The March 2012 Digital Edition of Anesthesiology News by McMahon Group

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The Independent Monthly Newspaper for Anesthesiologists AnesthesiologyNews.com • M a r c h 2 0 1 2 • Volume 38 Number 3

Team Approach Slashes Central-Line Infections Houston—Can hospitals drive their rates of central-line bloodstream infections to zero? Although the goal sounds like a pipe dream, new research has found that multidisciplinary team approaches are making great strides in dramatically reducing rates. At the University of Massachusetts Memorial Medical Center in Worcester, for example, a team of clinicians dedicated to preventing central-line infections

Hospitals Feeling the Pain Of Sedative Shortage

n late January, the call went out at Rochester Medical Center in upstate New York. Clinicians were advised to dramatically cut back on their use of two mainstay IV sedatives, diazepam and lorazepam, supplies of which were becoming increasingly tight. Curtis Haas, PharmD, director of pharmacy at the hospital, sent an email to staff clinicians, stating that “we currently have very low supplies of both IV diazepam and IV lorazepam and have directed providers ... to use IV midazolam. However, we’re not counting on receiving any more shipments of any IV products until at least next week and maybe not until mid-February and do expect this shortage to be long-term.”

see team page 27

see shortage page 22

Laughter, and Tears, on the Way To Safer Anesthesia (Part 2)

INside

y March 1965 I had been promoted to Senior Registrar in Anaesthesia at the Middlesex Hospital, Mortimer Street, London, W,1. The Middlesex Hospital was, but no longer is, one of London’s best and most famous teaching hospitals. The hospital has been razed and the land is now devoted to growing weeds. I suspect the site of the hospital was chosen by its founders in the 1740s because of its proximity to The Cambridge, a rather nice pub across the road. In 1965, Consultants in Anesthesia wanted as much private work as they

12 | Pain Medicine

08 | COMMENTARY Protecting your practice in the “we” society.

could gather. This meant they had to make themselves available whenever a surgeon’s secretary phoned them and said, “Professor Turner-Warwick has a couple of cystoscopies at The London Clinic on Wednesday at about half-past two. Are you available then, Dr. Dinnick?” The answer was always ‘yes’ whether or not Dr. Dinnick was really available. No, meant he was supposed to anesthetize a list of National Health Service patients on Wednesday see laughter page 17

How to minimize infection risk from spinal cord stimulator surgery.

24 | Policy & Management Expert witness testimony—a cautionary tale.

34 | CLinical Anesthesiology Potassium check called a “low-yield” diversion for patients with renal failure.

40 | technology Continuous capnography lowers monitoring costs.

Educational Review

Paravertebral Blocks: The Evolution of a Standard of Care, see insert at page 32.

Special Report Addressing Current Challenges In Managing Postsurgical Pain With EXPAREL®, a new DepoFoam® Formulation Of Bupivacaine, see insert at page 24.

McMahonMedicalBooks.com Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia Admir Hadzic,MD, PhD

see page 44

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March 2012

Discuss these and other articles @ AnesthesiologyNews.com.

Heard Here First: As consumers and purchasers of both health care and technology, we must demand

interoperability across EHR systems to move this forward. March 2012

See article on page 36.

The five most-viewed articles last month on AnesthesiologyNews.com 1. Seeing the (Green) Light in the OR 2. Laughter, and Tears, on the Way To Safer Anesthesia (Part 1) 3. Preinduction Licorice Gargle Relieves Post-Op Sore Throat, Cough 4. Survey Finds “Discouraging” Injection Habits Among Anesthesiologists 5. Hospital Closings Helping Reshape Anesthesia Job Market

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March 2012

C OMM E NT A R Y Can it be that it was all so simple then? Or has time rewritten every line?

The Way We Were

here are events in people’s lives that they are able to remember in detail—the sounds, sights and smells—years, even decades later. Included somewhere in the middle of my catalogue of vivid memories is my first successful axillary block. In residency, we were taught to perform these blocks by the feel of a needle passing into the axillary sheath, an exquisitely subtle sensation that I, as a novice, unsuccessfully struggled to appreciate the first five or six times I tried to perform the procedure. Then, there was that late Friday afternoon in 1972 when, for the first time, I got it, and it worked. Following this success, I started to seek out nerve blocks whenever possible. I learned new techniques and began to enjoy doing them with confidence. Those were the bad old days, when the value of regional anesthesia was not as appreciated as it is today. I often heard, “Why don’t you just put him to sleep?” And that was from my attendings! The comments from surgeons were even less polite. The development of nerve stimulation made regional blocks more accepted. Residency programs began to teach them, and more anesthesiologists became willing to perform them. At the same time, surgeons, seeing good results, faster turnover and satisfied patients, became more open, even anxious, to have their patients blocked. Enter ultrasound. Suddenly it was possible to teach the basics to the masses. True, ultrasound does come with a bit of a learning curve. But once learned, ultrasound allows even a complete numbskull to numb the upper and lower extremity. OK, not quite, but certainly any modestly skilled anesthesiologist can do so. I attended a few courses on ultrasound-guided blocks and soon found myself gravitating to this exciting new technology. Success rates were close to 100%.

Previously painful, even excruciating procedures like total knee replacements and rotator cuff repairs now could be consistently performed with minimal postoperative pain, not just in university centers but also in the hinterlands. Advances in regional anesthesia were accompanied by similar technological progress in other areas of anesthesia. Those of us who remember the adrenaline-fueled, sweaty-palmed tachycardia of a difficult airway case in the 1970s or 1980s can only marvel at the relative simplicity of fiber-optic or video-assisted intubations. End-tidal gas monitoring assures us of proper endotracheal tube placement and takes much of the guesswork out of judging anesthetic depth. Beep-by-beat

belief that despite the spectacular technological progress in medicine in the last half century, many doctors are unhappy with the field and would not encourage their children to enter it. We all have heard the commonly cited reasons for this dissatisfaction: decreasing income, Steven S. Kron, MD malpractice suits, government intrusions and more. Dr. Jacobs opines that, along with standardization by protocols, the technological improvement in care resulting from all our new bells and whistles have made medicine less satisfying to the current generation of physicians. Medicine is no longer an art requiring unique diagnostic insights, courage or manual dexterity. It has been simplified into a task performable by any individual trained to use the equipment and follow the protocols. On one hand, this transformation may benefit patient care by increasing the supply of trainable physicians and lowering costs. On the other, it will decrease the satisfaction of the individual doctor who once was able to make the diagnosis that others missed and do the difficult operation—or the slick nerve block—unaided by $50,000 gadgets. As a result, the quality and type of individual entering medicine will change. Entrepreneurial, risktaking, “I’ll sleep when it’s done” individualists will look elsewhere for professional satisfaction. In their place will be team players attracted to a 9-to-5 schedule built on the relative simplicity of following standardized protocols and pushing the correct button. As suggested in these pages before, there is of course another possibility: To complete his task, the button pusher doesn’t really need an MD. It’s also possible that these fears are merely those of medical Luddites, for we have seen technological advances initially opposed but ultimately enthusiastically accepted by the profession. Only time will tell.

oxygen saturation and the replacement of a difficult mask fit with a wellseated supraglottic airway are de eply comforting. This should be all great, but somehow on one level it isn’t. Allan Jacobs, a g ynecologic oncolo—Steven S. Kron, MD gist, practicing attorney and old high school chum of Dr. Kron is a retired anesthesiologist in Connecticut and a frequent mine, points to the oft-repeated contributor to Anesthesiology News.

PONV prevention:

Gets to work early.

PONV prevention that covers the entire at-risk period from post-op to PACU discharge Priming dose starts early Unique transdermal delivery system provides a priming dose of scopolamine upon application Statistically signiﬁcant reduction in nausea, vomiting, and retching 2 to 4 hours post-op1

Continuous release keeps working Extended release delivers a near constant dose over 24 hours2 66% of Transderm Scop® patch patients vs. 46% for placebo reported no retching/vomiting within the 24-hour period postadministration

Stays late. 1. Kotelko DM, Rottman RL, Wright WC, et al. Transdermal scopolamine decreases nausea and vomiting following cesarean section in patients receiving epidural morphine. Anesthesiology. 1989;71:675-678. 2. Transderm Scop® [package insert]. New Providence, NJ: Baxter Healthcare Corporation; 2006.

Indications and Important Risk Information for the Transderm Scop® patch (scopolamine 1.5 mg) Transdermal Therapeutic System

Indications The Transderm Scop® patch is indicated in adults for prevention of nausea and vomiting associated with recovery from anesthesia and surgery. The patch should be applied only to skin in the postauricular area. Important Risk Information The Transderm Scop® patch is contraindicated in: Persons who are hypersensitive to the drug scopolamine or to other belladonna alkaloids or to any ingredient or component in the formulation or delivery system. Patients with angle-closure (narrow-angle) glaucoma. The Transderm Scop® patch should not be used in children. The Transderm Scop® patch should be used with caution in the elderly or in individuals with impaired liver or kidney function; patients with pyloric obstruction, urinary bladder neck obstruction, or in patients suspected of having intestinal obstruction. Also use with caution in patients with a history of seizures or psychosis.

Since drowsiness, disorientation and confusion may occur, patients should not drive, operate dangerous machinery, or participate in activities that require alertness. Patients should not use alcohol. Use with caution in patients taking other drugs that can cause CNS effects, such as sedatives or tranquilizers. Rarely, idiosyncratic reactions have occurred. The most serious that have been reported include acute toxic psychosis, confusion, agitation, rambling speech, hallucinations, paranoid behavior and delusions. Since scopolamine can cause dilation of pupils and blurred vision upon direct eye contact, patients should be strongly advised to wash hands thoroughly with soap and water immediately after handling the patch. Because of an aluminized layer in the delivery system, it is recommended to remove The Transderm Scop® patch prior to undergoing an MRI. Skin burns have been reported at the patch site during an MRI.

Monitor glaucoma therapy in patients with chronic open-angle (wide-angle) glaucoma.

In ﬁve postoperative nausea and vomiting clinical studies, the most commonly reported adverse events were dry mouth (29%) and dizziness (12%).

Please see full prescribing information on the following page.

01/12 720254

Baxter is a registered trademark of Baxter International Inc. Transderm Scop is a registered trademark of Novartis AG.

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March 2012

C OMM E NT A R Y

vidualis di

ME o

the other extreme can see the benefits of co-opting the current zeitgeist. For instance, as the current wave of collectivism shapes trends in health care, hospitals seek to ride the wave to further their “me” interests. Take as examples the completely hospital-centric notions of accountable care organizations (ACOs), so-called “health care collaboration” and physician alignment.

share and giving back. Physicians are told that the future of health care is not in the “every man for himself ” situation, but rather in the “it takes a village” world. Of course, not everyone in a society buys into the “Me-We Cycle,” and that’s why trends eventually moderate and return to the antipode. People, businesses and organizations that espouse

he tides come in and out, ties get wider then narrower then wider again and society switches between respecting individualism and valuing community and cooperation. I call this the “Me-We Cycle.” Currently, our society is heavily motivated by a “we” mindset, focusing on shared sacrifice, paying your fair

Protecting Traditional Practice in Today’s ‘We’ Society

m m u ni

Physicians who want to survive the crush of the Me-We Cycle’s current collectivist position need to make sure they are not being taken advantage of. Internally, if you practice with others, you must take steps to ensure that your group is cohesive. Bringing cohesion to your group involves working through governance and management issues as well as weaving legal protections throughout your group’s agreements. These are not individual efforts; they require careful strategy and execution far beyond the traditional notions of shareholder, partnership, employment and subcontract agreements. Hospitals often use dissension within a group as both an excuse and a pathway to extend their tentacles of control. If there is no current discord within a group, hospitals often foster it.

ClipChart

Atlanta, GA: Karri Willoughby, charged with giving her stepfather, Billy Junior Shaw, a lethal injection of propofol, pleaded guilty to murder in February. Ms. Willoughby, a former nurse, received a 20-year prison sentence for the crime, which occurred in 2008. Scheduled to testify for the prosecution in the case was Stephen Shafer, MD, editor of Anesthesia & Analgesia, who was the government’s star witness last year in the trial of Conrad Murray, MD, Baxter Healthcare Corporation | 95 Spring Street | New Providence, NJ 07974 1-800-ANA-DRUG (1-800-262-3784) | 01/12 720254| www.baxter.com

March 2012

AnesthesiologyNews.com I 9

COMME N TA R Y Consider a group consisting of three physicians, an owner and two employed physicians who have offices located Mark F. Weiss, JD adjacent to a hospital. The physician-owner has held a medical directorship at the hospital for some time. One of the employed physicians becomes unhappy with his subordinate role, despite his inferior skills and management style. Instead of striking out on his own, the dissatisfied physician approaches the hospital’s CEO who convinces the physician that it would be too expensive to start his own practice. Instead, the CEO argues that if the physician could get the other doctor to join him, the hospital would “sponsor” their new practice through an existing controlled medical group. The two employed physicians take the bait. In this scenario, the hospital gains control of the practice, jettisoning its relationship with the original physician-owner. There’s now talk about folding the existing controlled medical group into a larger foundation model designed by the

hospital to be its physician entity for its planned ACO. To survive, you must take steps to stop or hinder the hospital’s efforts to take advantage through collaboration. Seek alliances with similarly situated groups and explore ways of using the hospital’s existing medical staff bylaws and political support within the medical staff to preserve physician control. Engage in a publicity push both within the medical staff and in the community at large.

Use hospital efforts to “align” physicians to argue for physician control. If your relationship with the hospital involves a contractual arrangement, build in restrictions and protective provisions, such as prohibitions on solicitation and fees for outplacement to the hospital. Eventually, the Me-We Cycle will shift back the other way, but this may take decades. If you’d like to wait it out, then you don’t need to take action other than to learn the words, “May I

have my paycheck, please?” —Mark F. Weiss, JD Mark F. Weiss, JD, is an attorney who specializes in the business and legal issues affecting anesthesia and other physician groups on a national basis. He holds an appointment as clinical assistant professor of anesthesiology at USC’s Keck School of Medicine and practices with the Advisory Law Group, a firm with offices in Los Angeles and Santa Barbara, Calif., representing clients across the country. He can be reached by email at markweiss@advisorylawgroup.com.

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

Michael Jackson’s personal physician. Jackson died in June 2009 of an overdose of propofol administered by Dr. Murray. Now as then, Dr. Shafer would have tried to debunk a defense theory that the victim managed to give himself the fatal injection, according to a report he prepared for the prosecution. Postmortem tests revealed the presence of not only propofol but vecuronium and pseudoephedrine in blood drawn from Mr. Shaw’s heart. Based on his analysis of the autopsy materials and pharmacodynamics of the drugs involved, Dr. Shafer wrote, “I believe the first event was oral administration of a combination of vecuronium and pseudoephedrine, with the expectation of death from paralysis, and falsely implying pseudoephedrine overdose.” When that failed, Dr. Shafer concluded, Ms. Willoughby subdued Mr. Shaw with another drug, possibly succinylcholine, traces of which would not be present on autopsy, and then administered the lethal injection of propofol.

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.

OFIRMEV and the OFIRMEV dot design are trademarks of Cadence Pharmaceuticals, Inc.

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March 2012

IN BRIEF

Opioid Use for Abdominal Pain Sees Recent Spike

rom 1997 to 2008, opioid prescriptions for chronic abdominal pain more than doubled in the United States, according to a new study in Clinical Gastroenterology and Hepatology (2011;9:1078-1085). In the study, the investigators estimated the national prescribing trends and factors associated

with prescribing opioids for chronic abdominal pain. They identified visits to outpatient clinics for this disorder using reason-for-visit codes from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2008. Data were weighted to produce national estimates of opioid prescriptions

over time. The researchers found that the number of outpatient visits for chronic abdominal pain consistently decreased over time from 14.8 million visits in 1997 to 1999 to 12.2 million visits in 2006 through 2008 (P=0.04). However, the adjusted prevalence of visits

when an opioid was prescribed increased from 5.9% in 1997 through 1999 to 12.2% in 2006 through 2008 (P=0.03). Opioid prescriptions were most common among patients aged 25 to 40 years (odds ratio [OR], 4.6) and less common among uninsured (OR, 0.1) and black (OR, 0.3) patients. The investigators noted that this increase in opioid prescriptions has been problematic, in part because no study has shown opioids to be effective for treating chronic abdominal pain. When used over long periods of time, opioids may worsen other gastrointestinal symptoms, such as constipation, nausea and vomiting. The growing use of opioids to treat “persistent abdominal pain highlights the growing challenges clinicians face trying to manage chronic illness without the time, infrastructure and incentives needed to take the integrated approach that experts suggest,” said lead study author Spencer D. Dorn, MD, MPH, assistant professor of medicine at the University of North Carolina at Chapel Hill, in a statement. The researchers speculated that the growth in opioid use likely has been driven by a tendency to generalize recommendations for the use of opioids in treating pain, campaigns to recognize pain as the “fifth vital sign” and marketing efforts. The researchers concluded that future studies could help illuminate the reasons for and consequences of this trend. —AN Team

March 2012

AnesthesiologyNews.com I 11

I N BR I E F

Look Mallampati, No Hands! movements of a pre-recorded procedure. Again, the rate of firstpass success was 100%, yet the mean intubation time was faster, at 41 seconds, the researchers said. For all mannequin procedures, the speed of intubation improved over time, the investigators noted. Finally, Dr. Hemmerling’s group tested their robot in 12 patients.

The device achieved successful intubation in 11 (91%) patients, with one attempt foiled by fogging of the video laryngoscope lens. “The 91% success rate in human trial is influenced by the small number of patients in this pilot study,” he said. “Don’t forget that the failure in one patient resulted from fogging of the video laryngoscope

and had nothing to do with the robot. Fogging is a common problem with video laryngoscopes whether they are attached to a robot or used manually.” —Adam Marcus

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n a feat that could have important implications for the performance of airway management in remote locations and public spaces—not to mention the operating room—Canadian researchers have developed the first intubating robot. In data presented at the 2012 annual meeting of the Society for Technology in Anesthesia, Thomas Hemmerling, MD, and colleagues at McGill University in Montreal, Quebec, reported early success with their Kepler Intubation System. The Kepler system consists of a joystick that manipulates a robotic arm, which in turn holds a video laryngoscope (Pentax AWS). An operator sitting in an “intubation cockpit” uses computer software to control the apparatus, which also can be programmed to perform automatically—the ultimate aim of the program, Dr. Hemmerling said. “One could imagine—obviously not in the near future— that these devices are placed similar to automated defibrillators in the public areas,” Dr. Hemmerling told Anesthesiology News. “Another part of development focuses on evaluating whether the Kepler system can be used with higher precision than manual, human intubation devices—similar to the advantages of the da Vinci surgical robot [Intuitive Surgical] in comparison with endoscopic surgery devices.” Dr. Hemmerling is the inventor of the McSleepy closed-loop anesthesia system. To demonstrate the feasibility of the device, Dr. Hemmerling’s group first tested it in mannequins. For 30 intubations, the operator in the cockpit was allowed to directly observe the procedure. For another 30 intubations, the procedure was performed blindly. In both cases, the technology delivered 100% first-pass success, according to the researchers, with similar mean intubation times of 46 and 51 seconds, respectively. The McGill team then had the robot perform 30 more intubations by following the

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March 2012

P A I N M E DI C I NE

Infection After Stim Implants Common—But Avoidable New Orleans—Although many risk factors make surgical site infections difficult to avoid during implantation of spinal cord stimulators, it is possible to reduce the infection rate using a variety of methods before, during and after surgery, according to speakers at the 2011 fall meeting of the American Society for Regional Anesthesia and Pain Medicine.

“The fight against a surgical site infection involves physicians’ complete vigilance, not just during the operation. We need to execute on all three phases of the game: preoperatively, intraoperatively and postoperatively,” said Maunak V. Rana, MD, director of pain management for Chicago Anesthesia Pain Specialists.

Common Risk Factors Dr. Rana and David Provenzano, MD, executive director of the Institute for Pain Diagnostics and Care at Ohio Valley General Hospital in McKees Rocks, Pa., discussed factors associated with increased infection risk after implantation, as well as tactics to control infection. Infection rates typically range from 2% to 13%, they said.

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Superficial infections are defined as those occurring within 30 days of an operation. If an infection occurs after implanting a device, the criteria extend to one year. The most common bacterial pathogens associated with such infections are Staphylococcus aureus and S. epidermidis. Risk factors for methicillinresistant S. aureus (MRSA) are hospitalization within the previous 30 days and age over 65 years, as well as IV drug abuse or antibiotic therapy. Dr. Provenzano added that MRSA carriers can have transient, intermittent or persistent colonization, which can occur at multiple sites (anterior area, perianal area, groin). High bacterial numbers and virulence, immunosuppression and prolonged surgery (>4 hours) may increase risk for infection. Other surgical subspecialties have observed that decolonization of carriers cuts the infection rate almost in half. “I test my patients,” Dr. Provenzano said. “Certainly, for any patient with a history of MRSA, I get a nasal swab.” Diabetes is one of the most important risk factors for developing a surgical site infection, likely because of how it affects circulation and cell-mediated immunity. In a recent study, diabetes was associated with almost a fivefold increased risk for the complication (J Neurosurg Spine 2010;12:540-546). Other risk factors are obesity, remote site of infection and inappropriate antibiotic prophylaxis. Prevention Is Key Based on published research and the Centers for Disease Control and Prevention recommendations published in 1999, Dr. Provenzano cited measures that could help prevent surgical site infections, including antibiotic prophylaxis (Table). Level 1A evidence supports giving a prophylactic antibiotic against the most common pathogens that cause infections during surgery, and providing an initial dose intravenously so that a bactericidal concentration is established in the serum and tissues when the incision is made. For eliminating S. aureus and S. epidermidis, Dr. Provenzano recommended administering cefazolin with the appropriate dose based on the patient’s weight. Vancomycin should be prescribed only for patients who are allergic to b-lactams, who are in the hospital for more than 24 hours prior to surgery or who have MRSA.

March 2012

AnesthesiologyNews.com I 13

Pa in M e d ic ine ‘The fight against a surgical site infection involves physicians’ complete vigilance, not just during the operation. We need to execute on all three phases of the game: preoperatively, intraoperatively and postoperatively.’ —Maunak V. Rana, MD

dosing is weight-based in obese patients. In addition to preoperative antibiotics, occlusive dressings can reduce the incidence of infection, as can irrigation, double-gloving and povidone-iodine– impregnated draping. Chlorhexidine gluconate remains the best prepping solution for preventing surgical site infections. In a recent comparison, chlorhexidine reduced the rate of deep and superficial infections by 50% over povidone-iodine (N Engl J Med 2010;362:18-26).

Finally, it is important to have an infection control plan. Investigators who adhered to strict asepsis, used double-layer hydrocolloid dressings and prescribed prophylactic antibiotics had an infection rate of 4.8% (four of 84 patients), including 1.2% during the trial (one patient) and 3.6% (three patients) during the second implantation stage (Neuromodulation 2011;14:136-141). Surgeon experience and patient education also played an important role in reducing infection.

Although these results on prevention are promising, both speakers called for research specific to reducing infection risks among stimulator patients. “In this ever-changing entity, we need more research on our end,” Dr. Rana said. —Caroline Helwick Dr. Rana has received financial support from Boston Scientific and St. Jude. Dr. Provenzano disclosed financial relationships with Cadence, Medtronic and Ortho-McNeil-Janssen.

Timing and dosing of antibiotics also are important for reducing infection risk. The Surgical Care Improvement Project aims to reduce surgical complications by 25%; the group’s quality measures include administering an antibiotic within one hour of surgery and discontinuing it within 24 hours. A single dose, compared with 24-hour dosing, is clinically effective and more cost-efficient, Dr. Provenzano noted. Suboptimal timing of antibiotic administration can raise the risk for infection by two- to threefold. It is critical that the patient receives the drug before the surgical incision and that

Intraoperative measures

Level IA Treat all remote infections Give antibiotics Do not remove hair unless interfering Level IB Control glucose (>200 mg/dL) Stop tobacco use (30 d) Shower with an antiseptic agent Level II Keep preoperative stay short Level IB Maintain positive pressure ventilation in OR Keep OR doors closed Remove gross contamination (clean around incision) Use appropriate antiseptic for skin preparation Perform surgical scrub for two to five minutes

Postoperative measures

Preoperative measures

Table. Measures To Help Prevent SSIs Based on the CDC’s SSI Guidelines

Level IB Protect with sterile dressing 24 to 48 hours Wash hands before and after dressing changes Level II Use sterile technique when dressing is changed Uncover wound after 48 hours Able to shower with uncovered wound

CDC, Centers for Disease Control and Prevention; OR, operating room; SSI, surgical site infection

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March 2012

PA IN MEDICINE

Experts Debate Efficacy Of Diagnostic Diskography SonoPlex – THE Ultrasound Nerve Block Cannula With SonoPlex, PAJUNK® has developed a new cannula-generation, an innovation, which for the first time facilitates the unerring localization by means of ultrasound technology. The distal end of the cannula shaft has been equipped with a circumferential array of reflectors. The nature of the „Corner Stone“ reflectors renders optimal reflection properties in any position, at steep and at flat puncture angles as well.

Visible cannula tip The distal end has been provided with two pattern-embossed sections, each having a length of 10 mm and separated from each other by a blank zone, which provides for additional orientation. The visibility of the cannula therefore covers a total length of 20 mm, and it is thus distinctively recognizable.

The reﬂection guarantee The embossed indentations at the tip of the cannula are shaped as if the corner of a cube had been impressed into the surface: This renders three surfaces which respectively coincide in 90° angles. The surface is thereby enlarged in such way to permit the - direct or indirect - reﬂection of the ultrasound waves from almost every angle of incidence.

100 % reflection - thanks to „Corner Stone“ reflectors The „Corner Stone“ reflectors reflect ultrasound waves in a spectrum of incidence angles ranging from 60° to -20°. The visibility of the cannula is therefore guaranteed at a flat puncture angle, and at a steep puncture angle as well.

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Regional Anaesthesia • Laparoscopy • Biopsy • Worldwide

New Orleans—Is diskography a good diagnostic tool for determining the source of low back pain? That question was debated at the 2011 fall meeting of the American Society of Regional Anesthesia and Pain Medicine by Leonardo Kapural, MD, PhD, professor of anesthesiology at Wake Forest University School of Medicine, in Winston-Salem, N.C., and David A. Provenzano, MD, executive director of the Institute for Pain Diagnostics and Care at the Ohio Valley General Hospital, in McKees Rocks, Pa. Diskography currently is used to determine whether the disk is a source of predominantly axial back or neck pain. It is indicated in patients with severe symptoms not diagnosed by other means or who fail to respond to surgical procedures. It also is used to assess disks before fusion, disk replacement or minimally invasive surgical procedures. “Diskography is a great diagnostic test if manometry is used and guidelines are followed. It can detect painful intervertebral disks, and can eliminate unnecessary treatments,” Dr. Kapural said. “Diskography can rule out adjacent segmented diskogenic pain and it remains the standard for visualizing internal disk architecture.” Dr. Provenzano disagreed, arguing that there is “no diagnostic gold standard and no meaningful follow-up therapeutic—so don’t do diskograms.” A Dispute Over Validity According to Dr. Provenzano, the diagnostic validity of diskography is questionable primarily because it yields a high number of false-positives—the technique has 81% sensitivity and 64% specificity. False-positive rates vary widely, from 10% in patients with no low back pain or chronic pain to 40% after lumbar diskectomies to 83% among individuals with somatization disorder. Even low-pressure injections in subjects without low back pain produced pain in 25% of subjects, which correlated with both anatomic and psychosocial factors (Spine 2006;31:505-509). The high falsepositive rate makes interpreting positive diskograms in clinical practice problematic, Dr. Provenzano noted. But Dr. Kapural argued that if clinicians use manometry and follow the

guidelines of the International Spine Intervention Society and the International Association for the Study of Pain, false-positives drop off substantially. He cited rates of approximately 3% per person and 2% per disk in asymptomatic patients, 6% per person and 4% per disk in chronic pain patients, 15% per person and 9% per disk in post-diskectomy patients and 50% and 22%, respectively, in individuals with somatization disorder. To limit false-positives, most diskography standards set a pressure criterion of no more than 50 psi. In an ongoing study (not yet published), Dr. Kapural found positive responses in three of 10 disks when the intradiskal pressure difference was above 50 psi. Overpressurization of the intervertebral disks happens frequently if a manometry control is not used, he noted, adding, “That, in turn, can cause falsepositive results.” All positive responses should be confirmed with repressurization and a small volume of contrast. If the patient has significant pain in a disk without a grade 3 tear, the clinician should consider pain referred from a contiguous disk, overlap of innervations or a fissure too small to discern by fluoroscopy. When pain is felt at all levels that are stimulated, “this is never a positive diskogram,” he said. Other Complicating Factors In addition to the problem of false-positives, Dr. Provenzano also expressed concern that technical issues make diskography a less-thanperfect diagnostic test. Factors that influence pressure measurements include injection speed, contrast viscosity, location of sensors and the needle profile. He noted that vertebral endplate deformation and transfer of pressure to adjacent disks may occur during the performance of diskography, adding that there is no correlation between annular tear and the site of low back pain. For instance, in one study, after repeat diskography where an abnormal disk was anesthetized, the authors determined that the pain felt in an adjacent, morphologically normal disk was caused by referred pain (Arch Orthop Trauma Surg 2007;127:699-703). “And if diskography works, what do you do for the disk problem?”

March 2012

AnesthesiologyNews.com I 15

Pai n Medi ci ne Dr. Provenzano continued. The rate of success with surgical interventions has varied from less than 50% in some studies to more than 86% in others. Similarly, adverse event rates are variable, but have been reported to be as high as 18% for device-related complications, 26% for neurological complications and 29% for dural injury; the need for reoperation has reached 46%, he said. Studies relating surgical outcomes to diskography results also have provided little conclusive evidence to perform the test, he said. Nonsurgical interventions can produce outcomes with similar efficacy rates to surgery. Dr. Provenzano, who admitted to using the diskography in selected circumstances, also expressed concern about the potential for negative clinical and biological consequences from diskography. A 2009 radiographic analysis in 87 patients found a threefold increase in the risk for

‘Diskography is a great diagnostic test if manometry is used and guidelines are followed. It can detect painful intervertebral disks, and can eliminate unnecessary treatments.’ —Leonardo Kapural, MD, PhD

adjacent-level disk degeneration in incorrectly marked disks after anterior cervical discectomy and fusion. In a 10-year cohort study involving small-gauge needles and limited pressurization, diskography resulted in accelerated disk degeneration, disk herniation, loss of disk height and signal and the development of reactive endplate changes compared with matched controls. And, in laboratory studies, bupivacaine has been shown to diminish cell viability, leading to cell necrosis. “The intervertebral disk is a vulnerable structure that lacks a significant blood supply, depends on diffusion for nutrition and has poor repair mechanisms,” Dr. Provenzano said. “The animal and clinical science data suggest there may be clinical consequences on the disk itself from needle puncture. The question is whether annular puncture leads to disk degeneration, and animal studies suggest it does.” Dr. Kapural maintained that the data support the use of diskography in diagnostic assessment. A systematic review of patients with lumbar (n=69), cervical (n=10) or thoracic (n=2) diskogenic pain found diskography useful in identifying a subset of patients with chronic spinal pain secondary to intervertebral disk disorders (Pain Physician 2007;10:147-164). Specifically, the study showed strong evidence that diskography could identify chronic lumbar diskogenic pain and moderate evidence that it could identify chronic cervical diskogenic pain; evidence was limited for its role in assessing chronic thoracic diskogenic pain. Dr. Kapural also pointed out that minimally invasive radiofrequency annuloplasty provides better success than surgery in selected patients and that biological treatments are just around the corner. For patients whose source of back pain is unclear, diskography can help determine if the disk is a source of their pain and thus define the pain generator. “In terms of the relationship between disk degeneration and pain, we are dealing with a lot of unknown factors,” Dr. Kapural said. “But to date, provocation diskography is the only available method of linking the morphologic abnormalities seen on MRI with clinically observed pain.” —Caroline Helwick Dr. Kapural has received consulting fees from Kimberly-Clark and Pfiedler Enterprises and research grants from Baylis Medical, Inc. Dr. Provenzano has received consulting fees from Medtronic and Ortho-McNeil-Janssen and has served on the speakers’ bureau for Cadence.

SonoLong – The new revolutionary echogenic catheter kit equipped with “3D Cornerstone” reflectors PAJUNK® has, as the first and only manufacturer, initiated a system, by which the catheter is introduced under sterile conditions directly from a cassette through the TRUE echogenic SonoPlex cannula. The SonoPlex cannula is equipped with “3D Cornerstone” reflectors, which render optimal reflection properties at steep and shallow puncture angles. This SonoLong kit is perfectly suitable for the optimal ultrasound guided continuous nerve block.

Visibility – regardless of the puncture angle

The distal end of the SonoPlex cannula is equipped with a pattern embossed section over the ﬁrst 20 mm. This new feature provides optimal visibility of the cannula tip, which can be identiﬁed with absolute certainty, regardless of steep or shallow puncture angles.

Maximum stability and improved echogenicity – through steel stylet

The catheter of the SonoLong kit has been provided with a steel stylet, which gives the catheter maximum stability and improves echogenicity. It is removed after catheter insertion.

Optimal ﬂow and localization – through central opening and depth graduations

The distal end of the radiopaque catheter is open. This ensures the free ﬂow of the anesthetic – particularly in connection with the post-operative injection pump. In addition, the 50 cm long catheter, has been provided with ascending depth graduations at intervals of 5 cm. Therefore its exact position can be determined at any time. Please e-mail us for a free sample kit or visit our website for more information richard.ﬁscher@pajunk-usa.com www.sonoplexusa.com

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Regional Anaesthesia • Laparoscopy • Biopsy • Worldwide

16 I AnesthesiologyNews.com

March 2012

P A I N M E DI C I NE

Pacira Pharmaceuticals Inc.

Rise in Narcotics Scripts To Elderly Linked to More Falls and Fractures Chicago—Following the recall of the cyclooxygenase-2 (COX-2) inhibitor Vioxx in 2004 because of concerns over potential cardiovascular adverse events, narcotic analgesics became an even more important means of treating and controlling chronic pain. A study presented at the 2011 annual meeting of the American College of Rheumatology has found that prescriptions for narcotic analgesics and falls and fractures in elderly patients with osteoarthritis both rose substantially once Vioxx (rofecoxib, Merck), a nonsteroidal anti-inflammatory drug (NSAID), was taken off the market (abstract 911). Lead author Lydia Rolita, MD, of New York University School of Medicine, in New York City, suggested that the increase in falls and fractures is associated with the rise in the use of narcotics in these patients. “These findings strongly indicate that recommendations for the treatment of chronic pain need to be re-evaluated,” Dr. Rolita said. However, she added, the study does not establish a cause–effect relationship between narcotic analgesics and falls or fractures. The investigators reviewed medical records for 10,000 patients over the age of 65 years who were diagnosed with osteoarthritis between 2001 and 2009. They used ICD-9 codes to identify the number of falls and fractures that occurred in this time frame. Analgesic use was divided into three categories: narcotic analgesics with or without other analgesics; COX-2 inhibitors alone or with other analgesics; and non-COX-2 inhibitor NSAIDs, other analgesics or no analgesics. The researchers found that the percentage of study patients who received opioid prescriptions increased from 8% in 2002 to 20% in 2004 and doubled to 40% in 2009. Use of COX-2 inhibitors was low in this population, peaking at 8% in 2004 and then declining. Almost all of these patients were prescribed non-COX-2-blocking NSAIDs and/or other analgesics in 2002, but this number declined to about 70% by 2009. Patients older than age 70 years who had more comorbidities experienced a greater number of falls and fractures regardless of the type of pain medication they took. The incidence

of falls and fractures increased from less than 1% in all patients in 2001 to 4% in 2009. Use of narcotic analgesics was associated with a 3.7 times greater risk for falls and fractures than use of COX-2 inhibitors (P<0.001), and a 4.4 times greater risk than nonCOX-2 NSAIDs (P<0.001) from 2005 to 2009. The investigators stated that the incidence of falls and fractures “appears to be associated with the increased use of narcotic analgesics.”

‘We need to rethink our management of chronic pain in the elderly. We can’t just say ‘no’ to NSAIDs and use narcotics instead.’ —Eric Matteson, MD “Using narcotic analgesics—not abusing them—is associated with more falls and fractures in the elderly,” said Eric Matteson, MD, chair of the Division of Rheumatology at Mayo Clinic in Rochester, Minn., who was not involved in the study. “We need to rethink our management of chronic pain in the elderly. We can’t just say ‘no’ to NSAIDs and use narcotics instead.” Dr. Matteson said he advises his patients to try nonpharmacologic pain management approaches, including exercise to improve strength and endurance and weight loss. “Weight loss is associated with a reduction in pain associated with arthritis,” he said. In situations where patients anticipate having pain, such as after exercise, he encourages them to take one or two acetaminophen tablets. “Patients could also try one or two Tylenol [acetaminophen] tablets with one ibuprofen, or perhaps two over-the-counter–strength ibuprofen, or an over-the-counter naproxen tablet.” However, he said, he encourages patients not to rely on NSAIDs on a regular basis. —Alice Goodman

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Introducing EXPAREL®: Non-Opioid Postsurgical Pain Control For Up to 72 Hours Q: What is EXPAREL (bupivacaine liposome injectable suspension)?

A: EXPAREL is a local analgesic that uses bupivacaine and is indicated for administration into the surgical site to produce postsurgical analgesia. A single dose given at the close of surgery provides up to 72 hoursa of analgesia with reduced opioid requirementsb and without the need for catheters and pumps.

Q: What does EXPAREL do?

A: In a pivotal soft-tissue trial compared with placebo, in which all patients with inadequate pain control received opioids for rescue pain relief, EXPAREL demonstrated a 30% reduction in cumulative pain scores and a 45% reduction in opioid consumptionb through 72 hours.c

Q: How does EXPAREL work?

A: EXPAREL uses DepoFoam®, a multivesicular drug delivery technology, to release bupivacaine over time. Other formulations of bupivacaine should not be administered within 96 hours following the administration of EXPAREL.

Q: How is EXPAREL administered?

A: EXPAREL is infiltrated into the surgical site using the same technique surgeons already use to infiltrate local anesthetics for postsurgical analgesia, and can be administered using needles as narrow as 25 gauge. The recommended dose is based on the surgical site and the volume required to cover the area; the maximum dose should not exceed 266 mg (or one 20 mL vial).

Q: What important safety considerations should I know before using EXPAREL?

A: EXPAREL is contraindicated in obstetrical paracervical block anesthesia and should not be used in patients under 18 years old. As with other local anesthetic products, patients should be monitored for cardiovascular and neurological status, and vital signs should be performed during and after injection of EXPAREL. Because amide-type local anesthetics such as bupivacaine are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk for developing toxic plasma concentrations. The most common adverse reactions (incidence ≥10%) following administration of EXPAREL were nausea, constipation and vomiting.

Q: Why is a new non-opioid option for postsurgical pain management valuable?

A: More than 90 million surgical procedures are performed every year in the United States.d Surveys have indicated that postsurgical pain often is undertreated, with as many as 80% of patients reporting pain after surgery.e Current options to prolong postsurgical analgesia rely heavily on medication delivery devices. Although effective, these devices can be prone to catheter-related issues and often deliver opioids, which are associated with a range of unwanted and potentially costly side effects.f As the only single-dose local analgesic capable of providing pain control for up to 72 hoursa with a reduced reliance on opioids,b EXPAREL has the potential to play an important role in the management of postsurgical pain.

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A: EXPAREL is available in 1.3%, 20 mL single-use vials. EXPAREL can be used as supplied or diluted with up to 280 mL of normal saline to accommodate administration into larger surgical sites. Please see brief summary of Prescribing Information on adjacent insert. For more information, visit www.EXPAREL.com or contact: Pacira Pharmaceuticals, Inc. 5 Sylvan Way Parsippany, NJ 07054 Phone: (855) RX-EXPAREL (855-793-9727) email: medinfo@pacira.com a

Pivotal studies have demonstrated the safety and efficacy of EXPAREL in patients undergoing bunionectomy or hemorrhoidectomy procedures; additional studies are under way to further demonstrate the safety and efficacy in other procedures. b The clinical benefit of the attendant decrease in opioid consumption was not demonstrated. c Gorfine SR, et al. Dis Colon Rectum. 2011;54:1552-1558. d Cullen KA, et al. Natl Health Stat Report. 2009(11):1-25. e Apfelbaum JL, et al. Anesth Analg. 2003;97:534-540. f Adamson RT, et al. Hosp Pharm. 2011;46(6 Suppl 1):1-8. EXP-AP-0037-201201

March 2012

AnesthesiologyNews.com I 17

PR N Laughter continued from page 1 afternoon at The Middlesex. On Wednesday either I, or one of my fellow Senior Registrars would be called to take over Dr. Dinnick’s National Health list at about one-thirty so that he could rush over to the London Clinic, visit and check the private patient and then anaesthetize him or her for TurnerWarwick at 2.30 and then go home and send a bill for numerous guineas. A guinea is, or was, one Pound and one Shilling: these days 105 p. Even though National Health salaries for Consultants were quite generous, living in Central London was expensive. Immediate availability when a surgeon called any time 24 hours a day remained an imperative for success in private practice. We Senior Registrars felt quite sympathetic to our Consultants’ financial difficulties and thus we never grumbled about our role, as it were, ‘off the bench’. Perhaps we felt some connection to our own aspirations to become Consultants. Sometimes when a Consultant anesthesiologist was booked for two private cases at the same time one of us would be sent as a ‘super-sub’ to the London Clinic and would end up with a few guinea-crumbs from the Consultants’ table, a modest check at the end of the month. The point is that our superiors considered us fully competent. Otherwise they would not have donated the occasional private patient to us. I had passed all my specialist examinations. I had had every imaginable clinical experience including 18 months at the London Chest Hospital doing cardiothoracic anesthesia, neurosurgical anesthesia at the Maida Vale Hospital for Neurosurgery and so on. I had written and published several papers of clinical and scientific interest in Anaesthesia and The British Journal of Anaesthesia, at that time among the few leading journals in our specialty in the world. By then we had been married nearly five years

Middlesex Hospital, London, early 19th century.

and owned two babies and a small house in the far suburbs with a 100% mortgage. If it were not for Aideen’s professional fees as a freelance violinist running all over the United Kingdom’s discovered and undiscovered parts for work, our two babies would have gone hungry. I believe that marasmus, such a threat- Gerald Zeitlin, MD ening word, describes what might have happened to Louise and Jon if there had been a slump in the fiddling business. That is why the conversation I had after lunch one day, with Dr. Peter Dinnick, the chief of anaesthesia at the Middlesex Hospital, on one of the back stairwells of the hospital remains so utterly clear in my memory; so vivid I can report it word for word: Act One: The Back Staircase at the Middlesex Hospital Dr. Dinnick: (in a well-cut suit, going down). “Aah! Zeitlin!” Dr. Zeitlin: ( wearing a ‘scrub suit’, going up). “Yes. Sir.” Dr. Dinnick; “I think I’ll be done at the Clinic by 7. Two hips and a fractured elbow. Why don’t you spread the word I’ll be buying bitters for the boys at the Cambridge in the Private Bar.” Dr. Zeitlin: “Yes Sir, Thank you Sir. And I’ll see the patients coming in for your G.Y.N. list tomorrow.” Dr. Dinnick: “Aah! Zeitlin! Very good.” Dr. Zeitlin: (ascends two steps and is now level with Dr. Dinnick who is about to take the next step down. It is quite clear to Dr. Zeitlin from this that Dr. Dinnick has assumed that the thought of free beer had ended any substantive speech on Dr. Zeitlin’s part. Despite my correct assumption about his assumption I looked for

If there was one reason why Dinnick wanted me to go to America for a year it was not to polish my curriculum vitae. It was simple. He did not want more competition for the gold of private practice if I should be appointed as another Consultant at the Middlesex. and found a mote of courage for my next major pronouncement). “Sir.” Dr. Dinnick (detecting a note of anxiety in that syllable). “What is it Zeitlin? No trouble with a surgeon I hope, old chap?” Dr. Zeitlin: “Oh No Sir! Not at all Sir. In fact things went very well yesterday with Oswald Eyeball. (Dr. Dinnick’s secret name for an amazingly compulsive eye surgeon.) Ha, Ha!” Dr. Dinnick: “Aah! Very good! Pleased to hear it. But what’s troubling you old chap?” Dr. Zeitlin: “Well, Sir. I was thinking of applying for a Consultant job. Perhaps in a year or two (in a defensive tone of voice). I would value your support Sir. If you think it appropriate. Sir.” Dr. Dinnick: (after a long pause; only one of the modern testing kits now available over-the-counter at Walgreen’s could decide whether it was a pregnant pause or not) “Aah! I see now! Let me think for a moment, old chap.” Dr. Zeitlin: “Of course, Sir.” Dr. Dinnick: (after thinking). “Well, Zeitlin you are a bit thin on the ground. (inexperienced, in AmerEnglish). You should think about getting your B.T.A. [BTA was the informal slang for the mystical Been-To-America Diploma]. Dr. Dinnick: (after another thoughtful pause) “Yes, that’s the best way. Spend a year in the States, doing research or something useful like that, get published, polish your C.V. so to speak, come back home, spend a little more time with us and then we’ll see, won’t we.” Dr. Zeitlin: “Oh! Thank you Sir! Jolly good idea Sir!” Dr. Dinnick: “Well then. See you across the road. About seven. Tell the boys I’m paying. If I’m late put it on my tab.” It was not “a jolly good idea.” I know that sounds bitter. I still feel bitter even though poor old Dinnick is now sleeping underground. What Dinnick did not know, nor would he have cared was that my C.V. was already polished. When I arrived at the Middlesex two years earlier there was no academic program at all for us residents. I persuaded the Consultants to give us two lunchtime lectures a month. If there was one reason why Dinnick wanted me to go to America for a year it was not to polish my curriculum vitae. It was simple. He did not want more competition for the gold of see laughter page 18

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PRN Laughter continued from page 17 private practice if I should be appointed as another Consultant at the Middlesex. The following week Aideen and I left the babies with her mother and took the Underground to the American Embassy in Grosvenor Square. I have been told recently that the surrounding real estate, some of the fanciest in London, has fallen dramatically in value. No one wants their Spode china tea sets spoiled by an Al Queda car bomb intended for the Embassy. There we applied for permanent visas to the USA. We told ourselves this was only a precaution. We’d spend a year there, then another perhaps in Australia, see the world, that sort of thing, and then settle down in Jolly Olde England. We had to apply for visas for the babies in addition to our own. On the form we completed for two year old Louise we swore she had never engaged in prostitution or drug-running. This encouraged us so much about the rule of law in the United States that we went and had a cup of tea we could ill afford in an expensive little café near Grosvenor Square. That September I traveled on one of Sir Samuel Cunard’s smaller liners, the SS Sylvania from Liverpool to Boston, Massachusetts. That year in Boston, Mass., had been a particularly murderous one. Gangs in South Boston and Revere felt in need of target practice; what could be better than the bodies of their rivals in the drug trade? The news of this sporting activity was so startling and so frequent it reached the British newspapers. Each morning on my way to work I glanced at the Daily Telegraph waiting on our doorstep. If a Boston murder appeared on the front page I took it with me to work and threw it away. If Aideen asked me why the Telegraph had not come when I got home that evening I felt quite justified in lying to her. “The newsboy has the ‘flu.” On the S.S. Sylvania in late September 1965 I

shared an Underclass cabin that contained two double bunks. It slept myself and three other gentlemen. One was a Chinese divinity student, very pleasant, but the other two were more interesting, two Irishmen in their 70s who smoked all night and kept the porthole shut. They had emigrated to America 50 years earlier, illiterate farmboys from Killarney, and made good. Harold became Postmaster in Medford and

They had become American, an affliction from which there is no return.

Oscar became Chief of Police in Brockton. They never lost touch. They married their colleens and the four of them dreamt their whole American lives that when they collected their pensions they would buy a cottage overlooking the Irish Sea and would live there happily ever after and their grandchildren who had all attended Harvard or Yale and then in turn had become Mayors of their suburban towns or Massachusetts legislators, would visit regularly. “So … why are you on this boat from Liverpool to Boston?” I asked. “We are re-emigrating. To America,” Oscar said, coughing a smoke-ring at the iron ceiling. “Our wives have already flown home. We’re traveling with the luggage,” Harold said. “We bought a lovely cottage on the beach in Hyannis on Cape Cod. You can walk to the supermarket, go to watch the Celtics in Boston and be home before midnight. The Kennedy compound is down the road and they wave to us when they’re in residence.” My question “But why leave Ireland?” was almost swamped as they both interrupted each other. “We couldn’t stand the rain.” “We couldn’t afford the income tax.” “We didn’t hate the British enough.” “The urinals in the pubs stank.” “We would not have the priests tell us how to live.” “The poverty made me sick” “Some of the kids had no shoes.” They had become American, an affliction from which there is no return. I reached the quarter-finals of the deck tennis tournament before we docked in Boston. This is a sport in which you have to catch a rope ring thrown by your opponent over a net on a rolling ship. It results in two handfuls of filthy broken nails. This was of no consequence other than that anesthesiology is a ‘hands on’ specialty; we do things to patients with our hands. Patients, nurses see laughter page 21

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PR N Laughter continued from page 18 and surgeons watch us. I did not want have to start with excuses in this brave new world so I scrubbed and scrubbed them in the week before I began work. We slid into Boston Harbor five days later very early on Sept. 23, 1965. A cool, thick mist lay on the city although I could see the tip of the Custom House Tower, pointed out to me by a fellow-passenger at the rail. As we docked I knew for certain this was America. I could not see any streets paved with gold but I did see most of the longshoremen and dockhands smoking cigars. In London only successful businessmen at weddings and clubby Presbyterian stockbrokers smoked cigars. Longshoremen in Liverpool smoked Players cigarettes broken in half: that is if they were not on strike and on the dole. I walked down the gangplank and stood bewildered as our crate of cribs, clothes and kitchen equipment was dumped at my feet by a gentle, accurate crane driver. How did he know this embarrassing pile of domesticity was mine? The family would arrive a week later by plane. “Hi Gerry. Nice morning. Roy sent me to pick you up,” came a voice out of nowhere “I’m Jeep.” No one, unintroduced, had ever before called me by my first name let alone my nickname. ‘Jeep’ was rugged with the tight hair only seen on cowboys in Westerns, a composite of all the tough handsome Hollywood film actors with whom I had grown up and aspired to but knew I would never become. He had an accent that I later learned was called Southern Intellectual. I surmised as we shook hands that this must be Dr. Ellison ( Jeep) Pierce, the Vice-Chairman of the Anesthesia Department at the Peter Bent Brigham Hospital, one of the Harvard teaching hospitals. The Peter Bent Brigham Hospital was named in memory of a Vermont native who came to Boston as a young man, started out as a restaurateur and then, like so many of them made a fortune investing in the railroad business. He died in 1877 and in his will stated that the bulk of his fortune was to be used 25 years later to found a hospital for the sick and indigent of Boston. The hospital opened in January 1913 and the first operation there took place on the 28th of that month. The only description of that first operation I have been able to find makes no mention at all of who gave

A steak the size and thickness of a volume of the Encyclopedia Britannica arrived, enough to feed a British family for a week. It was then I began to understand Jeep’s sense of humor.

“Something American. Would you please order for me?” I said. A steak the size and thickness of a volume of the Encyclopedia Britannica arrived, enough to feed a British family for a week. It was then I began to understand Jeep’s sense of humor.  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.

Jeep drove me to the tiny house we had rented for the year we were to spend in America, a house belonging to a local church in a far suburb called Natick. It was so small that I painted Ellison C. “Jeep” Pierce, MD the whole interior in one day before the anesthetic and what agents or tech- the rest of the family arrived by plane The preceeding is the second installment of an excerpt from his new book, “Laughing and niques were used. Typical. a week later. Crying About Anesthesia: A Memoir of Risk and Until I met him I did not know That evening, after work, Jeep took Safety” (Allandale Publishers, 2011). Dr. Zeitlin that Dr. Pierce was called ‘Jeep’ by me to Ken’s Steakhouse for supper. I will donate half the proceeds of the sales of the one and all. Jeep was to have consider- should not have allowed him to order book, which he wrote in part “for a non-medical able influence on my career in Amer- for me. audience to help them understand what we do,” ica and, as we will see, had a profound “What would you like?” he said, to the Foundation for Anesthesia Education and effect worldwide on the safety of passing me an enormous menu. Research. anesthesiology. ‘Roy’ must have been Dr. Leroy Vandam, the professor of anesthesia at the Brigham, the Harvard teaching hospital where I went to work as a junior faculty member. They gave me the title of Instructor in Anesthesia at Harvard Medical School without my asking. I never got an academic promotion, partially because I left acaGet the latest news from the best-read anesthesiology publication demia for the middle years of my in the country delivered directly to your computer or mobile American career. There may have been other reasons: I never asked. These device for free! days when I give a talk illustrated with slides I put: Gerald L. Zeitlin, MD, FRCA, Non-Emeritus Instructor in Anesthesia, Harvard Medical School, Boston, MA, on the title page. I can discern how many in the audience are awake from the volume of snickers. Without a word, Jeep loaded our household goods onto and into his Volvo, one of the tiny early imports to the U.S.A. As he squeezed me into the passenger seat he said, “I don’t suppose Dr. Matson would be very pleased about that.” “Excuse me, but why is that?” Already I felt less inhibited. None Follow us on of the ‘Sir’ business I always used in London. “He operated on my back. Fixed a anesthesianews protruding disk. Just three weeks ago.” Already I felt less inhibited. None Each installment contains articles from the of the ‘Sir’ business I always used in current month’s issue ahead of print, as well as London. links to podcasts and other Web-exclusive content

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P OLI C Y & M A NAGEMENT Shortage continued from page 1 Dr. Haas said he knew the switch to midazolam, although helpful, would only be a temporary solution; he anticipated there would be a domino effect causing midazolam to become scarce. He thus urged his colleagues to use oral benzodiazepines whenever possible “even in our intubated patients if the gut works,” and to choose propofol for hemodynamically stable intubated patients with gastrointestinal

Typical airway view.

function. For hemodynamically unstable patients, he recommended “trying to use a fentanyl infusion along with intermittent or even ATC [aroundthe-clock] oral [benzodiazepines],” and to use IV midazolam “as our preferred intermittent-dose benzodiazepine for anxiety and agitation if an oral route is not an option.” Dr. Haas ended the email with an optimistic plea: “We ask that you pass this along to the appropriate providers and encourage judicious use of the

IV products. Hopefully, if we all conserve as much as we can we’ll be able to squeeze by until our next shipment.” Unfortunately, as soon as one shortage of sedatives or anesthesic agents is dealt with, another one crops up, Dr. Haas said in an interview. “Just last week [late February], a shortage of preservative-free morphine for neuroaxial anesthesia hit us hard. Whether it’s Astramorph or Duramorph and other equivalents, they’re simply unavailable. We hear there may

be some new shipments coming in early March, but there’s no guarantees; we have maybe enough drug to last another seven to 10 days.” In the meantime, Dr. Haas noted, his colleagues in anesthesiolog y are looking at possible alternatives, such as fentanyl. “It’s not preferred, but at least it’s an option,” he said. Preservative-free hydromorphone or bipuvicaine are other options for neuroaxial anesthesia, “but bipuvicaine has been in short supply as well. So this is very much still a moving target.” Nationwide Problem Rochester is far from alone in feeling the pinch on key sedatives and anesthetics. Hospitals across the country are facing similar shortfalls in the supply of these and other important drugs, including certain treatments for cancer. One major facility in the Midwest listed no fewer than eight “new or high-priority” shortages during the second week of January. On the list: etomidate, heparin, ketorolac, morphine, ropivacaine and alfentanil. Those drugs joined a roster of nearly two dozen other agents, from diazepam and midazolam to lorazepam and rocuronium, in the “ongoing” category. Reasons for the low supply are unclear, but involve production issues, indefinite plant shutdowns and drug makers exiting the market. When they are able, hospitals and clinics adapt by using substitute drugs or stretching their stocks to the limit. When no alternative is possible, many facilities are turning to the so-called “gray market” for pharmaceuticals, a poorly regulated network of suppliers who charge several times the usual rate for the medications. Keith Candiotti, MD, director of clinical research and chief of perioperative medicine at the University of Miami Leonard M. Miller School of Medicine, said his facility recently had been forced to pay as much as 20 times the regular rate for some anesthetic agents. Miami is having trouble finding fentanyl, sufentanil and even midazolam, Dr. Candiotti said, as well as diazepam and lorazepam. “If you are willing to pay a premium you can find drug right now, but the supply is clearly reduced,” he said. Beyond Anesthesia Although anesthesiologists may have workarounds, other clinicians who depend heavily on benzodiazepines have been even harder hit by the shortages. Gastroenterologists, who rely on the drugs in combination with

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POLICY & M A N A G E ME N T opioids for endoscopic procedures, are among them, according to Lawrence Cohen, MD, of Mount Sinai School of Medicine in New York City. “We, like many other groups throughout the country, have been affected by the shortage of certain sedatives and opioid drugs,” Dr. Cohen said. “Currently, there are shortages of fentanyl, midazolam and meperidine—the last one created by the unavailability of fentanyl, which has led to increased use and hoarding of meperidine.” The fallout from the sedative shortage could range from limiting the number of endoscopic procedures to a shift in sedation methods, Dr. Cohen continued. In early February, the American College of Gastroenterology wrote to FDA commissioner Margaret Hamburg, MD, to express its “deep concern” regarding the shortage of sedatives. “Members across the United States are experiencing tremendous difficulty in accessing certain sedative and narcotic agents that are used routinely during endoscopic procedures such as colonoscopy,” the letter stated. “We urge FDA to use its full authority under current law to help resolve these shortages as supplies continue to dwindle.” The letter, which cited shortages of fentanyl, meperidine and midazolam, noted that the cost of endoscopy might rise if gastroenterologists turned to propofol and required the presence of an anesthesiologist to perform monitored anesthesia care. An FDA spokesperson said Dr. Hamburg would “carefully review the letter and respond directly to the American College of Gastroenterology in a timely manner.” On Jan. 18, an FDA interim final rule took effect, broadening the circumstances under which the sole manufacturer of certain critical drugs must report to the FDA about stopping production. No longer will a company that interrupts, but does not permanently cease, the manufacture of a critical drug be exempt from the requirement to give the FDA a six-month advance notice. According to the U.S. Department of Health and Human Services, the intent of the presidential executive order that led to the rule was “to take action to help reduce and prevent drug shortages, protect consumers, and prevent stockpiling and exorbitant pricing of drugs in shortage.” The rule does not set monetary penalties for failure to provide the

required advance notice. Senate bill 296 and House bill 2245 do specify such fines; both bills await committee action. Joseph M. Hill, director of federal legislative affairs for the American Society of Health-System Pharmacists, said there is a “downstream hope” that with more information, the FDA may be able to work behind the scenes to help stop shortages. Mr. Hill said 2011 was a record-setting year for drug shortages, with 267 reported.

At the time this article went to press, the FDA had at least 115 drugs on its list of current shortages, with the latest addition being IV zinc sulfate caused by “manufacturing delays.” Drug shortages create more than logistic headaches for hospitals and clinics—they also pose ethical dilemmas. In a recent editorial in the American Journal of HealthSystem Pharmacy, Michael Manolakis, PharmD, PhD, assistant dean at the Wingate University School of

Pharmacy, in Wingate, N.C., wrote of three such ethical problems: rationing, hoarding and gray market buying. To the last problem, he wrote: “Despite assurances of pedigree, a purchase from a secondary market represents a disruption in the integrity of the drug supply chain, and it places a patient at risk. Until every hospital refuses to pay the marked-up prices for short-supply products, the problem will persist.” —Adam Marcus and George Ochoa

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P OLI C Y & M A NAGEMENT

‘Aliens Among Us’: The Perils of Expert Witness Testimony

or most Americans, the manslaughter trial of Conrad Murray, MD, was compelling theater, a chance for all to see Michael Jackson’s personal physician brought low in court. For anesthesiologists, however, the trial offered a different sort of spectacle. Two of our most prominent colleagues, Steven Shafer, MD, and Paul White, MD, PhD, testified as experts for the prosecution and defense, respectively. Although both Drs. Shafer and White believed they were serving the cause of justice, each man perhaps unwittingly put himself at significant risk from an unlikely body: the American Society of Anesthesiologists (ASA). Since 2003, the ASA has seated a committee whose function is to review the expert testimony of society members upon receiving a complaint about that testimony from a member of the ASA. More than that, the charge of the committee on expert witness testimony review (CEWTR) is to consider complaints lodged against an ASA member regarding such testimony—for practically any reason. This article was inspired by a recent experience the authors had with the ASA CEWTR. The experience resulted in dismissal of a complaint against one of us ( J.B.) after going through this frustrating and onerous process. In its landmark 1985 ruling in Mitchell V. Forsyth, the U.S. Supreme Court, in striking down the government’s claim that officials in the executive branch could not be sued for actions taken in the name of national security, stated that “the judicial process is an area of open conflict, and virtually in every case there is, if not always a winner, at least one loser. It is inevitable that many of those who lose will pin the blame on … witnesses and will bring suit against them in an effort to re-litigate the underlying conflict.” “Aliens Among Us” was the title of an editorial written by past-president Mark Lema, MD, PhD, and appearing in the “Ventilations” section of the December 2002 edition of the ASA Newsletter. In the editorial, Dr. Lema strongly urged the creation of an ASA committee to review plaintiff expert witness testimony given by a society member upon receipt of a complaint from another member about that testimony because “as a rule … plaintiff ’s work is bad” and we need [such a program] as our security blanket against being bushwhacked by members of the third kind”—the alien plaintiff expert witnesses. The ASA quickly heeded Dr. Lema’s suggestion and created the CEWTR, which began considering complaints brought by any member of the ASA against any other member of the ASA concerning expert witness testimony given on record on or after Oct. 16, 2003. By 2007, 18 medical subspecialties had created CEWTRs, perhaps in response to court rulings that have progressively eroded the immunity and absolute privilege of expert witness testimony in a primary judicial proceeding against punishment for that testimony in a subsequent secondary judicial process. How does the CEWTR work in practice? Any complaint the committee receives must fulfill various administrative criteria including a narrative statement on the grounds on which the complaint deems the testimony to be in violation of the Guidelines for

Does the law enable a professional body to review the quality of a physician’s testimony in a medical malpractice proceeding? Expert Witness, which are available at the ASA Web site. The guidelines essentially state that testimony should be accurate, truthful, relevant to the injury and should reflect an evaluation of performance in light of generally accepted standards. The chair of the CEWTR then designates one or more of its members to serve as investigators to determine whether the complaint adequately alleges a violation of the guidelines. If so, the complaint is then sent to the accused ASA member, who then has 30 days to respond. The investigators then present their findings to the CEWTR, which determines whether the respondent likely failed to abide by the guidelines. Respondents are entitled to an oral hearing, at which the investigators present the case for violation of the guidelines and the respondent offers a defense. If the CEWTR determines the complaint is valid after the oral hearing, the committee members determine a sanction—which may consist of a written reprimand to the member from the ASA with no loss of membership, suspension from the society or expulsion. The respondent has 30 days to submit written objections to the findings of fact and request an appeal to the Judicial Council (consisting of former officers of the ASA). If the Judicial Council agrees with the CEWTR findings, by a simple majority

vote, the matter goes to the ASA Board of Directors for approval of the sanctions. If at any point in this review process the complaint is determined to be invalid, the complaint is dismissed. Legal Confusion: Immunity … All of these steps, however, take place against a backdrop of legal confusion over whether and to what extent expert witness testimony is privileged. In other words, is testimony offered in one judicial proceeding immune from punishment in another setting? The courts have not spoken clearly on this subject. The majority of states have recognized such immunity from retaliatory litigation to anyone who testifies as an expert in court, based on the policy that experts are evaluated by a carefully selected jury and screened by the voir dire process and a duly appointed judge. Yet, sparse case law has eroded the immunity doctrine in disciplinary actions taken by professional societies or state licensure boards as long as the groups act in good faith and do not violate public policy. The CEWTR review process can be considered a secondary judicial or quasi-judicial proceeding because the committee functions as both a judge, making evidentiary rulings, and a jury, finding facts, deciding guilt or innocence and recommending punishment. Indeed, the Office of the General Counsel for the ASA is on record stating that the ASA expert testimony review process is a judicial or quasi-judicial process. More than a dozen state courts have held that expert witness testimony given in one primary proceeding is absolutely privileged against and immune from punishment in a subsequent secondary action (Table). Most notable among this is Fullerton v. Florida Med. Ass’n Inc., a 2006 case in which a Florida

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POLICY & M A N A G E ME N T appeals court ruled that “defamatory statements made in the course of judicial proceedings by parties, witnesses and counsel are absolutely privileged, no matter how false or malicious those statements might be, provided the statements are relevant to the subject of the inquiry.” The court also held that federal law provided no reciprocal immunity to the Florida Medical Association in its role as an examiner of the quality of the plaintiff physician’s judicial testimony. That same year, the North Carolina Supreme Court ruled that the state medical board could not discipline a surgeon by revoking his medical license because the surgeon had a good faith basis for making the statement for which the medical board sought to impose discipline. Similarly, in Yancey v. Weis, a Dr. Yancey appeared as an expert witness for a patient in a medical negligence suit against Dr. Weis and a refractive surgery center. After Dr. Weis was found liable in the malpractice trial, Dr. Weis and his expert witness, Dr. Hardten, sent a letter to the American Academy of Ophthalmology (AAO). The letter stated that “many of the statements made by Dr. Yancey misled the jury.” Dr. Yancey filed a lawsuit against Drs. Weis and Hardten and the AAO claiming defamation. A jury found the defendants defamed plaintiff Dr. Yancey when they claimed that his testimony against them was misleading. The jury awarded Table. Cases Concerning Absolute Privilege and Immunity of Expert Witness Testimony Affirmed? Case Name

State

Ingber v. Mallillo

Offen v. Brenner

McKinney v. Chapman

Fisher v. Lint

Yes

Mahoney & Hagberg v. Newgard MN Fullerton v. Florida Med. Ass’n, Inc.

Fariello v. Gavin

Oesterle v. Wallace

Montemayor v. Ortiz

Smith v. Hodges

State ex rel. Oklahoma Bar Ass’n OK v. Dobbs In Re Lustegarten

Wright v. Truman Road Enters, Inc.

McGregor v. Rutberg

Yancey v. Weis

Brousseau v. Jarrett

Pollack v. Punijabe

Davis ex rel. Davis v. Wallace

Marrogi v. Howard

LLMB of Mich. v. Jackson-Coors Co.

Deatherage v. State of Washington Examining Board of Psychology

Austin v. American Assoc. of Neurological Surgeons

Dr. Yancey $350,000, including $200,000 in compensation for “future harm to his reputation, mental distress, humiliation and embarrassment.” In its rulings, the Minnesota court that heard the case concluded that nothing in the law “provides or reasonably implies [a] professional body is empowered to review the quality of a physician’s testimony in a medical malpractice proceeding.” The rationale for these rulings in support of immunity for expert witnesses is, at least in part, that the testimony should be unrestrained and therefore completely honest. However, the downside of this position is that immunity may frustrate accountability for dishonesty of any kind. Taken together, and recognizing that expert witness testimony review programs are essentially secondary judicial proceedings, these rulings strongly imply that CEWTRs should not have the right to render opinion on, and punishment for, expert witness testimony given in a primary judicial proceeding. … Or Not On the other hand, courts have reached the opposite conclusion in at least eight rulings. In Deathearage v. State of Washington Examining Board of Psychology, the court in 1997 held that the state Board of Psychology could discipline a member who allegedly failed to meet professional ethical standards in rendering expert testimony in several child custody cases; the court held witness immunity did not extend to professional disciplinary hearings. Four years later, in Austin v. American Association of Neurological Surgeons, a federal circuit court reasoned that “there is nothing wrong in having a professional association sanction one of its members for irresponsible testimony” so long as the association acts in good faith and does not violate public policy. The court dismissed Dr. Austin’s claim that he had been suspended in “revenge” for having testified as an expert witness for the plaintiff in a medical malpractice suit brought against another member of the association. Dr. Austin appealed to the U.S. Supreme Court, which refused to hear the case. As a derivative of the absolute privilege of expert witness testimony issue, do CEWTRs have immunity for their actions against expert witnesses for their testimony? The fact that 12 states have ruled that witness testimony is absolutely privileged strongly implies that CEWTRs do not have immunity for punishing expert witnesses for their testimony. Indeed, the court in Fullerton specifically addressed this issue, holding that “the statutes provide no immunity to the defendants.” The Fullerton court ruled, “Based upon our examination of all pertinent provisions of that [federal] statute, we agree with appellant that it fails to immunize the Florida Medical Association from liability when that body acts to evaluate the testimony of a medical expert given in a medical malpractice action.” Finally, subspecialty societies—which are voluntary associations of members—may argue that immunity does not exist if the accused expert witness is a member of the group because being a member means that the individual has agreed to certain administrative procedures and guidelines. Moreover, a dispute between a member and the society is governed by the law of contracts rather than defamation law.

Defenders of CEWTRs also may argue the American Medical Association has passed a resolution (Peer Review of Medical Expert Witness Testimony) that expert witness testimony is a scholarly endeavor that is part of the practice of medicine. As such, it is subject to peer review by medical societies and state medical boards, both of which have standards that can be violated by their members. The suit–countersuit sequences may continue, as individual physician reviewers providing expert opinions to a regulatory authority have been sued for malpractice, negligence and defamation by physicians being investigated by those authorities. Vulnerable to Bias From the moment it receives a complaint, the committee is entirely dependent on the qualifications, fairness and intellectual integrity of the committee members and the appointed investigators, who act as both judge and jury. Clearly, Dr. Lema’s editorial inspired the creation of the ASA CEWTR. It also reflected his clear bias about plaintiff expert witnesses (they are bad as a general rule). Dr. P.G. Morgan has observed that Dr. Lema “probably represents the majority opinion within the ASA” and Dr. T.G. Poulton noted that Dr. Lema stated in his editorial that “most ASA officers would only testify for defense.” It is reasonable to hypothesize that at least some potential CEWTR members and investigators may be similarly predisposed to think poorly of plaintiffs’ witnesses. In both criminal and civil courts, jurors who render opinions about defendants and determine punishment are vetted by a pretrial selection process known as voir dire. In the case of CEWTR jury persons and investigators, there is no vetting of their qualifications to be fair to both the plaintiff expert witness and the defendant doctor. Indeed, the basis for the selection of these punishment-determining jury persons is completely unknown to the doctors who are accused of rendering substandard testimony. The vetting process of CEWTR members and investigators should properly include the specific medical qualifications of these candidates on the major specific medical issues of the case, and importantly, the medicolegal qualifications and experience of these candidates. Indeed, it has been recommended that each specialty develop some sort of forensic certification for CEWTR members and investigators. We find it troubling that the ASA CEWTR review process, and likely that of other medical speciality groups, has no discernible rules for the admission and review of evidence. Indeed, the complaining member may submit whatever evidence he or she wants to submit, no matter how biased, weighted or incomplete it may be. What’s more, to our knowledge, the ASA CEWTR does not gather or require any specific evidence. Likewise, there are no objective checks and balances for challenging the “findings of fact” made by the committee and judicial council, which should reflect the entirety of the record, not simply what facts the investigators pick and choose. Thus, the initial and perhaps biased and weighted evidence may lead the investigators to advance the complaint, requiring the accused member to spend time and money in a defense. see witness page 26

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P OLI C Y & M A NAGEMENT Witness continued from page 25

aware of a complaint pursued by the CEWTR that did not even meet the Although the initial complaint may basic procedural filing requirements meet administrative criteria for accept- mandated by the ASA itself. ability by the CEWTR, from personal Related to this point, the CEWTR experience that threshold is disturb- review process does not permit meaningly low. The complaint may be vague ingful cross-examination of the invesor overbroad, and may include bogus tigators or the complainant. The accusations. For example, one com- respondent is not allowed to ask clarplaint with which we are familiar ifying questions; false testimony and involved 30 different allegations. Such bias in the CEWTR, if it exists, can an unfocused charge can be difficult to rule the review process completely respond to. What’s more, we also are unchallenged.

Even if CEWTRs may lawfully render opinions about the quality of expert witness testimony and punishment for such testimony, the vast majority of complaints are against members of the society who served as plaintiff expert witnesses against members who were defendants. Indeed, the American Association of Neurological Surgeons runs the longest established and busiest program of this kind in the country, and the overwhelming majority (57 of 59; 97%) of complaints are

related to testimony from witnesses acting for plaintiffs. What’s more, we know from discussion with the ASA Office of General Counsel that the CEWTR has never pursued a case against an expert for the defense. Based on this finding, the name “Expert Witness Testimony Review Committee” is erroneous and misleading; rather, it should be named “Plaintiff Expert Witness Testimony Review Committee.” Although we recognize that irresponsible testimony from a defense expert is just as objectionable as it is from a plaintiff expert, we do not foresee members of an association complaining about defense expert witness testimony. Ultimately, bias by CEWTR jurors is never without serious consequence. As awareness of the CEWTR program increases (which it undoubtedly is), complaints to the committee will increase dramatically. Yet some patients undoubtedly are injured solely because of physician actions that are clearly outside the standard of care. Someone must speak fairly for those patients. We strongly favor guidelines for ethical testimony, but intimidation of that process by the prospect of having to defend that honest testimony at the peril of one’s good standing in a professional society is a bad outcome that jeopardizes patients’ rights. In addition, such irresponsible behavior subjects the ASA to potential litigation, which could result in substantial monetary harm to the members at large. We believe that if the ASA CEWTR members and investigators are vetted by an open, transparent process for their qualifications and fairness, rules of evidence are developed and crossexamination is allowed, then the ASA Expert Witness Testimony Review Program will be in a much better position to withstand a legal challenge to its existence, avoid accusations of “circling our professional wagon … constituting protective guilds or good-old-boy networks” and serve its membership in a proper manner. —Jonathan L. Benumof, MD, and Benjamin T. Benumof, PhD, Esq

Innovative Research Labs, Inc. Call us toll free at 888.551.9700 for more information www.castrgard.com • sales@castrgard.com • 3612 NE 41st Street, Seattle WA 98105 • fax: 206.525.1490

Jonathan Benumof, MD, is professor of anesthesiology at the University of California, San Diego, and has been an expert witness in hundreds of medical malpractice cases, 80% for the defense, and 20% for the plaintiff. Benjamin Benumof, PhD, Esq, an attorney based in San Clemente, Calif., is the founding partner of the law firm Wilcox-Benumof, which specializes in professional liability, personal injury, real estate, land use, environmental law, business law and litigation.

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CLIN I CA L A N E STH E SI OL OG Y Team continued from page 1

Infection rates declined steadily throughout the study period, from in eight of the hospital’s intensive care 5.86 per 1,000 catheter-days in 2004 units (ICUs) cut the rate by almost to 0.6 per 1,000 in 2011. Studies have 90% over a seven-year period. Simi- shown that although programs can larly, a team effort at the Ohio State be successful in reducing the numUniversity Medical Center in Colum- ber of central-line infections, complibus, decreased infection rates in a ance can drop off over time (Arch Surg 25-bed ICU by roughly 33% in one 2004;139:131-136). The new study year. Researchers presented details of demonstrates a program with stamina. the two approaches at the 2012 annual In the UMASS program, ICUs meeting of the Society of Critical Care receive data on their infection rates on Medicine (abstracts 583 and 584). a monthly basis, allowing for timely

reaction. The program includes elements of the Pronovost study, such as the use of a dedicated catheter cart for supplies, checklists to ensure adherence to infection-control procedures, empowering nurses to halt a procedure if checklist elements are not followed and removal of unnecessary catheters. Clinicians also rely on a preprocedural time-out, and they use chlorhexidine sponges and catheters impregnated with antibiotics. Reeducation is key. “If you don’t continue

to re-educate your staff and monitor progress, rates will creep back up again,” Dr. Walz said. In both the UMASS and Ohio State approaches, researchers investigate any identified infections to determine if opportunities to prevent them were missed. At Ohio State, infection rates fell from 2.9 per 1,000 catheterdays in 2009 to 1.95 per 1,000 in 2010. The researchers noted that their data for 2011 were incomplete but see team page 28

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to the physician who put in the line and ask them questions about the event, because it is still fresh in everyone’s mind.’ —Mathew Exline, MD

Involving caregivers at all levels and providing frequent, regular feedback on infection rates to hospital staff are two key elements that have made these programs a success, experts said. Matthias Walz, MD, chief of vascular anesthesiology at UMASS Medical Center, said the guidelines at his facility were developed by a small task force and then approved by the institution’s Critical Care Operations Committee prior to implementation. “From the ICU physicians to the ICU nurses, respiratory therapists, pharmacy team, occupational therapists—everybody is at the table.” Because all disciplines were involved in creating the guidelines, all caregivers feel they have a stake in the process, he said. Although the landmark study by Peter Pronovost, MD, and colleagues is an example of a success story—a reduction in central-line infection rates of 66% in 18 months (N Engl J Med 2006;355:2725-2732)—the UMASS project is unique for its long follow-up, Dr. Walz said.

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C LIN I C A L A N ES THES IO LO GY

Clot-Busting Drug Signals Risk for Catheter Infections Houston—The use of tissue plasminogen activator (tPA) to unclog malfunctioning central venous catheters is associated with an increased risk that patients will develop a catheter-related bloodstream infection. The retrospective study, presented at the 2012 annual meeting of the Society of Critical Care Medicine

(abstract 621), revealed a nearly threefold increase in risk for the infections in pediatric patients whose lines were dosed with tPA. “It is almost three times more likely for a central line to become infected if tPA has been used than when it has not been used,” said Mara Nitu, MD, associate professor and interim clinical section chief for pediatric critical

care at Riley’s Hospital for Children at Indiana University Health, in Indianapolis, who led the study. “The clot that prompts the need for tPA, not the tPA itself, is the true culprit. The medication use is just a signal; it should raise the concern level for higher likelihood of line infection.” Fibrin sheets and thrombi that are created when a clot forms provide

attractive growth media for bacteria, she added. Studies in adults have linked the presence of a clot to an increased risk for catheter-related blood infection, but research had not been conducted in pediatric populations. To fill this knowledge gap, Dr. Nitu and her colleagues reviewed quality and infection control records to identify the number of central venous catheters used in patients in the pediatric intensive care unit at their facility between July 2008 and December 2010. They also identified the prevalence of catheterassociated blood infections. After identifying 40 patients with the complication, they examined the medical records of these patients to determine if tPA was used five days before a positive culture. Electronic medical records from the pharmacy revealed the total number of times tPA was ordered for a central line. Of the 3,289 central venous catheters used during the 2.5-year time period, 12% required at least one dose of tPA. In the 40 patients who had an infection, 28% involved tPA during the five days before infection. Patients

Team continued from page 27 appeared to indicate further reductions in infections. The Ohio State approach includes weekly surveillance of infection rates from its clinical epidemiology unit. “Previously, we would get quarterly data and you would hear that you had three central-line infections, but you wouldn’t hear who the patients were, and you were so far removed from the events that no one could remember what actually happened,” said Mathew Exline, MD, associate director of the ICU at the institution. “Now, you can go to the nurse who drew the blood culture and you can go to the physician who put in the line and ask them questions about the event, because it is still fresh in everyone’s mind.” Ohio State also incorporates components of the Pronovost study with an emphasis on re-education regarding line insertion and maintenance, the use of daily checklists to increase adherence to guidelines and identifying noncompliance with evidencebased guidelines. “Unless you really have someone who is a champion who says, ‘This is really important, we need

March 2012

AnesthesiologyNews.com I 29

CLIN I CA L A N E STH E SI OL OG Y

were 2.87 times as likely to develop a catheter-related infection when tPA was used (95% confidence interval, 1.42-5.6; P=0.002). The average age of the catheter was not a statistically significant risk factor (16.1 days in tPA patients vs. 25.6; P=0.6). Nasia Safdar, MD, PhD, assistant professor in the Section of Infectious Diseases in the Department of Medicine at the University of WisconsinMadison, said “the take-home message is that thrombus formation should caution people to be vigilant for the risk for a [catheter-associated blood infection]. An occluded catheter that requires multiple doses of tPA should probably be removed.” Dr. Nitu said that when doctors realize they need to use tPA, they should be more aggressive in their planning to remove the line. “A central line that malfunctions and requires tPA should trigger the immediate planning of either replacing or removing the line,” she said.

Contact

the editor of Anesthesiology News amarcus@mcmahonmed.com

Video Laryngoscope

—Kate O’Rourke Drs. Nitu and Safdar reported no relevant disclosures.

to focus on it,’ there are so many things going on in the ICU, that it is easy for the checklist to fall by the wayside,” Dr. Exline said. Trish Perl, MD, professor of medicine, pathology and epidemiology at Johns Hopkins University, in Baltimore, said the two studies add to the growing evidence that teamwork can reduce central line–related blood infections. “I think the use of teams works so well because there is a lot of wisdom that you can get from individuals with different experiences. For example, my perspective may be very different from somebody who is in the trenches,” Dr. Perl said. And she echoed the importance of having a strong advocate. “If you have a really good and engaged champion, it makes a lot of difference,” Dr. Perl said. “If people really believe low rates are achievable and it is an expectation and the institution and employees have accountability and hence really facilitate the interventions, it makes a lot of difference.” —Kate O’Rourke

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Complications Rare After Hip Replacement, U.K. Study Finds

ewer than 1% of patients who undergo total hip replacement surgery will suffer a postoperative complication, according to a fiveyear retrospective analysis by British researchers. The researchers found that cardiovascular, renal and pulmonary complications developed in 0.7% or fewer patients. Mortality rates were highest

among patients with stroke and acute renal failure, the investigators said, but the overall rate of death was 0.2% in the study, which included more than 250,000 cases. Edward Mariano, MD, MAS, associate professor of anesthesia at Stanford University School of Medicine, and chief of the Anesthesiology and Perioperative Care Service at the VA Palo

Alto Health Care System in Palo Alto, Calif., called the number of cases in the study “truly noteworthy.” “Based on these coding data, the occurrence rates of serious postoperative complications and mortality appear to be low,” said Dr. Mariano, who was not involved in the study. The data correlate fairly well with a Mayo Clinic study published 10 years

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ago (Anesthesiology 2002;96:1140), Dr. Mariano added. In the current study, Robert Sanders, MD, clinical research fellow at the National Heart and Lung Institute in London, and several colleagues analyzed the English National Health Services database, a unique trove of information that includes data from every hospital admission in that country. They found 256,439 total hip arthroplasties performed between January 2005 and February 2010. The researchers used British coding information as well as ICD-10 codes to document the rate of myocardial infarction (MI), chest infection, pulmonary embolus (PE), stroke and acute renal failure that occurred within 90 days of surgery. According to findings that Dr. Sanders presented at the 2011 annual meeting of the American Society of Anesthesiologists (ASA; abstract 1507), PE and chest infection were the most common complications, each occurring in 0.7% of the patient

March 2012

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CLIN I CA L A N E STH E SI OL OG Y Table. Mortality Associated With Post-Arthroplasty Complications

Other factors also may limit the The ASA abstract also did not study’s generalizability and clinical include data on the time frame for Odds Ratio 95% Confidence Interval applicability, he added. complications, Dr. Mariano said. Stroke 9.80 5.38-17.86 “The data sources in the present “That would be very useful informastudy lack information on prophylac- tion to know and also to compare with Acute renal failure 4.81 3.58-6.61 tic measures taken by clinicians, mak- the Mayo Clinic findings,” he said. The ing it difficult to determine the extent earlier Mayo study showed that MI Chest infection 4.05 3.06-5.36 to which prevention was responsible occurred after a median of one day; PE Myocardial infarction 4.03 3.01-5.40 for the low rates of complications,” he occurred after a median of four days; said. Therefore, he emphasized, the and deep vein thrombosis occurred Pulmonary embolus used as index complication findings should not change a clinician’s after a median of seven days. population. Emboli were associated diagnostic and procedural coding data- level of vigilance regarding potential with a 3.9% mortality rate, and chest bases may under-report actual events. complications. —David Wild infection with a rate of 14.3% (Table). The analysis also showed that MI occurred in 0.5% of patients, with an associated 16.2% mortality rate. Fewer than 0.5% of patients had acute renal You know capnography measures real-time adequacy of ventilation. failure after arthroplasty, and 0.03% experienced a stroke, with mortality rates of 16.3% and 28.6%, respectively. “Medical complications are fortunately rare events following total hip replacement,” according to the authors, who declined to be interviewed for this article. Although the study population is impressively large, it is possible complication rates are higher than found in the analysis, Dr. Mariano noted. He said

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picture of ventilation. 1 ASA Standards for Basic Anesthetic Monitoring, Committee of Origin: Standards and Practice Parameters (Approved by the ASA House of Del egates on October 21, 1986, and last amended on October 20, 2010 with an effective date of July 1, 2011) - Viewed 3-21-11 at ww.asahq.org/.../Standards%20 Guidelines%20Stmts/Basic%20Anesthetic%20Monitor ing%202011.ashx 2 Stoelting R and Overdyk F. Anesthesia Patient Safety Foundation, Conclusions and Recommendations from June 08, 2011 Conference on Electronic Monitoring Strategies to Detect Drug-Induced Postoperative Respiratory Depression. Accessed August 25, 2011 at http://www.apsf.org/announcements. php?id=7. 3 Standards for Basic Anesthetic Monitoring. American Society of Anesthesiologists. Accessed 6/20/11 at http://www.asahq.org/For-Healthcare-Professionals/~/media/For%20Members/documents/Standards%20Guidelines%20Stmts/Basic%20Anesthetic%20Monitoring%202005.ashx

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Survey Finds Poor Management of Peripheral IVs

esearchers are calling for the development of clinical guidelines for the management of peripheral IV lines after finding “great variability” in how clinicians attend to these devices. The results of a national survey presented at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 1106) showed that even

when treating patients with major IV catheter infiltrations, physicians do not conduct regular inspections of IV sites. “I think we’d see significant reductions in the occurrence and severity of PIV [peripheral IV] infiltrations if best-practice opinions were followed,” said senior investigator David Metro, MD, associate professor and director of the residency program in

the Department of Anesthesiology, at the University of Pittsburgh School of Medicine. “However, there is no commonly accepted standard for the management and documentation of PIVs.” Complications from PIVs typically are minor, but severe adverse events can require fasciotomy or skin grafting and can possibly lead to death, Dr. Metro said. A 2006 analysis of

the Closed Claims database found that complications related to PIVs accounted for 2.1% of claims submitted between 1970 and 2001, with compensation averaging $38,400 per claim (ASA Newsletter 2006;70:11-13,16). In the absence of professional guidelines describing how best to manage PIVs, Dr. Metro and several colleagues set out to understand how clinicians are managing PIVs. They examined survey responses from 266 attending anesthesiologists, anesthesiology residents and certified registered nurse anesthetists to whom they had sent a 15-item Web-based questionnaire (Table 1). Dr. Metro’s team found that half of respondents conducted regular visual or palpatory inspections of PIV sites when lines were inserted in the patient’s arms, with the number dropping notably when there was no arm access (Table 2). Although 81%, 76% and 77% of clinicians, respectively, said they believed that gravity drip IVs, pressure bag IVs and pump IVs should be examined at regular intervals, only 43%, 56% and 40% did so for the respective IV types (P<0.0001). The Table 1. Select Questions From a 15-Item PIV Management Questionnaire 1. Has a patient in the past, under my care, had an IV infiltration? A. No B. Yes (minor requiring discontinuation of IV only) C. Yes (requiring medical intervention) 2. When evaluating IVs preoperatively, you always, sometimes, rarely or never: A. Open IVs to assess flow B. Visually inspect the site C. Palpate the IV site D. Flush the IV 3. When evaluating peripheral IVs intraoperatively WITH or WITHOUT access to arms, you always, sometimes, rarely or never: A. Open IVs to assess flow B. Visually inspect the site C. Palpate the IV site D. Flush the IV

PIV, peripheral IV

Table 2. Peripheral IV Assessment Practices Access to Arms, % Visual inspection

Palpation

Always

Sometimes

39.6

Rarely

Never

0.4

PRINTER-FRIENDLY VERSION AT ANESTHESIOLOGYNEWS.COM

Paravertebral Blocks: The Evolution of a Standard of Care KEVIN KING, DO Clinical Assistant Professor Department of Anesthesiology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

JACQUES E. CHELLY, MD, PHD, MBA Professor of Anesthesiology (with Tenure) and Orthopedic Surgery Vice Chair of Clinical Research Director of the Regional and Orthopedic Fellowships Director of the Division of Acute Interventional Perioperative Pain and Regional Anesthesia Department of Anesthesiology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania The authors have no relevant financial conflicts to disclose.

Introduction

n 1905, Sellheim of Leipzig, Germany, first described a method to block nerves

lateral to the spinal column as an alternative to central neuraxial blocks. This paravertebral approach was found to be safer than spinal anesthesia in the context

of the limited monitoring and resuscitating capacity that characterized the era.

Yet 30 years later, the technique was hardly mentioned in the literature and rarely practiced. Not until the late 1970s, when Eason and Watson reintroduced it, did the paravertebral approach gain widespread use.1 Since that time, the technique has experienced extraordinary growth. As was the case initially, it is considered to be safer than neuraxial blocks—and particularly the thoracic epidural—for perioperative analgesia. The importance of this comparison is highlighted by the increased number of surgical and trauma patients who receive enoxaparin for thromboprophylaxis, a clear contraindication for the use of an epidural. At the University of Pittsburgh Medical Center (UPMC), the paravertebral technique was introduced in 2003 as a single block for the perioperative management of patients undergoing open radical prostatectomy. This method was soon followed by the use of

I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G

continuous paravertebral blocks (CPVBs) for the perioperative management of pain in patients undergoing thoracic surgery. Between July 1, 2010, and June 30, 2011, a total of 8,637 paravertebral blocks (PVBs) were performed, including the placement of 6,747 continuous paravertebral catheters.

Anatomy Perhaps the most useful confirmation of the boundaries and contents of the paravertebral space (PVS) was performed by Klein et al on an unembalmed cadaver with an ankle endoscope.2 They confirmed PVS is well defined by anatomic structures that were previously

A N E ST H E S I O LO GY N E WS • M A R C H 2 0 1 2

reported by Eason and Wyatt. Klein et al reported that the neural structures are simply surrounded by loose areolar or adipose tissue within the space.2 The wedge-shaped thoracic PVS can be distended by percutaneous introduction of medication for therapeutic purposes. The boundaries of the three-sided wedgeâ&#x20AC;&#x201D;posterior, medial boundary, and anterolateralâ&#x20AC;&#x201D; extend caudally and cephalad, as the segmental spaces communicate up and down. The PVS is bounded posteriorly by transverse processes, the rib heads, and the ligaments that travel between the adjacent transverse processes and ribs. The medial boundary is the vertebral body, the intervertebral disks, and the intervertebral foramen at each level. The anterolateral boundary is the parietal pleura. Laterally, the space tapers as it communicates with the intercostal space. The thoracic PVS is the only location outside of the neuraxial column in which injected local anesthetic can block the ventral and dorsal rami, and the gray and white rami communicantes that carry the sympathetic fibers. The PVS extends from the cervical to the sacral spine. The PVS is subdivided into an anterior (extrapleural) and a posterior (subendothoracic) space by the endothoracic fascia, which is continuous with the internal intercostal membrane laterally and the prevertebral fascia medially. Karmakar presented the first known

Table. Indications for Paravertebral Blocks

Single Level

Unilateral Breast surgery

T1-T6

Inguinal hernia

T10-L1

Bilateral Prostatectomy, hysterectomy

T10-L1

Small umbilical hernia

T7-T10

Continuous Level

Unilateral Breast surgery with node dissection

T2-T3

Nephrectomy (lateral approach)

T6-T7

Thoracotomy, VATS

T4-T5

Bilateral Major abdominal surgery (liver resection, midline approach for a nephrectomy, Whipple, pancreatectomy, small bile resection, etc)

T7-T8

AAA

T7-T8

Pelvic surgery (cystectomy, hysterectomy with node dissection)

T10-T11

AAA, abdominal aortic aneurysm; VATS, video-assisted thoracic surgery

I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G

radiologic evidence of a PVB spreading contralaterally by a nonepidural route following the injection of a large volume of local anesthetic solution.3 The local anesthetic and radiologic dye had spread anterior to the vertebral bodies.

Indications Single PVBs primarily have been used for patients undergoing breast surgery with and without axillary dissection,4-7 inguinal and umbilical hernia repair,8,9 and thoracotomy and video-assisted thoracic surgery (VATS; Table). Although the technique has been shown to be effective in this indication, Hill et al demonstrated that for VATS, single PVBs do not provide analgesia beyond 8 hours postoperatively.10 Therefore a CPVB is preferred in this indication11-13 because it provides longer-lasting analgesia and shorter hospital length of stay (LOS).14 For breast surgery, the blocks are performed between T2 and T6, and a continuous technique is indicated for surgery including breast reconstruction. It is important to recognize that, based on a retrospective analysis, evidence supports the concept that the use of PVBs delays recurrence and the development of metastases.15 Multiple studies have shown that for patients undergoing axillary dissection during breast surgery, PVBs provide improved postoperative analgesia, and reduced incidence of nausea and vomiting, compared with general anesthesia alone, and shorter LOS.16,17 At UPMC, unilateral CPVB is used at T4-T5 for thoracotomy, as well as VATS and esophageal surgery. This technique also has been recommended for postoperative pain management following cardiac surgery.18,19 Mid-thoracicâ&#x20AC;&#x201C;level CPVB is used for major abdominal cases 20-22 such as chemoperfusion, partial hepatectomy, nephrectomy, colectomy, and for the occasional open repair of an abdominal aortic aneurysm. For trauma and rib fracture cases, CPVBs are placed at the corresponding level of the injury. In this indication, it is not unusual to place 2 paravertebral catheters in the case of extended rib fractures. Lower thoracic single-shot PVBs are routinely performed bilaterally at T10, T11, and T12 for radical prostatectomy due to the visceral input. Studies performed at UPMC have shown great efficacy with lower pain scores.23 The same levels are blocked for laparoscopic abdominal hysterectomy. They even have been used for more minor abdominal surgeries such as umbilical hernia repair. These blocks are not routinely performed for laparoscopic cholecystectomy, although they provide excellent postoperative analgesia.24 Pediatric anesthesiologists or anesthesiologists with advanced training in pediatric regional anesthesia can place pediatric PVBs.25 PVBs also have been recommended for labor analgesia26,27 and the treatment of chronic pain syndromes.28 The use of CPVBs also has been advocated for multiple rib fractures.29 At UPMC, CPVBs have become the standard of care for the management of pain associated

with multiple rib fractures, for several reasons: 1. Regional anesthesia has been shown to decrease morbidity and mortality in patients with multiple rib fractures. 2. Most patients received thromboprophylaxis with enoxaparin and the use of enoxaparin is a contraindication of epidurals. 3. PVBs have been shown to be equally effective as epidural analgesia.17,30-34 4. The use of CPVBs for the management of pain following multiple rib fractures has been shown to be effective and safe in patients receiving enoxaparin for thromboprophylaxis. The thoracic PVB is indicated for analgesia after thoracic, abdominal, or pelvic surgery when patients do not have an absolute contraindication—such as refusal, infection at the intended procedure site, or pharmacologic or uncontrolled anticoagulated states. Of particular concern for many clinicians is the patient who presents for surgery prior to a 24-hour waiting period after having received therapeutic anticoagulation for the treatment of known venous thrombosis or pulmonary embolus. (Such a regimen might include enoxaparin 1 mg/kg subcutaneously twice daily; fondaparinux [Arixtra, GlaxoSmithKline] 7.5 mg subcutaneously once daily, and noninterrupted heparin infusion with prothrombin time 2 to 3 times the normal rate). In its Third Evidence-Based Guidelines, the American Society of Regional Anesthesia and Pain Medicine advises against the use of deep and plexus blocks in patients receiving antithrombotic or thrombolytic therapy.35 These recommendations are based on very few case reports. For the past 10 years, clinicians at UPMC have performed peripheral nerve blocks and PVBs in patients receiving thromboprophylaxis for deep vein thrombosis and pulmonary embolism either postoperatively or because of multiple rib fractures. The combination of CPVBs and thromboprophylaxis has not been associated with any significant bleeding, particularly at the time of the removal of the paravertebral catheter. At UPMC, administration of the thromboprophylaxis is not discontinued and these catheters are removed without consideration for the type of drug used for thromboprophylaxis or the timing of administration.36-39

Techniques PATIENT POSITIONING Most PVBs are best performed in the sitting position. However, in patients lacking mobility—because they are intubated, for example, or have experienced trauma— PVBs can be performed in the lateral position. Although it is possible to perform PVBs when the patient is prone, it is important to recognize that this position increases the time required to perform the block.

LOCALIZATION

OF THE

THORACIC LEVEL

Regardless of the technique, it is necessary to first determine the level at which the PVB should be

Figure 1. Classic approach for single blocks. The needle is introduced 2.5 cm lateral from the spinous process in search of the transverse process.

performed. Several approaches are available: 1. Use the C7 spinous process (vertebra prominens) as the initial point to count down spinous processes. 2. Start at the edge of the scapular, which enables the localization of the space between T7 and T8 within ±1 level (Technique 1 has been shown to be more accurate than this technique).40 3. Localize the 12th rib and count the ribs upward, using either surface landmarks or ultrasound.

BLIND TECHNIQUES Several techniques are described based on the use of surface landmarks not requiring the use of ultrasound: classic, neurostimulation, loss of resistance, and intercostal. Classic (Figure 1). The needle (22-gauge Tuohy for single PVBs and an 18-gauge Tuohy for CPVBs) is introduced 2.5 cm lateral from the top of the desired vertebral body in search of the transverse process. Once contact is made with the transverse process, the needle is withdrawn to the skin and is redirected caudally 1 cm below the transverse process. The depth of the PVS varies according to the thoracic level.41 Frequently, the correct positioning of the needle is associated with a loss of resistance as the needle travels through the costal ligament. Next, 5 mL of local anesthetic solution is slowly injected per level (single PVBs) or before the introduction of the catheter, which is positioned 3 to 5 cm beyond the tip of the needle in the case of CPVB. The Tuohy introducer needle is removed and the catheter is secured in place with Steri-strips (3M) and covered with a transparent dressing. Neurostimulation. Using the same landmark as the classic approach, a 10-cm 18-gauge insulated Tuohy is

A N E ST H E S I O LO GY N E WS • M A R C H 2 0 1 2

connected to a nerve stimulator set up to deliver 1.5 mA, 0.1 milliseconds at a frequency of 2 Hz. The positioning of the needle produces an ipsilateral contraction of the corresponding intercostal muscles.42,43 Loss of Resistance. Using the same landmark as the classic approach, an 18-gauge Tuohy needle is connected to tubing, which is also connected to a pressure transducer filled with saline. A sudden drop in pressure characterizes the introduction of the needle in the PVS.44 Intercostal. In this approach, an 18-gauge Tuohy needle is introduced between 2 ribs corresponding to the desired paravertebral level 8 cm from the corresponding spinous process. After the rib is contacted, the needle is oriented at a 60-degree angle and introduced medially for another 2 cm with the bevel oriented medially. Three milliliters of local anesthetic is injected slowly after negative aspiration for blood before the introduction of the catheter. The catheter is introduced 6 cm beyond the tip of the needle.45

Figure 2a. Ultrasound-guided classic approach.

ULTRASOUND-GUIDED THORACIC PARAVERTEBRAL BLOCK There are at least three described approaches to performing an ultrasound-guided PVB: The classic approach, in which the probe is positioned parallel to the spinal processes46; an intercostal approach, which is used only for the placement of a paravertebral catheter47; and a proximal lateral approach, in which the probe is placed perpendicular to the spinous processes. Classic. After identifying the proper thoracic level, the curved low-frequency probe is placed longitudinally parallel and medially in search of spinous processes.48 These will appear as bright white lines in a wave or sawtooth pattern. Next the probe is translated laterally in search of the transverse processes. Between the bright, hyperechoic cortices of the transverse processes and the underlying acoustic shadows is a less echogenic line connecting the bone that represents the costotransverse ligaments (CTL). Typically, the PVS is confirmed by viewing the CTL and an underlying echogenic line

Figure 3. When the transducer is too lateral, the paravertebral space appears narrower.

Figure 2b. Ultrasound-guided classic approach. Left: The ultrasound transducer is positioned longitudinally at the level of the spinous process. Center: The transducer is moved laterally in search of the transverse processes. Right: The injection of the local anesthetic solution pushes the pleura anteriorly and disperses over several thoracic levels.

I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G

that represents the proximal and distal pleura. The PVS is between the CTL and the line of the pleura (Figures 2a and 2b). The PVS may have less anterior-posterior dimension if the probe is placed too far lateral of the spinous processes. (Figure 3). The needle is advanced in-plane and medially. A distinctive loss of resistance is felt when the needle passes through the CTL. After proper placement of the needle, local anesthetics may be injected. The injection may result in an isolated push anteriorly of the pleura, or better, a distribution of the anesthetic solution throughout multiple levels, but with a less evident push of the pleura. Multilevel distribution confirms that the needle is indeed in the PVS. Our institution and others have reported that the spread resulting from a single injection of 10 to 15 mL of local anesthetic with dye can take several shapes and can extend up to 6 or 7 dermatomes. Intercostal. The ultrasound transducer is positioned between the ribs of the desired level at a distance of 8 cm from the spinous process. The needle is placed in-plane and medially, between the internal and innermost intercostal muscles. Two to 3 mL of local anesthetic should be injected prior to placing the catheter, which should extend 8 cm beyond the tip of the needle (Figure 4).47

has been reported to be associated with 30% to 70% epidural spread and with the frequent placement of the catheter in the epidural space.48 Therefore, this is not a recommended approach. Furthermore, Luyet reported that the use of this technique is associated with a failure rate of up to 45% when inserted 5 cm beyond the needle, as the catheters became lodged into the epidural space and dislodged into paraspinal muscle. Regardless of the technique, once the needle is in the paravertebral space, 5 mL of ropivacaine 0.5% is injected slowly after negative aspiration for blood. If a single PVB is performed, this process is repeated at another level. Naja et al demonstrated that the spread of local anesthetic was greater when using a multilevel injection than with a single injection,42 without any effects on the local anesthetic absorption.49 If a CPVB is performed, the catheter is introduced after the initial injection. When the catheter is secured in place, another 10 mL of ropivacaine 0.5% is injected slowly after negative aspiration for blood, for a total of 15 mL per catheter. The paravertebral catheter is infused with either bupivacaine 0.0625% or lidocaine 0.25% at a starting

PROXIMAL LATERAL APPROACH The probe is placed perpendicular to the longitudinal plane of the spinous processes (Figure 5). The needle is introduced in-plane in a medial direction. This approach

Figure 4. Intercostal approach to the paravertebral space. The line indicates the space between ribs 6 and 7.

Figure 5. Proximal lateral approach with horizontally oriented probe and needle position (top), with corresponding sonoanatomy (bottom).

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rate of 7 mL per hour. The rate can be increased to 10 mL per hour if necessary. Orders should also include a bolus of 3 mL per hour, as needed, given by the nurse. The advantage of lidocaine is that it is safer, and when in doubt, determining the plasma level of the drug is simple. Ropivacaine 0.2% also has been reported as an alternative for continuous infusion. Regardless of the solution, the total rate should not exceed 20 mL per hour.

Complications Complications of PVBs are rare. The most frequent is the development of vagual episodes during the performance of the block, and serious adverse events include development of a pneumothorax, major bleeding, infection, epidural or intrathecal spread, headache, and local anesthetic toxicity.50-53 Hypotension also may occur; however, it is less frequent than has been associated with thoracic epidurals. In this regard, the use of ultrasound to guide the blocks may help avoid the complications related to an incorrect placement of the needle or catheter, such as pneumothorax, epidural injection, and the placement of an epidural catheter. Pneumothorax is considered a classic complication of PVB, and is estimated to occur in between 0.5% and 1% of patients undergoing blocks (Figure 6). Yet it often is difficult to establish that the block caused the pneumothorax, particularly in patients undergoing major abdominal or pelvic surgeries or those in whom a central line has been placed. Clinicians must be vigilant for this event. Performing a PVB under direct vision at

Figure 6. Chest x-ray illustrates 15% pneumothorax following continuous paravertebral block. No chest tube was placed. 6

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least theoretically reduces the risk for placing the needle beyond the pleura, as long as the clinician maintains good visualization of the needle. Visualization of the needle during the performance of a PVB is among the most challenging aspects of the procedure because the needle often is introduced at a steep angle. Use of echogenic needles or software that enhance the quality of the image can facilitate visualization of the needle and should be considered. At UPMC, we have observed 3 pneumothoraces requiring the placement of a chest tube. In every case, the PVBs were not performed with the use of ultrasound. Although it is important to recognize that the use of ultrasound would most likely not completely eliminate this complication, performing these blocks under direct visualization can certainly help reduce the frequency of this complication.

CONTINUOUS PARAVERTEBRAL OR THORACIC EPIDURAL: NOT JUST A MATTER OF PREFERENCE Many clinicians consider their choice of method to be a matter of personal preference. However, the data suggest otherwise. It is well established that the placement of a thoracic epidural is difficult and associated with frequent failure. In contrast, the success rate associated with PVBs is high. As discussed earlier, the use of epidural is contraindicated in patients receiving thromboprophylaxis initiated postoperatively. We have placed paravertebral catheters in patients undergoing major surgery or with multiple rib fractures in whom thromboprophylaxis was initiated after the procedure. In these patients, the catheters were removed without interruption and timing of the anticoagulation administration. Using such an approach, we did not observe any significant bleeding. The same is true for patients who have transient coagulopathy, such as those undergoing liver resection. However, the risk for epidural hematoma in patients taking low-molecular-weight heparin who receive an epidural catheter is well established. Indeed, in these patients, use of an epidural is contraindicated. The relative safety of PVBs in anticoagulated patients is particularly important, considering that regional anesthesia and analgesia reduce overall morbidity and mortality in this patient population. Continuous PVBs are less likely to cause hypotension associated with sympathetic blockade, particularly when placed unilaterally. Because the local anesthetic solutions for PVBs do not include opioids, patients benefiting from these techniques are less likely to experience pruritus or urinary retention. As a result, placement of a PVB does not necessitate the use of a Foley catheter, thus reducing the patientâ&#x20AC;&#x2122;s risk for urinary tract infections, which are associated with these devices. PVBs are associated with fewer side effects, consume fewer nursing resources, and require less monitoring than do thoracic epidurals.54 In many institutions, patients who receive thoracic epidurals must be

Steps To Minimize Complications and Failed Blocks epinephrine may be indicated), changes associated with an epidural and intrathecal administration of local anesthetics.

1. Use ultrasound guidance whenever possible. 2. Perform a full assessment of each patient prior to the procedure. The basic medical history can help avoid the performance of deep blocks on patients who are actively anticoagulated. 3. Be prepared to treat side effects and complications: vagal response during the performance of the block (5%-10% of symptoms include bradycardia and hypotension, possibly preceded or accompanied by lightheadedness, diaphoresis, and nausea. Approximately 50% of these patients require more than simply a change of posture. IV fluid boluses, IV glycopyrolate or atropine, ephedrine, or even

admitted to the intensive care unit, which is not necessary with PVBs. In patients with multiple rib fractures and lumbar spine trauma, the use of continuous thoracic PVB for analgesia and preservation of respiratory function does not interfere with neurologic assessment for signs of spinal cord compression. Although this may not be a common occurrence, it displays the versatility and efficacy of CPVBs.

The Case for Thoracic Epidurals Despite the advantages of PVBs, thoracic epidural analgesia is not without its advocates. In a recent review, Norum and Brevik argued that optimally conducted epidural analgesia has not been compared with PVBs, and that most studies of the 2 techniques were seriously flawed because the thoracic catheters was placed several segments too low.55 They also noted that only 1 of the 10 studies they reviewed used opioids and adrenaline (epinephrine) in the thoracic epidural solution. Epidurals performed without an opioid and adrenaline (or α-2 agonist) lose efficacy and the increased volume to achieve analgesia causes dose-related adverse effects of local anesthetics including hypotension, lower extremity motor block, and urinary retention. The authors also stated that the most sensitive outcome variable for post-thoracotomy pain relief is pain intensity on coughing (dynamic pain). However, many studies used depth of breathing. Although persuasive, the authors admit their personal bias against PVBs reflects a case of sudden and permanent paraplegia in a patient receiving the block, and they speculate that this complication resulted from disruption or injection into the radicular artery that supplied the lower spinal cord. This case has not been published. The authors state the available randomized controlled studies were not large enough to evaluate for the rare but serious or fatal events that can occur in patients receiving these blocks.

4. Use in-plane needle advancement. Do not advance unless the tip is visible. 5. When advancing the needle, keep a closed system with fluid-filled tubing connected to the Tuohy needle. Doing so confers some safety and prevents a parietal pleural puncture from converting to a pneumothorax. 6. Avoid the temptation to push the paravertebral catheter too far. No more than 4 to 5 cm should be inserted beyond the tip of the needle.

Conclusion The indications for the safe use of PVBs have expanded in recent years, as more anesthesiologists become experienced with the technique. This procedure increasingly is recognized as an effective and safer alternative to the thoracic epidural in patients receiving thromboprophylaxis.

References 1.

Eason MJ, Wyatt R. Paravertebral thoracic block—a reappraisal. Anaesthesia. 1979;34(7):638–642.

2. Klein SM, Nielsen KC, Ahmed N, Buckenmaier CC, Steele S. In situ images of the thoracic paravertebral space. Reg Anesth Pain Med. 2004;29(6):596-599. 3. Karmakar MK, Kwok WH, Kew J. Thoracic paravertebral block: radiological evidence of contralateral spread anterior to the vertebral bodies. Br J Anaesth. 2000;84(2):263-265. 4. Greengrass R, O’Brien F, Lyerly K, et al. Paravertebral block for breast cancer surgery. Can J Anesth. 1996;43(8):858-861. 5. Buckenmaier CC 3rd, Steele SM, Nielsen KC, Klein SM. Paravertebral somatic nerve blocks for breast surgery in a patient with hypertrophic obstructive cardiomyopathy. Can J Anesth. 2002;49(6):571-574. 6. McElroy, S. Colaizzi I, Flemming T, Chelly JE. Continuous paravertebral nerve blocks for postoperative pain management after secondary breast reconstruction using tissue expanders. Anesth Analg. 2009;108;S324. 7. Moreno MG, McElroy S, Colaizzi I, Fleming T, Chelly JE. Continuous paravertebral nerve block for postoperative pain management after radical mastectomy with axillary node dissection (RMAND). Anesth Analg. 2009;108:S327. 8. Klein SM, Greengrass RA, Weltz C, Warner DS. Paravertebral somatic nerve block for outpatient inguinal herniorrhaphy: an expanded case report of 22 patients. Reg Anesth Pain Med. 1998; 23(3):306-310. 9. Hadzic A, Kerimoglu B, Loreio D, et al. Paravertebral blocks provide superior same-day recovery over general anesthesia for patients undergoing inguinal hernia repair. Anesth Analg. 2006;102(4):1076-1081. 10. Hill SE, Keller RA, Stafford-Smith M, Grichnik K, et al. Efficacy of single-dose, multilevel paravertebral nerve blockade for analgesia after thoracoscopic procedures. Anesthesiology. 2006;104(5):1047-1053. 11. Marret E, Bazelly B, Taylor G. Paravertebral block with ropivacaine 0.5% versus systemic analgesia for pain relief after thoracotomy. Ann Thorac Surg. 2005;79(6):2109-2113.

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12. Català E, Casas JI, Unzueta MC, Diaz X, Aliaga L, Villar Landeira JM. Continuous infusion is superior to bolus doses with thoracic paravertebral blocks after thoracotomies. J Cardiothorac Vasc Anesth. 1996;10(5):586-588. 13. Ben-David B, Merman R, Chelly JE. Paravertebral blocks for thoracoscopy: single no, continuous yes. Anesthesiology. 2007; 106(2):398-399.

and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs—a pilot study. J Trauma. 2009;66(4):1096-1101. 34. Scarci M, Joshi A, Attia R. In patients undergoing thoracic surgery is paravertebral block as effective as epidural analgesia for pain management? Interact Cardiovasc Thorac Surg. 2010;10(1):92-96.

14. Chelly JE, Ben-David B, Rest C, Uskova A, Pizzi L. Continuous paravertebral blocks reduce the hospital length of stay following thoracotomy. ASA, CD 2005.

35. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010; 35(1):64-101.

15. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006;105(4):660-664.

36. Gierl B, Alarcon L, Chelly JE. Safety associated with the removal of paravertebral catheters in trauma patients receiving enoxaparin for thromboprophylaxis. ASRA 2010.

16. Naja MZ, Ziade MF, Lönnqvist PA. Nerve-stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial. Eur J Anaesthesiol. 2003;20(11):897-903.

37. Conrad E, Chelly JE, Shick V, Mukalel J. Combination of enoxaparin and continuous paravertebral blocks for major gynecologic surgery. ASRA 2011.

17. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2006;96(4):418-426. 18. Olivier JF, Bracco D, Nguyen P, Le N, Noiseux N, Hemmerling T; Perioperative Cardiac Surgery Research Group (PeriCARG). A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks. Heart Surg Forum. 2007;10(5):E357-E62.

38. Gierl BT, Conrad E, Alarcon L, Chelly JE. Safety associated with the removal of paravertebral catheters in trauma patients receiving LMWH for thromboprophylaxis. ASA CD 2011. 39. Chelly JE, Schilling D. Thromboprophylaxis and peripheral nerve blocks in patients undergoing joint arthroplasty. J Arthroplasty. 2008;23(3):350-354. 40. Teoh DA, Santosham KL, Lydell CC, Smith DF, Beriault MT. Surface anatomy as a guide to vertebral level for thoracic epidural placement. Anesth Analg. 2009;108(5):1705-1707

19. Lee JK, Pearce-Smith B, Wei L, Chelly JE. Continuous paravertebral catheters in patients who underwent minimally invasive cardiac surgery: a case series. ASRA 2011.

41. Chelly JE, Uskova A, Merman R, Szczodry D. A multifactorial approach to the factors influencing determination of paravertebral depth. Can J Anesth. 2008;55(9):587-594.

20. Culp WC Jr, Culp WC. Thoracic paravertebral block for percutaneous transhepatic biliary drainage. J Vasc Interv Radiol. 2005;16(10): 1397-1400.

42. Naja ZM, El-Rajab M, Al-Tannir MA, et al. Thoracic paravertebral block: influence of the number of injections. Reg Anesth Pain Med. 2006;31(3):196-201.

21. Burns DA, Ben-David B, Chelly JE, Greensmith JE. Intercostally placed paravertebral catheterization: an alternative approach to continuous paravertebral blockade. Anesth Analg. 2008;107(1): 339-341.

43. Boezaart A, Lucas SD, Elliott CE. Paravertebral block: cervical, thoracic, lumbar, and sacral. Curr Opin Anaesthesiol. 2009;22(5):637-643.

22. Finnerty O, Carney J, McDonnell JG. Trunk blocks for abdominal surgery. Anaesthesia. 2010;65 Suppl 1:76-83.

44. Richardson J, Cheema SP, Hawkins J, Sabanathan S. Thoracic paravertebral space location. A new method using pressure measurement. Anaesthesia. 1996;51(2):137-139.

23. Chelly JE, Ploskanych T, Dai F, Nelson JB. Multimodal analgesic approach incorporating paravertebral blocks for open radical retropubic prostatectomy: a randomized double-blind placebocontrolled study. Can J Anesth. 2011;58(4):371-378.

45. Burns DA, Ben-David B, Chelly JE, Greensmith JE. Intercostally placed paravertebral catheterization: an alternative approach to continuous paravertebral blockade. Anesth Analg. 2008;107(1):339-341.

24. Naja ZM, El-Rajab M, Ziade F, Al-Tannir M, Itani T. Preoperative vs. postoperative bilateral paravertebral blocks for laparoscopic cholecystectomy: a prospective randomized clinical trial. Pain Pract. 2011;11(6):509-515.

46. Montoya M, Fanelli A, Chelly JE. Frequent epidural spread can be prevented when performing an ultrasound guided approach to the paravertebral space. Br J Anaesth (E-letter). June 16, 2009.

25. Tsai T, Rodriguez-Diaz C, Deschner B, Thomas K, Wasnick JD. Thoracic paravertebral block for implantable cardioverter-defibrillator and laser lead extraction. J Clin Anesth. 2008;20(5):379-382. 26. Suelto MD. Paravertebral lumbar sympathetic block for labor analgesia. Anesthesiology. 2000;93(2):580. 27. Choi S, Brull R. Neuraxial techniques in obstetric and non-obstetric patients with common bleeding diatheses. Anesth Analg. 2009; 109(2):648-660. 28. Chaturvedi A, Dash HH. Sympathetic blockade for the relief of chronic pain. J Indian Med Assoc. 2001;99(12):698-703. 29. Karmakar MK, Chui PT, Joynt GM, Ho AM. Thoracic paravertebral block for management of pain associated with multiple fractured ribs in patients with concomitant lumbar spinal trauma. Reg Anesth Pain Med. 2001;26(2):169-173. 30. Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth. 1999;83(3):387-392. 31. Dhole S, Mehta Y, Saxena H, Juneja R, Trehan N. Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 2001;15(3):288-292. 32. Casati A, Alessandrini P, Nuzzi M, Tosi M, et al. Prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery. Eur J Anaesthesiol. 2006;23(12):999-1004. 33. Mohta M, Verma P, Saxena AK, Sethi AK, Tyagi A, Girotra G. Prospective, randomized comparison of continuous thoracic epidural

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47. Ben-Ari A, Moreno M, Chelly JE, Bigeleisen PE. Ultrasound-guided paravertebral block using an intercostal approach. Anesth Analg. 2009;109(5):1691-1694. 48. Luyet C, Eichenberger U, Greif R, Vogt A, Szücs Farkas Z, Moriggl B. Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: an imaging study. Br J Anaesth. 2009;102(4):534-539. 49. Lemay E, Guay J, Côté C, Boivin MC, Varin F. The number of injections does not influence local anesthetic absorption after paravertebral blockade. Can J Anesth. 2003;50(6):562-567. 50. Merman R, Burman K, Uskova, A, Chelly JE. Hypotensive bradycardic events and paravertebral blocks in the sitting position. Anesth Analg. 2006;102:S-134. 51. Adelman H, Irwin I. Acute aseptic meningitis following paravertebral lumbar sympathetic blocks. Anesthesiology. 1946;7:422-425. 52. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia. 1995;50(9):813-815. 53. Lin HM, Chelly JE. Post-dural headache associated with thoracic paravertebral blocks. J Clin Anesth. 2006;18(5):376-378. 54. Pintaric TS, Potocnik I, Hadzic A, Stupnik T, Pintaric M, Jankovic VN. Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery. Reg Anesth Pain Med. 2011;36(3):256-260. 55. Norum HM, Breivik H. A systematic review of comparative studies indicates that paravertebral block is neither superior nor safer than epidural analgesia for pain after thoracotomy. Scand J Pain. 2010;1(1):12-23.

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CLIN I CA L A N E STH E SI OL OG Y

most common definition of a regular interval was every 15 minutes or less. Fewer than half (43%) of clinicians who responded to the survey said they believed it was best practice to document IV function at some point during surgery, and only 5.7% reported doing so. Dr. Metro said he was surprised to find inspection and documentation practices did not differ significantly between the 6.3% of respondents who said they had cared for a patient with a major IV infiltration requiring medical intervention and the 93.7% of staff who had not. “Caregivers might be shocked when a complication occurs, but it doesn’t change how they practice,” Dr. Metro said. “We’re simply not taught to pay

much attention to PIVs and it’s not embedded in our culture of care.” Sanjay M. Bhananker, MD, associate professor of anesthesiology and pain medicine at Harborview Medical Center and Seattle Children’s Hospital, in Washington, said that the harried pace of the clinical day may relegate the management and documentation

of PIVs to low-priority status. “I believe that some complications can be avoided by properly examining and documenting PIVs and the results of this survey should definitely prompt clinicians to consider whether they’re doing a good job,” Dr. Bhananker, who was not involved in the study, told Anesthesiology News. “However, while best-practice guidelines would probably help, there is the reality of time constraints. In an ideal world, you would keep close track and a detailed

record of lines, but when you’re multitasking to take care of your sick patients in a busy clinical day, checking and documenting IV lines every 15 minutes becomes impractical.” Dr. Bhananker noted that computerized decision support systems, which generate electronic reminders according to electronic anesthesia records, may help improve monitoring and documentation of PIV functioning. —David Wild

4. When taking over a new case from a colleague, you: A. Evaluate each IV B. Assume IVs function unless told otherwise 5. In your opinion, what is the best practice in documenting IVs? A. Less than every 15 minutes B. 15, 30, 60 minutes C. Routine at longer intervals D. Sporadic E. Once at the beginning F. Only if problem G. Never 6. How often do you document IV function in the anesthesia record? A. Less than every 15 minutes B. 15, 30, 60 minutes C. Routine at longer intervals D. Sporadic E. Once at the beginning F. Only if problem G. Never

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C LIN I C A L A N ES THES IO LO GY

Potassium Check Before Surgery May Be ‘Low-Yield’ Diversion Findings suggest test is a cause of avoidable delays and cancellations

hecking potassium levels in patients with renal failure before undergoing surgery may be a costly waste of time, a new study suggests. Among thousands of procedures in renal failure patients that took place over a 10-year period at Vanderbilt

University in Nashville, Tenn., potassium levels were checked before surgery in more than 50% and within two hours before surgery in 8%. Those who underwent preoperative potassium testing fared no better following the procedure than those who received no such testing.

The findings suggest that routine testing of potassium in renal failure patients is unnecessary and can lead to expensive delays in surgery, study author Jesse M. Ehrenfeld, MD, MPH, assistant professor of anesthesiology and biomedical informatics at Vanderbilt, told Anesthesiology News.

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“What we’ve shown is testing doesn’t add much in this particular group of patients,” he said. In addition, 13 (2%) of the patients tested within two hours of surgery had elevated potassium levels—defined as a concentration in blood of more than 6 mEq/L. But these patients were no more likely to experience an adverse event than those with normal potassium levels, Dr. Ehrenfeld and his team reported at the 2011 annual meeting of the American Society of Anesthesiologists (ASA; abstract 1652). “We had some markedly high potassium levels in patients who went through surgery and did fine,” he said. How many surgeries are postponed or canceled outright because patients have high potassium levels (hyperkalemia) is hard to estimate, Dr. Ehrenfeld noted. “But it happens with a great enough frequency that we decided to study the issue.” Typically, doctors worry about patients in renal failure because they are likely to have electrolyte imbalances, which can disrupt the electrical activity of the heart. Concerned that surgery could exacerbate the problem, leading to cardiac arrest, doctors often test patients at risk and postpone renal transplants, the insertion of an

March 2012

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CLIN I CA L A N E STH E SI OL OG Y arteriovenous fistula and other procedures if potassium levels are high. Delaying surgery is bad both for patients, who have fasted and prepared for the procedure, and hospitals, which have dedicated space and resources to the procedure. “A delay is a significant expense to the hospital and health care system,” Dr. Ehrenfeld said. To determine the utility of testing for potassium—and potentially delaying procedures in the process—the researchers reviewed the records of 8,456 surgeries that took place over a 10-year period among 1,861 patients with chronic renal failure. In more than 4,400 instances, patients had their potassium levels checked before surgery; 698 had the test two hours prior, among whom 13 (2%) had values exceeding 6 mEq/L. All of these patients underwent surgery as planned and did not appear to experience more adverse events following surgery than the group that did not undergo testing before surgery, the researchers said. These results likely only apply to patients in renal failure, Dr. Ehrenfeld

noted. They are constantly exposed to high levels of potassium and develop a tolerance to the mineral. These data indeed suggest that it may not always be necessary to check potassium levels in renal failure patients before surgery, said Norman Cohen, MD, associate professor of anesthesiology and perioperative medicine at Oregon Health & Science University (OHSU), who did not participate in the study. But the findings are not quite convincing enough for

him to stop doing so in his patients. “I’m a little concerned about using preliminary, retrospective data from one practice to advocate for a change in practice overall,” Dr. Cohen told Anesthesiology News. “Just because in those 13 patients with high potassium levels there were no adverse outcomes does not mean that with a larger group of patients, you wouldn’t see a difference.” Still, Dr. Cohen said he plans to ask OHSU to review its own patient

records to look for the same patterns. Ultimately, the most convincing experiment would randomize patients and follow them prospectively, said Dr. Cohen, who also is vice president for professional affairs at the ASA. So far, based on the Vanderbilt data, Dr. Cohen added, it does appear that testing potassium levels in all renal failure patients before surgery “is a lowyield endeavor.” —Alison McCook

‘We had some markedly high potassium levels in patients who went through surgery and did fine.’ —Jesse M. Ehrenfeld, MD, MPH

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T E C H NO L O G Y

Towers of Babel in Hospitals as Record Systems Struggle To Communicate

lectronic medical record systems in hospitals are spreading, but seldom communicating. “It’s a huge problem,” said Richard P. Dutton, MD, MBA, executive director of the Anesthesia Quality Institute, an offshoot of the American Society

of Anesthesiologists. Lack of integration across hospital departments increases the cost of care; results in duplicative tests; reduces billing; and can undermine compliance with insurance, regulations and quality guidelines such as those from the Surgical Care

Improvement Project, experts said. Installing electronic record systems incurs substantial capital cost and requires additional personnel, said Ronald A. Kahn, MD, professor of anesthesiology and surgery at Mount Sinai Medical Center, in New

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No System Is an Island Jesse M. Ehrenfeld, MD, MPH, assistant professor of anesthesiology and biomedical informatics and director of Perioperative Data Systems Research for the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, Tenn., said that “in spite of some recent progress in moving toward the adoption of common, interoperable standards, the notable lack of integration across EHR [electronic health record] systems remains a problem for anesthesiologists and other clinicians who work across the perioperative environment.” According to Dr. Ehrenfeld, lack of integration causes inefficiency, undermines clinical decision support and increases chances of data entry–related mistakes. Such failure to communicate “can be downright dangerous.” For example, a patient who is allergic to penicillin might have the allergy noted only in a hospital EHR, without the information transferring to the anesthesia information management system. The result would be that the operating room team would not have this needed information. “Lack of EHR integration, in my mind, is a clear patient safety issue,” Dr. Ehrenfeld said. Dr. Kahn, however, said integration of EHR systems was not as important as having electronic medical records in the anesthesia department. “Anesthesia is a different work environment. The record we require is much different.”

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The Choice of

Continuous Motion

Indication for Use - Chronic, intractable pain of the trunk and/or limbs-including unilateral or bilateral pain. Contraindications: Diathermy. Warnings: Defibrillation, diathermy, electrocautery, MRI, RF ablation, & therapeutic ultrasound can result in unexpected changes in stimulation, serious patient injury or death. Rupture/piercing of neurostimulator can result in severe burns. Electrical pulses from the neurostimulator may result in an inappropriate response of the cardiac device. Precautions: The safety and effectiveness of this therapy has not been established for: pediatric use, pregnancy, unborn fetus, or delivery. Follow programming guidelines & precautions in product manuals. Avoid activities that stress the implanted neurostimulation system. EMI, postural changes, & other activities may cause shocking/jolting. Adverse Events: Undesirable change in stimulation; hematoma, epidural hemorrhage, paralysis, seroma, CSF leakage, infection, erosion, allergic response, hardware malfunction or migration, pain at implant site, loss of pain relief, chest wall stimulation, & surgical risks. For full prescribing information, please call Medtronic at 1-800-328-0810 and/or consult Medtronic’s website at www.medtronic.com. USA Rx Only Rev 0209

UC201205073 EN

Learn more by visiting www.adaptivestim.com.

Neurostimulation Systems for Pain Therapy Brief Summary: Product Technical Manuals and Programming Guides must be reviewed prior to use for detailed disclosure.

York City. The three main obstacles, he said, “are cost, cost, cost.” A 2009 study found that only 1.5% of U.S. hospitals had a comprehensive electronic record system across all major clinical units, with an additional 7.6% possessing a basic system in at least one clinical unit (N Engl J Med 2009;360:1628-1638). The anesthesiology department is particularly in need of integrated digital medical records “because we care for all kind of patients, from neonates to nonagenarians,” Dr. Dutton said. “We have to interface with multiple systems.” Yet, anesthesiology has been the “last part of the hospital to get touched by this.”

Outside Looking In Another pressing problem, experts said, is a lack of integration between hospitals and outside clinicians. “The

March 2012

AnesthesiologyNews.com I 37

TE CH N OL OG Y inability to transfer information from one provider or clinic to another represents a cumbersome reality that all patients face when they see physicians in more than one practice setting. This lack of integration leads to redundant forms, questions, time and effort, and in some cases a bad game of telephone, in which key pieces of information are incorrectly transmitted.” Dr. Ehrenfeld noted that there has been movement toward a solution with the implementation of pilot health information exchanges (such as in Tennessee and Massachusetts), but much more progress is needed. “The key obstacles are cost, privacy concerns and an unwillingness of many large health care systems to let others access their store of patient information—which they often view as proprietary.”

to crack,” he said. National integration may be needed. Dr. Dutton said that there is a trend in hospital purchasing toward enterprise systems (from vendors such as Epic, Cerner and General Electric), in which all systems are seamlessly integrated and acquired from a single vendor. However, his prediction is that the future lies in buying individual components to take advantage of evolution in different technological niches. “It’s better to have an umbrella where you can plug in and

out,” Dr. Dutton said. “As consumers and purchasers of both health care and technology, we must demand interoperability across EHR systems to move this forward,” Dr. Ehrenfeld said. Hospitals tend to think in terms of locally installed solutions, Dr. Rowley pointed out. “They will create a ‘hub’ for others to connect into (a local hospital-centered health information exchange), expecting each physician to create a connection. However, many

small practices have implemented a Web-based EHR solution, and this does not work with such an approach. Web-based EHRs can be accessed from within a hospital, and this does not require waiting for traditional hubs to be built and enrolled into.” Will the problem of lack of integration of systems be solved? Dr. Dutton said, “We’re making constant progress on it.” —George Ochoa

‘There is no single easy way to connect all players. Many locally installed systems don’t have the ability to connect with hospitals without an upgrade, which means additional cost.’ —Robert Rowley, MD

Robert Rowley, MD, chief medical officer for the EHR company Practice Fusion, in San Francisco, said that standards are not yet mature. “There is no single easy way to connect all players,” Dr. Rowley said. “Many locally installed systems don’t have the ability to connect with hospitals without an upgrade, which means additional cost.” Anesthesiologists in particular, he said, need data from outside physician practices—lists of problems, medications and allergies, along with records of preoperative histories and physicals. “These have traditionally been obtained via fax or hand-carried paper copies,” Dr. Rowley said. “In-hospital access to external Web-based EHR information will help this data flow tremendously.” Make Demands Dr. Dutton said that the connection between the hospital and the providers should be seamless. “It’s a tough nut

NAROPIN® was associated with more spontaneous vaginal deliveries and fewer instrumented deliveries than bupivacaine.1-3 A Block Well Done. An 18% higher proportion of spontaneous vaginal deliveries and a 32% lower proportion of instrumented deliveries were observed in patients who received NAROPIN vs bupivacaine (P<0.05; P<0.01).2 To learn more about the clinical beneﬁts of NAROPIN in labor and delivery, visit www.naropin-us.com.

Using NAROPIN beyond recommended doses to increase motor block or duration of sensory block may negate its favorable cardiovascular advantages, in the event that an inadvertent intravascular injection occurs. Like all amide-type local anesthetics, NAROPIN may be associated with adverse reactions. In clinical trials, side effects were mild and transient and may reﬂect the procedures, patient health status, and/or other medications used. Adverse events reported at a rate of ≥5%: hypotension, nausea, vomiting, bradycardia, fever, pain, postoperative complications, anemia, paresthesia, headache, pruritus, and back pain. Important Safety Information There have been adverse event reports of chondrolysis in patients receiving intra-articular infusions of local anesthetics following arthroscopic and other surgical procedures. NAROPIN is not approved for this use. Please see dosage and administration details in Prescribing Information at www.naropin-us.com. Please see accompanying brief summary of Prescribing Information. www.naropin-us.com

NAROPIN is indicated for the production of regional or local anesthesia for surgery and for acute pain management. 1. NAROPIN Prescribing Information. Data on ﬁle. 2. Writer WDR, Stienstra R, Eddleston JM, et al. Neonatal outcome and mode of delivery after epidural analgesia for labour with ropivacaine and bupivacaine: a prospective meta-analysis. Br J Anaesth. 1998;81:713717. 3. Asik I, Göktug A, Gülay I, Alkis N, Uysalel A. Comparison of bupivacaine 0.2% and ropivacaine 0.2% combined with fentanyl for epidural analgesia during labour. Eur J Anaesthesiol. 2002;19:263-270. Naropin® and logo are registered trademarks of APP Pharmaceuticals, LLC. and APP ® are registered trademarks of APP Pharmaceuticals, LLC. ©2011, APP Pharmaceuticals, LLC. All Rights Reserved. 0173-NAR-05-4/11

WHY COMPROMISE?

38 I AnesthesiologyNews.com

March 2012

T E C H NO L O G Y

Data Drive Dispute Over MRIs and Epidural Steroid Injections

embers of the interventional pain community are concerned that insurance companies will exploit findings from a randomized, multicenter study of epidural steroid injections for lumbosacral radiculopathy as a rationale to cut off reimbursement of preinjection MRI (Arch Intern Med 2011 Dec 12. [Epub ahead of print]).

The study, funded by the U.S. Army and Department of Defense, showed that there were no statistically significant differences in rates of positive outcomes between patients who underwent preinjection MRI and those who did not. Furthermore, MRIs had only minor effects on clinicians’ decisions about whether and how to perform epidurals. Other clinician-researchers have

Naropin

(ropivacaine HCl) Injection

BRIEF SUMMARY INDICATIONS AND USAGE Naropin is indicated for the production of local or regional anesthesia for surgery and for acute pain management. Surgical Anesthesia: epidural block for surgery including cesarean section; major nerve block; local infiltration. Acute Pain Management: epidural continuous infusion or intermittent bolus, e.g., postoperative or labor; local infiltration. CONTRAINDICATIONS Naropin is contraindicated in patients with a known hypersensitivity to ropivacaine or to any local anesthetic agent of the amide type. WARNINGS In performing Naropin blocks, unintended intravenous injection is possible and may result in cardiac arrhythmia or cardiac arrest. The potential for successful resuscitation has not been studied in humans. There have been rare reports of cardiac arrest during the use of Naropin for epidural anesthesia or peripheral nerve blockade, the majority of which occurred after unintentional accidental intravascular administration in elderly patients and in patients with concomitant heart disease. In some instances, resuscitation has been difficult. Should cardiac arrest occur, prolonged resuscitative efforts may be required to improve the probability of a successful outcome. Naropin should be administered in incremental doses. It is not recommended for emergency situations, where a fast onset of surgical anesthesia is necessary. Historically, pregnant patients were reported to have a high risk for cardiac arrhythmias, cardiac/ circulatory arrest and death when 0.75% bupivacaine (another member of the amino amide class of local anesthetics) was inadvertently rapidly injected intravenously. Prior to receiving major blocks the general condition of the patient should be optimized and the patient should have an i.v. line inserted. All necessary precautions should be taken to avoid intravascular injection. Local anesthetics should only be administered by clinicians who are well versed in the diagnosis and management of dose-related toxicity and other acute emergencies that may arise from the block to be employed, and then only after ensuring the immediate (without delay) availability of oxygen, other resuscitative drugs, cardiopulmonary resuscitative equipment, and the personnel resources needed for proper management of toxic reactions and related emergencies (See also ADVERSE REACTIONS, PRECAUTIONS, and MANAGEMENT OF LOCAL ANESTHETIC EMERGENCIES). Delay in proper management of dose-related toxicity, underventilation from any cause, and/or altered sensitivity may lead to the development of acidosis, cardiac arrest and, possibly, death. Solutions of Naropin should not be used for the production of obstetrical paracervical block anesthesia, retrobulbar block, or spinal anesthesia (subarachnoid block) due to insufficient data to support such use. Intravenous regional anesthesia (bier block) should not be performed due to a lack of clinical experience and the risk of attaining toxic blood levels of ropivacaine. Intra-articular infusions of local anesthetics following arthroscopic and other surgical procedures is an unapproved use, and there have been post-marketing reports of chondrolysis in patients receiving such infusions. The majority of reported cases of chondrolysis have involved the shoulder joint; cases of gleno-humeral chondrolysis have been described in pediatric and adult patients following intra-articular infusions of local anesthetics with and without epinephrine for periods of 48 to 72 hours. There is insufficient information to determine whether shorter infusion periods are not associated with these findings. The time of onset of symptoms, such as joint pain, stiffness and loss of motion can be variable, but may begin as early as the 2nd month after surgery. Currently, there is no effective treatment for chondrolysis; patients who experienced chondrolysis have required additional diagnostic and therapeutic procedures and some required arthroplasty or shoulder replacement. It is essential that aspiration for blood, or cerebrospinal fluid (where applicable), be done prior to injecting any local anesthetic, both the original dose and all subsequent doses, to avoid intravascular or subarachnoid injection. However, a negative aspiration does not ensure against an intravascular or subarachnoid injection. A well-known risk of epidural anesthesia may be an unintentional subarachnoid injection of local anesthetic. Two clinical studies have been performed to verify the safety of Naropin at a volume of 3 mL injected into the subarachnoid space since this dose represents an incremental epidural volume that could be unintentionally injected. The 15 and 22.5 mg doses injected resulted in sensory levels as high as T5 and T4, respectively. Anesthesia to pinprick started in the sacral dermatomes in 2-3 minutes, extended to the T10 level in 10-13 minutes and lasted for approximately 2 hours. The results of these two clinical studies showed that a 3 mL dose did not produce any serious adverse events when spinal anesthesia blockade was achieved. Naropin should be used with caution in patients receiving other local anesthetics or agents structurally related to amide-type local anesthetics, since the toxic effects of these drugs are additive. Patients treated with class III antiarrhythmic drugs (e.g., amiodarone) should be under close surveillance and ECG monitoring considered, since cardiac effects may be additive. PRECAUTIONS: General: The safe and effective use of local anesthetics depends on proper dosage, correct technique, adequate precautions and readiness for emergencies. Resuscitative equipment, oxygen and other resuscitative drugs should be available for immediate use. (See WARNINGS and ADVERSE REACTIONS.) The lowest dosage that results in effective anesthesia should be used to avoid high plasma levels and serious adverse events. Injections should be made slowly and incrementally, with frequent aspirations before and during the injection to avoid intravascular injection. When a continuous catheter technique is used, syringe aspirations should also be performed before and during each supplemental injection. During the administration of epidural anesthesia, it is recommended that a test dose of a local anesthetic with a fast onset be administered initially and that the patient be monitored for central nervous system and cardiovascular toxicity, as well as for signs of unintended intrathecal administration before proceeding. When clinical conditions permit, consideration should be given to employing local anesthetic solutions, which contain epinephrine for the test dose because circulatory changes compatible with epinephrine may also serve as a warning sign of unintended intravascular injection. An intravascular injection is still possible even if aspirations for blood are negative. Administration of higher than recommended doses of Naropin to achieve greater motor blockade or increased duration of sensory blockade may result in cardiovascular depression, particularly in the event of inadvertent intravascular injection. Tolerance to elevated blood levels varies with the physical condition of the patient. Debilitated, elderly patients and acutely ill patients should be given reduced doses commensurate with their age and physical condition. Local anesthetics should also be used with caution in patients with hypotension, hypovolemia or heart block. Careful and constant monitoring of cardiovascular and respiratory vital signs (adequacy of ventilation) and the patient’s state of consciousness should be performed after each local anesthetic injection. It should be kept in mind at such times that restlessness, anxiety, incoherent speech, light-headedness, numbness and tingling of the mouth and lips, metallic taste, tinnitus, dizziness, blurred vision, tremors, twitching, depression, or drowsiness may be early warning signs of central nervous system toxicity. Because amide-type local anesthetics such as ropivacaine are metabolized by the liver, these drugs, especially repeat doses, should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations. Local anesthetics should also be used with caution in patients with impaired cardiovascular function because they may be less able to compensate for functional changes associated with the prolongation of A-V conduction produced by these drugs. Many drugs used during the conduct of anesthesia are considered potential triggering agents for malignant hyperthermia (MH). Amide-type local anesthetics are not known to trigger this reaction. However, since the need for supplemental general anesthesia cannot be predicted in advance, it is suggested that a standard protocol for MH management should be available. Epidural Anesthesia: During epidural administration, Naropin should be administered in incremental doses of 3 to 5 mL with sufficient time between doses to detect toxic manifestations of unintentional intravascular or intrathecal injection. Syringe aspirations should also be performed before and during each supplemental injection in continuous (intermittent) catheter techniques. An intravascular injection is still possible even if aspirations for blood are negative. During the administration of epidural anesthesia, it is recommended that a test dose be administered initially and the effects monitored before the full dose is given. When clinical conditions permit, the test dose should contain an appropriate dose of epinephrine to serve as a warning of unintentional intravascular injection. If injected into a blood vessel, this amount of epinephrine is likely to produce a transient “epinephrine response” within 45 seconds, consisting of an increase in heart rate and systolic blood pressure, circumoral pallor, palpitations and nervousness in the unsedated patient. The sedated patient may exhibit only a pulse rate increase of 20 or more beats per minute for 15 or more seconds. Therefore, following the test dose, the heart should be continuously monitored for a heart rate increase. Patients on beta-blockers may not manifest changes in heart rate, but blood pressure monitoring can detect a rise in systolic blood pressure. A test dose of a shortacting amide anesthetic such as lidocaine is recommended to detect an unintentional intrathecal administration. This will be manifested within a few minutes by signs of spinal block (e.g., decreased sensation of the buttocks, paresis of the legs, or, in the sedated patient, absent knee jerk). An intravascular or subarachnoid injection is still possible even if results of the test dose are negative. The test dose itself may produce a systemic toxic reaction, high spinal or epinephrine-induced cardiovascular effects. Use in Brachial Plexus Block: Ropivacine plasma concentrations may approach the threshold for central nervous system toxicity after the administration of 300 mg of ropivacaine for brachial plexus block. Caution should be exercised when using the 300 mg dose. (See OVERDOSAGE.) The dose for a major nerve block must be adjusted according to the site of administration and patient status. Supraclavicular brachial plexus blocks may be associated with a higher frequency of serious adverse reactions, regardless of the local anesthetic used. Use in Peripheral Nerve Block: Major peripheral nerve blocks may result in the administration of a large volume of local anesthetic in highly vascularized areas, often close to large vessels where there is an increased risk of intravascular injection and/or rapid systemic absorption, which can lead to high plasma concentrations. Use in Head and Neck Area: Small doses of local anesthetics injected into the head and neck area may produce adverse reactions similar to systemic toxicity seen with unintentional intravascular injections of larger doses. The injection procedures require the utmost care. Confusion, convulsions, respiratory depression, and/or respiratory arrest, and cardiovascular stimulation or depression have been reported. These reactions may be due to intra-arterial injection of the local anesthetic with retrograde flow to the cerebral circulation. Patients receiving these blocks should have their circulation and respiration monitored and be constantly observed. Resuscitative equipment and personnel for treating adverse reactions should be immediately available. Dosage recommendations should not be exceeded. (See DOSAGE AND ADMINISTRATION.) Use in Ophthalmic Surgery: The use of Naropin in retrobulbar blocks for ophthalmic surgery has not been studied. Until appropriate experience is gained, the use of Naropin for such surgery is not recommended. Drug Interactions: Specific trials studying the interaction between ropivacaine and class III antiarrhythmic drugs (e.g., amiodarone) have not been performed, but caution is advised (see WARNINGS). Naropin should be used with caution in patients receiving other local anesthetics or agents structurally related to amide-type local anesthetics, since the toxic effects of these drugs are additive. Cytochrome P4501A2 is involved in the formation of 3-hydroxy ropivacaine, the major metabolite. In vivo, the plasma clearance of ropivacaine was reduced by 70% during coadministration of fluvoxamine (25 mg bid for 2 days), a selective and potent CYP1A2 inhibitor. Thus strong inhibitors of cytochrome P4501A2, such as fluvoxamine, given concomitantly during administration of Naropin, can interact with Naropin leading to increased ropivacaine plasma levels. Caution should be exercised when CYP1A2 inhibitors are coadministered. Possible interactions with drugs known to be metabolized by CYP1A2 via competitive inhibition such as theophylline and imipramine may also occur. Coadministration of a selective and potent inhibitor of CYP3A4, ketoconazole (100 mg bid for 2 days with ropivacaine infusion administered 1 hour after ketoconazole) caused a 15% reduction in in-vivo plasma clearance of ropivacaine. Pregnancy Category B: There are no adequate or well-controlled studies in pregnant women of the effects of Naropin on the developing fetus. Naropin should only be used during pregnancy if the benefits outweigh the risk. Labor and Delivery: Local anesthetics, including ropivacaine, rapidly cross the placenta, and when used for epidural block can cause varying degrees of maternal, fetal and neonatal toxicity (see CLINICAL PHARMACOLOGY and PHARMACOKINETICS). The incidence and degree of toxicity depend upon the procedure performed, the type and amount of drug used, and the technique of drug administration. Adverse reactions in the parturient, fetus and neonate involve alterations of the central nervous system, peripheral vascular tone and cardiac function. Maternal hypotension has resulted from regional anesthesia with Naropin for obstetrical pain relief. Local anesthetics produce vasodilation by blocking sympathetic nerves. Elevating the patient’s legs and positioning her on her left side will help prevent decreases in blood pressure. The fetal heart rate also should be monitored continuously, and electronic fetal monitoring is highly advisable. Epidural anesthesia has been reported to prolong the second stage of labor by removing the patient’s reflex urge to bear down or by interfering with motor function. Spontaneous vertex delivery occurred more frequently in patients receiving Naropin than in those receiving

challenged the investigators’ conclusion that MRIs may not be necessary in most cases. They believe that the study’s results do not reflect the importance of preinjection MRIs for such things as identifying unexpected results and assessing spinal morphology. “If a patient has unrecognized severe stenosis at L4-5 or metastatic disease, for example, and the physician chooses

bupivacaine. Nursing Mothers: Some local anesthetic drugs are excreted in human milk and caution should be exercised when they are administered to a nursing woman. The excretion of ropivacaine or its metabolites in human milk has not been studied. Based on the milk/plasma concentration ratio in rats, the estimated daily dose to a pup will be about 4% of the dose given to the mother. Assuming that the milk/plasma concentration in humans is of the same order, the total Naropin dose to which the baby is exposed by breast-feeding is far lower than by exposure in utero in pregnant women at term (see Precautions). Pediatric Use: The safety and efficacy of Naropin in pediatric patients have not been established. Geriatric Use: Of the 2,978 subjects that were administered Naropin Injection in 71 controlled and uncontrolled clinical studies, 803 patients (27%) were 65 years of age or older, which includes 127 patients (4%) 75 years of age and over. Naropin Injection was found to be safe and effective in the patients in these studies. Clinical data in one published article indicate that differences in various pharmacodynamic measures were observed with increasing age. In one study, the upper level of analgesia increased with age, the maximum decrease of mean arterial pressure (MAP) declined with age during the first hour after epidural administration, and the intensity of motor blockade increased with age. This drug and its metabolites are known to be excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Elderly patients are more likely to have decreased hepatic, renal, or cardiac function, as well as concomitant disease. Therefore, care should be taken in dose selection, starting at the low end of the dosage range, and it may be useful to monitor renal function. (See PHARMACOKINETICS, Elimination.) ADVERSE REACTIONS Reactions to ropivacaine are characteristic of those associated with other amidetype local anesthetics. A major cause of adverse reactions to this group of drugs may be associated with excessive plasma levels, which may be due to overdosage, unintentional intravascular injection or slow metabolic degradation. The reported adverse events are derived from clinical studies conducted in the U.S. and other countries. The reference drug was usually bupivacaine. The studies used a variety of premedications, sedatives, and surgical procedures of varying length. A total of 3,988 patients have been exposed to Naropin at concentrations up to 1.0% in clinical trials. Each patient was counted once for each type of adverse event. Incidence ≥5%: For the indications of epidural administration in surgery, cesarean section, postoperative pain management, peripheral nerve block, and local infiltration, the following treatment-emergent adverse events were reported with an incidence of ≥5% in all clinical studies (N=3988): hypotension (37.0%), nausea (24.8%), vomiting (11.6%), bradycardia (9.3%), fever (9.2%), pain (8.0%), postoperative complications (7.1%), anemia (6.1%), paresthesia (5.6%), headache (5.1%), pruritus (5.1%), and back pain (5.0%). Incidence 1-5%: Urinary retention, dizziness, rigors, hypertension, tachycardia, anxiety, oliguria, hypoesthesia, chest pain, hypokalemia, dyspnea, cramps, and urinary tract infection. Incidence in Controlled Clinical Trials: The reported adverse events are derived from controlled clinical studies with Naropin (concentrations ranged from 0.125% to 1.0% for Naropin and 0.25% to 0.75% for bupivacaine) in the U.S. and other countries involving 3,094 patients. Tables 3A and 3B list adverse events (number and percentage) that occurred in at least 1% of Naropin-treated patients in these studies. The majority of patients receiving concentrations higher than 5.0 mg/mL (0.5%) were treated with Naropin. Table 3A Adverse Events Reported in ≥1% of Adult Patients Receiving Regional or Local Anesthesia (Surgery, Labor, Cesarean Section, Post-Operative Pain Management, Peripheral Nerve Block and Local Infiltration)

Adverse Reaction Hypotension Nausea Vomiting Bradycardia Headache Paresthesia Back pain Pain Pruritus Fever Dizziness Rigors (Chills) Postoperative complications Hypoesthesia Urinary retention Progression of labor poor/failed Anxiety Breast disorder, breast-feeding Rhinitis

N 536 283 117 96 84 82 73 71 63 61 42 42 41 27 23 23 21 21 18

Naropin total N=1661

(%) (32.3) (17.0) (7.0) (5.8) (5.1) (4.9) (4.4) (4.3) (3.8) (3.7) (2.5) (2.5) (2.5) (1.6) (1.4) (1.4) (1.3) (1.3) (1.1)

N 408 207 88 73 68 57 75 71 40 37 23 24 44 24 20 22 11 12 13

Bupivacaine total N=1433

(%) (28.5) (14.4) (6.1) (5.1) (4.7) (4.0) (5.2) (5.0) (2.8) (2.6) (1.6) (1.7) (3.1) (1.7) (1.4) (1.5) (0.8) (0.8) (0.9)

Table 3B Adverse Events Reported in ≥1% of Fetuses or Neonates of Mothers Who Received Regional Anesthesia (Cesarean Section and Labor Studies)

Adverse Reaction Fetal bradycardia Neonatal jaundice Neonatal complication-NOS Apgar score low Neonatal respiratory disorder Neonatal tachypnea Neonatal fever Fetal tachycardia Fetal distress Neonatal infection Neonatal hypoglycemia

N 77 49 42 18 17 14 13 13 11 10 8

Naropin total N=1661

(%) (12.1) (7.7) (6.6) (2.8) (2.7) (2.2) (2.0) (2.0) (1.7) (1.6) (1.3)

N 68 47 38 14 18 15 14 12 10 8 16

Bupivacaine total N=1433

(%) (11.9) (8.2) (6.6) (2.4) (3.1) (2.6) (2.4) (2.1) (1.7) (1.4) (2.8)

OVERDOSAGE Acute emergencies from local anesthetics are generally related to high plasma levels encountered, or large doses administered, during therapeutic use of local anesthetics or to unintended subarachnoid or intravascular injection of local anesthetic solution. (See ADVERSE REACTIONS, WARNINGS, and PRECAUTIONS.) MANAGEMENT OF LOCAL ANESTHETIC EMERGENCIES: Therapy with Naropin should be discontinued at the first sign of toxicity. No specific information is available for the treatment of toxicity with Naropin; therefore, treatment should be symptomatic and supportive. The first consideration is prevention, best accomplished by incremental injection of Naropin, careful and constant monitoring of cardiovascular and respiratory vital signs and the patient’s state of consciousness after each local anesthetic and during continuous infusion. At the first sign of change in mental status, oxygen should be administered. The first step in the management of systemic toxic reactions, as well as underventilation or apnea due to unintentional subarachnoid injection of drug solution, consists of immediate attention to the establishment and maintenance of a patent airway and effective assisted or controlled ventilation with 100% oxygen with a delivery system capable of permitting immediate positive airway pressure by mask. Circulation should be assisted as necessary. This may prevent convulsions if they have not already occurred. If necessary, use drugs to control convulsions. Intravenous barbiturates, anticonvulsant agents, or muscle relaxants should only be administered by those familiar with their use. Immediately after the institution of these ventilatory measures, the adequacy of the circulation should be evaluated. Supportive treatment of circulatory depression may require administration of intravenous fluids, and, when appropriate, a vasopressor dictated by the clinical situation (such as ephedrine or epinephrine to enhance myocardial contractile force). Should cardiac arrest occur, prolonged resuscitative efforts may be required to improve the probability of a successful outcome. The mean dosages of ropivacaine producing seizures, after intravenous infusion in dogs, nonpregnant and pregnant sheep were 4.9, 6.1 and 5.9 mg/kg, respectively. These doses were associated with peak arterial total plasma concentrations of 11.4, 4.3 and 5.0 μg/mL, respectively. In human volunteers given intravenous Naropin, the mean (min-max) maximum tolerated total and free arterial plasma concentrations were 4.3 (3.4-5.3) and 0.6 (0.3-0.9) μg/mL respectively, at which time moderate CNS symptoms (muscle twitching) were noted. Clinical data from patients experiencing local anesthetic induced convulsions demonstrated rapid development of hypoxia, hypercarbia and acidosis within a minute of the onset of convulsions. These observations suggest that oxygen consumption and carbon dioxide production are greatly increased during local anesthetic convulsions and emphasize the importance of immediate and effective ventilation with oxygen, which may avoid cardiac arrest. If difficulty is encountered in the maintenance of a patent airway or if prolonged ventilatory support (assisted or controlled) is indicated, endotracheal intubation, employing drugs and techniques familiar to the clinician, may be indicated after initial administration of oxygen by mask. The supine position is dangerous in pregnant women at term because of aortocaval compression by the gravid uterus. Therefore, during treatment of systemic toxicity, maternal hypotension or fetal bradycardia following regional block, the parturient should be maintained in the left lateral decubitus position if possible, or manual displacement of the uterus off the great vessels should be accomplished. Resuscitation of obstetrical patients may take longer than resuscitation of nonpregnant patients and closed-chest cardiac compression may be ineffective. Rapid delivery of the fetus may improve the response to resuscitative efforts.

APP Pharmaceuticals, LLC

0173-NAR-05-4/11

Rev. 11/08

to perform a translaminar epidural at this level, he or she runs the risk for an inadvertent dural puncture, bleeding and possible nerve injury,” said Peter Staats, MD, an interventional pain physician in private practice and adjunct associate professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore. “Finally, there is a reality of medical-legal concerns that remain unaddressed in our society. When a physician has an adverse event, it will be hard to defend repeatedly sticking a needle into an area that he or she did not fully understand ahead of time. And if the insurers follow the implications of this study and do not allow a physician to appropriately image a patient prior to injection therapy, I am quite certain that injuries will occur.” Andrea Trescot, MD, pain management physician with Orthopaedic Associates, in St. Augustine, Fla., agreed with these criticisms and added some of her own. “They did not select patients whose pathology would have responded to an [epidural injection]; so without an MRI it’s possible that many of them could have, for example, sacroiliac pathology that mimicked lumbar radiculopathy—that is very common in this type of patient,” Dr. Trescot said. “I think most pain physicians would be uncomfortable doing a transforaminal epidural without knowledge of the anatomy at that level because compression of the nerve in the foramen can increase the swelling of the nerve, increasing the risk for an intravascular injection and the risk for injuring the nerve with the needle itself.” A commentary accompanying the paper also defended the use of MRI in radiculopathy patients and points to significant weaknesses in the study design (Arch Intern Med 2011 Dec 12. [Epub ahead of print]). For example, the commentators said the study did not analyze outcomes according to specific diagnoses and was underpowered to explore secondary outcomes such as reduced need for additional injections and improved functional status. Some physicians were more strident in their criticisms of the study. “This study is at odds with my 20 years of experience performing epidural pain procedures and is at odds with many well-regarded studies published in the specialty literature,” said Lawrence Kamhi, MD, teaching attending in the Pain Fellowship Program at Beth Israel

March 2012

AnesthesiologyNews.com I 39

TE CH N OL OG Y Table. Selected Study Outcomes

Outcome Mean leg pain at 3 mo; NRS score Mean ODI score at 3 mo

Overall success at 3 mo, N (%)

MRI Patients + MRI-blinded Patients for Whom MRI Did Not Affect Treatment Plan (N=104)a

MRI-blinded Patients Who Received Different Injection From That Proposed by Evaluating Physician (N=22)

P Value

2.4

4.8

0.01

28.2

38.7

0.04

42 (40)

5 (23)

0.12

MRI, magnetic resonance imaging; NRS, numeric rating scale; ODI, Oswestry Disability Index a

Excludes five patients who did not receive epidural steroid injections after their MRIs were reviewed and one patient lost to follow-up before first visit. b Negative Global Perceived Effect at one month carried over to three months. c Successful procedure defined as a ≥2-point decrease in leg pain plus a positive global perceived effect.

Medical Center, in New York City. For their part, the investigators argued that their results were consistent with other research. They cited, for example, two other studies showing imaging did not appreciably improve management or outcomes in neuropathic back pain (Radiology 2004;231;343-351; Radiology 2005;237:597-604). They also mentioned that MRIs frequently demonstrate abnormal findings in asymptomatic volunteers (N Engl J Med 1994;331:69-73; Ann Intern Med 2002;137:586-597) and that ESIs performed away from the main site of the abnormality usually reach the affected area (Pain Physician 2004;7:77-80; Pain Physician 2004;7:211-215). In the new study, Dr. Cohen’s team analyzed the outcomes of 132 patients with lumbosacral radiculopathy. They randomized 65 patients to an epidural steroid injection based on history and physical examination alone, and 67 to a decision to have an injection based on history, physical exam and an MRI. In the second group, an evaluating physician viewed the MRI findings and produced an independent treatment recommendation. Thirty-two patients in the non-MRI group dropped out of the study at one month post-procedure due to negative outcomes, whereas the other 32 patients in that group had successful outcomes at one month. The respective numbers in the MRI group were 26 and 34, with the remaining two patients being lost to follow-up. In the non-MRI group, 23 patients had positive outcomes at three months, as did 24 in the MRI group. The team compared outcomes of patients from the first group whose clinical and MRI findings were incongruent with the injection approach with the outcomes of the subjects in both groups with congruent MRI, clinical findings and injections (Table). Dr. Cohen and his co-investigators— including Anita Gupta, DO, PharmD, chief of pain medicine at Drexel

University College of Medicine, in Philadelphia; Col. Chester Buckenmaier III, MD, program director and founder of the Defense and Veterans Center for Integrative Pain Management, in Rockville, Md.; Scott R. Griffith, MD, pain management consultant to the U.S. Army Surgeon and lieutenant colonel, Walter Reed National Military Medical Center, Bethesda, Md.; and To-Nhu Vu, MD, PharmD, of York Hospital, in York, Pa.—acknowledged that MRI see MRI page 42

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March 2012

T E C H NO L O G Y

Continuous Capnography Linked to Lower Monitoring Costs

apnography, an established feature of perioperative monitoring to assess adequacy of ventilation, can result in significant cost savings when deployed in intensive care units. A new study has found that around-the-clock capnography of mechanically ventilated patients in a pediatric ICU decreased the number of blood gas measurements required, lowering expenditures over a five-month period by nearly $1 million. The author of the study, Courtney Rowan, MD, pediatric critical care fellow at Riley Hospital for Children at Indiana University Health, in Indianapolis, compared the total number of blood gas measurements taken in the ICU at Riley from April to September 2011, a month after the hospital began continuous capnography of all patients, to the same time period in 2010. “We knew this was a noninvasive way to wean mechanical ventilation and that it allowed for earlier identification of unplanned extubation,” Dr. Rowan said. “We also knew that it can be used as a tool to assess pulmonary blood flow in certain patient populations. Overall, we felt it would be useful for clinical management and add to patient safety.” The retrospective study showed the number of blood gas measurements declined from 13,171 to 8,070, resulting in a total cost savings of $985,130. The average number of blood gas measurements per

encounter decreased from 21.6 to 13.8, according to Dr. Rowan, and such measurements per ventilator-day also declined, from 4.7 to 3.3. The initial investment in capnography devices— the hospital uses Philips technology—cost roughly $112,000. Dr. Rowan presented her study at the 2012 annual meeting of the Society of Critical Care Medicine (abstract 340). Dr. Rowan said continuous capnography may result in additional cost savings by decreasing the number of blood transfusions. “Multiple blood draws can lead to iatrogenic anemia, especially in small infants,” Dr. Rowan told Anesthesiology News. The monitoring also might save money by lowering the number of catheter-related bloodstream infections. “Every time we draw blood to measure blood gases, we risk putting an infection in the central line,” Dr. Rowan said. “They can be expensive to treat, and add time to the patient’s hospital stay.” Mark Nunnally, MD, associate professor of anesthesia and critical care at the University of Chicago Medical Center, said the findings were intriguing. “Using capnography for day-to-day monitoring in the ICU is still somewhat on the fringes of mainstream critical care,” Dr. Nunnally said. “But if I were in charge of purchasing for an ICU, this is the kind of abstract that would grab my attention. The cost data alone are compelling.”

However, Dr. Nunnally noted that capnography is not useful for all patients. Although the technology directly gauges the partial pressure of carbon dioxide in respiratory gases, it indirectly monitors partial pressure in arterial blood. In most patients, the difference is very small. But it can be much greater in patients with pulmonary dysfunction, such as emphysema or asthma, or some forms of congenital heart disease. The primary benefits of capnography are twofold, Dr. Rowan said. It serves as a noninvasive means to wean patients from mechanical ventilation, and it quickly and accurately signals adverse respiratory events, such as accidental extubations. “If a little kid pulls out their breathing tube in the ICU—and we’ve all seen it happen—very quickly there is a big change on the vital signs screen to show us they are no longer intubated,” she said. “Capnography allows for a much more rapid response of the medical team.” Dr. Rowan said every ventilated child in the ICU at Riley undergoes continuous capnography, and its affiliated hospitals are looking into making the technology mandatory as well. “You can’t deny it’s an added safety feature,” she said. “The money you save is a nice bonus, but we use them mainly because it’s the right thing to do for patients.” —Dana Hawkins-Simons

In a large observational study …

First-Pass Intubation Success Same in Direct Versus Video Laryngoscopy Chicago—Video laryngoscopes are used in almost 25% of first attempts at intubation, especially in patients who have a documented history of difficult intubation or whose physical characteristics may make intubation challenging. The interim findings come from a descriptive study at the U.S. Veterans Affairs (VA) Medical Center and the University of Pittsburgh School of Medicine. The investigators reported that first-pass success rates between video laryngoscopy (VL) and standard direct laryngoscopy (DL) were not statistically different in the target patient populations. “The VA in Pittsburgh has been successfully using video laryngoscopes for quite a while, but we wanted to look at some of the factors that made people choose a video laryngoscope over a standard laryngoscope,” said Daniel S. Cormican, MD, a resident at the institution. “We also wanted some

hard data on success and complication rates.” Dr. Cormican and his colleagues prospectively collected data on 998 intubations performed at the hospital between July 1 and Dec. 31, 2010. Intubations were performed with a standard laryngoscope, GlideScope video laryngoscope (Verathon Medical) or Storz Endoskope video laryngoscope (Karl Storz). After each intubation, clinicians completed a data form that tracked information such as laryngoscope used, reason for device selection, training level of laryngoscopist and patient morphologic features, particularly those that may affect intubation. Laryngoscopists included medical students, student nurse anesthetists, certified registered nurse anesthetists, residents and anesthesiologists. Overall, the success rate for firstattempt intubation was 89.5% across all providers and laryngoscopes. The

highest success rate was with standard DL at 90.3% (687 of 761), followed by intubation with the GlideScope (88.8%; 142 of 160) and Storz Endoskope (84.1%; 58 of 69). Dr. Cormican presented the results at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 189). VL was used 20 times for rescue purposes after standard DL failed, and proved to be successful in all cases. With VL, no intubation failures occurred that required switching to another technique or waking the patient. Intubation was eventually successful in all patients without the need to return to spontaneous ventilation or use an alternate technique, such as a laryngeal mask airway. The researchers also found that video laryngoscopes were used as a first-attempt device in 22.9% (229 of 998) of cases, primarily because the practitioner expected difficulty with

the intubation (55.1% of instances). In 44.3% of cases, practitioners cited “training purposes” as the reason for using a video laryngoscope in the first attempt at intubation. “So, if an attending had, for example, seen an initial attempt by a med student and wasn’t convinced he or she should try another one right away, he may have asked the student to use one of the video laryngoscopes,” Dr. Cormican said. The morphologic characteristics of patients with expected difficult intubation were analyzed by logistic regression; it was found that these patients had decreased cervical range of motion (P<0.001), decreased mouth opening (P=0.004) and a history of difficult intubation (P=0.001). Dr. Cormican said the data showing why the anesthesiologists opted for a video laryngoscope proved most insightful. “We often look at a patient see intubate page 42

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T E C H NO L O G Y Intubate continued from page 40 and decide he or she will be a difficult intubation, but now we’re putting a name to the factors that influence these decisions,” he said. “We believe the video laryngoscope is an excellent advancement in our airway device armamentarium,” Dr. Cormican said, “given that patients with what appear to be difficult airways can be intubated with the same

success rate as non-difficult airways under standard laryngoscopy—not to mention the success of the device as a rescue tool.” D. John Doyle, MD, PhD, professor of anesthesiology at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, in Ohio, said that the study shows how commonplace VL has become in daily anesthesia practice. “It also reminds us that despite great technical advances

in video laryngoscopy, the technique remains suboptimal for some patients,” said Dr. Doyle, who is a member of the editorial board of Anesthesiology News. “It is not clear whether or not the superior success rate for standard laryngoscopy compared to the GlideScope that the authors encountered was due to inexperience with the GlideScope in comparison to a standard laryngoscope, or perhaps something inherent in the Glide-Scope

design,” Dr. Doyle said. “In any event, the authors’ fully successful use of video laryngoscopy for rescue purposes, after prior standard laryngoscopy had failed, once again shows how video laryngoscopy remains an important arrow in our ‘airway quiver.’” —Michael Vlessides Dr. Cormican received no external funding for the study.

MRI continued from page 39

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might have improved outcomes in the non-MRI patients who received a different injection from that proposed by the evaluating physician and who then had poor outcomes. However, they said an alternate explanation is more credible. “We feel it was more likely that these patients failed to improve because their pathology was discordant with their symptoms, rather than because they received the [injection] at the ‘wrong level,’” lead investigator Steven Cohen, MD, said. “Therefore, they would have probably fared poorly even if the doctor had looked at the MRI before injecting them.” The team also found that in 66% of the non-MRI group patients (43 of 65), the treating physician and the independent evaluating physician decided on the same injection approach. In 82% of the other cases (18 of 22), the evaluator recommended a different approach. In only 7% of cases in the second group (five of 67), the treating physician opted not to perform an injection after reviewing the MRI. Three of these individuals received an epidural without steroids and the other two received only medication. However, within the next six months, three of these patients were re-evaluated and received a steroid injection. None of the patients in either group had a red-flag condition that would have been a contraindication for a steroid injection, Dr. Cohen noted. Dr. Cohen and his team agreed that the study was not adequately powered to detect differences in outcomes between the patients in either group who had red-flag indicators. They suggested that MRIs be reviewed in people at high risk for serious disease, such as the elderly or those with a significant personal or family history of cancer. —Rosemary Frei, MSc

Deadline abstracts: December 15th 2011 Online submission: www.euroanaesthesia.org

ESA Secretariat Phone +32 (0)2 743 32 90 Fax +32 (0)2 743 32 98 E-mail: registration@euroanaesthesia.org

Drs. Cohen, Gupta, Griffith, Buckenmaier, Vu, Staats, Trescot and Kamhi did not report any conflicts of interest.

March 2012

AnesthesiologyNews.com I 43

TE CH N OL OG Y

Two Cases of Spinal Meningitis Linked to Intrathecal Pump

wo cases of spinal meningitis after intrathecal drug delivery systems were accessed or refilled have been reported by Virginia researchers. The cases were presented at the 2011 annual fall meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 073). “The report is very important because the first case is the first documented case of direct infection after refill in an intrathecal drug-delivery pump,” said Alessandro Dario, MD, director of the Functional Neurosurgery Unit at the University of Insubria School of Medicine, in Varese, Italy. Dr. Dario was the primary author of a previous study of 890 pump refills in which the drug remaining in the reservoir was linked with no cases of pump-related infection, despite five patients having recurrent urinary tract infection and three having respiratory tract infection (Neuromodulation 2005;8:36-39). The patient in the first case was 40 years old and had chronic pain from failed back surgery syndrome. Her pump, in place for three years, was refilled in a single attempt using sterile technique. Eleven days later, the patient began to develop malaise and low back pain with spasms. Cultures from the catheter tip revealed the presence of Staphylococcus aureus and coagulase-negative S. aureus. Cultures from the pump pocket and drug reservoir were negative. Lynn Kohan, MD, assistant professor of anesthesiology at the University of Virginia, in Charlottesville, and lead author of the case reports, called the first patient particularly intriguing because of the lack of positive cultures. “In addition,” Dr. Kohan said, “the catheter was examined for a foreign body and one was not found. The patient did happen to have a urinary tract infection, but it was positive for E. coli only.” She said that based on Dr. Dario’s earlier findings and the negative cultures obtained by her own team, “an infection from the refill would indeed be rare.” The second case involved a 39-yearold man who also was prescribed an intrathecal pump for management of failed back surgery syndrome. In this case, however, the patient appeared to have tried to extract the medication from the pump in an unsterile manner. The patient presented to an outside

hospital with signs and symptoms consistent with spinal meningitis. Cerebrospinal fluid cultures were positive for Serratia marcescens. Puncture sites were evident over the area of the pump reservoir. Cultures of the catheter tip, drug reservoir and pump pocket also were positive for S. marcescens. The pump reservoir was empty, although 23 mL

of medication should have remained. “Obviously, this patient—after being treated appropriately for his infection and post-op wound checks—was discharged from our office because his tampering with the pump at home violated our policies,” Dr. Kohan said. “This underlines the fact that scheduled refills with one-shot puncture are

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safe,” Dr. Dario added. “However, selfmanipulation of the pump is very dangerous—first, because of abstinence symptoms in case of successful emptying, and mainly because of the risk for infection.” —Rosemary Frei, MSc Drs. Dario and Kohan reported no conflicts of interest.

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A D LI B

Oregon Program Seeks To Blend Anesthesia Training With Critical Care

nesthesiology played a pioneering role in the emergence of critical care medicine, but lately the intensive care unit has held little allure for anesthesiology trainees. One program is trying to change that trend the easy way: Oregon Health & Science University, in Portland, integrates a residency in anesthesiology with a fellowship in critical care medicine. Approved as an innovation by the Accreditation Council for Graduate Medical Education (ACGME), the Oregon Scholars Program (OSP) weaves the core anesthesiology residency together with fellowship training in either critical care or medical research across a four-year curriculum. The combination in effect cycles participants in and out of resident and fellow roles and helping them keep their skills fresh in both areas. Graduates are able to sit for both anesthesiology and subspecialty board exams. Anesthesiology and critical care medicine “both have steep learning curves,” said Michael Hall, MD, chief resident and a critical care fellow in the OSP program. “It’s been a nice track for me to combine both,” without needing to take a full year away from anesthesiology following residency to complete a critical care fellowship. “I like anesthesiology and I like working in the ICU, but I hadn’t been sure how to split them.” Participants get experience in a variety of adult and pediatric ICU settings, with rotations structured to promote a balance between the two medical fields, Dr. Hall said. “A goal of the program is to train me to take care of any ICU patients.” Once he completes the program in July 2012, Dr. Hall said he plans to pursue an additional fellowship in cardiac anesthesiology, hoping eventually to work both as a cardiac-specialized intensivist in a surgical ICU and a cardiac anesthesiologist in the operating room. The Oregon program starts the second year after medical school; its 48 months offer an opportunity for anesthesiologists to develop a subspecialty without adding more years of training. Of the current participants, nine are in the critical care track and three are in the research track, said program director Christopher Swide, MD. The first class graduated in 2010. “Most of our graduates practice in both the ICU and the OR, with one in private practice and several in academic practice. None is doing critical care full-time and only one is not doing any critical care medicine,” Dr. Swide said. The ACGME’s Residency Review Committee for Anesthesiology approved the OSP as an innovation in 2006. It is one of about a dozen anesthesia residency programs granted this status to waive some of ACGME’s usual requirements, such as the timing of rotations. Oregon was the first institution to combine anesthesiology and critical care medicine in this way, but several other academic centers are following its lead, Dr. Swide said. The research track also is supported by a training grant from the National Institutes of Health.

‘Being a full-time intensivist can be demanding. When you’re in the OR, by contrast, there is a beginning and an end to your day and to your responsibility for the patient, which changes the way you perceive your day.’ —Scott Schartel, DO Stacy Fairbanks, MD, chief resident-cum-fellow of OSP’s research track, said she appreciates the opportunity to mix research with residency, spending fourmonth segments in the research lab without letting her clinical anesthesiology skills get rusty. “Even during the lab rotation I do one to two weekend calls per month in the OR,” she said. Dr. Fairbanks’ personal research interest is to identify sex-specific differences in response to ischemic strokes, to see if they might point to pathways or mechanisms to guide future treatment. The pursuit of research questions requires time that is protected from OR responsibilities, she said. “When they said I’d have 18 months of protected time during this program, that’s what I got.” Dr. Fairbanks said the OSP course also served her well in job hunting, and she has already landed a position at the University of Colorado in Denver, that is half research and half clinical. Scott Schartel, DO, professor of anesthesiology at Temple University in Philadelphia and president of the Society for Education in Anesthesiology, noted that anesthesiology in recent years has fallen behind

pulmonology as a training ground for critical care doctors. In 2008, only 61 anesthesiology graduates nationally completed fellowship training in critical care medicine. Dr. Schartel said combining the two specialties offers opportunities for a professional life with more balance. “Being a full-time intensivist can be demanding,” he said. “When you’re in the OR, by contrast, there is a beginning and an end to your day and to your responsibility for the patient, which changes the way you perceive your day.” The opportunity to cross roles and settings also fits with recent trends in anesthesiology toward broadening beyond its traditional roles. Speaking in October at the 2011 annual meeting of the American Society of Anesthesiologists, Patricia Kapur, MD, chair of anesthesiology at the University of California, Los Angeles, called for anesthesiologists not just to provide intraoperative care but also to play a role in perioperative care, critical care, pain management, palliative care and even telemedicine—“caring for the highest acuity cases.” —Larry Beresford

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