June 2104

The best-read anesthesiology publication in the United States

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THE INDEPENDENT MONTHLY NEWSPAPER FOR ANESTHESIOLOGISTS AnesthesiologyNews.com • J u n e 2 0 1 4 • Volume 40 Number 6

anesthesiologynews @anesthesianews

As Nitro Shortage Eases, Lessons Learned for Future

B

y mid-April, the nitroglycerin shortage that had gripped hospitals for months showed some signs of abating, with Baxter, one of three major manufacturers of the drug, announcing that it had returned its customers to a 100% allocation following months of severe restrictions.

As a result, at least one facility— Tampa General Hospital, in Florida— said it was able to ease limits on the use of the critical cardiac medication.

But no such relief was in sight at Carilion Roanoke Memorial Hospital,

Reduce Costs With Selective Pre-Op Testing NYC panel highlights waste in system

R

outine preanesthetic tests cost more than $60 billion every year, but far fewer than 1% reveal pertinent abnormalities relating to the anesthetic or the surgery, according to a 1989 study published in the Canadian Journal of Anesthesia (1989;36:S13-S19).

For that reason, national guidelines recommend minimizing preoperative testing in low-risk, stable patients undergoing non-em mergent surgery. The American Society of Anesthesioologists

see nitro shortage page 10

see testing page 12

Critical Question: Experts Discuss The Best Model for ICU

I

s it time for a different approach to critical aat Stanford University, in Stanford, care in the United States?

Calif., said years of increasing subspeAt the 2014 Critical Care Congress of cialization of ICUs have driven up the Society of Critical Care Medicine, specosts but failed to produce measurable advantages for patients. cialists made the case for a more multidisciplinary approach to the delivery of critical “If you look at the assessments care services and the training of critical carre that have been done, there is a lack physicians in this country. oof evidence that specialized ICU care During a panel discussion on subspecialty and genis financially beneficial, [with] the possible exceperal ICUs, Andrew J. Patterson, MD, PhD, division tions being neuro ICUs and cardiothoracic ICUs. chief for critical care medicine in the Department There is also no consistent benefit in terms of length of Anesthesiology, Perioperative and Pain Medicine see critical page 20

5 8

PAIN MEDICINE

Seeking ways to cut wait times for spinal cord stimulation.

13

CLINICAL ANESTHESIOLOGY

Nitrous or nerve block for labor: a pain-free choice.

16

CME: PREANESTHETIC ASSESSMENT

Lesson 310: Preanesthetic Assessment of the Patient With Addison’s Disease

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CORRESPONDENCE

A farewell to residents.

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4 I AnesthesiologyNews.com

JUNE 2014

Comment on these and other articles @ AnesthesiologyNews.com.

Heard Here First: There are always alternative structures to a sale

alternative strategies for the success of your practice. Even if you are committed to and

June 2014

The five most-viewed articles last month on AnesthesiologyNews.com

seeking a buyer, you can’t stop or even 1. Current Concepts in the Management of the Difficult Airway (Educational Review)

develop your business while you are searching for the right one. There might not be a buyer. slow your efforts to

2. Hypothermia During Surgery Affects Even Warmed Patients 3. POISE-2 Disappoints on Prevention of Post-Op Heart Attacks 4. OSA Screener of Limited Clinical Use in Children 5. Airway on Demand: Pedunculated Mass (Video)

Register for free @ AnesthesiologyNews.com to read these and other articles.

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You might realize that you don’t want

You might decide you want to buy.

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JUNE 2014

AnesthesiologyNews.com I 5

CORRESPONDENCE

A Farewell Letter to Residents Dedicated to the Clinical Anesthesia Class of 2014

I

t is that time of year again. Just when we have all the confidence in the world that you know enough to do no harm, it is time for you to graduate and start your careers!

These are a few things I know for sure about your career in anesthesia: Ellen R. Basile, DO

1. You are going to make mistakes. In the beginning, there will be more than you expected; and as the years move forward, there will be less. My advice is pay attention to your mistakes. The growth potential from our failures is exponentially higher than from our successes. Own your mistakes; people tend to have more respect for those who are honest than those who point fingers. If nothing else, you will be able to sleep better at night.

2. Someone will die on your table. This is anesthesia. You are aware of the life-and-death stakes. I hope you will be able to learn something from the case. Becoming a better anesthesiologist from these cases is one way we can honor our patients. And most importantly, pay attention to your own well-being. These events have the potential to be very traumatic.

Please talk to someone whom you can trust about your experience and feelings. Just because you are a doctor does not mean that you are immune to the human response to death.

3. You will save a life, likely many times in the course of your career.

It is quite possible that you will not receive the recognition you deserve for your efforts on behalf of your patients. Realize that without you, those patients most likely would not have made it off the operating room table. Pay attention to your successes so that you can build on them—and repeat them.

4. You never are really finished. After what feels like 24/7 in the operating room for three years, you are thinking that nothing will come through those doors that you can’t handle.

Wrong. Residency is just a foundation. You have much left to learn about your craft. My hope for you is that you continue to learn every day

My advice is pay attention to your mistakes. The growth potential from our failures is exponentially higher than from our successes.

for the rest of your career. If you are paying attention, the learning will happen naturally with little effort.

5. Duty hour regulations, two breaks and a lunch are over. Nobody cares anymore if you are up for 24 hours straight. If you are going home exhausted, you are probably doing a great job. Pay attention to your life beyond medicine. It is so easy in our profession to burn out, or worse, turn to drugs or alcohol to cope with the daily stresses of our jobs. If you have friends, parents, a spouse or children, pay attention to them when you are not at work. One day, you are going to retire. The time you invest in these relationships is far more important than what kind of doctor you were. Anesthesia is a fantastic career, but you mustt have a life outside the operating room—it will keep you sane.

Most of all, I wish you a life filled with all that you deserve. Medicine is a noble profession, and you have chosen a field that takes patients through a vulnerable, stressful event in their lives.

Be aware of your contributions, and take pride in your work. I take pride in my work, and you are certainly a huge part of my job. It matters to me that you are paying attention, and that you give a damn. While I am sad to see you go, it is part of our cycle of life in medicine. Be good, and know that I am proud of you, and thank you for all that you will do for our field and for our patients.

As always,

Ellen Ellen R. Basile, DO, is assistant professor in the Department of Anesthesiology at the University of Oklahoma and the Children’s Hospital at OU Medical Center, in Oklahoma City.

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COMMENTARY

Anesthesia Group Acquisitions and Alternatives Mark F. Weiss, JD

I

n a period of rapid change, physician practices react differently to the resulting uncertainty.

Hospitals seek to employ or otherwise “align” primary care physicians. They seek to control specialty referrals through employment models, account- Mark F. Weiss, JD able care organizations and other hospital-centric networks. And particularly for anesthesiologists, competitive pressure is mounting from large regional and national groups.

Many anesthesia groups are interested in seeking shelter from uncertainty through a sale to a large regional or national group or to a private equitybacked venture. Yet others are forging new routes, alone or in alliance with other practitioners and creating their own futures. Which route is best for you?

Acquisitions It’s important to understand the basic economic structure of an anesthesia group acquisition. As opposed to the sale of, for example, a manufacturing business that includes inventory, machinery, raw materials and real estate, all of which can be valuated and sold, the only thing that most anesthesia groups have to sell is their future cash flow. Accordingly, the usual anesthesia practice acquisition is essentially a valuation, at a multiple of the group’s reconstructed earnings—reconstructed because most groups don’t have significant, or any, earnings in the technical sense due to the fact that they annually distribute all of their available cash to their physician owners.

To illustrate, if the group is normally distributing $100x to the physicians when the amount of compensation required to recruit and retain is $70x, a purchaser likely would value the group based on a multiple of the difference—that is, a multiple of $30x. As part of the sale, the group’s physicianowners would receive an employment contract for $70x per year, often for a guaranteed number of years.

The savvy reader might realize that, all things being equal, the group has financed the purchase price by forgoing the collection of the additional $30x: That’s correct. However, those physicians nearing the end of their active careers may be more than happy to obtain four, five, six or more times that $30x up front because they have no intention of working for more than one or two additional years.

Even physicians who foresee many years of continued practice sometimes favor an acquisition because it results in a shifting of risks, for example, the risk that the hospital contract might be terminated, or that collections will plummet, one year into the term of a multiple-year employment guaranty.

Although certain risks can be shifted, sellers do assume other risks, such as the fact that continued practice without a sale might be more remunerative or that the lump-sum purchase price received might

not deliver a higher return than would a continued Importantly, your management services orgainvestment in their own careers. nization, or MSO, structure can be a vehicle to create initial relationships that later might be How long the hot acquisition market will last is anyone’s guess. Certainly, large groups in key marexpanded to make the client a target for merger or acquisition. kets—“key” being different for each potential acquirer—tend to drive higher valuations. But that’s not to say that a smaller group, in a particular buyer’s 3. Do Your Own Mergers and Acquisitions. Instead of simply thinking of M&A from the perspective of viewpoint, wouldn’t make a prime candidate to fill in perceived gaps in their footprint. a target, consider that your group can become an One more point: Many anesthesiologists want to acquirer. Although you might actually consider know the magic multiple that will apply in connecbuying another local group, that is, engaging in a true acquisition, there is no reason to restrain your tion with their imagined acquisition. In other words, thinking to paying cash. they want to know now, up front, what their practice is worth.

Your group can combine with other groups The real answer is that it’s worth what an actual through merger to form your own larger entity. buyer will pay you to acquire your practice. If Buyer Although size by itself doesn’t ensure success, it can enable your group to establish a wider geoA will pay $30 million and Buyer B will pay $40 milgraphic presence, achieve economies of scale and lion, then your practice is worth the latter. That’s potentially create stronger payment rate contracttrue even if Buyer B is a fool. On the other hand, if ing power. Size also serves to create leverage in no buyer is interested in your practice, then for you, for now, there’s absolutely no value to be had through connection with facility contract negotiations. an acquisition.

There is a plethora of ways to structure mergers, from those in which your group essentially Although you can look to the greater market for makes itself larger by subsuming other groups into trends, such as the fact that anesthesia practices are selling like hotcakes, to gauge the likelihood that its fold, to structures in which your group and another create a new entity. there is a potential buyer in the wings, the only way of actually knowing is to engage in the process of looking for one, or preferably many.

4. Nontraditional Models. Within bounds permitted between competitors (although the truly entreAlternatives preneurial reader will realize that there is no need to deal only with competitors), nothing limits the Just because the acquisition market is hot doesn’t types of nontraditional or hybrid ventures that can mean that you should be interested in a sale. Again, unlike the calculus that the owner of a manufacturing be constructed. Consider, for example, the use of business uses, no one is likely to pull enough cash out cooperative ventures, limited-scope joint ventures of a sale to head off and buy a villa on Lake Como or and alliance models. even a nice second home in Aspen. And for the many Conclusion who seek to control their own futures, no sale can More options exist for your practice than you may deliver that ability.

But there are multiple alternatives to a sale: have considered. There are always alternative structures to a sale and alternative strategies for the suc1. Elevate Your Game. Immediately begin taking steps cess of your practice. Even if you are committed to seeking a buyer, you can’t stop or even slow your to cement your relationship with the facilities at which your group currently provides services, and efforts to develop your business while you are searchintensify your efforts to secure additional services ing for the right one. There might not be a buyer. If contracts. At the same time, tighten up your group’s there is one, you might not like the price. You might internal operations. Get your governance structure realize that you don’t want to sell. You might decide in order to enable your group to make quick deciyou want to buy. sions. Review your compensation plan to make The best strategy formulation is not a straight-line certain that it creates the proper incentives and process. It’s not an on-off, f sell or don’t sell, merge motivators. And begin to amass capital to enable or don’t merge situation. Rather, it’s a fluid, circular the group to expand on multiple fronts. process, keeping options open even as you explore a primary one, continuing to build as you, for exam2. Create a Profit Stream From Your Internal Business ple, continue to search for the right deal—that is, the right deal for you.

Function. If your group has an internal business operation with a dedicated practice manager, consider expanding that function into a separate spun- Mark F. Weiss, JD, is an attorney who specializes in the business offf business entity that provides management and legal issues affecting physicians and physician groups on services to other groups as well as to your own. a national basis. He was a clinical assistant professor of anesFor example, you can sell your manager’s and thesiology at University of Southern California Keck School of your group leaders’ business expertise; you can Medicine and practices with The Mark F. Weiss Law Firm, a firm repackage billing services; and you can operate a with offices in Dallas, Texas, and Los Angeles and Santa Barbara, locum service with your own group’s physicians or Calif., representing clients across the country. He can be reached with third parties. by email at markweiss@advisorylawgroup.com.

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PAIN MEDICINE

Researchers Suggest Ways To Reduce SCS Wait Times

P

roponents of spinal cord stimulation (SCS) studying prolonged wait times for the procedure believe that patients and physicians need to be educated about the benefits of SCS in order to streamline the process from initial presentation to receipt of treatment.

“SCS wait times remain a significant issue, which reduces the long-term

success of therapy,” wrote Krishna Kumar, MBBS, MS, clinical professor of neurosurgery at the University of Saskatchewan’s College of Medicine, and Syed Rizvi, MD, a neurology resident at the University of Saskatchewan, in Saskatoon, Canada, in a poster presented at the American Academy of Pain Medicine’s (AAPM) 2014 annual meeting. “Educating patients and health care

providers with respect to consideration of SCS early within the pain care continuum, improved funding and further research are needed to bolster long-term success of SCS therapy.”

The poster, updating data from a paper published last year in which Drs. Kumar and Rizvi analyzed 437 SCS patients (Pain Practt 2013 Oct. 25. [Epub ahead of print]), featured a

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review of data from 443 patients.

The researchers found that the average time from symptom onset to implantation was 5.12 years. The first physician contact took lace a mean of 3.4 months after pain onset. Family physicians cared for patients for an average of 11.9 months and specialists averaged 39.8 months.

Non-implantingg anesthesiologists took the longest to refer individuals for implantation, whereas neurosurgeons were the quickest—the difference in average referral time between these two categories of providers was 2.15 years (P<0.001).

Drs. Kumar and Rizvi also analyzed a multiple linear regression model and discovered that implantation delay can be predicted by age, sex, whether treatment is covered by workers’ compensation and the referring specialty.

The researchers further found that women’s pain duration was an average of 11.92 months shorter than men’s.

Workers’ compensation patients had an average of 8.97 months’ shorter pain duration than patients without workers’ compensation benefits. Controlling for sex and referring specialty, each year

Non-implanting anesthesiologists took the longest to refer individuals for implantation, whereas neurosurgeons were the quickest—the difference in average referral time between these two categories of providers was 2.15 years.

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‘By placing spinal cord stimulation down the treatment pathway, we are lessening the chance of success.’

—Timothy Deer, MD

@anesthesianews anesthesiologynews

JUNE 2014

AnesthesiologyNews.com I 9

PAIN MEDICINE of increased age was associated with a 1.1-month longer period of pain.

“This poster from Drs. Kumar and Rivzi is of critical importance,” said Timothy Deer, MD, director of The Center for Pain Relief, Charleston, W.Va. “It shows us that by placing spinal cord stimulation down the treatment pathway, we are lessening the chance of success. This information should encourage insurance companies to seek out centers of excellence and try to obtain access to SCS early in the severe nerve pain patient. This will lead to improved outcomes and could help reduce the need for addictive medications and lower the cost of chronic long-term care.”

Ezra B. Riber, MD, president of the South Carolina Society of Interventional Pain Physicians, said long wait times are due in part to previous widespread inappropriate selection of patients, leading to suboptimal outcomes. This has led to more skepticism from insurance carriers about the efficacy of SCS, resulting in difficulties with authorization and reduced reimbursement.

“Part of the challenge is educating primary care physicians on which patients are appropriate candidates for neuromodulation—some of these individuals have nonsurgical, end-stage

conditions,” Dr. Riber said. “And education is also key for recognizing which cases should be referred for surgical spine evaluation and which should be sent straight to the pain doc to shorten the delay to SCS treatment.”

interviews podcasts procedural videos

—Rosemary Frei, MSc Dr. Deer is a consultant for Axonics, Nevro, Spinal Modulation and St. Jude Medical. Dr. Kumar is a consultant for Boston Scientific and Medtronic Inc., and has received research grants from Medtronic Inc. Dr. Riber does not have any relevant financial conflicts of interest to disclose.

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JUNE 2014

PRN NITRO SHORTAGE

CONTINUED FROM PAGE 1

in Virginia, which reported that its shipments of nitroglycerin had just been cut. Indeed, “I’d like to know where [Tampa General] is getting their nitro!” said Lisa L. Deal, PharmD, an emergency medicine pharmacy specialist in the hospital’s Department of Pharmacy.

Given the changeable nature of nitroglycerin supplies, drug shortage experts say it may not yet be time to ease up on strategies for stretching supplies of the vasodilator. The coping methods, such as advocating alternative agents and sharpening patient selection criteria for the drug, may well prove indispensable if nitroglycerin once again experiences supply chain hiccups.

The rationing measures were needed because of the high demand for nitroglycerin, which is widely regarded as the optimal “stat” drug for treating the millions of people who experience myocardial infarctions or worsening heart failure in the United States each year.

“With its short halff life and ability to be easily titrated for maximum effect, IV nitroglycerin really is the drug of first choice for these patients, especially in emergency room [ER] settings,” said Nicole M. Acquisto, PharmD, BCPS, an emergency medicine clinical pharmacy specialist at the University of Rochester Medical Center, in N.Y. The drug also is widely used, said C. Michael White, PharmD, the director of the University of Connecticut/Hartford Hospital Evidence-based Practice Center, in Storrs. Patients in cardiac crisis who are fortunate enough to make it to the hospital alive, Dr. White noted, “typically get IV nitroglycerin. If we can’t give them that ideal first option, then the potential to negatively impact a large number of people is certainly there.”

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‘‘[Nitroglycerin] [Nitrogl is something we’re rreally eally concerned co about because if addition supplies don’t come in additional soon, yo soon, you can only do conservation lon before things run out.’ so long —Erin Fox, PharmD, FASHP —

Conservation Has Its Limits For hospitals that rely on pharmacies’ just-in-time ordering to keep inventories lean and drug costs as low as possible, the prolonged squeeze on nitroglycerin stocks has triggered deep concerns about running short and being unable to treat their most critical patients. The situation is especially serious for smaller and rural hospitals, where a single individual with an acute coronary event could wipe out an entire stock in a single visit.

The nitroglycerin crisis first surfaced in 2012 when Hospira, followed later by American Regent/Luitpold, halted production because of manufacturing issues. It has deepened in recent months after Baxter— prompted by rising demand—limited the drug to 40% and then 20% of normal shipments.

It was just the latest, but one of the most serious of the more than 300 drug shortages that Erin Fox, PharmD, FASHP, is following as the director of the Drug Information Service at the University of Utah Hospitals and Clinics, in Salt Lake City. Dr. Foxx said nitroglycerin “is something we’re really concerned about because if additional supplies don’t come in soon, you can only do conservation so long before things run out.”

Utah Hospitals and Clinics has instituted measures to preserve supplies, including “trying to limit the time patients spend on nitroglycerin drips,” she said. In the procedure areas that may need only small amounts, she said, the pharmacy department is drawing up doses “to make sure we have it for all of our patients.”

Asked to comment on Baxter’s announcement of a return to 100% allocations, Dr. Foxx said she was encouraged, “but I will believe it when I see it. Baxter says they are now going to allocate 100% of [a hospital’s] past usage, but they have a complicated rolling allocation ordering period and specific times when you can order. They refuse to provide the details in writing for our buyers.”

Baxter spokesperson John O’Malley said that “the increased allocation details are being communicated both verbally and via a letter sent directly to customers.” Mr. O’Malley added that the company’s “primary goal is—and always has been—to ensure that patients’ needs are met, and we have taken a number of actions to enable continued access to products needed for critical patient therapies.”

Those actions, he noted, date back to January 2014, when Baxter first began putting supplies of nitroglycerin products “through a temporary allocation and fulfillment process ... to expedite product for urgent need.

Effective E Ef fectiv April 15, however, we returned customers to 100% allocation.”

Down to a Week’s Supply Katelyn R. Dervay, PharmD, BCPS, a pharmacotherapy specialist in emergency medicine at Tampa General Hospital, said she spoke with Baxter in midApril and was told that her facility “is now up to a 120% allocation of the IV bottles for infusion. So we have removed our own restrictions on the product.”

Dr. Dervayy added, however, that “the nitro vials are still not available.”

Restrictions on IV nitroglycerin at Tampa General began in March, when it became evident that “using the drug the way we used to, we had about a week’s supply,” she explained. As a level 1 trauma center licensed for more than 1,000 beds, Tampa General had to apportion its diminishing supply among several key departments and procedure areas where IV nitroglycerin is routinely used, including the emergency department (ED), cardiac catheterization lab, cardiac operating rooms and coronary care units, Dr. Dervay said. “We worked with our providers to identify the most appropriate patients for this medication,” Dr. Dervayy said, including those with heart failure accompanied by pulmonary edema and those undergoing cardiac catheterizations. “ED patients who presented with angina were given an alternative form of nitroglycerin to relieve their symptoms,” such as sublingual tablets, spray or paste, she noted.

A Different Story Carilion Clinic, a seven-hospital health care system in southwest Virginia, has been on even more of a roller coaster when it comes its nitroglycerin supplies. In early April, the system had enough IV nitroglycerin on hand to supply its flagship Roanoke Memorial Hospital for one to two months, according to Dr. Deal. As a result, Carilion had not yet had to impose restrictions, she said, but would if supplies dropped below one month’s use. “We get allocated five boxes of 12 drips a month from Baxter,” she said at the time. “As of right now, we’re OK.” But by mid-April, Dr. Deal got a different story from her staff. “I just called my inventory technician and he said our allocation had been reduced—so I don’t see any signs [of improvement].”

If it turns out that nitroglycerin supplies continue to be pressured and restrictions on the drug’s use are needed, Dr. Deall said, “we would save those multidose vials and use them in the [catheterization] lab because nitroglycerin can be used intra-arteriallyy during cath procedures to vasodilate cardiac vessels.”

JUNE 2014

AnesthesiologyNews.com I 11

PRN Down Six Cases At Maimonides Medical Center, in New York City, Victor Cohen, PharmD, BCPS, a clinical pharmacy manager and specialist in emergency medicine, said that the 711-bed facility has been reduced to four cases a month of injectable nitroglycerin, down from its usual 10 cases. To conserve the drug for patients who need it most, he said, “we alerted everyone” to use alternative agents whenever possible, including sublingual and topical formulations of nitroglycerin. For hypertensive patients, he said, “you can use other vasodilators, especially if an afterload reduction is needed.” Dr. Cohen mentioned that IV nicardipine had been recommended, and added that “you can also use Cleviprex” (clevidipine injectable emulsion; The Medicines Company), a relatively new drug that has “been shown to be very helpful in acute hypertension.”

He cited two studies supporting the use of clevidipine in this setting. In the VELOCITY (Evaluation of the Effect of Ultra-Short-Actingg Clevidipine in the Treatment of Patients with Severe Hypertension) trial, 94% of 127 patients with severe hypertension (systolic blood pressure [SBP]>180 mm Hg) who received IV clevidipine achieved target SBPs within 30 minutes (Congest Heart Faill 2010;16:55-59). In the PRONTO (Clevidipine in the Treatment of Blood Pressure in Patients With Acute Heart Failure) trial, 104 severely hypertensive patients (mean SBP: 186.5 mm Hg) were randomized to receive IV clevidipine (51) or standard hypertensive care (53). More patients in the clevidipine group (71%) achieved the prespecified target blood pressure range than those receiving standard care, and time to target was more rapid for clevidipine-treated patients ((Am Heart J 2014;167:529-536).

Uncharted Territory The lack of IV nitroglycerin also has had an effect on other types of cardiac patients. Dr. White said he received a message from a colleague at a nearby community hospital that had to switch from papaverine to IV nitroglycerin plus verapamil for its patients undergoing bypass surgery after the papaverine supply dried up. “Now they can’t get the nitroglycerin,” he said.

“So what are we supposed to do?” the colleague asked. “And the answer was, ‘I don’t know,’” Dr. White said, “because there is nothing else that has really been studied.”

Baxter said it is taking steps to limit such instances where clinicians run out of supply—and options. “As the only

manufacturer supplying the U.S. market with nitroglycerin in an intravenous or injectable form, Baxter is deploying product through the company’s primary distribution centers in order to enable and support expedited shipping,” the company noted in an email. “We also have worked to increase material supply and have redirected manufacturing operations in order to increase production.”

—Bruce and Joan Buckley None of the sources reported any relevant financial conflicts of interest.

questions comments story ideas Contact Editor Adam Marcus at

amarcus@mcmahonmed.com

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12 I AnesthesiologyNews.com

JUNE 2014

CLINICAL ANESTHESIOLOGY TESTING

CONTINUED FROM PAGE 1

(ASA) released a guideline in 2012 that advised against routine testing, such as labs, chest xx rays and electrocardiograms (EKG). But the ASA suggested a tailored approach for anything with a high risk.

Yet testing remains a common practice. Roughly half of low-risk patients still undergo unnecessary preoperative testing, according to two recent studies (Ann ( Surgg 2012;256:518-528 and Anesth Analg 2011;112:207-212).

An interdisciplinary panel of physicians from around New York City met recently to discuss the appropriate use of pre-op testing at the New York Academy of Medicine. The session, “Why Bother!

The Comprehensive Pre-Op Panel,” was organized after the American Board of Internal Medicine (ABIM) Foundation listed preoperative testing in patients undergoing routine surgery as one of five medical services of questionable value.

Preoperative testing has been an accepted part of medicine for more than 150 years since the English physician John Snow wrote about the benefit of examining his patient before administering chloroform. In the 1990s, however, doctors began to ask if these tests made any difference in outcome, and the answer was “we always did it that way,” said Elizabeth Frost, MD, clinical professor of anesthesiology at the Icahn School of Medicine at Mount Sinai, in New York City, who appeared on the panel.

“I’ve heard surgeons say that their administrator orders the tests, that the patient expects to give blood and be tested, that anesthesia will cancel the case if there are no tests, that there’s a legal liability without testing and that they have to support the hospital and labs,” Dr. Frost said.

Dr. Frost is the creator of the PreAnesthetic Assessment, a series of continuing medical education articles (published in Anesthesiology News and online).

The ABIM Foundation’s “Choosing Wisely” campaign, an initiative to reduce the overuse of tests and procedures, created a guideline to help clinicians better understand and deal with the controversial medical services. The framework consists of four points: evidence of harm or little benefit, frequent misuse in practice, that it be measurable and that it be under provider control.

Preoperative testing certainly is measurable and under provider control, but many physicians are unconvinced about the other two aspects, said panelist Deborah Korenstein, MD, editor of ACP Smart Medicine, a publication of the American College of Physicians.

“There is strong evidence that pre-op testing does not change outcomes or surgery cancellation rates for patients undergoing minor procedures like cataract surgery,” Dr. Korenstein told attendees. “Studies have looked for harms that were a direct result of the tests, like bleeding and nerve damage from blood draws; and although they are rare, they are not nonexistent.”

These tests also can have non-physicall consequences, such as false-positive results that trigger patient anxiety and even surgical delays, she continued.

So what do all these tests cost? A chest X-rayy is $128, EKG is $216, CBC is $156, electrolytes is $626, urinalysis is $85 and a stress test is $2,300, for a grand total of $3,511, according to prices from Dr. Frost’s bill at White Plains Hospital in 2012 and the cost of a stress test at Mount Sinai.

“Pre-op lab and EKG testing should clearly be driven by history, physical and surgical risk only,” said Dr. Frost, a member of the editorial board of Anesthesiology News. “You should do a test only if it can correctly identify abnormalities, if it can change the diagnosis, or if it’s going to change the management plan or outcome. Such tests are very expensive, can cause delays and can come with unforeseen complications.”

Dr. Frost researched policies around the world and found that several other countries shared her views.

Germany and Thailand are using preoperative guidelines that reduce unnecessary testing; the United Kingdom believes that there is no evidence of clinical benefit and cost-effectiveness of routine testing; and Canada supports pregnancy tests but discourages nearly all the rest.

Yet the United States has no consensus. After the ASA released its list of indications for preoperative tests, a surgeon from Texas wrote in a peerreviewed journal that the recommendations lacked clarity, were not specific to ambulatory surgery and were not based on well-designed studies (Adv ( Surg 2013;47:81-98).

Panelist Tomas Heimann, MD, chief of surgery at James J. Peters VA Medical Center, in New York City,

A System for Reducing Needless Testing

T

he radiology department at Weill Cornell Medical Center, in New York City, implemented a clinical decision support system that has improved health care by influencing physician choices.

The system was embedded into the department’s electronic ordering system several years ago to assist with real-time decisions. After a specific image or procedure is entered into the machine, a menu will appear and ask for more information. The system then scores the request based on previously applied criteria, and either approves it or suggests another course that is more appropriate.

There are some guidelines that indicate when a physician should do a specific test, but the problem is what they are and how to remember them all in the moment, said Keith Hentel, MD, executive vice chairman and associate professor of radiology at Weill Cornell.

“With the evidence that we’ve incorporated into our clinical practice, it’s now clear that the pre-op chest x-ray is an avoidable test,” Dr. Hentel said.

“Clinical decision support is one mechanism that can be used to reduce imaging, and it could be easily applied to other fields. I would encourage individual practices to get started reducing unnecessary testing and then make their results known, because big changes are being made to health care.”

—P.B.

and professor of surgery at Mount Sinai, said the problem is not that preoperative testing is useless, but rather that the wrong tests are often performed.

“Our system is flawed because if a patient has an operation at Montefiore [in New York City] and is now at Mount Sinai with a complication, that information isn’t always provided,” Dr. Heimann said.

“We’re doing a lot of tests now that have some usefulness, but a lot of them aren’t really making any difference. If you’re about to operate on a patient to remove his gallbladder, these routine tests aren’t going to help you. It’s critical that we’re doing tests of clinical benefit.”

—Paul Bufano

Computer Detects Fake Expressions of Pain Better Than People

I

s the patient cringing with neck pain telling the truth despite no evidence of trauma, or is he just looking to collect some insurance money? Thanks to a fully automated facial expression recognition system that operates in real time, the answer can now be discerned with a little more confidence.

A joint study from researchers at the University of California, San Diego, the State University of New York’s University at Buffalo and the University of Toronto has found that a computer vision system can distinguish between

real and faked expressions of pain more accurately than humans do.

The study involved two experiments with 205 human observers who were asked to assess the authenticity of people’s painful expressions in video clips, some of whom were being subjected to actual pain induction, whereas others were faking their emotion.

The researchers found that even after training, people could not differentiate between the two actions more than 55% of the time. In contrast, using a machine that automatically

measures facial movements and performs pattern recognition on those movements, 85% accuracy was attained.

The system’s superiority is attributed to its ability to distinguish the subtle differences between pyramidally and extrapyramidally driven movements that people cannot decode. The study showed that the most identifiable feature of pretended pain is how and when the mouth opens and closes.

Pain fakers’ mouths open with less variation and too regularly.

The researchers published their findings in Current Biology (2014;24:738-743).

—Paul Bufano

JUNE 2014

AnesthesiologyNews.com I 13

CLINICAL ANESTHESIOLOGY

Ether or? Nitrous or Nerve Block for Labor

F

or women giving birth, nitrous oxide may be a viable alternative to having an epidural block, a recent study has found.

Although the researchers were quick to point out that nitrous oxide (NO) may not be for everyone, it could stand in when an epidural block is contraindicated, or for women who simply do not wish to receive one. Likewise, they note that NO offers a safe alternative to IV narcotics.

The retrospective cohort study, presented at the 2014 Pregnancy Meeting (abstract 598), examined the outcomes of 6,192 laboring women at the University of California, San Francisco Medical Center (UCSF) between 2007 and 2012. The investigators focused on single-child, head-down births with no unusual complications.

NO was administered using an FDAapproved device called the Nitronox (Porter Instruments). The researchers accounted for the effects of age, ethnicity, insurance status and the length of each stage of labor in their comparison of outcomes between women who received NO and those who did not.

Of the women examined in the study, 14% opted to use NO for pain control during delivery. Of these, 42% also received an epidural injection compared with 76% of women who did not receive NO. Maternal use of NO did not significantly affect the rate at which babies were admitted to intensive care, according to the researchers. Nor did NO significantly affect the babies’ five-minute Apgar score or the odds of complications for the mother, such as acidemia or postpartum bleeding.

“The findings show that this offers a different option,” said Melissa Rosenstein, MD, a clinical fellow in the Division of Maternal-Fetal Medicine at UCSF. “No one is saying that women who want an epidural shouldn’t use one, but nitrous oxide is a good option for women who don’t want to be completely numb, but just want to take the edge off.

“What’s nice is that there’s no commitment,” Dr. Rosenstein added. “If the woman doesn’t like it, we can put it away and go back to breathing, or have an epidural if she prefers.” She also noted that, unlike an epidural, NO can be used in the second stage of labor because it does not blunt the urge to push.

The results indicate that NO should be more widely available for childbirth than it currently is, said Manuel Vallejo, MD, DMD, professor and chair of the Department of Anesthesiology at West

Virginia University, in Morgantown.

“This study tells me that nitrous oxide can be safely used, with no harm to neonates. It tells me that it should be in the toolbox,” Dr. Vallejo said. “The epidural is still the gold standard, but using nitrous oxide, some women might be able to get further along before they need an epidural, and some women may not need one at all.”

NO also can be administered safely by a midwife in the event that an anesthesiologist is unavailable during childbirth, Dr. Rosenstein said. NO is commonly used for anesthesia during labor in Canada and throughout Europe, but remains relatively uncommon in the United States.

“When I presented the findings, the international folks all said,

‘Yeah, we have this, it’s no big deal,’” Dr. Rosenstein said. “We wanted to release these findings to let people in the United States know about it. Trying to show that nitrous oxide is better or worse than an epidural is not the point,” she added. “The point is that it relieves pain in a totally different way.”

—Ajai Raj

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14 I AnesthesiologyNews.com

JUNE 2014

CLINICAL ANESTHESIOLOGY

Clot-Blocking Therapy Appears Safe in Patients Undergoing Emergency Neurosurgery San Franciscoâ&#x20AC;&#x201D;Chronic antiplatelet and anticoagulation therapy usually is discontinued before elective neurosurgery, yet when it comes to emergency procedures, such a luxury is not possible.

But a recent study shows that patients taking chronic blood-thinning

therapy are not at elevated risk for perioperative problems after emergency neurosurgery because of the treatment. â&#x20AC;&#x153;It is common practice to withhold antiplatelet and anticoagulation agents prior to elective neurosurgery,â&#x20AC;? said Alex T. Lee, MD, acting assistant

professor of anesthesiology at the University of Washington, in Seattle, who led the research. â&#x20AC;&#x153;However, we wanted to assess how being on these medications prior to an emergency procedure affects postoperative outcomes.â&#x20AC;?

Dr. Lee and his colleagues reviewed

Rationale, Reversal, and Recovery Of Neuromuscular Blockade Part 2: Ongoing Challenges and Opportunities Case Study Dennis is a 68-year-old man undergoing open abdominal surgery (colectomy).

Current Symptoms Â&#x2021; Dyspnea Vital Signs Â&#x2021; Height: 175 cm Â&#x2021; Weight: 85 kg 6LJQLÂżFDQW 0HGLFDO +LVWRU\ Â&#x2021; Hypertension Â&#x2021; Congestive heart failure Â&#x2021; Obstructive sleep apnea &XUUHQW 0HGLFDWLRQV Â&#x2021; Metoprolol 100 mg PO Â&#x2021; Ramipril 2.5 mg PO Laboratory Results Â&#x2021; Apnea hypopnea index: 26/h Â&#x2021; Left ventricular ejection fraction: 30%-35% Anesthesia is induced with sufentanil, propofol, and 0.6 mg/ kg rocuronium based on total body weight and maintained ZLWK GHVĂ&#x20AC;XUDQH LQ DLU R[\JHQ DQG VXIHQWDQLO 6XUJLFDO FRQGLWLRQV DUH GLIÂżFXOW ZLWK D ODFN RI DEGRPLQDO ZDOO PXVFOH relaxation and poor paralysis. An extra dose of rocuronium is administered for deeper neuromuscular block (NMB), and fewer than 2 train-of-four (TOF) responses are noted.

Global Education Group and Applied Clinical Education are pleased to introduce part 2 of a 3-part interactive CME series featuring challenging cases in NMB. Each activity presents a clinical scenario that you face in your daily practice. After reading the introduction to the case, consider the challenge questions, and then visit ZZZ &0(=RQH FRP QPE WR ÂżQG 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, NMB reversal via a unique multimedia learning experience and earn 1.0 AMA PRA Category 1 Credit.â&#x201E;˘ Complete the whole series and earn a total of 3.0 AMA PRA Category 1 Credits.â&#x201E;˘ This activityâ&#x20AC;&#x2122;s distinguished faculty

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the records of 129 adult patients aged 18 years and older who had undergone emergency neurosurgery at the University of Washington over a one-year period. Sixteen were on warfarin, with or without aspirin; five were on clopidogrel, with or without aspirin; and 26 were on aspirin alone.

The primary outcome measure was the volume of perioperative blood products transfused; secondary outcomes included in-hospital mortality, time spent in the ICU and hospital, number of days on mechanical ventilation, duration of surgery, and incidence of myocardial infarction and thrombotic episodes, the researchers reported. As a control group, the researchers included 82 patients who were not taking antiplatelet agents or anticoagulants.

Patients in the control group were significantly younger than those on blood therapy (Table). â&#x20AC;&#x153;When looking at the demographic profiles of the patients, one of the interesting things we found was that patients on Coumadin [warfarin], clopidogrel and aspirin also tended to receive more burr-hole procedures for the same indications,â&#x20AC;?

Dr. Lee said at the 2013 annual meeting of the American Society of Anesthesiologists (abstract 1075). â&#x20AC;&#x153;Indeed, in those patients, 60% of procedures were burr holes, whereas in the control group, 70% of patients underwent craniectomy or craniotomy.â&#x20AC;?

â&#x20AC;&#x153;It is common practice to withhold antiplatelet and anticoagulation agents prior to elective neurosurgery. However, we wanted to assess how being on these medications prior to an emergency procedure affects postoperative outcomes.â&#x20AC;? â&#x20AC;&#x201D;Alex T. Lee, MD

JUNE 2014

AnesthesiologyNews.com I 15

CLINICAL ANESTHESIOLOGY Table. Patients Not Taking Blood Drugs Were Much Younger Than Those on Medication

standing, compared with more poly- on the drug reflect the overall results of trauma in the patients who are younger this observational study. “Anesthesioloand not yet on these medications.” gists in general recognize and endorse No Blood Larger studies, he added, may shed the antagonism of Coumadin, whereas Drugs Coumadin Clopidogrel Aspirin some light on the impact of chronic our treatment of antiplatelet therapies antiplatelet therapy on longer-term out- such as aspirin and clopidogrel remains 50±22 77±12 83±20 75±13 Patient age, y comes after neurosurgical procedures. limited,” he told Anesthesiology News. <0.001 0.001 <0.001 P value Martin H. Dauber, MD, assis- “Dr. Lee’s [study], which showed no tant professor of anesthesia and criti- outcome differences, reflects that neucal care at the University of Chicago, roanesthesiologists already know this, Patients taking warfarin also in the chronic treatment group are noted that the large differences in the and practice accordingly.” received a larger volume of fresh fro- undergoing their procedures for rea- FFP transfusion requirements between zen plasma (FFP) before surgery than sons such as mechanical falls from patients taking warfarin and those not —Michael Vlessides those in the control group (706±702 vs. 58±322 mL; P<0.0001), as well as during the procedure (895±858 vs.

American Society for Enhanced Recovery (ASER), 252±605 mL; P=0.0005).

“Even the aspirin group did not Duke Department of Anesthesiology and Department of Surgery receive more platelet volume compared with the control group,” Dr. Lee said.

PRESENT Patients in the control group tended to have longer surgeries than those taknd ing aspirin (121±51 vs. 76±24 min; P=0.0008), but not those taking warfarin or clopidogrel.

October 10, 2014 The researchers observed no differences in other primary or secondary outcomes between the groups. “We New Orleans Downtown Marriott at the Convention Center didn’t find any difference in mortality, New Orleans, LA length of ICU or hospital stay, or duration of mechanical ventilation, regardless of whether you were on Coumadin, This activity has been approved for 6.25 AMA PRA Category 1 credits™. clopidogrel or aspirin,” Dr. Lee said.

As Dr. Lee pointed out, it’s possible that surgeons’ choices may have affected the study results.

This one day symposium will address issues related to enhanced recovery for colorectal “It may be that surgeons choose more and other surgery from a multidisciplinary perspective. conservative procedures for patients who are coming on chronic Coumadin, clopidogrel or aspirin therapy,” he said.

Topics include: Activity Co-Chairs “I think it’s also highly likely that if we look at the mechanism of injury, we t History and Fundamentals of Enhanced Tong J Gan, MD, MHS, FRCA would probably find that more patients Recovery Timothy E Miller, MB, ChB t Preoperative Education and Optimization Julie K Thacker, MD t Perioperative Fluid Management. How Little, How Much?

Confirmed Speakers t Hemodynamic Management. Is it Cost Solomon Aronson MD, MBA, FACC, FCCP Effective?

Maxime Cannesson, MD, PhD t Successful Pain Management Strategy Lee A. Fleisher, MD t The Role of Regional Anesthesia in Enhanced Stuart A. Grant, MB ChB Recovery Stefan D. Holubar MD, MS, FACS t Enhanced Recovery Strategy in Laparoscopic Monty Mythen, MD, FRCA Colectomy. Should I Adopt it?

Edward N. Rampersaud Jr., MD Roy G. Soto, MD t How Do You Get Your Team Together and Robert H. Thiele, MD Reaching Consensus? t Enhanced Recovery Beyond Colorectal Surgery t Debate: Performance metrics are an efficient way to promote enhanced recovery t Enhanced Recovery Case Studies

2 US Enhanced Recovery Symposium

http://anesthesiology.duke.edu To exhibit at this event, please contact via phone: 919-681-4660 or e-mail: info@aserhq.org

16 I AnesthesiologyNews.com

JUNE 2014

Continuing Medical Education

CME

WRITTEN BY: Crystal I. Leach, MS, MD Intern Department of Surgery Louisiana State University Health Sciences Center New Orleans, Louisiana

Alan David Kaye, MD, PhD Professor and Chairman Department of Anesthesiology Louisiana State University Health Sciences Center New Orleans, Louisiana

REVIEWED BY: Charles J. Fox, MD Professor and Chairman Department of Anesthesiology Louisiana State University Health Sciences Center Shreveport, Louisiana

LESSON 310

Preanesthetic Assessment of the Patient With Addison’s Disease

DISCLOSURES The authors have no relationships with pharmaceutical companies or manufacturers of products to disclose.

PROFESSIONAL GAPS Addison’s disease is a well-recognized but seldom encountered disease perioperatively. Recent guidelines have summarized strategies for steroid supplementation based on the results of large studies and evidence-based medicine.

TARGET AUDIENCE Anesthesiologists

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

LEARNING OBJECTIVES At the completion of this activity, the reader will be able to: 1. Describe the adrenal gland and hypothalamic–pituitary–adrenal (HPA) axis.

2. Classify adrenal insufficiency.

3. Describe Addison’s disease.

4. Describe the systemic changes caused by Addison’s disease.

5. Define adrenal crisis.

6. Explain the effects of etomidate as a triggering cause of Addison’s disease.

7. Describe etomidate analogues for possible future use.

8. Apply appropriate preoperative testing and evaluation of the patient suspected to have Addison’s disease.

9. Develop an anesthetic plan for the patient with a previous incident or family history of Addison’s disease.

10. Anticipate, recognize, and manage likely perioperative complications related to adrenal insufficiency disease.

CASE A 41-year-old man presented to the emergency room with a 2-day history of nausea, vomiting, and pain in his right lower quadrant. Vital signs demonstrated a slight increase in temperature, and lab studies showed leukocytosis with a white cell count of 12.5. Chest radiograph was within normal limits. Acute appendicitis was diagnosed and appendectomy scheduled. The patient gave a 3-year history of Addison’s disease, which was initially diagnosed with weakness, hypotension, and weight loss. The patient also stated he has been stable on his current medications, which included fludrocortisone 0.2 mg per day and prednisone 4 mg twice daily. An electrolyte panel was within normal limits.

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 Sinai in New York City. She is the author of Clinical Anesthesia in Neurosurgeryy (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 post-test and course evaluation before January 31, 2015. (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: June 1, 2014

Termination Date: May 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.

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.

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

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.

Adrenal Gland and HPA Axis

T

he adrenal gland consists of a cortex or outer regions and a medulla or central region.

The cortex is made up of 3 regions: the zona glomerulosa, zona fasciculata, and the zona reticularis, which produce mineralocorticoids (eg, aldosterone), glucocorticoids (eg, cortisol), and sex hormones, respectively.1 The medulla produces catecholamines, such as epinephrine and norepinephrine. Direct destructive insults to the adrenal gland or to the hypothalamus or pituitary gland can cause adverse effects resulting in disruption in the production or release of these hormones.

The HPA axis controls the overall output of glucocorticoids from the adrenal cortex. Specifically, the hypothalamus releases corticotrophin-releasing hormone (CRH), which stimulates the anterior pituitary gland to produce adrenocorticotropic hormone (ACTH). After release, ACTH stimulates the adrenal cortex to produce cortisol.2 Cortisol provides negative feedback to both the hypothalamus and pituitary gland to control the release of CRH and ACTH.2,3 Cortisol plays an important role in metabolic and endocrine functions essential for human survival,3 particularly during stress conditions such as surgery, anesthesia, trauma, severe illnesses or infection, exercise, or burns when an intact or normal functioning HPA axis responds by increasing the release of ACTH and cortisol.2-12 The degree of increase in cortisol levels depends on the severity of the stressful event.2,4 Normal physiologic cortisol output in a nonstress state may range between a total of 15 and 30 mg per day, whereas a stressful state may cause a normally functioning HPA axis to increase the output of cortisol to 60 to 100 mg/m2 per day.2 Although the adrenal glands are capable of secreting up to 300 mg per day, output rarely exceeds 150 mg even in response to major surgical stress.5 This HPA axis response to stress is necessary for maintaining proper physiologic functioning.

Cortisol is required for the metabolism of carbohydrates, lipids, and proteins, and for the maintenance of vascular tone and endothelial integrity.3,11,12 Cortisol also facilitates the effects of catecholamines to increase vascular tone, vasoconstriction, and exert positive inotropic effects.2-4 Surgery has been found to be one of the most potent activators of the HPA axis.3 Studies have reported that maximum levels of ACTH and cortisol are reached during the early postoperative period, particularly following reversal of anesthesia and endotracheal extubation.3,13 Widmer et al reported that in patients undergoing coronary artery bypass graft surgery, plasma cortisol levels increase significantly during the operation, with peak cortisol levels achieved 30 minutes after extubation. Reports have also shown that ACTH levels return to normal within 24 hours,3,12,13 whereas cortisol levels decline more slowly, reaching high normal values approximately 48 to 72 hours after surgery.3,12

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Continuing Medical Education Adrenal Insufficiency Classification of Adrenal Insufficiency Adrenal insufficiency (AI) may be classified as primary, secondary, or tertiary.2 Primary AI (Addison’s disease) is caused by disease, destruction, or malfunction of the adrenal glands.2,6 Secondary AI results from disease or insult to the pituitary gland, which reduces production and release of ACTH and leads to atrophy of the adrenal cortex. Secondary AI can stem from iatrogenic causes such as exogenous administration of corticosteroids.4,6 Administration of exogenous glucocorticoids suppresses both hypothalamic CRH and pituitary ACTH. In general, patients who receive the equivalent of 20 mg per day of prednisone for more than 5 days are at increased risk for suppression of the HPA axis.2,4 Patients treated for approximately 1 month may be at risk for HPA suppression for up to 6 to 12 months after stopping therapy.

Receiving an equivalent dose of 5 mg or less of prednisone over any period of time usually will not significantly suppress the HPA axis.4 Tertiary AI results from hypothalamic disease or may have an iatrogenic etiology.2 Presenting signs and symptoms of AI typically occur when greater than 80% to 90% of the adrenal gland is destroyed or is nonfunctional.6

Addison’s Disease Primary AI or Addison’s disease results in a deficiency of both cortisol and mineralocorticoid. In 1930, tuberculosis accounted for 70% of cases of Addison’s disease.2,4,6,7,10 Today, however, the most common cause is autoimmune adrenalitis, which can be sporadic or familial in nature and can involve other endocrine organs including parathyroid glands, thyroid glands, ovaries, and islet cells of the pancreas.10 Other less common causes of Addison’s disease include fungal infections such as histoplasmosis, coccidiodomycosis, and cryptococcosis. Primary AI may occur in patients with HIV secondary to dissemination of infectious agents such as cytomegalovirus and Mycobacterium avium-intracellulare.6,10 Bilateral adrenal hemorrhage can result from clotting abnormalities triggered by anticoagulant drugs, heparin therapy, coagulopathy, thromboembolic disease, or a hypercoagulable state. Disseminated infections such as meningococcemia (WaterhouseFriderichsen syndrome), physical trauma, postoperative states, sepsis, and severe stress also may cause bilateral adrenal hemorrhage.8 Bilateral hemorrhaging of the adrenal glands inhibits adrenal function and therefore may cause primary AI. Additional causes of Addison’s disease include metastases, amyloidosis, sarcoidosis, and drugs such as ketoconazole, rifampin, and etomidate.6,10 Presenting signs and symptoms of Addison’s disease include hypotension; fatigue; weakness; anorexia; nausea and vomiting; weight loss; and hyperpigmentation of the skin, skin creases, and buccal mucosa.1,6,7,10 Hyperpigmentation occurs as a result of the elevated levels of ACTH found in primary AI and the relationship between ACTH and melanocyte-stimulating hormone. Secondary and tertiary AI result in depressed levels of ACTH and are not associated with hyperpigmentation. Laboratory examination is likely to reveal hypoglycemia, eosinophilia, hypoaldosteronism, hyponatremia, and hyperkalemia. The low aldosterone levels in patients with primary AI cause hyponatremia and water loss with subsequent hypovolemia and hypotension.2,6 Other classic laboratory findings in AI are hypercalcemia, azotemia,

and mild metabolic acidosis.10 As reported by Frederick et al, a random serum cortisol level of less than 10 mcg/dL during stress is suggestive of Addison’s disease, and less than 5 mcg/dL is virtually diagnostic. Patients with Addison’s disease also have suppressed levels of 24-hour urine cortisol and 17-hydroxycorticosteroids.10 Secondary and tertiary causes of AI do not result in hypoaldosteronism because aldosterone production is primarily regulated by the renin–angiotensin system. Electrolyte disturbances are typically not seen in either secondary or tertiary AI.2 Generally, patients with Addison’s disease receive routine replacement doses of hydrocortisone ranging from 20 to 30 mg per day in divided doses, primarily administered in the morning. These patients may still develop symptomatic AI when exposed to stressful states such as surgery and the perioperative period due to their inability to sufficiently increase cortisol levels proportionate to the stress.2

Addisonian Crisis Addisonian crisis, also referred to as acute AI, is a lifethreatening emergency. It occurs most often in patients with primary AI, but may also occur in patients with secondary or tertiary AI.8 A thorough history and physical examination plus a high index of suspicion for Addison’s disease are the most important tools for effective diagnosis of the condition.10 Addisonian crisis typically is precipitated by the onset of a stressful event in an individual who is unable to mount an appropriate cortisol stress response. Precipitating factors can include surgery, trauma, infection, alcohol withdrawal, and excessive loss of fluid and sodium through sweating or diarrhea.10 Glucocorticoids are not stored and must be synthesized by the body on demand.5 In a surgical patient with a normal functioning HPA axis, prompt elevated production and secretion of cortisol occurs at the onset of surgery. This secretion of cortisol remains elevated for approximately 3 days postoperatively.5 However, in patients with HPA axis suppression or those who are unresponsive to stress, cortisol secretion fails to occur.5 Acute failure of cortisol secretion leads to Addisonian crisis. In the perioperative period, Addisonian crisis may present as circulatory collapse and hypotension.5 In the postoperative period, the diagnosis may be missed or delayed due to nonspecific symptomatic complaints accompanied by a rapid, nonspecific deterioration lacking an obvious underlying etiology.10 Symptoms include lethargy, weakness, weight loss, fever, diarrhea, nausea, and vomiting, which may be intractable. Confusion, stupor, or coma may occur. In patients with primary AI, electrolyte disturbances, cutaneous and/or mucosal hyperpigmentation and volume depletion secondary to aldosterone deficiency are likely to occur. Hypotension may vary from mild orthostasis to shock. The patient also likely will present with abdominal pain of severity that may be confused with an acute abdomen.10

Considerations for Assessment and Management Preoperative Assessment Preoperative screening aims to identify patients who are at increased risk for HPA axis suppression, including those who are being treated for diagnosed AI while maintaining a high index of suspicion for patients with undiagnosed or suspected AI. For example, a high index of suspicion should be maintained

for patients taking 20 mg or more of prednisone (or the equivalent) for 5 or more days, or patients who exhibit laboratory findings of hyponatremia, hyperkalemia, unexplained hypotension, or eosinophilia.4 Similarly, a high index of suspicion should be held for patients undergoing chronic corticosteroid therapies for underlying medical conditions such as uncontrolled persistent asthma or severe rheumatoid arthritis.5 These patients have an increased risk for suppression of the HPA axis and may require additional corticosteroid coverage perioperatively in order to meet stress demands.2,4,5,8,10 Patients with undiagnosed primary AI may present with fatigue, weight loss, nausea, vomiting, diarrhea, and hyperpigmentation.2 Basic or routine laboratory examination may reveal hypoglycemia, electrolyte abnormalities, and eosinophilia.2 Diagnostic testing of the HPA axis can be performed in the medically stable patient if one suspects undiagnosed primary AI,2 but investigation for adrenal suppression is rarely done preoperatively.2,5 Furthermore, emergent cases may not permit the time necessary to conduct diagnostic testing.

The anesthesiologist, again, must rely on and maintain a high index of suspicion based on the patient’s preoperative clinical presentation and medical history. Tests to detect perioperative adrenal suppression or to identify patients who will respond to supplemental glucocorticoids have been neither sensitive nor specific.4,14 However, the short ACTH stimulation test has been found to reliably assess adrenocortical function.4 Kohl et al reported that preoperative abnormalities in the short ACTH stimulation test justify supplemental perioperative glucocorticoid administration and that a systematic approach should be taken to determine the necessity of steroid supplementation for those at risk for perioperative

Table 1. Guidelines for Adrenal Supplementation Therapy Medical or Surgical Stress

Corticosteroid Dosage

Minor • Inguinal hernia repair • Colonoscopy • Mild febrile illness • Mild-moderate nausea/vomiting • Gastroenteritis • Laparoscopic appendectomy

25 mg of hydrocortisone or 5 mg of methylprednisolone IV on day of procedure only.

Moderate • Open cholecystectomy • Hemicolectomy • Significant febrile illness • Pneumonia • Severe gastroenteritis • Exploratory laparotomy

50-75 mg of hydrocortisone or 10-15 mg of methylprednisolone IV on day of procedure. Taper quickly over 1-2 d to usual dose.

Severe • Major cardiothoracic surgery • Whipple procedure • Liver resection • Pancreatitis

100-150 mg of hydrocortisone or 25-30 mg of methylprednisolone IV on day of procedure. Taper quickly over 1-2 d to usual dose.

Modified from reference 4.

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Continuing Medical Education adrenal suppression. If the clinician suspects the presence or development of AI and the surgical procedure is emergent, steroids should be administered.4 However, if there is less urgency and time allows, the findings of Kohl et al suggest conducting an ACTH stimulation test to see if the adrenal gland responds appropriately to supraphysiologic doses of ACTH. In patients who are predetermined to have a high risk for developing perioperative AI, but results from the preoperative ACTH stimulation test are normal, steroids should be administered per guidelines (Tables 1-3) in a stress dose consistent with the level of injury if these patients present preoperatively with unexplained hypotension refractory to volume repletion.4 These guidelines have been developed to assist in the determination of an appropriate steroid stress dose based on the severity of the surgical procedure. For example, if a patient with presumed or previously diagnosed AI undergoes a minor surgical procedure such as an inguinal hernia repair, guidelines suggest giving a steroid stress dose of 25 mg hydrocortisone IV at induction of anesthesia or the morning of the procedure.

Perioperative Management Patients with Addison’s disease require glucocorticoid supplementation perioperatively in order to prevent Addisonian crisis. The dose of corticosteroid supplementation with hydrocortisone or an equivalent should be determined on an individualized basis.2 This dose should be based on the acuity of the operation and anticipated severity of the surgical procedure.2-6,10-14 The literature shows some variation in dosing guidelines.

For example, most guidelines support adding 100 to 150 mg hydrocortisone IV for major procedures (Tables 2 and 3). However, Axelrod suggests using methylprednisolone 10 mg IV during surgery and every 8 hours afterward, tapering to baseline dose in 2 to 3 days for procedures with major operative stress.14 The use of 10 mg IV methylprednisolone was favored over the

higher dose of hydrocortisone because a previous report documented that hydrocortisone at doses greater than 100 mg per day should be avoided due to its significant mineralocorticoid action and high risk for fluid retention.14 Overall, supplementation guidelines are similar and maintain the need for additional glucocorticoid coverage tailored to the patient’s need and anticipated surgical severity. In the event that supplementation was not given and Addisonian crisis ensued, Frederick et al provide therapeutic management.10 The mainstay of emergency treatment of Addisonian crisis is hydrocortisone, which has mineralocorticoid and glucocorticoid effects.10 An initial dose of 100 mg IV is given and repeated every 6 hours for 24 hours.10 If after 24 hours progress is satisfactory, the dose is reduced to 50 mg every 6 hours on the second day and then tapered as an oral dose thereafter.10 Supportive measures are performed, including insertion of large-bore IV catheters and subsequent replacement of volume. Volume replacement initially can be approached by giving 5% dextrose in normal saline at a rate of 500 mL per hour for the first 4 hours.10 Monitoring fluid volume and predicting fluid responsiveness noninvasively in the mechanically ventilated patient can be successfully done by using the pleth variability index.21 A blood sample should be drawn to check levels of serum glucose, cortisol, and electrolytes. Hypoglycemia and/or derangements in electrolyte levels need to be treated accordingly.

Other considerations for perioperative management include the effects of certain drugs in patients with known or

Corticosteroid Coverage

Minor surgery

25 mg hydrocortisone at induction of anesthesia. Resume normal medication postoperatively.

Moderate surgery

Usual dose of steroids preoperatively and then 25 mg of hydrocortisone IV at induction, followed by 25 mg IV every 8 h for 24 h. Usual preoperative dose is then continued.

Major surgery

Modified from reference 5.

Usual dose of steroids preoperatively, then 50 mg of hydrocortisone IV at induction, followed by 50 mg IV every 8 h for 48-72 h. Continue this infusion until the patient has started light eating, then restart the usual preoperative dose. It is advisable to consult an endocrinologist postoperatively for patients undergoing major surgery.

Postoperative Management During the postoperative period, steroids should be continued until the stress response diminishes.3-5,14 Typically, the supplemental steroid dose is rapidly tapered to the patient’s regular glucocorticoid replacement dose over 24 to 48 hours.3-5,14 Rapid tapering prevents adverse effects such as postoperative infection, gastrointestinal hemorrhage, and delayed wound healing that may result from receiving excessively high corticosteroid dosages.

Table 3. Guidelines for Glucocorticoid Supplementation in Patients With Adrenal Insufficiency

Table 2. Perioperative Steroid Coverage Strategies Surgical Stress

suspected AI. Etomidate, an anesthetic-sedative drug, is frequently used as an induction agent4,9,15-20 and also can be used as a sedative by continuous infusion.16 For patients who are hemodynamically unstable, etomidate is a particularly favorable option.4,15-20 However, etomidate inhibits adrenal mitochondrial hydroxylase activity16 and cortisol biosynthesis,9 decreasing steroidogenesis, which may precipitate acute AI or Addisonian crisis.4,9,15-20 Etomidate is best avoided in patients with known or suspected AI.4,9 In recent years, carboetomidate and methoxycarbonyl-etomidate,19,20 drugs that are analogues of etomidate but do not cause suppression of adrenocortical function, have been developed for possible future use. Addison’s disease also has a propensity to cause electrolyte disturbances, including hyperkalemia. This effect may be highly important in patients receiving succinylcholine, a depolarizing neuromuscular blocking agent with a side effect of inducing hyperkalemia.22

a

Surgical Stress

Glucocorticoid Dosagea

Minimal • <1 h under local anesthesia (eg, routine dental work, skin biopsy)

Usual replacement dose, 15-30 mg hydrocortisone/d.

Minor • Inguinal hernia repair • Colonoscopy • Laparoscopic appendectomy • Dental procedure requiring >1 h under local anesthesia (eg, multiple extractions, periodontal surgery)

•

Moderate • Open cholecystectomy • Segmental colon resection • Lower limb revascularization • Total joint replacement • Abdominal hysterectomy • Exploratory laparotomy

•

Severe • Cardiothoracic surgery • Whipple procedure • Esophagogastrectomy, total proctocolectomy • Liver resection • Pituitary adenomectomy, severe facial trauma • Dental procedure under general anesthesia, severe facial trauma

•

Critical illness/intensive care • Major trauma • Life-threatening complication

IV hydrocortisone, 200 mg/d maximum (eg, 50 mg every 6 h, or by continuous infusion).

Give parentally if fasting.

Modified from reference 3.

IV hydrocortisone 25 mg or equivalent at start of procedure.

Usual replacement dose after procedure.

• Double the daily dose of glucocorticoid on day of procedure (eg, 40 mg oral hydrocortisone). Usual replacement dose next day.

IV hydrocortisone 75 mg/d on day of procedure (eg, 25 mg every 8 h).

• Taper over next 1-2 d to usual replacement dose in uncomplicated cases.

IV hydrocortisone 150 mg/d (eg, 50 mg every 8 h).

Taper over next 2-3 d to usual replacement dose in uncomplicated cases.

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Continuing Medical Education Management of the Case Presented A review of the past medical history provided no additional information other than the 3-year history of Addison’s disease. Physical examination demonstrated a Mallampati 1 class airway, clear lungs to auscultation, and a regular heart rate and rhythm. Vital signs were all within normal limits, except for a low-grade fever. An IV route was secured in the emergency room. Risks and benefits were discussed with the patient, including the use of regional or general anesthesia.

The patient opted for general anesthesia. The surgeon discussed the possibility of needing to open and to not be able to perform the procedure via a laparoscopic technique. The patient stated that he had taken all of his medications before the start of his nausea and vomiting. He was administered 50 mg of hydrocortisone by IV as a stress dose. Standard monitors were placed before induction. A rapid sequence induction was facilitated with propofol, succinylcholine, lidocaine, and fentanyl. The patient was maintained under anesthesia with cis-atracurium and desflurane. The procedure was successfully completed by a laparoscopic technique. Normothermia was maintained. A total of 2,300 mL of lactated Ringer’s solution was delivered to account for prior fluid deficit and intraoperative fluid maintenance. Intraoperative blood loss was less than 50 mL. The patient was brought to the recovery room in stable condition, and additional hydrocortisone at a dose of 25 mg IV every 8 hours was administered during the next 2 days. Hydromorphone by patient-controlled analgesia was used for postoperative pain management and to minimize pain-mediated stress. The patient was discharged home without issues on postoperative day 2.

Conclusion Addison’s disease is a complex disorder with many features and various degrees of severity. Patients who are not well maintained on a hormone regimen and require surgery can be significantly dehydrated, and have electrolyte abnormalities.

For patients who are newly diagnosed or for those who are on stable regimens, surgery imposes additional stress that requires supplemental steroid dosing. The anesthesiologist must be aware of appropriate preoperative evaluation and correct dosing and administration of IV hydrocortisone perioperatively.

Whenever appropriate, consultation with an endocrinologist may be beneficial to minimize morbidity and mortality.

References 1.

Goljan EF. Rapid Review: Pathology. 3rd ed. Philadelphia, PA: Mosby Elsevier Health Sciences; 2011:498-450.

2.

Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders. Anesthesiol Clin North America. 2004;22(1):93-123.

3.

Jung C, Inder W. Management of adrenal insufficiency during the stress of medical illness and surgery. Med J Aust. 2008; 188(7):409-413.

4.

Kohl B, Schwartz S. How to manage perioperative endocrine insufficiency. Anesthesiol Clin. 2010;28(1):139-155.

5.

Draper R. Precautions for patients on steroids undergoing surgery.

Egton Medical Information Systems (EMIS). 2011;1-3.

6.

Graham GW, Unger BP, Coursin DB. Perioperative management of selected endocrine disorders. Int Anesthesiol Clin. 2000;38(4):31-67.

7.

Aono J, Mamiya K, Ueda W. Abrupt onset of adrenal crisis during routine preoperative examination in a patient with unknown Addison’s disease.

Anesthesiology. 1999;90(1):313-314.

8.

Nieman L. Treatment of adrenal insufficiency in adults. UpToDate.

2013:1-14.

9.

Nieman L. Causes of primary adrenal insufficiency (Addison’s disease).

UpToDate. 2013:1-12.

10. Frederick R, Brown C, Renusch J, et al. Addisonian crisis: Emergency presentation of primary adrenal insufficiency. Ann Emerg Med. 1991;20(7):802-806.

11.

Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA. 2002;287(2):236-240.

16. Jackson WL Jr. Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock? Chest.

2005;127(3):1031-1038.

17.

Sunshine JE, Deem S, Weiss NS, et al. Etomidate, adrenal function, and mortality in critically ill patients. Respir Care. 2013;58(4):639-646.

18. Chan CM, Mitchell A, Shorr AF. Etomidate is associated with mortality and adrenal insufficiency in sepsis: a meta-analysis.

Crit Care Med. 2012; 40(11):2945-2953.

12. Arafah BM. Hypothalamic pituitary adrenal function during critical illness: limitations of current assessment methods. J Clin Endocrinol Metab. 2006;91(10):3725-3745.

19. Cotten JF, Forman SA, Laha JK, et al. Carboetomidate: a pyrrole analogue of etomidate designed not to suppress adrenocortical function.

Anesthesiology. 2010;112(3):637-644.

13. Widmer IE, Puder JJ, König C, et al. Cortisol response in relation to the severity of stress and illness. J Clin Endocrinol Metab.

2005;90(8):4579-4586.

20. Cotten JF, Husain SS, Forman SA, et al. Methoxycarbonyl-etomidate: a novel rapidly metabolized and ultra-short-acting etomidate analogue that does not produce prolonged adrenocortical suppression. Anesthesiology. 2009;111(2):240-249.

14. Axelrod L. Perioperative management of patients treated with glucocorticoids. Endocrinol Metab Clin North Am. 2003;32(2):367-383.

15. Forman SA. Clinical and molecular pharmacology of etomidate.

Anesthesiology. 2011;114(3):695-707.

21. Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care. 2011;1(1):1-9.

22. Urman RD, Ehrenfeld JM. Pocket Anesthesia. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:2-29.

Post-Test 1. Which region of the adrenal gland produces glucocorticoids? a. Medulla b. Zona reticularis c. Zona glomerulosa d. Zona fasciculata 2. Corticotrophin-releasing hormone from the ___________ stimulates release of __________ from the ___________ pituitary gland, which in turn stimulates release of __________ from the ___________. a. hypothalamus; adrenocorticotropic hormone; posterior; cortisol; adrenal cortex b. hypothalamus; adrenocorticotropic hormone; anterior; cortisol; adrenal medulla c. hypothalamus; cortisol; posterior; cortisol; adrenal cortex d. hypothalamus; adrenocorticotropic hormone; anterior; cortisol; adrenal cortex 3. Presenting signs and symptoms of adrenal insufficiency (AI) occur when ___________. a. >80%-90% of the adrenal gland is destroyed b. ≥70% of the adrenal gland is destroyed c. between 45% and 60% of the adrenal gland is destroyed d. ≥25% of the adrenal gland is destroyed 4. What is the most common cause of primary AI today? a. Tuberculosis b. Autoimmune adrenalitis c. Histoplasmosis d. HIV e. Bilateral adrenal hemorrhage 5. Primary AI differs from secondary and tertiary AI in that ___________. a. primary AI causes only mineralocorticoid deficiency b. primary AI causes only glucocorticoid deficiency c. primary AI causes both mineralocorticoid and glucocorticoid deficiency d. primary, secondary, and tertiary AI all cause the same effects on the adrenal gland 6. A patient who has received ≥20 mg of prednisone per day for 8 days is at ___________. a. decreased risk for suppression of the hypothalamic–pituitary– adrenal (HPA) axis b. increased risk for activation of the HPA axis c. increased risk for suppression of the HPA axis d. no risk for change in suppression of the HPA axis

7. A patient who has received 3 mg of prednisone per day for the past 5 weeks and does not exhibit signs and symptoms of AI is scheduled to undergo a moderately stressful surgical procedure (ie, open cholecystectomy). Of the following options, which is the best glucocorticoid supplementation for this patient? a. Give 25 mg of hydrocortisone IV on day of procedure only. b. Give the patient’s usual daily dosage of 3 mg of prednisone only. c. Give 50 to 75 mg of hydrocortisone IV on day of procedure or intraoperatively, and taper rapidly over next 1 to 2 days to the patient’s usual dose. d. Give 100 to 150 mg of hydrocortisone IV on day of procedure or intraoperatively, and taper rapidly over next 1 to 2 days to patient’s usual dose.

8. A patient who has a history of persistent asthma and uses high-dose corticosteroids regularly is scheduled for a Whipple procedure. Of the following options, which is the best glucocorticoid supplementation for this patient? a. Give 25 mg of hydrocortisone IV on day of procedure only. b. Give the patient’s usual daily dosage of 3 mg of prednisone only. c. Give 50 to 75 mg of hydrocortisone IV on day of procedure or intraoperatively, and taper rapidly over next 1 to 2 days to the patient’s usual dose. d. Give 100 to 150 mg of hydrocortisone IV on day of procedure or intraoperatively, and taper rapidly over next 1 to 2 days to patient’s usual dose.

9. A patient with a history of moderate to severe rheumatoid arthritis is scheduled for a total knee arthroplasty. Which glucocorticoid supplementation therapy should be considered for this patient? a. Give 25 mg of hydrocortisone IV on day of procedure only. b. Give the patient’s usual daily dosage of 3 mg of prednisone only. c. Give 50 to 75 mg of hydrocortisone IV on day of procedure or intraoperatively and taper rapidly over next 1 to 2 days to the patient’s usual dose. d. Give 100 to 150 mg of hydrocortisone IV on day of procedure or intraoperatively, and taper rapidly over next 1 to 2 days to the patient’s usual dose.

10. Which of the following drugs should be avoided perioperatively to prevent triggering acute AI in a surgical patient with known primary AI or at risk for adrenal suppression? a. Thiopental b. Propofol c. Etomidate d. Ketamine

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CLINICAL ANESTHESIOLOGY CRITICAL

CONTINUED FROM PAGE 1

of stay and there is no survival benefit, again, with the exceptions of neuro ICUs and cardiothoracic ICUs,” Dr. Patterson said.

All speakers stressed that it is difficult to compare subspecialty and general ICUs because of disparities between patient populations, hospital sizes and referral patterns. Moreover, a clear definition of a subspecialty ICU does not exist, making fair comparisons challenging.

As a result, there is a lack of high-qualityy data examining this issue, said Kenneth Krell, MD, a critical care and internal medicine physician at Eastern Idaho Regional Medical Center, in Idaho Falls.

But the available evidence does not show any significant differences in riskk adjustedd mortality between general and subspecialty ICUs for all conditions other than cardiac surgery and intracranial hemorrhage, he said.

“What we’re seeing is that it’s not the specialized unit that’s going to be the most equipped to take care of those patients who have a multitude of comorbidities and who are simply sicker than having one organ failing,” Dr. Krell said.

The Evidence The most notable study to address this question was published five years ago, and it relied on data collected before 2006 ((Am J Respir Crit Care Med 2009;179:676-683). Physicians from the University of Pennsylvania conducted a retrospective review of more than 84,000 patients admitted to 124 ICUs between January 2002 and December 2005. The patients were classified by admission into a general ICU, a diagnosis-appropriate or “ideal” specialty ICU, or a diagnosis-inappropriate or “non-ideal” specialty ICU. (Patients in the latter group reflect what is known as “boarding,” the practice of admitting patients to a non-ideal specialty ICU because the right ICU is not available or is full.)

The study was limited to patients admitted with one of six specific diagnoses or procedures: abdominal surgery, acute myocardial infarction, cardiac surgery, intracranial hemorrhage, ischemic stroke or pneumonia.

After adjusting for potential confounders, the investigators could not detect any consistent survival advantage for patients admitted to an ideal specialty ICU. Mortality rates in the ideal specialty ICU hovered at a nearly identical rate to those in the general ICU. However, patients admitted to a non-ideal specialty ICU had a significantly greater risk for dying.

There was one exception: cardiothoracic surgery patients. When specialization was examined as a continuous variable, each 10% increase in specialization was associated with an 18% reduction in the odds of death among cardiothoracic surgery patients (odds ratio, 0.82; 95% confidence interval, 0.76-0.88).

The study had several important limitations beyond the narrow patient population. The investigators could not adjust for key organizational factors, such as intensivist staffing. They used in-hospital mortality as the outcome rather than 28-dayy mortality, which is a measure less sensitive to variation in discharge practices between hospitals. The investigators advised that their results should be viewed with caution for patients with intracranial hemorrhage,

as other studies showed improved outcomes with specialty ICU care in this group. Finally, the investigators did not evaluate other patient-centered outcomes, such as functional status and quality of life.

Even so, they concluded: “Our study suggests that investments (such as dividing a general ICU into specialty ICUs or building a hospital with several specialty ICUs) should not take place with the expectation of improved patient outcomes.”

Dr. Krell said it was unclear why specialized ICUs do not translate into significantly improved survival.

One possibility, he suggested, may be that critical illness syndromes are common among all ICU patients.

“Perhaps ICU patients, regardless of the organ that’s failing, are more alike than different.”

the NSICU also had shorter hospital stays and lower total costs of care than national benchmarks. This initial study was confirmed by later studies.

Importantly, both the trauma study and the neurocritical care studies stress that the presence of a fulltime intensivist on the unit is as important as ICU subspecialization.

“It may not be the presence of that particular subspecialty unit and that particular subspecialty intensivist that improves outcomes as much as it is the presence of an intensivist in an organized ICU,” Dr. Krell said.

(One well-known study involving more than 100,000 critically ill adults and 123 ICUs showed higher mortality rates among patients managed by

‘It may not be the presence of that particular subspecialty unit and that particular subspecialty intensivist that improves outcomes as much as it is the presence of an intensivist in an organized ICU.’ —Kenneth Krell, MD

Other studies have shown that some patients treated in subspecialized ICUs do benefit. In a retrospective review of more than 2,600 trauma patients at a level I trauma center in Virginia, patients admitted to the surgical trauma ICU were sicker yet had similar outcomes to patients treated in non-traumaa ICUs ((J Emerg Trauma Shock 2008;1:74-77).

“Our study supports the concept of specialized ICU care, appropriately triaged between trauma and non-trauma ICUs,” concluded authors Therese M. Duane, MD, and her colleagues from Virginia Commonwealth University Health System, in Richmond.

The researchers argued that the most severely injured patients should be preferentially placed in specialized trauma ICUs, where the staff possesses years of experience in the “complex trauma care that only a surgery/trauma ICU can provide.”

ICU specialization may not be as important for less severely injured patients as long as the management of these patients is guided by an ICU team with a surgical intensivist and dedicated, experienced nursing personnel, they noted.

Similar findings were reported in patients with intracerebral hemorrhage treated in specialized neurocritical care units ((J Neurosurg Anesthesiol 2001;13:83-92). Patients cared for in a new neuroscience ICU (NSICU) had higher rates of survival and improved disposition at discharge than those treated two years earlier in a general ICU. Patients treated in

critical care physicians than those who were not [[Ann Intern Med 2008;148:801-809]. The authors cautioned that, despite efforts to adjust for illness severity, some markers may have been unaccounted for and confounded the results.)

Other organizational factors, too, have been shown to significantly affect patient outcomes, said Dennis A. Taylor, DNP, chair of the research and evidence-based practice council at Carolinas Medical Center, in Charlotte, N.C. Things like coordination of care, protocols and specialty trained nurses lower the odds of mortality and failure to rescue, he said.

The debate over specialty and general ICU care is becoming more important against the backdrop of the enormous cost of health care in the United States, Dr. Patterson said. Today, critical care accounts for more than $180 billion each year. It is impossible to tease out what percentage of that figure is attributable to subspecialty critical care.

What is clear, however, is that the up-front expenses associated with a specialty ICU are higher but without a proven financial benefit in the long term, Dr. Patterson said.

He noted that some data support financial benefit of neurocritical care units and cardiac surgery or cardiovascular specialty units. “But otherwise, what we know is that there is some reason to believe that see critical page 22

The McMahon Group Celebrates the Best of Its Outstanding Employees

2013

Once a year the McMahon Group takes time to look back at the previous year and acknowledge the exxtraordinary talents and persistence of its employees. The 43--year-old company publishes best-read medical newsspapers and websites, creates custom media for medical industry firms and hospital systems and produces certified medical education platforms for clinicians.

Here is a review of the winners of the 2013 employee awards: MANAGEMENT/SUPPORT/IT/FINANCE/PRODUCTION

MANAGEMENT/SUPPORT/IT/FINANCE/PRODUCTION

Employees are asked to select two outstandding members from these diverse departments. The first winner was ROSA DIMICCO, whose challenging work in Finance includes overseeing accounts payyable.

The seconnd winner was YUMI VELIZ, who as part of the IT Department manages requests for IT assistance and maintains all servers and the infrastructture of the McMahon network.

MOST IMPROVED SALESPERSON OF THE YEAR

SALES ACHIEVEMENT AWARD OF THE YEAR

MATTHEW SPOTO,, whose work on Gastroenterology & Endoscopy News has brrought in new clients and maintained steady relationships with existinng clients, clients resulting in a record year.

DAVID KA APLAN, publication director of Pharmacy Practice Newss as well as Speciallty Pharmacy Continuum, received this award for, among other accomplisshments, hments spearheading new pharmacy publications. publications

ASSOCIATE/SENIOR/PROJECTS EDITOR OF THE YEAR

MANAGING EDITOR/COPYEDITOR OF THE YEAR

This award was given to Associate Projects Editor CARLOS PERKINS JR., whose job includes working closely with sponsoring companies to create great medical education programs that are delivered on time.

This year, Copy Editor ELIZABETH ZHONG won the award for her efforts in fine-tuning all the editorial material that is assigned to her. Her work helps ensure acccuracy in all of our publications, medical education programs and sponsoredd custom media.

MAX GRAPHICS PERSON OF THE YEAR

SALESPERSON OF THE YEAR

Longtime staffer FRANK TAGARELLO, who manages the Graphics Department, received the award for his inveentive design work on such publications as Clinical Oncology News and Pharmacy Practice News and a variety of medical education projects.

For the eigghth year in a row, RICHARD TUORTO, the senior group publicatioon director of both Anesthesiology News and Pain Medicine News, won the award for bringing in the most revenue in the calendar year.

MCMAHON GROUP PERSON OF THE YEAR

PARTNERS’ AWARD

The winner of this year’s award was HYONG KWON, manager of the company’s IT development team, who oversaw innumerable projects, including updating our websites, creating tablet and digital versions of our publications, and managing the IT staff, to name just a few. There is a constant stream of IT requests that land on his desk and, somehow, Hyongg is able to continually perfect our digital presence.

From time to time, CEO and Managing Partner Ray McMahon extends a special award to an individual whose efforts over many years have madee a fundamental difference in the well-being of the company. This year that award went to his son, MATTHEW MCMAHON, whose position as thhe company’s general manager puts him front and center for major decisioons involving policy, finance and overall governance.

22 I AnesthesiologyNews.com

JUNE 2014

CLINICAL ANESTHESIOLOGY CRITICAL

that physician with or without consultation from an intensivist. In a closed ICU, the patient’s care is transsome ICUs that are specialized may be financially ferred to an intensive care physician who is trained in critical care medicine and who has no clinical respondisadvantaged.”

Financial models suggest that a cost-effective sibilities outside the ICU. In one study of high-risk option for critical care may be intensivist staffing surgical patients, mortality among ICU patients in the ICU. A 2006 analysis of the Leapfrog Group was 25.7% in the open-format group and 15.8% looked at the costs associated with having a ded- in the closed-format group (P=0.01) (BMC Surg icated intensivist present during daytime hours 2011;11:18). and available by pager at night (Crit Care Med “Closing an ICU to a particular patient cohort 2006;34:S18-S24). Cost savings ranged from based on diagnosis or admitting service does not $510,000 to $3.3 million for six- to 18-bed ICUs. affect outcome, and may actually increase cost by The best-case scenario demonstrated savings of $4.2 creating redundancy and decreasing the overall ICU million to $13 million. The worst-case scenario was a bed availability,” she said. net cost of $890,000 to $1.3 million.

Current Trends in ICU Care A detailed report on the economics of ICU orgaToday, approximately one-third of the 6,000-plus nization, published in 2012, showed that certain aspects of ICU organization, such as the inclusion of ICUs in the United States are subspecialty units, a staff pharmacist on a multidisciplinary ICU team, most often catering to patients with neurologic, can be financially and clinically beneficial (Crit Care respiratory, cardiac, surgical and trauma diagnoses.

Clin; 28:25-37). The authors noted that few studies That’s an increase from 2006, when 25% of ICUs have examined the economics of the ICU, and even were classified as subspecialty ICUs. fewer acknowledge the competing economic interests Critical care training, too, has become increasof patient, hospital, payor and society. ingly specialized, Dr. Krell said. In 2010, the majority In an interview, Wendy Greene, MD, associate of diplomates in critical care represented specialties professor of surgery and associate director of trauma such as cardiac, surgical or neurocritical care. and critical care at Howard University College of This shift occurred as a response to the growing Medicine, in Washington, D.C., said that the clini- burden of critically ill patients in the United States. cal and financial implications of various ICU struc- Since 1991, patients with many serious conditions tures are still being debated. At present, she said, data present more frequently in hospitals, a trend attribsuggest that intensivist-directed high-intensityy staff- uted in part to the aging patient population. Between ing and a closed ICU improve outcomes and shorten 2000 and 2005, the number of ICU beds in the stays. country increased by 7% while total hospital beds High-intensityy staffing was shown to reduce the decreased 4% (Crit Care Medd 2010,38:65-71). As length of stay in 10 of 13 studies examining hos- ICUs expanded and technologies improved, so did pitalization and in 14 of 18 studies addressing the demand for highly trained specialists and staff to ICU length of stay, she said. “No study found look after severely ill patients. increased length of stay with high-intensityy staffing Proponents of specialty ICUs point to multiple after case mix adjustment.” benefits of these units. They are managed by staff Dr. Greene pointed to a growing body of evi- with expertise in caring for very sick patients. Subdence suggesting that a closed ICU format is a more specialty units are more likely to use set protocols favorable setting to minimize the effects of high- and possess specialized technology befitting their riskk surgery. In an open ICU, patients can be admit- patient population. Other benefits include phyted by their physician and receive care directed by sician convenience, reduction of diagnoses and CONTINUED FROM PAGE 20

By the Numbers

Pathology Ophthalmology Emergency medicine Anesthesiology Gastroenterology

58%

of physicians believe the greatest challenge to the Health 2.0 movement is that patients often misinterpret what they read online, causing tension in the patient–doctor relationship.

Source: MetaData Group

treatment variability, increased nurse expertise and education and focused training for fellows (Crit Care 2009;13:314).

Today, the majority of ICU patients in the United States are treated in smaller hospitals that lack the number of beds that would justify fragmented ICUs, Terence O’Keeffe, MD, associate professor of surgery and medical director of the surgical ICU at the University of Arizona, in Tucson, said.

“The size of the hospital is key. Once you’re in a larger hospital, subspecialty care makes more sense. If you’re in a small hospital, you’re much better off having a multidisciplinary ICU with a specialized intensivist available in-house during the day and then 24/7 from home,” Dr. O’Keeffe said.

Finding intensivists to provide coverage is one of the biggest issues in critical care today. The United States is experiencing a well-documented shortage of intensivists, a shortfall driven by numerous factors, including low compensation rates and poor work–life balance for intensivists (Crit Care Med 2013;41:2754-2761).

Dr. O’Keeffe suggested that an option for critical care in the United States is to follow a more European-style model, which is heavily dependent on multidisciplinary care. The European Society of Intensive Care Medicine has emphasized multidisciplinary training in critical care so intensivists across Europe could move from one country to another.

This model has been picked up by countries such as Argentina, Australia, New Zealand and Uruguay, and in the United States, at the University of Pittsburgh.

Dr. Krell said the multidisciplinary model may help draw more specialists to the field and improve overall quality of care in ICUs. “I would suggest we need to look beyond our individual fiefdoms and our silos in academic ICUs and academic training to what the needs are out there in the community,” he said. “I would suggest they are much more in the areas of multidisciplinary ICUs with well-trained general multidisciplinary intensivists who can take care of this load of critically ill patients.”

—Christina Frangou

#4

Physical medicine & rehabilitation Family practice Pediatrics Internal medicine Orthopedic surgery 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Top 10 specialties that identified tension in the patient–doctor relationship due to patients misinterpreting medical information on the Web.

JUNE 2014

AnesthesiologyNews.com I 23

TECHNOLOGY

Seeking Satisfaction With EHRs

W

ith increasing frequency, doctors and patients are finding a third party crowding the examination room: the electronic health record (EHR). To some practitioners, EHRs are a boon, offering electronic prescribing, notes that are more legible and remote access to patient files. But to others, the systems are barriers to effective communication, demanding that attention be split between patients and computers.

A spate of recent studies reflects just how varied physician responses have been to EHRs. Last November, IDC Health Insights surveyed 212 clinicians and found that 58% felt neutral, dissatisfied or very dissatisfied with EHRs. RAND Corporation reported in October on several factors contributing to physician dissatisfaction with EHRs, such as interference with patient care, poor usability and the large amount of time consumed by data entry.

“An EHR is a source of both promise and frustration, which stems from a mismatch of expectation and reality,” said Anil Makam, MD, assistant professor of internal medicine at the University of Texas Southwestern Medical Center, in Dallas, who specializes in health care information technology.

“It’s not like installing Microsoft Windows. These things are not ready out of the box.”

For users who are learning how to implement EHRs in practice, the adoption process can be costly and disruptive.

Of more than half of the health care providers who reported being neutral or dissatisfied in the IDC Health Insights survey, 85% reported that EHRs result in a loss of productivity and 66% said the diminished time cut into patient visits.

In some cases, physicians may overlook features that can optimize EHR use. With systems such as Epic, clinicians can optimize the EHR system by customizing their own note templates and order sets. “This reduces the number of clicks or words you have to type,” Dr. Makam noted.

“Instead of reinventing the wheel,” he said, a gastroenterologist who frequently sees patients with peptic ulcer disease, gastrointestinal bleeding or inflammatory bowel disease, for example, could create templates that automatically populate with the necessary information.

The 10th revision of the International Statistical Classification of Diseases

and Related Health Problemss (ICD-10) may pose problems for EHR developers.

By Oct. 1, 2014, all EHR systems must support ICD-10 codes to remain compliant with meaningful use.

Beyond 2014, however, the outlook for EHRs trends toward the positive.

“The potential for EHR technology to enhance communication between physicians, patients and health care

teams is unparalleled,” said Ellen J. Scherl, MD, associate professor in the Division of Gastroenterology and Hepatology at Weill Cornell Medical College, in New York City.

And if clinicians can turn data in EHRs into actionable information through decision-support systems and predictive analytics, Dr. Makam said, the functionality of these systems

could greatly improve. This is “a huge advantage we’re just beginning to tap into,” he said.

But without increased interaction between clinicians and vendors, the promising future of EHRs may never come to fruition. “The successful evolution of the EHR is dependent on physicians’ input,” Dr. Scherl said.

—Ben Guarino

EXP-AP-0020-201301

For the Management of Postsurgical Pain

EXPAREL® (bupivacaine liposome injectable suspension)

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Pivotal studies have demonstrated the safety and efficacy of EXPAREL in patients undergoing bunionectomy and hemorrhoidectomy procedures.

The clinical benefit of the attendant decrease in opioid consumption was not demonstrated.

EXPAREL is a liposome formulation of bupivacaine indicated for administration into the surgical site to produce postsurgical analgesia.

Important Safety Information: EXPAREL is contraindicated in obstetrical paracervical block anesthesia. EXPAREL has not been studied for use in patients younger than 18 years of age. Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. Other formulations of bupivacaine should not be administered within 96 hours following administration of EXPAREL. Monitoring of cardiovascular and neurological status, as well as vital signs should be performed during and after injection of EXPAREL as with other local anesthetic products. Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations. In clinical trials, the most common adverse reactions (incidence ≥10%) following EXPAREL administration were nausea, constipation, and vomiting.

Reference: Gorfine SR, et al. Dis Colon Rectum. Dec 2011;54(12):1552-1559.

Please see brief summary of Prescribing Information on reverse side.

For more information, visit www.EXPAREL.com ©2013 Pacira Pharmaceuticals, Inc., Parsippany, NJ 07054

EXP-AP-0039-201302