August 2011 AN by McMahon Group

24th Annual

Corporate Profiles

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The Independent Monthly Newspaper for Anesthesiologists AnesthesiologyNews.com • A u g u s t 2 0 1 1 • Volume 37 Number 8

Pushing Mobility Can Reduce Costs, Deaths in ICU Pts

arly and aggressive physical therapy in intensive-care patients requiring short-term ventilator support can reduce mortality by 25% and substantially shorten hospital lengths of stay, Minnesota researchers have found. The findings, presented at the 2011 Society of Critical Care Medicine’s annual meeting (abstract 95), also show that the cost of implementing a mobility

Better Outcomes Seen With Standardized Handoff Protocol Two studies in cardiac surgery patients add to understanding of risk factors

andovers of patients during surgery are associated with an increased risk for mortality, but use of a standardized protocol might help lower that risk, according to new research presented at the 2011 annual meeting of the Society of Cardiovascular Anesthesiologists. Christopher Hudson, MD, staff anesthesiologist at the University of Ottawa Heart Institute, in Canada, and his colleagues

see mobility page 16

see handoff page 53

Interventionalist Battles Insurance Company INSIDE 12 | CLinical Anesthesiology Over Minimally Invasive Spine Procedures Epidurals not to blame for tear risk during labor.

oliath, meet David. An interventional pain physician has successfully sued an insurance company after the firm disallowed reimbursement for a percutaneous discectomy. This may pave the way for more broadbased action to try to force the company, 32BJ, and the firms from which it in turn gets coverage— Empire, WellPoint and Anthem, which are part of the Blue Cross and Blue Shield Association—to reconsider

their blanket policy against covering this interventional pain procedure. Meanwhile, it has spawned “copy-cat” denials by at least one and possibly many other health insurance plans.

“When did WellPoint/Empire become qualified to determine what constitutes the standard of care of medical practice?” asked Lawrence Kamhi, MD—the pain physician who successfully sued, and who practices at Beth Israel Hospital in New York City. “What license to practice medicine does WellPoint possess? Its unilateral action usurps that which is the proper domain of the various medical specialty boards.” The policy in question is see fight page 54

14 | CLinical Anesthesiology Rapid CO2 changes during ECMO linked to greater mortality in peds.

56 | Pain Medicine An EHR primer for the pain practitioner.

66 | ad lib Cliff jumping and other adventures of residency.

10 | Guiding Fluid Management in the

Surgical Setting: Part 1 of a 2-Part Series

59 | CME—PreAnesthetic Assessment Lesson 293: PreAnesthetic Assessment of the Drug Abuser: Value of Urine Drug Screening

anesthesianews accompanies this issue.

Does D o the anesthesiologist's or C R CRNA's signature have to be legible? Find the answer at: www.anesthesiallc.com/an-aug11

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August 2011

Discuss these and other articles @ AnesthesiologyNews.com.

Heard Here First: We have taken on the challenge of being

August 2011

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

perioperative physicians. But it’s now time to become peripartum physicians as well. For some centers, that means we

1. Fair Market Valuation: the Death Spiral of Physician Compensation

may even need to redefine

2. Findings Support Less Cautious Stance on Catheter Removal

peripartum intensivists.

ourselves as

3. Anesthesia Billing Cases Allege Rampant Fraud 4. More Evidence One Size of Anesthesia Doesn’t Fit All 5. Commonsense Pledge Cuts In-hospital Falls

Robert S. Lagasse, MD, New Haven, CT Alex Macario, MD, MBA, Stanford, CA ALIX MATHIEU, MD, MBA, MS, Cincinnati, OH The Independent monthly Newspaper for Anesthesiologists

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FASTEST GROWING IV SEDATIVE1

Different situations require different sedative solutions The first and only alpha2 agonist indicated for sedation2,3 Nonintubated patients prior to and during surgical and other procedures.2 Initially intubated and mechanically ventilated patients during treatment in an intensive care setting.2 Administer Precedex® by continuous infusion not to exceed 24 hours.2

Important Precedex Safety Information Clinically signiﬁcant episodes of bradycardia, sinus arrest and hypotension have been associated with Precedex infusion and may necessitate medical intervention. Moderate blood pressure and heart rate reductions should be anticipated when initiating sedation with Precedex. Prolonged exposure to dexmedetomidine beyond 24 hours may be associated with tolerance and tachyphylaxis and a dose-related increase in adverse events.

Learn more at www.Precedex.com A right fit for today’s sedation management practices Please see the brief summary of Prescribing Information on adjacent page. References: 1. Based on increases in weight of active ingredient sold (either mcg or mg). IMS Health National Sales Perspective 2Q 2009. US nonretail market, all channels injectables. 2. Precedex [package insert]. Lake Forest, IL: Hospira, Inc; 2008. 3. Kamibayashi T, Maze M. Clinical uses of α2-adrenergic agonists. Anesthesiology. 2000;93:1345-1349. Hospira, Inc. 275 North Field Drive, Lake Forest, IL 60045 P10-2637/R1, Mar., 11. Printed in the USA.

For more information on Advancing WellnessTM, contact your Hospira representative at 1-877-9HOSPIRA (1-877-946-7747) or visit www.hospira.com.

Reference EN-2680

Precedex®

(dexmedetomidine hydrochloride) injection

For Intravenous Use Rx only

To report SUSPECTED ADVERSE REACTIONS, contact Hospira, Inc. at 1-800-441-4100 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 1 1.1

INDICATIONS AND USAGE Intensive Care Unit Sedation Precedex® is indicated for sedation of initially intubated and mechanically ventilated patients during treatment in an intensive care setting. Precedex should be administered by continuous infusion not to exceed 24 hours. Precedex has been continuously infused in mechanically ventilated patients prior to extubation, during extubation, and post-extubation. It is not necessary to discontinue Precedex prior to extubation. 1.2 Procedural Sedation Precedex is indicated for sedation of non-intubated patients prior to and/or during surgical and other procedures. 4 CONTRAINDICATIONS None 5 WARNINGS AND PRECAUTIONS 5.1 Drug Administration Precedex should be administered only by persons skilled in the management of patients in the intensive care or operating room setting. Due to the known pharmacological effects of Precedex, patients should be continuously monitored while receiving Precedex. 5.2 Hypotension, Bradycardia, and Sinus Arrest Clinically significant episodes of bradycardia and sinus arrest have been reported with Precedex administration in young, healthy volunteers with high vagal tone or with different routes of administration including rapid intravenous or bolus administration. Reports of hypotension and bradycardia have been associated with Precedex infusion. If medical intervention is required, treatment may include decreasing or stopping the infusion of Precedex, increasing the rate of intravenous fluid administration, elevation of the lower extremities, and use of pressor agents. Because Precedex has the potential to augment bradycardia induced by vagal stimuli, clinicians should be prepared to intervene. The intravenous administration of anticholinergic agents (e.g., glycopyrrolate, atropine) should be considered to modify vagal tone. In clinical trials, glycopyrrolate or atropine were effective in the treatment of most episodes of Precedex-induced bradycardia. However, in some patients with significant cardiovascular dysfunction, more advanced resuscitative measures were required. Caution should be exercised when administering Precedex to patients with advanced heart block and/or severe ventricular dysfunction. Because Precedex decreases sympathetic nervous system activity, hypotension and/or bradycardia may be expected to be more pronounced in patients with hypovolemia, diabetes mellitus, or chronic hypertension and in elderly patients. In clinical trials where other vasodilators or negative chronotropic agents were co-administered with Precedex an additive pharmacodynamic effect was not observed. Nonetheless, caution should be used when such agents are administered concomitantly with Precedex. 5.3 Transient Hypertension Transient hypertension has been observed primarily during the loading dose in association with the initial peripheral vasoconstrictive effects of Precedex. Treatment of the transient hypertension has generally not been necessary, although reduction of the loading infusion rate may be desirable. 5.4 Arousability Some patients receiving Precedex have been observed to be arousable and alert when stimulated. This alone should not be considered as evidence of lack of efficacy in the absence of other clinical signs and symptoms. 5.5 Withdrawal Intensive Care Unit Sedation With administration up to 7 days, regardless of dose, 12 (5%) Precedex subjects experienced at least 1 event related to withdrawal within the first 24 hours after discontinuing study drug and 7 (3%) Precedex subjects experienced at least 1 event 24 to 48 hours after end of

study drug. The most common events were nausea, vomiting, and agitation. Tachycardia and hypertension requiring intervention in the 48 hours following study drug discontinuation occurred at frequencies of <5%. If tachycardia and/or hypertension occurs after discontinuation of Precedex supportive therapy is indicated. Procedural Sedation Withdrawal symptoms were not seen after discontinuation of short term infusions of Precedex (<6 hours). 5.6 Tolerance and Tachyphylaxis Use of dexmedetomidine beyond 24 hours has been associated with tolerance and tachyphylaxis and a dose-related increase in adverse reactions [see Adverse Reactions (6.1)]. 5.7 Hepatic Impairment Since Precedex clearance decreases with severity of hepatic impairment, dose reduction should be considered in patients with impaired hepatic function [see Dosage and Administration (2.2)]. 6 ADVERSE REACTIONS 6.1 Clinical Studies Experience Because clinical trials are conducted under widely varying conditions, adverse reactions rates observed in the clinical trials of a drug cannot be directly compared to rates in clinical trials of another drug and may not reflect the rates observed in practice. Use of Precedex has been associated with the following serious adverse reactions: • Hypotension, bradycardia and sinus arrest [see Warnings and Precautions (5.2)] • Transient hypertension [see Warnings and Precautions (5.3)] Most common treatment-emergent adverse reactions, occurring in greater than 2% of patients in both Intensive Care Unit and procedural sedation studies include hypotension, bradycardia and dry mouth. Intensive Care Unit Sedation Adverse reaction information is derived from the continuous infusion trials of Precedex for sedation in the Intensive Care Unit setting in which 1007 patients received Precedex. The mean total dose was 7.4 mcg/kg (range: 0.8 to 84.1), mean dose per hour was 0.5 mcg/kg/hr (range: 0.1 to 6.0) and the mean duration of infusion of 15.9 hours (range: 0.2 to 157.2). The population was between 17 to 88 years of age, 43% ≥65 years of age, 77% male and 93% Caucasian. Treatment-emergent adverse reactions occurring at an incidence of >2% are provided in Table 2. The most frequent adverse reactions were hypotension, bradycardia and dry mouth [see Warnings and Precautions (5.2)]. Table 2: Adverse Reactions With an Incidence >2%— Intensive Care Unit Sedation Population <24 hours*

Adverse Event Hypotension Hypertension Nausea Bradycardia Atrial fibrillation Pyrexia Dry mouth Vomiting Hypovolemia Atelectasis Pleural effusion Agitation Tachycardia Anemia Hyperthermia Chills Hyperglycemia Hypoxia Post-procedural hemorrhage Pulmonary edema Hypocalcemia Acidosis Urine output decreased Sinus tachycardia Ventricular tachycardia Wheezing Edema peripheral

All Randomized Precedex Precedex Placebo Propofol (N = 1007) (N = 798) (N = 400) (N = 188) (%) (%) (%) (%) 25% 12% 9% 5% 4% 4% 4% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 2%

24% 13% 9% 5% 5% 4% 3% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 2%

12% 19% 9% 3% 3% 4% 1% 5% 2% 3% 1% 3% 4% 2% 3% 3% 2% 2%

13% 4% 11% 0 7% 4% 1% 3% 5% 6% 6% 1% 1% 2% 0 2% 3% 3%

2% 1% 1% 1%

3% 1% 0 1%

4% 3% 2% 2%

1% 1%

0 1%

2% 2%

<1% <1% <1%

1% 1% 0

1% 0 1%

5% 2% 2%

* 26 subjects in the all Precedex group and 10 subjects in the randomized Precedex group had exposure for greater than 24 hours.

Adverse reaction information was also derived from the placebo-controlled, continuous infusion trials of Precedex for sedation in the surgical intensive care unit setting in which 387 patients received Precedex for less than 24 hours. The most frequently observed treatmentemergent adverse events included hypotension, hypertension, nausea, bradycardia, fever, vomiting, hypoxia, tachycardia and anemia (see Table 3). Table 3: Treatment-Emergent Adverse Events Occurring in >1% Of All Dexmedetomidine-Treated Patients in the Randomized Placebo-controlled Continuous Infusion <24 Hours ICU Sedation Studies Adverse Event

Randomized Dexmedetomidine (N = 387)

Placebo (N = 379)

28% 16% 11% 7% 5% 4% 4% 4% 3% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 2% 2%

13% 18% 9% 3% 4% 6% 3% 4% 5% 4% 2% 1% 3% 3% 3% 2% 2% 2% 1% <1% <1%

Hypotension Hypertension Nausea Bradycardia Fever Vomiting Atrial Fibrillation Hypoxia Tachycardia Hemorrhage Anemia Dry Mouth Rigors Agitation Hyperpyrexia Pain Hyperglycemia Acidosis Pleural Effusion Oliguria Thirst

In a controlled clinical trial, Precedex was compared to midazolam for ICU sedation exceeding 24 hours duration. Key treatment emergent adverse events occurring in dexmedetomidine or midazolam treated patients in the randomized active comparator continuous infusion long-term intensive care unit sedation study are provided in Table 4. The number (%) of subjects who had a dose-related increase in treatment-emergent adverse events by maintenance adjusted dose rate range in the Precedex group is provided in Table 5. Table 4: Key Treatment-Emergent Adverse Events Occurring in Dexmedetomidine- or Midazolam-Treated Patients in the Randomized Active Comparator Continuous Infusion Long-Term Intensive Care Unit Sedation Study* Adverse Event Hypotension1 Hypotension requiring intervention Bradycardia2 Bradycardia requiring intervention Systolic Hypertension3 Tachycardia4 Tachycardia requiring intervention Diastolic Hypertension3 Hypertension3 Hypertension requiring intervention† Hypokalemia Pyrexia Agitation Hyperglycemia Constipation Hypoglycemia Respiratory Failure Renal Failure Acute Acute Respiratory Distress Syndrome Generalized edema Hypomagnesemia

Dexmedetomidine (N=244)

Midazolam (N=122)

56%

28% 42%

27% 19%

5% 28% 25%

1% 42% 44%

10% 12% 11%

10% 15% 15%

19% 9% 7% 7% 7% 6% 5% 5% 2%

30% 13% 2% 6% 2% 6% 6% 3% 1%

2% 2% 1%

1% 6% 7%

† Includes any type of hypertension. 1 Hypotension was defined in absolute terms as Systolic blood

pressure of <80 mmHg or Diastolic blood pressure of <50 mmHg or in relative terms as ≤30% lower than pre-study drug infusion value. 2 Bradycardia was defined in absolute terms as <40 bpm or in relative terms as ≤30% lower than pre-study drug infusion value. 3 Hypertension was defined in absolute terms as Systolic blood pressure >180 mmHg or Diastolic blood pressure of >100 mmHg or in relative terms as ≥30% higher than pre-study drug infusion value. 4 Tachycardia was defined in absolute terms as >120 bpm or in relative terms as ≥30% greater than pre-study drug infusion value.

The following adverse events occurred between 2 and 5% for Precedex and Midazolam, respectively: renal failure acute (2.5%, 0.8%), acute respiratory distress syndrome (2.5%, 0.8%), and respiratory failure (4.5%, 3.3%). Table 5. Number (%) of subjects who had a dose-related increase in Treatment Emergent Adverse Events by maintenance adjusted dose rate range in the Precedex group Precedex mcg/kg/hr Adverse Event

≤ 0.7* N = 95

> 0.7 to ≤ 1.1* N = 78

> 1.1* N = 71

6% 5% 5% 3% 2% 2%

5% 8% 5% 5% 4% 6%

14% 14% 9% 7% 9% 10%

Constipation Agitation Anxiety Oedema peripheral Atrial fibrillation Respiratory failure Acute Respiratory Distress Syndrome

*Average maintenance dose over the entire study drug administration

Procedural Sedation Adverse reaction information is derived from the two trials for procedural sedation in which 318 patients received Precedex. The mean total dose was 1.6 mcg/kg (range: 0.5 to 6.7), mean dose per hour was 1.3 mcg/kg/hr (range: 0.3 to 6.1) and the mean duration of infusion of 1.5 hours (range: 0.1 to 6.2). The population was between 18 to 93 years of age, 30% ≥65 years of age, 52% male and 61% Caucasian. Treatment-emergent adverse reactions occurring at an incidence of >2% are provided in Table 6. The most frequent adverse reactions were hypotension, bradycardia, and dry mouth [see Warnings and Precautions (5.2)]. Pre-specified criteria for the vital signs to be reported as adverse reactions are footnoted below the table. The decrease in respiratory rate and hypoxia was similar between Precedex and comparator groups in both studies. Table 6: Adverse Reactions With an Incidence > 2%—Procedural Sedation Population

Adverse Event Hypotension1 Respiratory depression2 Bradycardia3 Hypertension4 Tachycardia5 Nausea Dry mouth Hypoxia6 Bradypnea

Precedex N = 318 (%)

Placebo N = 113 (%)

54% 37% 14% 13% 5% 3% 3% 2% 2%

30% 32% 4% 24% 17% 2% 1% 3% 4%

Hypotension was defined in absolute and relative terms as Systolic blood pressure of <80 mmHg or ≤30% lower than pre-study drug infusion value, or Diastolic blood pressure of <50 mmHg.

Respiratory depression was defined in absolute and relative terms as respiratory rate (RR) <8 beats per minute or > 25% decrease from baseline.

Bradycardia was defined in absolute and relative terms as <40 beats per minute or ≤30% lower than pre-study drug infusion value.

Hypertension was defined in absolute and relative terms as Systolic blood pressure >180 mmHg or ≥30% higher than pre-study drug infusion value or Diastolic blood pressure of >100 mmHg.

Tachycardia was defined in absolute and relative terms as >120 beats per minute or ≥30% greater than pre-study drug infusion value.

Hypoxia was defined in absolute and relative terms as SpO2 <90% or 10% decrease from baseline.

Postmarketing Experience The following adverse reactions have been identified during post approval use of Precedex. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Hypotension and bradycardia were the most common adverse reactions associated with the use of Precedex during post approval use of the drug.

Table 7: Adverse Reactions Experienced During Post-approval Use of Precedex Body System

Preferred Term

Body as a Whole

Fever, hyperpyrexia, hypovolemia, light anesthesia, pain, rigors

Cardiovascular Disorders, General

Blood pressure fluctuation, heart disorder, hypertension, hypotension, myocardial infarction

Central and Peripheral Nervous System Disorders

Dizziness, headache, neuralgia, neuritis, speech disorder, convulsion

Gastrointestinal System Disorders

Abdominal pain, diarrhea, vomiting, nausea

Heart Rate and Rhythm Disorders

Arrhythmia, ventricular arrhythmia, bradycardia, hypoxia, atrioventricular block, cardiac arrest, extrasystoles, atrial fibrillation, heart block, t wave inversion, tachycardia, supraventricular tachycardia, ventricular tachycardia

Liver and Biliary System Disorders

Increased gamma-glutamyl transpepsidase, hepatic function abnormal, hyperbilirubinemia, alanine transaminase, aspartate aminotransferase

Metabolic and Acidosis, respiratory acidosis, Nutritional Disorders hyperkalemia, increased alkaline phosphatase, thirst, hypoglycemia Psychiatric Disorders

Agitation, confusion, delirium, hallucination, illusion

Red Blood Cell Disorders

Anemia

Renal Disorders

Blood urea nitrogen increased, oliguria

Respiratory System Disorders

Apnea, bronchospasm, dyspnea, hypercapnia, hypoventilation, hypoxia, pulmonary congestion

Skin and Appendages Disorders

Increased sweating

Vascular Disorders

Hemorrhage

Vision Disorders

Photopsia, abnormal vision

OVERDOSAGE The tolerability of Precedex was studied in one study in which healthy subjects were administered doses at and above the recommended dose of 0.2 to 0.7 mcg/kg/hr. The maximum blood concentration achieved in this study was approximately 13 times the upper boundary of the therapeutic range. The most notable effects observed in two subjects who achieved the highest doses were first degree atrioventricular block and second degree heart block. No hemodynamic compromise was noted with the atrioventricular block and the heart block resolved spontaneously within one minute. Five patients received an overdose of Precedex in the intensive care unit sedation studies. Two of these patients had no symptoms reported; one patient received a 2 mcg/kg loading dose over 10 minutes (twice the recommended loading dose) and one patient received a maintenance infusion of 0.8 mcg/kg/hr. Two other patients who received a 2 mcg/kg loading dose over 10 minutes, experienced bradycardia and/or hypotension. One patient who received a loading bolus dose of undiluted Precedex (19.4 mcg/kg), had cardiac arrest from which he was successfully resuscitated.

6.2

Manufactured and Distributed by: Hospira, Inc. Lake Forest, IL 60045 USA Licensed from: Orion Corporation Espoo, Finland Printed in USA Hospira, Inc., Lake Forest, IL 60045 USA

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I N BRIE F

“Tenfold” Errors Pose Problem in Peds Units

edication errors in which dosages are 10 times higher or lower than appropriate account for 4.5% of medication-related safety errors in children, Canadian researchers have found. Children are at particular risk for these so-called “tenfold” dosing errors because of wide ranges in age, weight, dosage,

formulations and dilutions used in these patients, according to the researchers. The investigators, Catherine Doherty, MD, and Conor McDonnell, MD, anesthesiologists at the Hospital for Sick Children in Toronto, offered several suggestions for hospitals to prevent tenfold errors in pediatric units.

Under the microscope.1 Echogenic pattern under coating helps reduce impact on feel.

NG I M N COSOO

Their recommendations included increased vigilance for specific drug use; pharmacotherapy clinical care bundles for sepsis in the emergency room, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU); opioid ordering and dispensing;

Under ultrasound.2 Echogenic pattern produces clear, crisp image with reduced artifacts and acoustic shadowing.

Stimuplex® Ultra. Echogenicity without Compromise. Improved visibility without negatively impacting tactile feel and acoustic needle shadowing. Same tactile feedback, needle feel and overall handling as B. Braun’s clinically-proven3 Stimuplex A needle. Reduced acoustic shadowing and artifacts under the needle may facilitate safer needle advancement during Supraclavicular and Popliteal nerve blocks. 30 degree, short bevel. Most experts agree that short bevel needles (30-45°) carry less risk of causing nerve injuries during PNB than sharp needles with longer beveled tips.4

Learn more about Stimuplex Ultra. Scan the QR code or go to http://bit.ly/stimultra 1. Microscope image at 25x from Uni of Hanover, Stimuplex Ultra 22G. 2. Stimuplex Ultra 22G, animal model, 45 degrees. 3. A. Sardesai, N. Denny., M. Herrick, A. Lynch, A. W. HarropGriffiths, “A study of the characteristics of single-injection insulated block needles in a biologic model.” RAPM Vol. 29 No. 5, (Sept- Oct, 2004.) 4. Admir Hadzic, Peripheral Nerve Blocks: Principles and practices. 2004. The McGraw-Hill Companies Inc.

and the development of new drug delivery systems and IV pumps. “Intravenous pumps need to be redesigned and re-imagined while taking human factors engineering and safety practices into account. Many pediatric tenfold errors could be avoided if the design of the keypad did not have the ‘decimal point,’ ‘zero’ and ‘confirm’ buttons side by side,” Dr. McDonnell told Anesthesiology News. To identify the scope of the problem, Drs. McDonnell and Doherty collected data from 300 pediatric care centers that voluntarily submitted all medication-related safety reports. The information contained in the reports included reporting rates, types of errors, frequency of errors, drugs and drug classes, and patient harm. Approximately 6,000 reports were submitted between 2004 and 2009, or about three per day over the study period. Of those, 252 were tenfold medication errors; 178 involved overdoses and 74 were underdoses. Opioids were the drug class most frequently cited in a tenfold error, and morphine was the most commonly involved drug. Patient harm was reported in 22 cases. Errors resulted from incorrect dosage calculations, documentation of decimal points and the addition of extra zeros. Tenfold errors occurred most often in the PICU and NICU; however, errors that led to harm were most likely to take place on the hospital wards. The study was presented at the 2011 annual meeting of the Canadian Anesthesiologists’ Society (abstract 1066898). —Kevin Enright

11-2724_AN_7/11_BB

August 2011

AnesthesiologyNews.com I 9

CL I N I CA L A N ESTHESIOL OGY

Pre-op Aspirin Cuts Post-op Renal Failure in Cardiac Surgery Patients

postoperative dialysis (0.8% vs. 3.1%; P=0.014). Nevertheless, the 30-day mortality rate did not differ significantly between iscontinuing aspirin therapy previous myocardial infarction (25.9% events (8.6% vs. 12.5%; groups (4.1% vs. 5.8%; prior to elective cardiac sur- vs. 14.6%; P<0.001), angina (29.1% P=0.035), in a multiP=0.396). gery may someday fade from vs. 17.4%; P<0.001) and family history variate logistic regresThe researchers prepractice if the results of a retrospective of coronary artery disease (58.9% vs. sion analysis. The adjusted odds ratio sented more data at Euroanaesthesia study of more than 1,000 patients are 43.2%; P<0.001). was 0.585. The incidence of postop- 2011 confirming many of those findvalidated in future prospective trials. Aspirin taken preoperatively signif- erative renal failure also was signifi- ings. But that study, which included Jian-Zhong Sun, MD, PhD, and col- icantly reduced the incidence of post- cantly lower in the aspirin group (2.6% nearly 2,900 bypass patients, found see aspirin page 16 leagues at Thomas Jefferson University, operative cardiocerebral ischemic vs. 5.2%; P=0.035), as was a need for in Philadelphia, found that patients who took aspirin within five days of cardiac surgery had significantly fewer cardiocerebral ischemic events and less renal failure postoperatively than their counterparts who did not receive aspirin therapy within that period. “Over the past four decades, tremendous progress has been made in the field of cardiac surgery,” said Dr. Sun, associate professor of anesthesiology at Jefferson. “However, major cardiocerebral and renal complications remain common and significant after cardiac surgery, especially for older and sicker patients.

TURN UP THE POWER OF PREWARMING

It was not particularly surprising to find that aspirin-taking patients experienced fewer cardiocerebral adverse events; the reduction in renal complications, however, was unforeseen. In the surgical setting, Dr. Sun said, early postoperative aspirin therapy has been reported to improve postoperative complications in patients receiving coronary artery bypass grafts. However, whether preoperative aspirin therapy can reduce major adverse cardiocerebral and renal events in these patients has yet to be determined. Dr. Sun and colleagues analyzed data from 1,148 cardiac surgery patients, of whom 860 took aspirin within five days of surgery and 288 did not. The investigators presented their study results at the 2010 annual meeting of the American Society of Anesthesiologists (abstract A1190). Patients taking aspirin were significantly more likely than the other group to have a history of hypertension (84.5% vs. 69.3%; P<0.001), diabetes (35.2% vs. 23.6%; P<0.001), peripheral artery disease (11.1% vs. 4.2%; P<0.001),

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THE SCIENCE BEHIND POSITIVE PATIENT OUTCOMES

Part 1 of a 2-Part Series

Guiding Fluid Management in the Surgical Setting Faculty Maxime Cannesson, MD, PhD Department of Anesthesiology & Perioperative Care School of Medicine University of California, Irvine Irvine, California

Introduction The assessment of intravascular volume status and optimization of hemodynamics remains an important clinical challenge. This is particularly true in the intraoperative and critical care settings,1 where rapid and dynamic changes in hemodynamic parameters can be caused by anesthetics, blood loss, impaired cardiac contractility, and changes in systemic vascular resistance (SVR) and autonomic nervous system outflow.2 A key determinant of successful hemodynamic optimization is the ability to characterize where left ventricular cardiac mechanics lie on the Frank-Starling curve— whether relative hypovolemia is present and whether administration of fluids will result in preload-dependent increase in cardiac output (CO)—thereby increasing blood flow and oxygen delivery.3 Often, the clinician’s inability to accurately and proactively assess this parameter leads to misuse of fluids, inotropes, or pressors, resulting in worse outcomes during surgery that persist into the postoperative period. For example, the use of fluid administration in a patient whose cardiac mechanics are at the upper end of the Frank-Starling curve actually can impede forward CO as well as lead to pulmonary edema, resulting in impaired oxygenation and poor outcomes.4 In this manner, empiric fluid management strategy has the potential of prolonging mechanical ventilation and hospital length of stay (LOS), and causing worse overall outcomes.5-7 The concept of goal-directed hemodynamic management, which relies on evidence-based interventions guided by continuous monitoring of key hemodynamic parameters, has evolved as a response to the poor outcomes seen with empiric volume management. Clinical evidence shows that

FloTrac Sensor

goal-directed hemodynamic optimization of high-risk patients, initiated in the operating room (OR) and continued in the intensive care unit (ICU), not only improves shortterm outcomes, but also increases long-term survival.5,8 In fact, one recent meta-analysis of 29 studies concluded that a preemptive strategy of hemodynamic monitoring and intervention significantly reduces surgical morbidity and mortality.5 Despite the demonstrated value of goaldirected hemodynamic management, the American Society of Anesthesiologists guidelines do not offer definitive recommendations regarding the optimal parameters on which to guide evidence-based interventions.9 This review will briefly discuss the limitations associated with traditional methods used to assess circulatory parameters, as well as an emerging and perhaps more sensitive and proactive strategy to assess hemodynamics for the optimization of CO and patient outcomes.

Traditional Strategies For Fluid Management In the Perioperative Setting The key question to ensure tissue perfusion and circulatory optimization is whether administration of fluids under specific situations would result in a clinically relevant increase in CO, thereby enhancing tissue perfusion and oxygen delivery.1,2,10 Furthermore, a strategy that does not require an empiric fluid challenge in order to determine whether fluid administration would increase CO has the obvious benefit of precluding fluid administration and volume overload–induced complications in patients whose cardiac mechanics were proactively characterized as “fluid nonresponsive.”3 Unfortunately, methods that have been used to assess fluid responsiveness over the past several decades have failed to reliably satisfy either of these standards.1,2,10-13 The most rudimentary measure used for this purpose is the mean arterial pressure (MAP), but this value alone provides little useful information regarding actual blood flow or oxygen delivery.2 Similarly, measurement of central venous pressure (CVP) via placement of a central venous catheter in combination with measured urine output are loose and highly indirect measures with a large degree of temporal lag that correlate very poorly with CO.2,10 In fact, Marik and colleagues have shown that CVP has only about 50% predictability for fluid responsiveness.14 This has led investigators to state that CVP should not be used in ICUs or ORs because of its lack of accuracy.10,13 Placement of a pulmonary artery catheter (PAC) allows measurement of pulmonary artery occlusion pressure (PAOP) as well as estimation of CO and SVR through the

ANESTHESIOLOGY NEWS • AUGUST 2011

thermodilution method.2,10,15 However, PAC placement is not suitable for all patients, and high-profile studies suggest that placement of a PAC as part of a standardized protocol does not necessarily improve patient outcomes.16,17 Additionally, placement of an intravascular catheter, whether for measurement of CVP or PAOP, is associated with various complications, including vascular trauma and bleeding, infection, air embolism, deep venous thrombosis, and arrhythmia.18-20 In an effort to determine fluid responsiveness, intraoperative transesophageal echocardiography (TEE) also has been used to assess left ventricular function, but this technique is cumbersome and the value of the measured data is highly operator-dependent.1,10 As indicated above, the poor sensitivity of these methods for dynamic assessment of CO is further complicated by the fact that although they can sometimes identify when CO increases in response to fluid administration (which may therefore prompt consideration of additional fluid administration), they cannot reliably predict fluid responsiveness without an empiric fluid challenge.4,21

FloTrac® System: Using Stroke Volume Variation To Guide Hemodynamic Management Investigators have suggested that hemodynamic assessment can be more specifically and dynamically assessed in a prospective fashion through the assessment of stroke volume (SV) and stroke volume variation (SVV).14,22-25 These principles are based on the fact that SV is 1 of the 2 determinants of CO and that SV is the first parameter to change when a patient has volume loss. The natural phenomenon of SVV, which occurs due to normal changes in SV resulting from respiratory cycle–induced changes in venous return, acts as a small endogenous physiologic fluid challenge and can be used as an assessment of the Frank-Starling state (ie, fluid responsiveness) of the left ventricle without the need for an empiric challenge with exogenous fluids.3,4,23-25 Because arterial pulse pressure is directly proportional to SV, SVV can be used as an indicator of pulse pressure variation (PPV).3,14,25 This strategy has the advantage of easy and relatively noninvasive monitoring through placement of a peripheral arterial catheter.26 In fact, this is the basis by which the FloTrac system (Edwards Lifesciences) operates.27 The FloTrac system consists of a sensor connected to an existing radial or femoral arterial line and processing display unit, which requires input of the patient’s height, age, weight, and sex.26,27 The system calculates vascular tone and CO continuously without the need for independent calibration.27

The FloTrac system displays the CO on a continuous basis and reports the SVV.26 The system also is capable of reporting SVR and venous oxygen saturation if a central venous oximetry catheter is used.27 FloTrac system–determined SVV has been shown to be a reliable predictor of increases in CO in response to fluid administration,27,28 with SVV less than 8% roughly corresponding to fluid nonresponsiveness and SVV greater than 14% roughly corresponding to fluid responsiveness.26,29 For example, Benes and colleagues performed a study of 120 patients undergoing elective intra-abdominal surgery who were randomized to either routine intraoperative care (control group) or fluid management guided by SVV as determined by the FloTrac system.28 Patients in the FloTrac system group received more intraoperative fluids (1,425 mL [1,000-1,500] vs 1,000 mL [540-1,250]; P=0.0028),28 had fewer hypotensive events (2 [1-2] vs 3.5 [2-6]; P=0.0001), lower lactate levels (1.78 ± 0.83 mmol/L vs 2.25 ± 1.12 mmol/L; P=0.0252), fewer complications (18 [30%] vs 35 [58.3%] patients; P=0.0033), and shorter hospital LOS (9 [8-12] vs 10 [8-19] days; P=0.0421).28 Ramsingh and colleagues studied the use of FloTrac system versus conventional hemodynamic management in 41 patients undergoing major abdominal surgery.30 The FloTrac system group experienced significantly shorter hospital stays (7.25 ± 4.6 days vs 10.1 ± 6.6 days; P=0.01) and experienced a faster return of both gastrointestinal function (P=0.002) and ability to urinate (P= 0.02).30 Several clinical situations in which physiologic SVV is altered interfere with the utility of this parameter to assess fluid responsiveness, as with other pulse pressure/ pulse contour systems. These include openchest procedures, use of low tidal volume mechanical ventilation, right ventricular failure, and arrhythmia.31-33 However, SV and CO are still valuable parameters.

Conclusion Goal-directed perioperative hemodynamic and fluid management results in improved short- and long-term outcomes and can be easily achieved/integrated. Traditional measures, including MAP, CVP, PAOP, and even intraoperative TEE, have specific drawbacks that limit their use for the optimization of perioperative volume status. By contrast, SVV can be used to predict whether CO will increase in response to a fluid challenge. The FloTrac system can easily and dynamically assess SVV through analysis of PPV via an arterial catheter and has been shown to result in improved outcomes when used to guide perioperative fluid management.

Supported by Edwards Lifesciences

1. Hamilton MA. Perioperative fluid management: progress despite lingering controversies. Cleve Clin J Med. 2009;76 (suppl 4):S28-S31. 2. Grocott MP, Mythen MG, Gan TJ. Perioperative fluid management and clinical outcomes in adults. Anesth Analg. 2005;100(4):1093-1106. 3. Cannesson M, Aboy M, Hofer CK, Rehman M. Pulse pressure variation: where are we today? J Clin Monit Comput. 2010 Apr 14. [Epub ahead of print] 4. Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005;103(2): 419-428. 5. Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg. 2011;112(6):1392-1402. 6. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137(6):511-520. 7. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368-1375. 8. Rhodes A, Cecconi M, Hamilton M, et al. Goaldirected therapy in high-risk surgical patients: a 15-year follow-up study. Intensive Care Med. 2010; 36(8):1327-1332. 9. Crawford AM, Josh GP; American Society of Anesthesiologists. Perioperative fluid management: minimization versus goal-directed therapy. http//www.asahq. org/Knowledge-Base/Anesthesia-Practice/ASA/Perioperative-Fluid-Management-Minimization-VersusGoal-Directed-Therapy.aspx. Accessed May 3, 2011. 10. Ahrens T. Stroke volume optimization versus central venous pressure in fluid management. Crit Care Nurse. 2010;30(2):71-72. 11. Conners AF Jr, Dawson NV, Shaw PK, Montenegro HD, Nara AR, Martin L. Hemodynamic status in critically ill patients with and without acute heart disease. Chest. 1990;98(5):1200-1206. 12. Hoeft A, Schorn B, Weyland A, et al. Bedside assessment of intravascular volume status in patients undergoing coronary bypass surgery. Anesthesiology. 1994;81(1):76-86. 13. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172-178. 14. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37(9):2642-2647. 15. Hansen RM, Viquerat CE, Matthay MA, et al. Poor correlation between pulmonary arterial wedge pressure and left ventricular end-diastolic volume after coronary artery bypass graft surgery. Anesthesiology. 1986;64(6):764-770. 16. Hadian M, Pinsky MR. Evidence-based review of the use of the pulmonary artery catheter: impact data and complications. Crit Care. 2006;10(suppl 3):S8. 17. Connors AF Jr, Speroff T, Dawson NV, et al; SUPPORT Investigators. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA. 1996;276(11):889-897. 18. Kusminsky RE. Complications of central venous catheterization. J Am Coll Surg. 2007;204(4):681-696. 19. Reynen K. 14-year follow-up of central embolization by a guidewire. N Engl J Med. 1993;329(13):970-971. 20. Scott WL. Complications associated with central venous catheters. A survey. Chest. 1988;94(6): 1221-1224. 21. Gardner RM. Direct blood pressure measurement— dynamic response requirements. Anesthesiology. 1981;54(3):227-236. 22. Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest. 2002;121(6):2000-2006. 23. McGee WT. A simple physiologic algorithm for managing hemodynamics using stroke volume and stroke volume variation: physiologic optimization program. J Intensive Care Med. 2009;24(6):352-360. 24. Tavernier B, Makhotine O, Lebuffe G, Dupont J, Scherpereel P. Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. Anesthesiology. 1998;89(6):1313-1321. 25. Michard F, Boussat S, Chemia D, et al. Relation between respiratory changes in arterial pulse

Case Study: A 49-Year-Old Man Is Referred for a Right Nephrectomy Under General Anesthesia The medical history includes a history of smoking (1 pack per day for 30 years), alcohol use, and IV drug use now discontinued. The patient’s height is 1.83 m and weight is 63 kg. A preoperative echocardiograph (EKG) is normal; left ventricular ejection fraction is 45%. Additionally, the EKG shows mild pulmonary hypertension (systolic pulmonary artery pressure is 40 mm Hg) and moderate right ventricular dysfunction (right ventricle is slightly dilated). The plan for anesthesia management consists of induction with IV etomidate and fentanyl and maintenance using inhaled sevoflurane and fentanyl boluses. Vascular access consists of a peripheral IV (16-gauge needle), a left subclavian central venous double-lumen catheter equipped with central venous oxygen saturation (ScvO2) readings (PreSep central venous oximetry catheter, Edwards Lifesciences), and a left radial arterial line. Hemodynamic monitoring relies on central venous pressure, cardiac output (CO) monitoring (FloTrac Monitor, ScvO2 monitoring, Edwards Lifesciences), and stroke volume variation (SVV). The goal of the hemodynamic management was to keep SVV below 13% and ScvO2 above 75%, and to maximize CO. Baseline crystalloids infusion is 5 mL/kg per hour. After 1 hour of surgery, the estimated blood loss is 800 mL (Figure 1). At this stage, it was decided to administer 500 mL of IV fluids (6% hydroxyethyl starch) because the SVV was significantly higher than 13% (18 %) with a low CO and a low ScvO2. At this point, we measured hemoglobin (Hb) and hematocrit. Volume expansion induced a significant increase in CO (from 2.9 to 3.5 L/min; 21% increase) and a significant decrease in SVV (from 17% to 10%). At the same time, we observed an increase in ScvO2 and in other hemodynamic parameters. Hb was measured at 7.9 g/dL, which led to the decision to transfuse 2 units of blood (Figure 2). Because SVV was in the “gray” or “inconclusive zone” (between 8% and 13% corresponding to SVV values for which fluid responsiveness prediction is unclear) and

Figure 1.

Data observed after 1 hour of surgery. Estimated blood loss is 800 mL.

pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000;162(1):134-138. 26. Cannesson M, Musard H, Desebbe O, et al. The ability of stroke volume variations obtained with Vigileo/FloTrac system to monitor fluid responsiveness in mechanically ventilated patients. Anesth Analg. 2009;108(2):513-517. 27. Manecke GR. Edwards FloTrac sensor and Vigileo monitor: easy, accurate, reliable cardiac output assessment using arterial pulse wave. Expert Rev Med Devices. 2005;2(5):523-527. 28. Benes J, Chytra I, Altmann P, et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care. 2010;14(3):R118.

ScvO2 and Hb were still low, it was logical at this point to give more fluid and to switch to blood because of the Hb value. At this stage, Hb was measured at 10.7 g/dL. SVV was 8%, below the threshold for fluid administration. The only abnormally low parameter was ScvO2 (66%), indicating that there was a mismatch between oxygen consumption and oxygen delivery. Because Hb and oxygen saturation were normal and because SVV suggested that the patient was now a nonresponder to volume expansion, it was decided to administer a small dose of dobutamine (5 mcg/kg per minute), thus increasing CO and ultimately oxygen delivery (Figure 3). Moreover, blood transfusion increased ScvO2 but had very little impact on CO (only 5% increase). At the end of surgery, the patient was extubated in the operating room. Dobutamine was discontinued 1 hour after surgery. The patient stayed overnight in the intensive care unit and was sent back to the ward on day 1. The postoperative course was uneventful. Fluid management during surgery has a large impact on postoperative outcome. As can be seen in this case, fluid management and administration was based on a well-defined strategy aimed at optimizing CO and oxygen delivery. This management allowed better and more rational fluid administration and helped to tailor hemodynamic optimization based on the patient’s specific situation. In the absence of this simple hemodynamic monitoring system, it is more likely that fluid administration would have been different and would have resulted in a different outcome. Moreover, once CO and SVV have been optimized, this monitoring system helped to introduce dobutamine in order to improve ScvO2 (in this case Hb was already normalized). Implementing simple protocols for fluid and hemodynamic optimization is easy and can help to improve patient outcomes. Moreover, they have the ability to standardize hemodynamic management and to decrease individual variation between anesthesiology providers.

Figure 2.

Figure 3.

Data observed after 2 units of blood.

Data observed after introduction of dobutamine (5 mcg/kg per minute).

29. Derichard A, Robin E, Tavernier B, et al. Automated pulse pressure and stroke volume variations from radial artery: evaluation during major abdominal surgery. Br J Anaesth. 2009;103(5):678-684. 30. Ramsingh D, Gamboa J, Applegate R. Evaluation of a goal directed protocol in low-moderate risk patients having major abdominal surgery. Presented at American Society of Anesthesiologists Annual Meeting; October 18, 2010; San Diego, CA. 31. Rueter DA, Kirchner A, Felbinger TW, et al. Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function. Crit Care Med. 2003;31(5): 1399-1404. 32. de Waal EE, Rex S, Kruitwagen CL, Kalkman CJ, Buhre WF. Dynamic preload indicators fail to predict fluid

responsiveness in open-chest conditions. Crit Care Med. 2009;37(2):510-515. 33. Charron C, Fessenmeyer C, Cosson C, et al. The influence of tidal volume on the dynamic variables of fluid responsiveness in critically ill patients. Anesth Analg. 2006;102(5):1511-1517. This 2-part series is sponsored and funded by Edwards Lifesciences. Dr. Maxime Cannesson is a paid consultant of Edwards Lifesciences. CAUTION: Federal (United States) law restricts this device to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events.

ANESTHESIOLOGY NEWS • AUGUST 2011

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Preexisting Conditions May Significantly Influence Maternal Outcomes

hen it comes to preventing poor outcomes in laboring women, hospitals must do a better job of figuring out how much risk they are willing to accept and when to recommend that mothers-to-be seek care at facilities better equipped to handle potentially complicated cases. That is the implication of a new study that found that preexisting conditions unrelated to pregnancy can greatly increase the likelihood for maternal morbidity and mortality. The preliminary analysis, presented at the Society for Obstetric Anesthesia and Perinatology annual meeting in Las Vegas, suggests that facilities should determine their

current acceptable threshold for maternal risk and consider improving their capacity to rapidly escalate care for women at high risk or at least know when to recommend that a pregnant woman seek care elsewhere. “An increasing proportion of maternal deaths are happening among women with preexisting medical conditions,” said Jill M. Mhyre, MD, associate professor of anesthesiology at the University of Michigan Health System in Ann Arbor and lead author of the study (abstract 11). “And there are indications that these conditions are becoming more severe.” Dr. Mhyre noted that much of the problem is tied to the rising prevalence of obesity.

In the new study, Dr. Mhyre and colleagues looked at hospitalizations for delivery between 2003 and 2006 from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Then they evaluated the impacts of a range of conditions that are thought to predispose women to adverse maternal outcomes—from cardiovascular disease to sickle cell disease to systemic lupus erythematosus. But they did not limit their analysis to mortality. Rather, they also included “near-miss” morbidity, defined as an end-organ injury that either prolongs a woman’s hospital stay by at least seven days or sends her to another hospital. “There are not enough maternal deaths to drill down on individual

effect sizes for a long list of predictors,” Dr. Mhyre explained. “Combining maternal deaths with severe morbidities increases our power to understand the relationship between specific demographic characteristics and preexisting conditions and adverse outcomes.” Joy Hawkins, MD, director of obstetric anesthesiology at the University of Colorado Hospital in Aurora, agreed with this approach. “We miss bad outcomes by just looking at mortalities, because most women with complicated pregnancies won’t die,” Dr. Hawkins told Anesthesiology News. The researchers determined that 1.3 of every 1,000 hospitalizations in the database had been complicated by near-miss morbidity or mortality.

Perineal Tear Risk Equivalent With, Without Epidural Analgesia Large U.K. retrospective study may help inform delivery options

pidural analgesia during labor traditionally has been regarded by physicians and patients as a risk factor for severe perineal trauma after vaginal delivery—a perception now disputed by British researchers. In a retrospective study of 18,229 deliveries at the Royal Victoria Infirmary, in Newcastle upon Tyne, England, the investigators found that epidurals did not increase the rate of perineal tears, and in some cases, helped protect against tearing by reducing the woman’s uncontrolled urge to push at the moment of delivery. The study was presented at the 2011 annual meeting of the Society for Obstetric Anesthesia and Perinatology (abstract 13). For all vaginal deliveries, researchers compared the incidence of third- and fourth-degree perineal tears between patients who received epidural analgesia and those who did not; subgroups comprised those who had spontaneous and those who had assisted delivery. Among women who had spontaneous vaginal delivery, the risk for thirdor fourth-degree tears was 1.9% (37 of 1,989

patients) if they had an epidural, compared with a 2.7% if they did not (230 of 8,564 patients; relative risk [RR], 0.7; P<0.05). The risk for perineal tear also was lower for women who received an epidural and who had assisted vaginal delivery: 4.6% (80 of 1,746 patients) in the epidural group compared with 6.9% in the no-epidural group (81 of 1,176 patients; RR, 0.68; P<0.05). And for those who had

assisted vaginal delivery, the rate of fourth-degree tears was significantly lower if they received an epidural (0.23%) than if they did not have an injection (0.85%; P<0.05). Overall, the researchers found the risk for sustaining a third- or fourth-degree perineal tear did not differ between the epidural and no-epidural groups— about 3% (P>0.05). The assumption in the medical literature has been that epidural analgesia is causally associated with instrumental delivery, leading to higher third-degree tear rates, said Malcolm W. MacDougall, MBChB, PhD, specialist registrar at the hospital, and lead author of the study. “But,” he said, “the quality of this evidence is quite poor, and fails to take into account that patients requesting epidural analgesia are more likely to do so because they are in more pain, which could result from a higher fetal weight, advanced maternal age, reduced parity, shoulder dystocia, increased duration of second stage, raised body mass index or

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CL I N I CA L A N ESTHESIOL OGY After adjusting for other characteristics and medical conditions, advanced maternal age was associated with an elevated risk for near-miss events. Compared with women aged 20 to 34 years, the risk increased twofold for women aged between 35 and 39 years and threefold for women aged 40 years and older (P<0.01 for both). Risks also increased after adjustment for race, with the odd ratio (OR) for black women 2.4 that for whites, and among women with certain preexisting medical conditions, particularly pulmonary hypertension (OR, 12.0), malignancy (OR, 18.4), lupus (OR, 10.0), chronic renal disease (OR, 6.6), sickle cell disease (OR, 7.0) and placenta previa (OR 10.0; P<0.05 for all). For conditions in which the OR was 10 or greater, the team calculated that the risk for near-miss morbidity or death was 1 in 67. An estimated 0.6% of delivering women have at least one

induction or augmentation of labor— all of which are risk factors for thirddegree tears.” Dr. MacDougall said he believes that in some women, perineal injury results from rapid, uncontrolled delivery of the fetal head. Rapid descent of the fetal head produces severe pain, which in turn causes an overwhelming urge to push just when the perineum is most vulnerable to injury, resulting in a third- or fourth-degree tear. By providing superior analgesia, epidurals can diminish the urge to push, allowing greater control of the fetal head as it is delivered, and reducing perineal trauma. “Our study findings are not meant to reassure, [or to] encourage or promote the use of epidural analgesia,” Dr. MacDougall told Anesthesiology News. But he said the findings could be useful in informing patients about the pros and cons of each type of analgesia, and patients can decide from there. David Wlody, MD, interim chief medical officer and chair of anesthesiology at Long Island College Hospital, in New York City, believes the study findings are strong and might be used to educate patients who are so concerned about tears that they insist on a cesarean delivery. The results could “influence their decision and help reduce the rapidly increasing cesarean section rate.” Dr. Wlody is a member of the Anesthesiology News editorial board. —Karen Blum

condition with an OR that high, they said. Redefining Role “We need to send sick women—or women with high potential to become sick—to facilities that have sufficient resources to provide intensive antepartum and peripartum care,” Dr. Mhyre said. “If you’re a freestanding birth center with very little capacity to escalate care, then it may be appropriate to exclude women with any conditions

where the independent OR is 3 or greater.” In effect, this would drop the probability of an adverse outcome to 1 in 1,600 and exclude 12% of all delivering women, including those with a malignancy, chronic renal disease or multiple gestation. The exclusion would also eliminate close to 60% of all near-miss maternal morbidity or mortality events. “Being aware of these risk factors will allow referral to a maternal–fetal medicine specialist and early consultation

with an anesthesiologist before delivery to develop a care plan and optimize her safety,” Dr. Hawkins said. This enhanced role for anesthesiologists is key, according to Dr. Mhyre. “We have taken on the challenge of being perioperative physicians,” she said. “But it’s now time to become peripartum physicians as well. For some centers, that means we may even need to redefine ourselves as peripartum intensivists.” —Lynne Peeples

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FREE, No-Obligation Evaluation of Your Informed Consent Process Our experience has shown plaintiff attorneys often focus on a practice’s informed consent process to undermine a jury’s conﬁdence in the quality of anesthesia care delivered. Every new PPM policyholder receives this evaluation as part of our extensive audit of current practice protocols. Call us today at 800.562.5589 to arrange your free, no-obligation evaluation. Take ownership of your own reputation and advantage of this free review. Call PPM today.

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Smokers’ Lung Function Likely Mediated by Heavy Metals Large retrospective study of NHANES data

esults of a recent study may help guide the future treatment of patients with chronic obstructive pulmonary disease (COPD). Two analyses of a cross-section of more than 8,000 Americans have shed light on the pathogenesis of the disease. The researchers found that high levels of cadmium and cobalt in the urine and blood serum may significantly increase the risk for developing COPD. The findings were presented at the 2011 annual meeting of the Society of Critical Care Medicine (abstracts 44 and 48). “Interventions may ultimately target heavy metal concentrations, but at present all we can do to minimize the effects of these metals is reduce industrial exposure and emphasize the role these metals play in first- and secondhand smoke–related COPD,” said Brian Carlin, MD, assistant professor of critical care and pulmonology at Drexel University College of Medicine, in Philadelphia. Dr. Carlin was not involved in the study. “The findings are based on one of the largest databases around and add another piece of the puzzle being put together on the effects of heavy metals on lung function.” Cadmium and cobalt are constituents of tobacco

The researchers found that for every 10-fold increase in the concentration of cadmium in the urine, the risk for COPD nearly tripled.

smoke. Shikhar Agarwal, MD, a resident in the Department of Internal Medicine at the Cleveland Clinic, in Ohio, and a colleague, conducted the two analyses. They examined heavy metal concentrations in the urine of 612 patients with COPD and 7,570 subjects without COPD. The subjects were

registered in the National Health and Nutrition Examination Survey database, representing a crosssection of the U.S. population. In their initial analysis, the researchers looked for statistical associations between COPD and urine concentrations of more than a dozen heavy metals.

Rapid Gas Change During ECMO Linked to Mortality Risk Pediatric study shows plunging carbon dioxide worsens odds of survival that control the rate of carbon diox- slowly. This has been done in operatide removal so that in patients with ing rooms, but not so much in ECMO low pH and high carbon dioxide, we practices that we’re aware of.” remove carbon dioxide much more Dr. Bembea and her colleagues started with the premise that abrupt 60 removal of arterial carbon dioxide at the commencement of ECMO may 50 cause sudden changes in cerebral blood flow and volume. These changes, the 40 researchers speculated, might contribute to neurologic injury and increased 30 mortality. The researchers examined data from 20 201 pediatric patients who underwent ECMO at Johns Hopkins Hos10 pital between 2002 and 2010. Blood gas data before and after the initia0 tion of ECMO were available for 169 0 to 5 5 to 14 14 to 26 27 to 108 (84%) patients. Reasons for use of Change in pCO2 (mm Hg) ECMO involved reversible life-threatening conditions including respiratory Figure. Mortality and the magnitude failure (51%), cardiac failure (23%) of pCO2 decrement caused by and sepsis (5%), and cardiopulmonary the initiation of ECMO support. resuscitation (21%). The patients’ ages Change in pCO2 before and after ranged from newborn to 16 years, with ECMO intervention by multivariate a median of 10 days. logistic regression was significantly Dr. Bembea’s group found that after associated with mortality. The adjusting for potential confounders increase in mortality occurred in the such as age, use of epinephrine, volume greatest quartile of pCO2 decrease (P=0.019). of fluid administered and reason for

Mortality, %

he dramatic drop in carbon dioxide that occurs at the initiation of oxygen treatment in critically ill infants and children may decrease their chances for survival, new research suggests. In a retrospective study of children undergoing extracorporeal membrane oxygenation (ECMO), researchers from the Johns Hopkins University School of Medicine, in Baltimore, found that those who experienced the most extreme fall in carbon dioxide at the start of the therapy were less likely to live through it than those with more modest drops. Melania Bembea, MD, assistant professor of pediatric anesthesiology at Hopkins, and leader of the study, said the investigation was the first to pinpoint the association between plummeting carbon dioxide and increased mortality. She emphasized that al though the change in blood gas concentrations is multifactorial, the speed at which patients eliminate carbon dioxide from the body is modifiable. “We have made changes in our practice,” Dr. Bembea told Anesthesiology News. “We have adjusted the settings

and duration of ECMO, the magnitude of the decrease in carbon dioxide partial pressure (pCO2) was significantly associated with increased mortality. Children in the highest quartile of decrease—27 to 108 mm Hg—were about 50% more likely to die during treatment than those in the second and third quartiles (odds ratio, 1.51; 95% confidence interval, 1.07-2.13; P=0.019) (Figure). The study also found a significant association between poor survival and ECMO in the presence of CPR and increasing patient age, which the authors stated was consistent with previous research. The researchers presented their findings at Pediatric Anesthesiology 2011, a meeting cosponsored by the Society of Pediatric Anesthesia and the American Academy of Pediatrics (abstract 10). Joseph Savino, MD, professor of anesthesiology and critical care at the University of Pennsylvania School of Medicine, in Philadelphia, said the association between the pCO2 changes and survival deserved further investigation. But he stressed that a larger study with more prospective data was

August 2011

AnesthesiologyNews.com I 15

CL I N I CA L A N ESTHESIOL OGY They controlled for the presence of known COPD risk factors, including age, gender, race, hypertension, hyperlipidemia, diabetes, body mass index, C-reactive protein, cardiovascular disease and chronic kidney disease. The researchers found that for every 10-fold increase in the concentration of cadmium in the urine, the risk for COPD nearly tripled (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.83.9; P<0.05). The presence of a high level of cobalt also increased the odds of developing COPD, but to a lesser extent (OR, 1.5; 95% CI, 1.01-2.2; P<0.05). A high cadmium level was associated with an increased risk for both emphysema and chronic bronchitis, whereas cobalt was associated only with a higher incidence of chronic bronchitis. In a second analysis, Dr. Agarwal and his colleague examined lead and cadmium levels in serum for a possible correlation with development of COPD in 5,709 active smokers (of whom 597 had been diagnosed with COPD), 6,833 former smokers (of whom 725 had COPD) and 13,657 never-smokers (of whom 638 had

essential before making conclusions about pCO2 and outcome. Dr. Savino said other factors could affect the outcome and should be included in the analysis. These factors included the types of ECMO used (venovenous or venoarterial), the degree of anticoagulation, patients’ temperatures and the form of blood gas analysis (alpha-stat or pH-stat) used. “The authors are scraping the surface of an important clinical paradigm that is poorly understood and needs more rigorous investigation,” said Dr. Savino, who was not involved in the research. “I hope they continue and pursue such an issue in a multicenter approach that would provide larger numbers of patients and the opportunity for protocol-based care plans for entry into a national, and possibly international, database.” However, Dr. Savino acknowledged that such data on a wide scale are difficult to gather without the existence of a centralized ECMO system. “Questions such as this could be more easily answered if the United States had a centralized care system for ECMO patients, akin to our solid-organ transplant system,” the United Network for Organ Sharing (UNOS), he said. —Jennifer Hanawald

COPD). Similar to the first analysis, known COPD risk factors were controlled, as well as the presence of high cadmium and lead levels. As expected, current smokers were 2.4 times more likely to have COPD than never-smokers (95% CI, 2.072.88; P<0.001). However, after controlling for high cadmium levels, they found that the odds of developing COPD dropped to 1.72 times among smokers compared with never-smokers, which suggested that the relationship

between smoking and COPD was mediated by cadmium (95% CI, 1.342.19; P<0.001). It also was determined that serum concentrations of cadmium above 0.5 mcg/L increased the risk for emphysema and cadmium levels higher than 0.74 mcg/L were associated with a higher risk for chronic bronchitis. Statistical adjustment for the presence of lead did not affect the risk for COPD. In an interview with Anesthesiology News, Dr. Agarwal emphasized the

study was not a controlled, interventional trial and the findings only generate hypotheses. “The results provide a platform other investigators can use to conduct further research in order to better understand the effects of heavy metal exposure,” he said. “Future research may ultimately lead to the development of direct interventions, like antioxidant therapy, that may help reduce or mitigate the effects of heavy metals.” —David Wild

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16 I AnesthesiologyNews.com

August 2011

C LI N I C A L A N ESTHESIO LO GY Mobility continued from page 1 protocol is easily offset by the savings from briefer hospital stays. “I’ve always thought early mobility makes sense empirically but the true benefits of such an approach have, until recently, not been demonstrated in outcome studies, so this is a useful report,” said Stuart Lowson, MD, associate professor of anesthesiology at the University of Virginia, in Charlottesville, who was not involved in the study. Dr. Lowson pointed to a recent study from Johns Hopkins University that also found benefits of an earlymobility initiative (Arch Phys Med Rehabil 2010;91:536-542). Dr. Lowson’s hospital has an activity coordinator on its surgical intensive care unit (ICU) in charge of a similar protocol. “We have a strong sense that it is an integral part of facilitating patient recovery, and in particular speeding up the ventilator-weaning process,” he said. Clinicians at Minnesota’s St. Cloud Hospital introduced a mobility protocol for ICU patients requiring ventilator support in late 2009 and set out to document its benefits. The program has become a component of the hospital’s ventilator bundle, a quality improvement initiative meant to reduce the incidence of ventilatorrelated complications, said lead investigator John Olsen, MD, co-medical director of the hospital’s ICU. The protocol includes an assessment by a physical therapist after 24 hours of ventilator support, patient education and physical therapy. Patients progress to walking independently in as little as three days, depending on their stability. Pediatric patients, patients on ventilator support for less than 24 hours and those undergoing cardiac surgery are excluded from the program, Dr. Olsen noted. For the study, Dr. Olsen and his colleagues compared lengths of stay,

Aspirin continued from page 9

in-hospital mortality, and hospital and ICU costs in ventilated patients during the six months before implementation of the program and the nine months after it began. The analysis included 145 patients in the first period and 366 in the later period. Rates of in-hospital mortality decreased from 32.4% before the program to 23.8% after implementation. Average length of stay in the ICU decreased from 8.7 to seven days, and mean ICU costs fell by more than $4,500, from $38,062 to $33,560. Mean length of overall hospital stay also decreased, the researchers said, from 16.1 to 14.5 days, and overall hospital costs per patient dropped from an average of $56,187 to $50,271. Assuming that 488 patients would have been treated in a one-year period, St. Cloud would have saved as many as 41 lives and nearly $3 million, the Minnesota group reported. In an interview with Anesthesiology News, Dr. Olsen said he was surprised at the magnitude of the reduction in mortality. “At this point, it’s difficult to explain why this happened,” he said. “As the study period was rather short, it may have been a random event, but the difference was quite striking and we included a fairly large number of patients.” One explanation, Dr. Olsen said, is that early mobility reduced sedation requirements, although the researchers did not look at that question. “Because other quality improvement programs we had previously instituted were fairly mature by the time we began the mobility protocol and we didn’t launch any other projects during this period,” Dr. Olsen added, “I can’t easily attribute the mortality improvement to another project.” The mobility program is continuing, he said, and the improvements in costs and length of stay have persisted.

Breathing Easier for Obese After Surgery Respiratory morbidity, mortality lower for overweight than lean patients

bese adults who have undergone surgery are less likely to develop respiratory insufficiency and respiratory distress syndrome, a recent study has found. Researchers also found that when obese patients do develop respiratory complications, their mortality rate is nearly three times lower than that of their non-obese counterparts. “Although the assumption is that patients with obesity have worse perioperative and long-term outcomes, this study clearly shows that in the setting of [severe respiratory illness], this is not the case and obesity might actually be protective in this setting,” said lead author Stavros G. Memtsoudis, MD, PhD, an anesthesiologist at the Hospital for Special Surgery in New York City, in a statement. The nine-year study identified nearly 9 million patients who had undergone procedures known to have a high risk for respiratory complications, including laparoscopic abdominal surgery and hip and knee arthroplasty. Investigators found that the rates of respiratory complications were lower in obese patients than in nonobese patients (1.82% vs. 2.01%,

respectively). Fewer obese patients required mechanical ventilation than non-obese (50% vs. 55%). The mortality rate among intubated, obese patients was significantly lower than that for non-obese patients (11% vs. 25%; P<0.0001). And the overall mortality rate among obese patients with respiratory illness was 5.45%, compared with 18.72% among the nonobese (P<0.0001). The researchers offered several theories for how obesity might protect against the respiratory-related illness and death. Obese patients might store more energy or have better nutritional status to fight off acute illness, they said. Similarly, fatty tissue might be advantageous in a setting of a high inflammation, acting as a kind of neutralizing sink for inflammatory cytokines. Finally, they suggested that surgeons might be more vigilant with obese patients because of the worry that this population may be more prone to problems after surgery. The researchers reported their findings in the Journal of Intensive Care Medicine [Epub ahead of print July 2011]. —Kevin Enright

—David Wild

Nevertheless, he does not currently advise that other clinicians follow this that aspirin therapy reduced 30-day course of action, particularly in light of mortality by about 40% compared the fact that several professional organito no such treatment (3.5% vs. 6.5%; zations recommend against it. P=0.031). “I believe we still need more evidence, Dr. Sun told Anesthesiology News that and maybe then [the] guidelines will whereas it was not particularly surpris- be changed,” he said. “But, at this time ing to find that aspirin-taking patients it’s still too premature to change guideexperienced fewer cardiocerebral lines based on one institution’s study. I adverse events, the reduction in renal wish we had randomized, prospective complications came as a bit of a surprise. studies to provide more evidence.”

Daniel T. Bainbridge, MD, associate professor of anesthesia at the Schulich School of Medicine and Dentistry, the University of Western Ontario, in London, Canada, said it was important to emphasize that the most significant concern regarding aspirin use in cardiac surgery patients is the risk for bleeding. “Nevertheless, I think the data from [Dr.] Sun and colleagues tell the story: 800 patients on aspirin and only 200 who were not,” he said.

“At our institution, the ratios are similar: 80% to 90% who are on aspirin, 10% to 20% who are not,” he said. “This is likely because many practitioners feel the reduction in cardiovascular complications outweighs the small increased risk for bleeding— although this is not true for clopidogrel [Plavix, Bristol-Myers Squibb/ Sanofi] patients.” —Michael Vlessides

24th Annual

Corporate Proﬁles 2011-2012

18 20 22 23 24 26 28 30 32 34 35 36 38 40 42 44 46 48 50

abeo Ambu Anesthesia Business Consultants Arizant Healthcare Inc., a 3M Company APP Pharmaceuticals BMEYE CompONE Services, Ltd. Dräger Edwards Lifesciences McMahon Publishing GE Healthcare KARL STORZ Endoscopy-America, Inc. LMA North America Masimo Corporation MCKesson Mindray Sheridan Healthcare, Inc. Verathon Medical Zotec Partners

Available online @ AnesthesiologyNews.com

24th Annual

Corporate Profiles 2011-2012

aBeo

beo continues to surpass expectations, quickly becoming the most recognizable billing and practice management company in the field. Rather than a rigid list of services, abeo offers customized solutions focused on the needs of consumers. “abeo continues to exceed our expectations when it comes to managing our receivables and assisting us in our practice. Their outstanding customer service department and increased collection efforts in today’s economy have proven them to be a valued partner in our success.” Dave Flory, MD Fairbanks Anesthesia, Inc.

abeo’s Focus abeo’s business model differs from its deep-discount– driven competitors who expect clients to adapt their practice to a preexisting service delivery model. At abeo, the ideology is “If it makes sense for our client, it makes sense for us.” abeo’s unique strategy has enabled the company to adapt its services to accommodate the varying structures and operating philosophies of its diverse client base. abeo’s staff understands that their clients work hard and have high expectations; in today’s market, bottomline performance alone is not sufficient. Innovation and dedication are required to become a leader in the world of self-pay and deductible/copay collection efforts. With this in mind, abeo continues to develop state-of-the-art processes and technological solutions to meet the individual needs of the doctor and physician group. Technology solutions such as the abeoCoder for the iPhone, BlackBerry and Android devices, are designed to save doctors time and make billing more efficient. abeoCoder has received rave reviews from anesthesiologists. abeo continues to work on technology solutions for the future.

Client Satisfaction

abeo has a proven track record of improving clients’ collections and service far above the previous billing agency. abeo stands by its claim of putting its clients first, and has consistently proven this with superior customer service. “During the transition from our previous billing service, they [abeo] took over all of the account receivables and did a great job catching up on those accounts that had been ignored or not even billed out yet. We saw our collections increase rather dramatically.” Daniel Nelson, MD Rancho Mirage Anesthesia Consultants

Anesthesiology News • August 2011

AT A GLANCE

Why abeo? abeo attributes its success in optimizing clients’ revenues to many factors, including the following: • Dedication to anesthesia: In today’s vastly changing environment, working with an anesthesia-specific provider is not only an advantage, it’s a must. • abeo’s staff: abeo has one of the most tenured executive management teams in the anesthesia billing and practice management industry. • Ability to execute: Billing is about day-to-day discipline and execution. Using its vast resources, abeo is able to implement the best practices consistently across its entire reach. • MedSuite: This technology is the backbone of abeo’s billing operation. MedSuite was designed specifically to support anesthesia billing and is one of the best platforms in the marketplace today. MedSuite is a rich Internet application that uses the latest technology in a user-friendly way. Its features include: - MedSuite on demand (immediate physician access 24/7); - User-definable dashboard; - Account-level access to payments and adjustments; - Dictionary change logs; and - No large up-front costs.

Revenue Cycle Management Despite the fact that it is a full-service provider, abeo’s core business is the management of the anesthesia revenue cycle. In addition to the basic revenue cycle services, abeo specializes in: • Compliance oversight: In addition to its basic compliance program, abeo conducts internal audits and annual coding documentation training. • Managed care contract enforcement: abeo does more than negotiate and administer contracts. It goes the extra mile to ensure that payers adhere to the elements of the contract. • Credentialing: As credentialing becomes more complex, abeo is putting more resources into ensuring that trained professionals are handling the client’s credentials. • Outstanding balances: Each account is touched on a monthly basis. This approach helps increase cash flow and greatly reduces the amount of bad debt. Most billing agencies do not have the dedicated resources or expertise to pursue these outstanding balances.

Practice Management abeo gives clients the opportunity to purchase services as a package or à la carte, based on the client’s requirements. Some of the most sought-after services are:

CorporaTe offICe 7301 N state hwy. 161, ste. 365 Irving, TX 75039 phone: (972) 861-1270 web site: www.abeo.com

ChaIrMan and ChIef eXeCUTIVe offICer mark smith

ChIef operaTIons offICer steve Avery

presIdenT, praCTICe ManageMenT mark wines

presIdenT, proVIder serVICes J.r. Thompson

ChIef InforMaTIon offICer phil warenik

• Payer contracting: has strong relationships with all major payers and effective strategies to maximize contracted rates of reimbursement. • Hospital contracting: abeo works with clients to develop strategies in progressing relationships with various facilities to maximize compensation contracts. • Strategic management and planning: By evaluating potential M&A expansion opportunities, and analyzing billing and scheduling data, abeo identifies opportunities to improve overall practice procedures. • Anesthesia data analytics: By creating custom reporting packages illustrating operational performance by site/case/volume etc, abeo produces quality data that allow for analysis that leads to solutions. • Compensation and financial management: abeo develops and designs clients’ compensation models to distribute income across physician groups. abeo also manages clients’ financial accounts, including all client group expenses, payroll compensation reports, budget development and execution. • Benefit procurement: abeo designs and implements practice benefits such as health and liability insurance, retirement, disability insurance and flexible spending and cafeteria plans.

This corporate profile was reviewed and approved by abeo.

24th Annual

Corporate Profiles 2011-2012

aMBU Unfolding Our Mission

deas may be conceived in one person’s head, but they always originate from a collaboration of minds. Since 1937, we have been leading the way in health care, and it makes no difference to us whether ideas arrive through meticulous research or by a clever question asked by you. All that matters is that we transform ideas into efficient solutions that work to your advantage. Without this responsiveness to your needs for functionality, we would never have invented the Ambu bag™, the legendary BlueSensor™ electrodes or launched the world’s first single-use videoscope, the aScope™. The challenges in health care are growing dramatically, which only fuels the need for solutions that make a real difference in life. This is why we are firmly determined to fully release the breakthrough power of singleuse devices. So the next time you think about how to

AT A GLANCE optimize care for your patients, please hold the thought. … Maybe we can make it work for life.

Corporate Story Since 1937, breakthrough ideas have fueled our work of bringing efficient health care solutions to life. This is what we have been doing within our fields of excellence—anesthesia, patient monitoring and diagnostics and emergency care. Every day, more than 60 million users worldwide prefer the functionality of our products: from our early inventions like the Ambu bag™ and the legendary BlueSensor™ electrodes to our newest landmark solutions like the aScope™, the world’s first single-use videoscope—proving our dedication to accelerating the power and potential of single-use products.

address 6740 Baymeadow dr. glen Burnie, md 21060 phone: (410) 768-6464 web site: www.ambuusA.com

Our colleagues on all continents are ready to service our customers wherever, whenever. This commitment to new ideas, hard work and superior service has made Ambu one of the most recognized companies within our field. And we will continue to lead the way. Ambu is listed on the NASDAQ OMX Copenhagen.

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Anesthesiology News • August 2011

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This corporate profile was reviewed and approved by Ambu.

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24th Annual

Corporate Profiles 2011-2012

anesThesIa BUsIness ConsUlTanTs

AT A GLANCE

nesthesia Business Consultants, LLC (ABC) is the largest billing and practice management company dedicated to the complex and intricate specialty of anesthesia and pain management. It is both an American Society of Anesthesiologists Practice Management Supporter and an Anesthesia Quality Institute Preferred Vendor. Tony Mira, the company’s founder, president and CEO, has maintained a concentration on providing services exclusively to anesthesia and pain management professionals since ABC’s inception more than 30 years ago. ABC distinguishes itself by providing optimal business tools to strengthen business processes and enhance cash flow—all while keeping pace with constant changes in the health care environment. ABC prides itself on the longevity of its client relationships and its ability to customize its services to the unique requirements of each practice. ABC offers its clients innovative billing and reimbursement services, as well as valuable practice management tools and solutions that allow them to realize their own particular strategic visions and business plans.

• • • •

Payment Processing Collection Services Reporting Compliance Services

The ABC Management Advantage

The ABC Technology Advantage

Strategic Partnerships

ABC distinguishes itself through its focus, operational approach and management structure: • Unlike many competitors who continually redefine their market focus, ABC has remained true to its core market of anesthesiologists, CRNAs and pain management specialists, enhancing the credibility of its insight and advice. • ABC believes its relationship with its clients is a true partnership, not just a client/vendor relationship. A partnership in which ABC not only helps improve the billing process, but also helps the group operate more efficiently in the OR, and more proactively in its relationship with the hospital. • ABC’s centralized approach allows effective management and oversight, ensuring consistent results. • Managing a business based on the input and expectations of shareholders does not always result in the most appropriate business decision making. Since ABC is privately held, it has a much greater flexibility in setting its agenda, managing the business and being responsive to its clients’ needs.

In order to ensure flexibility with our clients and their varying level of needs, ABC has carefully crafted a portfolio of products to meet our clients’ needs during the entire perioperative process.

ABC is pleased to offer strategic alliances which complement our in-house products and technology, and together provide a full arsenal of products designed to encompass the entire perioperative process.

Leading-Edge Technologies

ePREOP

address

Management Support Services No one company is more qualified to furnish critical management information and proactively advise practice decision makers. Although many management companies have isolated areas of strength and specific competence, ABC stands alone in its ability to provide a full range of management support services. • Strategic Management • Practice Management - Practice Consulting - Financial Services - Quality Management (PQRS) - Human Resources Consulting - Contracting Services - Compliance & HIPAA - Education & Training

ABC has created and maintains the most advanced, secure and reliable software designed especially for anesthesia billing and practice management, F1RSTAnesthesia™. This powerful tool converts clinical information into claims for reimbursement. It supports electronic claims editing to ensure consistently high billing acceptance rates, and minimizes manual intervention in payment posting through direct remittance processing. Providers also are able to receive real-time or historical information through F1RSTAnesthesia’s Web-based technology or advanced data warehousing/data-mining technology. ABC is committed to constantly updating the F1RSTAnesthesia™ software to adapt to meet the changing needs of its clients. Its accomplished in-house technology staff continually works to improve this powerful software. Updates to this family of products include: The ABC Service Advantage F1RSTAnesthesia Record (FAR), an electronic pen that ABC offers a full cadre of services, designed to assist allows the electronic capture of medical records without your needs, ranging from a specific area of service to an any change in the workflow. all-encompassing solution partner. F1RSTAccess, a mobile Web application that allows clients Billing and Reimbursement Services to view the reports on their Because all processing is performed in a central Apple iPhone 3G/4G or iPad location, ABC maintains a high standard for quality device. control and efficiency, resulting in faster claims resoF1RSTTouch tracks and lution and higher levels of reimbursement. Extensive reports charge information and management reporting options allow both manageprovides customers with the ment and client to monitor subtle changes in payer ability to quickly collect and mix and reimbursement patterns. Services include: • Patient Charge Collection Tony Mira, president and report clinical workflow or metric information. Chief executive officer • Charge Coding, Entry and Claims Scrubbing Anesthesiology News • August 2011

255 west michigan Ave. Jackson, mI 49201 phone: (800) 242-1131 fax: (517) 787-0529 web sites: www.anesthesiallc.com www.communiquenews.com http://twitter.com/AnesthesiallC

serVICes full-service billing and practice management firm dedicated exclusively to anesthesiologists and pain management physicians.

eMployees 850+

ePREOP™ is an easy-to-use Web-based preoperative and postoperative evaluation tool. It collects and transfers patient data, creates an easy-to-read patient health history, and then uses that information to generate clinical guidelines for the Patient History portion of a preoperative evaluation. It is also capable of providing a method of collecting patients’ surgical and medical histories, along with patients’ credit card information, streamlining any complications on future co-payments. ePREOP also collects and automatically uploads Quality Data requested by AQI and outlined by the WHO survey. ePREOP works with providers to improve outcomes and save health care dollars.

iMDsoft iMDsoft® is a leading Anesthesia Information Management System (AIMS) provider for the perioperative space. iMDsoft’s powerful MetaVision® collects all clinical, operational and physiological data from a patient during a procedure with a combination of automatic operations and touchscreen technology. It then creates a complete and accurate anesthesia record, containing all the information necessary for billing, and analysis tools that promote patient safety, enhance quality initiatives, and facilitate cost containment, revenue capture, research and compliance. This family of products creates a fully-integrated end-to-end solution for the perioperative environment, streamlining workflow and improving outcomes. ABC invests in cutting-edge technology, proven processes and industry experts, setting the industry standard for anesthesia billing and practice management.

This corporate profile was reviewed and approved by Anesthesia Business Consultants.

24th Annual

Corporate Profiles 2011-2012

arIZanT healThCare InC., a 3M CoMpany Now proudly part of 3M Infection Prevention

or 50 years, 3M has contributed innovative solutions to the worldwide campaign against health care–associated infections. Reducing inadvertent perioperative hypothermia is a proven step in helping reduce surgical site infections along with a range of other serious complications. That’s why we’re proud to offer patient-warming solutions that have set the standard for innovation and quality: 3M™ Bair Hugger™ therapy, 3M™ Ranger™ blood and fluid warming and 3M™ Bair Paws™ patient adjustable warming gowns. In 1987, Bair Hugger therapy became the world’s first forced-air warming system. Since then, the importance of maintaining normothermia has become part of patient care improvement efforts backed by health care and government organizations across the globe. Today, 3M’s surgical warming products are used to maintain normothermia for more than 20 million patients each year. We look forward to partnering with you on the mission to improve patient outcomes through effective patient warming.

3M™ Bair Hugger™ Therapy (www.bairhugger.com) Bair Hugger therapy was the first forced-air warming product line, and today it remains the market leader. Forced-air warming therapy is a simple, safe and cost-effective method to prevent unintended hypothermia and its Bair hugger therapy fullaccess underbody blanket associated complications, which include an increased rate of wound infection,1 increased hospital length of stay2 and higher mortality rates.3 Maintaining perioperative normothermia has been cited by quality improvement initiatives around the world as a key factor in reducing the rate of surgical site infections. Many of these same initiatives, including the Centers for Medicare & Medicaid Services’ new normothermia quality measure, include forced-air warming in their definition of active warming. Bair Hugger warming units are used in more than 80% of U.S. hospitals, and more than 125 million patients have experienced the benefits of Bair Hugger therapy. Our ongoing commitment to innovation and patient warming has resulted in a product lineup of 25 single-use Bair Hugger warming blanket models, including five adult and two pediatric underbody series blankets. The Bair Hugger therapy underbody series warms from underneath the patient, addressing a clinical need to prevent unintended hypothermia while providing clinicians full patient access. The full-access underbody blanket is showing rapid acceptance by the trauma community with its ability to be pre-set in the trauma bay

and then warm the patient from admission and assessment to computed tomography and into the OR or ICU. The underbody series was developed by working directly with clinicians to ensure the designs meet a wide range of warming demands including cardiothoracic, cosmetic, gynecologic, urologic, orthopedic, pediatric, reconstructive, transplant, trauma, vascular and other major surgical procedures.

3M™ Bair Paws™ Flex Gown (www.bairpaws.com) The Bair Paws flex gown combines the best of both worlds: the comfort and convenience of the Bair Paws gown with the powerful, proven warming of Bair Hugger upper- and lower-body blankets. With the Bair Bair paws flex gown Paws flex gown, patients arrive in the OR already warm when prewarmed before surgery. The same gown enables upper- or lower-body warming in the OR thanks to effective warming tools built right into the gown. Separate upper and lower inserts allow you to activate warming where you want it, with the upper warming insert including all the features of a Bair Hugger upper body blanket. When the patient is ready for the PACU, simply perforate off the upper body warming “sleeves,” head drape and adhesive strip to provide maximum postoperative comfort while maintaining comfort and clinical warming capabilities. The tools that helped the patient in the OR are now conveniently out of the way. The gown’s flexibility eliminates the costs and hassles of buying, storing and using multiple items like cotton gowns and blankets, and various OR warming products while improving patient satisfaction by keeping patients warm, cozy and covered. This all-in-one warming capability makes the Bair Paws flex gown a great option for achieving normothermia-related quality measures.

3M™ Ranger™ Blood and Fluid Warming Systems (www.rangerfluidwarming.com) A complete protocol for perioperative temperature management should include both forced-air warming and the warming of infused blood and fluids to help maintain a patient’s core body temperature.

This corporate profile was reviewed and approved by Arizant Healthcare Inc., a 3M Company.

AT A GLANCE address 10393 west 70th st. eden prairie, mN 55344 phone: (800) 733-7775 web site: www.arizanthealthcare.com

worldwIde eMployees 363

prodUCTs 3m™ Bair hugger™ therapy; 3m™ Bair paws™ patient adjustable warming system; 3m™ ranger™ blood and fluid warming systems.

VICe presIdenT, paTIenT warMIng Teri woodwick sides

Ranger blood and fluid warming systems feature highly conductive heating plates that disperse heat immediately, handling sudden changes in flow with ranger irrigation warming unit ease. Dry heat technology disperses heat evenly, eliminating dangerous hot spots and overheating of fluids by monitoring the temperature four times every second, automatically adjusting to maintain a consistent set point. And because the system utilizes dry heat technology rather than the water-based method, concerns regarding water in the operating room—and its potential ties to nosocomial pathogens—are eliminated. The latest introduction to the Ranger product lineup, the Ranger irrigation fluid warming system is an intuitive, easy-to-use solution for high-volume surgical irrigation. The Ranger irrigation system quickly adapts to flow rates of zero to 865 mL per minute. The system’s disposable sets feature a patient line contained within its own sterile packaging, and each latex-free, disposable set is designed for use during surgical procedures and/or postoperative irrigation. 3M is a trademark of 3M Company, used under license in Canada. BAIR HUGGER, BAIR PAWS and RANGER and the BAIR HUGGER, BAIR PAWS and RANGER logos are trademarks of Arizant Healthcare Inc., used under license in Canada. 1. Barie PS. Surgical site infections: epidemiology and prevention. Surg Infect (Larchmt). 2002;3[supp]:S9-S21. 2. Jeran L. American Society of PeriAnesthesia Nurses Development Panel. Clinical guideline for the prevention of unplanned perioperative hypothermia. J Perianesth. Nurs. 2001;16:305-314. 3. Tryba M, Leban J. Does active warming of severely injured trauma patients influence perioperative morbidity? Anesthesiology. 1996;85:A283.

Anesthesiology News • August 2011

24th Annual

Corporate Profiles 2011-2012

app pharMaCeUTICals AT A GLANCE A Responsive Leader in Anesthesia and Analgesia APP Pharmaceuticals’ commitment to the clinical specialty of anesthesia is reflected in the breadth of its product portfolio and the company’s rapid response to meeting the clinical needs of its customers. This was especially evident during the propofol shortage. As other manufacturers experienced recalls of generic propofol injection, which resulted in manufacturing interruptions, APP recognized the vital clinical importance of maintaining a consistent supply of this important and essential drug. The company acted decisively to increase production of APP Diprivan® (propofol 1%) and APP Propofol 1% (authorized generic Diprivan®) at the onset of this critical market shortage to help stabilize product supply. In addition, APP supplemented supply by importing international Fresenius Propoven 1% (propofol 1%) in agreement with the FDA. Fresenius Propoven 1% (propofol 1%) is manufactured in FDA-compliant facilities by APP’s parent company, Fresenius Kabi, the leading manufacturer of propofol injection in the world. Working together, the two companies have combined their efforts and are focused on increasing propofol supply by bringing new capacity on line. As a result, APP is producing at levels to supply the entire U.S. market. Through its immediate actions, ongoing communication with pharmacies and physicians, and expedited manufacturing and shipping processes, APP is committed to helping ensure continual access to this important and essential drug.

A Broad, Growing Anesthesia and Analgesia Portfolio APP Pharmaceuticals offers an extensive portfolio of products that continues to grow based on the evolving practice of anesthesia and pain management. As the number of overall clinical procedures continues to shift from inpatient to outpatient settings, APP’s products remain in step with the changing dynamics of anesthesia and pain management. The most prominent brands of the APP anesthesia and analgesia portfolio are Naropin®

(ropivacaine) and the Diprivan (propofol) family of products. APP is the sole U.S. supplier of Naropin, a unique brand with distinct clinical benefits.1-3 APP also offers an array of propofol products, including APP Diprivan® (propofol 1%) and APP Propofol 1% (authorized generic Diprivan®), both with patented formulations that include ethylenediaminetetraacetic acid (EDTA). As a supplier of both multisource and branded products, APP brings convenience, efficiency and value to the supply chain process by offering a comprehensive selection of anesthesia and analgesia products, including: • Astramorph® (morphine) • EMLA (lidocaine/prilocaine) • Flumazenil Injection • Midazolam Hydrochloride Injection • Neostigmine Methysulfate Injection • Nesacaine® (chloroprocaine) • Polocaine® (mepivacaine) • Sensorcaine® (bupivacaine) • Sumatriptan Succinate Injection • Xylocaine® (lidocaine)

Global Health Care Resources APP Pharmaceuticals’ comprehensive product portfolio also includes anti-infective, critical care and oncology pharmaceutical products. With more than 120 marketed products in 400 dosage forms, APP’s products are used in hospitals, long-term care facilities, alternate care sites and clinics throughout North America. In 2008, Fresenius Kabi Pharmaceuticals Holding, Inc., a wholly owned subsidiary of Fresenius Kabi AG, acquired APP Pharmaceuticals, Inc. As a leading provider of infusion therapy and clinical nutrition in Europe, Latin America and Asia Pacific, Fresenius Kabi’s core product range includes infusion solutions, blood volume substitutes, IV drugs and parenteral and enteral nutrition, as well as medical devices. The company also provides concepts for ambulatory health care and is focused on managing and providing home therapies. With the philosophy “caring for life” and a

address 1501 east woodfield rd., ste. 300 east schaumburg, Il 60173-5837 main phone (847) 969-2700 Toll free (888) 391-6300 web site: www.Apppharma.com

CUsToMer serVICe (orderIng): Toll free (888) 386-1300 fax (800) 743-7082

MedICal affaIrs Toll free (800) 551-7176 fax (847) 413-8571

prodUCTs A leading supplier of multisource and branded injectable pharmaceutical products primarily focused on the anesthetic/analgesic, anti-infective, critical care and oncology markets.

eMployees 1,800

comprehensive product portfolio, Fresenius Kabi aims at improving the quality of life of critically and chronically ill patients all over the world.

A Trusted Partner APP Pharmaceuticals continues to meet the clinical needs of pharmacists and physicians through the manufacture and distribution of high-quality, cost-effective injectable pharmaceutical products. In anesthesiology, APP has demonstrated this commitment through its collaboration with the medical community and the FDA. In addition, as a trusted partner, clinicians can be assured that APP’s commitment to excellence and value also remains strong in the therapeutic areas of infectious disease, critical care and oncology. Through the continuous expansion of its broad portfolio of products, APP Pharmaceuticals is dedicated to providing ongoing, affordable health care to patients throughout the country.

References 1. Beaulieu P, Babin D, Hemmerling T. The pharmacodynamics of ropivacaine and bupivacaine in combined sciatic and femoral nerve blocks for total knee arthroplasty. Anesth Analg 2006;103:768-774. 2. Bertini L, Tageriello V, Mancini S, et al. 0.75% and 0.5% ropivacaine for axillary brachial plexus block: a clinical comparison with 0.5% bupivacaine. Reg Anesth Pain Med 1999;24:514-518.

3. Writer WDR, Stienstra R, Eddleston JM, et al. Neonatal outcome and mode of delivery after epidural analgesia for labour with ropivacaine and bupivacaine: a prospective meta-analysis. Br J Anaesth 1998;81:713-717.

Anesthesiology News • August 2011

This corporate profile was reviewed and approved by APP Pharmaceuticals.

A Responsive Leader in Anesthesia and Analgesia Responsiveness is our commitment to clinicians. APP Pharmaceuticals has continually demonstrated our dedication to meeting your clinical needs by supplying the market during times of critical shortages. We will continue to offer high-quality injectable pharmaceutical products that help provide affordable healthcare for your patients. This is the commitment we have demonstrated in the past and continue to live by. A trusted leader in injectable products and APP are registered trademarks of APP Pharmaceuticals, LLC.

Medical lnformation 800-551-7176 Customer Service 888-386-1300 www.APPpharma.com

24th Annual

Corporate Profiles 2011-2012

BMeye

MEYE specializes in noninvasive advanced hemodynamic monitoring. BMEYE provides a unique noninvasive solution for the measurement of cardiac output (CO)—the next standard vital sign—and other advanced hemodynamic parameters. Its monitors are safe, precise and easy to use, making hemodynamic monitoring a reality in daily clinical practice.

The Noninvasive Solution cc The Nexfin monitor (Figure 1) connects to the patient by simply wrapping an inflatable cuff around the middle phalanx of the finger (Figure 2). The pulsating finger artery is “clamped” by figure 1. ccnexfin monitor. applying equivalent counter pressure that results in a pressure waveform. This is how cc Nexfin provides beat-to-beat continuous BP in a totally noninvasive manner, without the need for arterial cannulation. The resulting BP waveform serves as the basis for the measurement of continuous CO. cc Nexfin measures real-time continuous CO and other hemodynamic parameters (Table) by a novel pulse contour method (Nexfin CO-Trek), which is based on the

founded in 2005 headquarters in Amsterdam, The Netherlands

Type

Parameters

Label

hemodynamics

Cardiac output/cardiac index systolic/diastolic blood pressures mean arterial pressure heart rate stroke volume systemic vascular resistance Contractility index

Co/CI sys/dia

The Clinical Need It is well known that patients may respond in a variable and sometimes unpredictable manner to surgery, fluids, anesthetic agents, vasoactive drugs and other interventions. All of these factors may induce significant and rapid changes in CO, which is the main determinant of oxygen delivery (DO2) to the tissues. However, the parameters that are routinely monitored today during surgery, like blood pressure (BP) and heart rate, are neither sensitive nor specific enough for the timely identification of hemodynamic deterioration (i.e., a decrease in cardiac output). This is why it is evident that noninvasive continuous CO must become the next standard vital sign.

AT A GLANCE

Table. Monitored parameters

ppV sVV

oxygen transport

do2I spo2 sphb pI

oxygen delivery index oxygen saturation Total hemoglobin perfusion index

frank gorski frank.gorski@bmeye.com steven otis steven.otis@bmeye.com Toll free (877) 263-6962 web site: www.bmeye.com

mAp hr sV sVr dp/dt

fluid pulse pressure variation responsiveness stroke volume variation

ConTaCTs In norTh aMerICa

For which procedures? cc

systolic pressure area and a physiologic three-element Windkessel model. In order to better guide hemodynamic management, ccNexfin also includes advanced algorithms to compute dynamic fluid responsiveness parameters, i.e., stroke volume variation and pulse pressure variation. In addition to these essential hemodynamic parameters, ccNexfin has integrated pulse CO-oximetry measurements with the Masimo Rainbow® SET technology, allowing clinicians to get real-time, continuous and noninvasive values of oxygen saturation and hemoglobin content. These values in combination with cardiac output, allow ccNexfin to also provide oxygen delivery DO2. With ccNexfin you will be able to: • Evaluate within minutes your patient’s CO—the next standard vital sign • Extend the scope of your hemodynamic management by monitoring patients at risk who don’t need invasive lines • Identify occult hemodynamic instability • Optimize your patient’s hemodynamic status prior to induction of anesthesia • Determine the need and bridge the time for invasive hemodynamic monitoring • See the immediate effect of diagnostic and therapeutic interventions • Improve patient convenience during long monitoring periods

Nexfin has benefits over the whole range of low-, moderate- and high-risk procedures including: • Major general surgery—including oncologic procedures • Cardiac surgery • Thoracic surgery—one-lung ventilation, induced pneumothorax • Orthopedic surgery—fractured hip, joint replacement, spine • Bariatric surgery • Obstetric and extensive gynecologic surgery • Urology—radical and/or high risk for bleeding procedures

Where in the hospital can ccNexfin be used? cc

Nexfin is a light, small monitor and can be used in many parts of the hospital (Figure 3): • Operating room, intensive care unit and emergency department • Step-down and intermediate care unit • Outpatient cardiology and preoperative anesthesia clinics • Patient ward—where events such as orthostatic hypotension can be easily diagnosed

The Applications For which patients? cc

26 figure 2. finger cuff—the only sensor on the patient.

Anesthesiology News • August 2011

Nexfin is perfectly suited for all surgical patients who are at risk for developing hemodynamic instability, or who may benefit from perioperative hemodynamic optimization. The populations who may benefit greatly from ccNexfin include: • Diabetic patients • The elderly • Patients with other sig• The obese nificant comorbidities • Pregnant women • Cardiac patients

figure 3. ccnexfin can be easily applied by any health care worker and it displays reliable data within two minutes after starting up.

This corporate profile was reviewed and approved by BMEYE.

Care fully

in control

www.bmeye.com

24th Annual

Corporate Profiles 2011-2012

CoMpone serVICes, lTd.

ompONE partners with medical practices to provide comprehensive billing and practice management services powered by intuitive technologies designed to help medical providers enhance revenue. CompONE will free you from the administrative burden of running your practice and allow you to focus on practicing medicine. In today’s competitive billing environment, you cannot afford to settle for the status quo. You need innovative technologies, highly engineered systems and streamlined processes. You need a practice management team you can trust. You need CompONE—a solution for a more profitable practice. Since its founding in 1987, CompONE has become the envy of the industry by leading the way with advantages and benefits no other company can offer in the area of medical billing, revenue cycle management and technology services. We are one of the largest paperless medical billing and management services in the country. Through our paperless environment, CompONE manages physicians’ billing and collection needs more efficiently and effectively than our competitors.

Revenue Cycle Management When you select CompONE for revenue cycle management services, you gain a strategic partner with the vision to help you achieve your financial and operational goals. CompONE appoints to your group a dedicated practice management consultant (PMC) with extensive experience in billing for both anesthesia and pain management. Throughout our relationship, your PMC will continuously monitor your practice’s performance. CompONE’s revenue cycle management solutions are more than simple billing and scheduling services. More than ever, physicians are turning to CompONE for their consulting and financial services. The reason is simple: CompONE combines consulting and financial expertise that delivers sustained, measurable value to our clients, along with the expertise to implement outsourced solutions and technology to achieve your goals.

Proprietary Technologies CompONE’s proprietary technologies turn chaos into highly structured processes and fail-safe systems designed to provide incomparable service. Take a look at the advantages that only CompONE can offer:

• PaperBytesTM: Converts paper billing documents into electronic images that are indexed, stored, retrieved and managed to transform the billing process into a truly paperless environment. • DenyThis!TM: A Web-based reporting and analysis tool created to analyze denied or delayed insurance claims. • ClaimsBusterTM: Enables CompONE to resolve payment problems quickly and decisively by tracking and reporting collector productivity, payer performance and data entry accuracy. • ChargePadTM: A software solution that makes capturing charges a real-time event. Features include: - ability to retrieve hospital patient demographics, - ability to track and confirm charge submissions to CompONE, - customizable dictionaries.

Performance Guarantee CompONE is so confident in its processes, people and technologies that it will guarantee a positive financial outcome—inclusive of the fee. We can offer such a performance guarantee because of our extensive experience in improving accounts receivable metrics, assisting with the negotiation of managed care contracts and enhancing revenue through improved documentation resulting from feedback from our nationally certified coders.

AT A GLANCE address CompoNe services, ltd. 4400 will rogers pkwy., ste. 105 oklahoma City, oK 73108 phone: (800) 300-6717 web site: www.compone.com

serVICes • • • • • •

Billing (revenue cycle management) Consulting financial management Accounting managed care contract negotiation Compliance and lost revenue in-services • electronic health records

eMployees 150

presIdenT and Ceo mark michaud

ChIef operaTIng offICer debra Chaney

Free Practice Assessment CompONE offers a free assessment to determine how much additional revenue we can generate for your practice. This assessment is done with no obligation and can be completed quickly and discreetly. Contact us to set up your free practice assessment today!

Compliance Staying on top of today’s ever-changing billing compliance regulations can be an overwhelming task. With fines and penalties exceeding $10,000 for each potential false claim submitted, groups have a vested interest in knowing that their bills are being submitted in a compliant and accurate manner. CompONE meets all HIPAA and OIG guidelines for third-party billing companies, and will work as your champion to maximize your revenue while mitigating your risk.

Anesthesiology News • August 2011

This corporate profile was reviewed and approved by CompONE Services, Ltd.

24th Annual

Corporate Profiles 2011-2012

drÄger Technology for Life®

räger develops innovative equipment and solutions trusted by people the world over when lives are on the line. In clinical settings, industry, mining and emergency services, Dräger products protect, support and save lives. “Technology for Life” means more than merely guaranteeing technical excellence. It means assuming responsibility for the lives of those who use our products and depend on them. Technology for Life is both our guiding principle and the central challenge that we draw on for inspiration and motivation. “We do everything we do with passion—and we do it for life.” —Stefan Dräger, Executive Board Chairman

Global Leader in Medical Technology For more than 100 years, Dräger has been creating solutions that protect life, from innovative anesthesia delivery systems to professional diving technology and gas detection equipment. As a leader in medical and safety technology, Dräger employs more than 10,000 people worldwide. The company is present in more than 190 countries to effectively serve customers around the globe. The expertise of our management and employees is crucial to the growing globalization of our company. Our employees are characterized by their customer focus, entrepreneurial attitude, flexibility and global orientation.

AT A GLANCE The company is headed by Stefan Dräger, the fifth generation of Dräger family members to lead the organization. Having your name on the equipment that your customers rely on makes it personal.

Bringing Transparency to Anesthesia Transparency is an integrated anesthesia solution that simplifies operation so you can focus on your patients. By incorporating a single, intuitive user interface across three distinct workstations, Dräger enables anesthesia professionals to efficiently transition from one care area and case type to the next. Truly digital anesthesia delivery and seamless integration of patient monitoring information enables the automated data capture that helps users focus on patients, not paperwork.

Transparency is an integrated monitoring solution that makes it easier to get all the information you want. It starts with an open architecture design and an ability to host multiple applications simultaneously. The widescreen format of the Infinity® Omega C700 for information technology puts more of that data at your fingertips at one time. As an electronic version of the traditional patient folder, it saves you time, facilitates decision making and helps reduce the potential for medical errors. Plus, uninterrupted patient monitoring of up to

gloBal headQUarTers drägerwerk Ag & Co. KgaA moislinger Allee 53-55 23558 lübeck, germany phone: +49-451-882-0 fax: +49-451-882-2080 email: info@draeger.com

norTh aMerICan headQUarTers draeger medical, Inc. 3135 Quarry rd. Telford, pA 18969 phone: (800) 4-drAger (437-2437) fax: (215) 723-5935 email: info.usa@draeger.com web site: www.draeger.com

prodUCTs Anesthesia workstations, monitoring systems, enterprise solutions, information technologies, ventilation therapy, home mechanical ventilation, warming therapy, architectural systems, accessories, surgical lighting and video systems, drägerservice®, education and training.

eMployees Approximately 10,000 worldwide

presIdenT and Ceo stefan dräger

eight parameters from pre-op to the postanesthesia care unit ensures the most complete patient picture possible.

Transparency is platform consistency that protects your investment and your patients.

30 Infinity omega-s brings together patient data from diverse sources—such as vital signs, lab data, dICoM images (x-ray, MrI, CT, Us) and access to the patient’s electronic patient record (epr). The Infinity omega-s solution is part of dräger’s comprehensive anesthesia workplace.

Anesthesiology News • August 2011

Dräger’s consistency of platforms makes training more transparent, helping minimize training costs and reduce errors. In fact, the use of a consistent user interface across Dräger anesthesia product lines can significantly reduce the time needed to learn all the platforms required to support various care settings, ranging from the operating room to magnetic resonance imaging and mobile environments. More importantly, it enables a familiarity that allows you to react intuitively, confidently and efficiently. To learn more about how Dräger can help bring transparency to your anesthesia care, contact your local anesthesia sales representative or visit us on the Web at www.draeger.com, or at one of the many trade shows we attend during the year.

This corporate profile was reviewed and approved by Dräger.

Transparency is

simplifying operation so you can focus on your patients.

Enhance user interaction across devices and workstations.

D-22412-2010

MT-5651-2008

By incorporating a single, intuitive user interface across three distinct workstations, Dr채ger enables anesthesia professionals to efficiently transition from one care area and case type to the next. The digital precision of our piston delivery makes it easier for users to get the ventilation that they set, so they can respond confidently to changing patient situations and acuity levels. Plus, truly digital anesthesia delivery and seamless integration of patient monitoring information enables the automated data capture that helps users focus on patients, not paperwork. VISIT WWW.DRAEGER.COM/TRANSPARENCY OR EMAIL INFO.USA@DRAEGER.COM TODAY

24th Annual

Corporate Profiles 2011-2012

edwards lIfesCIenCes

dwards Lifesciences’ hemodynamic monitoring and management systems provide tailored hemodynamic optimization and clarity into patient status, enabling clinicians to make even more informed and rapid decisions when a patient’s hemodynamic balance becomes disrupted. Edwards is credited with pioneering the practice of hemodynamic monitoring with the launch of the original Swan-Ganz catheter in the early 1970s. Today, Edwards’ extensive line of hemodynamic monitoring catheters, sensors and bedside patient monitoring tools continues to build on this gold standard. The goal of these systems is to provide the clarity clinicians need, each and every moment they need it, when caring for and treating patients in high-risk surgery. Solutions include the following: • The FloTrac sensor is the first minimally invasive hemodynamic monitoring device that connects to any existing arterial line and automatically calculates key flow parameters such as cardiac output, stroke volume and stroke volume variation on a continuous basis. Used on more than 775,000 patients, the FloTrac sensor is trusted by more clinicians than any other fluid management solution.

global view of tissue oxygenation. Edwards’ PediaSat oximetry catheter also is available for pediatrics. • Edwards is a global leader in the broader field of disposable pressure-monitoring devices. The TruWave disposable pressure transducer and the VAMP closedloop arterial blood sampling system protect both patients and clinicians from the risk for infection. • Advanced technology versions of the Swan-Ganz catheter and the Vigilance II monitor provide a single, continuous monitoring solution for the most complex patients.

AT A GLANCE address one edwards way Irvine, CA 92614 phone: (800) 424-3278 (949) 250-2500 email: CriticalCare@edwards.com web site: www.edwards.com/ CriticalCare

prodUCTs hemodynamic monitoring systems including the floTrac sensor; presep and pediasat oximetry catheters; swan-ganz pulmonary artery catheter; Truwave disposable pressure transducer; VAmp (Venous Arterial blood management protection) system; Vigileo and Vigilance II monitors.

swan-ganz catheter

Edwards recognizes that assessing a patient’s hemodynamic and oxygenation status and minimizing the risk for infection are fundamental requirements for treating critically ill patients. Edwards will continue to leverage its experience and leadership in this area to help clinicians advance patient care. CAUTION: Federal (United States) law restricts this device to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions and adverse events.

floTrac sensor

• Edwards also offers the PreSep oximetry catheter, which provides the security of an early warning by continuously measuring a patient’s central venous oxygen saturation, providing an earlier and more

presep oximetry catheter

pediasat oximetry catheter

Vigileo monitor

Edwards, Edwards Lifesciences, the stylized E logo, FloTrac, PediaSat, PreSep, Swan-Ganz, TruWave, VAMP, Vigilance, Vigilance II and Vigileo are trademarks of Edwards Lifesciences Corporation.

Anesthesiology News • August 2011

Vigilance II monitor

This corporate profile was reviewed and approved by Edwards Lifesciences.

Advanced Fluid Therapy Navigation

Optimize your high-risk surgical patients’ fluid balance. The FloTrac system enables an individualized approach for delivering and tailoring fluid therapy for perioperative hemodynamic optimization. Used on over 775,000 patients, the FloTrac sensor is trusted by more clinicians than any other fluid management solution. Visit Edwards.com/FloTrac to experience advanced therapy navigation. For professional use. CAUTION: Federal (United States) law restricts this device to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events. Edwards, Edwards Lifesciences, the stylized E logo, and FloTrac are trademarks of Edwards Lifesciences Corporation. © 2011 Edwards Lifesciences Corporation. All rights reserved. AR06500

Edwards Lifesciences Irvine, USA I Nyon, Switzerland edwards.com

Tokyo, Japan

Singapore, Singapore

São Paulo, Brazil

24th Annual

Corporate Profiles 2011-2012

MCMahon pUBlIshIng

cMahon Publishing was founded in 1972 by Raymond E. McMahon and has grown to become one of the nation’s largest familyowned medical publishers. McMahon publishes a broad array of medical newsmagazines in various specialties, including anesthesiology, gastroenterology, general surgery, hospital pharmacy, infectious diseases, pain medicine, rheumatology and oncology. The combined circulation of McMahon Publishing publications is approximately 250,000 doctors and pharmacists. McMahon newsmagazines are accompanied by a full line of digital media, including Web sites, e-Newsletters, digital editions, podcasts, Twitter feeds and other electronic communication to readers. Foremost among McMahon publications is Anesthesiology News. Launched 36 years ago, Anesthesiology News has been the best-read publication in the field for the past 14 years (according to Kantar Media). Nearly 95% of the 44,832 U.S.-based anesthesiologists read this publication each month.

AT A GLANCE address 545 w. 45th st., 8th fl. New york, Ny 10036 phone: (212) 957-5300 fax: (212) 957-7230 web sites: www.mcmahonmed.com www.anesthesiologynews.com www.cmezone.com

prodUCTs medical newsmagazines, custom medical publications, educational reviews, educational and instructional pocket guides, special editions.

eMployees 70

pUBlIsher, Ceo and ManagIng parTner raymond e. mcmahon

general Manager, parTner matthew mcmahon

anesThesIology news Senior Group Publication Director richard Tuorto Manager, Publication Sales Angela labrozzi Account Manager david Nathanson Executive Manager, Classifieds Nancy parker Managing Editor Adam marcus Associate Managing Editor Janine gleason Production Manager martin Barbieri Art Director Blake dennis

6 McMahon Publishing

Supplement to Anesthesiology News • AnesthesiologyNews.com • 2010

Common Peripheral Nerve Blocks in Pediatric Patients Santhanam Suresh, MD, FAAP Amod Sawardekar, MD Melanie Kho, MS

Current Concepts In the Management Of the Difficult Airway Carin A. Hagberg, MD

The Pharmacology of Intravenous Anesthetic Induction Agents: A Primer Hugh C. Hemmings Jr, MD, PhD

Sonopathology: Case Studies and Clinical Pearls With an Anesthetic “Game Changer” Brian D. Sites, MD John Antonakakis, MD

Evidence-based Review Of Radiofrequency Ablation Techniques For Chronic Sacroiliac Joint Pain

Spinal Cord Stimulation For the Treatment Of Chronic Pain Timothy Deer, MD

Anita Gupta, DO, PharmD

Intrathecal Therapy For the Management of Cancer and Noncancer Pain Oscar de Leon-Casasola, MD Richard L. Rauck, MD

Therapeutic Hypothermia Daniel I. Sessler, MD Case Report Alaa A. Abd-Elsayed, MD, MPH Ehab Farag, MD, FRCA

The next Special Edition to be published October 2011 Please pass this issue along to your staff.

Anesthesiology News • August 2011

@ anesthesianews

This corporate profile was reviewed and approved by McMahon Publishing.

24th Annual

Corporate Profiles 2011-2012

ge healThCare

ealthymagination is GE Healthcare’s $6 billion commitment to global health. Through this effort, GE is touching more lives through innovation and strategic partnerships developed in response to two simple questions: What are the biggest challenges facing health care consumers and providers, and how can we help? GE Healthcare provides transformational medical technologies and services that are shaping a new age of patient care. Join us on our global journey as we continue to focus on reducing costs, increasing access and improving quality through innovation.

Anesthesia Carestation: A century in the making

AT A GLANCE

treatment plans and adjust as needed based on a continuous flow of centralized, relevant information. From the OR to the surgery center, GE’s broad anesthesia portfolio is ready to meet today’s clinical demands. The Avance* Carestation is designed to simplify and integrate GE’s most advanced technologies in an interactive, knowledge-based system. Aespire* View is a cost-effective solution that integrates a 12” color ventilator display and advanced ventilation modes including PCV-VG and has the capability of capturing fresh gas flow data. The Aestiva,* one of the most widely used anesthesia systems in the world, is available in a number of configurations, including MRI-compatible.

Our broad expertise across the perioperative care Patient monitoring: Above, beyond area is the by-product of a century of anesthesia and at the bedside innovation. The breakthrough ideas of a small Ohio GE’s robust lineup of perioperative monitoring company in 1910, the predecessor solutions targets all levels of patient to the Anesthesia division of GE acuity. GE’s most recent addition, Healthcare, have evolved into ideas the CARESCAPE * Monitor that continue to open new frontiers B650, is a flexible and scalable in anesthesia. solution providing access to the Today’s innovative vision for right clinical information, when anesthesia delivery extends across and where it is needed. Consult three digital dimensions. We call with your GE representative to it a Carestation. The foundation determine the best anesthesia and of GE’s Aisys* Carestation* is the patient monitoring solutions for your facility. digital platform that integrates therapy, patient monitoring and information management. The Ultrasound for Aisys Carestation is the only anesthesia: Once you fully digital anesthesia solution use it, it’s hard to currently offered in the United imagine ever working States.** Clinicians can appreciate without it the Aisys for what it delivers in the GE is an innovator in expanding There is a lot of ability in a operating room. CFOs enjoy the Carestation! ge aisys Carestation ultrasound’s role in health care and added peace of mind knowing that with CaresCape Monitor B850 and anesthesia delivery. The Venue* their investment can prepare them Centricity perioperative anesthesia— 40 and LOGIQ e* ultrasound for future breakthrough technology ranked #1 in 2011 for anesthesia systems, designed for anesthesia, by Klas† when available. provide clarity in visualizing the With GE’s CARESCAPE * nerve, needle and anesthetic spread for precise placement of regional Monitor B850 and Centricity * nerve block procedures. Experience Perioperative Anesthesia, ranked #1 confidence and improved patient in 2011 for Anesthesia by KLAS,† experience with our compact, your Carestation can help provide portable, intuitive and affordable exceptional clinical decision solutions. support and data management throughout the continuum of care. From scheduling to billing With you from start to record management, this helps to finish: Accessories, maximize efficiency and return on service, financing and investment. more Navigator Application Suite* is GE’s portfolio includes more a smart technology available with than 3,500 available product your Carestation that analyzes solutions. Our latest innovation, the drug therapy information to model enFlow* IV Fluid/Blood Warmer, and help predict the effect of is a mobile, compact system that supported anesthesia-related drugs ge Venue 40 anesthesia. Ultrasound can help prevent hypothermia by and drug interactions. Navigator guidance made easy for regional rapidly and automatically warming helps clinicians determine effective nerve Blocks. fluids to 40 C. This corporate profile was reviewed and approved by GE Healthcare.

address 3000 North grandview Blvd. waukesha, wI 53188 phone: (262) 544-3011 fax: (262) 548-2244 web site: www.gehealthcare.com

prodUCTs Anesthesia Carestations and ventilators; decision support tools; patient monitors; monitoring systems for the entire perioperative environment; information management systems and remote viewing; networking solutions; and related services, supplies and accessories; ultrasound; surgical equipment.

presIdenT and Ceo, ge healThCare John dineen

presIdenT and Ceo, ge healThCare sysTeMs Tom gentile

From surgical imaging drapes to cardiac monitoring to temperature management, we offer products compatible across a wide range of equipment platforms. Having us as your single-source solution saves time and helps reduce the hassle of multiple purchase orders and vendor research. GE Healthcare offers a variety of service support options and a comprehensive technical support department committed to keeping your facility running smoothly—with minimal downtime. Additionally, GE offers project management for major installations, Six Sigma–based services for improving care quality and efficiency, various finance packages, knowledgeable and caring representatives and quality clinical and technical education. Headquartered in the United Kingdom, GE Healthcare is a $17 billion unit of General Electric Company (NYSE: GE). Worldwide, GE Healthcare employs more than 53,000 people committed to serving health care professionals and their patients in more than 100 countries. For more information about GE Healthcare, visit our Web site at www.gehealthcare.com. * GE, GE Monogram, Aespire, Aestiva, Aisys, Carestation, CARESCAPE, Centricity, enFlow, LOGIQ, Navigator Application Suite, Venue and Vivid are trademarks of General Electric Company. ** As of January 2011, among major U.S. anesthesia delivery manufacturers (Spacelabs, Drager, Mindray, Penlon), only GE features digital vaporization, digital ventilation and digital gas delivery. †

Anesthesiology News • August 2011

24th Annual

Corporate Profiles 2011-2012

Karl sTorZ endosCopy-aMerICa, InC.

n 1945, in the small town of Tuttlingen, Germany, Dr. Karl Storz founded a company that has grown into a global corporation and international leader in the field of endoscopy. Today, the KARL STORZ organization, although still a family-held company, has offices and distribution agents in more than 25 countries worldwide. Now celebrating more than 65 years in business, a significant milestone for a family-owned enterprise, the KARL STORZ company has what is probably the industry’s most complete line of endoscopic equipment, with more than 8,000 different products encompassing more than 15 specialty areas, allowing true standardization with one company. The KARL STORZ organization today continues a family legacy of dedication to developing innovative products that support the judgment of surgeons and physicians, and extend and strengthen their skills through exceptional device design and functionality. This quest to set new standards of quality is balanced by a commitment to supporting humanitarian and social initiatives. KARL STORZ Endoscopy-America offers an array of products to simplify tracheal intubation and other airway management applications—including emergency and unexpectedly difficult intubations. Fiber-optic video intubation scopes, optical intubation stylets and video laryngoscopes create a comprehensive video intubation system. Fiberscopes specially designed for intubations have sandblasted shafts for easy insertion of endotracheal tubes, with no need for lubricants. Other products include ergonomically optimized airway carts and standard laryngoscope blades with brilliant LED light sources. A critical facet of the company’s latest airway management products is its focus on offering systems-based solutions, rather than standalone devices. The result is product offerings that combine exceptional portability, affordability and flexibility.

A History of Milestones The KARL STORZ company’s history of innovation includes the extracorporeal electronic flash (1956), cold light source (1960), Hopkins® rod lens system (1965), ultrasound lithotriptor (1970), direct-coupled interface endoscopes (1999) and OR1® Integrated Surgical Suites (2000). In 2001, the company launched the first all-digital imaging system, Image 1®, and its 1080p60 Image 1® high-definition video platform was released just six years later. And, KARL STORZ introduced its first video laryngoscope to the market in 2002.

Recent Notable Advancements

KARL STORZ video laryngoscope blades have been shown to be beneficial in performing tracheal intubation in difficult airways.1 The portable C-MAC® Video Intubation System has been designed for both expected and unexpected difficult airway situations, as well as standard intubations. Standard Macintosh blades are used to promote ease of use, with a reduced learning curve. The standard shaped blade also facilitates training, while its Anesthesiology News • August 2011

AT A GLANCE

video output feature allows simultaneous viewing that enhances difficult airway management and teaching. address Results of a recent study that compared the C-MAC® 2151 e. grand Ave. video laryngoscope with direct laryngoscopy suggest el segundo, CA 90245-5017 that combining the benefits of direct laryngoscopy with phone: (424) 218-8100; video laryngoscopy in one device may serve for both (800) 421-0837 2 routine airway management and educational purposes. web site: www.karlstorz.com ® The C-MAC system has benefited from the addition of Miller blades in sizes 0 and 1 for pediatric and neoprodUCTs natal intubations. And, a specialized blade, the dBlade™, Intubation fiberscopes, video which has a very acute angle, facilitates intubation of laryngoscopes (Cmos and fiberoptic), patients with very anterior airways. In the first clinical standard laryngoscopes (led and ® ™ evaluation of the C-MAC dBlade , it was found that xenon light), optical intubation the highly angulated blade afforded a good view of the stylets, complete airway management glottis, resulting in successful intubation of patients with cart solutions, or integration and 3 difficult airways. KARL STORZ is the only company telemedicine. now offering eight different reusable and highly durable video laryngoscope blades. eMployees KARL STORZ Brite Blade™ laryngoscopes, with patmore than 3,500 worldwide ented LED technology, continue to provide the brightest illumination of the airway among “green standard” parenT CoMpany intubating laryngoscopes. A “stubby handle” Brite Blade KArl sTorZ gmbh & Co. Kg also is available, with a shorter handle that facilitates techniques used for pediatric and neonatal intubations. presIdenT and Ceo The stubby handle also allows easier positioning of Charlie wilhelm the laryngoscope in obese patients whose greater chest wall mass can impede proper placement of standard laryngoscopes. Expanding on the successful C-MAC® video larynReferences goscope, the new C-CAM™ and C-HUB™ platform rep1. Jungbauer A, Schumann M, Brunkhorst V, Börgers A, Groeben H. resents an innovative system-based approach to airway Expected difficult tracheal intubation: a prospective comparison of management, allowing imaging challenges in every disdirect laryngoscopy and video laryngoscopy in 200 patients. Br J cipline to be overcome in both stationary and mobile Anaesth 2009;102:546-550. settings, and offering an economic solution for doctors’ 2. Cavus E, Neumann T, Doerges V, et al. First clinical evaluation of the C-MAC dBlade videolaryngoscope during routine and difficult offices, intensive care and emergency medicine. intubation. Anaesth Analg 2011;112:382-5. The new C-CAM™ camera head used on the porta3. Cavus E, Carsten T, Moeller T, Kieckhaefer, Doerges V, Wagner K. A ® ble C-MAC video screen incorporates the latest CMOS randomized, controlled crossover comparison of the C-MAC videotechnology to provide a superior solution for applicalaryngoscope with direct laryngoscopy in 150 patients during routine induction of anaesthesia. BMS Anesth 2011;11:6. tions with flexible intubation fiberscopes and optical stylets. The ultra-small, ultra-light device is easy to hold and control, and provides plug-and-play ease of use. With it, the C-MAC® becomes a system for airway management combining video laryngoscopy with flexible fiberscopes and optical stylets. The C-HUB ™ platform allows direct connection with C-CAM™, flexible CMOS intubation scopes and C-MAC ® laryngoscope blades, or to any size of external display, as well as directly to any computer interface. The C-HUB can also be used in integrated operating rooms to route the signal to any Karl sTorZ Brite Blade™ mounted monitor without Karl sTorZ offers an array of airway laryngoscopes use patented interfering the surgical video management solutions on one video led technology for brilliant equipment. illumination of the airway. platform. This corporate profile was reviewed and approved by KARL STORZ Endoscopy-America, Inc.

C-MAC – ®

Make your Video Laryngoscope a SYSTEM! A Single Instrument is not Airway Management

W E N

KARL STORZ Endoscopy-America, Inc., 2151 E. Grand Ave, El Segundo, CA 90245, USA, Phone: (424) 218-8100, Fax: (800) 321-1304, E-Mail: info@ksea.com KARL STORZ GmbH & Co. KG, Mittelstraße 8, D-78532 Tuttlingen/Germany, Phone: + 49 7461 / 70 80, Fax: 07461 / 70 81 05, E-Mail: karlstorz-marketing@karlstorz.de KARL STORZ Endoscopy Canada, Ltd., 2345 Argentia Road, Suite 100, Mississauga, Ontario, Canada L5N 8K4, Phone: (800) 268-4880, Fax: (905) 858-0933 KARL STORZ Endoscopia, Latino-America, 815 NW 57 Ave, Suite #480, Miami, Florida 33126-2042, USA, Telefono: (305) 262-8980, Telefax: (305) 262-8986 A-0810004

www.karlstorz.com

24th Annual

Corporate Profiles 2011-2012

lMa norTh aMerICa

he LMA™ airway is a supraglottic airway that has a proven track record of safety and efficacy. LMA™ airways have been used more than 300 million times, building on a 20-year history of innovation and trust. The subject of more than 3,000 clinical references, each LMA™ airway has been carefully designed and tested to meet exacting standards. Today, it is used in approximately one-third of all general anesthesia cases in the United States. LMA™ airways are included in the American Heart Association Guidelines for Resuscitation and the American Society of Anesthesiologists Difficult Airway Algorithm.

LMA North America Family Of Products LMA™ North America is dedicated to improving patient care through the sale of high quality and innovative products for anesthesia and airway management. The newest products from LMA™ are the LMA Atomization™ family. The LMA Atomization™ family of products consists of LMA MAD Nasal™ Intranasal Mucosal Atomization Device, the safe and painless way to deliver medication directly into your patients’ blood stream without an intravenous line. The LMA MADgic Airway™ Intubating Airway with Mucosal Atomization and Oxygen Delivery, the most innovative choice to create a temporary airway to facilitate fiber-optic intubation. For your difficult and awake airways requiring a fiber-optic scope, the LMA MADgic Airway™ can come to the rescue, combining atomized topical anesthetic and oxygen delivery in an innovative and elegantly designed fiber-optic oral airway. The LMA MADgic™ Laryngo-Tracheal Mucosal Atomization Device, the most versatile choice to administer medication across the entire upper airway and beyond the vocal cords. For all of your difficult and awake intubations, bronchoscopies, transesophageal echocardiograms and endoscopies. The LMA MADomizer™ Refillable Bottle Atomizer, the simple, effective and targeted topical medication delivery system that eliminates the risk of crosscontamination. The LMA MADomizer™ is safe, effective and customizable to the individual needs of your patients. The LMA MADdy™ Pediatric Mucosal Atomization Device, the ideal pediatric device to deliver topical solutions across the nasal and oropharyngeal mucous membranes. The LMA MADgicWand™ Pharyngeal Tissue Retractor/Atomizer, helps to reduce the stress of fiber-optic intubation by providing thorough, precise topical anesthetic deposition.

The LMA MADett™ Endotracheal Mucosal Atomization Device, delivers atomized medication beyond the ETT tip, resulting in more rapid and higher peak blood levels than nebulized or endotracheally injected medication. The JED™ Jaw Elevation Device by Hypnoz. Designed as a hands-free solution for MAC airway maintenance, the JED™ helps clinicians maintain an open airway during any procedure in which a patient is sedated and the airway may become compromised. This externally applied, noninvasive device assists the user in performing an optimal jaw thrust, eliminating the need for the clinician to manually maintain a jaw thrust during the procedure. The JED™ may be left in place following the procedure, providing an open airway until sedation wears off. The LMA Supreme™ is the first and only single-use LMA with a built-in drain tube designed to channel fluid and gas safely away from the airway. The carefully tested design facilitates easy insertion. With its advanced features, the LMA Supreme™ is an effective alternative to an endotracheal tube (ETT) in many cases. Now available in pediatric sizes 1 and 2 for neonates/infants from 5 kg to 20 kg. The McGRATH® Series 5 and HLDi video laryngoscopes are fully portable and are designed to provide a clear view of the vocal cords during intubation. A small camera with a powerful light source is located at the distal end of the blade. Once a clear image of the vocal cords and surrounding anatomy is obtained, a standard ETT is then guided by the clinician through the vocal cords and into the larynx while viewed in real time on the color video display. The units have no external cables and operate on a single AA battery. The McGRATH® Series 5 HLDi video laryngoscope is the only video laryngoscope that is entirely waterproof. The LMA Classic™ is the original laryngeal mask airway. It is best suited for elective surgeries in patients who are breathing spontaneously and also is used with assisted and controlled ventilation. The LMA Classic Excel™ is an upgraded version of the original LMA Classic™. The improved design is reusable up to 60 times. A removable airway connector facilitates intubation in the case of an unforeseen airway complication. The LMA Classic Excel™ is a cost-efficient solution for your airway needs. The LMA Unique™ is a single-use version of the LMA Classic. It provides the same reliability and ease of insertion and is ideal for hospitals that have problems with lost equipment and cleaning concerns. The reusable LMA ProSeal™ is designed to provide separation of the respiratory and alimentary tracts and higher seal pressures, with no increase in

AT A GLANCE address 4660 la Jolla Village dr., ste. 900 san diego, CA 92122 phone: (800) 788-7999 web site: www.lmANA.com

prodUCTs lmA Airway management™, lmA Atomization™, lmA ems™, lmA Visualization™

eMployees 80

ChIef eXeCUTIVe offICer steven r. Block

mucosal pressures. The patented risk-reduction features mean wider application of LMA benefits to more patients. The LMA Flexible™ is designed for head, neck and upper torso procedures, available in either single use or reusable. The highly flexible wire-reinforced airway may be positioned away from the surgical field without loss of seal, and has been shown to better protect the trachea and esophagus from descending blood and secretions than can an ETT. The LMA Fastrach™ is a rescue airway that facilitates continuous ventilation during and between intubation attempts. It can be used in anticipated or unexpected difficult airway situations. It is available as a reusable or as a cost-effective single-use option that is ideal for crash carts.

Services and Education LMA North America is committed to clinical education and invests significant resources to educate clinicians through airway seminars, visiting lecturer programs and hands-on workshops. The company supports anesthesia research through organizations such as the Society for Airway Management, the ASA and the Anesthesia Patient Safety Foundation. LMA North America provides grants and other support to teaching hospitals. The company supplements these activities with an extensive library of clinical articles and instructional materials on its Web site and in multimedia formats.

38 The lMa Mad nasal™ Intranasal Mucosal atomization device

Anesthesiology News • August 2011

The lMa Madgic™ laryngo-Tracheal Mucosal atomization device

The Jed™

The lMa supreme™

The McgraTh® series 5 hldi

This corporate profile was reviewed and approved by LMA North America.

Mistify

your patients.

24th Annual

Corporate Profiles 2011-2012

MasIMo CorporaTIon Proven technology, proven performance, proven leadership

or more than 20 years, Masimo has focused on a singular mission—to help clinicians improve patient outcomes and reduce cost of care by taking noninvasive monitoring to new sites and applications. The result is a portfolio of clinically proven products that lead the way in innovation, performance and patient safety.

Gold-standard Pulse Oximetry With Masimo SET® Masimo Signal Extraction Technology (Masimo SET) is the world’s leading pulse oximetry technology, proven by both objective research and the real-world success of customers and partners. More than 100 independent, peer-reviewed studies have shown that Masimo SET outperforms all other pulse oximetry technologies, providing clinicians with unmatched sensitivity and specificity to make critical patient care decisions even under the most demanding clinical conditions of motion and low perfusion.

rainbow® Acoustic Monitoring™ for Continuous and Noninvasive Respiration Rate Masimo rainbow Acoustic Monitoring provides continuous and noninvasive Acoustic Respiration Rate (RRa™) that is accurate, easy to use and patient tolerant. Featuring an innovative adhesive sensor with an integrated acoustic transducer that is easily and comfortably applied to the patient’s neck, rainbow Acoustic Monitoring captures, separates and processes the respiratory signal using Masimo’s patented Signal Extraction Technology.

AT A GLANCE

rainbow Pulse CO-Oximetry for Continuous and Noninvasive Hemoglobin Monitoring Continuous and noninvasive total hemoglobin (SpHb®) is part of the Masimo rainbow SET technology platform—a breakthrough noninvasive blood constituent monitoring platform that measures physiological parameters that previously required invasive blood sampling and time-consuming laboratory analysis. Masimo SpHb helps clinicians trend hemoglobin status to enable real-time patient management decisions. In fact, a randomized controlled trial at a major U.S. teaching hospital showed that clinicians using Masimo SpHb reduced the frequency of intraoperative blood transfusions from 4.5% to 0.6% (Ehrenfeld JM, et al. American Society of Anesthesiologists 2010 annual meeting: LB05). In addition to SpHb, the upgradable rainbow platform allows clinicians to measure oxygen content (SpOC™), carboxyhemoglobin (SpCO®), methemoglobin (SpMet®) and pleth variability index (PVI®), as well as oxygen saturation (SpO2), pulse rate (PR) and perfusion index (PI). PVI has been shown to help clinicians assess fluid responsiveness and improve fluid management to reduce patient risk (Cannesson M, et al. Br J Anesth 2008;101:200-206. Forget P, et al. Anesth Analg 2010;111:910-914).

40 parker Irvine, CA 92618 phone: (949) 297-7000 web site: www.masimo.com

prodUCTs masimo seT measure-through motion and low perfusion pulse oximeters and sensors; masimo rainbow pulse Co-oximeters and sensors; masimo rainbow Acoustic monitors and sensors; sedline brain function monitoring; and patient safetyNet.

MIssIon sTaTeMenT Improving patient outcomes and reducing cost of care by taking noninvasive monitoring to new sites and applications.

eMployees 2,000+

ChaIrMan and Ceo Joe Kiani

SEDLine® Brain Function Monitoring SEDLine brain function monitoring advances neuromonitoring technologies to improve the care of patients under anesthesia or sedation. The core product is a stateof-the-art electroencephalogram (EEG)-based brain function monitor. Using four channels of information, the SEDLine monitor measures the effects of anesthesia and sedation by monitoring both sides of the brain’s electrical activity to enable more individualized titration that helps to enhance anesthetic control throughout all phases of anesthesia.

Patient SafetyNet™

The adhesive acoustic sensor is placed comfortably and conveniently on the patient’s neck.

address

The Patient SafetyNet system combines gold-standard Masimo SET pulse oximetry, breakthrough rainbow measurements and remote patient monitoring with wireless clinician alerts—providing an unmatched level of patient safety on general care floors. The system can either be integrated into an existing IT infrastructure or operate as a standalone system. For many years, clinicians have understood the risk of not continuously monitoring patients on the general floor. However, excessive false alarms due to patient motion made general floor monitoring an elusive goal.

Multiple studies over the last decade have shown that Masimo SET improves the process of care in neonates and pediatric patients—but a recent landmark study was the first to show that Masimo SET improves clinical outcomes in adults. After implementing Masimo SET and Patient SafetyNet in a postsurgical floor where only intermittent spot checking had been used before, a major academic medical center significantly reduced rescue events by 65%, intensive care unit (ICU) transfers by 48% and annualized ICU bed usage by 135 days with no sentinel events (Taenzer AH, et al. Anesthesiology 2010;112:282-287). Just as pulse oximetry is a standard of care in the operating room, postanesthesia care unit and ICU, we now believe that pulse oximetry will become a standard of care on the general floor. When rainbow Acoustic Monitoring is used in conjunction with rainbow Pulse CO-Oximetry and Patient SafetyNet, clinicians can follow key indicators of oxygenation, ventilation, circulation and bleeding—enabling them to monitor more patients, more safely than ever before.

Anesthesiology News • August 2011

This corporate profile was reviewed and approved by Masimo Corporation.

Why Settle for Anything Less Than the Complete Picture?

Get the complete picture with SEDLine brain function monitoring ®

SEDLine helps you improve anesthetic case management by revealing the full picture of the brain’s response to anesthesia. Complete information about both sides of the brain enables individualized titration for optimal results.1 SEDLine features: > 4 channel EEG with integrated algorithm for proven performance > Superior resistance to electrocautery2 > Multiple screen views in a high-resolution monitor Call your Masimo representative to explore how SEDLine compares to your current brain function monitoring technology in performance and price.

Drover DR et al. Anesthesiology 2002, 97:82–89 White PF et al. Anesth Analg 2004, 99:1429-1435

24th Annual

Corporate Profiles 2011-2012

MCKesson A More Holistic Approach to the Practice and Business of Anesthesiology

obody becomes an anesthesiologist to track quality metrics, master arcane billing codes, record every detail of the day’s work or worry about complex laws, regulations and guidelines. You become an anesthesiologist to care for patients. And at McKesson, we’ll help you focus on doing just that. Our anesthesiology solutions minimize the time and attention you must devote to the operational and financial aspects of your practice, while at the same time enabling you to deal with them more successfully. Our holistic approach addresses your entire practice, including medication dispensing, coding and billing, compliance, automated information management and business management. It’s the most comprehensive set of technology and service solutions available for anesthesiology.

Specialists in Your Specialty McKesson has more than 500 employees dedicated to anesthesiology, bringing a deep expertise in all care models and practice settings. Our staff includes clinical experts who bring their understanding of anesthesia workflows and processes to all of our offerings. In fact, all McKesson technology solutions in this area have been either developed by anesthesiologists or greatly influenced by professional input through consultation and testing. This includes the products and services we’ve added to our solution set over the years through carefully considered acquisitions, which also have brought additional experts to our organization. This level of understanding and professional participation helps guard against “technology for technology’s sake” and keeps our focus on solving practical problems faced by practices like yours and enhancing your clinical and business abilities.

The Central Role of Technology McKesson’s advanced technology reaches from the operating room to the boardroom, allowing you to efficiently improve productivity, financial performance, business management and compliance, while maintaining your focus on patient care. • The company’s Anesthesia-Rx™ automated dispensing cart facilitates anesthesia provider efficiency in the OR while reducing errors and automatically capturing medication information for charging and narcotics tracking. • McKesson’s Anesthesia Quality Focus™ data collection and reporting system allows you to monitor and improve patient outcomes, linking clinical and patient demographics by payor and facility and

AT A GLANCE

linking to McKesson billing and practice management solutions to track and report detailed quality metrics. • McKesson Revenue Management Solutions for Anesthesiology provide outsourced billing and financial management services to help your practice collect its cash faster, employing a team of certified coders who have consistently realized the industry’s highest percentage of first-time processing and payment of claims. • The McKesson Anesthesia Care™ integrated information management system seamlessly shares data with surgical management software and the hospital clinical information system to give caregivers a full medical picture of the patient. The system helps anesthesiologists focus on the patient while automatically documenting the anesthesia event with touchscreen charting, physiologic data capture, real-time drug allergy and contraindication warnings, comorbid modifiers, SNOMED CT coding for analytics, and professional fee coding for streamlined claims processing. • The McKesson Practice Focus™ for Anesthesia system gives administrators and physicians advanced, Web-based business intelligence tools that enable real-time performance surveillance and retrospective performance measurement, bringing an unprecedented level of visibility into financial outcomes for your practice.

address

Addressing the Audit Factor

Senior Vice President and General Manager, Physician Revenue Management Solutions patrick leonard

Worrying about the possibility of a Medicare or Medicaid audit has become a serious distraction for many anesthesiology groups. The increased incidence of these audits has raised the already high importance of complete and verifiable anesthesia compliance and documentation. Once again, McKesson can help. Our expertise in billing, reimbursement, documentation and reporting allows you to take a proactive stance and avoid costly, resource-draining problems. Through our technology solutions and consultation services, McKesson helps ensure that: • Providers are only capturing allowable anesthesia time, with appropriate documentation to support recorded start and end times. • Compliance with medical direction requirements is satisfied. • Separate payable services such as invasive monitoring lines and postoperative pain services are fully documented.

5995 windward pkwy. Alpharetta, gA 30005 web site: www.mckesson.com/ anesthesiology

prodUCTs and serVICes • revenue cycle management services (including billing and accounts receivable management), business management consulting services, best practice advisory services, compliance services and health care trend analysis • Advanced technology solutions that reach from the operating room to the boardroom, improving productivity, financial performance, business management, compliance and patient care

senIor ManageMenT Executive Vice-President and Group President, McKesson Corporation pat Blake President, McKesson Provider Technologies david souerwine

McKesson’s guidance in proper and accurate claim preparation and coding can further serve to protect your practice from any negative audit outcomes.

Keep Your Focus McKesson’s comprehensive set of anesthesia management solutions helps anesthesiology groups like yours focus on patients and spend less time on the necessary, but secondary, aspects of your practice. Using our solutions, our customers better manage hands-on patient care delivery, better account for costs, improve group performance and assure accurate, prompt reimbursement. We look forward to helping your practice do the same. For more information, visit us at www.mckesson.com/anesthesiology.

Anesthesiology News • August 2011

This corporate profile was reviewed and approved by McKesson.

You focus on the patient. We’ll focus on you. You became an anesthesiologist to care for patients. McKesson can help you maintain your focus on patient care, and minimize the time and attention you have to devote to everything else.

Automated medication dispensing Billing and coding

From the operating room to the board room, we offer the most comprehensive set of

Compliance

technology and service solutions available for anesthesiology. Our solution set enables you to

Anesthesia information management

improve productivity, ﬁnancial performance, business management and compliance, while solving practical problems and enhancing your clinical and ﬁnancial results. McKesson’s anesthesiology solutions allow you to focus on making sure your patient is successfully managed. Let us focus on you to ensure your practice is successfully managed.

www.mckesson.com/anesthesiology 1.800.300.2599

Practice management

24th Annual

Corporate Profiles 2011-2012

MIndray Health Care Within Reach

indray is dedicated to the goal of delivering high-quality medical instrumentation to a global market. We are singularly focused on patient care as a leading developer, manufacturer and marketer of patient monitoring, life support, in vitro diagnostics and medical imaging products. With more than 6,000 employees and R&D centers on three continents, Mindray offers the medical community a range of innovative solutions designed to contain costs while ensuring the highest-quality products for patient care. Mindray’s sales professionals and clinical education specialists provide your staff with comprehensive, onsite training and in-service on demand 24 hours a day, seven days a week. Our dedicated field service and inhouse technical support organization is one of the largest direct service teams in the industry. Individually and collectively, they are committed to enhancing patient care while protecting your investment. Learn how we can help you maximize your resources with some of the most advanced and accessible medical instrumentation in the industry.

Ultrasound Imaging Tools for Anesthesia Professionals Mindray’s M Series diagnostic ultrasound imaging systems are practical and effective procedural tools for anesthesia professionals. They enable visualization of target structures before and during anesthesia procedures. The M5 and M7 ultrasound systems are uniquely designed for the procedural room environment. Notable attributes include compact and durable design, a sealed surface for easy cleaning and infection control, exceptional image quality and simple and intuitive operation. The M Series offers customizable reports and a complete on-board solution for patient information management and connectivity. Users also can select from a wide range of specialty transducers and optional features to meet clinical needs.

Powerful, Practical, Modular Technology in Anesthesia Monitoring The DPM6 and DPM7 offer a broad range of patient monitoring capabilities in a rugged, modular design. The DPM7’s large 17-inch touch-screen display is most appealing in the operating room, where visibility and convenience are essential. The DPM6’s flexibility and modularity combine with its 12-inch touch-screen display and matching user interface to offer a complementary monitoring solution for postoperative areas. Supporting up to eight invasive pressures and features

AT A GLANCE such as auto-identification of anesthetic agents, carbon dioxide, nitrous oxide and oxygen, combined with monitored anesthesia care and bispectral index monitoring, the DPM6 and DPM7 represent a powerful combination of advanced functionality and extraordinary value.

Clear, Explicit, Precise Anesthesia Delivery Drawing on a history of innovation and user input, the A5 Anesthesia System has proven to be the simple-to-use, full-featured anesthesia system that offers comprehensive safety features for use across a range of patients. With its efficient design and comprehensive standard features, the A5 is an ideal fit for any acuity anesthesia delivery environment. The A5 includes many standard features such as a central brake with integrated wheel guards, top to bottom mounting rails, ample equipment shelf and workspace with adjustable lighting and a breathing system maintained at body temperature

norTh aMerICan headQUarTers mindray North America 800 macArthur Blvd. mahwah, NJ 07430

MIndray gloBal headQUarTers Keji 12th road south high-Tech Industrial park Nanshan, shenzhen 518057 p. r. China

prodUCTs Anesthesia delivery systems, medical imaging, patient monitoring, in vitro diagnostic equipment

eMployees 6,000 worldwide

presIdenT MIndray norTh aMerICa david gibson

that virtually eliminates internal condensation. Standard ventilator modes include volume control ventilation, pressure-controlled ventilation with or without volume guarantee, pressure support and synchronized intermittent mandatory ventilation with either volume or pressure control support. Unique features include a 15-inch color touch-screen display, ergonomically tilted for comfortable interaction and visibility. And the auxiliary oxygen and air blender provides a flow-controlled method of adjusting the oxygen concentration at the patient interface. Finally, every A5 Anesthesia System provides the industry standard HL7 communication output, in IHE protocol and PCD format, for connection to anesthesia information systems and electronic medical records.

Learn More To learn more about how Mindray can help you realize more value in medical instrumentation technology, contact your local sales representative at (800) 288-2121, or visit us at www.na.mindray.com.

Anesthesiology News • August 2011

This corporate profile was reviewed and approved by Mindray.

â&#x201E;˘

ANESTHESIA SYSTEM

D I A G N O S T I C U LT R A S O U N D S Y S T E M

healthcare within reach The Mindray A5's clear, intuitive touch screen interface simplifies operation. The explicit HL7 architecture provides ready access when integrating medical data. The precise, advanced ventilator delivers the care your patient needs. The Mindray M series ultrasound imaging systems are practical and effective procedural tools for anesthesia professionals. They enable visualization of target structures before and during anesthesia procedures. The M7 is uniquely designed to be easily accessed and used in the procedural room environment. Notable attributes include compact, portable, and durable design, a sealed surface for easy cleaning and infection control, exceptional image quality and simple and intuitive operation.

Mindray North America, 800 MacArthur Blvd., Mahwah, NJ 07430 1.800.288.2121 www.na.mindray.com

24th Annual

Corporate Profiles 2011-2012

sherIdan healThCare, InC.

he key challenge within today’s health care industry is change. Providers, hospitals, payers and patients are experiencing these emotional and stressful changes directly. As a result of recently passed health care reform, the next five years will be marked by uncertainty over price controls, rapidly changing reimbursement methods, new clinical operating paradigms and reactionary solutions designed to control health costs and trim governmental budgets. Health care stakeholders’ reactions to change will differ across the industry. Some may choose a defensive posture intended to protect financial performance by increasing premiums or lowering payments. Others may believe that consolidation and control will provide shelter from uncertainty. Many will put their heads in the sand and ignore change in the hopes of weathering the storm. Sheridan Healthcare, Inc., is embracing change, anticipating and planning for health care transformation— from reengineering clinical services to augmenting back office support to physicians and allied health providers. Successfully expanding within the health care industry for more than a half-century, Sheridan has been able to continuously evolve and grow by focusing first and foremost on the patient’s well-being and satisfaction. From this strong foundation and professional culture, Sheridan has maintained one of the highest retention rates in the industry, both among providers and clients. Physician led and managed, Sheridan understands the needs of providers and strives to improve their lives through consummate leadership, management support, effective training and positive work environments. These attributes enable providers to focus on what they do best: practice medicine. Our providers are part of a 58-year tradition. As one of the nation’s largest providers of anesthesia services, Sheridan’s goal is to deliver quality clinical services to our client facilities through the dedication of our accomplished clinical professionals.

Advantages to the Individual “There are many advantages to the individual anesthesia provider at Sheridan,” said Gilbert Drozdow, MD, MBA, president of Sheridan’s Anesthesia Division. “We offer extensive experience in anesthesia services, a robust business infrastructure and we are sensitive to the professional needs of our providers.” Lifestyle and the quality of life are important to providers. Sheridan offers extensive benefits to enhance and maintain job satisfaction—from income security to flexible scheduling and travel opportunities.

Sheridan encourages its providers to grow professionally and embrace clinical leadership, both in client facilities and at the corporate level. The Sheridan Leadership Academy is the driving force of professional development at Sheridan, teaching clinical leaders to hone their skills to optimize service, improve clinical care, and lead quality initiatives. Our quality management team includes staff physicians and nurses who also lead quality initiatives and provide a professional outlet for personal development.

Providing Business Benefits When a client facility outsources its medical and regulatory processes to Sheridan, clinicians are better able to focus clinically. Client facilities benefit from Sheridan’s vast experience in developing health care protocols, improving revenue cycle management, streamlining operating room management, insuring successful accreditation, expediting credentialing and focusing on customer service. Sheridan is a metric-driven organization, with systems to collect, evaluate and report data effectively. Continuous and timely feedback allows for improvements in efficiency and quality care. In addition to helping providers and clients meet and exceed their professional and strategic goals, clinical data allow Sheridan to prepare for and adapt to changes within the health care industry.

AT A GLANCE address sheridan healthcare, Inc. 1613 North harrison pkwy. sunrise, fl 33323 web site: www.sheridanhealthcare.com

serVICes multistate practice management company providing services in anesthesiology, emergency medicine, radiology and neonatology with pediatric subspecialties

VIsIon To deliver industry-leading healthcare solutions that demonstrate measurable excellence and value and make us indispensable to our customers

eMployees medical providers: 1,836 support: 600

ChaIrMan and Ceo mitchell eisenberg, md

presIdenT, anesThesIa serVICes gilbert drozdow, md, mBA

Industry Innovations Sheridan’s focus on adapting to change includes technological innovations, such as Inspire Health Solutions™.This Sheridan subsidiary is committed to improving provider efficiency and effectiveness. Inspire supports our client facilities and physicians with Webbased features including electronic health records, clinical integration, decision support, revenue cycle management and productivity management solutions. Sheridan providers can rely on a supportive leadership and leverage the company’s content specialists and operations managers to assist them in adapting to new technologies and clinical systems. “There is always a resource within our Anesthesia Services Division that can apply themselves to any project, regardless of its complexity,” Dr. Drozdow said. “And many times, solutions are readily available because they have already been addressed.”

Growing Anesthesia Services

Sheridan remains confident in our ability to be both sensitive and flexible regarding the individual needs of our providers. Sheridan extends an open invitation to individual anesthesia providers and group practices to visit our corporate site, learn more about our history, and examine our supportive and value-enhancing infrastructure. “Our success has depended upon a dedicated team of physician leaders willing to make a professional and personal investment in Sheridan’s progress,” Dr. Drozdow said. “We will continue to invest in our healthcare providers to build a successful company in our continually evolving industry.”

With a new generation of anesthesia professionals entering a rapidly evolving health care environment,

* “Sheridan” includes Sheridan Healthcare, Inc., and its subsidiaries and affiliates.

Anesthesiology News • August 2011

This corporate profile was reviewed and approved by Sheridan Healthcare, Inc.

24th Annual

Corporate Profiles 2011-2012

VeraThon MedICal A consistently clear airway view defines GlideScope video laryngoscopes

irways come in many shapes and sizes. Which is why GlideScope® video laryngoscopes are designed for a wide variety of patients. From the digital Cobalt AVL to the portable Ranger, reusable and single-use GlideScope configurations are available for the range of patients you see every day. GlideScope video laryngoscopes consistently provide a clear, real-time view of the airway and tube placement, enabling quick intubation. In fact, the GlideScope video laryngoscope achieves a Cormack-Lehane (C/L) grade I or grade II view 99% of the time.1

a wide range of patients. Operational in seconds, the Ranger also features a DVR option enabling recording of intubations to help verify tube placement and support training.

foUnder and Ceo

Anesthesiology News • August 2011

gerald mcmorrow

glidescope ranger single Use

Preterm and Pediatric Stats The GlideScope Cobalt AVL offers another big advancement for little airways with the addition of two new single-use configurations: the “0” Stat for patients 1.5 kg and smaller, and the “2.5” Stat for patients 10 kg to 28 kg.

BladderScan Bladder Volume Instruments From the makers of GlideScope instruments, BladderScan® bladder volume instruments are portable, 3D ultrasound devices that quickly, accurately and noninvasively measure urinary bladder and post-void residual volume. BladderScan instruments help diagnose and monitor postoperative urinary retention—POUR—and improve patient outcomes by reducing the duration of urinary catheterization or avoiding it altogether.2 Designed to be used by physicians or nurses, without the need for a sonographer, the instruments are easy to use, learn and teach.

The GlideScope Ranger Single Use

20001 North Creek pkwy. Bothell, wA 98011 phone: (800) 331-2313 (u.s. & Canada only); (425) 867-1348 fax: (425) 883-2896 web site: www.verathon.com Verathon designs, manufactures and distributes reliable, state-of-the-art medical devices and services that offer a meaningful improvement in patient care to the health care community.

glidescope Cobalt aVl

In an emergent situation, choosing the right video laryngoscope is important. The GlideScope Ranger is a portable, rugged video laryngoscope, designed to meet military specifications. The Ranger is available in two reusable sizes and six single-use configurations, giving paramedics, physicians and other first responders the flexibility to deal with

address

prodUCTs

The Cobalt AVL The GlideScope Cobalt AVL defines advanced video laryngoscopy—with airway views in DVD clarity, and real-time recording to capture the details of difficult airway cases. For patients from preterm to the morbidly obese, the Cobalt AVL has been enhanced to include improved features designed to help users get the view they need and place a tube quickly. For example, the Cobalt AVL offers a redesigned color monitor, featuring a unique onboard 4-Step Technique video tutorial that describes and illustrates tips for successful GlideScope intubation. Another advanced element of the Cobalt AVL is its integrated, real-time recording capability. These highquality digital files of intubations are downloadable and viewable on a personal computer. The recordings can be valuable for teaching and helping confirm tube placement. As part of the Cobalt AVL family, the reusable GlideScope Direct intubation trainer combines the characteristics of a standard Macintosh blade with AVL video technology to facilitate instruction of classic direct laryngoscopy (DL).

AT A GLANCE

Used in acute care, primary care, urology and extended care settings, the BladderScan BVI 9000 series instruments, with NeuralHarmonics® technology, feature accelerated speed and sharpened accuracy in bladder volume measurement. Each BVI 9000 series instrument, in addition to providing distinct modes for measuring bladder volume in adult men and women, offers a unique capability tailored to the needs of specific patient groups. The BladderScan BVI 9400 offers a Small Child mode for patients weighing as little as 15 pounds. The BladderScan BVI 9600, tailored for emergency departments, offers both bladder volume measurement and AortaScan® mode to noninvasively measure the diameter of the abdominal aorta to help identify the presence of abdominal aortic aneurysms (AAA). The AortaScan AMI 9700 instrument is also available to help physicians assess for AAA.

Verathon Products Support Improved Patient Care Across a spectrum of patients—from newborns to the elderly—health care providers need medical devices that are proven, practical and reliable. Verathon instruments can support an evidence-based approach to care, to help evaluate, diagnose and manage an array of patients. GlideScope, BladderScan, and AortaScan instruments are designed to help manage cases in a wide range of clinical settings—from prehospital to acute care to extended care and more.

References 1. Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early-clinical experience with a new video laryngoscope (GlideScope) in 728 patients. Can J Anesth 2005;52:191-198. 2. Moore DA, Edwards K. “Using a portable bladder scan to reduce the incidence of nosocomial urinary tract infections.” Medsurg Nursing 1997;6:39-43.

Bladderscan BVI 9400

GlideScope, the GlideScope symbol, GVL, Verathon, and the Verathon Torch symbol are trademarks of Verathon Inc.

This corporate profile was reviewed and approved by Verathon Medical.

24th Annual

Corporate Profiles 2011-2012

ZoTeC parTners

otec Partners is a revenue cycle management solutions company with a proven track record of solving real-world, bottom-line challenges for the nation’s top anesthesia groups. As an industry leader in medical billing and practice management software and services, Zotec is committed to the continual pursuit of excellence in the anesthesiology revenue cycle management industry. Zotec delivers effective solutions through innovative software, personalized service and measurable client results. Zotec’s unparalleled software and services are used by more than 5,500 physicians in 45 states, helping them to drastically increase efficiencies, reduce labor costs and increase revenue. Zotec’s clients trust the company with their cash flow, the safety and security of their invaluable patient records and sensitive patient interactions, helping them operate as efficiently as possible.

Technology The Electronic Billing Center (EBC) is the foundation of Zotec’s revenue-enhancing solutions and has handled millions of transactions throughout numerous specialties across the nation. EBC is the most stable Windows NT product on the market. This powerful software helps practices enhance workflow management, eliminate unnecessary labor, track productivity and get cash in the door.

Use of the EBC is growing rapidly because it provides extremely accurate claims processing and aggressive client- and carrier-defined follow-ups on submitted claims using specific tools integrated into the software. From the moment a charge is created, Zotec carefully manages it to ensure maximum payment with minimum effort. The company carefully evaluates each charge and moves it through the revenue cycle, using technology when possible and human intervention when necessary. With Zotec’s sophisticated revenue cycle management tools, your staff will spend less time, resources and efforts chasing paper while your operation collects more money.

Contract Variance With Zotec technology doing the heavy lifting, the majority of labor dollars are spent on the resources necessary to address the 20% of all health care claims that are either inappropriately paid or denied. It is impractical to believe a manual process, no matter how well intended, can efficiently recognize these variances. If continual short payments are not addressed, the cumulative impact on revenue is substantial. Zotec helps to quickly and efficiently identify payments where the allowed amount does not meet the expectation of the contract.

11460 N. meridian st. Carmel, IN 46032 phone: (317) 705-5050 fax: (317) 705-5055 email: sales@zotecpartners.com web site: www.zotecpartners.com

serVICes unlike other practice management software firms, Zotec partners does not dictate how our clients access and use our technology, allowing anesthesiology groups to customize Zotec’s services to fit the group’s needs. By outsourcing billing services to Zotec partners, anesthesiology practices have full access to our operations with near real-time performance reporting via the Internet. Additionally, Zotec provides all labor for a reasonable percentage of the amounts collected.

eMployees more than 400 in 12 locations across the united states

In today’s economy, it is necessary to look at trends daily so that problem areas can be identified quickly. Every anesthesia practice has databases full of information, but this information is only valuable if it can be accessed and presented in a meaningful way. Our robust decision support systems can manage anesthesiology groups proactively, helping them rapidly identify shifts in such areas as cases, carriers and volumes. Decision support systems can send alerts to notify business managers and physicians that key statistical benchmarks or key performance indicators are out of line.

presIdenT

Zotec Partners has begun aggressively integrating outbound phone dialers into our phone system and EBC. This allows calls to be made, patients to be transferred into our automated phone system and a payment or change to insurance information to be made without any human interaction. Patients have the option to speak with a live person during business hours, but this new automation allows for them to make arrangements at their convenience.

Results Using Zotec enables physicians to reduce their overhead and payment turnaround time, reducing costs by up to 45%. Practices that employ our software or outsource billing completely can drive down costs by Anesthesiology News • August 2011

address

Decision Support Systems for Reporting

Innovation in Self-Pay Collections (Automated Phone Systems, Outbound Dialers, Patient Portals and Easy Payment Plans)

Business Intelligence

AT A GLANCE

T. scott law

creating a more efficient accounts receivable process and a much shorter payment period, reducing risk and liability. An estimated 5% to 10% of revenue is lost through manual and inconsistent auditing. Zotec uses repeatable and automated auditing with a “trust-but-verify” approach. Our technology performs accurate and timely audits. Rather than attempting to balance accounts at the end of a period, Zotec looks at trends daily with our proprietary decision support system, that can send alerts to physicians letting them know that accounts or statistical benchmarks are inconsistent.

Client Support and Services Every company claims to support its customers. At Zotec, it is a way of life. Every product or service we offer comes with 24/7/365 technical support. There is never a time our clients cannot reach us. And there’s never a time when we can’t provide quick, accurate support designed to keep your operation running smoothly. Zotec is a high-tech company, with a high-touch service philosophy. Our support also is high-tech with the very latest analytical tools, backed by knowledgeable industry experts. When you have questions, you need prompt, results-oriented answers. That’s what Zotec client support is all about.

This corporate profile was reviewed and approved by Zotec Partners.

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56 I AnesthesiologyNews.com

August 2011

P A I N M EDI C I NE

Electronic Health Records: A Primer for Pain Specialists

any goals for the future (e.g., adding pain services, new locations). Consider your immediate needs and your future objectives. It is better to grow into your software over time than replace the costly system whenever How do you find the best EHR for your practice? your practice expands. As you create this list, determine what specific Dear Arizona Pain Specialists, bill facility charges on a uniform bill- an electronic system that allows for all workflows are vital to your practice. e are considering purchasing ing form. veterans’ health records to be shared. • Review medical software vendors. To an electronic health record 3. The ability for physicians to set up Health care workers treating veterans in narrow the lengthy list of medical (EHR) system for our pain “bundled” services; an EHR allows the system are able to see current medisoftware vendors, identify those who practice. We’re not sure how to get the provider to select the applicable cal records for any patient treated in any offer products for your practice size started or if it’s even worth the headinjection with one click of a mouse. VA facility. and specialty. The size and specialty ache. Can I get some advice please? All related items automatically appear The American Recovery and Reinof your practice typically indicate on the encounter form. vestment Act, which President Obama the features you will most likely use. Thank you, 4. The ability to review each visit and signed in February 2009, initially Regardless of features and support, Technophobe note clinical trends. included $26 billion toward the Health it would not make sense to purchase 5. The ability to thoroughly track refer- Information Technology for Economic an enterprise application designed for Dear Technophobe, ral sources, both incoming and outand Clinical Health Act (HITECH). 200-plus physicians if you are a sole ravo! You have taken the first going, for purposes of sharing patient This is an unprecedented investment in practitioner. Do not base your decistep, which is to simply begin information and to grow business. health information technology, with the sion on price alone. The EHR softthe conversation. In today’s ware will in essence run all important environment of costly paper charts, aspects of your business, and a good lost time searching for patient records, decision can be invaluable. A few undecipherable scribbles and high docthousand dollars in savings at the ument storage fees, there is no question beginning may cost the practice much as to whether you should purchase an more later in both upgrades and manEHR system. The question is, which power. Avoid this classic mistake by EHR is the best fit for your practice? considering the growth of your busiPain management services are crucial ness before purchasing. • Look for consistent success and stabilto the well-being of patients and the entire health care system. A clinic that ity. Has the vendor been in existence is focused on the needs of its patients for many years with a significant cusshould be as efficient and secure as tomer base and a vested interest in possible; it is fundamental to improvthe industry? Ten-plus years of experiing the quality of life for those living ence provides a long-term reputation with pain. In this scenario, medical and track record you can research. records software solutions are a must. These companies invest a significant Selecting an appropriate EHR for a amount of money to stay current by pain practice requires significant finanemploying large programming teams cial and time investments. No shortto increase product functionality. • Take several test drives. At first glance, cuts can be taken during the EHR selection process; it is too costly, in 6. The ability to bill claims and track goal of establishing an EHR for each vendors may appear to be simiterms of both software and manpower, denials, and respond appropriately. person in the United States by 2014. lar. However, there are differences to rush such a decision. One must A fully functional EHR system gives in how and to what degree the softThings To Know spend the time and resources to prop- physicians, nurses and technicians a ware accomplishes your goals. Have erly screen medical software vendors. patient’s comprehensive medical history To make the best selection of an each vendor illustrate how its prodOnce an EHR system is purchased, a at the point of care, whether in the doc- appropriate, effective EHR for your uct functions for each of the items dedicated, ongoing effort is required to tor’s office, ASC or emergency room. It practice, consider the following: you have listed as your top 10 prioriset up and implement it. Unfortunately, also is remotely accessible to providers • An EHR is a marriage. Think of ties. Also, ask about tracking hospital there are no perfect software solutions who are on call, allowing them to make an EHR selection as a relationship rounds, off-site visits and procedures or implementation shortcuts, regard- informed decisions to expedite patient between your practice and the EHR in remote locations. Make sure your less of what any charismatic EHR sales- care. product/vendor. Implementing an practice has a record of service to person might tell you. EHRs also have the potential to EHR for your practice will dramaticompare with what a hospital billAs pain specialists, our practices can increase efficiency and contain costs cally change the workflow for every ing department is sending. There is be quite complex; robust software may by reducing duplication and improvarea and process of your practice. no gray area on this feature; the sysbe required to perform many of our ing patient safety. Their ability to calcuThink about this choice as you would tem will either be able to track this or duties, including the following: late, network, automatically check facts think about any major decision. You not. Create a scorecard to keep track 1. The ability to monitor multiple and provide targeted research results is will be tied to the EHR software, supof results. This will help you narrow ordered and performed services. remarkably powerful. Applied to medport team company and product idiothe vendor list. Make sure you do not 2. The ability to submit different codical care, EHRs provide the patient syncrasies for a long time. make the EHR decision based solely ing/bills as required by different setand physician with current, accurate • Make a top 10 list. The first step in on how well the system performs for tings (offices, ambulatory surgery information. selecting an EHR is to identify the a clinician; instead think about billcenters [ASCs], hospitals). For serThe federal government supports most important items and services ing, scheduling, authorization and vices performed in an ASC, the EHR development and implementation. for your practice. This would include every other process that occurs in EHR must have an application to Veterans hospitals nationwide share your most profitable services and your office.

W B

August 2011

AnesthesiologyNews.com I 57

Pa in M e d ic in e doctors can make better clinical decisions with ready access to full medical histories for their patients, including new patients, returning patients or patients who see several different providers. Laboratory tests or x-rays downloaded and stored in the patient’s EHR make it easier to track results. Automatic alerts built into the systems direct attention to possible drug interactions or warning signs of serious health conditions. E-prescribing lets doctors send prescriptions electronically to the

pharmacy, so medications can be ready and waiting for the patient. Although EHR systems require ongoing investments of time and money, clinicians who have implemented them have reported long-term savings. With the efficiencies that EHRs promise, their widespread use has the potential to result in significant cost savings for our health care system. The best advice we can give is to take your time. Despite the fervor for EHRs in government and the press, now is

the time to be sure you have conducted a thorough evaluation, taking into account the specific functional needs of pain medicine and your practice. —Paul Lynch, MD, Tory McJunkin, MD, Tina Sebring, MS, MPA, and Ryan Tapscott, MS Drs. McJunkin and Lynch are the founders of Arizona Pain Specialists. Through their partner company, Boost Medical, they provide practice management and consulting services to other pain doctors throughout the country.

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• Cost of ownership. Most software vendors have a preferred payment structure that can range from full payment at software delivery to a pay-as-yougo plan. Consider the financing plan carefully. No upfront costs and a monthly rental fee may not be a better financial choice. Compare the purchase of licenses and professional services upfront with a one-time capital outlay to a monthly rental fee. Negotiate the final payment after you have gone live to maintain leverage for any remaining issues. There is always pain as the dust settles in any new endeavor. It is nice to have a financial safety net. • Existing customer references. Obtain two to three references from each shortlisted vendor. Ensure references are from a practice of similar size and specialty. It is preferable to have the references in your geographic location so that you and your staff can visit the facility and see the system being used in day-to-day operation. Diligence with this step is imperative. Unfortunately, it often is skipped. You would not hire a physician without calling references first. Consider this the same type of homework; it is critical to avoiding a classic EHR purchasing mistake. • What about meaningful use? In order to participate in the HITECH EHR incentive program, the EHR software system must be certified by one of three certifying organizations. This ensures the features are in the system for your practice to use in order to demonstrate Meaningful Use Attestation for a 90-consecutive day period. For the official list of certified EHR products, visit http://onc-chpl.force. com/ehrcert. • Assistance. Selecting the right medical software solution for your office can be a daunting task. The good news is you have options for additional assistance. The Internet provides a flurry of information at no additional cost. There also are consulting firms available for hire in every major city. As more organizations adopt EHRs, physicians will have greater access to patient information, allowing faster and more accurate diagnoses. Complete patient data helps ensure the best possible care. Patients too, will have access to their own information. They will have the choice to share it with family members securely over the Internet, to better coordinate care for themselves and their loved ones. Digital medical records make it possible to improve the quality of patient care in numerous ways. For example,

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Anesthesiology Board Review: Second Edition Kerri Robertson; David J. Lubarsky; Sudharma Ranasinghe

This guide is presented in a quick-hit question/answer format consisting of short clinical questions with concise answers. Emphasis is on distilling key facts and clinical pearls that are essential for exam success. Only the right answer is provided—there are no multiple-choice distractors—so there’s no chance of an incorrect answer staying in your mind.

Anesthesiology Keywords Review Raj K Modak

This review book is based on the keyword list distributed to residency program directors each year. Each of the 316 entries begins with a keyword, followed by a list of key points and a one- or two-page discussion written by a resident and reviewed by Yale University faculty.

ORDER ONLiNE For pricing, a more complete review and easy ordering with a credit card, go to McMahonMedicalBooks.com. We can supply any medical book in print, so if you don’t find the book you want, email your request with billing information to RMcMahon@McMahonMed.com. If you are an author and would like your medical book featured in this book section, contact Ray McMahon, Publisher, at RMcMahon@McMahonMed.com.

Avoiding Common Anesthesia Errors Catherine Marcucci, MD

This pocket book succinctly describes 215 common, serious errors made by attendings, residents, fellows, CRNAs and practicing anesthesiologists in the practice of anesthesia and offers practical, easy-toremember tips for avoiding these errors. The book can easily be read immediately before the start of a rotation or used for quick reference. Each error is described in a one-page entry that includes a brief clinical scenario, a short review of the relevant physiology and/or pharmacology and tips on how to avoid or resolve the problem.

Basics of Anesthesia: With Evolve Website: Fifth edition Robert K. Stoelting, MD

Widely acknowledged as the foremost introductory text, this latest edition provides the most authoritative and complete overview of anesthesia theory and practice and continues to serve as an excellent primer on the scope and practice of anesthesiology. The new edition is presented in full color and includes updated information on new and rapidly changing areas in anesthesia practice. The new topics include approach to learning anesthesia, medical informatics, basic cardiopulmonary physiology, hemostasis, congenital heart disease, trauma, bioterrorism and medical direction in the operating room.

Beyond Pain: A Comprehensive Pain Board Review for the Pain Management Physician

Thomas Moshiri, MD A detailed and intensive review of the core knowledge needed to pass the pain boards. Containing the essential information you must know and condensing complex subjects into easy to understand topics. No other book contains all the information you need in an easy to understand manner in one single location.

Board Stiff Three: Preparation for Anesthesia Orals Expert Consult: Online and Print

Christopher J. Gallagher The new edition of this popular anesthesia review book is written in the same winning style that was the hallmark of Board Stiff Too. Dr. Gallagher’s signature humor and engaging writing style make this terrific prep book a fun read while still delivering all the most important things you need to know for the boards. In addition to a thorough content review, the new edition also features an extensive section with self-assessment questions.

For Doctors Only: A Guide to Working Less & Building More, Third Edition

Christopher R. Jarvis; David B. Mandell; Jason M. O’Dell This volume helps physicians move beyond theory and into practice by outlining how to find quality advisors and construct a collaborative, multidisciplinary planning team.

Pocket Pain Medicine (Pocket Notebook Series) Richard D. Urman; Nalini Vadivelu

Pocket Pain Medicine is an invaluable tool for every resident and practicing physician who needs to understand the essentials of acute and chronic pain management, including all current guidelines and standards of care. This concise, up-to-date, evidence-based reference guide is written in the popular Pocket Notebook Series format that is ideal for today’s fast-paced health care environment. Information is presented in a schematic, outline format, with diagrams and tables for quick, easy reference. AN0811

CONTINUING MEDICAL EDUCATION

aUgUsT 2011

Lesson 293: PreAnesthetic Assessment of the Drug Abuser: Value of Urine Drug Screening WRITTEN BY:

TARGET AUDIENCE

Natalie F. Holt, MD, MPH Assistant professor, Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut; staff anesthesiologist, West Haven Veterans Affairs Medical Center, West Haven, Connecticut

Anesthesiologists

REVIEWED BY: Roberta L. Hines, MD Nicholas M. Greene professor and chair, Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut

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

NEEDS STATEMENT Nearly 9% of the population over the age of 12 report active use of at least one illicit substance. Anesthesia in the context of recent illicit drug use may lead to excess morbidity and mortality, due in part to drug interaction. Urine drug screening before surgery is one approach available for detecting recent drug abuse. However, the test itself has limitations, including the potential to generate false-positive and false-negative results. Moreover, some illicit substances are not detected in the urine. Anesthesiologists should have a basic understanding of how urine drug screening is performed in order to best use and interpret this test in clinical practice. The topic has received considerable attention in the media, and has been identified by committee as necessary information for clinical anesthesiologists.

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

LEARNING OBJECTIVES At the end of this activity, the participant should be able to: 1. Discuss the epidemiology of substance abuse in the United States. 2. Explain the general purpose and performance characteristics of a screening or diagnostic test. 3. Describe the methodology of urine drug screening, and the drugs typically screened. 4. Identify circumstances that may lead to false-positive or false-negative results from a urine drug screen. 5. Interpret the positive results of a urine drug screen with respect to the timing of most recent drug ingestion. 6. List methods by which urine samples may be adulterated in order to interfere with the accuracy of drug screening. 7. Describe how to validate a urine specimen to identify suspected adulteration. 8. Identify methods available for confirming the results of an initial urine drug test. 9. Summarize the potential risks of administering anesthetics to a patient who admits acute drug abuse. 10. Develop an informed approach to the use of urine drug screening, preoperatively.

CASE HISTORY A 36-year-old man was scheduled for left inguinal hernia repair. His medical history was significant for hypertension, chronic low back pain, and depression. He also gave a history of illicit substance abuse, including intermittent marijuana, cocaine, and heroin. He had smoked approximately one pack of cigarettes per day since age 17, but denied using alcohol. His current prescription medications included metoprolol and bupropion. In the preoperative area, the patient appeared somewhat anxious, but was otherwise alert and appropriate. His vital signs were blood pressure, 130/82 mm Hg; heart rate, 76 beats per minute; respiratory rate, 10 breaths per minute; oxygen saturation, 99% on room air; temperature, 37.2°C. The surgical resident informed the anesthesiologist that a urine drug screen, ordered for the morning of surgery, was positive for amphetamines, cannabinoids, and cocaine. Upon questioning, the patient admitted to smoking marijuana daily, but otherwise insisted he had been taking only his prescribed medications. He said he stopped using IV drugs more than 13 months previously, and had never abused amphetamines.

ased on data from the 2009 US National Survey on Drug Use and Health, about 8.7% of the population at least 12 years old (21.8 million people) are actively involved in the use of at least one illicit substance. The most popular illicit drugs of abuse are marijuana (16.7 million; 6.6%), cocaine (1.6 million; 0.7%), and hallucinogens (1.3 million; 0.5%). In recent years, the nonmedical use of prescription psychotherapeutic drugs has risen dramatically. These include painkillers, stimulants, sedatives, and tranquilizers. In 2009, 7 million people (2.8% of the population) at least 12 years old reported abusing any of these agents in the previous 30 days.1 Among patients presenting to the emergency department, the estimated prevalence of illicit substance abuse is significantly higher than in the general population.2 In one study, 38% of trauma patients tested positive for cocaine

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

A COURSE OF STUDY FOR AMA/PRA CATEGORY 1 CREDIT Read this article, reflect on the information presented, then go online (www.mssm.procampus.net) and complete the lesson post-test and course evaluation before August 31, 2012. (CME credit is not valid past this date.) You must achieve a score of 80% or better to earn CME credit. TIME TO COMPLETE ACTIVITY: 2 hours RELEASE DATE: August 2011 TERMINATION DATE: August 31, 2012 ACCREDITATION STATEMENT The Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

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

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aUgUsT 2011

Table 1. Performance Characteristics of a Screening/Diagnostic Testa Disease/Condition (as determined by gold standard) Test Result Positive Negative

Present

Absent

 PPV = TP/(TP+FP)

 NPV = TN/(FN+TN)

 Sensitivity = TP/(TP+FN)

 Specificity = TN/(FP+TN)

FN, false-negative; FP, false-positive; NPV, negative predictive value; PPV, positive predictive value; TN, true-negative; TP, true-positive a The performance of any test with 2 unique results (positive/negative) is described by 4 parameters: sensitivity, specificity, PPV, and NPV. Sensitivity is defined as the ability of a test to correctly identify disease-positive patients. Specificity is defined as the ability of the test to correctly identify disease-negative patients. PPV is defined as the proportion of patients with a positive test result who are in fact diseasepositive. NPV is defined as the proportion of patients with a negative test result who are in fact disease-negative.

A drug screen is a panel of laboratory tests performed on a biologic specimen to identify evidence of specific drugs or chemicals. Drug screening can be performed using several bodily fluids, including blood, saliva, and hair; however, urine is the preferred sample because it has higher concentrations of identifiable metabolites and is easily obtained and processed in a laboratory. There is no uniformity among institutions as to which drugs are tested in routine UDT. Most drug screens include testing for 5 substances (known as the “NIDA 5”) mandated by the National Institute on Drug Abuse (NIDA) to be included in federal workplace drug testing: 1. cannabinoids (tetrahydrocannabinol) 2. cocaine (benzoylecgonine) 3. opiates (morphine and codeine) 4. amphetamines (including methamphetamine) 5. phencyclidine.4 In hospitals and chronic pain centers, urine drug screening frequently includes testing for additional commonly abused agents, including barbiturates, benzodiazepines, methadone, and propoxyphene. However, even these more comprehensive panels are by no means all-inclusive. They fail in particular to detect new and emerging substances of abuse, particularly synthetic cannabinoids, stimulants, and hallucinogenics.5,6 A recent example is that of a “spice product” popularly marketed under the brand names K2 and Spice. These products emerged in the European market in the early 2000s, and rapidly gained worldwide favor fueled in part by Internet retailers. It was not until 2008 that the active ingredients were discovered to be novel synthetic chemicals active

Table 2. Impact of Prevalence on Test Error Ratesa,b

False-Negative Rate (Negative Drug Tests That Are False), %

Urine Drug Screening

at cannabinoid receptors.7 Following a growing number of alerts from hospitals and poison control centers that reported adverse reactions, including psychosis, hallucinations, and seizures, as well as several deaths associated with use of these substances, the US Drug Enforcement Administration took emergency measures and classified synthetic cannabinoids as Schedule I drugs under the Controlled Substances Act, making their use illegal in all states as of March 2011.8 There are several methods for identifying drugs or drug metabolites in urine. The most commonly used are chromatography, mass spectroscopy, and immunoassay. Gas chromatography–mass spectroscopy is considered the “gold standard” among testing methods based on its superior accuracy profile. However, because of cost and turnaround time, most laboratories use immunoassay techniques for drug screening. Routine urine drug screening by immunoassay costs approximately $11 in the author’s institution, and results are typically available in less than 60 minutes. Immunoassays rely on competitive binding between a drug that is chemically labeled with an enzyme,

False-Positive Rate (Positive Drug Tests That Are False), %

abuse when admitted to the hospital. At another major hospital center, health care workers estimated that 0.5% to 1% of patients presenting for elective surgery exhibited evidence of cocaine abuse, based on positive results from urine drug testing (UDT) for cocaine metabolites.2 Current evidence suggests that anesthesiologists greatly underestimate the prevalence of illicit substance abuse among patients undergoing preoperative visits. In a recent study conducted in Germany, patients presenting for elective surgery were asked to complete a computerbased survey on illicit substance abuse. An anesthesiologist then interviewed the same patients. Data from 2,938 patients were analyzed retrospectively. The investigators found that 7.5% of the patients voluntarily reported illicit substance abuse within the previous 12 months of the survey. However, in 2 out of 3 patients, the anesthesiologist’s interview failed to elicit this information.3

Prevalence of Drug Use In Tested Population, %

55.1

0.41

18.4

2.2

7.0

6.4

2.4

17.0

Assumes test sensitivity of 80% and specificity of 98%. Test error rates are significantly affected by the prevalence of the condition in the population in which the test is being applied. When a test is used in a population in which the true prevalence of the condition is low, the false-positive error rate is quite high. That is, a significant fraction of positive test results will in fact be incorrect. As prevalence increases, the false-positive error rate decreases, but the false-negative error rate increases. Adapted from reference 9. b

radioisotope, or fluorophore, and a drug present in a biologic specimen. The degree to which labeled drug and drug in a sample compete for binding sites is used to quantify the drug in the sample and provide a qualitative assessment of the presence or absence of the substance of interest.

Performance Characteristics of Screening/Diagnostic Tests The technical efficacy of any test is characterized by 2 intrinsic properties: sensitivity and specificity. Sensitivity refers to the ability of the test to correctly recognize the presence of a condition when in fact it exists. Specificity describes the ability of the test to correctly identify the absence of a condition when that condition is indeed absent. As a preventive health tool, screening tests are usually employed for conditions in which early detection leads to meaningful improvement in survival outcomes. As such, they are applied to a population at risk but with no overt evidence of illness. The general consensus is to avoid a failure to diagnose (false-negative) and, therefore, highsensitivity testing methods are favored. A certain percentage of positive screening tests will yield false-positive results, which is acceptable because in usual practice a positive screening test is followed up with a confirmatory test that has high specificity (few false-positives); the confirmatory test results drive further intervention and treatment decisions. The sequential application of a high-sensitivity test and another with high specificity provides maximal diagnostic accuracy. In clinical practice, definitive evidence of the presence or absence of a condition is unknown. The intent of the test is to help answer this question. Therefore, the relevant characteristics of a diagnostic test from the clinician’s point of view are not sensitivity and specificity, but are instead its predictive values. The positive predictive value of a test is defined as the proportion of patients with a positive test result who are correctly diagnosed; the negative predictive value describes the proportion of patients with a negative test result who are in fact disease-free—or, in this case, drug-free (Table 1). Unlike sensitivity and specificity, the predictive values of any given test vary based on the population prevalence (also called pretest probability) of the condition in which the test is being applied. When applied to a population in which the condition of interest is very common, the positive predictive value of a screening test is high. When it is used in a population in which the condition is rare, however, the positive predictive value falls dramatically. Furthermore, holding prevalence constant, positive and negative predictive values vary inversely. That is, as the positive predictive value of a test rises, its negative predictive value falls. Understanding these relationships is critical to the appropriate application and interpretation of any screening or diagnostic test. Table 2 illustrates the influence of drug prevalence on the likelihood that positive UDT is false, using an estimated test sensitivity of 80% and specificity of 98%.9

Interpretation of Urine Drug Screening Results The potential that any test result obtained in clinical practice may be incorrect is appreciated in theory, but often forgotten in practice. This is perhaps particularly true in the case of urine drug screening because of physicians’ lack of familiarity with this testing method and its several limitations. Over the years, the accuracy of urine drug screening has been a cause for concern. In the mid-1980s,

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10-20%

Norcodeine

5-13% 32-46%

6-monoacetylmorphine

minor 100%

6-25 min

Morphine 5%

Medications ~100%

Norcodeine glucuronide

Codeine glucuronide

75%

Normorphine

Antibiotics ~80%

Morphine 3-glucuronide

Normorphine glucuronide

Quinolones (ofloxacin, gatifloxacin)

Rifampin

Antidepressants Bupropion

× ×

Sertraline

Figure. The metabolic pathways of codeine, heroin, and morphine. Heroin and codeine are metabolized to morphine, with subsequent degradation through a common pathway. Therefore, the ingestion of codeine, heroin, and morphine is indistinguishable unless unique metabolite testing is employed. Adapted from reference 17.

Trazodone

× ×

Venlafaxine

Antihistamines/decongestants

Diphenhydramine the Centers for Disease Control and Prevention (CDC) reported the results of an evaluation of 13 laboratories performing urine drug screening tests for 262 methadone treatment facilities. The CDC found that average rates of false-negatives were 59% for barbiturates, 69% for amphetamines, 12% for methadone, 64% for cocaine, and 62% for morphine. Mean false-positive rates were much better—less than 3% for most drugs, but averaging as high as 12% for methadone.10 By the late 1980s, the accuracy of UDT laboratories had improved sharply. Three independent studies using blinded controls found false-negative rates ranging from 20% to 31%, and false-positive rates from 0% to 2%.11 The performance of UDT in clinical practice is likely to differ from that found in experimental evaluations. For example, owing to cross-reactivity between metabolites of abused substances and legitimately prescribed medications as well as some over-the-counter (OTC) drugs, it is likely that false-positive rates are higher than those reported using controlled samples. Other potential reasons for variability in performance between institutions are differences in the immunoassay techniques used, the values chosen as cutoffs, whether confirmatory tests are routinely performed before releasing results, and whether sample validation techniques are used. And, as mentioned previously, the predictive value of urine drug screening is critically linked to the a priori likelihood of drug use (pretest probability) in the population to which it is being applied. Many clinicians are unfamiliar with the circumstances that may produce inaccurate results of a urine drug screen. There are numerous reports in the literature of prescription and OTC medications that may cause falsepositive urine drug screens. The results of a recent study at a university hospital revealed that 25 of 116 (21.5%) formulary medications could lead to false-positive results in urine drug screening, including medications from the following drug classes: antibiotics, antidepressants, antihistamines, antipsychotics, and decongestants.12 Specific examples are summarized in Table 3. Ingestion of certain foods containing poppy seeds also can produce false-positive urine drug screens for both

Benzodiazepines

Codeine

False-Positive Result

Opiates

100% 2-6 min

minor

Table 3. Medications Associated With False-Positive Urine Drug Screens Using Immunoassay Techniquesa

Methadone

Heroin

Phencyclidine

Hydromorphone

Amphetamine/ Methamphetamine

~5%

Hydrocodone

morphine and codeine.13,14 As a result, in 1998 the US Department of Health and Human Services changed the opiate screening cutoff level from 300 to 2,000 ng/mL. By contrast, experiments have evaluated the possibility of testing positive for cannabinoids by passive inhalation of marijuana smoke. This research supports the conclusion that although measurable cannabinoid concentrations can be detected after high-volume exposures, these concentrations are well below those considered positive using conventional cutoffs.15 Compounding the problem of false-positives and falsenegatives is evidence of a lack of proficiency by physicians when interpreting results—even truly accurate ones.16 For example, the urine drug screen for a patient with a valid prescription for acetaminophen and codeine (Tylenol No. 3, McNeil-PPC, Inc) would be expected to be positive for codeine, but also for morphine as a result of metabolic conversion of the former compound to the latter. A lack of awareness of UDT methods and drug pharmacology may therefore lead to false accusations. On the other hand, heroin abuse may go undetected in a patient being treated with extended-release morphine because the tested urine metabolite is the same for both drugs. Heroin undergoes rapid conversion to morphine, 6-monomorphine, and morphine glucuronide. Conventional immunoassay techniques test only for morphine. Gas chromatography–mass spectroscopy is necessary to detect 6-monomorphine, which is a product of heroin metabolism, but not of codeine or morphine (Figure).17 Similarly, identifying abuse of synthetic opioids such as oxycodone, hydrocodone, oxymorphone, and fentanyl requires special testing because these agents do not produce the metabolites commonly assayed in opiate drug screening tests.16

Urine Specimen Validation and Adulteration Techniques The motivated individual may employ several techniques to avoid detection of illicit substances in urine drug screening, including dilution of the sample with water or

Phenylpropanolamine

Antipsychotics Chlorpromazine Promethazine

× ×

× × ×

Quetiapine Thioridazine Other agents

Dextromethorphan Ranitidine Verapamil

× ×

Several prescription and over-the-counter drugs have been reported to produce false-positive urine drug screening results. The likelihood of obtaining a false-positive result depends on the drug dose and type of immunoassay used for testing. Adapted from reference 12.

other substances, substitution with a “clean” urine specimen, or adulteration with chemicals that interfere with drug screening methods. Even a cursory search of the Internet will return an impressive array of adulterants, kits, and advice aimed at facilitating the interested reader’s evasion of UDT. Although laboratory testing methods have caught up with some of the oldest of these tricks, several of the newer techniques available live up to their promise whereby illicit substances are likely to go undetected unless clinical suspicion is high. When urine drug screening is performed in the federal workplace, mandatory procedures for specimen testing and verification must be strictly followed, including measurement of creatinine concentration, specific gravity, pH, and temperature. Validity testing for common adulterants also is included. These procedures may not be uniformly applied in other settings. Therefore, when there is a strong clinical suspicion of substance abuse, specimen validation and confirmatory testing should be considered to guide

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Table 4. Characteristics Suggestive Of a Valid Urine Specimena,b Temperature

90°F-100°F (32°C-38°C)

3.0-11

Specific gravity

1.003-1.02

Creatinine

≥20 mg/dL

Immunoglobulin G

≥0.5 mcg/mL

Nitrites

≤500 mcg/mL

Specific tests for common adulterants, including glutaraldehyde, potassium chlorochromate, bleach, and other oxidants, also are available. b When urine is sent for drug screening, it is best to verify that the specimen has not been adulterated with chemical additives or diluted/substituted with water or other liquids. Several characteristics may be measured for validation. Out-of-range values should raise suspicion of specimen tampering, and observed urine retrieval should be considered.4,15

decision making. Characteristics suggestive of an unadulterated urine specimen are summarized in Table 4.4,15

Risks of Anesthesia in Patients With Substance Abuse Little is known about the risks associated with performing elective surgery on patients with clear indicators of acute substance abuse. Even less is known about the subset of patients who are clinically “nontoxic” and mentally appropriate, but in whom there is evidence of recent illicit substance use based on urine drug screening. Several factors affect the length of time a drug can be detected in a urine specimen. These include variables intrinsic to testing (eg, assay method, chosen cutoff value), and the pharmacokinetics of the substance in question. Additionally, patient variables such as body mass, coingestions, and urine pH influence drug metabolism and, therefore, duration of detection.16 Table 5 summarizes the current data on duration of detection for common drugs of abuse in urine specimens.15 It is important to note that there is no direct relationship between the length of time drug metabolites may be detected in a urine specimen, and the concentration of active drug at relevant tissue receptors. Thus, the clinical significance of a positive urine drug screen in the absence of symptoms of intoxication is a matter for debate. Among the illicit drugs most commonly abused, cocaine is probably of most concern to the anesthesiologist, primarily because of the potential for significant cardiovascular complications. It has been estimated that there is a 24-fold increase in the risk for acute myocardial infarction during the first 60 minutes after cocaine use.18 Multiple mechanisms are responsible for this effect. Cocaine inhibits norepinephrine, dopamine, and serotonin reuptake and enhances release of norepinephrine and epinephrine from the adrenal medulla. Cocaine also induces vascular endothelial dysfunction, which reduces prostacyclin synthesis and promotes vasoconstriction and coronary artery vasospasm. It also may independently promote platelet aggregation and thrombosis and lead to early atherosclerosis.18 Cocaine blocks sodium channels on cardiac myocytes, which slows repolarization and prolongs the corrected QT interval (QTC), predisposing patients to cardiac dysrhythmias.2 Cocaine-related myocardial irritability in combination with ischemia-induced ventricular dysfunction results

in an increased risk for potentially fatal cardiac complications. The fact that anesthesia and the stress of surgery may exacerbate these effects, and that the preferred treatment of cocaine-induced chest pain and arrhythmia remains somewhat controversial, is more likely to deter many anesthesiologists from proceeding with elective procedures in patients with evidence of recent cocaine use. Nevertheless, the physiologic impact of cocaine is rapid and short-lived. The majority of patients who present to the emergency room with cocaine-related complaints do so within the first 3 hours of use.19 Peak plasma concentrations of cocaine occur within 1 to 60 minutes, depending on route of administration. The half-life of IV cocaine is approximately 30 minutes; for inhalational cocaine it is about 45 to 90 minutes. Plasma and liver esterases account for the rapid hydrolysis of cocaine into inactive metabolites, including ecgonine methyl ester and benzoylecgonine. The biologic half-lives of these metabolites are 6 and 8 hours, respectively. Therefore, the significance of the presence of cocaine metabolites in the urine of a patient with no overt evidence of cocaine intoxication is questionable.2 In a prospective, nonrandomized blinded study, Hill et al compared the intraoperative and immediate postoperative course of 40 patients who tested positive for cocaine metabolites but had no signs of acute intoxication (defined by normal blood pressure, heart rate, temperature, and electrocardiogram—including QTC <500 milliseconds) with an equal number of drug-free controls. No differences in intraoperative mean end-tidal concentration of sevoflurane, total fentanyl dose, duration of anesthesia,

Table 5. Detection Times for Drugs Of Abuse in Urine Specimensa Drug/Drug Class

Time

Amphetamines/Methamphetamines

48 h

Barbiturates Short-acting

24 h

Long-acting

3 wk

Benzodiazepines Short-acting

Long-acting

30 d

Cocaine

2-4 d

Marijuana Single use

Daily use

10-15 d

Opioids Codeine

48 h

Heroin

48 h

Hydromorphone

2-4 d

Methadone

Morphine

48-72 h

Oxycodone

2-4 d

Propoxyphene

6-48 h

Phencyclidine

3-8 d

a The length of time that drug metabolites may be detected in a urine specimen is variable, depending in part on amount and route of ingestion, genetic variations in drug metabolism, and test method of detection. Adapted from reference 15.

aUgUsT 2011

or postanesthesia recovery time were found between the groups. Furthermore, the cocaine-positive patients exhibited no increased risk for hemodynamic instability (measured as a drop in mean arterial blood pressure >40% of baseline); there also was no evidence of ST segment changes in either group.2 In contrast to cocaine, it is likely that many anesthesiologists would be relatively unfazed by urine drug screen evidence of recent opiate or benzodiazepine ingestion; clinicians are relatively familiar with the clinical effects of these drugs, their common use perioperatively, and the availability of reversal agents. The clinician’s reaction to toxicologic evidence of stimulants and psychotropic agents, such as amphetamines, hallucinogens, and cannabis, is perhaps most likely to lie in between these 2 extremes. In general, decisions to proceed with elective surgery are likely to be heavily influenced by the patient’s demeanor and vital signs at the time of presentation. Medicolegal concerns such as the ability to obtain informed consent might also be a factor. To obtain informed consent, the patient’s decision-making capacity must be intact. Biochemical detection of an illicit drug in a urine specimen does not imply a priori intoxication or lack of capacity.20 However, the patient should be able to understand the diagnosis, recommended intervention including its risks and benefits, and available treatment alternatives.21,22 In the case of a solely elective procedure, if there is any doubt about the patient’s capacity, the case should be postponed.

Practical Application of Preoperative Urine Drug Screening In recognition of the controversy that surrounds decisions to delay surgery in patients with evidence of recent drug abuse, Granite et al conducted a survey of oral and maxillofacial surgery and anesthesiology training programs in the United States to determine practice standards on cocaine screening and management of patients presenting with traumatic maxillofacial injuries in need of surgical treatment. Based on 114 completed surveys, the researchers discovered that 10% of hospitals had a policy requiring the cancellation of urgent cases if patients tested positive for cocaine. However, 45% of hospitals had policies requiring the cancellation or delay of elective surgery for facial trauma in the event of a cocaine-positive urine drug screen. Among these, the most common delay interval reported was 2 days or less (54%), with 30% waiting 3 to 5 days, and a small fraction waiting even longer. Nevertheless, 40% of respondents indicated that they allowed surgery (either elective or urgent) to proceed in the face of cocaine-positive results as long as the patient was hemodynamically stable. Based on a half-life of cocaine of 60 to 90 minutes and an elimination time of approximately 5 half-lives, the authors recommended that an 8-hour delay should be sufficient time in the vast majority of patients.23

Management of the Case Presented The initial surgery was cancelled on the basis of the urine drug screen results. The anesthesiologist did not request confirmatory UDT. The patient was counseled about the importance of abstaining from illicit substances, and the surgical service was advised to schedule the case no sooner than 48 hours later. The patient was extremely agitated by the decision and left the hospital without discharge instructions. He has not returned for rescheduling since the event. Could this case have been better managed?

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Summary

patient: is it safe? Br J Anaesth. 2006;97(5):654-657. 3.

In the absence of strong guidelines or robust clinical evidence, the use of preoperative urine drug screening in patients with a history of substance abuse is likely to remain variable among institutions and practitioners. More research is needed to understand whether recent substance abuse in clinically nontoxic patients affects intraoperative stability or postoperative outcomes. Physicians should become more informed about the intended purpose, limitations, and interpretations of UDTs so that these tools may be applied in clinical situations in which the results will be most likely to provide predictive value. Implementation of institutional policies on preoperative urine drug screening also might be advisable to avoid provider-based variations that may be perceived as an indication of patient bias or inconsistent practice standards.

References 1.

Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings. Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4856 Findings. Rockville, MD: SAMHSA 2010. http://www.oas.samhsa. gov/NSDUH/2k9NSDUH/2k9Results.htm. Accessed July 6, 2011. Hill GE, Ogunnaike BO, Johnson ER. General anaesthesia for the cocaine abusing

Kleinwächter R, Kork F, Weiss-Gerlach E, et al. Improving the detection of illicit substance use in preoperative anesthesiological assessment. Minerva Anestesiol. 2010;76(1):29-37. Jaffee WB, Trucco E, Teter C, Levy S, Weiss RD. Focus on alcohol and drug abuse: ensuring validity in urine drug testing. Psychiatr Serv. 2008;59(2):140-142.

Peters FT, Martinez-Ramirez JA. Analytical toxicology of emerging drugs of abuse. Ther Drug Monit. 2010;32(5):532-539.

Maurer HH. Chemistry, pharmacology, and metabolism of emerging drugs of abuse. Ther Drug Monit. 2010;32(5):544-549.

Auwärter V. Dresen S, Weinmann W, Müller M, Pütz M, Ferreirós N. “Spice” and other herbal blends: harmless incense or cannabinoid designer drugs? J Mass Spectrom. 2009;44(5):832-837.

13. Selavka CM. Poppy seed ingestion as a contributing factor to opiate-positive urinalysis results: the Pacific perspective. J Forensic Sci. 1991;36(3):685-696. 14. Trafkowski J, Madea B, Musshoff F. The significance of putative urinary markers of illicit heroin use after consumption of poppy seed products. Ther Drug Monit. 2006;28(4):552-558. 15. Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83(1):66-76. 16. Reisfield GM, Webb FJ, Bertholf RL, Sloan PA, Wilson GR. Family physicians’ proficiency in urine drug test interpretation. J Opioid Manag. 2007;3(6):333-337. 17.

Reisfield GM, Salazar E, Bertholf RL. Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci. 2007;37(4):301-314.

18. Maraj S, Figueredo VM, Lynn Morris D. Cocaine and the heart. Clin Cardiol. 2010;33(5):264-269.

DEA Public Affairs. DEA moves to emergency control synthetic marijuana. US Drug Enforcement Administration: November 24, 2010. http://www.justice.gov/ dea/pubs/pressrel/pr112410.html. Accessed July 6, 2011.

19. Brody SL, Slovis CM, Wrenn KD. Cocaine-related medical problems: consecutive series of 233 patients. Am J Med. 1990;88(4):325-331.

Barnum DT, Gleason JM. The credibility of drug tests: a multistage Bayesian analysis. Ind Labor Rel Rev. 1994;47(4):610-621.

20. Aldridge J, Charles V. Researching the intoxicated: informed consent implications for alcohol and drug research. Drug Alcohol Depend. 2008;93(3):191-196.

10. Hansen HJ, Caudill SP, Boone DJ. Crisis in drug testing: results of CDC blind study. JAMA. 1985;253(16):2382-2387. 11.

Davis KH, Hawks RL, Blanke RV. Assessment of laboratory quality in urine drug testing: a proficiency testing pilot study. JAMA. 1988;260(12):1749-1754.

12. Brahm NC, Yeager LL, Fox MD, Farmer KC, Palmer TA. Commonly prescribed medications and potential false-positive urine drug screens. Am J Health Syst Pharm. 2010;67(16):1344-1350.

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

21. Alfandre DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260. 22. Malone D, Friedman T. Drunken patients in the general hospital: their care and management. Postgrad Med J. 2005;81(953):161-166. 23. Granite EL, Farber NJ, Adler P. Parameters for treatment of cocaine-positive patients. J Oral Maxillofac Surg. 2007;65(10):1984-1989.

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

Post-Test 1. The prevalence of illicit substance abuse in the population of the United States aged 12 years and older is approximately: a. 1% b. 5% c. 10% d. 20%

2. What is the most common laboratory method for routine screening of drugs in the urine? a. Gas chromatography b. Mass spectroscopy c. Liquid chromatography d. Immunoassay

3. Which of the following terms denotes the ability of a test to detect a condition when the condition is in fact present? a. Sensitivity b. Specificity c. Positive predictive value d. Negative predictive value

4. A patient being treated for chronic back pain is taking acetaminophen with codeine as prescribed; which drug(s) would be expected to be detected in a urine drug screen? a. Codeine b. Morphine c. Oxycodone d. Codeine and morphine

5. Which of the following test results would be most likely to raise suspicion of urine specimen tampering? a. pH is 6.7. b. Temperature is 28°C. c. Specific gravity is 1.01. d. Nitrite concentration is 50 mcg/mL.

6. Except for _______, metabolic conversion of the following agents results in at least one shared metabolite. a. Codeine b. Heroin c. Morphine d. Oxycodone

7. After cocaine is taken, its metabolites typically are present in the urine for: a. 6 hours b. 24 hours c. 3 days d. 6 days

8. Depending on the route of administration of cocaine, its half-life in plasma is approximately: a. 0-15 minutes b. 15-30 minutes c. 30-90 minutes d. 90-120 minutes

9. Which substance(s) would likely be detected in the urine of a patient using heroin? a. Heroin b. Hydromorphone c. Morphine d. Heroin and morphine

10. Cocaine increases the synthesis or plasma concentration of all of the following, except: a. Dopamine b. Epinephrine c. Norepinephrine d. Prostacyclin

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seniors, and Taft-Hartley multiemployer health plans for 26 million employees and their families. Even more interesting is that the American system that cares for our sickest patients with the best results at the lowest cost with the highest patient satisfaction is the U.S. Department of Veterans Affairs system, in which physicians have no financial stake in whether patients live or die. Simply allowing physicians to do their job produces excellent, efficient safe patient care. These facts do not bode well for ACOs. However, reading between Dr. Johnstone’s lines, one might conclude that if ACOs are representative of health care reform, we are better off with no reform at all. This conclusion throws too many babies out with the bath water. As mentioned above, the United States already has highly efficient, highly effective, less costly means of providing health care. All of these efficient U.S. health care systems use single-payer financing and none uses an ACO. Perhaps Dr. Johnstone’s most powerful statement is his reprise of “the common criticisms that our health care system is fragmented, wasteful and of middling quality.” These criticisms are not only common, they are unfortunately true. Our insurance companies fragment us into the insurable (healthy) and uninsurable (sick); waste hundreds of billions of dollars in transactional expenses (40% of premiums are lost to billing costs); and places our country in an

embarrassingly low position in public health results. Given the absence of any prior experience showing success, ACOs are unlikely to correct this horrific situation. Successful systems within the United States provide us with far more promising models. —Samuel Metz, MD Willamette Valley, Ore. The writer is affiliated with Mad As Hell Doctors.

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the editor of Anesthesiology News

ama rcu s

To the Editor: n his commentary, “ACO Angst: Think Home Sweet Home” ( June 2011, page 34), Robert Johnstone, MD, makes one point deserving emphasis and another deserving modification. Dr. Johnstone doubts that accountable care organizations (ACOs) will reduce costs or improve care. His doubt is firmly corroborated by the absence of examples of ACOs (or variants that place financial risks on providers) reducing costs or improving care anywhere in the world. The United States remains the only nation placing financial risks on providers. Consequently, we also are distinguished by our first-place showing in per capita health care costs and our last-place rank among common public health outcomes. This doubt also is corroborated by Dr. William Hsiao’s studies in Vermont (Dr. Hsiao designed Taiwan’s national health plan). He followed four rules: universal access, no added federal money, no reduction in benefits and no reduction in physician payment. His resulting plan honored all four rules, placed no financial risk on physicians and assured health care for all Vermonters for less money than the state spends now. ACOs were nowhere to be seen. Curiously, American health care systems that do provide better care at lower costs do not use ACOs. These systems include TriCare for 9 million uniformed service members, Medicare for 44 million

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66 I AnesthesiologyNews.com

August 2011

A D L IB

Cliff Jumping and Other Adventures of Residency

t’s August. Some of you are new residents who just graduated from medical school or internship. Some of you are new staff who just graduated from residency or fellowship and are finally starting out. I wonder if your fears and insecurities are similar. I wonder if you realize that you are not alone. I was six months out of residency, still unsure of myself in my new role as an attending anesthesiologist and still attempting to understand the inner workings of my new hospital. It was a Friday evening. Seemingly everyone in my department had gone home for the weekend, and I alone took the call. The emergency room reported that it had a 42-year-old woman with mental retardation and muscular dystrophy who had fallen, dislocated her elbow and needed an emergent closed reduction. When I arrived in the ER, I discovered that she had eaten a full meal just a few hours ago, and since then had received several doses of narcotics. Upon examining her, I saw that she was overweight, with a short neck, a small thyromental distance, a large tongue and a Mallampati Class 4 airway. Down’s facies made me suspicious for atlanto-axial instability. Her father explained that she also had a history of acid reflux and obstructive sleep apnea. These are the times when I wish I were still a resident, when I’d give anything for someone else to be in charge. The transition from medical student to resident, and resident to attending anesthesiologist is, I imagine for some, relatively smooth. Perhaps they are ready for a new sense of purpose. They feel confident in their own decision making and long for autonomy. For me, and a few of my colleagues, however, it was like stepping off a cliff. During our first year as attendings, we took notes. We discovered that becoming an attending anesthesiologist makes you:

• Embrace the breath-stealing terror that comes with knowing you are it, and there is no turning back: You push the propofol. You push the paralytic. You get the airway. Or you bear the burden if you do not. • Doubt decisions you never doubted, and invent questions you never had. Was it overkill to draw a type-and-cross for a laparoscopic cholecystectomy? Should you postpone the case if the patient dipped tobacco on the way to the hospital? • Go back to the basics: How are you going to secure the airway, optimize oxygenation and ventilation, and assess, monitor and treat the circulation? And then in five minutes, are you ventilating appropriately while you are managing the hypotension? • Ask for help. Search the literature. Gather resources. It makes you remember you are not a cowboy, and this is not a rodeo. You are a physician, and this is the life you are protecting. • Understand the value of knowing the people with whom you work. Which surgeons can you trust and which need to be watched more closely? You see firsthand how so much of what we do depends on what they do—and how well they do it. Who of your colleagues do you want beside you when you can’t intubate your patient? Leaving the people you knew so well means losing one set of your relied-on resources; it requires that you depend more on yourself and your ability to figure it out. • Discern, with surprise and uneasiness, that occasionally you actually know more than some of your older, more experienced colleagues. Do you try to teach them a better way? Do you step in and take over? Or do you stand back, out of respect, and watch in silent shock? • Trust your instincts and listen to them. • Want to teach. As you go through the rigor of studying for both your written and oral board exams, you start to realize how much you’ve

learned and want to share with those still learning. • Rediscover the parts of your life that got swallowed up by the long hours, poor nutrition and sleep deprivation of resiKristin Adams Forner, MD dency: You learn to cook. You compete in triathlons. You travel the world. You breathe again. Remember, every day, that what we do is a privilege. Into no one else’s hands do people give up complete control of their lives. In no other field will you participate in so many of life’s greatest and most challenging moments. In no other specialty will you be able to call yourself a comforter, and have so many tools for being so. This is the season for which you have worked so hard, and so long. Although you may fall, you will learn to pick yourself back up. And next year, when you have conquered your initial fears and insecurities, you will stand back and watch the new recruits do the same. After asking for help from colleagues, searching the literature, gathering resources and trusting my instincts, I gave my patient an uncomplicated supraclavicular block and avoided her airway altogether. And I went home that night with a new sense of confidence that could only have been gained from realizing I was it and there was no going back, from embracing my terror and refusing to give in to it, and from stepping off that threatening cliff and walking into all that awaited me. —Kristin Adams Forner, MD Dr. Forner is staff anesthesiologist and medical director for the Department of Anesthesiology at Wright-Patterson Air Force Base, in Dayton, Ohio. You can read more of her writing at www.docbehind thedrapes.com.

Report Shows Steady Climb in Cesarean Births

he share of births by cesarean delivery reached 34% in 2009 (Figure 1), an all-time high, according to a new report from HealthGrades, which tracks physician and hospital performance. At the top of the list was Florida, where nearly 40% of babies were delivered by cesarean section in 2009 (Figure 2). Utah, at just over 20%, had the lowest rate of such births. The report is available at www.healthgrades.com.

Vaginal deliveries

Cesarean deliveries

100%

80%

60%

80% 40% 60%

Figure 1. Vaginal and cesarean rates (2007–2009, 19 states).

Florida

New Jersey

Texas

Virginia

Nevada

Maryland

New York

Maine

Oregon

Arizona

Iowa

Figure 2. Delivery rates by state (2007–2009, 19 states).

California

2009

Massachusetts

2007

Pennsylvania

2005

Rhode Island

2004

Washington

2002

Colorado

% Vaginal deliveries % Cesarean deliveries

Wisconsin

20%

Utah

20%

40%

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