best interests. Many nurses, already burdened with educational debt, may decide to forgo anesthesia training. Many anesthesiologists may decide on additional training to acquire highly sought skills,

such as fellowships in pediatrics or pain, or broad competence in regional anesthesia. Some may improve their value by becoming perioperative physicians, able to provide patient care from the preoperative through the postoperative period and to coordinate care across the surgical spectrum. They may adjust their personal expectations to involvement in all aspects of anesthesia practice, efficiency in the operating room as the group measure and recertification as an individual standard.

Anesthesia societies should acquire and share this information widely. More data might reduce the uncertainty and anxiety that anesthesia clinicians are increasingly experiencing, and facilitate the career choices everyone must make. Good information will drive good decisions. —Robert E. Johnstone, MD Dr. Johnstone is professor of anesthesiology at West Virginia University in Morgantown.

He recently served as vice president for professional affairs of the American Society of Anesthesiologists. This commentary represents his personal views.

Recommended Reading 1. CMS. Critical access hospitals center. https://www. cms.gov/center/cah.asp. 2. Gold J. When ‘critical access’ hospitals are not so critical. Kaiser Health News. http://www.kaiserhealthnews.org/Stories/2011/December/08/medicare-critical-access-rural-hospitals.aspx. 3. Joynt KE, et al. Quality of care and patient outcomes in critical access rural hospitals. JAMA. 2011;306:45-52.

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P A I N M E DI C I NE

Experts Face off on Strength of Support For Vertebral Augmentation New Orleans—Is percutaneous vertebral augmentation an effective treatment modality to reduce the pain of vertebral compression fractures? Two pain experts squared off on opposing sides of this issue in a session at the 2011 fall meeting of the American Society of Regional Anesthesia and Pain Medicine. “Vertebral augmentation doesn’t do squat,” said Oscar A. de Leon-Casasola, MD, professor of anesthesiology and medicine at the University of Buffalo and chief of pain medicine and professor of oncology at Roswell Park Cancer Institute, both in Buffalo, N.Y. Allen W. Burton, MD, practicing pain medicine specialist and anesthesiologist at Houston Pain Associates,

Ultrasound continued from page 1

countered, stating, “Considerable level 1 evidence supports vertebroplasty and balloon kyphoplasty.” Dr. Burton pointed out that several professional societies have called vertebral augmentation safe, effective and durable for appropriate patients and have said the benefits outweigh both the procedural risk and the risks associated with conservative therapy. Prime candidates for vertebral augmentation have axial or mechanical pain from a recent fracture (in the last three to 12 months) as well as concordant movement-related pain. Indications include painful osteoporotic vertbral fractures refractory to treatment, painful vertebrae due to benign or malignant bone tumors or painful fractures

with osteonecrosis. Dr. Burton emphasized that people with painful acute compression fractures do not simply get better but require treatment. Two Studies, ’Fatal’ Flaws Dr. de Leon-Casasola spoke against vertebroplasty by describing the results of two studies published in The New England Journal of Medicine (2009;361:557-568 and 2009;361:569-579) that evaluated the efficacy of bone cement in vertebroplasty for painful osteoporotic fractures compared with a sham procedure in patients with spinal fractures less than 12 months old. In one of the studies, investigators randomized participants with one or

“Aside from the fact that [the decrease in pain was] statistically significant, I don’t In fact, most studies comparing traditional local- think a decrease in numeric pain ization techniques with ultrasound are not powered scores of less than 1 means anything to look at pain outcomes, and instead define block to the patient,” said lead author Stesuccess through surrogates like the number of needle phen Choi, MD, staff anespasses or block performance time. Of the 16 studies thesiologist at Sunnybrook that evaluated pain severity, eight reported improved Health Sciences Centre analgesia with ultrasound guidance, whereas the in Toronto, Ontario, Canremaining eight reported no difference. Of the eight ada. The result speaks to the trials reporting better pain outcomes with ultra- importance of statistically sound guidance, only a single study demonstrated a versus clinically significant decrease in numeric pain score greater than 1. results, he added, noting that previous research has shown that the minimal clinically Advertisement important difference in pain is Featuredservice at least 1.3 units. “When you look at the outcomes that are important to patients, very few of those were actually assessed in the studies,” Dr. Choi said. In addition, the range of designs and end points makes the studies difficult to compare. “The 23 trials look impressive until you look at each individual trial,” said Dr. Choi. “Because of the differing blocks, when you break it down you can’t actually compare them; no common effect was [measured]. From that perspective, there is actually very little data.” The studies included in the review had 11 unique primary Complimentary Informed Consent Review end points, all of which essentially purported to charOur experience has shown plaintiff attorneys often acterize a better block when comparing ultrasoundfocus on a practice’s informed consent process guided and landmark or peripheral nerve stimulation to undermine a jury’s confidence in the quality techniques. of anesthesia care delivered. Contact us today at Despite the limitations of these studies, “when the (800) 562-5589 to arrange your free, no-obligation techniques are really put to the test (meaning one evaluation. provides a better quality surgical block), the data Take ownership of your own reputation and advandon’t suggest that ultrasound is better, just equivalent,” tage of this complimentary review! said John Antonakakis, MD, an anesthesiologist at www.ppmrrg.com Portsmouth Regional Hospital in Portsmouth, N.H. See our ad on page 11. Because of this, Dr. Antonakakis said, “it’s an inefficient use of research time and resources to look at

two painful osteoporotic vertebral fractures that were unhealed and less than 12 months old to undergo vertebroplasty or a sham procedure. The primary outcome was overall pain (on a scale of 0 to 10, with 10 being the maximum imaginable pain) at three months. Overall, 71 people (35 in a vertebroplasty group and 36 in a placebo group) completed the six-month follow-up. The investigators found that vertebroplasty did not result in a significant advantage in any measured outcome at any time point; disability measures and other health-related outcomes and opioid consumption also were similar in the two groups. see vertebral page 10

[pain outcomes] because first you have to prove that ultrasound gives you a better block. If we haven’t shown that ultrasound provides a better surgical block, why would we think that patients’ pain is going to be any different? “There is nothing magical about ultrasound; it doesn’t have intrinsic therapeutic benefits that we know of,” Dr. Antonakakis said. “It’s simply a tool used for nerve localization and deposition of local anesthetic. The outcomes that have been studied to date— that is, how easy it is to perform the block and how quickly it sets up— are important to measure [and] are the appropriate outcomes to study with ultrasound.” Whether or not there is a landmark trial demonstrating better outcomes, “ultrasound itself has revolutionized regional anesthesia; it has allowed more people to become practitioners and thus more offer it to patients,” said Dr. Choi. He said novel applications of ultrasound in the field—such as blocks that use tissue planes to deliver anesthetic further away from the nerve—will only reinforce physicians’ dependence on ultrasound. “Is it going matter if there is a major conclusive trial?” Dr. Antonakakis added. “Ultrasound has simplified regional anesthesia and given practitioners more confidence. Even if the literature shows that ultrasound and traditional techniques are equivalent, and it allows more practitioners to offer nerve blocks to their patients means that more patients will benefit.” —Gabriel Miller Drs. Antonakakis and Choi reported no relevant financial relationships or commercial interests.

February 2012

AnesthesiologyNews.com I 9

Pa in M e d ic ine

New Pain Guidelines Push for Intrathecal Therapy With Opioids and Nonopioids as First-line Treatment

roposed new guidelines for the management of nociceptive and chronic neuropathic pain recommend intrathecal therapy (IT) using both opioid and nonopioid agents for this patient population, according to a presentation by the 2011 Polyanalgesic Consensus Conference (PACC) and a study published in the May-June issue of Pain Physician (2011;14:E283-E312). The proposed guidelines, developed by a team of pain specialists from the United States and Australia, position ziconotide (Prialt, Jazz Pharmaceuticals), as well as morphine and hydromorphone, as first-line options for IT in patients suffering from moderate to severe chronic cancer pain and noncancer pain caused by other terminal illnesses. Historically, IT has not been widely used in these patient populations,

in part, because it involves surgically implanting a compromised” life expectancy, for whom the goal pump into the subcutaneous tissue to act as both a of treatment is palliative care. IT is also suggested drug reservoir and delivery system. However, data for cases in which disease progression has been published over the past 20 years has demonstrated “arrested” but the likelihood of recurrence is high, its safety and efficacy in select chronic pain patients such as cancer patients, or in patients who have over traditional medical management with opioid residual pain even after their cancer has been eradtherapy. icated. IT also can be used in patients for whom medication management is an issue or in those with comorbid conditions, such as obesity or sleep apnea. ‘These guidelines are very According to Dr. Deer, the PACC formed to develop the guidelines by the International Neubalanced, very well done, and romodulation Society (INS). Dr. Deer currently serves as president-elect of the INS. The PACC the fact that they focus largely on was supported by an unrestricted educational grant from Azur Pharma. cancer patients is important.’ Mellar P. Davis, MD, professor of medicine at the Cleveland Clinic Lerner College of Medicine —Mellar P. Davis, MD of Case Western Reserve University in Cleveland, and an expert in palliative care in the cancer setting, “There is a major lack of knowledge about IT,” said the guidelines are a positive step. IT is indeed noted Timothy Deer, MD, a pain specialist and a viable option in patients with pain who are sufpartner at the Center for Pain Relief in Charles- fering from life-threatening illnesses or are at end ton, W.Va., who served as lead author on the pub- of life. In the past, clinicians treating these patients lished guidelines. “Many primary practice doctors have opted for other therapeutic options, such as have never heard of IT. The need for outreach to opioid rotation, rather than bringing in a pain speoncology, primary care, radiation oncology and oth- cialist and considering the IT approach, he noted. ers is very critical. IT can be a tremendous help to “The guidelines up until now have been more patients suffering from pain who do not respond general and not particular to cancer patients,” said to oral medications or who have unacceptable side Dr. Davis, who was not part of the PACC projeffects. It’s evolving. The approval of new medica- ect. “These guidelines are very balanced, very well tions such as ziconotide give new options to those done, and the fact that they focus largely on canwho do not tolerate opioids or who have opioid- cer patients is important. These patients can benefit resistant pain.” from a multidisciplinary approach to pain manageThe guidelines recommend the use of IT in a ment that includes intrathecal therapies.” stepwise approach for the management of moderate severe chronic pain in patients with “severely —Brian P. Dunleavy

High-Dose Opioids May Delete Memory Trace of Pain

ustrian researchers have discovered a surprising, new potential effect of opioids: The drugs not only temporarily dampen pain but in high doses may remove the spinal cord’s memory trace of pain (Science 2012;335:235238). The memory trace, which can amplify a person’s experience of pain and may lead to chronic pain syndromes, can be triggered by several mechanisms, including long-term synaptic

potentiation. In order to study pain memory, the researchers recreated a surgical procedure in vivo, which allowed them to stimulate pain fibers under controlled conditions. Despite deep anesthesia, the researchers were able to reserve long-term synaptic potentiation in the spinal cord and found a memory trace for pain. When high doses of IV opioids were administered over the course of an hour, the researchers completely resolved the potentiation and thus deleted the memory trace for pain. Based on these results, a new project, sponsored by the Vienna Fund for Science, Research and Technology, is exploring whether this discovery can be used to treat patients. “If our approach turns out to be effective under clinical conditions, this would herald a paradigm shift in pain therapy,” wrote the authors,

led by Jürgen Sandkühler, MD, at the Center for Brain Research at the Medical University of Vienna. “It would mean moving away from the temporary, purely symptom-based pain therapy to a long-term removal of the cause of pain based on pain mechanisms using opioids.” —AN Staff

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P A I N M E DI C I NE Vertebral continued from page 8 In the other trial, investigators randomly assigned 131 patients who had one to three painful osteoporotic vertebral compression fractures to undergo either vertebroplasty (n=68) or a simulated procedure without cement (n=63). At one month, there was no significant difference between the vertebroplasty group and the control group in pain outcomes. Both groups showed immediate improvement in disability and pain scores after the intervention. In addition, a one-year follow-up of this study population found no differences between treatment arms (Spine 2010;35:478-482). Dr. Burton maintained, however, that “fatal flaws” in the two New England Journal trials “tainted” the conclusion. “We should not throw out a good technique because of two flawed studies,” Dr. Burton told attendees. “I caution against worshipping blindly at the randomized controlled trial altar.” Dr. Burton pointed to an editorial written by the North American Spine Society that took exception to the two studies, noting a “disconnect” between them and earlier studies (Spine J 2010;10:238-240).

The editorial alleged that patient selection was not well controlled, the populations were enriched for patients with less severe pain, the sham procedures were equivalent to a facet block and the outcomes reporting was unduly complicated. Dr. Burton elaborated on these complaints, noting that screening 1,813 patients to enroll only 131 in one of the studies amounted to selection bias. He added that the trials were underpowered and that high crossovers from the sham procedure to vertebroplasty, and not the reverse, implied efficacy for the procedure. “If these studies had a positive result, they would have been rejected for these reasons,” he maintained. Not All Positive Studies Are Sponsored Dr. Burton then described several trials that showed a benefit of vertebroplasty. VERTOS II (Vertebroplasty versus Conservative Treatment in Acute Osteoporotic Vertebral Compression Fractures), conducted in 202 patients with acute fractures and significant pain, found that vertebroplasty offered immediate and sustained pain relief and improvements in quality of life and disability at an acceptable cost (Lancet 2010;376:1085-1092).

“I caution against worshipping blindly at the randomized controlled trial altar.” —Allen W. Burton, MD “This study was sponsored by The Netherlands Organisation for Health Research and Development, the Dutch equivalent of our National Institutes of Health, which disputes the notion that all positive trials are industry-sponsored,” he added. Two studies of balloon kyphoplasty also showed results in favor of vertebroplasty. The FREE (Fracture Reduction Evaluation) trial found that balloon kyphoplasty provided greater improvements at one month than nonsurgical management, with results sustained through 12 months and improvements observed in six secondary outcomes (Lancet 2009;373:1016-1024). “This was a large prospective study with rigorous criteria and lots of controls,” Dr. Burton said. A 2011 study found that balloon kyphoplasty was

Evidence Points to Better Approach for Back Injections 10

Midline interlaminar Parasagittal interlaminar

6 5 4

5 4 3

1 0

Midline interlaminar Parasagittal interlaminar

Pain at Rest

nerve inflammation is centered in most patients with low back pain (Anes Analg 2008;106:638-644). They then set out to compare the PIL approach with the midline interlaminar (MIL) approach for LESI. Dr. Candido and his colleagues randomized 22 patients to receive LESI with the MIL approach and 22 with the PIL method. All patients had a history of unilateral lumbosacral radiculopathic pain and herniated, bulging or degenerated disks. The Advocate researchers did not include patients who had diskogenic pain without radiculopathic pain; history of previous spinal surgery and LESI in the past year; allergy to methylprednisolone, lidocaine or iodinebased contrast; concurrent use of systemic steroid medications; or opioid habituation. Each subject received 120 mg or 2 mL of methylprednisolone acetate with 1 mL of 1% lidocaine, through either the PIL or MIL approach to LESI alone. The subjects were blinded to treatment. The two groups of patients had similar demographics, including age, ratio of males to females, height, weight and duration of symptoms, and similar levels of self-reported pain both at rest and while moving (Figures 1 and 2). Both groups experienced clinically and statistically significant reductions

Pain During Movement

hen performing steroid injections for low back pain, many clinicians feel the approach they take with the needle is purely a matter of personal preference. But new research suggests that the position can significantly affect how much pain a patient will experience. The studies, presented at the 2011 annual fall meeting of the American Society for Regional Anesthesia and Pain Medicine (abstracts A010 and A038), found that the lateral parasagittal approach reduces pain more effectively, at least over the short term, than the midline approach for fluoroscopically guided interlaminar lumbar epidural steroid injections (LESI) in patients with unilateral lumbosacral radiculopathic pain. “The parasagittal approach is now our default approach,” said Kenneth D. Candido, MD, chair of the Department of Anesthesiology at Advocate Illinois Masonic Medical Center, in Chicago, and leader of the study. “The midline approach is limited to individuals with bilateral leg pain or with isolated low back pain, not unilateral radicular pain.” Dr. Candido’s group previously had shown that the parasagittal interlaminar (PIL) approach was better than the transforaminal approach for targeting steroids to the anterior or ventral epidural space, where the spinal

Basal

Day 1

Day 7

Day 28

Basal

Day 1

Day 7

Day 28

Figure 1. Numeric rating score for pain during movement.

Figure 2. Numeric rating score for pain at rest.

in unilateral and lumbosacral radiculopathic pain during movement at one, seven and 28 days postprocedure, but the reduction was greater with the PIL approach. The PIL approach also led to greater improvement in self-reported pain scores, as measured on a numeric rating scale, at rest over time with the PIL approach (P<0.026 for PIL group and 0.044 for MIL). Patients had similar baseline Oswestry Low Back Pain (OLBP) scores: an average of 21.25 for PIL approach

patients and 19.50 for MIL approach subjects. The OLBP scale ranges from 0, which is the highest level of function, to 50, which is the lowest. All patients in both treatment groups experienced improvement in their everyday activities and quality of life. However, only subjects who received the PIL approach experienced significant reductions in OLBP scores between baseline and one, seven and 28 days after the procedure (P=0.037)— an effect Dr. Candido said was both statistically and clinically significant.

February 2012

AnesthesiologyNews.com I 11

Pa in M e d ic ine superior to nonsurgical management (Lancet Oncol 2011;12:225-235). At one month, patients randomized to the kyphoplasty group (n=65) experienced rapid back relief, with an 8.3-point improvement in back function as measured by the Roland-Morris Disability Questionnaire versus a mean change of 0.1 points in the control group (n=52). In addition, 75% of patients in the kyphoplasty group reached the meaningful self-care threshold (≥70 score) compared with 39% in the control group. The most common adverse events within the first month were back pain (four of 70 in the kyphoplasty group and five of 64 in the control group) and symptomatic vertebral fracture (two in the kyphoplasty group and three in the control group). “For painful vetebral compression fractures in patients with cancer, balloon kyphoplasty is an effective treatment that rapidly reduces pain

The team has recruited another 56 patients into the study and are analyzing the data out to six months for all 100 subjects, Dr. Candido said. “I’m not surprised by the results. They’re pretty much what the literature says; I’ve done systematic reviews on this,” said Sukdeb Datta, MD, MBA, medical director of the Laser Spine & Pain Institute in New York City. “You shouldn’t be doing the epidural in midline, you should do it with the lateral parasagittal approach and target the side that is worse.” Another expert also applauded the study and said he uses “the parasagittal approach for unilateral radicular symptoms.” David Provenzano, MD, executive director of the Institute for Pain Diagnostics and Care at Ohio Valley General Hospital, in Pittsburgh, said the next step is to further compare it to the transforaminal approach for both safety and efficacy outcomes. “This will help us to define whether both approaches are similar or whether one is superior to the other,” Dr. Provenzano said. “In theory the parasagittal approach may be safer, because you may not be at heightened risk for intravascular injection of particulate steroids.” —Rosemary Frei, MSc Drs. Candido, Datta and Provenzano reported no conflicts of interest.

and improves function,” Dr. Burton maintained. He further noted that minor complications are rare, major complications are very rare and the majority of complications are transient and self-limited. “Also, there are downsides to conservative care,” he added.

clinically meaningful. In VERTOS II, the difference in pain as measured by a visual analog scale was 2.6 at one month and 2 at one year. Analgesic use was reduced at one day, one week and one month, but thereafter the difference lost statistical significance. Furthermore, function was not improved, opioid consumption was similar and Statistical Improvement Only comprehensive medical management Dr. de Leon-Casasola, however, was not well defined. questioned whether the differences “This was a statistical improvement seen in the positive trials were actually only. Vertebral augmentation does not

do anything after one month of the procedure, and the costs are significantly higher,” Dr. de Leon-Casasola concluded. “I have had patients who became pain-free after these procedures and have brought me fruit baskets, but a few months later they are back in my office.” —Caroline Helwick Dr. Burton reported receiving consulting fees for Medtronic, Boston Scientific and Stryker. Dr. de Leon-Casasola reported no relevant conflicts of interest.

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PRN Laughing continued from page 1

Too Pink. Very Black. I felt I was trapped in the bell tower of Hampstead named Otto by his parents, the Belams. Church and the clapper, swinging back I called him ‘Sir’. One quiet afternoon and forth was deafening and stunning me. Dr. Belam asked me if I would kindly “Boing, too pink,” Then it swung the replace him at a dental surgeon’s office in other way, under the pull of gravity, a shopfront in nearby Holloway Road. smashing into me in the middle. “All she needs for her extractions is “Boing, very black.” some gas from a McKesson machine. She I cut the oxygen to 5%. To put it keeps open on Wednesday evenings for another way, I increased the nitrous oxide the working men. She is very quick. Get Gerald Zeitlin, MD to 95%. I felt nervous. My hand holding there just before six.” the nose mask felt shaky. The one element The dentist was a middle-aged lady with frosty drummed into me over and over during my short hair. She met me in her empty waiting room. years in anesthesia was: “Otto phoned me you’d be coming. Go in there “If in doubt give more oxygen.” and fiddle with his machine. The first one’ll be “What are you going to do? He’s still pink and his here in ten minutes. No fillings. Just exodontia on teeth are clenched,” she said, less kindly. Wednesday evenings.” “I dare not give him any less oxygen. I’m afraid to.” I knew just enough Latin to guess that the ‘ex’ in “Well Otto is not, so why are you? exodontia meant ‘out’. Exodontia must be the sciAnd without waiting for an answer Dr. Frosty said, ence of outing teeth, or, as is it called in respectable “You are no use to me. Go back to the hospital and middle-class circles, ‘tooth pulling’. tell Otto not to send me people without experience. I had never seen such an anesthesia machine I’ll use local, but all these big men hate needles,” she before. I ‘fiddled’ with it. I peered at the dial at the said without any kindness at all. top. This indicated that by turning the dial one could I did as she told me. The next day I never said a deliver a mixture of two gases, in precise percentages word to Dr. Belam, nor he to me; which was odd from zero to one hundred; or, from one hundred to because she must have complained to him. It seemed zero. Very ingenious. And it made sense, to be able as though Otto and I had attended a drunken party to vary precisely the percentage of oxygen the patient each not knowing the other would be there. When breathes. I read an engraved label indicating that the we met, sober, the next day neither would acknowlMcKesson Company in Toledo, Ohio had made it. I edge his obscene but observed behavior to the other. had never encountered an American machine before. It was only when I dug around in the medical litI stood back to gain perspective. erature that I came across a description of the anesThen I saw the ugliness of my situation. The only thesia technique called ‘saturation,’ and it became two gas cylinders attached were one each of nitrous clear to me that was what Dr. Belam was oxide and oxygen. Nitrous oxide is a very weak anes- using on the dentist’s patients. thetic agent; so feeble at rendering people unconElmer I. McKesson was born in scious that it has become known as ‘laughing gas’, Walkerton, Ind., in 1881 and died that is, it makes you drunk and giggly. Never before suddenly in 1944. During McKeshad I given it without adding something more son’s internship at the Toledo Hospotent, ether and more recently, halothane. pital he became interested in Dr. Frosty the dentist introduced me to the first anesthesia and devoted the patient, a muscular builder still in his paint-covered rest of his professional overalls. He was sweating, not from exertion but fear. life to the specialty. A Anesthesia for dental surgery requires the patient to brilliant engineer who breathe a gas mixture from a mask that fits over the ran a successful businose but leaves the mouth accessible. I cursed myself ness, the McKesson for not even thinking of asking Dr. Belam about taking some Pentothal for intravenous use. I must have been mesmerized by that phrase so rarely used by anesthesiologists about surgeons, “She’s quick.” I applied the nasal mask and dialed a 90% nitrous, 10% oxygen mixture. “Please take some deep breaths through your nose,” I said. And he did. He closed his eyes but continued to sweat. My free hand counted his pulse rate: about 110 beats per minute. He was not frightened. He was terrified. “Shall I begin?” she asked. “Yes,” I said because I did not know enough to choose between ‘yes’ or ‘no’ and ‘yes’ seemed more optimistic. I am known as an optimist. “I can’t even open his mouth. Anyway he’s too pink. Otto gets them very black and then they relax and I can get the bite-block in—to keep his mouth open,” she said kindly.

Equipment Company in Toledo, Ohio, he manufactured some of the most sophisticated anesthesia machines ever made. For his time he was remarkably astute in his understanding of what happens to the patient under general anesthesia. All except his one profound misunderstanding of the human body’s need for oxygen. Yet his influence was such that incalculable harm was done, particularly to dental patients all over the world. About 30 years ago all the dentists in the United Kingdom stopped using general anesthesia in their offices because of the many complications including deaths, that resulted. The patients fared just as well and in complete safety when the dentists changed over to local anesthesia. The few patients who required general anesthesia, such as handicapped children, were sent to hospital and received it from a specialist anesthesiologist. McKesson stated in his various publications that because of nitrous oxide’s weakness and in order to use it effectively the patient should be given pure nitrous oxide. Not only did his patients look black (cyanosis) but he advised continuing with the pure nitrous oxide until the patient exhibited ‘jactitations’—an old-fashioned word meaning seizures— from oxygen deprivation. Then he gives the game away. “Anesthesia … with nitrous oxide is probably due to restricting oxygen in the nerve cell to amounts capable of supporting life functions only.” He imagined, without any proof at all, that by starving the brain of oxygen you produce anesthesia but that the tiny remaining amounts of oxygen are sufficient to keep the brain cells alive. He was guessing. McKesson was so influential that his technique

February 2012

AnesthesiologyNews.com I 13

PR N was widely used in the 1920s and 1930s. I wondered what Dr. Macintosh, the naked professor in Oxford who had interviewed me three years earlier, thought of this. I looked at Macintosh’s book published in 1940, “Essentials of General Anesthesia with Special reference to Dentistry.” To quote him: “To be effective in an average patient, its (nitrous oxide’s) weak anaesthetic qualities have to be reinforced deliberately by a reduction of the oxygen intake to such a level that some degree of cyanosis is usually noticeable and is not of serious import.” That is not the end of this story. One evening in the late 1970s when we were well settled in the United States our friends Dr. and Mrs. Abroms invited us to dinner. Dr. Abroms is a respected pediatric neurologist. Why is it that I find other people’s bookshelves so much more intriguing than my own? I have a bad habit at social gatherings of slipping away and browsing until my wife notices and brings me back. It’s not just the gleaming well-dusted, neatly arranged volumes that attract me. If I find something of interest, I look for a chair in a dim corner and start to read. That particular evening I discovered “Contributions to the Study of Cerebral Anoxia” by Dr. Cyril Courville. Anoxia, not enough oxygen, is one of the great spooks that haunt all anesthesiologists. I flipped a few pages and just as I heard my wife calling, “Gerald, where are you hiding this time? You’re a disgrace to the human race,” the words ‘nitrous oxide’ leapt up at me from the book. I rushed into the jolly drawing room but when no one was looking

Elmer I. McKesson, MD, inventor of early anesthesia devices (left). Images courtesy of the Wood Library-Museum of Anesthesiology.

I scribbled the name ‘Cyril Courville’ on the napkin from which I munched my mushroom vol au vent. The following Saturday I dashed off to Harvard’s Countway Library of Medicine and found Dr. Courville’s 1939 book, “Untoward Effects of Nitrous Oxide.” The book is only 161 pages long but is one of the most terrifying things an anesthesiologist might ever have to read. On page 45 we read the following, which is typical of the many cases he reports: “Case 12: Convulsive seizures and coma following administration of nitrous oxide anesthesia for extraction of teeth. Death after 2½ days. Autopsy. A married painter, 42 years old, having generalized convulsions was admitted to the Cedars of Lebanon Hospital on the afternoon of July 12, 1932. The patient was under the influence of the anesthetic for ½ hour. He failed to regain consciousness at the close of the anesthetic, and shortly after developed generalized convulsions.” Here is one paragraph from the detailed autopsy report: “The neurofibrillar structure was found to be altered more or less universally. In the cerebral cortex some of the cells proved to be entirely devoid of argentophilic material. Others showed typical granular degeneration. These changes were especially advanced in the Purkinje cells of the cerebral cortex, where fine and coarse granular fusiform and herudiform degeneration was observed.” You do not need to understand a single word of this pathological jargon in order to realize that this patient’s brain had been destroyed. It’s all too horribly simple. Brain cells die when they have been without oxygen for three to five minutes. Did Dr. McKesson have any excuse for this disastrous idea. I believe not. As long ago as 1868 a Chicago surgeon Edmond Andrews, with an interest in nitrous oxide anesthesia, wrote: “It is my impression that the best proportion of oxygen will be found to be one-fifth by volume, which is the same as in the atmospheric air.” Dr. Courville was a professor of pathology. I have sometimes defined a pathologist as a physician who examines bits of you before it’s too late and later, after it’s too late. Before we leave the subject of nitrous oxide and its use let us take a look at it from another perspective; that of one of the greatest figures in 20th-century history, Winston Churchill. When the Conservative party lost its majority in the House of Commons at the General Election of May 1929 in what used to be Great Britain, Churchill lost his job as Chancellor of the Exchequer. In the next two years his party increasingly shunned him. This was the start of the period in his life now called his ‘Wilderness Years’. That ended when war began in September 1939. His response to these reverses was to write and lecture, both with the additional and important motive of making money. On Dec. 11, 1931, he arrived by boat in New York and moved into the newly built Waldorf Astoria Hotel with his wife Clementine and daughter Diana. That was the start of his third speaking tour of North America. On the evening of Dec. 13, his old friend, the financier Bernard Baruch, invited him to his Fifth

Avenue mansion to meet some mutual friends. Churchill and Baruch had led the effort to produce adequate supplies of munitions for their soldiers in the last two years of what is called The Great War. Both had both lost large sums of money in the stock market crash. Baruch had gambled and regained most of his fortune. Churchill had not, and although I have not found any evidence that this was the reason Churchill went to see Baruch that evening it is likely he went for financial advice. Churchill’s finances remained in a precarious state nearly all his life. After dinner at the Waldorf, undoubtedly lubricated with brandy and champagne Churchill got into a taxi at about 9 p.m. He had forgotten to ask for directions and could not find Baruch’s home address in the hotel’s telephone book. Churchill later wrote, “I had been there by daylight on several occasions. I thought it probable I could pick it out from the windows of my taxicab.” For nearly an hour Churchill instructed the driver to drive loops up and down Fifth Avenue to allow him to identify the house. He failed and Churchill lost patience. He told the driver to let him off at a point in the middle of Fifth Avenue believing he could find the building more easily on foot. In two articles published by the London Daily Mail in early January 1932, Churchill described the subsequent events. “I no sooner got out of the cab than I instinctively turned my eyes to the left. About 200 yards away were the yellow headlights of a swiftly approaching car. I increased my pace toward the pavement about 20 feet away. Suddenly upon my right I was aware of something utterly unexpected and boding mortal peril. I thought. ‘I am going to be run down and probably killed’. Then came the blow. I felt it on my forehead and across the thighs.” The right front end of a small truck hit him. “I lay in the road, a shapeless mass,” he wrote. A small crowd including a policeman gathered and he was lifted into the original taxicab and taken immediately to Lenox Hill Hospital on 77th Street. Later in his Daily Mail article Churchill describes the events after his arrival at the hospital. “Soon I am on a bed. Presently come keen, comprehending eyes and deft firm fingers.” The fingers belonged to Dr. Otto Pickhardt, a surgeon on the staff of the Lenox Hill Hospital. He became Churchill’s private doctor in the United States for the next few months. “We shall have to dress that scalp wound at once,” Pickhardt said. “Will it hurt?” “Yes.” “I do not wish to be hurt any more,” Churchill said. “The anesthesiologist is already on the way,” Pickhardt replied. The anesthesiologist was Dr. Charles Sanford, one of the very few physicians specializing in anesthesiology in the early 1930s. He spent his whole professional life at the Lenox Hill Hospital. There are few more vivid descriptions of the patient’s experience of general anesthesia than in Churchill’s Daily Mail article. “More lifting and wheeling. The operating room. White glaring lights. The mask of a nitrous oxide inhaler.” see laughing page 14

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PRN Laughing continued from page 13 Churchill then reflects, “Whenever I have taken gas or chloroform I always follow this rule. I imagine myself sitting on a chair with my back to a lovely swimming bath into which I am to be tilted and I throw myself backwards; or, again as if one were throwing oneself backwards after a tiring day into a vast armchair. This helps the process of anaesthesia wonderfully. A few deep breaths and one no longer has the power to speak to the world.” He continues, “With me the nitrous oxide trance usually takes this form; the sanctum is occupied by alien powers. I see the absolute truth and explanation of things, but something is left out which upsets the whole, so by a larger sweep of the mind I have to see a greater truth. It is beyond anything the human mind was meant to master. The process continues inexorably. Depth beyond depth of unendurable truth opens. I have therefore regarded the nitrous oxide trance as a mere substitution of mental for physical pain. Pain it certainly is: but suddenly these

poignant experiences end, and without a perceptible interval consciousness returns. Reassuring words are spoken. I see a beloved face. My wife is smiling.” After a few days in hospital he was discharged back to the Waldorf Astoria. He had suffered widespread bruising and a vertical cut above his eyebrows, the scar from which can be seen in all the thousands of photographs taken later in his life. He had a tube inserted between his ribs, also under a general anesthetic, to drain a hematoma lying between lung and rib. But the most frightening occurrence, and in his Daily Mail description it is clear he was quite aware of this, was a complete loss of feeling and ability to move from the waist down while he was still lying in the taxi that took him to the Lenox Hill Hospital. He had suffered a contusion of the spinal cord that resolved itself in a few hours. If the blow had been harder he might well have been paralyzed from the waist down, a

Corporal Greg Caron

his ‘Black Dog’). It is also known, and Dr. Courville later wrote about this, that shorter periods of hypoxia (inadequate oxygen) gave rise to lesser complications. I speculate that this was possibly the trigger for Churchill’s depression. After all, he was about to embark on huge speaking tour which he loved doing, and for which he was to be paid very liberally. Churchill forced his sponsor to completely reschedule the tour while he and Mrs. Churchill got onto a boat and spent ten days in the Bahamas recuperating. You might have thought that the sponsor would sue Churchill to compel him to fulfill his contract as originally agreed, but Mrs. Churchill persuaded Dr. Pickhardt to sign statements that Churchill’s health required this rest period. Churchill did in fact complete the speaking tour, in the middle of a very severe North American winter, but his sponsor, Louis P. nearly uniformly fatal injury in Albers and his fellow investors in the 1931. World history might have been Albers Speakers Bureau went broke six different. months later. It is not clear whether While he was recovering he suf- this was simply the result of the Great fered one of his rare but recurrent epi- Depression or Winston Churchill sodes of depression (he called this breaking the terms of their contract. 

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McMahon Publishing, the publisher of this newspaper, is sponsoring a fundraiser for Cpl. Greg Caron. Cpl. Caron is an Ellington, Conn. Marine. He was injured in November in the line of duty after stepping on an IED in Afghanistan. He lost both of his legs and a finger, and also broke his collarbone. We are raising funds to help Greg and his family as they face a very long recovery.

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“Surgeons depend on excellent image quality from their monitors,” said Julian Goldman, MD, medical director of biomedical engineering at Partners Healthcare System in Boston. “Historically we have turned off the OR light to achieve that. They want high contrast and low glare.” That’s no different, he said, from anyone who prefers the house lights out in a movie theater, but surgeons cannot afford to experience “washout” on a monitor during a laparoscopic procedure. But what’s good for the surgeon is not necessarily ideal for others in the OR, including the patient. “There are a lot of hazards in the operating room,” said Kirk Shelley, MD, PhD, professor of anesthesiology at the Yale School of Medicine, in New Haven, Conn., and immediate past-president of the Society for Technology in Anesthesia. “One of them is tripping hazards. Also, there’s stuff overhead. You need a certain amount of light. We’re keeping anesthesia records. You have to take notes. You have to read the bottles.” Anesthesiologists and other personnel use desk lamps and flashlights to see what they are doing when lighting is low. Dr. Goldman was aware of previous experiments using green light, so he launched a pilot project for minimally invasive procedures in the “Operating Room of the Future” at Massachusetts General Hospital (MGH), in Boston, where he is principal anesthesiologist. The solution was decidedly low-tech— and cheap. Operating rooms often are too bright. The two ORs where the trial was held had nine fluorescent fixtures. The light meter reading with the white lights on was nearly 1,800 lux; with the lights off, it was 3.44 lux. (A typical living room, by contrast, is about 50 lux, Dr. Goldman said.) Ryan Forde, an engineer at MGH who helped lead the project, said most ORs have two or three switches and no dimmers, probably because of limitations with the ballast. Monitors have improved dramatically over the years to cut the glare, but more was needed. The human eye is most sensitive to the color green, said Dr. Goldman, a member of the editorial board of Anesthesiology News. So Mr. Forde rewired some switches and slipped green sleeves over just four bulbs (as opposed to 42 under “white” conditions). Under these conditions, the average light reading was 86 lux, just 5% of that under white lights.

Figure. Top to bottom: ambient room, green room, white room.

At first glance, the green light “looks weird,” Dr. Goldman admitted. “Initially a lot of people didn’t like it. I didn’t like it. It made me feel just a little off balance. But I and everyone else got used to it quickly.” Mr. Forde said eyes adjust quickly to the green, and in three to five minutes “you feel as if you have stepped into a bright room again.” The internal surgical site is unaffected because it is still illuminated under white light. No glare or screen washout was seen. Anesthesiologists were able to read labels and plunger lines without walking over to a reading light and potentially tripping en route. They could also better assess the patient to see whether his or her head or limbs moved. Flashlights are still kept handy, however, Dr. Goldman said. The success of the trial has led MGH to expand the green lights to 28 ORs. “Once you go green,” Dr. Goldman said, “it’s hard to go back.” —John Dillon

February 2012

AnesthesiologyNews.com I 17

CL I N I CA L A N E S TH E SIOL OG Y

Obese Children Require Less Propofol Chicago—Contrary to what many anesthesiologists may think, the effective dose of propofol is significantly lower for obese children than their non-obese counterparts, a recent study suggests. These findings become even more important, the researchers said, given that propofol decreases systemic vascular resistance, and unnecessarily large doses may result in moderate to severe hypotension. “There’s an increasing number of obese children presenting for surgery,” said study leader Olutoyin A. Olutoye, MD, staff anesthesiologist at Texas Children’s Hospital in Houston. “We’re faced with the challenge of how to exactly dose intravenous anesthetics in this subset of patients.” As much as 75% of excess weight in obese children is fat, which alters the distribution of lipophilic drugs such as propofol. Dr. Olutoye and her colleagues enrolled 40 obese and 40 non-obese children (aged 3-17 years), all of who were presenting for ambulatory surgical procedures. Each patient was assigned to receive a dose of propofol between 1 and 4.25 mg/kg, based on the previous patient’s response. “If a patient did not fall asleep with their assigned dose, the next patient received the next higher dose in the sequence,” Dr. Olutoye explained. “If a patient fell asleep, the next patient was randomized using a prestudy randomization process with a 95% probability to receive the same dose or 5% probability to receive the next lower dose. We started at the lowest dose of propofol where we did not expect a response,” said Dr. Olutoye, who presented her group’s findings at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 048). “That way we would be able to increase the dose until we got the desired effect.” The effective dose for 95% of patients (ED95) was significantly lower in obese patients (1.99 mg/kg; 95% confidence interval (CI), 1.745-2.183 mg/kg) than in non-obese patients (3.183 mg/kg; 95% CI, 2.681-3.225 mg/kg). The lack of overlap for the confidence intervals in the two groups indicates the results are statistically significant, Dr. Olutoye noted. The researchers also measured blood pressure throughout the procedures, given propofol’s well-documented hemodynamic effects. Obese patients had a higher baseline

blood pressure than non-obese patients. Moreover, both systolic and diastolic blood pressures were significantly lower two minutes after propofol therapy in both groups of patients. “We should bear this in mind, because propofol decreases blood pressure, and if these patients get an unnecessarily large dose to induce loss of consciousness—particularly in

patients who have been fasting prior to surgery—they could have an exaggerated decrease in blood pressure,” Dr. Olutoye said. Cheryl K. Gooden, MD, associate professor of anesthesiology and pediatrics at Mount Sinai School of Medicine, in New York City, said the results were impressive. “It is not part of my routine practice

to administer less propofol to my obese pediatric patients on a milligramper-kilogram basis as compared with non-obese patients,” Dr. Gooden told Anesthesiology News. “However, after reviewing the results of this study, I would definitely consider giving less propofol on a milligram-per-kilogram basis to my obese patients.” —Michael Vlessides

Less pain. Less opioids. From the start. OFIRMEV® provides significant pain relief*1 • OFIRMEV 1 g (Q6h) + patient-controlled analgesia (PCA) morphine demonstrated significant pain relief vs placebo + PCA morphine (P<0.05 over 6 h)1 • OFIRMEV 1 g (Q6h) + PCA morphine showed greater reduction in pain intensity over 24 h (SPID24)† compared to placebo + PCA morphine (P<0.001)2

OFIRMEV reduces opioid consumption*1 • OFIRMEV 1 g (Q6h) + PCA morphine significantly reduced morphine consumption vs placebo + PCA morphine (–46% over 6 h, P<0.01; –33% over 24 h, P<0.01)1 • The clinical benefit of reduced opioid consumption was not demonstrated

OFIRMEV from the start • Consider administering the first dose of OFIRMEV PreOp or post-induction • Schedule OFIRMEV Q6h for first 24 h and continue as clinically warranted

Indication OFIRMEV is indicated for the management of mild to moderate pain; the management of moderate to severe pain with adjunctive opioid analgesics; and the reduction of fever. Important Safety Information OFIRMEV is contraindicated in patients with severe hepatic impairment, severe active liver disease or with known hypersensitivity to acetaminophen or to any of the excipients in the formulation. Acetaminophen should be used with caution in patients with the following conditions: hepatic impairment or active hepatic disease, alcoholism, chronic malnutrition, severe hypovolemia, or severe renal impairment. Do not exceed the maximum recommended daily dose of acetaminophen. Administration of acetaminophen by any route in doses higher than recommended may result in hepatic injury, including the risk of severe hepatotoxicity and death. OFIRMEV should be administered only as a 15-minute intravenous infusion.

Discontinue OFIRMEV immediately if symptoms associated with allergy or hypersensitivity occur. Do not use in patients with acetaminophen allergy. The most common adverse reactions in patients treated with OFIRMEV were nausea, vomiting, headache, and insomnia in adult patients and nausea, vomiting, constipation, pruritus, agitation, and atelectasis in pediatric patients. OFIRMEV is approved for use in patients ≥2 years of age. The antipyretic effects of OFIRMEV may mask fever in patients treated for postsurgical pain. To report SUSPECTED ADVERSE REACTIONS, contact Cadence Pharmaceuticals, Inc. at 1-877-647-2239 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.com. Please see Brief Summary of Prescribing Information on adjacent page or full Prescribing Information at OFIRMEV.com.

*Randomized, double-blind, placebo-controlled, single- and repeated-dose 24-h study (n=101). Patients received OFIRMEV 1 g + PCA morphine or placebo + PCA morphine the morning following total hip or knee replacement surgery. Primary endpoint: pain relief measured on a 5-point verbal scale over 6 h. Morphine rescue was administered as needed. †SPID24=sum of pain intensity differences, based on VAS score, from baseline, at 0 to 24 h.

References: 1. Sinatra RS, Jahr JS, Reynolds LW, Viscusi ER, Groudine SB, Payen-Champenois C. Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. Anesthesiology. 2005;102:822-831. 2. Data on file. Cadence Pharmaceuticals, Inc.

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18 I AnesthesiologyNews.com

February 2012

C LI N I C A L A N ESTHESI O LO GY

Preinduction Licorice Gargle Relieves Post-Op Sore Throat, Cough Treatment shines in randomized, double-blind comparison with sugar water Chicago—Anesthesiologists who are looking for a quick, cheap and easy solution for the very real problem of postoperative sore throat and postextubation coughing may have one in the unlikeliest of treatments: licorice. The

finding comes from a recent study by Kurt Rützler, MD, and colleagues at the Medical University of Austria, in Vienna, in collaboration with Daniel I. Sessler, MD, professor and chair of the Department of Outcomes Research

at the Cleveland Clinic, in Ohio. The researchers found that when patients gargled with a licorice solution immediately before induction of anesthesia, the incidence and severity of sore throat was significantly reduced on the first postoperative day. “There was a small study published previously on this topic by a Turkish research group,” Dr. Sessler said. “The results of Agarwal et al [Anesth Analg 2009;109:77-81] were striking because it’s hard to understand how just gargling for a few minutes before surgery could prevent postoperative sore throat through the first postoperative morning. Furthermore, Agarwal and colleagues reported a 50% treatment effect, which sounded too good to be true.” To determine the plausibility of these results, the researchers enrolled a series of patients classified as American Society of Anesthesiologists (ASA) physical status 1-3 into the trial. All patients (age range, 18-90 years) underwent elective thoracic surgery requiring a double-lumen endotracheal tube. Data from 156 patients were available after the second interim analysis. The patients were randomly assigned to gargle, at five minutes before induction of general anesthesia, for at least 30 seconds with either Extractum Liquiritiae Fluidum (licorice, 0.5 g; n=76) or Sirupus Simplex (sugar, 5 g; n=80). Both solutions were kept in opaque brown bottles. Patients were not told that licorice was the test intervention, but instead that the purpose of the trial was to test gargling. Postoperatively, the patients were examined by blinded clinical investigators. Evaluations, based on an Table. Incidence of Postoperative Sore Throat by Treatment Time After PACU Arrival

Licorice, Sugar % Water, %

30 min

90 min

Average incidence

PACU, postanesthesia care unit

February 2012

AnesthesiologyNews.com I 19

CL I N I CA L A N E S TH E SIOL OG Y established scoring system, were conducted immediately after extubation; at 30 minutes, 90 minutes and four hours after arrival in the postanesthesia care unit (PACU); and on the first morning after surgery. Throat pain was assessed at each interval according to an 11-point Likert scale. The researchers presented the results of the study at the 2011 annual meeting of the ASA (abstract 177). Preoperative gargling with licorice decreased the mean score for sore throat pain at PACU arrival by 68% (95% confidence interval [CI], 23%-87%), compared with gargling with sugar water; the mean score decreased by 77% at 90 minutes after PACU arrival (95% CI, 45%-91%) and by 54% four hours after PACU arrival (95% CI, 4%-78%; P<0.001 for all comparisons; Table). When collapsed over time, the estimated odds ratio for coughing with licorice versus sugar was 0.64 (95% CI, 0.25%-1.18%). The investigators stated that the complete study included 236 patients with similar results and even greater statistical significance.

azunol and Strepsils lozenges (Reckitt Benckiser). Spraying the endotracheal tube with benzydamine hydrochloride, a nonsteroidal anti-inflammatory agent, also has been found to reduce the incidence of sore throat. Given the relative ease with which licorice solutions might be incorporated into clinical practice, Dr. Sessler recommended that institutions give serious thought to this option. “Licorice gargling is something that is dirt cheap, risk-free, simple to use

and has a substantial effect on a very real complication,” he said. “Furthermore, substantial efficacy is now well documented. So, why wouldn’t you use it?” Alex Macario, MD, MBA, professor of anesthesia and health research and policy at Stanford University School of Medicine in Stanford, Calif., called the trial a “nice example of outcomes research, as it studies an outcome that patients actually experience and we know [they] care about—not on

measurements that are surrogates for what may happen.” Dr. Macario, a member of the Anesthesiology News editorial board, said that similar to the systematic efforts of anesthesiologists in practically eliminating anesthesia deaths during routine surgery, common side effects such as sore throat will eventually disappear, by “perhaps using simple and safe preventive interventions such as the licorice gargle.” —Michael Vlessides

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‘Licorice gargling is something that is dirt cheap, risk-free, simple to use and has a substantial effect on a very real complication. … So, why wouldn’t you use it?’ —Daniel I. Sessler, MD “It’s quite unusual to have a large study show as big a treatment effect as an initial small study,” Dr. Sessler told Anesthesiology News. “Almost always, larger replication trials find much smaller effects than the original trials. That wasn’t true in this case, despite the fact that our study employed more involved operations with much larger, stiffer endotracheal tubes. There’s no question this [finding] is true.” Determining why this effect exists is the next challenge. “Licorice is a complicated compound and contains many molecules known to have biologic activity,” Dr. Sessler said. “I don’t know which of the proposed mechanisms is the important one, but it is not completely implausible that licorice would have an effect.” Other researchers have demonstrated a benefit from use of ketamine,

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20 I AnesthesiologyNews.com

February 2012

C LI N I C A L A N ESTHESI O LO GY

Sleep Hygiene Linked to Post-op Behavior Problems in Peds Chicago—Children who experience sleep-disordered breathing are significantly more likely to exhibit maladaptive behaviors following surgery than those without the respiratory problem, a new study has found. The investigators, from the University of Michigan, in Ann Arbor, said they were intrigued by the fact that postoperative behavioral problems— like fussiness, disobedience and introversion—also seem to be mitigated by daytime sleepiness. “All of us have taken care of obstructive sleep apnea patients at one time or another,” said Robert E. Christensen, MD, clinical lecturer in anesthesiology at the institution. “Sleep-disordered breathing represents the full spectrum of disorders, not just those patients who qualify for the full diagnosis of obstructive sleep apnea. We were interested in those patients, specifically in their postoperative behavior and the

impact of anesthesia there.” Although children with sleepdisordered breathing are known to be at increased risk for airway complications after surgery, information regarding postoperative behaviors in this population of patients is scarce. Dr. Christensen and his colleagues enrolled 337 children, aged 2 to 14 years, scheduled for elective surgery in their study. Before the procedures, parents of the subjects completed the Sleep-Related Breathing Disorders subscale (SRBD) of the Pediatric Sleep Questionnaire. Children with scores of 0.33 or higher on the SRBD were considered to have sleeping trouble, including sleep-disordered breathing, snoring and daytime sleepiness. One week after surgery, the Michigan researchers readministered the SRBD scale to parents, who also completed a questionnaire about their child’s behavior after discharge. A

behavior was considered maladaptive if parents rated it as “more/much more” than normal. The investigators, who reported their results at the 2011 annual

meeting of the American Society of Anesthesiologists (abstract 049), found that 26.7% of children had sleepdisordered breathing. Those who did see sleep page 28

Twice-daily Testing May Better Detect Post-op Delirium Chicago—Although research has yielded insights into optimal methods for identifying postoperative delirium, the optimal timing and frequency of these assessments is more clouded. A Cleveland Clinic study has shed more light on the subject, however, concluding that assessments performed in the morning and evening of the first three postoperative days (PODs) achieve optimal detection of this adverse event while minimizing interference in the patient’s healing process. Jing You, MS, a biostatistician in the Department of Outcomes Research at the Cleveland Clinic, told Anesthesiology News that postoperative delirium is not only associated with increased morbidity and mortality, but failure to recognize delirium delays treatment of affected patients, possibly prolonging hospital stays and increasing economic burden. Optimizing the timing of assessments to catch as many cases as possible makes good clinical and fiscal sense, she said. With that in mind, the researchers accessed data from 198 patients undergoing cardiac surgery at the institution. Trained investigators used the Confusion Assessment Method (CAM) to assess delirium in the mornings and early evenings of PODs 1 to 5. Patients were considered delirious if CAM testing proved positive at any time during the five days, including while they were in the postanesthesia care unit (PACU). As Ms. You reported at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 103), 21% of patients (41 of 198; 95% confidence interval [CI], 15%-27%) experienced delirium at least once during all the postoperative

assessments. The observed sensitivity of a single CAM assessment ranged from 0.07 (PACU) to 0.49 (morning of POD 3; Table). “We also looked at 14 different logical combinations of time periods,” Ms. You told Anesthesiology News. “These all yielded sensitivities of around 0.75, which is certainly better than the individual time-point sensitivities. The strongest predictive combination was from the morning of POD 1 to the evening of postoperative day 4, which caught 39 of 41 delirious patients [0.95 sensitivity; 99% CI, Table. Observed Sensitivity of a Single Confusion Assessment CAM Assessment Cases of Delirium Time Diagnosed Sensitivity Postanesthesia

0.07

POD 1 a.m.

0.24

POD 1 p.m.

0.32

POD 2 a.m.

0.34

POD 2 p.m.

0.34

POD 3 a.m.

0.49

POD 3 p.m.

0.32

POD 4 a.m.

0.34

POD 4 p.m.

0.22

POD 5 a.m.

0.24

POD 5 p.m.

0.15

CAM, Confusion Assessment Method; POD, postoperative day

0.79-1.00].” Among the six assessment combinations, the researchers found a 0.90 sensitivity (99% CI, 0.72-1.00) from the morning of POD 1 to the evening of POD 3. “So our suggestion is to perform the CAM assessment in both the morning and evening between day 1 and day 3,” Ms. You added. “We think that achieves optimal detection while minimizing interference with the healing process.” Terri Monk, MD, professor of anesthesia at Duke University Medical Center in Durham, N.C., noted that the 21% incidence of postoperative delirium observed during the first five days after cardiac surgery is markedly lower than the 37% to 52% incidences previously reported for such patients. “In this study, the delirium assessments were performed twice a day, at early morning and late evening,” Dr. Monk said. “Since delirium is known to fluctuate during the day, it is quite possible that postoperative delirium occurred between the two testing periods and the diagnosis was missed in some patients. “As such,” Dr. Monk continued, “the data do not support the researchers’ conclusion that delirium screening in the early morning and late evening of the first three postoperative days is optimal for the detection of postoperative delirium. A large study performing delirium screening at multiple times during a 24-hour period is needed to determine the true incidence and optimal timing to diagnose postoperative delirium.” —Michael Vlessides

CONTINUING MEDICAL EDUCATION

FEBRUARY 2012

Lesson 296: PreAnesthetic Assessment of the Elderly Patient With Coexisting Alcohol or Substance Use Disorder WRITTEN BY:

TARGET AUDIENCE

Ethan O. Bryson, MD Associate professor, Departments of Anesthesiology and Psychiatry, Mount Sinai Medical Center, New York, New York

Anesthesiologists, certified registered nurse anesthetists, anesthesiologist assistants

Elizabeth A.M. Frost, MD Professor, Department of Anesthesiology, Mount Sinai Medical Center, New York, New York

REVIEWED BY: Ram Roth, MD Assistant professor, Department of Anesthesiology, Mount Sinai Medical Center, New York, New York

DATE REVIEWED: December 2011 DISCLOSURES The authors and the reviewer have no relationships with pharmaceutical companies or manufacturers of products to disclose. This educational activity may contain discussion of published and/or investigational uses of agents for the treatment of disease. The FDA has not approved some uses of these agents. Please refer to the official prescribing information for each product for approved indications, contraindications, and warnings.

PROFESSIONAL GAPS Recent reports by the American Association of Retired Persons and press releases have highlighted a growing problem with drug and alcohol addiction in the elderly population that is both doctor- and patient-induced. This information should be emphasized to the anesthesia community because of potential drug interactions and other perioperative concerns.

CALL FOR WRITERS If you would like to write a CME lesson for Anesthesiology News, please send an email to Elizabeth A.M. Frost, MD, at ElzFrost@aol.com.

LEARNING OBJECTIVES At the end of this activity, the participant should be able to: 1. Describe the altered physiology that occurs during withdrawal. 2. List the potential anesthetic problems associated with substance abuse. 3. Identify postanesthetic complications of the newly sober elderly patient. 4. Describe the altered effects of different anesthetic agents in this patient population. 5. Discuss the altered physiology of the geriatric patient. 6. Identify potential drug–drug interactions, including alcohol. 7. Identify potential medical consequences of substance abuse. 8. Outline a management plan for the newly sober geriatric patient. 9. Present a plan for appropriate intraoperative monitoring. 10. Identify appropriate referral sources for continued recovery of the elderly patient.

CASE HISTORY A 74-year-old woman presented for surgical repair of a hip fracture 2 days after falling. She reported that she had fallen because she might have had “one too many” cocktails and was unsteady on her feet. Her medical history was significant for hypertension, osteoporosis, chronic lower back pain, and mild anxiety. Her medications included metoprolol, amlodipine, spironolactone, oxycodone, zolpidem, and alprazolam. The patient was widowed and lived alone. Her son and her daughter accompanied her to the hospital and expressed concern that their mother might be drinking too much and was often confused.

n December 2009, the Substance Abuse and Mental Health Services Administration reported that 4.3 million adults over the age of 50 years had used an illicit drug in the past year. The number of older adults with problems related to substance abuse and alcohol use is expected to double by the year 2020 and has been a topic of discussions by the Anesthesia Patient Safety Foundation. Alcohol and substance abuse among the elderly population is a hidden national epidemic. It is believed that about 10% of the population of the United States abuses alcohol, but surveys have revealed that as many as 17% of adults over age 65 have an alcohol abuse problem. A researcher at the University of Kentucky College of Medicine, in Lexington, found that 2.5 million older adults and 21% of older hospitalized patients had alcohol-related problems.1 Elderly alcohol abusers can be divided into 2 general types: the “hardy survivors,” who have been abusing

PREANESTHETIC ASSESSMENT Dr. Elizabeth A.M. Frost, who is the editor of this continuing medical education series, is clinical professor of anesthesiology at the Mount Sinai School of Medicine in New York City. She is the author of Clinical Anesthesia in Neurosurgery (Butterworth-Heinemann, Boston) and numerous articles. Dr. Frost is past president of the Anesthesia History Association and former editor of the journal of the New York State Society of Anesthesiologists, Sphere. She is also editor of the book series based on this CME program, Preanesthetic Assessment, Volumes 1 through 3 (Birkhäuser, Boston) and 4 through 6 (McMahon Publishing, New York City).

A COURSE OF STUDY FOR AMA/PRA CATEGORY 1 CREDIT Read this article, reflect on the information presented, then go online (www.mssm.procampus.net) and complete the lesson posttest and course evaluation before February 28, 2013. (CME credit is not valid past this date.) You must achieve a score of 80% or better to earn CME credit. TIME TO COMPLETE ACTIVITY: 2 hours RELEASE DATE: February 2012 TERMINATION DATE: February 28, 2013 ACCREDITATION STATEMENT The Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT The Mount Sinai School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits.™ Physicians should only claim credit commensurate with the extent of their participation in the activity. It is the policy of Mount Sinai School of Medicine to ensure objectivity, balance, independence, and scientific rigor in all CMEsponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices.

CONTINUING MEDICAL EDUCATION

This lesson is available online at www.mssm.procampus.net

alcohol for many years and have reached age 65, and the “late-onset” group, who begin abusing alcohol later in life. Alcohol abuse in the latter group often is triggered by life changes, such as retirement; death or separation from a family member, a friend, or a pet; health concerns; reduced income; sleep impairment; and familial conflict. The metabolic absorption rate of alcohol is higher in the elderly and in women than in younger individuals and in men. Thus, the same amount of alcohol results in higher blood alcohol levels in the former group, causing a greater degree of intoxication. Drug interactions and the often unexpected effects of anesthetic agents that occur in the elderly patient in withdrawal can complicate anesthetic care. Because of the patient’s altered physiology, critical situations may arise at any time. The anesthesia care provider should be aware of potential problems and how they can best be managed. It is increasingly common for elderly trauma patients to have coexisting drug addiction and alcoholism. The American Society of Anesthesiologists has indicated that the anesthesiologist is well positioned to intervene to direct the trauma patient to a recovery program. Hospital admission may present a teachable moment when the anesthesia care provider can offer the necessary support to an addicted patient to get into a recovery program.

Preanesthetic Assessment In the case presented, the patient had a clear surgical need. Despite her recent alcohol use, she was not currently intoxicated. However, the effects of chronic substance use and possible withdrawal might have complicated her intraoperative management. The drug- and alcohol-abusing patient is at high risk for many related medical problems that potentially complicate anesthetic management. For many addicted patients, admission to the hospital for surgical intervention related to an injury sustained while intoxicated represents their “bottom” or low point, during which they may be more responsive to interventions aimed at initiating a program of recovery. Depending on the individual, his or her health status, and personal relationships, there may be a number of reasons why an elderly person becomes addicted to alcohol or drugs. Special considerations for the geriatric patient who is abusing drugs include: • Physical pain: can be chronic resulting from deterioration with aging, or acute such as postoperative pain that is not well controlled. • Emotional pain: can be especially prevalent in isolated patients and widowed individuals who may not have the support of family or friends. • Confusion: such as in the early stages of Alzheimer’s disease, that can be caused by or result in unintentional abuse of prescription medication. • Insomnia: caused by a lack of daytime activity or frequent napping. A detailed history and physical examination of the patient are essential. Many substance-abusing patients have experienced a withdrawal. In the geriatric population, a lack of prescription analgesics or sleeping aids (eg, expired prescriptions and an inability to renew them) may be causative. Patients often are honest regarding their drug use in order to avoid experiencing the discomfort of pain or sleeplessness again, provided the

Table 1. Medical Conditions Associated With Chronic Alcohol Use Organ System

Problems

Central nervous system

Wernicke-Korsakoff syndrome, alcohol withdrawal syndrome, cerebellar degeneration, cerebral atrophy

Cardiovascular

Dilated alcoholic cardiomyopathy, dysrhythmias, hypertension

Gastrointestinal Esophagitis, gastritis, panand hepatobiliary creatitis, liver cirrhosis, portal hypertension, esophageal varices Skin and musculoskeletal

Myopathy, osteoporosis

Endocrine and metabolic

Ketoacidosis, hypoalbuminemia, hypomagnesemia

Hematologic

Thrombocytopenia, leukopenia, anemia

questions are posed in a nonaccusatory manner. Younger patients may exaggerate their daily opioid use in an attempt to receive more of the drug, whereas geriatric patients who imbibe or use hypnotics may downplay the extent of their use. In this case, although the patient had received opioids for a legitimate medical need, the dose and frequency needed to be addressed, as well as the hazards of combining these drugs with alcohol. In general, specific questions should be posed, without leaving room for interpretation—for example, “How much alcohol do you drink each day?” instead of “Do you drink alcohol?” Geriatric patients may not realize that they are drinking to excess and blame empty bottles on pilfering by caregivers. It is essential to find out how much of a drug the patient has been taking, in addition to when they last used it. Some patients might not consider marijuana or other substances to be a drug, thus direct questions about specific agents are important. If a patient says, “No,” it is reasonable to probe further and ask “Never?” or “Have you ever?” It is not unusual for elderly patients to indulge or experiment with drugs such as marijuana so as to appear “cool” to their children who may be using those drugs themselves. When assessing the addicted patient, it is important not to stereotype. The disease of addiction does not discriminate according to age or appearance. Establish a comfort level by asking every patient, from a young man in his 20s to a woman in her 80s, the same questions. The signs commonly seen in an alcoholic of a younger age such as problems at work and marriage difficulties may not be present in the older alcoholic. The disease of alcoholism in the elderly patient who no longer works or whose spouse has died may slowly progress undetected until an acute injury brings it to light. These patients are much less likely to voluntarily enter a rehabilitation program. Body language and the volume and tone of voice of the health care worker are important; all patients deserve privacy, respect, and kindness.

FEBRUARY 2012

Inappropriate questioning can make patients feel that they are being judged, and lead them to give less than honest answers. If the patient appears hesitant to answer, it might help to say something like, “I am not the police; I am not here to judge you. I only need to know these things so that I can care for you in a safe and effective manner.” Universal precautions should always be observed. In the case of an obtunded patient who cannot provide his or her history, it is appropriate to inquire about the patient’s drug use from friends or family.

Complications of Perioperative Alcohol Use Acute alcohol intoxication has been associated with increased risk for traumatic injury (eg, related to falls) that can complicate the patient’s medical management, perioperatively. In the patient who is acutely intoxicated, common findings include nystagmus, slurred speech, unsteady gait, and inability to coordinate gross motor functions. Polysubstance abuse is common and intoxication with other drugs of abuse (more likely medically prescribed), or interaction between medications and alcohol, also must be considered. Chronic alcohol consumption can lead to problems affecting almost all organ systems (Table 1), including a variety of neurologic deficits. Patients should be evaluated for signs of cerebellar degeneration and cerebral atrophy because acute intoxication may mask signs of chronic dysfunction. Thiamine deficiency can result in Wernicke’s encephalopathy, which should be considered in the confused patient with encephalopathy, oculomotor dysfunction, and gait ataxia. If left untreated, this disorder can progress to Korsakoff’s syndrome, resulting in selective anterograde and retrograde amnesia. Dilated cardiomyopathy, dysrhythmias, and hypertension should be considered, as well as peripheral neuropathy which should be documented prior to administration of neuraxial anesthesia. In a recent study, 20% of adult patients presenting for surgery were found to have a history of problematic alcohol use that ranged in severity from hazardous use and harmful consumption to abuse and dependence.2 Of these patients, almost 50% were physically dependent on alcohol and at risk for alcohol withdrawal syndrome (AWS). There is a linear dose–response relation between hazardous drinking and postoperative morbidity.3 The rate of complications in patients who consume 3 to 4 drinks per day is 50% higher than in those who consume 0 to 2 drinks. In patients who consume more than 5 drinks per day, the complication rate increases by 200% to 400%. Postsurgical morbidity and mortality is 2 to 5 times greater in the chronic alcoholic than in the general population, regardless of the surgical procedure. Complications include not only AWS, but also higher rates of postoperative infections, and increased risk for cardiovascular complications including dysrhythmias, sudden cardiac death, and hemorrhage. AWS is a potentially life-threatening condition that develops in up to 25% of alcohol-dependent patients. Mortality may reach 15% if AWS is not identified early and treated; even with proper treatment, the mortality rate is 2%.4

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FEBRUARY 2012

The pathophysiology of this syndrome is complex, but can be thought of as the reverse of intoxication. An increase in excitatory brain processes coupled with a decrease in activity of inhibitory processes usually develop within 6 to 24 hours after the last drink. Autonomic hyperactivity appears early, generally peaking in the first 24 to 48 hours with tremulousness, sweating, nausea, vomiting, anxiety, and agitation. If left untreated, neuronal excitation can progress to grand mal seizures. Following its initial symptoms, untreated AWS may lead to delirium tremens characterized by hallucinations (auditory and visual), disorientation, severe autonomic hyperactivity, and death secondary to cardiovascular or respiratory collapse.

Complications of Perioperative Drug Use Chronic substance abuse is commonly associated with developing a tolerance to the drug’s effects. Patients with chronic substance abuse—regardless of the drug being abused—often require a greater amount of opioid anesthetics per weight than other patients. This results from development of a cross tolerance to different classes of agents. Care of the patient who has been abusing stimulants such as cocaine, methamphetamines, and related drugs presents additional concerns during the perioperative period. Abuse of such agents can result in altered physiology that persists for days after the last ingestion. Like ephedrine, the primary mechanism of action of these drugs involves indirect sympathetic activation either by increased release, or decreased reuptake, of norepinephrine, dopamine, and serotonin from terminals in the central and autonomic nervous systems. Chronic abuse leads to catecholamine depletion that persists even though the patient has stopped active use.5 How long this depletion lasts is unclear, and thus directacting sympathomimetics such as phenylephrine should be used instead of indirect-acting agents in treating hypotension. The elderly patient who abuses alcohol and also takes angiotensin-converting enzyme inhibitors, and who becomes hypotensive intraoperatively, may respond best to vasopressin and methylene blue. Cocaine is both a direct- and indirect-acting agent that stimulates the sympathetic nervous system by blocking the presynaptic uptake of norepinephrine and dopamine, and also by directly stimulating dopaminergic receptors. Catecholamine depletion is seen more often with amphetamine use than in the cocaine-abusing patient. The composition of drugs produced illicitly—and not regulated—varies widely. Often, the white powder sold as cocaine also contains methamphetamines, among other compounds. Long-term use of amphetamines and cocaine warrants concern about cardiac dysrhythmias, even in the patient who is not acutely intoxicated. If time permits, such patients may benefit from a focused cardiovascular assessment, if appropriate.

Medical Consequences of Substance Abuse Addicted patients may appear to be healthier than they really are. Each case is different, but prolonged substance abuse should raise suspicion of organ damage; appropriate testing such as coagulation studies, liver function

tests, or hepatitis panel may be necessary. The route of drug ingestion also has implications. For example, parenteral abuse is associated with an increased risk for blood-borne viral infections such as HIV, hepatitis C, and hepatitis B—either through the sharing of injection equipment, or from unsafe sexual activities while intoxicated. Although both scenarios are less likely in the geriatric population, a recent increase in the incidence of sexually transmitted diseases among nursing home patients suggests that the possibility exists. Obtaining peripheral IV access often is a challenge in IV drug users. In patients abusing inhaled drugs (particularly methamphetamine), a thorough airway assessment is warranted because the smoke can be corrosive to dentition. Chronic marijuana smokers may present clinically with obstructive lung disease. In patients who report nasal administration—common with snorted cocaine or heroin—caution is warranted when inserting a nasogastric tube or nasal endotracheal tube because of nasal-septum atrophy. All users are at risk for drug dependency and overdose; many also may have associated mental health problems such as depression, anxiety, post-traumatic stress disorder, and sleeping disturbances.6 Cigarette smoking, obesity or other eating disorders, and chronic pain are common.

Interactions With Prescription Drugs Alcohol abuse in this generation is complicated by the use of prescription and over-the-counter (OTC) medications. The elderly population spends more than $500 million annually on medications. Combining medications and alcohol frequently results in significant adverse reactions. Reduced blood flow to the liver and kidneys in the elderly result in a 50% decrease in the rate of metabolism of some medications, especially benzodiazepines. Additionally, the long half-lives (often several days) of chlordiazepoxide and diazepam in the elderly cause prolonged sedation from these drugs; combined with the sedative effects of alcohol, the risk for falls and fractures can be elevated. Users of benzodiazepines can become confused and take additional doses. Veterans from the Korean or Vietnamese campaigns may have addictions to a wide variety of drugs that they continue to consume into their 80s and 90s. It is evident that geriatric patients often are prescribed many medications. As office visits become shorter because of financial constraints, the tendency of health care providers is to advocate mood-altering and antidepressant drugs rather than to listen more closely to patients’ problems. Benzodiazepines, monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake inhibitors often are given. MAO-A inhibition reduces the breakdown of primarily serotonin, epinephrine, and norepinephrine, and thus there is a higher risk for serotonin syndrome or a hypertensive crisis. When ingested, MAOIs slow the catabolism of dietary amines. Consumption of foods containing tryptophan, for example, may result in hyperserotonemia. The amount of tryptophan required to cause a reaction varies greatly among individuals, and depends on the degree of inhibition, which in turn depends on dosage and selectivity. Tyramine is broken down by MAO-A and MAO-B. Because inhibiting the action of MAO may result in its

excessive buildup, the patient’s diet must be monitored for tyramine intake. When foods containing tyramine are consumed, a hypertensive crisis may develop (the so-called “cheese effect“). MAO-B inhibition reduces the breakdown mainly of dopamine and phenylethylamine, so there are no dietary restrictions associated with this class of drugs, unless the dosage is high. The exact mechanism by which tyramine causes a hypertensive reaction is not well understood, but it is assumed that tyramine displaces norepinephrine from the storage vesicles and may trigger a cascade in which excessive amounts of norepinephrine can lead to a hypertensive crisis. Another theory suggests that proliferation and accumulation of catecholamines causes hypertensive crisis.7 Foods and drinks with potentially high levels of tyramine include liver, fermented substances such as alcoholic beverages, and aged cheeses.8 Certain meat extracts and yeast extracts (eg, Bovril, Marmite, and Vegemite)— often popular among the geriatric population—contain extremely high levels of tyramine, and should not be taken with these medications or alcohol. The most significant risk associated with MAOIs is the potential for interactions with OTC and prescription medicines, illicit drugs or medications, and certain supplements (eg, St. John’s wort).9 MAOI interactions with other drugs and certain foods are of particular concern for elderly patients who may feel depressed from adhering to dietary restrictions, and “don’t care if they live or die.”10 The use of OTC medications, solely or in combination with alcohol, also can have serious consequences. Laxatives, for example, can cause chronic diarrhea, which can lead to a sodium and potassium imbalance and dysrhythmias. Antihistamines, another popular OTC medication, can cause confusion; cold medications can elevate blood pressure and lead to strokes. Caffeine is frequently added to OTC medications, causing anxiety and insomnia. Often, the mixing of alcohol and OTC medications increases the occurrence of side effects and can intensify negative consequences. Nicotine dependence is a significant problem in the elderly, related to both addiction and boredom. The use of nicotine early in life sets the stage for morbidity and mortality from this addiction. More than 400,000 people in the United States die each year from smoking-related diseases. Elderly smokers not only continue to impair their respiratory systems, but also are more apt to die of respiratory diseases. The addictive potential of nicotine is manifested after coadministration of an MAOI. In rats, this combination specifically causes sensitization of the locomotor response, which is a measure of addictive potential.11 This may be reflected in the difficulties associated with smoking cessation, as tobacco contains a naturally occurring MAOI, in addition to the nicotine. Nicotine replacement products work successfully in the geriatric population, especially when combined with behavioral, supportive, and other therapies. In summary, MAOIs should not be combined with other psychoactive substances, such as antidepressants, painkillers, stimulants (both legal and illegal), or alcohol. Combinations that can be fatal include MAOIs and selective serotonin reuptake inhibitors, tricyclics, methylenedioxymethamphetamine, meperidine, tramadol, or dextromethorphan.

CONTINUING MEDICAL EDUCATION

This lesson is available online at www.mssm.procampus.net

Table 2. Suggested Doses for Adjuvant Therapy5

Have you ever felt you should Cut down on your drinking?

Adjuvant Drugsa

Suggested Dosages

Acetaminophen

650 mg PO, every 4 to 6 h as needed. Reduce dose if acetaminophen-containing opioid analgesics also are administered

Celecoxib

400 mg initially, followed by an additional 200-mg dose if needed on day 1. On subsequent days, the recommended dose is 200 mg bid, as needed

Clonidine

0.3 mcg/kg IV bolus preincision, followed by 0.3 mcg/kg per hour infusion or 1 mcg/mL added to local anesthesia for epidural or peripheral nerve block

Ketamineb

0.1-0.5 mg/kg IV bolus preincision, followed by 0.1-0.5 mg/kg per hour infusion

Ketorolac

30 mg IV every 6 h, as needed

Pregabalin

75-150 mg PO bid, or 50-100 mg PO tid

bid, twice daily; IV, intravenous; NSAIDs, nonsteroidal anti-inflammatory drugs; PO, per os; tid, three times daily a

The use of NSAIDs perioperatively may increase the risk for bleeding; the decision to administer should be made after discussion with the surgical team. b Care should be taken when administering ketamine to the elderly patient with hypertension or a delusional affect.

Postoperative Pain Management Hyperalgesia or hyperesthesia is common in the substance-abusing patient. Characterized by dramatically increased sensitivity to painful stimuli, this phenomenon is thought to develop through a spinal sensitization to glutamate and substance P.12 The chronic substance abuser may become hypersensitive to surgical and other stimuli, in addition to developing tolerance. These patients often will require even higher doses of anesthetic agents than would be expected from tolerance alone. Allodynia also may be present, whereby stimuli that normally are not painful to the patient may elicit the sensation of pain. Development of these phenomena may result from activity of N-methyl-D-aspartate (NMDA) receptor agonists.13 NMDA antagonists, such as ketamine, may be effective in relieving hyperalgesia and should be considered in refractory cases. Local anesthesia, whether administered directly in the surgical field or as a regional technique, can reduce the need for opioids. Regional techniques should be offered to the patient whenever appropriate, especially in cases of opioid tolerance or opioid-induced hyperalgesia. Suggested doses for adjuvant therapy for alternative methods of pain control are presented in Table 2. It should be noted that the opioid-tolerant elderly patient may require even lower doses of these medications. A “start low and go slow” approach is prudent.

Suggesting a Program of Recovery A certain degree of denial, rationalization, and minimizing can be expected when the addict or alcoholic is confronted. Often it is beneficial for the health care worker to conceptualize—separating the patient from the disease. If frustrated, the provider should direct negative sentiments at the disease instead of the patient. Ultimately the patient, who can begin to take responsibility for recovery, recognizes addiction. Often a well-timed push in the right direction can make a significant difference. Many anesthesia care providers might be uncomfortable bringing up the topic of substance abuse, and may not know what to say. To open a dialogue with the patient

FEBRUARY 2012

about the extent of his or her drug use, it is helpful to pose questions that are open-ended and that also encourage reflection. By asking questions such as the following, the health care worker is encouraging the addicted patient to consider the current situation and health consequences of continued drug use: • “Have you thought that perhaps you fell because of your drinking/drug use?” • “Have you ever considered drinking less?” • “Have you ever thought that you do not have to live like this anymore?” The postoperative check is the perfect time to broach the subject by inquiring about the patient’s plans after discharge; this may open a discussion about possible referral to an inpatient treatment center or sober community. Patients may become defensive at suggestions of addiction. The addict who is in denial may respond better to a statement such as, “I am not necessarily saying that you have these problems; however, we do see a lot of people here who have a problem with drugs or alcohol, and have sustained injuries exactly like yours. Please think about it.” Challenges that are unique to the addicted elderly patient may present barriers to treatment; these include matters of pride, economic restraints, and failing health. It can be very difficult for elderly patients who have lived long lives, raised families, and been successful, to view themselves as “drug addicts,” when they should be enjoying their golden years. As well, many of the physical symptoms of drug withdrawal may be too hard for the older patient in ill health to tolerate. Treatment should be expedited to prevent a further decline in health, but detoxification should proceed only in a medically monitored setting. Elderly patients already may have tried to become sober through self-help groups such as Alcoholics Anonymous, and may feel discouraged that it did not work for them. Some may have been involved in minor traffic accidents and had their driver’s license suspended because of alcohol-related problems that they might have attributed to poor eyesight or mechanical problems with a car. These patients should be encouraged to seek help again. Addiction is a chronic, relapsing disease and multiple attempts often are necessary before lasting sobriety is achieved. It is

Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever felt you needed a drink first thing in the morning (Eye opener) to steady your nerves or to get rid of a hangover? Each question is answered with a yes (1 point) or no (0 points) response. A score of 2 or more is considered indicative of an alcohol problem.

Figure 1. The CAGE questionnaire. The CAGE questionnaire is a diagnostic tool developed by John A. Ewing, MD, founding director of the Bowles Center for Alcohol Studies, University of North Carolina, Chapel Hill. CAGE is an acronym formed from the bolded letters in the questionnaire (cut-annoyed-guilty-eye).

important to request discharge planning and social work for appropriate referrals. Patients may not be interested in sobriety when they feel better prior to discharge, so the idea of entering a program should be broached early on—often with the support of family members. Not all patients will have access to the Internet, so local telephone numbers of the following organizations should be provided to patients: • Alcoholics Anonymous (www.aa.org) • Narcotics Anonymous (www.na.org) • Cocaine Anonymous (www.ca.org) It also is important to tell patients that meetings of these anonymous programs are free and widely available in most areas. Family members should be encouraged to help with transportation if necessary. Anesthesiologists perform a disservice when they treat the acute needs of the patient, but do not address the underlying problem of addiction, which often has contributed to the patient’s condition.

Management of the Case Presented Given the patient’s history of substance use, the diagnosis of alcohol use disorder (AUD) was considered. Preanesthetic assessment included use of the CAGE questionnaire (Figure 1) and AUDIT questionnaire to evaluate the patient. Answers provided on these two screening tools suggested AUD. Subsequently, a discussion was held with the orthopedic surgeon regarding the urgency of hip fracture repair and risks to the patient of proceeding. The consensus was that surgery should not be postponed until after the patient’s treatment and detoxification—which would require a minimum period of abstinence of 4 weeks. It was decided that inhibition of the sympathetic symptoms of withdrawal would be instituted with low-dose morphine (15 mcg/kg per hour) before induction of anesthesia, and for 3 days, postoperatively. Parenteral thiamine was administered preoperatively, and maintained for 5 days postoperatively to prevent Wernicke’s encephalopathy and Korsakoff’s syndrome. The decision was made to proceed with spinal anesthesia for the procedure so that the patient could be monitored for signs of AWS, intraoperatively. Because the potential for clotting abnormalities is elevated in

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FEBRUARY 2012

patients with alcoholic liver disease, prothrombin time and partial thromboplastin time levels were confirmed within normal limits before regional anesthesia was administered. Additionally, because chronic alcoholics may need higher doses of anesthetics, secondary to cross tolerance or metabolic tolerance (induced P450 system), the decision was made to avoid general anesthesia if at all possible. Surgery proceeded without incident; premedication with benzodiazepines to prevent withdrawal delirium in the postoperative period was not necessary. The patient did not develop autonomic instability. In the postoperative period, while the patient was recovering, a family meeting was arranged to discuss the patient’s diagnosis of AUD. Arrangements were made for direct admission to an inpatient rehabilitation facility at discharge, should the patient be amenable to such a plan.

Mental Health Services Administration, Rockville, Maryland) describes signals that might indicate an alcohol- or medication-related problem in an elderly person. Therapy of these elderly patients centers around education for, and from, health care providers, family, and pharmacies; increased attention by the patient’s family, that includes maintaining a medication inventory; attempts at increasing activity levels of the patient; and patient participation in the Twelve-Steps, or other self-help and support-group programs.

References 1.

Kork F, Neumann T, Spies C. Perioperative management of patients with alcohol, tobacco and drug dependency. Curr Opin Anaesthesiol. 2010;23(3):384-390.

Sørensen LT, Jørgensen T, Kirkeby LT, Skovdal J, Vennits B, WilleJørgensen P. Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery. Br J Surg. 1999;86(7):927-931.

Conclusion Alcohol and drug abuse may be difficult to detect in the elderly patient. A list published by the Center for Substance Abuse Treatment (Substance Abuse and

Hays LR. Substance use disorders in the elderly: prevalence, special considerations, and treatment. Paper presented at: Annual Meeting of the American Academy of Addiction Psychiatry; December 12-15, 2002; Las Vegas.

Visit www.mssm.procampus.net today for instant online processing of your CME post-test and evaluation form. There is a registration fee of $15 for this non–industry-supported activity. For assistance with technical problems, including questions about navigating the Web site, call toll-free customer service at (888) 345-6788 or send an email to Customer.Support@ProCEO.com.

Spies CD, Rommelspacher H. Alcohol withdrawal in the surgical patient: prevention and treatment. Anesth Analg. 1999;88(4):946-954.

Klein M, Kramer F. Rave drugs: pharmacological considerations. AANA J. 2004;72(1):61-67.

Bryson EO. The anesthetic implications of illicit opioid abuse. Int Anesthesiol Clin. 2011;49(1):67-78.

Giannini AJ. Psychotropic drug overdose. In: MS Keshavan, JS Kennedy, eds. Drug-Induced Dysfunction in Psychiatry. New York, NY: Hemisphere Publishing; 1992:41.

Mosher CJ, Akins S. Drugs and Drug Policy: The Control of Consciousness Alteration. Thousand Oaks, CA: Sage; 2007.

Villégier AS, Blanc G, Glowinski J, Tassin JP. Transient behavioral sensitization to nicotine becomes long-lasting with monoamine oxidases inhibitors. Pharmacol Biochem Behav. 2003;76(2):267-274.

10. Kramer PD. Listening to Prozac. New York, NY: Viking Penguin; 1993. 11. Guillem K, Vouillac C, Azar MR, et al. Monoamine oxidase inhibition dramatically increases the motivation to self-administer nicotine in rats. J Neurosci. 2005;25(38):8593-8600. 12. Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006;104(3):570-587. 13. Mizoguchi H, Watanabe C, Yonezawa A, Sakurada S. New therapy for neuropathic pain. Int Rev Neurobiol. 2009;85:249-260.

For inquiries about course content only, send an email to ram.roth@mssm.edu. Ram Roth, MD, is director of PreAnesthetic Assessment Online and assistant professor of anesthesiology at The Mount Sinai School of Medicine, New York, NY.

Post-Test 1.

The patient in alcohol withdrawal will likely exhibit: a. nystagmus, slurred speech, an unsteady gait, and inability to coordinate gross motor functions b. obtundation and difficulty in arousal c. tremulousness, sweating, nausea, vomiting, anxiety, and agitation d. no specific signs or symptoms

Potential anesthesia problems associated with substance abuse include: a. altered physiology that persists for days after the last ingestion b. tolerance to opioids and other anesthetics c. appearing healthier than his or her actual health status d. all of the above

Postanesthetic complications of the newly sober patient include: a. dramatically increased sensitivity to painful stimuli b. decreased incidence of withdrawal syndrome c. decreased incidence of postoperative wound infections d. decreased incidence of postoperative bleeding

Which of the following is a true statement about the altered effects of anesthetic agents in elderly patients who are drug- or alcohol-addicted? a. Propofol does not reliably induce general anesthesia in this population. b. Patients often will require a greater amount of opioid anesthetics per weight than the patient who is not abusing drugs. c. Ephedrine is the preferred drug for treatment of hypotension in these patients. d. In these patients, dopamine will not increase the blood pressure.

The potential medical consequences of substance abuse include: a. blood-borne viral infections b. obstructive lung disease c. atrophy of the nasal septum d. all of the above

Which of the following is a consideration for pain management in the newly sober patient? a. Hyperalgesia or hyperesthesia is not common in the substance-abusing patient. b. Allodynia may exist, and normally nonpainful stimuli may elicit the sensation of pain. c. N-methyl-D-aspartate antagonists, such as ketamine, are not effective in the reduction of hyperalgesia. d. Regional anesthesia should not be offered when there is tolerance of opioids or opioid-induced hyperalgesia.

When suggesting a program of recovery to the drug- or alcohol-abusing patient: a. denial, rationalization, and minimizing are rarely evident b. it is acceptable to be upset with the patient because it is not the job of the health care provider to address these issues c. the individual does not need to take responsibility for his or her own recovery d. a well-timed push in the right direction can make a significant difference in the patient’s life or health

Which of the following are appropriate referral sources for patients’ continued recovery? a. Self-help programs such as Alcoholics Anonymous and Narcotics Anonymous b. Inpatient treatment programs for medical detoxification, followed by therapy c. Outpatient treatment programs d. All of the above

What level of alcohol use suggests that a patient may have alcohol use disorder? a. Alcohol used socially on a monthly basis b. 1 to 2 drinks per day c. More than 2 drinks per day d. Alcohol is a legal drug and has not been associated with any use disorder.

10. The patient who drinks more than 2 servings of alcohol per day has an increased risk for which perioperative complication? a. Sudden cardiac death b. Pulmonary embolism c. Decreased tolerance to anesthetic agents d. Intraoperative hypotension

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C LI N I C A L A N ESTHESI O LO GY Sleep continued from page 20

were significantly more likely to exhibit maladaptive behaviors following surgery than children with healthier sleep hygiene (Table). Several other factors were significantly associated with maladaptive behaviors, including being overweight or obese, having had an adenotonsillectomy, preoperative and postoperative snoring and daytime sleepiness before and after surgery (P<0.01). Adenotonsillectomy (odds ratio [OR] 9.89; P<0.01) and postoperative daytime sleepiness (OR 2.8; P<0.01) also were independent risk factors for maladaptive behaviors. “Where it got really fun was when we started breaking down the elements of sleep-disordered breathing subscales,” Dr. Christensen noted. “And when we looked at the entire group—those with and without sleep-disordered breathing—those with daytime sleepiness had more behavioral problems.” This finding suggests that sleep hygiene, and the underlying sleepiness, might be leading to the increased

Table. Children With Sleep-disordered Breathing Were More Likely To

behavioral problems, not simply the Experience a Variety of Maladaptive Behaviors After Elective Surgery sleep-disordered breathing itself, Dr. Christensen said. If the link holds No SleepSleepdisordered disordered up in future studies, clinicians could Breathing, Breathing, alert parents to the importance of a n (%) n (%) Odds Ratiob good sleep hygiene before and after Behavior surgery. Avoid/afraid of new things 6 (2.5) 7 (7.9) 3.31 Mehernoor Watcha, MD, associDifficulty deciding 9 (3.8) 9 (10.2) 2.87 ate professor of pediatric anesthesiolFollows parent around the house 21 (8.9) 18 (20.5) 2.63 ogy at Baylor College of Medicine in Houston, congratulated the researchers Seeks attention 33 (13.9) 25 (28.4) 2.44 for following their patients beyond the Bad dreams/wakes a lot 27 (11.4) 35 (39.8) 5.11 recovery room. “Most of us think ‘Hey, I got them Fussy about going to bed 9 (3.8) 9 (10.2) 2.87 out of the PACU [postanesthesia care Fussy about eating 16 (6.8) 30 (34.1) 7.11 unit], my job’s done,’” Dr. Watcha said. Spends time doing nothing 43 (18.2) 33 (37.5) 2.69 But the new data show that “patients who have what is considered a normal Poor appetite 25 (10.6) 41 (46.6) 7.36 recovery still continue to have behav22 (9.3) 24 (27.3) 3.65 ioral problems for some time at home, Temper tantrums and this is a problem as far as the par- Disobeys 20 (8.47) 21 (23.9) 3.39 ent is concerned. Lack of interest in games/toys 8 (3.39) 9 (10.2) 3.25 “I wonder if any particular type Difficult getting child to talk 7 (2.9) 12 (13.6) 5.17 of anesthetic intervention is going to change this,” Dr. Watcha added. a “Either way, I think it’s very important b Behaviors reported by parents as “more/much more” than normal 95% confidence interval to continue this type of work.” P<0.05 for all —Michael Vlessides

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Anesthetic Management of the Obese Surgical Patient Jay B. Brodsky; Hendrikus J.M. Lemmens

Cambridge University Press, January 16, 2012 The management of obese and morbidly obese patients differs significantly from that of normal weight patients undergoing the same procedure. Anesthetic Management of the Obese Surgical Patient discusses these specific management issues within each surgical specialty area.

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Basics of Anesthesia: Expert Consult: Online and Print, Sixth Edition

Ronald D. Miller; Manuel Pardo Elsevier/Saunders, June 24, 2011 Widely acknowledged as the foremost introductory text, the new edition has been thoroughly updated to reflect new and rapidly changing areas in anesthesia practice, including new chapters on awareness under anesthesia, quality and patient safety, orthopedics and expanded coverage of new ultrasound techniques in regional anesthesiology with detailed illustrated guidance.

Case Studies of Near Misses in Clinical Anesthesia John G. Brock-Utne, MD, PhD, FFA

Springer, August 9, 2011 Drawing on 40-plus years of practice in major metropolitan hospitals in the United States, Norway and South Africa, this book presents 80 carefully selected cases that provide the basis for lessons and tips to prevent potential disaster.

Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia

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Richard D. Urman; Nalini Vadivelu Lippincott Williams & Wilkins, June 8, 2011 This book is an invaluable tool for every resident and practicing physician who needs to understand the essentials of acute and chronic pain management, including all current guidelines and standards of care.

Practical Ultrasound In Anesthesia for Critical Care and Pain Management

Philip M. Hopkins; Andrew R. Bodenham; Scott T. Reeves Informa Healthcare, December 15, 2008 This book is a stand-alone comprehensive reference that covers important aspects of ultrasound for the practicing anesthesiologist. Beginning with a background on the physics of equipment and practical applications, it covers subjects such as needle visualization, teaching, training, accreditation and getting the best out of your ultrasound equipment.

Techniques in Regional Anesthesia and Pain Management

McGraw-Hill, December 7, 2011

Steven Stanos Elsevier/Saunders, 2012

Featuring sections that progress from the foundations of regional anesthesia to the clinical applications of nerve blocks, Hadzic’s includes tips and insider perspective and also includes a unique atlas of ultrasound anatomy for regional anesthesia and pain medicine.

The concept underlying this publication is to combine the timeliness of a quarterly journal with the illustrative aspects of a procedure-oriented atlas. Exact techniques are well illustrated, giving precise drug dosages and helpful clinical pearls. AN0212

30 I AnesthesiologyNews.com

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A D L IB

Honing the Eye To Train the Mind Anesthesia program uses art to improve observation “Observe, record, tabulate, communicate. Use your five senses. … Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.” —William Osler, MD

f the practice of medicine is equal measure art and science, it follows that brushing up on the former will help with the latter. To that end, famous paintings—not patients— were the subject of an unusual course designed to teach observation skills to anesthesiology residents at St. Luke’sRoosevelt Hospital, in New York City. In a presentation at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 148), the clinicians who put together the fine art–based curriculum said they sought to boost “interpersonal and communications skills,” one of the six core competencies set forth by the Accreditation Council for Graduate Medical Education for the training of residents. Study co-leader Tova Sebaoun, MD, assistant professor of anesthesiology at St. Luke’s, said anesthesiology residents are highly skilled at collecting and analyzing verbal, written and electronically communicated data. But they may miss out on some of the clinically valuable visual cues from patients when they are interacting with them in person. However, between time pressure and technology, today’s residents face a sensory overload that appears to squeeze out the time for close observation and processing of patients’ appearances. “If I don’t explain the pathophysiology and disease process of diabetes, my residents will not see its connection with the fact that the patient looks way older than he or she should,” she said. “The No. 1 answer I get a lot in those discussions is ‘I didn’t think about that!’” Dr. Sebaoun and her colleagues asked anesthesiology residents at St. Luke’s to observe one painting per week for 10 weeks. They chose works painted by well-known artists that depicted at least one person prominently in the scene. A poster-sized print of each painting was hung in the anesthesiology lounge areas. Residents also received an electronic version and submitted their observations by email. There

“The map might hint that the husband is a traveler overseas,” Dr. Sebaoun said. “The blue is the predominant striking color of the painting and should really be noticed by anyone.” Visual arts have been used in other medical education programs. In a 2001 article, “Learning to look: developing clinical observational skills at an art museum,” Charles Bardes, MD, professor of clinical medicine at Weill Cornell Medical College, in New York City, and colleagues described a program developed in partnership with his institution and The Frick Collection, a private art museum near the hospital (Med Educ 2001;35:1157-1161). The course took place at the Frick and began with a pretest in which students made observations based on a photograph of a patient’s face. They then proceeded to examine painted portraits, where they worked with art educators to describe what they saw and make inferences. “Both the museum and medical faculty observed improvement in the students’ skills in description, interpretation and presentation,” the authors wrote. “In the post-test, describing the same photograph, students were more precise in their descriptions. They also inferred more from their observations, remarking that the subject appeared sad, anxious, worried and perhaps ill “Woman in Blue Reading a Letter” by Johannes Vermeer. Rijksmuseum, Amsterdam. as well.” The researchers in both studies cited enthusiastic feedback from the 70% of residents did not mention the color “blue,” residents and suggested there was a despite its dominating presence. The same percentage side benefit—students and faculty appreciated the non-medical interacof students failed to mention the large map hanging tions that took place between them. personally enjoyed it a lot,” said on the wall across most of the top half of the painting. Dr.“I Sebaoun, who plans to offer the course again with her colleagues. “I were no restrictions on comment in Blue Reading a Letter,” by Johannes think it was effective, in the sense that length, but residents were told not to Vermeer (above), which hangs in the the residents seemed to wake up to consult outside sources. At the end of Rijksmuseum in Amsterdam, The some sensory levels they forgot they the 10-week period, the authors and Netherlands, and 70% did not men- had. And it seems our residents comresidents analyzed the comments. tion the color “blue,” despite its domi- municated with us on a different level Residents made some surprising nating presence. The same percentage from anesthesia, as if a drop of humanomissions. For instance, about 20% of students failed to mention the large ity was added to our demanding life.” of residents did not notice that the map hanging on the wall across most female subject is pregnant in “Woman of the top half of the painting. —Jennifer Hanawald

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