July 2015

The best-read anesthesiology publication in the United States

THE INDEPENDENT MONTHLY NEWSPAPER FOR ANESTHESIOLOGISTS AnesthesiologyNews.com • J u l y 2 0 1 5 • Volume 41 Number 7

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Higher Sniffing Position Best for View

H

ead elevation before direct laryngoscopy may substantially increase the likelihood of obtaining a better laryngeal view, making it the ideal starting point when difficult visualization is expected, research has shown.

A research team led by Mohammad El-Orbany, MD, professor of anesthesiology at the Medical College of Wisconsin, in Milwaukee, studied the effects of head elevation on

High Ped M&M Rates With Multiple Intubation Attempts Phoenix—There is a disturbingly high rate of morbidity and mortality in children with difficult airways who have undergone multiple intubation attempts, according to a database analysis by a multicenter research team.

Severe complications in the cohort were also associated with body weight less than 10 kg and difficult airways that were unanticipated.

At the heart of the analysis is the PeDI (Pediatric Difficult Intubation) registry, a multicenter database of 14 tertiary care pediatric institutions with practice data relating to difficult direct laryngoscopy events in children aged g less than 18 years. “We formed the registry to collect outcome data in these patients because there aren’t very good data in airway management in children,

see sniffing page 6

see ped M&M page 11

Anesthesiology Acquisition Rate Still at Fevered Pace

F

or W. Scott Brosche, MD, a senior uncerrtainty, “another hospital was moving partner at Fredericksburg Aneesintto our area with a competing anesthesia group owned by a national corpothesia Associates Inc., in Virginia, passage of the Affordable ration,” Dr. Brosche said. “So we Care Act in 2010 was a cause for began to think about our options.” concern. How would the small, After considerable research and 16-physician practice, holding contracts acts with no small amount am of soul searching, Dr. Brosche just two hospitals and one ambulatory surand his partners sold their practice last year to the gery center, deal with the oncoming raft of legis- national medical group MEDNAX Services Inc., and lated health care reforms, such as bundled payments, became part of the company’s American Anesthesiolpay-for-performance, value-based purchasing and ogy division. “We had seen that small practices such accountable care organizations? In addition to this see fever page 19

7

CLINICAL ANESTHESIOLOGY

Communication distractions problematic during handoffs at ambulatory surgery centers.

8

CLINICAL ANESTHESIOLOGY

ERAS pathway with PSH framework works best for colorectal surgery patients.

12

COMMENTARY

Steven Kron, MD, discusses the image of the anesthesiologist in popular culture.

14

PAIN MEDICINE

Does regional anesthesia have higher complications than general in hip Fx surgery?

EDUCATIONAL REVIEW

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Current Concepts in the Management of the Difficult Airway

‘Put the Phone Away, You Are Having an Operation’

Respiratory Depression Injuries Overwhelmingly Preventable: Closed Claims Study

Anesthesia Management System: Smart and Saves Money

Failure To Use Reversal Agent Ups Reintubation Risk Sixfold

(Educational Review)

Tweets of Interest #anesthesianews Anesthesia Camp @anesthesiacamp Maternal mortality INCREASING. http://dcme.co/1GnMloZ Anesthesia Camp Rancho Mirage 2016 http://dcme.co/1GnMnxa

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Matt @themattmak The USA is just over 5% of the world’s population but uses over half of the world’s morphine #smaccUS

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6 I AnesthesiologyNews.com

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CLINICAL ANESTHESIOLOGY

SNIFFING

CONTINUED FROM PAGE 1

167 patients scheduled to undergo elective surgery with endotracheal intubation.

Patients who had their heads raised 6 cm by the pillow—the so-called sniffing position—showed better glottic exposure before direct laryngoscopy than simply positioning the patient’s head flat on the operating table. The study also found that in most cases, an “elevated sniffing position” (in which the back of the head is raised 10 cm by an inflatable pillow) proved to be superior for visualization in most cases.

The authors also found that in no case did head elevation actually worsen the laryngeal view.

“We should revisit the traditional head position,” Dr. El-Orbanyy said. “This study proved that even more elevation [than the traditional sniffing position] improves the view and that maybe this is a better starting position before direct laryngoscopy.”

Doctors at Illinois Masonic Medical Center, in Chicago, performed direct laryngoscopy on each of the patients, alternating through the three different head positions—flat, sniffing and elevated sniffing—to assess the views that best exposed the glottis.

An inflatable pillow, designed by Dr. El-Orbanyy and his team to provide various degrees of head elevation, was used during the study. A Macintosh blade, size 3 or 4, was used during the procedures, the researchers explained.

The order in which each patient was put through the three different head positions was selected at random, with “computer-generated, sealed envelopes containing one of six possible sequences,” Dr. El-Orbanyy noted.

Other safeguards were also taken. The three laryngoscopists who performed the procedures at Illinois Masonic Medical Center went through special training to minimize a factor that could have skewed the results—given that greater exertion might improve

Clockwise, from left: Head flat; the ‘sniffing position,’ at 6 cm; and the ‘elevated sniffing position,’ at 10 cm.

the view of the glottis on its own, the doctors practiced using the same exact lifting force with the laryngoscope blade in each head position.

In the majority of the cases studied, the best laryngeal views were obtained in patients whose heads were elevated either 6 or 10 cm.

More than 46% of patients whose heads were elevated by 10 cm offered the best view possible of their glottises; specifically, a 1a on the Cormackk Lehane classification system, as modified by Benumof. All of the patient’s vocal cords, including the anterior commissure, could be visualized, Dr. El-Orbanyy noted.

Of the patients whose heads were elevated by 6 cm, 34% scored in this top category compared with 24% of patients whose heads were not elevated. In fact, nearly all the patients whose heads were elevated earned either the top or next best viewing grade on the scale.

Of patients with no head elevation, 33% were grade 2 and only the arytenoids could be seen, with the vocal cords hidden from view. By comparison, only 15.6% of patients in the sniffing position and 6% of those in the elevated sniffing position were judged to be in this obstructed-view w category.

The most significant group is the difficult laryngoscopy group in whom only the epiglottis could be visualized (grade 3); 8.4% of patients in the headflat position fell into this category. This incidence decreased to 2.4% for patients in the sniffing position and 1.2% for those in the elevated sniffing position.

meaningful conclusions. It was not [just] seven or 10 patients.”

Previous studies have been clouded by a number of limitations and errors, he explained. A study

by Hubert J. Schmitt, MD, and Harald Mang, MD, reported that relatively poor laryngeal views improved in 19 of 21 patients when their heads were elevated beyond the sniffing position (J ( Clin Anesth 2002;14[5]:335-338). But the researchers also used external laryngeal manipulation and increased lifting force, making it difficult to isolate the role played solely by elevating the patients’ heads.

A 1999 study found better laryngeal views with head elevation ((Ann Otol Rhinol Laryngol 1999;108[8]:715-724). But the researchers used an uncommon laryngoscope blade, and the nomenclature they used for each head position was confusing when applied to the accompanying illustrations, Dr. El-Orbanyy wrote.

A 2003 study analyzed the effects of head elevation on laryngeal view using seven fresh human cadavers, the results of which were videotaped (Ann ( Emerg Medd 2003;41[3]:322-330). Richard M. Levitan, MD, and his team found that head elevation improved the view in all seven cadavers. But the head positions were not chosen at random and the head-flat position revealed 30% of the vocal cords, casting into doubt the value of this maneuver for a true difficult laryngoscopy situation, in which no vocal cords can be seen, according to Dr. El-Orbany. y Other Studies Flawed More recently, a South Korean team compared This study is the most comprehensive to date and laryngoscopic views on patients in the head-flat posiprovides strong support for head elevation after years tion with those propped up with 3-, 6- and 9-cm pilof contradictory reports on the issue, Dr. El-Orbany lows ((J Anesth 2010;24[4]:526-530). said. “One of the strengths of our study was the The study reported that the highest head elevation sample size,” he said. “It was large enough to draw yielded the most favorable results. But the researchers

JULY 2015

AnesthesiologyNews.com I 7

CLINICAL ANESTHESIOLOGY

Communication Distractions Lower Quality of Patient Handoffs in Ambulatory Surgery Center: Safety an Issue

J

ust like in the operating room (OR), patient handoffs in an ambulatory surgery center (ASC) are commonly derailed by communication distractions, which put patients’ safety at risk, according to investigators at the Cooper Medical School of Rowan University (CMSRU) in Camden, N.J. “We had previously looked into barriers to handoff communication in our hospital’s operating room,” said Erin W. Pukenas, MD, study author and assistant professor of anesthesiology at CMSRU. “The natural progression was to look at handoff patterns in other settings, too. And in our institution—as in others—there’s a real focus on efficiency in the ambulatory surgery center. So we thought it important to characterize the quality of handoffs in that setting, too.”

With that in mind, the researchers collected audio recordings of 80 ASC handoffs over a six-week period.

Trained observers rated the quality of each handoff, documented distractions and noted secondary task activity during the handoff. The handoffs were timed for completion of patient care and information exchange. Satisfaction surveys were also completed

had to remove and insert various pillows before examining each view, which could have “altered the final blade’s position during each attempt,” Dr. El-Orbanyy said.

An earlier study found no advantage to elevating patients’ heads after working with eight fully conscious volunteers (Anesthesiology ( 2001;94[1]:83-86).

Their heads, however, were not placed in a proper sniffing position, nor was laryngoscopy performed on any of the volunteers, Dr. El-Orbanyy noted.

“All those studies had some flaws in the methodology, or the sample size, or the conclusions,” he said. “The strength of our study is that it isolated the effect of head elevation on laryngeal exposure in a large number of subjects.”

the presence of distractions: 2.3 versus 1.5 minutes (P<0.001). Handoffs with communication distractors were rated lower in overall quality (P<0.05) by trained observers and associated with a greater number of errors, which were defined as a transfer of incorrect

and sent to the information senders and receivers in every handoff.

The researchers found that 40% (28) of handoffs were associated with communication distractions. Perhaps not surprisingly, information exchange times were significantly longer in

information. Handoff satisfaction scores rated by the sender were significantly lower in handoffs with distractions (P<0.05).

Monitors and equipment were the most common distractors, comprising see handoffs page 9

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CLINICAL ANESTHESIOLOGY

ERAS Pathways Within PSH Framework Ideal For Improving Colorectal Surgery Patient Outcomes Honolulu, Hawaii—Previous research has demonstrated that both the perioperative surgical home (PSH) and enhanced recovery after surgery (ERAS) pathways are effective at improving patient outcomes, while reducing costs and use of health care resources.

In a best-off both-worlds study, researchers have concluded that the implementation of a PSH combined with an ERAS program yields very promising results in colorectal surgery patients.

“ERAS care pathways have been shown to be of real benefit, but the question of how to best implement them can remain elusive,” said Matthew D. McEvoy, MD, vice-chair for educational affairs, residency program director and associate professor of anesthesiology at Vanderbilt University, in Nashville, Tenn. “So we wanted to look at continuing to improve the care we deliver to patients at our institution while maintaining—or reducing—costs.” The PSH approach improves on the ERAS model by placing multicomponent care pathways into a system of care that spans the period from operative decision to discharge and beyond.

Two Conceptual Models Combined To better describe the effects of combining these two conceptual models, anesthesiologists and colorectal surgeons at Vanderbilt teamed up to launch a perioperative consult service that coordinated surgical and anesthesia care along with an ERAS pathway that included daily rounding. “We started talking with our surgeons, in early 2014, about standardizing components of anesthesia throughout the perioperative period,” he said. “It took about three months to come up with an agreedupon ERAS pathway and another month or so where we met with key stakeholders from nursing, pharmacy and informatics to make sure we got everyone

on board with what the new changes might look like.”

To determine the effectiveness of the program, the researchers obtained perioperative records for all elective colorectal procedures performed for six months before the implementation of the program and 4.5 months after. Data analyzed included patient age and gender, intraoperative fluids given, estimated blood loss, number of antiemetics given by class, total opioids administered (morphine equivalents) and use of gabapentin, acetaminophen, ketorolac and ketamine (Figure).

As Dr. McEvoyy reported at the 2015 annual meeting of the International Anesthesia Research Society (abstract A-310), 285 charts were reviewed (171 preintervention, 114 post-intervention). There were no differences between groups with respect to age, gender, operative time and anesthesia time. Interestingly, post-intervention patients had greater estimated blood loss, but only by 30 mL (P=0.041).

Patients undergoing surgery after implementation of the PSH with ERAS had a significantly shorter median hospital length of stay (3.34 vs. 4.4 days; P<0.008), received less intraoperative fluids (1,580 vs. 1,948 mL), were more likely to receive all the designated components of multimodal analgesia, and received significantly lower morphine equivalents than controls in the pre-intervention group (5.3 vs. 33.8 mg; P<0.001). In addition, post-intervention patients were more likely to receive all components of multimodal analgesia than their counterparts (P<0.001).

“These results,” Dr. McEvoyy said, “were not only statistically significant, but clinically meaningful as well. We saw a 24% reduction in length of stay, accompanied with a 90% reduction in opioid use, along with static or improved pain control. We also had earlier return of bowel function and earlier return of the ability to eat.” b

100

a

Pre Post

a

a

Patients, %

80 a 60 40 20 0

Ketamine

Ketorolac

Gabapentin

Acetaminophen

PONV prophylaxis

Figure. Percentage of patients receiving each component before and after implementation of the Enhanced Recovery After Surgery protocol and Perioperative Surgical Home. a

P P<0.0001

b

PP=0.002 (Fischer exact test)

Teamwork Yet despite such promising results, Dr. McEvoyy recognized that long-term compliance with these types of program initiatives presents its own set of challenges. “[It has] often been described that although there’s an initial interest in these programs, that often wanes with time. It certainly takes more effort to deliver higher quality of care, and sustaining those gains is difficult. So you really have to find a way for the right team to lock in the improvements you’ve made.”

Teamwork, he added, is one of the key components of successful program implementation, especially between surgeons and anesthesiologists.

“We’re happy with the way that we now partner with our surgeons, from decision to discharge, and really have expanded the role of anesthesiologists throughout the perioperative period,” he said.

“Dr. Adam King has been a significant leader in this effort,” Dr. McEvoy added. “Dr. Warren Sandberg—the chair of our department—has fully supported our efforts. Colorectal surgeon Tim Geiger has been a key partner in this as well, as has the whole colorectal surgery group. Finally, the gains that we have made would not be possible without involvement from nursing and pharmacy. In short, I have been one of a group of leaders in this, and our program continues to be successful because of a partnership in which multiple people are invested.”

Adam King, MD, assistant professor of anesthesiology, agreed: “[It has] been an exciting opportunity to partner with the Department of Surgery to rethink surgical care from the patient’s perspective.

Each day has been a new chance to improve how we take care of patients. [It has] changed the way anesthesiologists, surgeons and patients think about the perioperative experience.”

Tim Geiger, MD, assistant professor of surgery, was the colorectal surgical lead on the project. “By breaking the traditional silos of medicine and truly working as a multispecialty team,” he told Anesthesiology News, “we have significantly increased the quality of care our patients receive.”

Such collaborations may help usher health care into a new era of effectiveness and efficiency.

“Everyone is saying there needs to be a fundamental re-understandingg of medicine,” Dr. McEvoy said. “Well, this is really an example of health care redesign.”

Is it worth the effort? For Dr. McEvoy, y the answer is as close as an 83-year-old patient who recently underwent an abdominoperineal resection under the PSH with ERAS program. “On postoperative day 3, the only reason she was still in the hospital was that she was waiting for the Foley catheter to be removed. Otherwise, she didn’t have any pain and wanted to go home. So it’s absolutely worth it.”

—Michael Vlessides The researchers reported no relevant financial conflicts of interest.

JULY 2015

AnesthesiologyNews.com I 9

CLINICAL ANESTHESIOLOGY HANDOFFS

CONTINUED FROM PAGE 7

19% of instances. Direct patient care, transient staff and patient communication were the next most common distractors, at 16% each. Other barriers to handoff communication included staff conversation (12%), auditory distraction (9%), role clarity (6%), charting (3%) and family communication (3%).

‘Even in some of our audio recordings there was so much alarm noise that we had to throw a few out of the study because we couldn’t hear the handoff.’

—Erin W. Pukenas, MD

“We took a close look at the auditory ddistractions andd found that alarms played a huge role,” Dr. Pukenas said in an interview with Anesthesiology News.

“Even in some of our audio recordings there was so much alarm noise that we had to throw a few out of the study because we couldn’t hear the handoff.”

The study also revealed that human behavior played a part in impeding handoffs, too.

“Sometimes the anesthesia staff would arrive in the PACU [postanesthesia care unit] and would have to wait several minutes for a nurse to be freed up, or it would be lunch time and nobody was sure who was covering the patient,” she said. “In essence, if someone’s standing there waiting for even just a few minutes, it’s an opportunity to improve efficiency, especially in the context of a surgery center where the goal for turnover is seven to 10 minutes. Two minutes can make a big difference.”

The researchers concluded that nearly 50% of the distractions recorded in this study might have been preventable.

“I would like people to know that distracted communication is not only a predictor for poor handoffs, but also has a significant impact on getting your patients back in the OR for the next case,” Dr. Pukenas said.

Dr. Pukenas said improving handoff quality begins with identifying and minimizing distractions within postoperative care environments. So the researchers took the study’s results to the hospital administration at Dr. Pukenas’ institution “to put processes in place so we could prevent these distractions from happening.”

“The benefit for the hospital is that we can get the anesthesia provider back to the OR more quickly, so the next case can get started,” she said. “So

now we have structure. We have someone assigned to each bed in the PACU, despite fluctuating levels of staff and acuity, and they have a process of handing off to each other during break time. We’re trying to minimize noise, too.”

Taral Patel, MD, study coinvestigator, said handoff problems exist in institutions of all types.

“I think this has been an issue with a lot of hospitals,” Dr. Patel said. “And it’s especially acute for residents,

because we’re the ones doing most of the handoffs.”

The researchers said more research on handoff communication in all settings is needed to ultimately improve safety and efficiency for patients.

The findings were originally presented at the American Society of Anesthesiologists’ annual meeting (abstract A3165) last fall.

—Michael Vlessides The researchers had no relevant financial relationships to disclose.

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CLINICAL ANESTHESIOLOGY

In Survey, Anesthesiologists Support Perioperative Surgical Home Model Honolulu, Hawaii—There is strong agreement among respondents to a nationwide survey that anesthesiologists’ coordination of health care following the perioperative surgical home (PSH) model will help reduce health care costs by improving efficiencies and outcomes.

A recent study found that American physicians are enthusiastic about strategies that focus on quality of health care and continuity of care, rather than strategies that focus on financial reforms ( (JAMA 2013;310:380-389). To that end, principal investigator Darren R. Raphael, MD, MBA, and his colleagues at the University of California, Irvine, queried anesthesiologists about the concept of the PSH, the health care model that calls for an anesthesiologist-led coordination of care extending from the decision to operate until 30 days after discharge.

After development by a task force of anesthesiologists, a cross-sectional survey was emailed to 6,000 randomly chosen members of the American Society Table. Demographics of Anesthesiologists Responding to Survey Respondents, n (%) N=883

Characteristics Age, y <30

22 (2)

30-39

180 (20)

40-49

153 (17)

50-59

340 (39)

60-69

157 (18)

≥70

31 (4)

Male

689 (78)

Regiona Midwest

279 (32)

South

246 (28)

Northeast

187 (21)

West

128 (15)

Other

36 (4) a

Practice setting

a

Community hospital

433 (49)

Freestanding surgery center

312 (36)

University hospital

254 (29)

Community hospital (teaching)

210 (24)

Children’s hospital

91 (10)

Office-based anesthesia

81 (9)

Other

31 (4)

Numbers mayy not add to 100% because of missingg data for some questions. q

of Anesthesiologists. Respondents were asked about responsibility for cost reduction, enthusiasm for cost reduction strategies, their understanding of the PSH model and comfort with new practice roles. Data were collected between March and May 2014.

As Dr. Raphael reported at the 2015 annual meeting of the International Anesthesia Research Society (abstract S-150), 883 anesthesiologists (14.7%) completed the survey (Table). The majority (75%) expressed fair or good understanding of the PSH model. More than half agreed that anesthesiologists should coordinate patient care from scheduling to hospital discharge (60%), and that coordination of preoperative (81%) and postoperative (64%) care should become standard.

‘There are also financial challenges, as we need to ensure that these perioperative activities are recognized by health systems as valuable and therefore compensated appropriately.’

—Alex Macario, MD, MBA

implementation is education. “We get calls from people saying they think PSH is a great idea, but they have no idea how Darren R. Raphael, MD, MBA to implement it,” he told Anesthesiology News. “I think that’s the key to future success: not only educating people about it, but also how to go about it.”

That responsibility, he explained, falls on the shoulders of professional societies such as the ASA. “I think our societies really have to be the force that motivates us for change. We see a great example of this in the … Perioperative Surgical Home Summit, which is jointly provided by the ASA and the University of California, Irvine, Department of Anesthesiology and Perioperative Care. It would be a tragedy to leave our colleagues to their own devices; it’s a difficult thing to do on your own.”

Nevertheless, the researchers saw the PSH as an opportunity for anesthesiologists to cement their role in the spectrum of perioperative care. “I think you have to believe, first of all, that we’re on a burning platform and there’s an urgent need to move into that space,” Dr. Raphael said. “Once we realize that, we’ll really see this as an opportunity, since we are the best-placed specialty to do this work.”

Alex Macario, MD, MBA, told Anesthesiology News that since the country is still in the early stages of adapting the PSH, each hospital and anesthesia group will need to determine the structure and function that work best for them. “At Stanford, there are examples that illustrate how this might work,” said Dr. Macario, who is professor of anesthesia and health research and policy at Stanford University School of Medicine, in Stanford, Calif. “For instance, a preoperative evaluation clinic has existed since the early 1990s, and clinical pathways for joint replacements were first developed more than a decade ago. The department also staffs a high-risk obstetric anesthesia clinic that consults with high-risk parturients early in pregnancy so there is a plan in place for when the patient arrives on the labor and delivery floor.”

The challenge going forward, Dr. Macario added, is to properly train anesthesiologists for the entire PSH spectrum, including evidence-based medicine.

“This begins with the decision for surgery and carries through to discharge,” he said. “It includes medical consultation prior to surgery—including prehabilitation to manage risk factors—as well as postoperative care on the patient wards, which historically not many anesthesiologists have undertaken.

“There are also financial challenges,” he added, “as we need to ensure that these perioperative activities are recognized by health systems as valuable and therefore compensated appropriately.”

Less Comfort With Post-op Period Most respondents also expressed comfort managing preoperative (95%), intraoperative (100%) and postoperative (79%) care. “In the preoperative phase, we see a very strong response of people feeling comfortable,” said Dr. Raphael, assistant professor of anesthesiology and perioperative care at the University of California, Irvine. “Although the majority of people also express feeling comfortable managing the postoperative phase, the response is less. It’s likely that people have been out of the postoperative management game for so long that they feel uncomfortable.”

Despite any trepidation they may have had about their involvement in the full spectrum of patient care, most respondents agreed that coordination of postoperative care would improve outcomes (89%) while reducing costs (82%), hospital length of stay (81%) and readmission rate (73%). In contrast, most anesthesiologists were either somewhat or not enthusiastic about Medicare payment cuts (99%), implementing bundled payments (95%) and eliminating fee for service (92%). Slightly more than half attributed the primary responsibility for cost reduction to hospitals (57%) and insurance companies (54%). About one-fifth or fewer indicated that they felt professional societies (21%), trial lawyers (18%) and employers (17%) bear no responsibility for cost reduction.

—Michael Vlessides As Dr. Raphael noted, while the PSH concept is clearly gaining traction in the minds of anesthesiologists across the country, the key to successful The researchers reported no relevant financial conflicts of interest.

JULY 2015

AnesthesiologyNews.com I 1 1

CLINICAL ANESTHESIOLOGY PED M&M

patient population. But it’s the thing we’re most familiar with, so we conand most of what we know comes from tinue to use it. In fact, 20% of our fifth single-center reports and case series,” intubation attempts were with direct explained John Fiadjoe, MD, assistant laryngoscopy.” professor of anesthesiology and critical care, Children’s Hospital of Phila- Cardiac Arrest Rate Troubling delphia. “So we decided to look at the Yet the most troubling finding of devices used, the numbers of attempts, the analysis was the overall complicathe providers managing the airway and tion rate. “The shocking thing was that the complications that occurred.” one in 75 of our patients had a cardiac Nine hundred cases, all presenting arrest,” he said. “Now if you look at the between August 2012 and November pediatric anesthesia literature on car2014, were analyzed. Difficult direct diac arrest, the number that’s assumed laryngoscopy was defined by at least one in general anesthetic cases in children is around 1.4 in 10,000. But in our difof the following four criteria: • Direct laryngoscopy by faculty fails to ficult airway patients, it’s one in 75, and visualize any part of the vocal cords. that’s astounding. And I’d venture to • Direct laryngoscopy was impossible say that most of the cardiac arrests we due to physical limitations (mouth observed are preventable, because for opening and other factors). the vast majority of these patients, they • Direct laryngoscopy has failed within were hypoxic cardiac arrests.” a sixx month period.

Helping improve outcomes such as • Direct laryngoscopy is deferred this, he continued, might be possible because the patient was expected to with educational efforts. “Our next step be challenging to intubate with conis to create an intervention to improve these complications,” Dr. Fiadjoe said. ventional direct laryngoscopy, and there was concern for potential harm. “We want to create a Web-based educa“Severe complications” were defined tional portal for practitioners to be able as pneumothorax, severe airway trauma, to review videos of the various techaspiration, cardiac arrest, death and niques they can use in these patients.” delayed recognition of esophageal intu- Hands-on workshops will also play a bation. Other complications included part in institutions’ efforts to reduce minor airway trauma, arrhythmia, bron- complication rates. chospasm, epistaxis, hypoxia, larynThere are other steps that anesthesigospasm and immediately recognized ologists can take when they treat chilesophageal intubation. dren with difficult airways, beginning In this study reported at Pediatric with reducing the total number of intuAnesthesiology 2015 (abstract A17), bation attempts. “It’s important that we univariate analysis revealed that patients move away from direct laryngoscopy if who had severe complications weighed it fails after the first couple of attempts. less (15.3 vs. 24.2 kg; P=0.016), more We should quickly move to something frequently had airway management else that gives us a higher success rate,” outside of the operating room (7.9% Dr. Fiadjoe said. Limiting the number vs. 2.0%; P=0.005), had more unantic- of attempts performed by trainee anesipated difficult airways (5.5% vs. 1.7%; thesiologists is also recommended.

Finally, the researchers recommended P=0.009) and required more intubation attempts (four vs. two; P<0.001) oxygenation during intubation in pedithan their counterparts who did not atric patients as another way to reduce have severe complications. Multivariate possible complications. “This gives analysis found similar results, except for more time to secure the airway, especially if you’re working with a trainee,” weight.

“It makes sense that the number of Dr. Fiadjoe added. intubation attempts correlated with “Most of us oxygenate prior to but not increasing complications,” Dr. Fiadjoe during intubation. But in these small said in an interview with Anesthesiology children, the oxygen consumption is News. “This has been shown in the past, very high and they consequently desatbut it has not been demonstrated for a urate quickly, even when they’re breathdifficult airway pediatric population.” ing spontaneously. You need a way to The analysis also showed that clini- give them oxygen throughout. We think cians turned to direct laryngoscopy fre- [a] high-flow w nasal cannula may be a quently, and persistently. “Folks were way, or using a modified nasal airway using direct laryngoscopy more often with oxygen flowing through it.” than you’d expect in a patient who was —Michael Vlessides known or suspected to be difficult,” he noted. “The success rate of direct The researchers reported no relevant financial laryngoscopy was only 12% in our conflicts of interest.

CONTINUED FROM PAGE 1

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JULY 2015

COMMENTARY “… and I said to myself, this is the business we’ve chosen.”

Wingmen Forever How is the anesthesiologist portrayed in popular culture?

Hyman Roth to Michael Corleone;

Steven S. Kron, MD

R

eflecting current norms as well as creating them, movies and television programs are still the best measure of society’s view of people and their professions.

I suspect that the number of medically themed programs is second only to crime-basedd entertainment. Before my family even got a television set, we listened to “Dr. Kildare” on the radio. He soon migrated to TV, joining “Marcus Welby, MD” and “Ben Casey.” More recent programs include “ER,” “Chicago

Steven S. Kron, MD “The Godfather II,” 1974 Hope,” “Grey’s Anatomy,” “House,” “St. Elsewhere,” “Scrubs,” and of course, “M.A.S.H.,” diagnosticians and pathologists. Howamong others. The movies also continue ever, the anesthesiologist characters are to have medical characters. generally shadowy figures from cenWe have become accustomed to see- tral casting whose involvement consists ing kindly and wise family doctors, of placing a mask on the patient when dashing surgeons, brilliant but brash the surgeon issues orders to “put him down fast!” or “give 1 cc of adrenaline stat!” when the anesthesiologist fearfully announces, “We are losing him!”

Once, in an episode of “Grey’s Anatomy,” the heroic surgeons were operating to remove a bomb from a patient’s abdomen (yeah, you read that right) when the anesthesiologist, fearing for his life, handed the bag to a nearby nurse and walked out. The American Society of Anesthesiologists complained to the producers about that one. After all, the complaint stated, we are professional physicians dedicated to our patients’ safety. I wonder if there was ever an apology.

In the 1970s book and movie “Coma,” patients were getting epidurals with 0.75% Marcaine instead of 0.5% or inhaling carbon monoxide instead of nitrous oxide. Anesthesiologists were unknowingly committing the harm, but it was the strong, talented and, naturally, beautiful surgical resident who figured out that the evil chief of surgery was the culprit, killing people and selling their organs on the black market.

At least in “M.A.S.H.,” the anesthesiologist was a cool Australian (although with minimal screen time and lines), but in general, we anesthesiologists are pretty much invisible in popular entertainment.

With that in mind, I was delighted to learn that a new TV show debuting on ABC had an anesthesiologist as a lead character. So, knowing nothing else about the program, entitled tled “BlackBlack ish,” and armed with a sackk of munchies and an adult beverage, I settled down in front of my TV, anticipat-ing the first episode and thee redemption of the profes-sion. Finally, we were beingg noticed!

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JULY 2015

AnesthesiologyNews.com I 13

PAIN MEDICINE

Paravertebral Catheters Reduce Post–Breast Surgery Opioid Use and Hospital Length of Stay Las Vegas—A multimodal perioperative analgesia protocol using gabapentin with paravertebral catheters (PVCs) reduces opioid use and hospital length of stay (LOS) for patients undergoing major breast surgery.

Researchers from Stamford Hospital, in Stamford, Conn., conducted a retrospective chart review of 139 patients who underwent mastectomy (84 bilateral, 55 unilateral) with and without reconstruction, from 2009 to 2014, to compare effectiveness between this protocol and conventional on-demand opioid-based pain management. PVCs have been shown to decrease opioid use and shorten LOS in patients after mastectomy, and gabapentin, a nonopioid adjuvant medication used in multimodal analgesia protocols, has “demonstrated opioid-sparingg effects in breast cancer patients,” according to the researchers.

Patients were separated into three groups based on postoperative analgesia type: conventional, PVC and PVC with gabapentin (PVC+G). The primary end points were postoperative opioid use and LOS. The researchers found that patients in the PVC group had decreased opioid use, LOS and postoperative nausea compared with those in conventional management, and the PVC+G group had further statistically significant decreases compared with the conventional analgesia group (Table). The study was presented at the 2015 annual Regional Anesthesiology and Acute Pain Medicine meeting (abstract 105).

“We noticed not only drastic—almost a 50%— decrease in narcotic usage and subsequent decrease in opioid side effects,” said Vlad Frenk, MD, lead study author and director of the Acute Pain Service at Stamford Hospital. “Our average length of stay decreased from 2.3 days to 1.6 days. What it translates to is that the patients who used to spend two nights in the hospital now spend one night in the hospital.”

The researchers conducted a subgroup analysis for bilateral mastectomies and mastectomies with tissue expander reconstruction to examine if the results were due to the type of surgeries performed or the analgesic

Or not.

The lead character, African-American Andre “D Dre” Johnson, worked his way up from the ‘hood to w beecome a successful advertiising executive living in a nice upper-middle-class neighborhood. He has four n adorable and precocious

Table. Outcomes With PVC Versus Conventional Pain Management CPM (n=51)

PVC (n=35)

PVC+G (n=53)

Hospital length of stay, d (SD)

2.3 (0.84)

2.1 (0.71)

1.6 (0.54)

Opioid use, mg (SD)

73 (42.9)

52 (32.3)

39 (25.3)

CPM, conventional on-demand opioid-based pain management; PVC, paravertebral blocks and catheters; PVC+G, paravertebral blocks and catheters with gabapentin; S , sta SD, standard da d de deviation at o

‘Our average length of stay decreased from 2.3 days to 1.6 days. What it translates to is that the patients who used to spend two nights in the hospital now spend one night in the hospital.’

—Vlad Frenk, MD Watch Dr. Frenk discuss this study at anesthesiologynews.com/multimedia

on the market that allows patients to regulate flow rates separately, according to Dr. Frenk.

“The maximum you can run the pump is at 14 cc per hour—7 cc per hour per side—which is way below safety limits, so it’s a safe infusion rate,” he said.

Dr. Frenkk said the pump is portable, safe and easy to use, and most patients feel comfortable enough to remove the catheters at home. “We usually give them a choice during hospital discharge to pull the catheters for them prior to leaving or keep it and pull it themselves. More than 70% of patients choose to go home with them. When the pump runs out on post-op day 2 or 3, they pull them out themselves.”

Dr. Frenk noted that he has not seen any PVCrelated infections or had a single patient to date who returned to have an ON-Q Q device removed since the implementation of PVC for breast surgery at his hospital.

—Martin Leung

modalities administered, and if they were biased by comparing unilateral with bilateral mastectomy.

“With a bilateral mastectomy, you would expect higher failure rate of your technique because you have to do it twice,” Dr. Frenkk said. “[It turns] out that our results were consistent across the subgroups, which makes us feel confident that the results we are getting can be attributed to analgesic modalities.”

All PVCs were placed preoperatively using ultrasound guidance and dosed with 15 cc 0.5% ropivacaine per side. In the postanesthesia care unit (PACU), they were attached to a single- or doublelumen disposable infusion pump (ON-Q, Q Halyard Health). Patients received a continuous infusion of 0.2% ropivacaine at 5 to 7 cc per hour per side, starting in the PACU and up to three days postoperatively. The ON-Q Q pump was used because it is the only disposable, true double-lumen pump currently Dr. Frenk is on Halyard’s speaker panel.

children, but is very concerned that they will lose the connection to their racial roots. In the pilot, his 13-yearold son announces that he is converting to Judaism to have a Bar Mitzvah like all his white Jewish friends. Subsequent episodes always contain similar racial references as well as the usual family sitcom interactions. I found the episodes that I watched amusing but epi ppredictable.

So anyhow, where is the anestthesiologist? Dre’s wife Rainbow ((“Bow”) is the mixed-race daughter of hippies. She happens to be aan anesthesiologist but in the conteext of the show, she could have been any successful professional or

businesswoman. There are minimal references to the specifics of her job.

From time to time, she is shown wearing her scrubs in the kitchen. Or she might be seen having a locker room conversation with another woman (anesthesiologist? nurse? surgeon?) about some personal matter unrelated to anesthesiology. Is it just possible that the program has constructed a subtle unspoken simile between the AfricanAmerican struggle to be acknowledged as equals and that of anesthesiologists?

Or perhaps the true role and importance of anesthesiology is now so universally acknowledged that it’s unnecessary to clarify or emphasize it?

Just kidding—after all, “Blackish” is

a sitcom. That Bow’s profession is so irrelevant to the plot is demonstrated by a quote from an IMDb (Internet Movie Database) review: “Rainbow is … a highly educated and successful surgeon” (sigh).

While disappointing, this is not all that surprising. Deep down I believe we all know that, our protestations notwithstanding, we have chosen to be sidekicks: Ed McMahon to Johnny Carson, Sancho Panza to Don Quixote; helpful and smart at times, important to the plot line always, but forever the wingmen.

Dr. Kron is an anesthesiologist in Hartford, Conn., and a frequent contributor to Anesthesiology News.

14 I AnesthesiologyNews.com

JULY 2015

PAIN MEDICINE NSQIP-Based Study Surprise:

Complications Higher With Regional Than General Anesthesia in Hip Fracture Surgery Las Vegas—Patients administered regional anesthesia for hip fracture surgery are significantly more likely to experience complications than those who received general anesthesia, a study has found.

The 7,764-patient review of information from the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database yielded an adjusted odds ratio (OR) of 1.43 for minor complications and 1.24 for total complications for regional compared with general anesthesia (P<0.05 for both). The study, presented at the American Academy of Orthopaedic Surgeons’ 2015 annual meeting (abstract P555), was also published in International Orthopaedics (2015 March 24. [Epub ahead of print]).

Paul Whiting, MD, an orthopedic trauma fellow at Vanderbilt University Medical Center, in Nashville, Tenn., and his co-investigators extracted data

from the NSQIP for patients whose records included one of four Current Procedural Terminology (or CPT) codes for hip fracture surgery performed during 2005 to 2011. Of the total number of patients included in the analysis, 75.2% received general anesthesia, 23.4% spinal anesthesia and 1.4% regional nerve blocks.

Spinal anesthesia had the highest total (minor plus major) complication rate (19.6%), followed by general anesthesia (17.9%) and regional nerve blocks (12.6%; between-group P=0.008). Multivariate analysis showed that spinal anesthesia carried significantly greater odds for minor complications as well as total complications, compared with general anesthesia. After combining the regional nerve block and spinal anesthesia groups, multivariate analysis again showed significantly greater odds for minor and total complications for regional versus general anesthesia.

There were no significant differences in the major complication rates among the three groups.

The researchers’ analysis showed an adjusted OR of 1.43 (95% CI, 1.15-1.77; P=0.001) for minor complications with spinal versus general anesthesia. There was also a statistically significantly higher OR for total complications, at 1.24 (95% CI, 1.05-1.48; P=0.014), but not for major complications (OR, 1.01; 95% CI, 0.81-1.24; P=0.95), when comparing the two groups.

There were no significant differences in the ORs for minor, major or total complications for regional nerve blocks versus general anesthesia, or for regional nerve blocks versus spinal anesthesia.

The investigators then combined spinal anesthesia and regional nerve block “due to … wide confidence intervals [in the adjusted ORs] and the non-occurrence of certain

Intraoperative Local Anesthetic Shows No Benefit for Postoperative Hernia Pain

P

ain is one of the most common complaints after inguinal hernia repair, but the incidence of chronic pain can vary significantly from study to study.

Estimates of chronic pain after open mesh and laparoscopic repairs tend to fall between 4% and 30% (Surg Endosc 2010;24:1707-1711; Ann Surg 2006;244:212-219), but some trials report values of greater than 50% (Br J Anaesth 2005;95:69-76).

Studies evaluating chronic pain after pure tissue repair report ranges from about 4% to 14% for various techniques ((Anesthesiology 2000;93:1123-1133).

“Such huge variations, caused by different definitions of pain or pain severity, make it almost impossible to identify specific causes or treatments,” said Uwe Klinge, MD, a surgeon in the Department of General, Visceral and Transplant Surgery, University Hospital of the RWTH Aachen, in Germany.

A new study published in Surgery attempted to better understand one facet of pain after inguinal hernia repair: the effect of intraoperative infiltration of local anesthetic on the development of chronic postoperative pain (Surgery 2015;157:144-154). The main hypothesis, according to study author Anita Kurmann, MD, a surgeon in the Department of Visceral Surgery and Medicine at Bern University

Hospital, in Switzerland, was that intraoperative local anesthesia may disrupt nociceptive signals and thus may decrease the incidence of chronic postoperative pain.

In the study, Dr. Kurmann and her colleagues randomized 356 patients with 402 hernia repairs to three procedures: Lichtenstein (open mesh), Barwell (open autogenous similar to Bassini or Shouldice) and totally extraperitoneal (TEP) inguinal hernia repair (laparoscopic), with or without a local anesthetic. The authors defined chronic pain as any pain lasting more than three months, as described by the International Association for the Study of Pain (Pain Suppll 1986;3:S1-S226).

A total of 322 inguinal hernia repairs were performed using the Lichtenstein technique, with 168 receiving local infiltration of bupivacaine 0.25% 20 mL (intervention group) and 154 receiving a saline solution (placebo group); 13 underwent the Barwell technique, with six in the intervention group and seven in the placebo group; and 51 underwent TEP, with 26 in the intervention group and 25 in the placebo group. About half of the patients in the intervention (44%) and placebo (48%) groups had a nerve resection of the ilioinguinal, iliohypogastric or genitofemoral nerves. Chronic pain was evaluated three

specific complications in the regional nerve block group.” This combined regional anesthesia group had a significantly higher risk for minor complications than the general anesthesia patients (adjusted OR, 1.43; 95% CI, 1.16-1.77; P=0.001). Total complications were also more common when comparing these two groups (adjusted

months postoperatively using the visual analog scale (VAS).

After accounting for patients lost to follow-up, the analysis included 347 hernia repairs in 307 patients.

Three months postoperatively, the authors reported an incidence of chronic pain of 5.8% (10 of 173 hernias) in the intervention group and 2.3% (four of 174) in the placebo group (P=0.114). The study also analyzed several outcomes one year postoperatively and found that the incidence of surgical complications—including recurrent hernia, and superficial and deep surgical site infections—bodily pain and physical functioning were similar in the intervention and placebo groups.

The authors could not confirm a difference in the development of chronic pain three months postoperatively between patients who received intraoperative infiltration of local anesthesia and those who did not.

“We concluded that there is not enough evidence that intraoperative infiltration of local anesthesia has an influence on the development of chronic postoperative pain and should not be practiced,” Dr. Kurmann wrote in an email.

Commenting on the study, Robert Bendavid, MD, FACS, FRCS(C), a surgeon at the Shouldice Hospital in Toronto, Ontario, Canada, remarked that once the activity of the local anesthetic agent has passed, it should not affect pain after surgery.

Dr. Bendavid also found the definition of chronic pain too limited. “Three months is not an adequate time frame to evaluate chronic pain,” he said. “There

JULY 2015

AnesthesiologyNews.com I 15

PAIN MEDICINE OR, 1.24; 95% CI, 1.05-1.48; P=0.012) whereas major complications were not.

Contradictory Results Two anesthesiologists who commented on the study for Anesthesiology News were not convinced of the results.

“This really bucks the trend. There are numerous other studies, including an 18,000-patient study, that show lower incidence of major complications when neuraxial anesthesia is used,” noted Paul Hilliard, MD, director of regional anesthesia and acute pain medicine, University of Michigan Hospital and Health Systems, in Ann Arbor, who was not involved in the study. “I think the choice is clear.

Unlike elective major joint surgery, patients with hip fracture are rarely ideal candidates for surgery, and a spinal or nerve block may be chosen precisely because these patients are at extremely high risk for complications from any anesthetic. Further studies should be completed to look at fracture complexity, preexisting medical comorbidities and choice of anesthetic on a larger scale.”

Siamak Rahman, MD, associate clinical professor of anesthesiology and director of acute pain management,

can still be healing and scarring going on up to a year after surgery, and chronic pain can take even longer to manifest. I’ve seen patients reporting pain six years after surgery.”

Although the current study did not explore the mechanisms of pain, the investigators surmised that postoperative chronic pain may arise from a range of factors, including intraoperative nerve injury, inflammatory reactions after surgery or scar tissue from the implanted mesh.

Dr. Bendavid noted that nerve entrapment could also explain chronic pain in inguinal hernia repair using mesh. In a recent study, he found that nerves can grow within scar tissue and through the pores and interstices of mesh (Int J Clin Med 2014;5:799-810).

“Pain is incredibly complex, and there are many reasons patients can experience chronic pain after inguinal hernia repair,” Dr. Klinge said.

Dr. Kurmann concluded that “further studies should focus on the pathophysiological pathway of chronic pain to identify specific interventions.”

—Victoria Stern

Department of Anesthesiology & Perioperative Medicine, UCLA Health System, agreed that this is an important area of research. He said a main weakness of the study is that the “authors did not have access to additional records [aside from the NSQIP data] to review, nor could they speak to patients.”

Dr. Rahman, who also was not involved in the study, noted that the NSQIP database does not report on surgeon volume, percentage of resident

involvement, time from admission to the procedure, receipt of blood transfusions, academic status of hospitals, patients’ insurance type and income group, total in-hospital costs or hospital readmissions. Nor did the study consider the type of hip fracture surgery, he added.

“Although our study has certain methodologic weaknesses inherent to large prospective database studies,” Dr. Whitingg told Anesthesiology News, “the combined outcomes

analysis demonstrating increased perioperative complications with regional versus general anesthesia contributes meaningfully to the growing literature on anesthesia type in hip fracture surgery. Ultimately, prospective trials will be required to demonstrate definitively the preferred method of anesthesia for hip fracture patients.”

—Rosemary Frei, MSc Drs. Hilliard, Rahman and Whiting reported no relevant financial conflicts of interest.

16 I AnesthesiologyNews.com

JULY 2015

PAIN MEDICINE

Limited Role for Continuous Analgesic Pumps in Lap Sleeve Gastrectomy

70 patients ((J Am Coll Surgg 2006;202:297-305), a continuous analgesia infusion pump of 0.5% bupivacaine after midline laparotomy reduced the average daily patient-controlled analgesia (PCA) morphine by 25 mg (33.7 vs. 60 mg; P=0.03). In a 21-patient, placebo-controlled study ((Anesthesiology Benefits in open procedures not seen in laparoscopic cases 2007;107:461-468), continuous administration of Boston—In patients undergoing laparoscopic double-blind, controlled trial at Obesity Week 2014 0.2% ropivacaine for 48 hours after open colorectal sleeve gastrectomy, a continuous infusion of local (abstract A102). resection for cancer reduced the average morphine anesthetic via an anterior abdominal wall catheter The proposed benefits of continuous analgesic used per day by 36 mg and decreased LOS, pain does not improve pain control and does not reduce infusion catheters include better pain control in the scores and antiemetic use. the use of narcotics or antiemetics, or decrease the perioperative setting, which can reduce the use of narStudies evaluating the use of these pumps in laphospital length of stay (LOS). cotics and their associated side effects. “This can lead aroscopic surgeries, however, have provided mixed “Our study does not support the increased cost of to a more comfortable recovery with faster return to results (Table 1), and to date, no studies have evaluusing the continuous infusion [analgesic] catheters,” normal activity, decreased length of stay and possibly ated their use in laparoscopic surgery. To address this, said Elaine Cleveland, MD, a general surgeon at Wil- decreased costs,” Dr. Cleveland surgeons at William Beaumont Army Medical Cend said. liam Beaumont Army Medical Center, in El Paso, These benefits have been shown in several studies. ter randomized patients undergoing laparoscopic Texas. She presented results from this randomized, In a randomized, placebo-controlled study involving sleeve gastrectomy to receive either 0.2% ropivacaine or 0.9% normal saline via an intraoperatively placed Table 1. Sample of Trials Testing Continuous Analgesia Pumps continuous pain catheter. Dr. Cleveland said the pumps cost $710 and are placed in either the preperiPatient Population Trial Design Outcome toneal space or subcutaneous tissue.

73 patients undergoing Continuous 0.5% bupi- No differences in postoperative pain scores, narcotic use, Postoperatively, catheter flow rates were set at 7 mL laparoscopic ventral vacaine vs. placebo time to return of bowel function or hospital length of stay per hour and patients received PCA with hydromorhernia repair phone plus IV antiemetics. On the morning of postop30 patients undergoing Continuous 0.375% No differences in shoulder pain, morphine requirements, erative day 1, patients were started on oral nausea and laparoscopic adjustable bupivacaine vs. or antiemetic requirements, but improvements were seen pain medications, and the catheter infusion rates were gastric banding placebo in subjective reports of pain by visual analog scale scores decreased to 4 mL per hour. Patients were discharged (1.8 vs. 3.5; P<0.046) P when they were ambulatory and oral medications 45 patients undergoing Continuous 0.2% ropiNo significant differences in pain scores, morphine requirecould control their pain and nausea. After discharge, laparoscopic Roux-en-Y vacaine vs. placebo ment or length of stay, but patients in the ropivacaine clinicians recorded total narcotic and total antiemetic gastric bypass surgery group were able to sit up a half-day sooner use, pain scores, hospital LOS and adverse events.

40 patients undergoing Bupivacaine pain pump No significant differences in pain scores, nausea scores, To be enrolled in the study, patients had to have a laparoscopic Roux-en-Y vs. meperidine patient- gas pain scores, antiemetic use throughout their stay, or body mass index (BMI) greater than 40, or greater gastric bypass surgery controlled analgesia, opioid use in the post-anesthesia care unit. discontinued at 06:00 h Patients receiving bupivacaine had a dramatic decrease than 35 with comorbidities. Patients were excluded the following morning in opioid use from leaving the postanesthesia care unit to if they had revision surgery, single-port surgery or 06:00 h afterward (average meperidine by patient-controlled an allergy to local anesthetic. Only 7% of patients analgesia, 217 vs. 129 mg meperidine equivalents; P=0.008).

P in the study were male; the average age was roughly Sou ces Su Sources: Surgg Endosc dosc. 2009;23:2637-2643; 009; 3 63 6 3; Obes Su Surgg. g 2008;18:1581-1586; 008; 8 58 586; Su Surgg O Obes bes Relat e at Diss. 2010;6:181-184; 0 0;6 8 8 ; Obes Su Surgg. g 2007;17:595-600.

00 ; 595 600

see pumps page 20

Synovial Cyst Rupture Provides Long-Term Pain Relief, Effective Alternative to Surgery

P

ainful Z-joint synovial cysts can be successfully treated by percutaneous fluoroscopic synovial cyst rupture, helping some 80% of patients avoid surgery, according to study findings reported at the American Society of Anesthesiologists 2014 annual meeting (abstract 1045).

Researchers from Case Western Reserve University School of Medicine/MetroHealth Medical Center, in Cleveland, conducted a synovial cyst rupture on 30 patients with moderate to severe lower back pain who had documentation of an associated synovial cyst by magnetic resonance imaging. Lumbar synovial cysts, which occur due to spondylosis of the facet

joints, can encroach on adjacent nerve roots and cause symptoms of radiculopathy.

The indication for cyst rupture was for the patient to avoid having surgery from radiculopathy in the leg, according to principal investigator Kutaiba Tabbaa, MD, director of pain management at MetroHealth Medical Center.

A 22-gauge 10- to 15-cm spinal needle was introduced into the joint under fluoroscopic guidance while patients were in the prone position. Aspiration of synovial fluid could be achieved if the cyst neck was widely connected to the facet joint. Then 1 to 2 mL of nonionic contrast iohexol 300 mg/mL was injected into the facet joint to identify

the intra-articular positioning of the needle and filling of the cyst, which confirmed the diagnosis of lumbar facet synovial cyst. The contrast agent and synovial fluids were aspirated, and 1 to 2 mL of preservative-free bupivacaine 0.5% was injected and trapped for three to four minutes.

To rupture the cyst, up to 10 mL of normal saline (sodium chloride 0.9%) was injected until a loss of resistance was felt. Then another 2 to 4 cc of iohexol 300 mg/mL was injected to identify free flow of the dye from the joint to the epidural space anteriorly and posteriorly. After satisfactory imaging of free flow of the dye, 80 to 120 mg of methylprednisolone

acetate (DepoMedrol) with 1 to 2 cc of preservative-free bupivacaine 0.5% was injected.

The procedure resulted in an average reduction of 71% in pain severity.

The mean Numerical Pain Rating Scale score before cyst rupture was 7.3.

It dropped to 2.1 after the procedure, a mean difference of 5.2 that was statistically significant (P<0.0001).

The researchers used phone interviews to determine the long-term success of the cyst rupture and need for subsequent surgery to relieve symptoms. They found that 14 patients achieved pain relief for more than six months. Seven achieved pain relief between one and six months. Nine

JULY 2015

AnesthesiologyNews.com I 17

PAIN MEDICINE had synovial cyst recurrence that required repeat rupture. Six required surgical intervention for cyst removal.

The procedure for one patient was aborted because the cyst could not be ruptured due to pain. No complications were reported among the 30 patients.

“Through this case series, we found that rupture of the synovial cyst in patients with lumbar radiculopathy was associated with immediate relief of radicular symptoms. In 80% of patients, synovial cyst rupture prevented future surgical interventions over the long term,” said study author Yashar Eshraghi, MD, an anesthesiology resident.

He noted that although this was a retrospective case series, he still considered it a good study because a 12-patient series was the largest among prior studies of this approach.

Michael Giovanniello, MD, a practicing physical medicine and rehabilitation physician at the SMART Clinic in Sandy, Utah, found the results impressive and that the procedure mirrors what he does in his own practice: He first ruptures the cyst with contrast and injects steroid after an appropriate rupture of the cyst.

‘Through this case series, we found that rupture of the synovial cyst in patients with lumbar radiculopathy was associated with immediate relief of radicular symptoms.

In 80% of patients, synovial cyst rupture prevented future surgical interventions over the long term.’

“This study provides useful information that you can rupture a cyst by an injection. It indicates that surgery is not always necessary to manage patients with a synovial facet cyst. These patients can effectively be managed by a minimally invasive fluoroscopic-guided injection,” said Dr. Giovanniello.

questions comments story ideas

—Caroline Helwick

Contact the editor, James Prudden, at

jprudden@mcmahonmed.com

Drs. Eshraghi, Tabbaa and Giovanniello did not report any relevant conflicts of interest.

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Opioids for Inpatient Pain Optimized by Stewardship Plan Anaheim, Calif.—An innovative inpatient pharmacy-directed pain management program combining “opioid stewardship” and physician-requested consultations has demonstrated significant cost avoidance, improvements in patient outcomes and increased patient satisfaction scores.

The initiative saved roughly $1.6 million in costs related to opioid adverse events, nearly $400,000 of which was directly attributed to the stewardship components of the program, according to Richard Poirier, PharmD, a pain management clinical pharmacy specialist at Kaweah Delta Medical Center in Visalia, Calif., who helped develop the Pharmacy Pain Management Service (PPMS) program.

The PPMS team also reduced opioid-associated rapid response and Code Blue calls by nearly 60% over a nine-month period after the program was rolled out, according to Dr. Poirier.

“These are very impressive outcomes,” said Benjamin Stevens, PharmD, who is a medical information officer at APCER Pharma, a consulting firm located in Princeton, N.J., that specializes in drug safety reporting, medical information and regulatory affairs. The improvements “can certainly be used to justify rolling out this protocol in other health systems,” said Dr. Stevens, who was not involved in the project and has previously published research on opioid oversedation.

Dr. Poirier said he and his colleagues developed the PPMS after the Joint Commission issued a warning on safe opioid use in hospitals (Sentinel Event Alert 2012;49:1-5). “We wanted to optimize use of pain management pharmacotherapy, minimize opioid-associated adverse events and costs, and improve HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] scores specific to pain management,” he explained.

To achieve these goals, three full-time clinical pharmacists with specialized pain management training were assigned to conduct a combination of proactive opioid stewardship activities and as-requested consultations for adult patients admitted to general medical or surgical floors or intermediate ICUs. The stewardship component comprises a daily review of lists that include patients who are deemed to be at risk for opioid-related complications or inadequate analgesia, such as those using more than four doses of as-needed pain medication in the previous 24 hours, patients with risk factors for opioid-related oversedation (Figure) and individuals prescribed high-riskk opioid medications, such as opioid drips, patient-controlled analgesia pumps, fentanyl patches and methadone.

“We want to make sure these agents are dosed appropriately, taking into consideration whether a patient is opioid-tolerant or opioid-naive,” Dr. Poirier said.

Provider-requested opioid consultations include a complete review of a patient’s medical records, a meeting with the patient to assess his or her pain, and treatment recommendations based on the obtained information. PPMS recommendations can include adding adjunctive pain medications for untreated pain, dose adjustments or conversions to

Risk Factors for Oversedation •

•

$48,708

Multiple prescribed opioids or respiratory depressants

$75,208

Renal or hepatic dysfunction

•

Respiratory failure or respiratory illness

•

Older age

•

High body mass index

•

Sleep apnea

•

Immediate postoperative period

$51,057

$27,324

$171,600

Identification of untreated pain Alternative drug recommendations Drug interactions and incompatibilities Prevention or management of adverse drug effects Adjustment of dosage, frequency or route of administration

$373,897 Total Cost Savings With Stewardship Interventions

Figure. Indirect cost savings with stewardship interventions.a a

Data collected over nine months.

‘These are very impressive outcomes ... [and] can certainly be used to justify rolling out this protocol in other health systems.’

—Benjamin Stevens, PharmD

alternative lower-riskk pain medication.

“Our PPMS pharmacists also perform daily rounds to evaluate the efficacy of newly implemented analgesic regimens and to assess the presence of drug-related toxicity,” Dr. Poirier added.

Finally, within two to three days of hospital discharge, a PPMS pharmacist attempts to contact patients they have provided consults for, with the goal of ensuring patients’ pain is managed effectively and safely, as well as to check that any insurancerelated barriers to pain treatment are addressed while the patients wait for a follow-up outpatient appointment. This follow-up component reduces the risk for readmission, he explained.

Word of the program spread quickly, with 1,335 interventions—81% of which were consultrelated—carried out over the nine-month period after the program’s launch in October 2013, he noted. Over the same period, he said, there was a 59% drop in opioid-associated rapid response and Code Blue calls.

“We also saw an overall decrease in use of opioids, particularly high-dose parenteral hydromorphone and transdermal fentanyl,” added Dr. Poirier, noting that despite a decrease in opioid usage, pain-specific HCAHPS scores simultaneously increased “to an all- time high for our institution.”

The researchers used published cost avoidance data (Pharmacotherapy 2003;23:113-132) to estimate the average value of each intervention at $1,000 to $2,000. Based on direct interventions they performed and documented, they estimated a cost avoidance savings of $1,622,449 during the ninemonth period.

Although only $373,897 of the savings were stewardship-related (Figure), Yleana Garcia, PharmD, who is a pain management clinical pharmacy specialist for the PPMS, said more staff time could have led to greater savings. “Because of the potential for greater cost avoidance and, most importantly, decreased preventable rapid response and Code Blue calls attributed with opioid stewardship interventions, we are requesting a half FTE [full-time equivalent] to be dedicated to stewardship alone,” said Dr. Garcia, whose team received an ASHP Best Practices Award for the project, which was originally presented at last year’s Midyear Clinical Meeting of the American Society of HealthSystem Pharmacists (ASHP).

A Strain on Resources PPMS pharmacists were initially meant to spend roughly equal time performing consults and stewardship activities, but Dr. Garcia said, “Provider satisfaction with the consult service resulted in an increase in the number of consults, which has decreased time allocated doing stewardship.”

Other PPMS initiatives have also chipped away at their resources, she added, including institutional pain management order set revisions, ongoing pain medicine education to providers and nurses, and reviews of new-start fentanyl patches to ensure dosing takes prior opioid use and age into consideration.

Although he is enthusiastic that the Kaweah program is replicable at other institutions, Dr. Stevens said comparing the hospital’s overall opioid use on a per-patient basis with that of other sites of care would help determine whether other facilities should expect similar results.

“If other health systems have similar patient populations and opioid use rates, I would assume these [outcomes] could be carried over to other institutions with equally strong results.”

—David Wild Drs. Garcia, Poirier and Stevens reported no relevant financial conflicts of interest.

JULY 2015

AnesthesiologyNews.com I 19

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as ours were increasingly being ousted from hospitals even though they had provided good care for many years,” Dr. Brosche said. “There was just no security.”

Now, little more than a year after completing the transaction, Dr. Brosche and his partners are satisfied. “We have people whose full-time jobs are to look at managed care, figure out contracts and manage the collection of quality data that is used to improve outcomes,” Dr. Brosche told Anesthesiology News.

“When you are part of a larger organization, it gives you the support you need to negotiate with insurance carriers.”

M&A on the Upswing Although mergers and acquisitions (M&A) in health care are far from new, anesthesia as a practice has been something of a latecomer to the game—but that’s been a good thing. The improved economy with its low interest rates combined with a growing demand for anesthesia services for aging baby boomers has meant that many anesthesia practices are able to demand premium valuations based on relatively high multiples of their earnings, in some cases eight, nine or even 10 times their annual cash flow. This has translated into more advantageous acquisition terms and higher purchase prices than had been the case for other medical specialties before health care reform.

“Up until 2012, we had seen only a handful of anesthesia M&A transactions,” said Christopher Jahnle, managing director of Haverford Healthcare Advisors, a financial consulting firm in Paoli, Pa., which advised Fredericksburg Anesthesiology on its sale. “Now it’s become a landslide. Literally for the first time in history, anesthesiologists have the opportunity to monetize their practices,” Mr. Jahnle said.

Experts differ on how long this trend will continue. Richard S. Cooper, an attorney with the McDonald Hopkins LLC law firm in Cleveland, predicted the growth trend will continue. “The initial wave of practices that decided to sell gives other practices a level of comfort in considering the sale of their own practice,” Mr. Cooper said. However, a sale by another group can also be viewed as a competitive threat, especially in a region where it might give the acquiring company leverage to compete for hospital contracts. “That often prompts the remaining independent practices to adopt a defensive posture and position themselves to be acquired,” Mr. Cooperr said in an interview.

But Mark F. Weiss, JD, an attorney specializing in physician business and legal issues, thinks the M&A market will likely contract over the next two years as the major companies round out their portfolios.

“There’s already been some cooling of the market frenzy,” Mr. Weiss said.

“When acquirers began acquiring anesthesia practices a few years ago, they were willing to pay higher multiples to establish their platforms and get the ball rolling. But now, some of the large

companies have acquired enough practices in a market or region such that filling in their portfolio does not warrant those same valuations.” This is not to say that some acquirers wouldn’t be willing to pay a high valuation for a strategic acquisition, for example, if a practice had some billing or information technology (IT) resources that could be applied to other members of the group. “But in my experience, the multiples are not as great as they have been,” Mr. Weiss told Anesthesiology News.

Getting Big and Cashing Out Typically, the main reason to sell is the ability to obtain payment for the value of the practice. Of course, this tends to be more important to senior owner-physicians who are closer to retirement than to younger physicians or those who do not own shares of the practice. But becoming part of a larger regional or national company can also allow a small- to mid-sized practice to expand by putting it in a stronger see fever page 20

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Jan Paul Mulier, MD, PhD Bariatric Anesthesiologist St. Jan’s Hospital Bruges, Belgium

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20 I AnesthesiologyNews.com

JULY 2015

PRN

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CONTINUED FROM PAGE 19

traded companies and numerous private equity– backed anesthesiology practice consolidators. These well-capitalizedd buyers spent nearly $1 billion on their practice acquisitions in 2014, Mr. Jahnle estimated.

The pace is picking up. Nearly a dozen acquisitions were completed in just the first quarter of 2015 by some of the industry’s largest players. For example, American Anesthesiology (the MEDNAX subsidiary), acquired Metropolitan Anesthesia Alliance PLLC, a group of three practices in Memphis, Tenn., with 27 anesthesiologists and 46 other providers. American Anesthesiology also acquired MEMAC Associates PC, in Warren, Mich., with 10 anesthesiologists and 18 other providers, along with Mosaic Anesthesia & Perioperative Services PC, a two-practice group in North Carolina with 15 combined anesthesiologists.

Also during the first quarter, private equity– backed U.S. Anesthesia Partners, the nation’s largest anesthesia-focused, single-specialtyy physician services organization, acquired Greater Colorado Anesthesia, PC, in Denver, with 90 anesthesiologists and 33 other providers, as well as Excel Anesthesia PA, with nearly 70 providers at 50 hospitals and ambulatory surgery centers in the Dallas-Fort Worth area.

Mr. Jahnle predicted that 30 or more acquisitions will be completed this year at high transaction valuations—the result of more acquirers chasing a limited number of anesthesia practices. This trend is likely to continue for at least the next 12 to 18 months because fewer than 15% of anesthesia practices are affiliated with one of the large national aggregators. “It’s really a seller’s market. We’re seeing just the tip of the iceberg,” Mr. Jahnle said.

market position, which can translate into potentially more pay for all physicians in the group.

“Many large groups are considered by insurance carriers to be top-tier providers, and their reimbursement rates can be much higher than what those in community practice could negotiate on their own,” Mr. Weiss said. In addition to more clout, other advantages in becoming part of a larger group include the ability to share best practices, have greater access to capital, maintain more robust infrastructure and operational resources, and have access to cross coverage in specialty care.

Large groups also have more resources to devote to collecting and reporting quality metrics—an increasingly important aspect to Medicare, which this year is imposing a 1.5% penalty on charges for physicians and other practitioners who failed to report on at least three quality measures during the 2013 program year (see Anesthesiology Newss December 2014, “Penalties for Poor Medicare Quality Reporting Start Now,” page 1). The Centers for Medicare & Medicaid Services (CMS) recently announced that nearly 40% of physicians and other providers who treat Medicare patients will have their payments docked this year.

“We spend close to $2 million per year on quality assurance and business intelligence reporting to our groups,” said Vincent J. Vilasi, MD, MBA, the CEO for the mid-Atlantic region of North American Partners in Anesthesia (NAPA), a large single-specialtyy anesthesia management company that last year acquired his anesthesiology practice, FOAA Anesthesia Services, in Fairfax, Va. “NAPA has a lot of data collection and Alternatives to M&A reporting capabilities. There was just no way we could Potential disadvantages in being owned by a larger afford that kind of annual spend, even as a 200-provider group,” Dr. Vilasii told Anesthesiology News. group include loss of autonomy and control. “When you become part of a bigger enterprise, you are subRising Trends ject to their governance and operational and orgaOnly 18 anesthesiology and pain practice acqui- nizational culture,” Mr. Cooperr said. On top of this, sitions were reported during 2009 to 2011 (Figure). physician practice compensation is often reduced to That number jumped to 16 in 2012, 24 in 2013, and help fund the acquisition. “You need to look at this 27 in 2014, the latter completed by 14 separate acquir- carefully because some of your key physicians, espeers including several multibillion-dollar, publicly cially younger doctors who are not owners, may decide

PUMPS

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35 years. The study was halted early after an interim analysis showed that an additional 20 patients would not change the outcomes.

The investigators found no benefit to the catheters. “The continuous infusion catheter provided no benefit regarding narcotic usage, pain scores, PCA attempts, antiemetic usage or hospital stay in the setting of laparoscopic sleeve gastrectomy,” Dr. Cleveland said (Table 2). Adverse events were minimal with no hypoxia or ileus in either group; urinary retention was identified in three patients, two in the ropivacaine group.

Dr. Cleveland said the study was limited in that it was performed at a single

Acquisitions, n

30

27 24

25 20 16 15 10 5

7

8

3

0 2009

2010

2011

2012

2013

2014

2015 (projected)

Figure. Recent anesthesiology practice acquisitions. to leave. Culture fit is critical for a successful long-term relationship,” he said.

There are several alternatives to M&A (“Anesthesia Group Acquisitions and Alternatives,” Anesthesiology Newss June 2014, page 6). One is to become stronger, for example, by banding together with other practitioners in a particular region and forming a management services organization or other affiliation entity. This keeps the practices independent but creates a united front when negotiating with payors and hospitals.

Another approach is to partner with one or more other groups in a local area or region. As practices grow in size, they gain more clout with hospitals. “Then, if you are still interested in selling, there is arguably more value, a higher multiple, in selling a larger group than a smaller group,” Mr. Weiss explained.

Still another approach is to join a large national aggregator or partnership. “Our model is very attractive to hospital-based physician groups that are not interested in being taken over by investor-owned or private equity–funded groups,” said Wesley A. Curry, MD, president and CEO of CEP America, an Emeryville, Calif., partnership of more than 1,700 physicians. The company focuses on anesthesiology, emergency medicine, hospitalists, intensivists, urgent care and post-acute services at 140 practice locations nationwide. The privately held partnership boasts of having no “super owners,” outside investors or debt.

“All income from our practices is fully deployed to

Table 2. Comparison of Outcomes Between Patients Receiving Ropivacaine and Placebo

Kelvin Higa, MD, director of minimally invasive and bariatric surgery, Ropivacaine Placebo P Value Fresno Heart and Surgical Hospital, Total narcotic, morphine equivalents 51.8 55.17 0.63 in Fresno, Calif., said the study was important in an era when emphasis Patient-controlled analgesia attempts 61.95 73.74 0.59 is placed on value-based care. “Today, Ondansetron, mg 10.6 10.6 0.98 the environment in which we pracPromethazine, mg 11.7 6.83 0.10 tice is changing. As surgeons, we were Hospital time, h 37.45 38.19 0.77 only taught to think about quality at any cost, and now we are charged institution and most of the patients site. In laparoscopic surgeries, the cath- with talking about value … and costwere young females, which may not eters are placed near the incisions, but effectiveness. This research is somerepresent the typical bariatric surgery may not directly deliver anesthetic to thing that any of us can do on a local these small trocar sites,” Dr. Cleveland level and can make a significant impact population.

So, why are analgesia pumps benefi- noted. “Additionally, open surgeries on the care of our patients.” cial in open but not laparoscopic sur- tend to have increased pain compared —Kate O’Rourke geries? “In open surgeries, the catheters to laparoscopic surgeries, and with are placed directly in the incision, deliv- that, local anesthetic can have a greater Drs. Cleveland and Higa reported no relevant conflicts of interest. ering local anesthetic into the operative impact in reducing pain.”

JULY 2015

AnesthesiologyNews.com I 21

PRN recruit and retain the best providers and invested in management services to improve patient care and operational performance,” Dr. Curryy told Anesthesiology News.

In December 2014, CEP America brought anesthesia into its emergency and acute care partnership with the entry of Group Anesthesia Services (GAS), a 36-physician practice serving California’s South Bay and Silicon Valley. Peter Nosé, MD, former GAS managing partner and president, said the decision to partner with CEP was based on uncertainty over changes in reimbursement models, especially those that move away from fee-for-service to payy for-performance and coordinated care.

“External forces threatened our practice model,” Dr. Nosé explained. “Joining an integrated practice provided an opportunity to join a robust acute care continuum that spans emergency medicine, hospital medicine and post-acute care,” he wrote in a recent blog post.

As Dr. Curryy put it, “Smaller hospitalbased physician groups are partnering with us because we have the ability to help them help hospitals integrate their patient care—the transition to coordinated care as defined by CMS.” Acquiring the Acquirers The private-equityy firms that back privately held M&A companies generally seek to create a financial “exit” for themselves, typically through the sale of the company to an even larger company or, less commonly, by attempting to “go public” and selling shares on the stock market. “These companies will have made their businesses large enough that they will be trying to pull in their returns from their investments,” Mr. Weiss explained. “For the private-equityy firms, especially, it’s not build and hold forever, but build, hold and exit, so they return money to their investors and themselves, just as in venture capital. It’s no secret that that’s their business.”

Last year, for example, privately held Sheridan Healthcare was acquired by publicly traded AmSurg Corp., another anesthesia industry giant, for a whopping $2.35 billion in cash and stock. Sheridan Healthcare provides outsourced anesthesiology, neonatology, emergency medicine and radiology staffing to more than 350 hospitals nationwide, while AmSurg supplies more than 1,800 physicians to over 235 outpatient surgery centers.

Also last year, publicly traded TeamHealth Holdings Inc., which serves about 990 civilian and military hospitals, clinics and physician groups in 47

states, acquired private equity–backed Florida Gulff to-Bay Anesthesiology Associates LLC, in Tampa Bay, whose more than 200 physicians and certified registered nurse anesthetists provide services to eight hospitals and 11 ambulatory surgery centers. The acquisition price was not disclosed.

Sales of large privately held platform companies can also be a financial windfall to the physician-owners of the smaller anesthesia practices within them.

“A good strategy for anesthesia practices

that have a tolerance for risk is to take cash as well as stock in the acquiring company,” Mr. Jahnle noted. “That way, if the buyer is itself acquired, the stock might be worth more. It’s like getting a second bite at the apple.”

Dr. Vilasi saw the pace of anesthesia mergers neither increasing rapidly nor dropping off suddenly. “A large number of the biggest anesthesia practices will be consolidated under the umbrella of a large strategic provider in the next five years or so,” he predicted. However,

M&A in anesthesia will continue only as long as it makes financial sense.

“When I talk to my clients, I’m not saying you have to sell. I’m saying make an honest appraisal of the long-term viability of your practice in its current form and make a rational, informed business decision,” said Mr. Cooper.r “If you decide not to sell, you may have to make other changes to remain strong in a competitive marketplace going forward.”

—Ted Agres

American Society of Regional Anesthesia and Pain Medicine Advancing the Science and Practice of Regional Anesthesia and Pain Medicine

PAIN MEDICINE

14

th

Annual Pain Medicine Meeting

November 19-21, 2015 Miami, Florida Fontainebleau Miami Beach

www.asra.com

• New anticoagulation guidelines specific for interventional pain procedures.

• How are nanotechnology, stem cells, and gene therapy influencing pain medicine?

• Lectures and workshops on Platelet Rich Plasma (PRP) injections for sports injuries.

• Cadaver and live model ultrasound and fluoroscopy-guided workshops on interventional techniques in cancer and non-cancer pain.

• Specialized nurse practitioner and physician assistant program and credits.

• New ePoster system and moderated ePoster track.

• Expert faculty eager to share their practical experience.

See You in Beautiful Miami!

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Cardiothoracic Anesthesiologist

E C H O C A R D I O G R A P H Y 2 015 :

The Role of Cardiac Imaging in Perioperative and Critical Care Medicine November 7–10, 2015 | Naples, Florida This course is intended for the clinician who utilizes echocardiography in their practice in the perioperative and critical care arena. The course will focus on common clinical dilemmas where echocardiography can play a role in diagnosis and treatment. Case-based presentations, practice guidelines, hands-on echocardiography workshops, and small-group discussions will be utilized to review two-dimensional transesophageal and transthoracic echocardiography, spectral Doppler, and 3D echocardiography techniques.

Topics • • • • • • • • • • •

Transesophageal and transthoracic echocardiography Mitral, aortic and tricuspid valve assessment Left and right ventricular function Echocardiography in heart failure Practical diastology assessment Spectral and color Doppler Basic transthoracic echocardiography Rescue echocardiography 3D echocardiography Echocardiography in congenital disease Echocardiography in transcatheter aortic valve replacement (TAVR), MitraClip, and aortic root procedures

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University Hospitals Case Medical Center in Cleveland, OH is seeking a full-Ɵme board eligible/cerƟĮed anesthesiologist who has completed a one year cardiothoracic anesthesia fellowship. NBE Advanced PerioperaƟve TEE Testamur status is necessary if you are not a Diplomate of the NBE. We are strongly encouraging applicaƟons from individuals who will signiĮcantly contribute to the growing academic core of a mid-sized academic anesthesia pracƟce. Our pracƟce involves providing anesthesia for thoracic, coronary, valve, major aorƟc, heart/lung transplant, ventricular assist device implantaƟon surgeries and electrophysiology/catheterizaƟon laboratory based procedures. Provision of some main operaƟng room anesthesia care is expected. MoƟvaƟon to teach residents, medical, nursing and anesthesia assistant students is a requirement. Faculty appointment at Case Western Reserve University School of Medicine will be commensurate with one’s academic record. University Hospitals is an equal opportunity employer. Interested applicants should send a cover lĞƩer along with their curriculum vitae to edwin.avery@uhhospitals.org.

Cardiothoracic Anesthesia - University of Miami Seeking Asst/Assoc/Prof with fellowship/experience in Cardiothoracic Anesthesia. Applicant should also be board ceƌƟĮed in advanced perioperaƟve TEE or testamur. Faculty member will provide clinical care, teaching, research, & academic development of trainees. Faculty member will maintain service commitments at Jackson Memorial Hospital and University of Miami Hospital.

Candidate must be ABA ceƌƟĮed or equivalent; have strong academic background, demonstrated excellence in research, clinical care & teaching.

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Electronic submissions preferred. Contact: Dr. Keith Candioƫ, Professor & ExecuƟve Vice Chairman, Dept. of Anesthesiology, University of Miami, 1611 NW 12 St., C302, Miami, FL 33136; phone (305) 585-3746; kcandioƫ@miami.edu

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UF Health UF Health is the Southeast’s most comprehensive academic health center. With its main campus located in Gainesville and more than 22,000 faculty and staff, UF Health includes six health colleges, nine research institutes and centers, two teaching hospitals, four specialty hospitals, dozens of physician medical practices and outpatient services throughout north central and northeast Florida, and two veterinary hospitals. We are dedicated to providing high-quality education, research, patient care and public service.

UF Department of Anesthesiology The department of anesthesiology at the UF College of Medicine includes 69 clinical faculty members, 20 active research faculty members, 79 residents, 16 fellows and a support and administrative staff of 38 people. It is a world-renowned academic department that typically publishes at least 26 books and book chapters and more than 55 manuscripts and is granted at least five U.S. patents each year.

Multiple fellowship-trained faculty cover each clinical subspecialty discipline, including: critical care medicine, pediatric, congenital cardiac, adult cardiac, neurosurgical and obstetric anesthesia, as well as regional and acute pain medicine and chronic pain. Research interests of the faculty span clinical, basic science, nanotechnology, simulation training and interactive Web projects. The Center for Safety, Simulation & Advanced Learning Technologies CSSAL5 , within the UF department of anesthesiology provides education, training and services to professionals around the world. CSSALT is endorsed to deliver Maintenance of Certification in Anesthesiology simulation sessions.

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Nerve Injury After Peripheral Nerve Block: Best Practices and Medical-Legal Protection Strategies DAVID HARDMAN, MD, MBA Professor of Anesthesiology Vice Chair for Professional Affairs Department of Anesthesiology University of North Carolina at Chapel Hill Chapel Hill, North Carolina Dr. Hardman reports no relevant financial conflicts of interest.

T

he risk for permanent or severe nerve injury after peripheral nerve blocks (PNBs) is extremely low, irrespective of its etiology

(ie, related to anesthesia, surgery or the patient).

The risk inherent in a procedure should always be explicitly discussed with the patient (sidebar, page 4).

In fact, it may be better to define this phenomenon as postoperative neurologic symptoms (PONS) or perioperative nerve injuries (PNI) in order to help standardize terminology. Permanent injury rates, as defined by a neurologic abnormality present at or beyond 12 months after the procedure, have consistently ranged from 0.029% to 0.2%, although the results of a recent multicenter Web-based survey in France, in which

ultrasound-guided axillary blocks were used, demonstrated a very low nerve injury rate of 0.0037% at hospital discharge.1-7 A 2009 prospective case series involving more than 7,000 PNBs, conducted in Australia and New Zealand, demonstrated that when a postoperative neurologic symptom was diagnosed, it was 9 times more likely to be due to a nonâ&#x20AC;&#x201C;anesthesia-related cause than a nerve

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blockâ&#x20AC;&#x201C;related cause.6 On the other hand, it is well documented in the orthopedic and anesthesia literature that there is an alarmingly high incidence of temporary postoperative neurologic symptoms after arthroscopic shoulder surgery, both with and without regional blocks.

Most of these involve minor sensory paresthesias and dysesthesias, but they can range as high as 16% to 30% in the first week postoperatively.1,8,9 The PNI rate associated with total shoulder arthroplasty has been previously reported to be 4% under general anesthesia alone, and represents the underlying independent surgical risk.10 Despite advances in surgical techniques, this number has not changed appreciably over time.

The most recent data from a clinical registry at Mayo Clinic, for 1993 to 2007, demonstrated a PNI rate of 3.7% during general anesthesia.11 This contrasts with a

16%-30%

PNI rate of 1.7% in patients who received a single-injection interscalene block (ISB). Patients who received an ISB had significantly reduced odds for PNI (odds ratio, 0.47).11 Factors not associated with an increased risk for PNI in this study included patient sex and longer operative time.

Over 97% of patients who developed PNI eventually recovered completely or partially at 2.5 years after the procedure, and 71% experienced full recovery. Notably, there was no difference in overall recovery from PNI between patients who received ISB and those who received general anesthesia alone.11 Not all surgical procedures have the same incidence of PNI, and this variation may be due to procedure-specific risk for nerve injury, apart from the use of peripheral nerve blockade and regional anesthesia. Data from three clinical registries at a single institution demonstrated a PNI incidence of 2.2% after total shoulder arthroplasty, 0.79% after total knee arthroplasty and 0.72% after total hip arthroplasty (Figure).11-13 The use of regional anesthesia was not an independent risk factor for PNI in any of these procedures; in fact, it reduced the risk for PNI in total shoulder arthroplasties.

Total shoulder arthroplasty:

Strategies To Reduce Medical-Legal Risk

2.2%

Before initiating a block, and particularly in a patient with previous injuries, I recommend that you take a focused history for the presence of current or previous paresthesias, dysesthesias, or pain in the limb that will receive the block. It would also be helpful to do a quick, focused sensory and motor neurologic exam.

Many of these patients have preexisting lesions; unfortunately, they are not noticed until the postoperative period, when we become much more observant of abnormalities.

Be careful with the administration of sedatives during the block procedure in order to not obscure any symptoms of paresthesia, dysesthesia, or pain during injection.14 Refer to the American Society of Regional Anesthesia and Pain Medicine (ASRA) Practice Advisory on Complications in Regional Anesthesia.15 Be advised that a favorite tactic of medical malpractice attorneys is to argue that patients given any amount of sedation would be unlikely to be able to report pain or paresthesia on injection.

I would recommend that you document in the chart that meaningful verbal communication with the patient was maintained throughout the block procedure.

Documentation of blocks is essential for clinical care, regulatory, billing, and medical-legal reasons. ASRA has published a recommended PNB note template.16 My experience reviewing cases for potential medical-legal problems has shown me that many of the block notes are poorly documented.

This is an area that can be rectified with the introduction of an electronic anesthesia medical record, which can allow you to create custom templates for every type of block you perform, and document detailed

Arthroscopic shoulder surgery Âą regional block, 7 days postoperatively:

Single-injection interscalene block:

1.7% Total knee arthroplasty:

0.79% Total hip arthroplasty:

0.72% Ultrasound-guided axillary blocks, at discharge:

0.0037% Figure. Rates of perioperative nerve injuries following each type of procedure.

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information pertaining to the block. Table 1 shows an example of a block form.

Patients discharged home after a PNB procedure should receive written instructions with precautions about how to take care of an insensate extremity, and how to prevent injury. Patients with a single-injection block should be called the next day and questioned about complete block resolution or persistent symptoms, and this contact should be documented until the symptoms resolve. Any patient with persistent motor weakness beyond the normal expected recovery time should be seen in clinic immediately, for examination and potential neurologic consultation.

You should be particularly vigilant when dealing with a patient returning for a second surgical procedure and block within an intervening short interval, for example, 3 months or less. Nerve injury can exist with subclinical symptoms, and a second insult, either distal or proximal, without necessarily having anything to do with your nerve block, can elicit clinical findings postoperatively. This phenomenon is known as the double-crush theory of nerve injury.17

Is There Anything We Can Do To Prevent Nerve Injury?

Ultrasound-guided techniques have been shown to have many advantages, including shorter procedure time, faster block onset, lower drug volume, fewer vascular punctures and, most recently, a reduction in the incidence of local anesthetic systemic toxicity (relative risk reduction, 65%).4,18-20 Although many benefits are associated with ultrasound-guided blocks, there is insufficient evidence to demonstrate a lower neurologic complication rate with this technique.21,22 For that matter, there is no evidence to show fewer neurologic complications associated with neurostimulation techniques versus paresthesia-seeking techniques.23 Many publications call into question the sensitivity and specificity of nerve stimulation techniques, and studies demonstrate that intraneural injections (defined as cross-sectional expansion in diameter of a nerve, but not necessarily intrafascicular) as observed using ultrasound occur frequently and do not invariably lead to nerve injury, during both supraclavicular and axillary blocks.24 Accidental intraneural injections (defined as crosssectional expansion in the diameter of a nerve) have also been shown to occur during ultrasound-guided blocks (without paresthesias) in about 17% of upperand lower-extremity blocks, in 2 case series without neurologic complications, even in the hands of experienced regional anesthesiologists.25,26 There has been an ongoing debate about whether or not these intraneural injections are preventable, whether they are subepineural or below a connective tissue outer wrapper outside the epineurium27 (ie, subparaneural), and whether or not they invariably lead to harm. Because of the limited resolution of current ultrasound probe technology, combined with the fact that it

is challenging to keep the tip of the needle visualized in the plane of the ultrasound beam at all times, it is difficult to distinguish between a subfascial, subepineural, or intrafascicular injection.28 Even exceptionally well-trained experts in regional anesthesia have subsequently realized that they may have contributed to a PNI after reviewing video clips of an interscalene block demonstrating intraneural injection, despite an uneventful block procedure without pain or paresthesia.29 Current thinking is geared to depositing local anesthesia farther away from the nerves, rather than around the nerves in the interscalene brachial plexus region.30 We should consider thinking about the maximum effective distance from the plexus that will still result in an effective block,31 with a paraplexus approach rather than an intraplexus approach. A conservative technique would involve using a hydrodissection approach with needle advancement, along with a nerve stimulator (no data support this) and a lower anesthetic mass and volume.32

Table 1. A Form Template for Describing a Block An example of a block form might include the following items: Focused neurologic exam prior to block Time-out (patient and block site identified and marked, informed consent verified) Patient level of awareness during block Aseptic skin prep, drape Type of needle used, depth to target prior to injection, and if catheter, depth at skin Ultrasound and/or nerve stimulator, with minimum threshold current Presence or absence of paresthesia or pain. If paresthesia, did it immediately resolve?

Presence or absence of resistance to injection.

Was pressure monitored? If resistance, was the needle repositioned?

Negative or positive aspiration for blood Local anesthetic, with concentration and volume Additives (perineural, IV, intramuscular), including total dose and preservative-free documentation Success of block (complete, partial, not yet assessable, failed) Block supplementation (yes or no) Ultrasound pre- and post-injection image capture and storage

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Informed Consent and Medical Negligence (Malpractice)

A

lthough anesthesiologists may be eager to tout the benefits of peripheral nerve

blocks (PNBs), many of us are not doing a very good job of disclosing the potentially catastrophic risks of these procedures to our patients.

A 2007 survey of academic regional anesthesiologists indicated that most of the respondents disclosed the minor risks for bruising, pain, and mild temporary neurologic symptoms such as paresthesias and dysesthesias, but almost 40% did not disclose the risks for local anesthetic systemic toxicity (ie, seizure and cardiac arrest) or long-term and disabling neurologic injury.38 At the same time, a recent international survey measuring patient satisfaction after peripheral nerve blockade affirmed that 90% of the respondents were satisfied or completely satisfied with the information provided about the nerve block, as well as the patient–anesthesiologist interaction.39 A shared decision-making approach when discussing a PNB procedure with a patient is a good idea, given the fact that the benefits of the block are short-term (for example, reduced pain and nausea as well as earlier readiness to discharge), without the accompanying long-term benefits such as improved functional outcomes.

Informed consent for a procedure involves 4 aspects: 1. A state of voluntariness 2. Competency and capacity for decision making 3. Disclosure of information about the procedure and risks associated with that procedure 4. Authorization by the patient to undergo the procedure Disclosure of information about risk should include procedure-specific risk, as well as patient-related relative risk. Patients should always be informed of alternative treatment options, and the entire discussion should be documented in the medical record. There is a trend to have an anesthesia consent that is separate from the surgical consent (although this is not required by regulatory agencies), and recent publications question whether or not a patient who is competent to sign a surgical consent has the same competency and capability to understand an anesthesia consent.40

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My practice is to circle the words “nerve injury” on a paper consent form and initial it, to document that I specifically discussed this with the patient, as well as to sign, date and specify the time.

Informed consent is a conversation with the patient, and much more than merely obtaining his or her signature on a form.

Lack of informed consent is a frequent allegation made by patients who have been injured, but it is usually successfully defended. Unfortunately, poor expectation management can set the litigation process in motion, and root cause analysis frequently demonstrates that patients and their families did not know a bad outcome could occur, which led to negative emotions, triggering a desire to sue. Fortunately, only a small minority of the claims in the American Society for Anesthesiologists’ Closed Claims project are based on informed consent issues.41 Medical negligence (malpractice) is ultimately determined in civil court and covered under tort law. It must be established that: 1. You had an obligation to take care of a patient (ie, duty), 2. You practiced below the local medical community standard of care (ie, breach of duty), 3. This breach of duty resulted in the injury (ie, proximate cause) and 4. The injury was significant enough that the patient is entitled to recover damages commensurate with the injury.42 What this boils down to with respect to regional anesthesia cases is proving that you did not provide prudent care to prevent an avoidable intraneural injection, or proper positioning and padding to prevent a positioning-related peripheral nerve injury, and that failure to provide this prudent care was the direct cause of the injury. This is an extremely high hurdle to overcome and, consequently, most of these cases will never go to trial, although they are a nuisance and time-consuming to defend.

On the other hand, if it is established that informed consent did not occur, this may be sufficient to prove negligence without having to demonstrate breach of duty or proximate cause; hence, the paramount importance of documenting informed consent in the medical record.

Using a test injection of as little as 0.5 mL of local anesthetic solution has been shown to be a sensitive indicator of potential intraneural needle placement, as evidenced by an increase in intraneural diameter under ultrasound.33 This may provide you with an opportunity to withdraw the needle to an extraneural position prior to injecting the remaining dose of local anesthetic solution.

Injection-pressure monitoring is a new modality, and has been recently demonstrated to have a sensitivity of 97% for detecting needle-nerve contact at the roots of the brachial plexus, with opening pressures greater than 15 psi.34 Presently, the major value of injection pressure monitoring may be in its negative predictive value, with low opening pressures as a marker to exclude either needle-nerve contact at the epineurium or subepineural needle placement at a location that could lead to nerve injury prior to injection.35 Although the presence of a catheter might seem to be inherently more likely to cause nerve injury than a single injection, multiple large series, case studies, and a meta-analysis have not shown this to be the case.1,36,37 The rationale for using adjuvants is to improve the quality, duration, or safety of the block. With continuous infusions for PNB catheters, there is no indication for using adjuvants other than perhaps when rebolusing a catheter after a secondary block failure, and adding epinephrine as a marker for intravascular injection.

Epinephrine, in concentrations of 1:200,000 to 1:400,000, has been used as a marker for intravascular injection in non–β-blocked patients in order to prevent delivering a full dose of local anesthetic and potentially prevent local anesthetic systemic toxicity (LAST). Solutions containing epinephrine have also been used to decrease systemic levels of local anesthetics via vasoconstriction and minimizing local absorption, and hence also increase duration of action, particularly with intermediate-duration local anesthetics such as mepivacaine and lidocaine.

Interestingly, the studies demonstrating a reduction in LAST with the use of ultrasound were performed in patient populations where the majority did not receive local anesthetic injections containing epinephrine.3,4,18 There is concern that when local anesthetic solutions with epinephrine are used in diabetic animal models, there is an increase in neurotoxicity.43 Case series in diabetic humans receiving epinephrine in local anesthetic solutions also show excessively prolonged block duration; hence, a conservative approach in diabetic patients may be to avoid epinephrine altogether, especially in large-diameter nerves such as the sciatic nerve.

Other commonly used adjuvants to enhance block quality and extend duration, without necessitating the use of continuous catheters, include buprenorphine, clonidine, dexmedetomidine, and dexamethasone.44 These are all off-label indications. When evaluating adjuvants, it is important to distinguish between systemic and perineural effects, while also appreciating the potential for perineural toxicity.45

Buprenorphine, clonidine, and dexmedetomidine46 appear to have direct perineural effects without perineural toxicity45 when used in normal clinical doses in preservative-free solutions, and have been shown to increase the duration of PNBs. Dexmedetomidine may even have neuroprotective effects in animal models of nerve injury.46 Dexamethasone has become an increasingly popular adjuvant, as studies have shown that it enhances the duration of ropivacaine blocks in the upper and lower extremity by a factor of 1.9, when given in doses of 8 to 10 mg perineurally.47,48 However, this effect is also present when the drug is administered systemically (IV or intramuscular) instead of perineurally.47,48 Liposomal bupivacaine (Exparel, Pacira) is an extended-release form of bupivacaine, and is approved for use to provide analgesia at the surgical incision site via direct local infiltration. Although not approved for perineural infiltration, there are reports of practitioners administering liposomal bupivacaine off-label for perineural and transversus abdominus plane (TAP) blocks.

Mechanisms of Nerve Injury When analyzing the cause of neurologic injury after regional anesthesia,49 it may be conceptually helpful to organize the causes of injury as being related to the patient’s underlying condition, the surgical procedure, or the block procedure. Most of the cases of PNI that we see have multifactorial etiology, and it is difficult to differentiate the magnitude of the contribution to the overall injury by the many component factors.

In one of the largest observational database studies of postoperative nerve injuries, which looked at 380,680 patients undergoing anesthetic procedures over a 10-year period at a major academic medical center, the authors concluded that peripheral nerve blockade was not an independent predictor of nerve injury after surgery.10 In contrast, patients with diabetes or hypertension and those using tobacco products were at higher risk, along with patients undergoing orthopedic surgery, neurosurgery, cardiac surgery, and general surgery.

The forces that cause nerve injury can be classified as those related to stretch, compression, ischemia, metabolic or toxic chemical injury, inflammation50 (Parsonage-Turner syndrome), and trauma (blunt or lacerating). Needle-related injury to the brachial plexus associated with performance of the block would cause either blunt or lacerating trauma as a mechanism of injury, or compression and ischemia from an intra- or extraneural hematoma.

Arthroscopic shoulder surgery has its own inherent risks for nerve injury,14 independent of anesthetic techniques, and these risks are associated with traction on the brachial plexus, due to positioning during surgery with abduction of the shoulder joint. In addition, irrigating fluid extravasation can cause tissue edema and compress the brachial plexus and peripheral nerves.

Arthroscopic portals can damage nerves, especially given the anatomic variability of nerve distribution.

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The Seddon classification of nerve injury (Table 2) is a useful clinical model to describe nerve injury, severity, and prognosis, dividing peripheral nerve injuries into 3 grades.49,51,52

Diagnosis and Treatment It is important to examine the patient and document the injury immediately, and then rule out a treatable cause, such as a hematoma or other mass effect causing compression and ischemia. This can be done with palpation on physical examination, or via imaging studies such as ultrasound or magnetic resonance imaging/ magnetic resonance neurography (MRI/MRN).

While purely sensory deficits can be managed conservatively and observed, any motor weakness is a serious injury and warrants an immediate neurologic consultation. This workup should include

Table 2. Seddon Classification of Nerve Injury Neurapraxia The most common and the least severe, this injury has the best prognosis.

This injury is limited to damage of the myelin sheath around the individual axon. Depending on the extent of damage to the sheath, nerve conduction may be slowed or completely blocked.

This is the injury seen usually as the result of nerve compression and stretch caused by patient positioning or due to tourniquet-related compression, stretch, and ischemia.

Since the axon is undamaged and remains in continuity, the nerve usually returns to normal function over a period of days to weeks with myelin regeneration and complete recovery.

Axonotmesis Constitutes more severe damage, with injury to the axon and the myelin sheath inside the protective endoneurium tube.

Due to preservation of the endoneurium, perineurium, and epineurium connective tissue highway, the nerve has the potential to regenerate on its own, although in some cases only incomplete recovery occurs.

Neurotmesis The most severe type of injury, this involves complete transection of the nerve, along with the connective tissue layers.

Surgical repair involving nerve transfers or nerve interposition grafts may completely or partially restore function, but the results are highly variable.

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electrodiagnostic (EDX) studies with nerve conduction studies (NCS; motor and sensory) and needle electromyography (EMG).

EDX studies, EMG, and NCS are helpful in that they can provide clues to the location, timing, and severity of the injury, and early signs of recovery.52-54 However, they cannot distinguish the cause of the injury, although they may be helpful when interpreted in light of the clinical picture.

Although it is usually recommended to obtain NCS 3 to 4 weeks after the diagnosis of a nerve injury, as most of them will have resolved spontaneously, in the event of a severe or profound deficit, a baseline study is appropriate. If there is a previously underlying and undetected injury, the EMG will show signs of chronic denervation, including increased insertional activity, fibrillation potentials, and sharp waves. EDX studies should be repeated at 1 month after injury, and then every 3 months to monitor recovery if the deficit does not show significant improvement.

There is no pharmacologic therapy that has been demonstrated to enhance neuroregeneration, so treatment is limited to physical therapy to maintain muscle mass and prevent flexion contractures, along with analgesic therapy using neuropathic agents and non-narcotic analgesics.

If there is no significant improvement in motor function by 6 to 9 months after injury, reconstructive nerve transfers or grafts should be considered, as the muscle fibers and neuromuscular junctions will irreversibly degenerate with fibrosis and function is unlikely to be restored. In the event that nerve transfers or grafting do not re-innervate the affected muscles, the only remaining surgical option to restore function is via tendon transfers from another viable muscle.

Although beyond the scope of this article, generally a demyelinating injury is diagnosed via NCS with a defining characteristic of a prolonged latency in motor and sensory stimulation. The needle EMG exam will confirm this with the absence of increased insertional activity and spontaneous activity, along with a lack of fibrillation potentials. All of these needle EMG findings are hallmarks of axonal injury. Axonal injury is further characterized on NCS with normal latencies but dramatically reduced amplitudes.

NCS can localize the site of the conduction block, and confirm or refute that the PNI lesion is at the site of the PNB; however, it may not always be possible to distinguish between anesthesia-related and surgical causes, when the surgical incision site and anesthetic block site, or tourniquet, are in close proximity.

Generally, block-related nerve injury for blocks performed at the brachial or lumbar plexus level is more likely to involve injury to multiple nerve distributions due to overlapping nerve root innervations. However, a nonâ&#x20AC;&#x201C;anesthetic-related inflammatory neuropathy such as neuralgic amyotrophy (Parsonage-Turner syndrome) could also mimic this presentation, along with stretch injuries to the brachial or lumbar plexus. In contrast,

a surgically caused injury or positioning injury would manifest as a mononeuropathy, or a mononeuropathy multiplex related to trauma to multiple nerves at or near the surgical site.

Conclusion Serious and permanent PNI after nerve block is a rare event, and most likely a result of multifactorial causes not necessarily related to the administration of a PNB. However, temporary minor injuries may be more common than appreciated. It is important to set expectations with patients about the risk for potential nerve

injury during the informed consent process, and meticulously document the block process in the medical record.

Post-block and postsurgical nerve injuries are neither entirely predictable nor preventable, even with expertly trained physicians utilizing best practices. EDX studies may be helpful in assessing the site of the nerve injury, its severity, whether or not a previously undiagnosed injury was present, and the time course and potential for recovery of function. It is important to understand the limitations of EDX and MRI/MRN with respect to determining the etiology of the nerve injury.

References 1.

Borgeat A, Ekatodramis G, Kalberer F, et al. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001;95:875-880.

15.

Neal JM, Bernards CM, Hadzic A, et al. ASRA practice advisory on neurologic complications in regional anesthesia and pain medicine. Reg Anesth Pain Med. 2008;33:404-415.

2.

Borgeat A, Dullenkopf A, Ekatodramis G, et al. Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery. Anesthesiology. 2003;99:436-442.

16.

Gerancher JC, Viscusi ER, Liguori GA, et al. Development of a standardized peripheral nerve block procedure note form. Reg Anesth Pain Med. 2005;30:67-71.

3.

Orebaugh SL, Kentor ML, Williams BA. Adverse outcomes associated with nerve stimulator-guided and ultrasound-guided peripheral nerve blocks by supervised trainees: update of a single-site database. Reg Anesth Pain Med. 2012;37:577-582.

17.

Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973;2:359-362.

18.

Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013;38:289-299.

19.

Orebaugh SL, Kentor ML, Williams BE. Adverse outcomes associated with nerve stimulator-guider and ultrasound-guided peripheral nerve blocks by supervised trainees: update of a single-site database. Reg Anesth Pain Med. 2012;37:577-582.

20.

Laur JJ, Weinberg GL. Comparing safety in surface landmarks versus ultrasound-guided peripheral nerve blocks: an observational study of a practice in transition. Reg Anesth Pain Med. 2012;37:569-570.

21.

Neal J, Brull R, Chan VW, et al. The ASRA evidence-based medicine assessment of ultrasound-guided regional anesthesia and pain medicine: executive Summary. Reg Anesth Pain Med. 2010;35:S1-S9.

22.

Liu SS, Zayas VM, Gordon MA, et al. A prospective, randomized controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg.

2009;109:265-271.

23.

Liguori G, Zayas VM, YaDeau JT, et al. Nerve localization techniques for interscalene brachial plexus blockade: a prospective randomized comparison of mechanical paresthesia vs. electrical stimulation. Anesth Analg. 2006;103:761-767.

24.

Bigeleisen P. Nerve puncture and apparent intraneural injection during ultrasound guided axillary block does not invariably result in neurologic injury. Anesthesiology. 2006;105:779-783.

25.

Liu SS, YaDeau JT, Shaw PM, et al. Incidence of unintentional intraneural injection and postoperative neurological complications with ultrasound-guided interscalene and supraclavicular nerve blocks. Anaesthesia. 2011;66:168-174.

26.

Hara K, Sakura S, Yokokawa N, et al. Incidence and effects of unintentional intraneural injection during ultrasoundguided subgluteal sciatic nerve block. Reg Anesth Pain Med. 2012;37:289-293.

27.

Franco C. Connective tissue associated with peripheral nerves.

Reg Anesth Pain Med. 2012;37:363-365.

28.

Orebaugh SL, McFadden K, Skorupan H, et al. Subepineurial injection in ultrasound-guided interscalene needle tip placement.

Reg Anesth Pain Med. 2010;35:450-454.

4.

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