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EROS Program Hastens Post-Labor Discharge— And Moms Love It San Francisco—He may be the god of love in Greek mythology, but when it comes to elective cesarean deliveries, EROS is all business. Indeed, a British research group has found that its Enhanced Recovery in Obstetric Surgery (EROS) program significantly reduces length of stay in the hospital while keeping women satisfied with their care. The researchers stressed, however, that a multidisciplinary approach is critical to the

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Anest Tied t

he choicce to use regional anesthesia ratheer than general anesthesia for total kn nee arthroplasty correlates strongly with an anesthesiologist’s boardcertification stattus, new research shows. The study foound that, compared with their board-cerrtified counterparts, non– board-certifiedd anesthesiologists were more likely to use general anesthesia than neuraxial anestthesia or peripheral nerve blocks. A growiing body of evidence shows that neuraxial anesthesia leads to better outcomes for patients than general anesthesia in jointt replacement procedures,

see EROS page 22

see TKA page 20

Block Nurses Improve RA Care San Francisco—As regional anesthesia continues to increase in popularity, hospitals are looking for ways to improve patient care and satisfaction while streamlining the provision of nerve blocks. Enter the concept of block nursing, which helps clinicians at Thomas Jefferson University Hospital, in Philadelphia, achieve these goals with minimal disruption to existing processes. “Our surgical populations are getting older and sicker, so general anesthesia for surgery isn’t always an option,” said Bernadette Grady, BSN, a block nurse at Jefferson. “And now postoperative pain is also being controlled by regional procedures. So the concept of a regional anesthesia or block nurse is new, but as far as we’re concerned, it’s vital.”

At Jefferson, the block nurse has several responsibilities. Pre-blockk duties, both before and after surgery, if necessary, begin with setting up the room and equipment for designated blocks, including catheters, nerve stimulators, ultrasound equipment, monitoring devices, local anesthetics, relevant paperwork and emergency equipment. “Lots of patients don’t know what a block is,” said Elird Bojaxhi, MD, clinical instructor in anesthesiology at Jefferson Medical College, also in Philadelphia. “A patient new to regional anesthesia may be concerned that a block will make his or her arm numb. Therefore, see block page 29

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PAIN MEDICINE

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CME: PREANESTHETIC ASSESSMENT

Lesson 309: Management of the Child With Emergence Delirium

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COMMENTARY

Should the ASA spend $1 million on MD/CRNA outcomes research? Hint: This author says no.

PRN

ASA’s tool for OSA screening in children prone to false positives.

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APRIL 2014

Comment on these and other articles @ AnesthesiologyNews.com.

Heard Here First: This tool really overcalls moderate to severe OSA in children.

April 2014

What do you do with all of these improperly diagnosed kids?

The five most-viewed articles last month on AnesthesiologyNews.com 1. ‘I Broke the Ultimate Taboo’: A Physician’s Downward Spiral 2. Researchers Close in on Causes of CRPS 3. Hypoxia After Surgery Much More Common Than Previously Believed 4. On Bricks and Mortar Boards

Admit them postoperatively? That’s

5. Study Supports Adductor Canal Blocks After TKA

simply not possible.

See article on page 24

Congratulations to Glenn A. Syperda, DO, of Tarpon Springs, Fla., winner of the 2014 Readex Survey contest. Dr. Syperda will receive a $500 American Express gift card.

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APRIL 2014

COMMENTARY

How (Not) To Spend $1 Million

ohn Neeld, MD, a past president of the American Society of Anesthesiologists (ASA), challenged members during his 2013 Rovenstine Memorial Lecture to spend $1 million to study the differences in outcomes between physician-directed and nurseonlyy anesthesia care (see Anesthesiology News, December 2013, page 1). Now an ASA committee is studying

how to do this, having been so directed at a recent meeting of the society’s board of directors. Dr. Neeld apparently was reacting to a nurse-funded study that shows that nurse-onlyy anesthesia care is as safe as physician-directed care. Nurses are using the study results in their campaign for physician equality and income. Dr. Neeld reasoned that

physician anesthesiologists should have a superior study to counter the nurses’ propagandizing, one that documents the safety advantage of medical direction by anesthesiologists. Several existing studies, as well as common sense, already support improved safety and outcomes when physicians are involved, but none cleanly addresses the differences between care with and without physicians. Of course, such studies would be difficult to construct, and, with 50

Robert Johnstone, MD, is professor of anesthesiology at West Virginia University in Morgantown, and a frequent contributor to Anesthesiology News.

million anesthetics delivered each year in the United States, could cost more than the proposed $1 million to carry out. If studied prospectively, who would volunteer to be in a nophysician, no-rescue control group? Would this even be ethical? If studied retrospectively, how would researchers correct for physician predominance with sicker patients, and for physician rescues of nurse-anesthetic problems? And would nurse activists accept a study, no matter how precise or robust, if it showed anesthesiologist direction improved outcomes, and deprived them of anesthesiologist salaries? Political Dead End Politically active physicians and nurses already hand copies of existing studies and other literature to legislators who, as their aides acknowledge in thankk you letters, count for constituent summaries then wastebasket. Would these aides recognize a superior study? Would such a study make a difference if not accompanied by contributions, calls or visits? Would a new study showing improved patient outcomes with physician anesthesiologist involvement simply motivate nurses to fund another that shows no improvement, an ever-escalating titfor-tat in the fog of complex health care and campaign for anesthesiologist salaries? A recent report in Psychological Science, from the Wharton School of Business, described how easy it is to accumulate and report statistically significant evidence for a false hypothesis.1 Some scientists question whether most published research findings are false.2 The leadership of the American Association of Nurse Anesthetists has already appealed to members for more battle money. “How sad that the ASA is using its premier lecture, the Rovenstine Lecture, to wage war … against CRNAs,” went one such plea. “We must make our voice heard” on Capitol Hill. Buying studies apparently is expensive. All this raises the question: Is a highquality physician-directedd versus nursealone comparative study the best way for the ASA to spend $1 million or more? To its great credit, the ASA has expended considerable effort and dollars previously addressing important issues concerning science, the public interest and patient safety.

APRIL 2014

AnesthesiologyNews.com I 7

COMMENTARY When anecdotal reports of unintended awareness during general anesthesia threatened the scientific understanding of, and public confidence in, anesthesia, the ASA funded two large studies of its incidence and causes. These studies brought evidence to discussions of unintended awareness, recognized high-risk situations, and halted industry campaigns to attach awareness monitors to every anesthesia patient. The studies cost a little more than $1 million. They also allied physicians, nurses and the public. When malpractice lawyers created a crisis of lawsuits, fear and legal expenses, ASA members recognized a need for trusted and expert review of cases, and spent considerable effort and more than $1 million on an expert witness review process. The situation appears more reasonable today, with liability insurance costs stable. When practice leaders sought performance and quality improvement benchmarks, anesthesiologists saw the need for a national registry of anesthesia cases. They have invested $6.4 million over five years so far to establish the Anesthesia Quality Institute (AQI) and National Anesthesia Clinical Outcomes Registry, according to Rick Dutton, MD, AQI’s director. The AQI registry database now exceeds 15 million anesthetics and sends many anesthesiologists periodic quality reports. This database could someday address provider-specific outcomes, but that would require more data and investment. Penny-Wise, Pound-Foolish? So anesthesiologists and the ASA have spent large sums of money in the past on worthy projects, and succeeded. Would outcomes studies comparing physicians and nurses be a wise use of future millions? Perhaps yes. Eliminating medical direction by physician anesthesiologists would threaten patient safety. And a well-done study might slow down nurse activists who bumfuzzle, besmirch and bedevil systems of care, physicians and the public. But probably no. Most anesthesia clinicians work in harmonious physician-led teams; most patients want physicians involved. Zealots are unlikely to let better studies stop their campaigns for more independence and income. A recent poll of 750 voters in Florida already shows overwhelming support for the direct involvement of an anesthesiologist physician with close supervision over nurse anesthetists. Nearly all (92%) of those surveyed said

they would want an anesthesiology physician directing their anesthetic care.3 So how should ASA members spend that million? One way could be to simply increase contributions to the institutes, foundations and related organizations the ASA already supports. ASA is the largest financial supporter of the Foundation for Anesthesia Education and Research (FAER), the Anesthesia Patient Safety Foundation (APSF) and the Wood Library Museum (WLM), currently

providing them more than $3 million per year. FAER supports anesthesiology education and research that improves care and solves challenges, advancing the specialty. APSF identifies and communicates patient safety improvements. Want to download a video on medication or fire safety in the operating room? Visit the APSF website. The WLM acquires, preserves and displays items and information on the art, science and history of anesthesia. Great professions have histories worth documenting.

Another is to design and fund an audacious project, something that would excite people, garner frontpage newspaper coverage, a Nobeltype prize. Call it the Great Research in Anesthesiology that is Notable and Distinguished Prize—the GRAND Prize. Put $1 million into the GRAND Prize fund each year, and award it after five or 10 years for a qualifying achievement. Appoint prominent citizens and scientists, even a current

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POLICY & MANAGEMENT New sterile compounding legislation:

Does Bill Have the Muscle To Stop Another NECC?

y the end of 2013, a sigh of relieff could be heard in some patient safety circles after newly passed legislation gave statee and federal officials broadened oversight powerss to regulate sterile compounders. With the new insspection muscle bestowed on those officials, the cchances of another New England Compoundingg Center (NECC)-type outbreak killing or injuring hundreds of patients seemed significcantly diminished. The latest details on the results of those t inspections, however, suggest that safety gaps still remain. Of the 30 sterile compounding facilitties that have registered with the FDA under th he bill’s new “outsourcing facility” category, 15 had been inspected by the FDA as of middMarch. That may not be surprising, given that it is still the relatively early days of the legislation’s rollout. The more striking finding is that all but two of the inspected facilities were issued Form 483s, which the agency sends if its inspectors have observedd “objectional conditions” at the compoundding facility. The Form 483s, which can be b viewed on the FDA’s website (http://1.uusa. gov/1h06JCj), listed several potential violations, including insufficient air filtration systems, failure to perform endotoxin testing on all finished sterile injectable drug products, and, in one case, an employee “dragging a full trash bag across the clean-room floor ... where aseptiic processing activities [were occurring].” The two facilities that were not issued Form F 483s were last inspected by the agency eight andd 10 years ago, respectively, according to the FDA. Christian Hartman, PharmD, MBA, BA who h chaired a special commission on compounding in

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Massachusetts, where NECC was located, said he is encouraged that the FDA is aggressively inspecting such facilities and citing them for potentially unsafe manufacturing conditions (see sidebar, page 9). But he said he was troubled by the fact that so few compounders have stepped forward to register. That slow

uptake, he noted, means that “facilities performiing compounding di similar i il to t NECC are iin some cases still going unregulated.” Dr. Hartman did acknowledge that the National Association of Boards of Pharmacy (NABP) and state boards are working with the FDA to strengthen state-level oversight for facilities that do not register under the new category. As a result, “state laws and efforts are moving in the right direction to ensure safer compounding,” he said. “But they are not yet where they need to be.”

according to Tom Van Hassel, RPh, MPA, director of pharmacy att Yuma Regional Medical Center, in Yuma, Ariz., andd former president of the Arizona State Board of Phaarmacy. “People are reluctant to register with the FD DA because they fear the possibility that the agency w will come in and shut them down,” he said. “The FDA has tremendous power.” Mr. Van Hassel saaid most facilities that could qualify as outsourcingg compounders will do so only if they are forceed to, or if doing so would help them gain a market advantage. If more purchasers chooose FDA-registered compounders, he noted, the reluctant majority also might opt to rregister. State Boards Tighten Their Grip The FDA A and some state boards of pharmacy are acttively promoting the benefits of registration. But B states also have been working hard to m meet a separate challenge that predates H.R. 32204: a lack of state resources available for pollicing sterile compounding facilities, notedd Dr. Hartman, senior director of clinical quality q and patient safety at Wolters Kluw wer Health, Pharmacy OneSource. “At the time of the NECC [crisis], our statee board of pharmacy—and I think thiis is true of many state boards— was underfunded and did not w have the appropriate board membership and training to carry out effective oversight,” he said. “Compounding is an extremely complex process and the quality ccontrols that have to be in place to make k it safe are hard to identify, so facility inspectors need to have specialized training.” Some relief has come as a result of the Special Commission on Compounding that Dr. Hartman chaired in 2012. The commission, which was convened by Massachusetts Gov. Deval Patrick, was charged with generating recommendations on statutory, regulatory and operational rules that would make compounding safer in that state. Following on the Special Commission’s recommendations, the state legislature increased the Massachusetts Board of Pharmacy’s budget from roughly $182,000 to $1.3 million. Now the board has enough funding to train its staff and can carry out thorough inspections of facilities engaged in sterile compounding, Dr. Hartman said. The Massachusetts state legislature also has handed the board more regulatory power to enforce manufacturing standards and it has put whistle-blower protection laws in place, so that “practitioners have the appropriate protections to raise alarm when facilities engage in unsafe practices,” he noted.

The Teeth in H.R. 3204 As for the outsourcing sterile compounders that have voluntarily registered with the FDA, they are now subject to the rules of the Drug Quality and Security Act (DQSA) (H.R. 3204), which was signed into law by President Obama in November 2013. Such facilities are expected to follow U.S. Pharmacopeial Convention (USP) Chapter <797> standards and are held to the same good manufacturing practices (GMPs) as large pharmaceutical manufacturers. Although that high bar may be reassuring to purSupport Remains Uneven chasers and patients, it also might be scaring away Unfortunately, not all state boards are receivoutsourcing compounders that would potentially qualify under the new outsourcing facility category, ing such support, according to Eric Kastango, RPh,

APRIL 2014

AnesthesiologyNews.com I 9

POLICY & MANAGEMENT MBA, chief executive officeer and president of Clinical IQ Q, LLC, a firm that provides trainiing for compounding facility insppec-tors. In many states, he said, “to change their pharmacy laws they need an act of legislature, and if you can’t get a sponsor who really cares or sees the need to make these changes, it can be a slow process.” Nevertheless, Mr. Kastango said most state legislatures and boards of pharmacy are addressing the issue in “a systematic andd multi-tiered way, which is exactlyy what we need them to do. In fact, I’ve been incredibly impressed with the tenacity with which many of the big states have been [pursuing] this issue.” For example, some state boards of pharmacy that until now have allowed compounders to operate without following USP Chapter <797> standards are working with legislators to put such a requirement in place, Mr. Kastango noted. And in states such as New Jersey and Massachusetts, boards of pharmacy have been flexing their new regulatory muscles, requiring licensees to complete attestations and following up with systematic audits by their newly trained inspectors or contracting out the survey process to the NABP. “I believe that at least six pharmacies received temporary cease-and-desist orders issued by the Attorney General’s office in New Jersey over the past several months because these pharmacies were not doing what they claimed to be doing in their attestation,” he said. The California Board of Pharmacy is also ramping up its enforcement efforts. The board is expected to implement revised regulations on July 1, 2014, that are more closely aligned with requirements in USP Chapter <797>. The board also is providing specific training to its inspections on USP Chapter <797>. In the interim, California’s Department of Public Health has been busy inspecting pharmacies for USP <797> compliance. “I’m cautiously optimistic that the big compounding operations that could be involved in another NECC have now been identified,” Mr. Kastango said. “That’s half the battle—knowing who’s out there.” Filling the Communication Gap Carmen Catizone, MS, RPh, DPh, executive director of the NABP, said his organization is working diligently to address the gap in communication that was one of the root causes of the NECC catastrophe. “We’ve developed a single Web portal that state boards can access and where they can find all the information collected and housed on pharmacies across the country, including inspection reports on compounders,” Dr. Catizone said. “State boards can now send their inspection reports in to the NABP and we immediately notify other states where that pharmacy is licensed or registered, as well as the states into which it supplies drugs.”

The NABP is also building a website by the end of 2014 which will list much of this in nformation. The site “will include a list of non–FDA-registered ccompounders and their inspection reports, when available,” Dr. Catizone noted. Mr. Van Hassel agreed that the issue of interorganizational communication is a priority area that needs to be addressed. “At the time of the NECC crisis, there was really poor communication in every direction, bbetween the FDA and individual boards of pharmacy, between ua boards of pharmacy in different states, and between the NABP and its state boards of pharmacies,” Mr. Van Hassel said. He thus commended the NABP for working with individual boards of pharmacy to develop the portal for sharing information. Based on these and other actions recently taken by the NABP and state boards, “everything is moving in the right direction to improve the quality and safety of compounded products,” Mr. Van Hassel stressed.

“It’s a very detailed process,” Mr. Van Hassel emphasized. He added a word of caution to hospitals that balk at such challenges and thus decide to continue purchasing products from outside compounding pharmacies: Don’t rely solely on state and federal inspections as a basis for vendor selection. As thorough as those inspections might be, “If you’re using [an outsourcing] compounder, develop a formal relationship with them and go inspect their plants, get their FDA and board of pharmacy reports, and make sure you’re comfortable with their practice.” The American Society of Health-System Pharmacists’ ASHP Foundation has developed a “Contractor Assessment Tool” for evaluating outsourcing compounders. The document can be accessed at http:// bit.ly/MUcirp. Still, no vetting process is fail-safe. In a statement, the FDA said, “Purchasers of drugs compounded at a registered outsourcing facility that has had a recent satisfactory FDA inspection will have some assurance that the conditions at that facility met applicable standards at the time of the inspection … [however], FDA inspections are a snapshot in time, and conditions can change at any time.” Like Mr. Van Hassel, the agency recommended using original FDA-approved medications if they are available, “unless the prescribing practitioner has determined that a compounded product is necessary for the particular patient and would provide a significant difference ... as compared with the FDAapproved commercially available drug product.” Mr. Kastango said sterile compounding is a risky process no matter how well it is regulated or how well suppliers are vetted. “As long as you’re taking things and aseptically manipulating them and as long as people are involved, there’s always the risk of contamination,” he said. “But with USP [Chapter] <797> compliance, proper inspections by trained individuals and adequate oversight, the lion’s share of the risk can be mitigated out of the process.”

Progress, Not Perfection As the combined efforts of so many stakeholders continue to take shape, purchasers looking for outsourced compounded drugs are still left wondering where to turn for reliably safe products. “Ideally, you would only use drugs made by large drug manufacturers,” Mr. Van Hassel said. “These are consistently the highest-qualityy products—period.” Many hospitals are choosing a different path— that is, to control their own quality processes and compound sterile products in-house, Mr. Van Hassel noted. However, the expense of doing so can be prohibitive, with construction of a clean room that meets USP Chapter <797> standards costing about —David Wild $500,000, he pointed out, and the additional staff, materials and training present further costs. Even Drs. Hartman and Catizone and Mr. Van Hassel reported no relevant financial conflicts of interest. then, there is no guarantee of sterility.

More Details on FDA Form 483

leven of the 13 sterile compounding outsourcers conform to appropriate standards of identity, that have registered with, and been inspected by, strength, quality and purity.” the FDA were issued a Form 483. The following con- ✔ “Failure to utilize positive and negative controls ditions were among those specified in the form: or conduct growth promotion testing for the micro✔ “The production area air supply lacks an appropribiological growth media used in the [REDACTED] ate air filtration system.” monitoring of laminar airflow hoods, personnel glove ✔ “Procedures designed to prevent microbiological monitoring, environmental monitoring, and media contamination of drug products purporting to be ster- fills.” ile are not established. Specifically, there is no sterile ✔ “Failed to investigate an estimated 22 lots with filtration performed during the aseptic processing of discrepant results for microbial testing. For ‘inconsterile injectable drug products.” clusive’ results, your firm does not have an investigation, rationale or justification to support that these ✔ “We noted a rust colored build up of material results are not sterility failures.” behind the HEPA filter screen near the screen retaining bolts of hood #13.” According to the FDA, issuance of a Form 483 “does not constitute a final agency determination of ✔ “Laboratory controls do not include the establishment of scientifically sound and appropriate test whether any condition is a violation of the FD&C Act procedures designed to assure that drug products or any of its relevant regulations.”

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POLICY & MANAGEMENT

CMS Rules PILD Will Be Covered Only in Clinical Trials

he Centers for Medicare & Medicaid Services (CMS) has spoken: Its Jan. 9, 2014, Coverage with Evidence Development decision for percutaneous image-guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS) means that for the foreseeable future, PILD will only be covered in the context of clinical studies.

The decision stipulates that new, robustly designed, randomized controlled trials must address whether PILD significantly improves function and/or quality of life and reduces pain compared with other treatments, and also whether it positively affects the overall management and clinical decision making for patients with LSS. “We recognize that LSS is a real

and important source of pain and functional limitation for patients, and that the development of effective minimally invasive procedures could have a potential place in the treatment armamentarium,” an individual who asked to be identified as a CMS official said. “However, more evidence is clearly needed for percutaneous image-guided lumbar

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decompression for lumbar spinal stenosis.” The CMS criteria mandate the research should clearly define and report all adverse events and the methods used to ascertain them. The goal is to give the opportunity for “the development of high-qualityy evidence for this procedure to answer the important questions of treatment effect, appropriate patient selection criteria and duration of benefit,” the decision stated (http://www.cms.gov/medicarecoverage-database/details/ncadecision-memo.aspx?NCAId=269). Many pain physicians are disquieted by the ruling. “The decision from CMS is disappointing, and illustrates the challenges companies face when they seek approval for new innovations that could be safer and more effective treatments for some patients,” said Lynn R. Webster, MD, president of the American Academy of Pain Medicine. David Caraway, MD, PhD, first executive vice president of the American Society of Interventional Pain Physicians, echoed Dr. Webster’s sentiment. However, he also pointed to a potential silver lining. “Those of us who understand this to be a valuable procedure for our patients are disheartened that it wasn’t fully covered because many patients are not surgical candidates and so will be left without any options to treat their disabling spinal stenosis,” Dr. Caraway said. “Having said that, the bright side is the decision leaves a path toward full coverage by CMS.” CMS Zigzags to Current Position CMS initiated a national coverage analysis of PILD in April 2013, and the next month met with representatives from Vertos Medical—the company that markets the surgical instruments for performing PILD, called the “mild tool kit”—and sought public comments on PILD coverage. After a second meeting with Vertos officials in August, CMS posted a proposed decision memorandum on Oct. 17, 2013. “In reviewing the evidence on PILD, we are confronted with weak studies, questions about missing information, questions about adverse events and conflicts of interest. After thoroughly reviewing the evidence for PILD for LSS, we have determined the evidence does not support a conclusion

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POLICY & MANAGEMENT of improved health outcomes for our Medicare beneficiaries,” CMS officials wrote. They proposed that PILD for LSS not be covered by Medicare. However, after the second public comment period, CMS changed course and in January issued a call for further study. It is possible CMS heeded the preponderance of groups and individuals who submitted their opinions during both comment periods and clamored for coverage of PILD. The agency’s decision echoed that of the North American Spine Society (NASS), which largely comprises orthopedic and neurosurgeons, but also members of other disciplines such as physiatrists and anesthesiologists. In the initial comment period, thenNASS president Charles Mick, MD, wrote to CMS recommending noncoverage, citing “significant problems with the body of literature as it currently stands.” In the second comment period, however, new NASS president William Watters III, MD, stated his group “would like to revise our recommendation” due to “the number of new studies and publications noting the safety and efficacy of the procedure.” He questioned some of CMS’ reasoning in proposing noncoverage, and concluded that “NASS believes it is premature to deny coverage of PILD based on limited research and would like to request CMS to consider including this procedure for further discussion under [the] ‘Coverage for Evidence Development’ category until more data [are] collected and [there is] sufficient evidence available to determine the utility of this procedure.” Joseph Cheng, MD, MS, chair of NASS’ Professional, Economic & Regulatory Committee, said the impetus for the society’s change of position was the concern expressed by its members about the potential ramifications of PILD noncoverage. “What we’re afraid of is the trend of ‘all-or-nothing’ policies among payors— they either approve or deny a procedure,” Dr. Chengg said. “With new treatments coming out in the field of spine treatment, there is rarely robust enough data to justify coverage of a new approach, and it’s a ‘Catch-22’—if it’s not covered, there could never be enough data collected to ever justify coverage.” Enough Evidence? However, many interventional pain physicians believe there already is sufficient evidence of the safety and utility of PILD.

“There were excellent studies from good places endorsing the efficacy of PILD/mild—in terms of significant long-term pain relief of neurogenic claudication and considerable improvement of function— including a study from the Cleveland Clinic,” said Lawrence Kamhi, MD, an interventional pain physician in Warwick, N.Y. “If the government can make the burden of proof of the utility of a procedure or a therapy impossibly onerous, our health care system

will soon have no covered treatments for medical illness.” Jim Corbett, Vertos president and chief executive officer, has a sanguine view. He noted CMS is asking for expansion of the evidence base, rather than closing the door permanently to reimbursement as it originally proposed in October. “The [coverage decision] recognizes the potential value of PILD and establishes criteria under which the procedure, through supplemental clinical

research—which is covered by CMS— can achieve national coverage. The CMS study criteria are quite comprehensive and unprecedented in the spine treatment world. This is new territory,” Mr. Corbett said. “We will be doing our best to develop a protocol that meets CMS requirements.” —Rosemary Frei, MSc Drs. Cheng, Kamhi and Webster did not report any relevant conflicts of interest. Dr. Caraway has been a consultant for Vertos.

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PAIN MEDICINE

The Long Road Back To Medical Practice Part 3 of 3

s I noted in Parts 1 and 2 of this article, I made some incredibly bad decisions in prescribing for several chronic pain patients, and had sexual relations with a single patient. Because of this, I had to sign a “Voluntary Agreement Not to Practice” pending a hearing before the medical licensure commission. There were no “non–patient contact” jobs in the area, so I was forced into an early, involuntary retirement. I also had to go for a forensic psychiatric evaluation in Kansas. Once that was done, I had to petition for a hearing to be allowed to resume practice. One problem in dealing with the state medical board is that everything takes time. When you have no income, and are depleting your financial resources month after month, it rapidly becomes painful. After two months, I attempted to call the attorney for the state board to ask about the hearing. Instead I got a sharp rebuke from my attorney. Once an attorney is involved, all communication must be between your attorney and the attorney for the board. My calls to the board’s attorney were improper. My attorney also made it very clear that once a physician’s certificate or license has been suspended or revoked, it will remain in suspension or revoked, at least until the bearer has completed substantial therapy/rehabilitation directed at the issues involved. The therapy/rehabilitation must be started immediately. If you have not done so, you can expect sharp questioning as to why not. Financial restrictions, although understandable, will not help your case before the medical board or medical licensure commission. The fact that you have not rehabilitated, regardless of the reason, will prevent them from considering an earlier restoration of your certificate and/or license. If they consider you to have an issue or problem that might potentially jeopardize the public, you cannot expect the board to permit your return to practice until you have successfully completed rehabilitation/therapy. Conversely, the medical board or medical licensure commission will look favorably on evidence that you have initiated treatment/rehabilitation voluntarily. Your future as a physician depends on this. The burden of proof is on you.

Determined for Redemption There were several options for a treatment program. I decided to return to Kansas for one that had been recommended after my evaluation. The facility conveniently had a program available starting one month later. That was a very wise decision. I found myself in a group of 12 physicians, some of whom had “boundary violations” (the term for sexual contact with a patient); the rest of the group had problems relating to disruptive behavior, such as outbursts of anger. The first week focused largely on selff evaluation. The second week was dedicated more to addressing our individual problems and learning better responses. The third week was concerned with preparing us to resume regular practice. Throughout the three weeks, we had individual sessions with the staff, as well as multiple group sessions. We had didactic lectures concerning various aspects of medical ethics and professional misconduct. Overall, I would say the program greatly increased my awareness of past and potential future problems. It will make me a better and more professional physician in the future. After I returned from the treatment program, my attorney formally requested a hearing date. To my dismay, this was scheduled six months later. There was no practical way to get this date moved up; I just had to wait. Meanwhile, several other ugly problems developed. I got a notice from the IRS that I owed approximately $40,000. I had no way to pay it. What’s more, one of the requirements to hold a federal DEA number is to possess a valid state controlled substance certificate. Because mine had been revoked, I was given a choice to voluntarily surrender my federal DEA certificate, or have another hearing to contest the matter. I had no real choice but to surrender it. The following month I got a letter from my attorney. I’d been waiting six months for a hearing, but approximately four weeks before it came my attorney realized that he had a conflict with another case. He called it “an inadvertent omission.” My hearing would be pushed back several additional months. That was a significant blow, as I was rapidly depleting my

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AnesthesiologyNews.com I 13

PAIN MEDICINE remaining savings, as well as the cash value of my life insurance. I needed to go back to work. The next month I received another letter from my attorney. We were still waiting on a hearing date. He discovered that my malpractice insurance would only pay $25,000 toward my legal expenses. He had thought that the coverage was $50,000 because two separate cases were involved: One was related to prescribing for my pain patients, and the second concerned the affair with DeeDee and the prescriptions that I had written for her. The letter included a bill for $14,000 to cover his services up to that point, and also requested an additional $10,000 as a retainer. I simply could not afford $500 per hour for the two-attorney team that had been representing me, and I was highly disappointed with the additional delay that his schedule conflict caused. I would simply have to represent myself.

The medical board or medical licensure commission will look favorably on evidence that you have initiated treatment/rehabilitation voluntarily. Your future as a physician depends on this. The burden of proof is on you. I contacted the medical licensure commission and was able to get the hearing scheduled a month earlier. My part of the actual hearing was relatively brief. The facts had already been documented by the medical board hearing. I had been found to have prescribed excessive controlled medicines, and excessive medications for other than legitimate medical purposes. I had violated the board rules concerning sexual misconduct. I also had been found on the forensic evaluation to have an impairment of my “fitness to practice” and that I would “require formal treatment, education, monitored accountability and workplace structure ... in order to return ... to a level of acceptable fitness to practice.” They asked me a few additional questions concerning my activities and treatment since leaving the program in Kansas. Then I was dismissed to await my fate.

After two weeks, I received a call from the investigator. He was coming to deliver and discuss the decision of the medical licensure commission. He showed up at my apartment about 40 minutes later. When I read the papers my heart leaped into my throat, and I jumped up out of my chair. My license was suspended. “Why don’t they just go ahead and hang me?” I asked the investigator. I felt that my life was over. He helped me calm down, reviewed the decision

in detail and answered questions. My license was suspended, not revoked. I had five conditions outlined to get my license reinstated. I had already met one of them by going to the rehabilitation program. The others were entirely reasonable and attainable. The decision also required that I surrender my medical license to him. I had to rip it out of the frame and mail it to him within three days. The last condition was the real problem. I was ordered to pay an

approximately $2,000 administrative fee (not a fine) that basically reimbursed the cost for the commission attorney communicating with my attorney. I had exhausted the last of my funds. I was able to start drawing my Social Security, which gave me some income, and kept me from becoming homeless. I was also separated from my wife, and the increased living expenses meant that I had no way to save anything to pay the fee. A few see long road page 14

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PAIN MEDICINE

U.S. Department of Veterans Affairs Leads the Way In Helping Patients Conquer Pain

or many members of the U.S. Armed Forces, pain is part of their job description. The rigors of serving in the military, regardless of whether a soldier faces combat, makes pain the leading cause of disability among military personnel. Both acute and chronic pain afflict service members in higher proportions than the general population. On the front lines in helping veterans cope with pain is the U.S. Department of Veterans Affairs (VA) premier pain clinic—the Chronic Pain Rehabilitation Program (CPRP) at James A. Haley Veterans’ Hospital ( JAHVH) in Tampa, Fla. A two-time winner of the American Pain Society’s Clinical Center of Excellence in Pain Management award, as well as winner of the prestigious Secretary of Veterans Affairs Olin E. Teague Award, CPRP is the largest pain center in the VA system, serving both veterans and active duty military personnel. The CPRP was the first VA pain program to implement a comprehensive clinical pathway for treating pain, which has served as the VA national model ever since. CPRP uses an outcomes-driven, interdisciplinary approach to treat pain and not only does it strive to reduce patients’ pain, but also to make patients more active, improve their psychological well-being, and reduce or eliminate the need for opioids. “What we seek for patients is that despite pain, they are able to live as full and productive a life as

LONG ROAD

possible,” said Michael Clark, PhD, CPRP, who heads the pain programs. Multiple-Program Assault Since opening in 1988, CPRP has treated more than 45,000 veterans and active duty service members (nearly 6,000 patients annually) through medical clinics and a variety of pain programs. For the most complex and serious pain patients, CPRP has a chronic pain rehabilitation inpatient program, a 12-bed unit at James A. Haley Veterans’ Hospital. “In this program, we accept people who have painrelated disabilities and a high level of impairment in many areas of their lives,” said Jennifer Murphy, PhD, clinical director of the program. “The patient’s pain issues often compromise functioning significantly. Many are unemployed and have psychiatric or medical issues that need to be monitored closely. Additionally, most of them have tried many treatments in the past without success.” To describe the inpatient program in military terms would be to call it an intense “boot camp” for chronic pain. Patients are enrolled for a threeweek stay and are in treatment for six to eight hours a day. “They’re busy throughout the day,” Dr. Murphy explained. “They wake at 6 a.m. and start activities, and don’t get back to their rooms until around 4:30 p.m.”

computer with printer, and a phone system. I sent letters to my patients months later, an old friend who is a informing them that I was reopening physician loaned me the money. I sent my practice on a cash basis, but that we a letter with a detailed practice plan, would resume filing insurance as soon the administrative fee and the other as possible. requirements to the commission. A few months after that, a “show cause” hearThen the ultimate ing was scheduled in approximately six weeks. That would be my fourth hear‘gotcha’ became clear: ing. More waiting. This hearing went rather smoothly. My medical license was My actual petition for reinstatement not enough; without was unopposed. After another month, I received official notification that a current DEA number, required a voluntary agreement with no organization was certain terms and conditions. After the agreement was approved, I still going to hire me. That had to file a formal document for reinstatement, get fingerprinted and have hit like the proverbial a criminal background check (at my ton of bricks. expense). A few weeks later, I received the official documents stating that my license was reinstated. I greatly underestimated the diffiI thought once my license was culty in getting reaccepted as an insurrestored, I would be able to resume ance provider. To my dismay, not only practice. I had rent-free use of an exam was I excluded from filing Medicare, room in my friend’s office. He loaned but even my prescriptions were not me enough money to get an additional covered by Medicare Part D insurance CONTINUED FROM PAGE 13

The James A. Haley Veterans’ Hospital in Tampa, Fla., is a 415-bed teaching hospital, providing a full range of patient care services, with state-of-the-art technology, as well as education and research.

The James A. Haley Veterans’ Hospital Comprehensive Pain Center team has made it the premier VA pain resource center and a national VA pain treatment referral center.

plans such as AARP. This meant patients would have to pay cash not only for their visit, but for all their medications as well. Understandably, that proved to be an impossible burden for my Medicare patients. I would have to get reaccepted as a provider for their prescriptions to be honored. I soon discovered another roadblock. Since I was starting my practice on a shoestring, I could not afford malpractice insurance. Both Medicare and Blue Cross required malpractice insurance in force to process my applications. This meant that I would only be seeing a meager number of patients able to pay cash. After two months, it became obvious that this was not going to work. I realized that I would have to work for a group that would provide malpractice coverage, and furnish an office. I had an attractive offer from a local clinic that I readily accepted. I would not be able to start until the malpractice coverage was issued, and they wanted me to get my DEA number as soon as possible. I submitted malpractice insurance applications to several

companies, and waited some more. I did find coverage at approximately 40% higher rates. Then another bombshell hit. To get the DEA certification restored, I first had to go to another hearing with the state medical board that had previously revoked my controlled substances certificate. Even worse, I would have to wait for months to have that hearing. Then my future employer told me that they would not be able to employ me until the DEA registration number was issued. I had no job, and worse, I had told all my patients I would be starting at that clinic the following month. I had stopped scheduling their followup appointments, pending the relocation. That stopped the meager income that was helping pay my expenses. I immediately went online and started applying for both locum tenens and permanent positions. I needed to work more than I needed to stay in my current location. Our children were grown, and I was about to be divorced as a result of the affair, so I would be free to travel. In the next several days, I received a barrage of phone calls

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PAIN MEDICINE Evening Social Activities Also Required Because most patients are limited physically, inpatient treatments focus heavily on improving function. “Function is important because chronic pain often takes over these patients’ lives,” Dr. Clark said. “Pain begins making decisions, rather than the individual. When that happens, a cascade of negative effects follows—withdrawal, depression, fatigue, sleep problems, relationship difficulties, work problems, financial problems, loss of selff worth, substance misuse or abuse, and increased pain [for example].” A defining characteristic of the inpatient program is that patients agree to eliminate opioids while in treatment. According to Dr. Murphy, y approximately half the people referred to the inpatient program are on opioids. “But many are finding that opioids don’t effectively manage their pain anymore; they are functionally impaired, not active socially and often dependent on these drugs,” she said. According to the experience of the inpatient program’s staff, weaning patients off opioids doesn’t make outcomes worse. In fact, a four-year study found that patients who stopped taking opioids had as great, or greater decrease in pain and better functional improvement than patients

from recruiters. I would send my curriculum vitae, copies of several reference letters and a detailed account of my practice history and the disciplinary actions. Then the ultimate “gotcha” became clear: My medical license was not enough; without a current DEA number, no organization was going to hire me. That hit like the proverbial ton of bricks. It would be several more months before the hearing to get my state controlled substances certificate back, and that was required before I could re-register with the DEA. The time finally arrived for my fifth hearing, again with the state medical board. I had to represent myself again, as I could not afford a lawyer. The hearing to get my license back had gone pretty well, but this one was rather difficult. The lawyer treated me like a hostile witness, requiring only yes or no answers to questions. I was able to explain that without a DEA number, I had not been able to find employment. Even the freestanding clinics with signs stating they do not prescribe controlled substances would not hire see long road page 16

who were not on opioids. According to the study, patients who completed the program demonstrated improvement “in all outcomes measures, from admission to discharge, and the opioid group improved as much or more than the nonopioid group on all measures,” despite ceasing opioids during treatment. To improve function, patients undergo physical and cognitivebehavioral therapies such as heated pool therapy, physical therapy,

relaxation training, individual and group psychotherapy, recreational and occupational therapy, walking sessions, upper extremity therapy and gait training. Transcutaneous electrical nerve stimulation, medication or other appropriate treatments also are employed. CPRP also has an outpatient program that involves many of the same approaches as the inpatient program, with patients in therapy two days per week for eight weeks.

Outcomes for both programs are impressive. “Our patients’ activity levels, on average, increase by 400% to 800% after the three weeks—that is, patients are four to eight times more active than they were before they entered the program,” Dr. Clark said. “That’s why it is intense. Patients will be going out on their own, and if we don’t get changes integrated before they leave, they’ll be right back where they started.” see VA page 16

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PAIN MEDICINE LONG ROAD

agreement, which I promptly signed and returned. The local clinic that me. I was also turned down for multi- had offered me a job called back and ple jobs in the corrections setting. At offered me the same position. They the end of the hearing, I was asked if have now paid for my malpractice, I would sign a “voluntary agreement” state controlled substances registration with a lifetime exclusion on treating and the DEA license. The insurance chronic pain, along with no prescrib- has been approved, but I am still waiting of any Schedule CII controlled ing on the DEA registration before I substances. I readily agreed as I was not can go back to work. I don’t know how in any position to negotiate. much longer that will take. A week later, I received the voluntary It has now been almost three years

CONTINUED FROM PAGE 15

The outcomes achieved can be attributed to the caliber of CPRP’s team of physicians, pain psychologists, nurse practitioners, nurses, rehabilitation therapists, pain pharmacists, and extended team members such as registered dietitians, social workers and chiropractors, Dr. Clarkk added. “One of the things our team lives by is that we do what’s right for the patient, not what’s easiest,” he said. “The team also has a free interplay of ideas that leads to a lot of innovation.” Expanding Help for Combat Veterans More than 1.5 million military personnel have served in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) over the past decade. Returnees are presenting with pain and functional problems ranging from severe polytrauma to a less catastrophic, concomitant triad of symptoms consisting of chronic pain, post-traumatic stress disorder and emotional distress or cognitive complaints. To address these problems, CPRP launched a special interdisciplinary, outpatient behavioral health program in 2010 called the Center for PostDeployment Health and Education (CPHE). “CPHE was developed specifically to address the overlapping symptom clusters, with related functional Advertisement

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since my extremely bad decisions resulted in the actions against my license. I am about to file bankruptcy to stop foreclosure on my house. I still have a divorce to go through and it will take a long time to rebuild relationships with my adult children. It has probably cost me more than $250,000 as well. My main purpose in writing this is to warn other doctors what can happen if you have an affair with a patient,

particularly if any controlled substance prescriptions are involved. You do not want to go there. If you have been involved with a patient, you should consult an attorney experienced in medical board issues immediately. I like to think that through this experience, I have learned some extremely painful but valuable lessons. Because of that, I know I will be a better physician in the future. —Name Withheld

CPRP also is in the forefront of innodifficulties, of these returning veterans,” said psychologist Michelle vative pain research to increase underA. Bosco, PsyD, CPHE team standing of chronic pain and to improve therapies. Funded by federal grants, the leader. “Our goals are to improve research has included studies examin[patients’] daily functioning, manage chronic pain, reduce stress, preing the types of pain and emotional disorders that veterans suffer after polyvent worsening of symptoms and foster independence. In so doing, trauma, which provided strong evidence that OEF/OIF veterans are at significant we provide treatment in multiple formats, including cognitiverisk for developing chronic and disabling behavioral psychoeducational Kristin Phillips, PhD, and Litsa pain, and emotional comorbidities. Another ongoing study is investigating groups, problem-focused individ- Banou, PhD, Chronic Pain an opioid-apneaa link to see if opioid cesual psychotherapy, medication Rehabilitation Program pain management and physical therapy.” psychologists, reviewing an sation improves central sleep apnea. CPHE works in close consulta- inpatient’s test results. “But that hypothesis has not been tion with other CPRP providers proven,” explained Dr. Clark. “What we and programs to ensure continuity do know from our study is that apneas of care and prevent duplication of services. Returning of all types seem to be much more common in individsoldiers can attend the Post-Deploymentt Clinic (PDC), uals with chronic pain than in the community at large, staffed by a full-time psychologist, to receive psycholog- regardless of whether they are taking opioids or not.” Other research projects have studied smoking and ical assessments and evaluations; same-dayy consultation and triage; and immediate needs assessment and cri- smoking cessation and how it affects chronic pain sis intervention. The PDC regularly conducts orienta- patients, and if actigraphy, a noninvasive method of tions to provide veterans with general information and monitoring human rest and activity cycles, can serve as to answer questions, thus ensuring these soldiers receive a valid outcomes measure for pain. complete care. On the Move Outcomes-Oriented, Research-Driven In the near future, CPRP will move into new quarSince its inception, CPRP has collected outcomes ters, allowing its pain services to be consolidated in a to monitor the success of its treatments and to guide central location. The new facility will have a state-off the development of its program. the-art inpatient and outpatient area on the third floor “We were among the first to develop an outcomes of JAHVH’s spinal cord injury building, as well as two instrument to be used with veterans, which is now in new floors for rehabilitation treatments, some of which national use and available to major medical systems, will be dedicated specifically to OEF/OIF veterans because it has been computerized,” Dr. Clarkk said. with severe injuries. The tool, called the Pain Outcomes QuestionnaireInpatient accommodations will consist of private VA (POQ), assesses key pain criteria identified by rooms, allowing for increased privacy during rehabilitamajor pain accreditation and professional organization. A new heated swimming pool, a child-care area, a tions, such as a patient’s pain history, average pain “city center” or core area for specialty VA services, and a intensity, pain interference, emotional distress, pain- climbing wall that several programs will use for physical related fear, satisfaction with treatment and use of rehabilitation will bea available to patients. CPRP also is enhancing pain services for female vetmedication. Before the existence of POQ, measuring pain out- erans because there has been a significant increase in comes usually relied on assessing a patient’s pain and the number of women referred for treatment. “We expect this trend to continue, so we are develpain-related problems when the patient first entered pain clinics, and then readministering the tests when oping more treatment options for pain problems spethe patient was being discharged. cific to women,” Dr. Clarkk said. “We also will continue “As a result, they lacked strong psychometric foun- to refine our approaches for those with pain and assodations as outcomes measures,” Dr. Clarkk said. “POQ ciated emotional comorbidities. We are breaking new is different because it was developed from the ground ground in this area, where there is little research to up primarily as an outcomes tool, rather than a clinical guide clinical efforts.” assessment tool.” —Tom McDonough

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prior-acts coverage dating back to 1980. Since 1987, we have reviewed the claims history of more than 17,000 practicing anesthesiologists. PPM’s claims department has investigated more than 12,000 adverse incident outcomes, and more than 3,700 claim or litigation files. With this information, PPM has an unparalleled ability to identify and address loss trends. PPM uses this data to establish fair and appropriate premium levels, manage claim files and provide anesthesia-specific risk management advice to its policyholders in the form of seminars, publications such as Anesthesia & the Law w and through a policyholder-only resource area on our website.

Q. What makes PPM unique? A. PPM is the only company of its kind in America—the only company founded by and for anesthesiologists exclusively. As well, PPM has historically turned down more than 25% of its applicants. A condition of insurance is that all physicians meet or exceed the American Society of Anesthesiologists (ASA) Standards of Care when practicing, thereby creating what we believe to be the safest risk pool in the country. No other company requires this of their insureds. Although only 4% of the total physician population is anesthesiologists, 100% of PPM’s clients are anesthesiologists, so 100% of our time is spent developing products and services specific to the professional liability needs of anesthesia practices. This is especially important in risk management efforts.

Q. Can you comment on PPM’s risk management efforts? A. Risk management is one of PPM’s strengths, and, again, is unique insofar as it is entirely anesthesia-specific. PPM’s five in-house attorneys spend all day, every day overseeing, managing and defending anesthesia claims exclusively. These same attorneys conduct our site-specific risk management seminars every year for our insured owners. Some examples of topics at the seminars include but are not limited to causes and prevention of intraoperative fires; postoperative druginduced respiratory depression; securing narcotics and medication in the operating room; top 10 anesthesia claims and how to avoid them; and wrong-site surgery. PPM’s risk management is proactive, designed for each insured group’s specific practice and provides practical, thoughtful advice. With a claims database in excess of 64 million administered anesthetics, more than 12,000 adverse incident reports and more than 3,700 claim reports, PPM’s policyholders are assured they are receiving insightful, valuable and important information they can use to mitigate their exposures moving forward and apply immediately in their practice setting.

PPM maintains a substantial database of more than 11,000 adverse anesthesia events and uses this information to identify areas of risk, monitor developing loss trends, and provide cutting-edge, timely and praactical anesthesia-specific risk management advice and strategies like: On-site risk management seminars for our po olicyholders and their staff presented by PPM in-house claims attorneys.. Exclusive online access to best practice proto ocols and documentation; white papers; current and archived issues of Anesthesia & Law, our risk management newsletter; and other useful infformation. Immediate email notification via Anesthesia Alerts of issues such as widespread drug contamination, dru ug shortages and significant changes to ASA standards. 24/7/365 telephone access to our experienced d attorneys and claims specialists for the expert risk man nagement advice you need, whenever you need it. Call PPM today to learn more about how our extensivve risk management program can help you protect your reputation.

Q. What else should I know? A. You should know that it costs nothing to evaluate your options. If you are not currently sharing risk exclusively with other ASA Standard of Care clinicians, isn’t it worth five minutes of your time to learn what PPM can offer that your existing carrier may be unable to provide? Call us at (800) 562-5589 and let us show you who we are and what we can do for you!

Add your good name to our growing list of ASA “standard of care” clinicians. Call us toll free today at 800.562.5589 and join other select anesthesiologists who have already secured ownership in their professional reputations. 9000 West 67th Street

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AnesthesiologyNews.com I 19

CLINICAL ANESTHESIOLOGY

Ketamine Offers Opioid-Sparing in Pediatric Patients San Francisco—Anesthesiologists looking to reduce the consumption of morphine after scoliosis surgery in pediatric patients may want to consider ketamine, Japanese researchers have found. In a retrospective study, a group from Keio University School of Medicine, in Tokyo, concluded that although ketamine had a morphine-sparingg effect after low-dose remifentanil-based anesthesia, this was not the case after highdose remifentanil-basedd anesthesia. “General anesthesia maintained with high-dose remifentanil is associated with acute opioid tolerance and/ or hyperalgesia, which is usually manifested by increased postoperative pain and opioid requirement,” said Rie Minoshima, MD, professor of anesthesiology at Keio. “Although ketamine could reduce morphine requirement after scoliosis surgery, the morphinesparingg effect of ketamine is controversial because higher doses of remifentanil could induce more severe acute opioid tolerance, thus overcoming the clinical effect of ketamine.” To better grasp the relationship between intraoperative remifentanil dose and clinical effect of ketamine, Dr. Minoshima and her colleagues enrolled 74 patients (ages 7-19 years) into the trial. Each patient underwent scoliosis surgery under anesthesia with propofol and remifentanil. Patients received either low-dose remifentanil (<0.2 mcg/kg per minute) or high-dose remifentanil (>0.3 mcg/kg per minute) during surgery, along with IV morphine by patient-controlled analgesia. Some also received a continuous infusion of ketamine at 1 mcg/kg per minute for 48 hours after surgery. The investigators measured a variety of parameters—including postoperative morphine consumption, pain scores at rest and with movement, and sedation scores—at six, 12, 24 and 48 hours after surgery. As Dr. Minoshimaa reported at the 2013 annual meeting of the American Society of Anesthesiologists (abstract 2112), the four groups were comparable with respect to duration of anesthesia and dose of propofol. The investigators found that postoperative 24-hour cumulative morphine consumption was significantly lower in the ketamine plus low-dose remifentanil (KL) group (0.40±0.17 mg/kg) than either the ketamine plus high-dose remifentanil (KH) group (0.59±0.27 mg/kg), low-dose remifentanil-only (NL) group (0.63 mg/kg) or the

high-dose remifentanil-only (NH) group (0.73±0.28 mg/kg; P=0.011). “We also found that NRS [numeric rating scale] scores on movement was significantly lower in group KL and group KH than in groups NH and NL at our various time points after surgery,” Dr. Minoshima added. “There was, however, no difference in NRS at rest and sedation score between the groups.”

Several previous studies failed to show the morphine-sparingg effect of ketamine after remifentanil-based anesthesia, Dr. Minoshima continued, “likely because the dose of remifentanil was relatively high and the ketamine infusion was stopped at the end of surgery. In our report, opioidtolerance hyperalgesia induced by lowdose remifentanil could be attenuated

by intraoperative and postoperative ketamine infusion.” Dr. Minoshima was quick to point out that the retrospective trial had several limitations, beginning with the fact that the starting point of the remifentanil infusion and the loading dose of ketamine were not determined. “There were also a variety of regimens see ketamine page 21

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Reference: 1 4th National Audit Project of the Royal College of Anesthetists and the Difﬁcult Airway Society: Major complications of Airway Management in the United Kingdom. Report and ﬁndings: March 2011. Editors: Dr. Tim Cook, Dr. Nick Woodall, and Dr. Chris Frerk.

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CLINICAL ANESTHESIOLOGY TKA

factors that can contribute to the decision regarding the anesthetic techalthough the authors of the latest nique,” said Peter M. Fleischut, MD, study cautioned that this is not univer- assistant professor in the Departsally agreed on. ment of Anesthesiology at NewYorkk Previous studies also suggested that Presbyterian Hospital/Weill Cornell the disparity in treatment choices Medical College, in New York City, might exist between board-certified and a co-author of the study. “For and non–board-certified practitioners. example, in this dataset non–boardNone, however, had been conducted certified anesthesiologists tended to take care of older patients” with a on such a large scale. “The results are what we had higher American Society of Anesthesihypothesized, but there are many ologists (ASA) surgical status. CONTINUED FROM PAGE 1

The results do not warrant drawing any conclusions about individual practitioners based on their board certification status, but rather raise questions about these larger-scale practice patterns that merit further investigation, according to the researchers, who presented their findings at the ASA’s 2013 annual meeting (abstract 1001). Emerging Findings From AQI The study is one of the first to use data in the National Anesthesia Clinical

Rationale, Reversal, and Recovery of Neuromuscular Blockade Part 1: Framing the Issues Case Study Harold is a 74-year-old man undergoing a video-assisted right upper lobectomy for stage I non-small cell lung cancer. Current Symptoms • Dyspnea • Coughing with hemoptysis • Chest pain Vital Signs • Height: 177.8 cm (70”) • Weight: 65 kg (143 lb) Signi¿cant Medical History • Hypertension • Chronic obstructive pulmonary disease (moderate) Current Medications • Metoprolol succinate ER 50 mg/d • Tiotropium bromide inhalation powder Laboratory Results • 2-cm lesion in right upper lobe revealed on chest computed tomography (CT) scan; malignancy con¿rmed with needle biopsy • No abnormal bronchopulmonary or mediastinal lymph nodes; brain CT, isotopic bone scan, abdominal ultrasonography negative for distant metastases • Forced expiratory volume in the ¿rst second: 43.6% of predicted value (1.44 L) • Carbon monoxide diffusing capacity: 71.7% of predicted values (20.19 mL/min/mmHg) • Cardiac ultrasonography: normal pulmonary artery pressure (22 mm Hg) At induction, Harold receives propofol 1.5 mg/kg and rocuronium 0.6 mg/kg. During the procedure, movement of the diaphragm interferes with surgery. This activity is jointly sponsored by Global Education Group and Applied Clinical Education. Supported by an educational grant from Merck.

Applied Clinical Education is pleased to introduce a new interactive 3-part CME series featuring challenging cases in neuromuscular blockade. Each activity will present a clinical scenario that you face in your daily practice. After reading the introduction to the case, consider the challenge questions, and then visit www.CMEZone.com/nmb1 to ¿nd out how your answers stack up against those of our multidisciplinary faculty panel. Access the activities on your desktop, laptop, or tablet to explore the issues surrounding safe, effective, neuromuscular blockade and reversal via a unique multimedia learning experience and earn 1.0 AMA PRA Category 1 Credit.™ Participate in the coming months as well to complete the whole series and earn a total of 3.0 AMA PRA Category 1 Credits.™ This activity’s distinguished faculty Jon Gould, MD Glenn S. Murphy, MD Chief, Division of General Surgery Alonzo P. Walker Chair in Surgery Associate Professor of Surgery Medical College of Wisconsin Senior Medical Director of Clinical Affairs Froedtert Hospital Milwaukee, Wisconsin

Clinical Professor, Anesthesiology University of Chicago Pritzker School of Medicine Director Cardiac Anesthesia and Clinical Research NorthShore University HealthSystem Evanston, Illinois

Challenge Questions 1. What would you do next? 2. What potential postoperative risks does this patient face?

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Outcomes Registry (NACOR), collected by the Anesthesia Quality Institute (AQI). Researchers examined approximately 97,000 NACOR records for patients who underwent total knee arthroplasty surgery between 2010 and 2013 in which the anesthesiologist’s board certification status was available. Board-certified anesthesiologists attended to 82% of these patients. Board-certified anesthesiologists provided general anesthesia for this procedure less frequently than non– board-certified anesthesiologists (36% vs. 62%, respectively). Board-certified anesthesiologists used either neuraxial or regional anesthesia in 41% of the procedures, whereas non–boardcertified anesthesiologists used these techniques 21% of the time. Regardless of why a given anesthesiologist might choose general over regional anesthesia for a knee replacement procedure, patients are entitled to care that leads to the best possible outcomes, said Stavros Memtsoudis, MD, PhD, clinical professor of anesthesiology and of public health at Weill Cornell Medical College, and the study’s senior author. Dr. Memtsoudis said previous work, including a recent study of his own published in Anesthesiology (2013;118:1046-1058), found that using regional anesthesia for total knee replacements is associated with better outcomes, including decreased blood loss, lower risk for blood clots, fewer organ-specific complications and decreased mortality. “These population-based database studies that we provide don’t really allow us to establish a causal relationship. We can’t account for all covariates that may play a part when it comes to outcomes,” Dr. Memtsoudis said. “What I always clarify is that our data provide information on associations. Thus, we can conclude that patients who received a neuraxial anesthetic in this cohort did better across a wide range of outcomes. “However, can we conclusively say that it was because of the neuraxial anesthetic? Not for sure; it may be, for example, that the performance of neuraxial anesthetics is a marker of a certain type of practice in a certain hospital,” he added. “For example, it may reflect that staff at these hospitals may be better trained to care for a particular patient group, they may be more involved, or may be part of a comprehensive perioperative practice that overall promotes better outcomes. Therefore, the question regarding what factors may contribute to the

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CLINICAL ANESTHESIOLOGY specific practice pattern is something we are looking into right now.” Dr. Memtsoudis and his colleagues will be publishing a study in Regional Anesthesia and Pain Medicine assessing whether neuraxial anesthesia is equally effective in reducing complications in patient subpopulations of different age and comorbidity burden. “From a patient perspective, it may not matter as much if the effects are due to cause or represent just an association,” Dr. Memtsoudis said. “Because if a patient chooses a place that provides neuraxial anesthesia for their cases, and they know that it is associated with better outcomes, then patients may not care whether it’s because neuraxial anesthesia is a marker of better care, or it’s because of the neuraxial anesthetic itself that better outcomes are achieved.” Perhaps more significant than the findings regarding practice patterns, at least from a research perspective, were the methods used to conduct this study, Dr. Fleischut said. “The most significant feature of this study was the large volume of data available to test the proposed hypothesis. As with other big data studies, having a wealth of information available permits an accurate identification of factors contributing to the outcome under investigation,” he said. In addition, the benefit of AQI data is that the data are from so many practices and providers throughout the country, even if some data are missing.” Richard Dutton, MD, MBA, executive director of the AQI, agreed, saying that NACOR opens up valuable opportunities for anesthesiologists to better understand and examine practice patterns in their discipline. “The whole purpose of NACOR is to inform us about ourselves—what we do and how we do it,” Dr. Dutton said. “And this was a particular study that demonstrated a substantial variability in practice. I think we’re going to see a lot more studies showing that variations in practice have important consequences for patients.” John Laur, MD, MS, medical director of the ambulatory surgery center at the University of Iowa Hospitals and Clinics in Iowa City, said he expects the study to generate some valuable hypotheses. For instance, smaller hospitals may hire nurse anesthetists rather than anesthesiologists, for financial reasons, or the non–board-certified anesthesiologists in the study may be recent graduates who are unfamiliar with the use of neuraxial anesthesia.

“One thing about these large database studies is that the methodology continues to improve for using them appropriately,” Dr. Laur said. “I think that people do need to understand the caveats of these types of studies, in that they’re more for helping to create understanding of possible causes that we could design a more thorough study to look into.” —Ajai Raj

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results. “To me it to me looks like the morphine consumption just keeps of intraoperative fentanyl that might going down as you add ketamine. So I have affected postoperative analgesic wonder if that’s just a statistical anomuse,” she added. “As such, further pro- aly, and more sample size would make spective studies are required to evalu- a difference. With that in mind, it ate our results.” seems like [the] conclusion should be Scott Byram, MD, assistant director that high-dose remifentanil increases of anesthesiology and medical direc- postoperative morphine consumption, tor of the acute pain service at Loyola independent of whether or not you use University, in Chicago, questioned ketamine.” whether a larger sample size might have generated statistically significant —Michael Vlessides CONTINUED FROM PAGE 19

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PRN ‘So now we pay attention to the little things, Given that enhanced recovery programs have and it’s made all the difference in the world.’ success of EROS. been successfully applied to “A few of us got together and real- many specialties through—Daniel Abell, MBChB ized we’ve got the perfect obstet- out the world in recent years ric population for enhanced recovery: (see Anesthesiology News, educating patients about They’re young, motivated to get home October 2013, page 1), What To Expect When and have support once they leave the Dr. Abell and his colleague, their hospitalization, reducYou’re Expecting hospital,” said Daniel Abell, MBChB, Saju Sharafudeen, MD, ing starvation times for both consultant anesthetist at King’s Col- helped introduce the EROS solids and liquids, removing “One of the biggest issues we’ve faced lege Hospital, in London. “So there program—a protocolurinary catheters within six has been managing expectation and disdidn’t seem to be any reason why we driven pathway—at King’s in June 2012. hours of anesthesia and promoting early seminating information,” Dr. Abelll told shouldn’tt be doing this.” EROS aims to reduce length of stay by mobilization. Anesthesiology News. “Because if they come in expecting to stay for four or five days, they’re going to stay for four or five days, no matter what you do.” To help determine the efficacy of EROS, the researchers compared data collected before and after the initiaRisk Evaluation and Mitigation Strategies: an Employer-Driven CME Initiative for Efﬁcacy and Safety tion of the program. Collected data included patient demographics; details about the surgery and anesthesia; urinary catheter removal times; time to Complete Parts 1 and 2 to meet the requirements of the FDA Blueprint print for for first mobilization after regional anesthesia; rates of readmission and recathPrescriber Education fo for Extended-Release and Long-Acting -Acting Opioid Ana Analges Analgesics lgesics ics eterization; and length of stay in the hospital. As Dr. Abell reported at the 2013 annual meeting of the American Society of Anesthesiologists (abstract 2102), 60 women underwent elecNavigating g Opioid RE REMS MS Navigating Na N avigating O Opioid REMS REMS tive cesarean deliveries at the institution; 45 of them were included in the EROS pathway (Table 1). When compared with 60 women who did not go through the enhanced recovery protocol, the women in the EROS group had significantly shorter lengths of stay and time to early mobilization SUPPLEMENTARY SUPPLEMENTAR S UPPLEMENTARY UPPLEMENTAR U M NTA .5 C (Table 2). Although recatheterization rates were higher in the EROS group LOW L OW BACK PAIN N (13.3%) than in the non-EROS patients (0%), the seven-dayy readmisA Virtual Patient Activity A Virtual Patient Activity sion rate was lower (2.2% vs. 8.3%, respectively. All patients were followed up on days 1 and 7 postsurgery, and 90% said they “agreed”” or “strongly

EROS

CONTINUED FROM PAGE 1

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Supportive home and social circumstances Agreement among midwife, surgeon and anesthetist that inclusion is appropriate

APRIL 2014

AnesthesiologyNews.com I 23

PRN Table 2. Women in EROS Program Enjoyed Better Outcomes Pre-EROS

EROS Patients (P Value)

Time to mobilization

22.01±6.12 h

9.9±5.05 h (<0.001)

Time to catheter removal

21.95±5.84 h

6.71±6.2 h (<0.001)

Time to first spontaneous void

25.38±5.5 h

12.64±6.2 h (<0.001)

Hospital length of stay

3.3±2.94 d

1.7±0.85 d (<0.001)

EROS, OS, Enhanced a ced Recovery eco e y in Obstetric Obstet c Surgery Su gge y

agreed”” that pain control was adequate School of Medicine, in Boston, noted that these results might not have to undertake routine tasks. Nearly every woman (97.8%) who received EROS care said they would recommend the program to a friend and would undergo the same program for any future cesarean deliveries. The researchers said they received no reports of problems with mobilization, urination and visits to the patients’ general practitioners. Much of the program’s success stems from education and a willingness to examine preexisting care patterns, Dr. Abell said. “Now our patients get an information booklet, a thorough preoperative briefing on their hospital stay and a phone call the day before their operation, all of which tell them about their stay and how they can get back to normal as quickly as possible. “And now we’re really doing all the things that we should have been doing all along,” he added. “In the hospital setting, things often go on for years, and nobody actually looks at [them]. For example, we had a traditional policy where the urinary catheter didn’t come out until the morning after the C-section. The women would be sitting in their beds, completely fine, but they weren’t going to move because they still had the catheter in. So now we pay attention to the little things, and it’s made all the difference in the world.” Scott Segal, MD, professor and chair of anesthesiology at Tufts University

widespread applicability in the United States, where there are minimum lengths of stay for new mothers. “Since the [President Bill] Clinton administration, it’s been federal law that mothers cannot be required to be discharged earlier than two days after a normal vaginal delivery and four days after a cesarean delivery,” said Dr. Segal, who was not involved in the U.K. study. “These investigators started at a baseline of 3.3 days [in the hospital]—already shorter than the U.S.

standard—and reduced it to 1.7,” he continued. “It would be interesting to know if the women discharged earlier wanted to go or would have stayed longer if they had been given the opportunity. Nonetheless, the fact that they could show discharge readiness this early might reduce health system costs, but might also require incentives for women to accept early discharge, or change in federal law.” —Michael Vlessides

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PRN

OSA Screener of Limited Clinical Use in Children, Study Finds

widely used screening tool for obstructive sleep apnea in children is wrong more than 75% of the time compared with polysomnography, Canadian researchers found. The study found that the 16-item American Society of Anesthesiologists (ASA) screening tool for moderate to severe obstructive sleep apnea (MSOSA) has a 78% false-positive rate

in pediatric patients compared with polysomnography (PSG), which is considered the gold standard method for identifying the breathing disorder. Canadian researchers used both the 16-item ASA questionnaire and PSG in 329 pediatric surgical patients and found the ASA tool diagnosed significantly more patients as having the condition than did PSG.

“The results of this study suggest that, in children, the tool serves little benefit in preoperatively screening for MSOSA,” said Cheryl Gooden, MD, associate professor of anesthesiology and pediatrics at the Icahn School of Medicine at Mount Sinai, in New York City, who was not involved in the work. “The low percent of specificity obtained in this study suggests more

false-positive results, and this would lead to an overestimation of patients with MSOSA.” The ASA screening tool is based on expert opinion and is intended for use in both adults and children ((Anesthesiology 2006;104:1081-1093). However, Kimmo Murto, MD, deputy academic chief of the Department of Anesthesiology at Children’s Hospital of Eastern Ontario in Ottawa, Canada, who led the latest research, said his group is the first to study the tool in pediatric patients. “Although the tool has never been validated in children, an informal survey of anesthesiologists that I conducted several years ago at a pediatric conference suggested that about 50% of anesthesiologists use it,” Dr. Murto said. Dr. Murto and his team used the screener in 329 children between the ages of 2 and 18 years who also underwent PSG. Following the instrument’s instructions, parents completed 11 questionnaire items. A trained anesthesia resident assessed patients for the presence of three physical signs, and a sleep lab technician measured the patients’ neck circumference and calculated their body mass index. Dr. Murto’s team assumed PSG was close to 100% accurate (Pediatrics 2002;109:e69). The investigators found that the ASA tool identified 85% of patients with MSOSA that PSG had confirmed (95% confidence interval [CI], 75%-91%). However, its false-positive rate of 78% (95% CI, 73%-83%) is higher than that with other screening tools for OSA in children, they noted (Laryngoscope 2012;122:2105-2114). Further analyses revealed the instrument had a positive predictive value of 26% (95% CI, 21%-31%) and a negative predictive value of 82% (95% CI, 71%-89%). “This tool really overcalls moderate to severe OSA in children,” Dr. Murto said. “What do you do with all of these improperly diagnosed kids? Admit them postoperatively? That’s simply not possible.” Dr. Murto said a multivariate analysis conducted by his team found two of the 16 variables in the ASA tool— parent-reported snoring heard through a closed door and observed pauses in breathing—were reliable and valid predictors of MSOSA. His team plans to include these two variables in an MSOSA screening tool it is creating. “We want to develop a six- to eightitem screening tool for MSOSA in see OSA page 30

CONTINUING MEDICAL EDUCATION

APRIL 2014

Lesson 309: Management of the Child With Emergence Delirium WRITTEN BY:

CALL FOR WRITERS

Rebecca Evans, MD Resident Department of Anesthesiology University of Utah Salt Lake City, Utah

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

LEARNING OBJECTIVES At the completion of this activity, the reader will be able to: 1. Recognize the surgical and anesthetic risk factors for emergence delirium. 2. State why the reported incidence of emergence delirium varies widely. 3. Recognize the signs of emergence delirium. 4. List the potential long-term sequelae and costs of emergence delirium. 5. Discuss the proposed etiology and pathophysiology of emergence delirium. 6. Identify pharmacologic techniques to prevent and treat emergence delirium. 7. Identify psychological techniques used to prevent and treat emergence delirium. 8. Describe the differential diagnosis of emergence delirium. 9. Identify the child most likely to experience emergence delirium. 10. Name scales used to diagnose emergence delirium.

John C. Sanders, MBBS, FRCA Attending Pediatric Anesthesiology Shriners Hospitals for Children Associate Professor Department of Anesthesiology University of Utah Salt Lake City, Utah

REVIEWED BY: Elizabeth A.M. Frost, MD Department of Anesthesiology Icahn School of Medicine at Mount Sinai New York, New York

CASE

DISCLOSURES The authors have no conflict of interest related to financial disclosures, research, and written presentation of this manuscript.

PROFESSIONAL GAPS Emergence delirium occurs commonly in the postanesthesia care unit and its diagnosis and management can be difficult. This manuscript presents a rational approach to a better understanding of the complication and thus improves management.

TARGET AUDIENCE Anesthesiologists

A 5-year-old boy (weight 18 kg; height 110 cm) presented for an adenotonsillectomy for treatment of obstructive sleep apnea. He had no prior anesthetic encounters, had an apnea– hypopnea index of 10, and had no other relevant medical history. The child appeared anxious in the preoperative area, and his mother told the anesthesiologist that he seemed more emotional than her 2 other children. A 9 mg dose of oral midazolam was given preoperatively. Induction continued with sevoflurane and nitrous oxide 40% in oxygen. A 22 g IV was established in the dorsum of the left hand. Tracheal intubation was achieved following administration of propofol 3 mg/kg after end-tidal sevoflurane reached 4.5%. Maintenance included sevoflurane at an end-tidal concentration of 3% in 100% oxygen, 5 mg of ketamine, and 35 mcg of fentanyl for analgesia. Dexamethasone, 10 mg, and 2 mg of ondansetron were given for antiemesis and to reduce airway swelling. A total of 400 mL of lactated Ringer’s solution was infused. The child was extubated while still deeply anesthetized in the operating room and transported to the postanesthesia care unit (PACU). After the child awoke, the nurse called with concerns that he was thrashing and crying, requiring 2 additional staff members to keep him from injury.

messaert et al first described emergence delirium in the 1960s as hyperexcitation after anesthesia with cyclopropane.1 The study aimed to define characteristics associated with a greater risk for emergence delirium through observation of patient characteristics such as age, sex, anesthetic agents used, duration of anesthesia, and emergent versus routine procedure. From his observations of 1,450 children, Smessaert and colleagues classified the recovery from anesthesia into 3 “modes”: 1) tranquil and uneventful recovery; 2) moderate degree of restlessness; and 3) markedly delirious and uncooperative, requiring special care and restraint. This landmark paper was the first to describe a higher incidence of delirium in patients under the age of 10 years. Since the initial description, further research has delved into defining and characterizing this self-limiting occurrence to improve patient care, educate

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

A COURSE OF STUDY FOR AMA/PRA CATEGORY 1 CREDIT Read this article, reflect on the information presented, then go online (www.mssm.procampus.net) and complete the lesson posttest and course evaluation before September 30, 2014. (CME credit is not valid past this date.) You must achieve a score of 80% or better to earn CME credit. TIME TO COMPLETE ACTIVITY: 2 hours RELEASE DATE: April 1, 2014 TERMINATION DATE: March 31, 2015 ACCREDITATION STATEMENT The Icahn School of Medicine at Mount Sinai is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

concerned family members, and improve the safety conditions for staff caring for the patient.

Definition The definition of emergence delirium has proven to be challenging, for several reasons. The patient population most commonly affected is often immature and unable to articulate perceived experiences. In addition, symptoms of emergence delirium are nonspecific, making it difficult to differentiate it from other causes of postoperative distress. Most definitions include characteristics such as an altered state of mentation, occurrence in the postoperative period, and duration that is limited.2-6 One of the most well-accepted definitions, by Sikich and Lerman in 2004, is “a disturbance in a child’s awareness of and attention to his/her environment with disorientation and perceptual

CREDIT DESIGNATION STATEMENT The Icahn School of Medicine at Mount Sinai designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. It is the policy of the Icahn School of Medicine at Mount Sinai to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.

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

Symptoms and Signs of Emergence Delirium Within 30 minutes of awakening from anesthesia, behaviors suggestive of emergence delirium include irritability; being uncompromising, uncooperative, or incoherent; and inconsolable crying, moaning, kicking, or thrashing.2 Some describe having a “glazed-over” appearance or “looking right through you” as hallmarks

Behavior

Score

Obtunded with no response to stimulation

Asleep but responsive to movement or stimulation

Awake and responsive

Crying (>3 min)

Thrashing behavior that requires restraint

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Anesthetic Involvement Anesthesiologists may well wonder why they should be concerned about a short and self-limiting complication. Emergence delirium may adversely affect both the patient and personnel caring for the patient. Possible injury to the patient from thrashing, loss of IV access, and damage to dressings or the surgical site may result from any cause of delirium.2,9 Personnel are at risk for injury while caring for a thrashing child. Additional staff support often is required to help keep patients safe.3,16 Surveyed parents of children with emergence delirium report dissatisfaction with their child’s care and concern that maladaptive behaviors may persist after surgery.14 A study performed by Kain et al and verified by Sadhasivam et al revealed a 1.4-fold increased incidence of postoperative maladaptive behaviors that may persist for weeks or months, such as general anxiety, nighttime crying, enuresis, temper tantrums, and separation anxiety, in patients diagnosed with emergence delirium.4,5

Risk Factors for Emergence Delirium

Behavior

Score

Asleep

Calm

Crying, but can be consoled

Crying, but cannot be consoled

Factors that put children at risk for emergence delirium include type of surgery, patient characteristics, and choice of anesthesia. Surgical risk factors include procedures on the thyroid, eye, middle ear, and tonsils. Voepel-Lewis et al reported that approximately 25% of children undergoing otolaryngologic or ophthalmic surgery experience emergence delirium,16 which is greater than twice the rates reported in children undergoing other surgeries, such as general or urologic procedures. Some authors suggest that the feeling of suffocation associated with surgeries around the face may explain this increased incidence of emergence delirium.2 Patient characteristics include the child being 2 to 6 years old. Also, a child described as emotional, less social, more impulsive, or less adaptable to environmental changes appears to be at greater risk. No sex-based difference has been observed.2 The presence of preoperative anxiety manifested by either the child or the parent is estimated to increase the risk for emergence delirium by 10%.5 However, accurate assessment of patient anxiety levels before anesthesia can be challenging. The modified Yale Preoperative Anxiety Scale, a measurement tool that assesses 27 behaviors in 5 different domains (activity, use of parent, vocalization, state of arousal, and emotional expressivity) is used by both research and clinical physicians to identify and quantify pediatric anxiety.18 The tool is validated and found to be reliable compared with longer questionnaires such as the State Trait Anxiety Inventory. When anxiety is identified, various nonpharmacologic measures (preoperative use of video games and parental presence) can be used to distract the child and decrease postoperative anxiety.19,20 The combination of identification and treatment of postoperative anxiety also may reduce the incidence of emergence delirium. Anesthetic choices may affect the risk for emergence delirium. Although the complication has been reported after all types of anesthesia, total IV anesthesia appears to decrease the risk compared with volatile anesthetics.18 Halothane is reported to have a lower risk, whereas all other volatile agents appear to carry similar risks for emergence delirium.6,21,22

Agitated and thrashing around

Reducing the Risk

Based on reference 9.

Table 2. PAED Scale Extremely

The etiology of emergence delirium remains unknown. Some clinicians suggest that rapid emergence from anesthesia is a potential trigger. The increased incidence of emergence delirium reported with use of short-acting, less soluble volatile anesthetics lends support to a rapid emergence theory.2,9 However, maintaining anesthesia at a higher minimum alveolar concentration and decreasing the rate of reduction of anesthetic concentration at the end of surgery to slow awakening is not associated with decreased risk. Use of short-acting IV anesthetics, such as propofol, appears to be protective, suggesting that other factors may be involved.2,9 Xenon, a nonvolatile inhaled anesthetic agent that provides a rapid awakening, has been associated with reduced postoperative delirium in adults, but has not been well studied in children. Other etiologies have been proposed. Risk for emergence delirium appears similar for sevoflurane, desflurane, and isoflurane, but reported rates for halothane are lower. Sevoflurane has been shown to increase activity of excitatory currents via the locus coeruleus. Volatile agents that cause less emergence delirium excite this pathway less. Also, α2 agents that reduce emergence delirium, such as clonidine and dexmedetomidine, reduce this excitatory current.12 One possible explanation for the difference in excitation of pathways with sevoflurane may be the blockage of gamma-aminobutyric acid A receptor– mediated inhibitory pathways at low concentrations, such as occurs during emergence. Sevoflurane, desflurane, and isoflurane cause similar electroencephalogram (EEG) changes, whereas halothane, which has a lower incidence of emergence delirium, results in a different EEG pattern.13 Although the EEG patterns do not point to a mechanism, they suggest that certain volatile agents have distinct actions in the brain.

Table 1. Cravero Scale

Very Much

Etiology

of emergence delirium.8 These behaviors typically are self-limiting, with a duration of approximately 5 to 15 minutes.2 Although emergence delirium is common in pediatric patients, it is important to rule out other causes of delirium and inconsolable behavior that may manifest in the PACU. Differential diagnosis for a patient with these behaviors includes postoperative pain, hypoxia, hypercarbia, airway obstruction, hypoglycemia, seizures, elevated intracranial pressure, hypo/hyperthermia, extrapyramidal effects, inadequate reversal of muscle relaxants, full bladder, and fear and anxiety.9

Quite a Bit

alterations including hypersensitivity to stimuli and hyperactive motor behavior.”7 Depending on the definition used and the population studied, the reported incidence of emergence delirium varies between 10% and 80%.2,3,5,6,8 Other terms, such as agitated emergence, emergence agitation, emergence excitement, or postanesthetic excitement, t are used interchangeably throughout the literature, but consistency in the definition would add necessary rigor to the study of this subject. According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), delirium is a psychiatric condition characterized by rapid, acute disturbances of attention, perception, and consciousness. Agitation is a more inclusive term that may include restlessness or distress from sources other than anesthesia, such as an absent parent. Studies that require delirium to fulfill diagnostic criteria for emergence distress typically report lower rates than do studies that accept agitation alone or with delirium as case-defining symptoms. For the purpose of this review, the term emergence delirium, which requires the presence of delirium, is used to describe this phenomenon.

Just a Little

CONTINUING MEDICAL EDUCATION

Not At All

Makes eye contact with caregiver

Actions are purposeful

Aware of surroundings

Restless

Inconsolable

Behavior

PAED, Pediatric Anesthesia Emergence Delirium Based on references 7 and 9.

Table 3. Watcha Scale

Based on reference 9.

Prophylactic pharmacologic treatment appears to reduce both severity of and risk for emergence delirium.

CONTINUING MEDICAL EDUCATION

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Uncontrolled postoperative pain is an obvious potential confounder when considering emergence delirium as an explanation for untoward symptoms after surgery. Strategies that provide excellent analgesia such as administration of 0.25 mg/kg of ketamine during dental surgery and a caudal block with 1 mL/kg of 0.25% bupivacaine for abdominal procedures significantly reduced the rate.15 Clonidine, provided as a caudal injection (2-3 mcg/kg), IV (2-3 mcg/kg), or in oral form (4 mcg/kg) also reduced the rate of emergence delirium diagnosis.23-25 Patel et al and Aarts et al reported that 0.2 mcg/kg per hour of dexmedetomidine for tonsillectomy and adenoidectomy surgery were beneficial.15,23 It is possible, however, that improved analgesia may have reduced the incidence by eliminating agitation caused by postoperative pain as well as preventing nonpainful delirium. An additional finding of interest was the reduction of emergence delirium in pain-free magnetic

Table 4. 10 Lessons To Learn About Emergence Delirium Emergence delirium is a common occurrence in the postoperative setting, in which a patient becomes dissociated from the environment. Symptoms of emergence delirium include a child who is irritable; uncompromising; uncooperative; incoherent; and inconsolably crying, moaning, kicking, or thrashing. Surgical, patient, and anesthetic risk factors contribute to emergence delirium. Modification of anesthetic management may reduce the incidence of emergence delirium. Emergence delirium must be differentiated from other medical causes of agitation including hypoxia, hypercarbia, postoperative pain, and inadequate reversal of neuromuscular blockade. Multiple tools and definitions have been developed to assess emergence delirium, leading to a wide range of reported incidence. Emergence delirium is a self-limiting event, usually lasting for 5-15 min after emergence. Treatment of emergence delirium is controversial. Some physicians believe no treatment is necessary given the self-limiting nature of the event; others believe sedative medications such as midazolam, fentanyl, clonidine, propofol, or dexmedetomidine should be provided to reduce the duration of the delirium event. Complications of pharmacologic treatment of emergence delirium include prolonged sedation and respiratory depression. Complications of emergence delirium include injury to the patient and/or staff, removal of medical equipment such as dressings and/or IVs, increased number of staff required for patient care, parental/patient dissatisfaction, and prolonged hospital stay. No single anesthetic plan is suitable for all children to reduce the incidence of emergence delirium. Professional assessment of the patient is necessary to determine the best anesthetic course.

resonance imaging (MRI) after administration of 1 mcg/ kg of fentanyl, suggesting that multiple pathways may be involved.15 Delaying emergence from volatile general anesthesia by administration of an IV agent such as clonidine, dexmedetomidine, or propofol is another prophylactic option. Addition of 1 mg/kg of propofol before withdrawal of inhaled agents significantly decreased the incidence of emergence delirium after pain-free MRI scans.15 The mechanism of action is not known. Further investigation into these medications and identification of the causes of emergence delirium may clarify how pharmacologic agents can help.

Diagnostic Tools Many tools can help identify, quantify, and guide treatment of patients experiencing or at risk for emergence delirium.6,9 For example, scores of 4 or higher on the 5-point Cravero scale are consistent with emergence delirium if symptoms persist for at least 3 minutes despite active measures by staff to calm the patient (Table 1).9 Because the Cravero scale measures agitation and sedation, diagnosis of emergence delirium with this metric is greater than scales that require delirium for diagnosis. The Pediatric Anesthesia Emergence Delirium (PAED) scale was developed by Sikich and Lerman (Table 2).7,9 This scale is the most commonly used and reliable tool for identification and quantification of emergence delirium. Five criteria are evaluated on a Likert scale to help caregivers differentiate between postoperative pain and delirium. Scores of 10 or higher are consistent with emergence delirium. The Watcha scale (Table 3) resembles the simplicity of the Cravero scale.9 Patient scores of 3 or higher for any duration of time in the postoperative period are consistent with emergence delirium. The Watcha scale more consistently correlates with the PAED scale, and both have slightly higher sensitivity than the Cravero scale. Routine use of one of these scales will improve identification, although choice of scale may differ based on the anesthetic practice setting. Choosing a scale that best fits a particular practice will aid in its successful use.

Treatment Several pharmacologic and nonpharmacologic treatments are available, recognizing that no additional treatment may be appropriate given the self-limiting characteristic.8 Withholding treatment decreases the child’s exposure to additional medications but prolongs the time that the child poses potential harm to him- or herself or staff, and increases parental stress. Pharmacologic approaches include small doses of fentanyl, propofol, clonidine, dexmedetomidine, or midazolam, titrated to sedation.2,8,11 Usually, when additional sedative effects wane, the child rouses but the delirium is no longer present. Avoidance of toxic side effects from the various pharmacologic treatments, such as respiratory depression, sedation, and prolonged stay in the PACU, is possible with careful titration. Environmental modifications, such as a darkened or quiet environment and parental presence in the PACU, also reduce the incidence and duration of emergence delirium.2 These modifications are generally easy to implement, are low-cost, and have no adverse effects. A combination of both environmental and pharmacologic approaches may be warranted for some patients.

Patient Identification and Management High-risk patients include children aged 2 to 6 years who are anxious at baseline and are to undergo potentially painful surgical procedures, and whose parents also are nervous. The ideal approach to provide safe and effective anesthesia must take into consideration the surgery planned, comorbidities, and future needs. Many strategies to reduce emergence delirium, however, arguably should be applied to all patients, including adequate education regarding the expected surgery, pain management, and anesthetic plan all accomplished before the date of surgery; a calming and reassuring preoperative visit; anxiolytic and amnestic premedication; a calm and quiet induction; thorough multimodal analgesia, including local anesthetic and regional techniques; and appropriate pharmacologic management to reduce the likelihood of postoperative residual paralysis, hypoxia, and hypercarbia. Awakening should occur in a calm, quiet recovery area with rapid access to parental presence. In a patient at high risk for emergence delirium, the use of total IV anesthesia with propofol and other prophylactic agents, such as α2 agonists or short-acting opioids, may be preferred.

Management of the Case Presented Assessment of the child is required to exclude critical threats to the child’s welfare. It was noted that the child had an adenotonsillectomy for moderate to severe obstructive sleep apnea, which can be associated with postoperative apnea, hypoxia, and hypercarbia. Vital signs indicated that the patient was not oversedated; blood oxygen saturations were 98% on 40% oxygen; and endtidal carbon dioxide was 41 mm Hg. Local anesthesia was not applied to the surgical site and 2 mcg/kg of fentanyl was given for analgesia. Upon questioning and application of the Wong-Baker FACES scale, pain was not the apparent reason for distress. Confusion was observed and the child described hallucinations. A diagnosis of emergence delirium was made. The IV line was protected with an extra wrap. The child’s mother was permitted to enter the PACU. Airway management devices were assembled and an IV bolus of 2 mcg/kg of clonidine was given. The child calmed and fell asleep, and on second awakening was calm. Alternative medications such as propofol and fentanyl would have been appropriate treatment for emergence delirium, but clonidine has the advantage after tonsillectomy in a patient with significant obstructive sleep apnea because it does not affect the carbon dioxide response curve while still allowing sedation and analgesia.

Conclusion Overall, children are at high risk for emergence delirium, and may require a multimodal approach for prevention or mitigation of emergence delirium. Modalities to pursue include adequate postoperative pain control, prophylactic pharmacologic treatment with the medications discussed, and a soothing PACU environment. Although commonly used, none of the drugs mentioned in this review are approved specifically by the FDA for the management of emergence delirium in children. Through identifying these patients and providing appropriate prophylactic treatments, the need for additional PACU staff and prolonged hospital stays may be reduced, while patient and parental satisfaction and safety improve. Lessons that can be learned from a review of emergence delirium are summarized in Table 4.

CONTINUING MEDICAL EDUCATION

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

References 1.

Smessaert A, Scheher CA, Artusio JF. Observations in the immediate postanesthesia period II. Mode of recovery. Br J Anaesth. 1960;32(4):181-185.

Vlajkovic GP, Sindjelic RP. Emergence delirium in children: many questions, few answers. Anesth Analg. 2007;104(1):84-91.

Cole JW, Murray DJ, McAllister JD, et al. Emergence behaviour in children: defining the incidence of excitement and agitation following anaesthesia. Paediatr Anaesth. 2002;12(5):442-447.

Sadhasivam S, Cohen LL, Szabova A, et al. Real-time assessment of perioperative behaviors and prediction of perioperative outcomes. Anesth Analg. 2009;108(3):822-826.

10. Oh AY, Seo KS, Kim SD, et al. Delayed emergence process does not result in a lower incidence of emergence agitation after sevoflurane anesthesia in children. Acta Anaesthesiol Scand. 2005;49(3):297-299. 11. Shung J. The agitated child in recovery. South Afr J Anaesth Analg. 2011;17(1):96-99. 12. Yasui Y, Masaki E, Kato F. Sevoflurane directly excites locua coeruleus neurons of rats. Anesthesiology. 2007;107(6): 6 992-1002. 13. Constant I, Dubois MC, Piat V, et al. Changes in electroencephalogram and autonomic cardiovascular activity during induction of anesthesia with sevoflurane compared to halothane in children. Anesthesiology. 1999;91(6):1604-1615. 14. Hapfelmeier G, Schneck H, Kochs E. Sevoflurane potentiates and blocks GABA-induced currents through recombinant alpha1beta2gamma2 GABAA receptors: Implications for an enhanced GABAergic transmission. Eur J Anaesthesiol. 2001;18(6):377-383.

Kain ZN, Caldwell-Andrews AA, Maranets I, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg. 2004;99(6):1648-1654.

Rosen HD, Cravero JP. Research on emergence agitation in children. Can J Anesth. 2013;60(8):822-823.

15. Aarts A, van der Hagen V, Russchen H. Does pharmacologic treatment prevent children from emergence agitation after sevoflurane anesthesia? Erasmus J Med. 2012;2(2):24-28.

Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology. 2004;100(5):1138-1145.

16. Voepel-Lewis T, Malviya S, Tait AR. A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit. Anesth Analg. 2003;96(6):1625-1630.

Manworren R, Paulos CL, Pop R. Treating children for acute agitation in the PACU: differentiating pain and emergence delirium. J Perianesth Nurs. 2004;19(3):183-193.

17. Burke CN, Voepel-Lewis T, Hadden S, et al. Parental presence on emergence: effect on postanesthesia agitation and parent satisfaction. J Perianesth Nurs. 2009;24(4):216-221.

Reduque LL, Verghese ST. Paediatric emergence delirium. Contin Educ Anaesth Crit Care Pain. 2013;13(2):39-41.

18. Kain ZN, Caldwell-Andrews AA, Weinberg ME, et al. Sevoflurane versus halothane: postoperative maladaptive behavioral

Visit www.mssm.procampus.net today for instant online processing of your CME post-test and evaluation form. There is a registration fee of $15 for this nonâ&#x20AC;&#x201C;industry-supported activity. For assistance with technical problems, including questions about navigating the Web site, call toll-free customer service at (888) 345-6788 or send an email to Customer.Support@ProCEO.com.

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changes: a randomized, controlled trial. Anesthesiology. 2005;102(4):720-726. 19. Patel A, Schieble T, Davidson M, et al. Distraction with a handheld video game reduces perioperative anxiety. Paediatr Anaesth. 2006;16(10):1019-1027. 20. Yip P, Middleton P, Cyna AM, et al. Non-pharmacological interventions for assisting the induction of anaesthesia in children. Cochrane Database Syst Rev. 2009;(3):CD006447. 21. Dahmani S, Stany I, Brasher C, et al. Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies. Br J Anaesth. 2010;104(2):216-223. 22. Meyer RR, MĂźnster P, Werner C, et al. Isoflurane is associated with a similar incidence of emergence agitation/delirium as sevoflurane in young children? A randomized controlled study. Paediatr Anaesth. 2007;17(1):56-60. 23. Bock M, Kunz P, Schreckenberger R, et al. Comparison of caudal and intravenous clonidine in the prevention of agitation after sevoflurane in children. Br J Anaesth. 2002;88(6):790-796. 24. Malviya S, Voepel-Lewish T, Ramamurthi R, et al. Clonidine for the prevention of emergence agitation in young children: efficacy and recovery profile. Paediatr Anaesth. 2006;16(5):554-559. 25. Tazeroualti N, De Groote S, De Hert A, et al. Oral clonidine vs. midazolam in the prevention of sevoflurane-induced agitation in children. A prospective, randomized controlled trial. Br J Anaesth. 2007;98(5):667-671.

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

Post-Test 1.

The age group most likely to develop emergence delirium is________. a. infants b. preschoolers c. teenagers d. all ages

Which of the following pharmacologic agents may contribute to emergence delirium? a. Clonidine b. Dexmedetomidine c. Isoflurane d. Fentanyl

Which set of characteristics is most likely to be related to emergence delirium? a. Uncontrolled movements, confusion, fear b. Crying, pulling at dressing, complaining of pain c. Thrashing, tachypnea, accessory muscle breathing d. Confused speech, snoring, respiratory obstruction

Which of the following family characteristics may contribute to emergence agitation? a. A family that insists on hugging the child at separation b. A child with anxious parents crying at separation c. A single parent d. An adopted child

Which inhaled agent is least likely to cause emergence delirium? a. Xenon b. Sevoflurane c. Isoflurane d. Desflurane Which of the following is nott a diagnostic criterion for emergence delirium? a. Uncontrolled movements b. Pain c. Confused speech d. Pulling at bandages

Which of the following characteristics of induction may contribute to emergence agitation? a. Parental presence b. Inhalation induction c. Active resistance at induction d. IV induction

Which of the following preoperative medication protocols is least effective in decreasing the incidence of emergence delirium? a. Preoperative midazolam b. Preoperative clonidine c. No preoperative medication given d. Preoperative diazepam

Which of the following anesthetic techniques is least effective in decreasing the incidence of emergence delirium? a. Total IV anesthesia with propofol and remifentanil, ketorolac for analgesia b. Caudal anesthesia with ropivacaine and clonidine to anesthetize the surgical site combined with general anesthetic c. Desflurane combined with oxygen and air, ketorolac for analgesia d. Sevoflurane combined with oxygen and air, fentanyl prn in recovery for analgesia

10. Which is nott an effective technique for decreasing severity and consequences of emergence delirium? a. Parental presence b. Restraint with tie-downs c. IV fentanyl d. IV clonidine

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PRN BLOCK

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designating a block nurse is very helpful in screening patients and educating them on what to expect.” Indeed, patient education plays a significant role in the block nurse’s daily responsibilities, although that’s not where they end. Ms. Gradyy also positions the patient for the procedure, connects the patient to necessary monitoring equipment and completes the time-out procedure with the rest of the block team, ensuring that the surgical side and site are correctly identified and clearly marked. “When you’re actually doing the block, it’s very helpful to have someone who is experienced in the procedure,” said Dr. Bojaxhi, whose group presented its experience with the block nurse program at the 2013 annual meeting of the American Society of Anesthesiologists (abstract S09). “When you bring the patient into the block room, the cart is always stocked and everything is drawn up, so you’re not running around and delaying the surgeon while looking for necessary materials.” After the block has been placed, the block nurse monitors the patient’s sedation level, respiratory rate and oxygen saturation. The nurse also assesses the block, looking for abnormalities and reporting them to the anesthesia provider, if necessary. The nurse then clears the area and resupplies it in anticipation of the next patient. “Patients often need reassurance and proper education on what to anticipate following the block,” Dr. Bojaxhi said. “This also serves to prevent unintentional injury to the blocked extremity. We often send patients home with pumps. The block nurse explains how they work, and teaches patients how to use them, remove them and so on.” Ms. Gradyy also calls block patients the day after their procedure to check on them. “Most do wonderfully, but all you need is one or two concerned patients not knowing what to do, and the patient and surgeon will be apprehensive on the use of blocks and nerve catheters,” Dr. Bojaxhi added. “Having someone to coach them through the process makes it so much easier.” Although both clinicians agreed that documenting increases in patient care efficiency has been challenging, the benefits of the block nurse have been very real. “I don’t know if we’ve saved enough time to schedule an extra case in a day,” Dr. Bojaxhi noted, “but having a block nurse has certainly helped us reduce surgical delay.” Yet perhaps the most attractive part

of employing a block nurse is that it need not be a full-time, dedicated position. Instead, the researchers suggested assigning those duties to a nurse in the postanesthesia care unit (PACU) on the morning of an institution’s busiest day of orthopedic surgeries. “You’ve got nothing to lose,” Dr. Bojaxhi said. Jeff Gadsden, MD, director of regional anesthesia at St. Luke’sRoosevelt Hospital, in New York City, agreed there are clear advantages to

having a nurse on the block team, and that block nursing has evolved into a specialized and dynamic position. “In addition to expertise at administering meds, monitoring vitals and troubleshooting acute care problems, nurses are often much more skilled than doctors at listening and responding to patients’ questions, and taking time to explain exactly what to expect,” Dr. Gadsden said. “Although the intrinsic value of block nurses seems obvious, one barrier to its widespread implementation is cost,

either real or perceived,” Dr. Gadsden continued. “There are creative ways to minimize cost, such as these authors have suggested with their redeployment of PACU nurses. However, this is not always possible, and it may not be until we have some solid outcomes data relating to patient satisfaction and/ or increased case throughput that the majority of departments choose to invest in this emerging and exciting nursing specialty.” —Michael Vlessides

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PRN OSA

invaluable. “Perhaps what this study has done is to provide the impetus for children that can also be used in the developing an identification and assessprimary care setting,” said Dr. Murto, ment tool of OSA that is evidencewho hopes to present preliminary find- based and clinically validated,” she said. ings from a validation study of the preDr. Murto was scheduled to present dictive tool his team is developing at a the findings at the Canadian Anesthesiologists’ Society’s 2013 annual meetfuture conference. Dr. Gooden said a streamlined ing (abstract 1653556) in Calgary, and accurate screening tool would be Alberta; however, the meeting was

canceled due to flooding. Jeffrey Gross, MD, professor and chair of the Department of Anesthesiology at the University of Connecticut Health Center, in Farmington, led the development of the ASA’s screening tool. He said he is not surprised by the high falsepositive rate Dr. Murto’s team found. “Our priority was to emphasize sensitivity over specificity,” said Dr. Gross,

who was not involved in the study. As to whether the ASA’s OSA screening tool should be used in pediatric patients, Dr. Gross said he was not aware of better options. “None of the available tools are both specific and sensitive,” he said. “One with fewer false-positives will have more false-negatives.” —David Wild

MILLION

Pauling, one of four winners of two Nobel prizes, proposed that anesthetics work by forming clathrate crystals in cell walls. The public and I followed this with excitement for several years until anesthesia theories advanced in other directions and Pauling retired. To win a GRAND prize, scientists from other disciplines might turn their interests to anesthesiology. The public might hear about exciting developments. Anesthesia clinicians— physicians and nurses—could unite in a common pursuit of ultimate theories.

Funding nurse–physician comparative studies seems divisive, and perhaps fruitless. Funding studies that advance common understanding, generate public excitement and unite sounds better. Join the debate: How should the ASA spend $1 million?

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CONTINUED FROM PAGE 7

Nobel laureate or two, to the GRAND Prize committee and let them decide. Inform the public from time to time how the GRAND Prize race is going. Let nurses serve on the prize committee, and help fund it. Anesthesiology research has potential Nobel prizes: for instance, discovering the mechanism of general anesthesia, or how to relieve pain without side effects. Recently, USA Today gave frontpage coverage to the stem cell research

of Charles Vacanti, a Harvard anesthesiologist and tissue engineer (whose latest study first made news in the pages of this magazine two years ago [ July 2012, page 1]). The New York Times noted that related research won a Nobel. When I started in anesthesiology, I learned about the Meyer and Overton correlation of lipid solubility and anesthetic potency. Because cell walls contain lipids, mechanism-off anesthesia theories at that time focused on molecular interactions with cell walls. Linus

References 1. Simmons JP. Psychol Sci. 2011;22:1359-1366. 2. Ioannidis JPA. PLoS Med. 2005;2(8):696-701. 3. http://www.12newsnow.com/story/24867860/voting-floridians-strongly-support-physician-led-careaccording-to-statewide-poll.

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Optimize Transfusion Decisions with Noninvasive and Continuous Hemoglobin (SpHb ) Monitoring ÂŽ

Enhance patient-centered decision making with real-time visibility to whether hemoglobin is stable, dropping, or rising.

4.5%

87%

Reduction in Blood Transfusion Frequency

0.6%*

SpHb Impact in Higher Blood Loss Surgery2 2.5

Average RBC Units Transfused Per Patient

Frequency of Intraoperative Blood Transfusions

SpHb Impact in Lower Blood Loss Surgery1

1.9 2

0.9

Average RBC Units Reduced Per Patient

1.5

1.0** 1

0.5

Standard Care Group

SpHb Group

Randomized controlled trial in 327 orthopedic patients. *p=0.03 vs Standard Care Group

Standard Care Group

SpHb Group

Prospective cohort study in 106 neurosurgery patients. **p<0.001 vs Standard Care Group

SpHb monitoring is proven to help clinicians reduce blood transfusion in both lower and higher blood loss surgery, and also helps initiate more timely transfusions when they are truly indicated.

To learn more, visit www.masimo.com/hemoglobin Ehrenfeld JM, et al. American Society of Anesthesiologists. 2010;LB05. 2 Awada WFN et al. Proceeding of the Society for Technology in Anesthesia Annual Meeting, 2013: p 51.

Caution: Federal law restricts this device to sale by or on the order of a physician.