The May 2012 Digital Edition of Anesthesiology News by McMahon Group

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The Independent Monthly Newspaper for Anesthesiologists AnesthesiologyNews.com • M a y 2 0 1 2 • Volume 38 Number 5

Anesthesiologists Take on Central Role In Stroke Care

ramatic technological advances in the way stroke is treated are greatly expanding the time frame and tools specialists have to treat the fourth biggest killer in the United States. This in turn is driving facilities that specialize in stroke care to overhaul their protocols to employ the latest therapies. At Montefiore Medical Center’s Stern Stroke Center, in New York City, a designated primary stroke center (PSC) for the state, one aspect of this evolution is the development of a teamwork

Cancelled Surgeries Costing Hospitals Millions

OR SCHEDULE

etween patient no-shows and cancellations on the day of surgery, hospitals are losing millions in revenue each year, researchers have found. The good news, according to the investigators, is that patients who have a preoperative visit with an anesthesiologist are substantially more likely to keep their appointment in the operating room. Researchers at Tulane University Medical Center found that in 2009, 327 of 4,876 (6.7%) scheduled elective outpatient surgeries were cancelled, costing the hospital

see stroke page 18

PATIENT

TIME

STATUS

CANCELLED CANCELLED CANCELLED CANCELLED

INside 12 | COMMENTARY Calif. court’s opt-out ruling could have national repercussions.

Modest pay increases; new data reporting requirements

ROOM

see cancelled page 23

CMS Rolls Out Changes For Ambulatory Surgical Centers ajor changes are under way in how the Centers for Medicare & Medicaid Services pays ambulatory surgical centers and hospital outpatient departments. The CMS 2012 final rule increased payment rates to ASCs by 1.6% this year, and rates under the Outpatient Prospective Payment System rose by 1.9%. But, in a move that will prove more significant in the long term, CMS has adopted new quality measures for surgery centers.

PROCEDURE

HERNIA REPAIR GALL BLADDER KIDNEY STONE CHOLECYSTECTOMY

The quality reporting system will be integrated over the next two years and will affect payments beginning in 2014. ASCs that fail to successfully report the quality measures will face a 2% reduction in facility fee reimbursement. Representatives of the Ambulatory Surgical Center Association (ASCA), a trade group, said its members welcome the changes even though the new policy will increase the data collection and paperwork for centers.

14 | CLinical Anesthesiology Anesthesiologists poor judges of blood loss during surgery.

26 | Pain Medicine N.H. hospital at forefront of individualized pain care.

30 | technology Prompting boosts accuracy of AIMS billing.

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Comment on these and other articles @ AnesthesiologyNews.com.

Heard Here First: She was whirled violently in the air, colliding with objects caught in the twister. A string of

barbed wire entangled her

legs. She held her belly with one hand and her mother with the other. Her mother shouted, May 2012

“I love you,” as she was pulled away;

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

Amanda would never see her alive again.

1. Neuromuscular Blockers Linked to Post-op Breathing Problems 2. Laughter, and Tears, on the Way To Safer Anesthesia (Part 3)

See article on page 10.

3. Cerebral Oximetry: Emerging Applications For an Established Technology (Educational Review) 4. IV Acetaminophen Improves Pain Management and Reduces Opioid Requirements in Surgical Patients: A Review of the Clinical Data and Case-based Presentations (Special Report) 5. A Conversation With Malpractice Attorney Gary Samms (Podcast)

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Go to AnesthesiologyNews.com/Renew.

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Expert Testimony Process “Broken From the Outset” To the Editor: read with great interest the article by Benumof and Benumof (“‘Aliens Among Us:’ The Perils of Expert Witness Testimony,” March 2012, pages 24-26). The authors illustrate the need for a transparent process by which medical specialties can fairly, and without bias, vet and review expert witness testimony. It is fascinating and telling, but also discouraging, to learn that the

American Society of Anesthesiologists (ASA) has pursued complaints only against plaintiffs’ expert witnesses and has yet to pursue a single complaint against a defense expert witness. The ASA’s process, by which a member anesthesiologist may, without risk for or threat of recourse, launch a complaint against a fellow ASA member who has rendered expert testimony, automatically engenders bias and promotes intimidation.

Certainly, physicians should be allowed to file complaints that contest fraudulent testimony, and those experts who act unethically should face serious discipline. Yet without establishing an open and fair review process or instituting a severe penalty for issuing frivolous or false complaints, the ASA is complicit in a spreading effort to silence all plaintiff ’s expert witness testimony, whether it be truthful or not. The process the ASA has

undertaken to address matters was broken from the outset. The current program should be dismantled or at least realigned with some reality based on culpability for individuals who file complaints that are dismissed. —David M. Eckmann, PhD, MD Dr. Eckmann is the Horatio C. Wood Professor of anesthesiology and critical care, and professor of bioengineering at the University of Pennsylvania, in Philadelphia.

IN B R I E F

ACGME To Change Standards for How Residents Are Measured

he Accreditation Council for Graduate Medical Education (ACGME), the nonprofit organization that evaluates and accredits more than 9,000 medical residency programs in the United States, has announced it will transform how these programs will be accredited in the coming years. As described in an article in The New England Journal of Medicine (2012;366:1051-1056), the ACGME’s next accreditation system (NAS) for graduate medical education is centered on six domains of clinical competency, developed in concert with the American Board of Medical Specialties. In an interview, the article’s lead author, Thomas J. Nasca, MD, chief executive officer of the ACGME, characterized these domains as “patient care and technical skills; medical knowledge; professionalism; interpersonal communication; systems-based practices; and practice-based learning and improvement.” The NAS “is the culmination of a decade’s worth of work building consensus around the competencies,” he said. The difference between the past accreditation system and the NAS, Dr. Nasca said, is that the new system will evaluate educational outcomes rather than just process, and the core or essential educational outcomes will be standardized for each specialty. “There must be simulation training in induction of anesthesia” is a process standard, he explained. “The resident demonstrates effective incorporation of knowledge and skill in the administration

of anesthesia” is an outcome standard. In July 2013, seven of the 26 ACGME-accredited core specialties will implement the NAS. The seven specialties are emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology and urology. In July 2014, the remaining specialties will apply the NAS. Dr. Nasca detailed some of the projected benefits of the NAS. Residents will be reassured that all programs teach and evaluate the same desired outcomes, with a “more targeted evaluation of performance, and more effective formative feedback—a focus on what is essential.” The program directors will get a less intrusive ACGME, with decreased administrative burden, giving them time for more mentoring and direct education. The public will be the “ultimate beneficiary,” because it will get better-trained physicians. “It’s not just an educational exercise,” Dr. Nasca said. “We will reassure the public of the completeness of the training and that each graduate has demonstrated the core skills required in their chosen specialty, prior to entering clinical practice in the profession.” Christine Stencel, spokeswoman at the Institute of Medicine (IOM), said the new accreditation system is consistent with recommendations of the IOM’s 2003 report Health Professions Education: A Bridge to Quality. However, Ms. Stencel noted that IOM

Pharmacy Group Urges Senate To Get Tougher on Drug Shortages

n April 6, the American Society of Health-System Pharmacists (ASHP) and 24 other health care organizations sent a letter to the Senate Committee on Health, Education, Labor, and Pensions to urge changes in draft legislation that would take a tougher stand against drug shortages. Heightened efforts to address the drug shortage are sorely needed, according to ASHP members. “The number of drug shortages has significantly increased over the last four years,” ASHP CEO Paul W. Abramowitz, PharmD, said in a statement. “This is a public health crisis that is putting patients at risk.” The bill aims at addressing drug shortages as part of the proposed reauthorization of the Prescription Drug User Fee Act. High among the requests in the letter is the institution of civil monetary penalties, or another enforcement mechanism, to ensure that drug manufacturers comply with the requirement to report production interruptions or product

will begin a study in June of the governance and financing of graduate medical education. “The committee for that study will likely take up aspects of the ACGME accreditation reported by Dr. Nasca in The

discontinuations. “We are concerned that a requirement lacking enforcement isn’t really a requirement,” the letter states. The letter also recommends that clinicians, patients and members of the supply chain be included in the task force created by the legislation to promote inter- and intraagency coordination, planning and decision making. The FDA should receive additional resources to address drug shortages, and the language requiring the agency to provide public notification about shortages should be strengthened, according to the letter. The FDA and Drug Enforcement Administration should work collaboratively, with appropriate flexibility, in developing quotas for manufacturers producing controlled drugs, the letter states. In addition to recommending changes, the letter expressed support for certain aspects of the draft legislation, such as inclusion of biologics and biosimilar products in the draft bill. —AN Staff

New England Journal of Medicine. IOM cannot prognosticate on what this related new study will conclude and recommend and therefore must withhold any judgments,” she said. —George Ochoa

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C OMM E NT A R Y

Simulation and the MOCA (Part 2) This article is the second in a two-part series. The first installment appeared in April.

re the required components for successful completion of the Maintenance of Certification (MOC)/Maintenance of Certification in Anesthesiology (MOCA) process based on evidence or opinion? The answer depends on the question. The majority of the literature that supports recertification extrapolate outcomes data from studies comparing performance between physicians with primary certification and their non-certified counterparts,16,17 as well as evaluating treatment outcomes in relation to the time since last board certification. Norcini and colleagues also demonstrated a 15% reduction in mortality among patients treated by certified physicians following acute myocardial infarction,18,19 while another group demonstrated an increased rate of treatment intensification (the initiation of new drugs or an increase in an existing antihypertensive medication) by physicians who were more recently board-certified.20 Because mandated recertification is a fairly new phenomenon, little if any evidence has demonstrated improvement in clinical outcomes from the process. Only one study by Holmboe evaluated the association between performance on the American Board of Internal Medicine (ABIM) MOC exam and basic quality-care performance measures.21 Although this study found a positive correlation between examination score on the MOC and performance on most of Advertisement

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the care measures, more research is required to firmly establish a relationship between the care provided and performance on any cognitive examination.21,22 Continuing Education For decades, continuing medical education (CME) credits have been the accepted currency for physician education after training, required by professional organizations, state licensing boards and hospitals. As the number of institutions requiring physician participation has grown, so has the CME enterprise. It has long been the belief that CME brings physicians up to date in their knowledge base, which in turn produces improvements in practice and patient outcomes. Despite its wide use and acceptance, little evidence exists to show that physicians who participate in CME improve their ability to care for patients.23-27 Simulation-based Training Simulation-based training is currently being used by medical schools, residency programs and licensure and recertification programs. Proponents of simulator-based training argue that simulators allow for the identification of deficiencies such as lapsed skills of an anesthesiologist, improve the dynamics in high-acuity team situations and provide more rapid acquisition and retention of skill sets.28-29 Although these objectives are impressive, few studies have demonstrated an improvement in patient outcome from simulator training.28 A comparison of the relative effectiveness of case-based learning (CBL) and simulation-based learning (SBL) in critical care unit teams found a nonsignificant trend toward greater benefit of SBL over CBL.30 These results suggest that a mix of the two learning approaches likely is most effective. What Will It Cost? To examine the costs of recertification, it is important to ask what drives the process to begin with. In the United States, the United Kingdom and Canada, four main factors have shaped the development of recertification systems: economic, political, social and professional.31 Because health care in the United

States is supported by a mix of public and private funding, recertification unsurprisingly is influenced most heavily by economic considerations. The medical boards refute accusations by physicians that recertification has less to do with improving the quality of care and outcomes than with the collection of revenue—but money undeniably plays an important role. Obvious conflict of interest between medical boards and their affiliated societies has been noted, with the creation of products that must be purchased in order to fulfill the recertification requirements. David Brown, MD, secretary of the American Board of Anesthesiology, told Anesthesiology News, for example, that unlike other boards that have developed products to sell to their physicians, the ABA has made a conscious decision not to do so, to avoid conflict of interest.32 Even so, MOCA requires mandatory CME credits obtainable only from the ASA (Table 1). Mark Warner, MD, immediate pastpresident of the ASA, has said that the society is not the exclusive provider of educational materials and activities for the MOCA and that other organizations may work with the ABA to develop products.32 However, at the moment, the ASA is the sole provider of these materials. Even the required simulation-based training must be performed in an ASA-endorsed simulation center. These institutions must go through a rigorous process for initial approval, subsequent site visits and recertification, and pay a $2,500 fee to the ASA—a cost that’s ultimately borne by the recertifying physician. Simulation training costs roughly $2,000 per doctor, with modest discounts available for groups. But that outlay merely covers the course fee. With only 27 endorsed centers in the country to date, most physicians must cover the costs of travel, housing and food for the one-day course, in addition to losing revenue while away from their practice. The ABA said it has tried to make the MOCA “the least onerous we can for our docs, with as much clarity and transparency as we can for society.”32 Given the lack of evidence to support the components of the MOCA, however, why does the board continue to increase the requirements of existing components while adding new ones? Instituted in 1990, the MOC is now in its third decade (Table 2). Perhaps the ABA should look to the

Table 1. Requirements and Cost Associated With the MOCA Exam

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MOCA Requirements

Number Needed

Cost

CME credits

240

Varies

CME from ACE or SEE: ASA member

$300/60 CME requiring 2 y = $600

CME from ACE or SEE: Non–ASA member

$830/60 CME requiring 2 y = $1,660

CME from ACE or SEE + ASA membership

$300/60 CME requiring 2 y, $600 + $625 = $1,225

CME patient safety education: ASA member

$120/10-CME module, 20 modules = $240

CME patient safety education: Non–ASA member

$160/10-CME module, 20 modules = $320

Simulation training

$1,500-$2,000

ASA membership fee

$625

Exam fee

$2,100

Total cost (worst-case scenario, non–ASA member)

$6,080 (+ cost of additional 240 required CME, airfare and hotel)

ASA, American Society of Anesthesiologists; CME, continuing medical education; MOCA, Maintenance of Certification in Anesthesiology; SEE, Self-Education and Evaluation Program

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AnesthesiologyNews.com I 9

COMME N TA R Y Table 2. Requirements and Cost Associated With the MOC Exam 17. Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist board certification and patient outcomes. Anesthesiology. 2002;96:1044-1052.

MOC Requirements

Number Needed

Cost

CME credits

100

Simulation training

0 may count toward CME requirement

0 $35 fee for cancellation or failure to show

Application fee

$1,675 ($1,840 for subspecialty)

Fee provides access to unlimited ABIM Self-Evaluation Modules for CME credit in addition to simulation training

Total cost

19. Norcini JJ, Lipner RS, Kimball HR. Certifying examination performance and patient outcomes following acute myocardial infarction. Med Educ. 2002;36:853-859. 20. Turchin A, Shubina M, Chodos AH, Einbinder JS, Pendergrass ML. Effect of board certification on antihypertensive treatment intensification in patients with diabetes mellitus. Circulation. 2008;117:623-628.

Application fee

ABIM, American Board of Internal Medicine; CME, Continuing Medical Education; MOC, Maintenance of Certification

ABIM as a model. How is it possible for the MOC to offer a written exam, computer modules that provide enough credits to complete the 100 CME credit requirement and a simulation course, for an application fee roughly one-third that of the MOCA?

18. Norcini JJ, Kimball HR, Lipner RS. Certification and specialization: do they matter in the outcome of acute myocardial infarction? Acad Med. 2000;75:1193-1198.

The ABA argues that it is attempting to create an exam that is not onerous for the physician. But is the MOCA a better recertification examination process than the MOC because it has more requirements and costs three times as much? The MOC has been in existence since 1990 (indeed, the MOCA is based on Conclusion it). Does the MOC fail to satisfactorily maintain its Maintenance of currency and proficiency within physicians’ competence because it is more convenient all of the medical subspecialties is, without ques- and manageable than the MOCA? Are anesthesiolotion, a necessity. Anesthesiologists take great pride— gists more current and proficient than our other coljustifiably—in shepherding patients through their leagues who take the MOC? procedures and incorporating the most up-to-date Lastly, but not least important, where are the data knowledge and equipment to provide safe and excel- to support the “grandfather” status? The ABA publent care. But that does not obviate questions about licly preaches its support of recertification of anesthe continuously increasing requirements of the thesiologists. The public has expressed its views MOCA process, as well as the exemption of certain regarding the value and expectation for physician individuals from participation in that process based recertification. In addition, the data demonstrate that solely on the date they obtained initial certification. physicians farther from initial certification are most As previously demonstrated, evidence supporting in need of external assessment. This exemption, and the components of the exam is lacking. Even so, the the questions previously posed, undermine the validrequirements continue to increase. Where are the data ity of the entire recertification process. demonstrating that the addition of 140 CME credits —Tania Haddad, MD from the inception of the MOCA in 2000 improves physician care when traditional CME has been shown Dr. Haddad is an anesthesiologist at Valley Anesthesiology to be ineffective? Where are the data that demon- Consultants, in Phoenix, Ariz. strate that simulation in a remote endorsed center is superior to a locally based and less costly simulation References center? Meanwhile, although the data to support 16. Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. Specialty these questions are not available, the revenue that board certification and clinical outcomes: the missing link. Acad Med. 2002;77:534-542. these requirements generate is easy to calculate.

21. Holmboe ES, Wang Y, Meehan TP, et al. Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries. Arch Intern Med. 2008;168:1396-1403. 22. Landon BE. What do certification examinations tell us about quality? (editorial). Arch Intern Med. 2008;168:1365-1367. 23. Davis DA, Taylor-Vaisey A. Translating guidelines into practice: a systematic review of theoretic concepts, practical experience, and research evidence in the adoption of clinical practice guidelines. CMAJ. 1997;157:408-416. 24. Schrock JW, Cydulka RK. Lifelong learning. Emerg Med Clin N Am. 2006;24:785-795. 25. Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, TaylorVaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282:867-874. 26. Mazmanian PE, Davis DA. Continuing medical education and the physician as a learner. JAMA. 2002;288:1057-1060. 27. Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39:112-145. 28. Boulet JR, Murray DJ. Simulation-based assessment in anesthesiology. Anesthesiology. 2010;112:1041-1052. 29. Cooper JB, Murray D. Simulation training and assessment: a more efficient method to develop expertise than apprenticeship. Anesthesiology. 2010;112:8-9. 30. Frengley RW, Weller JM, Torrie J, et al. The effect of a simulationbased training intervention on the performance of established critical care unit teams. Crit Care Med. 2011;39:2605-2611. 31. Shaw K, Cassel C, Black C, Levinson W. Shared medical regulation in a time of increasing calls for accountability and transparency: comparison of recertification in the United States, Canada, and the United Kingdom. JAMA. 2009;302:2008-2014. 32. Agres T. Mounting board demands foster growing unease. Anesthesiology News. October 2011.

ClipChart Washington, D.C.: The Drug Enforcement Administration is conducting an economic impact analysis of a rule to put propofol on its list of controlled substances. The study suggests the agency is in the final stages of its efforts to make the sedative a Schedule IV drug. The DEA proposed the change in October 2010, and had closed the move to public comment that December. The agency would not say how long the economic assessment would take. However, a spokeswoman for the DEA said the report’s findings were unlikely to derail the scheduling rule.

Atlanta, GA: The number of U.S. teens dying from overdoses of opioids and other prescription drugs nearly doubled in the last decade, even as the rate of accidental deaths among youths fell. The rate of accidental deaths among teens aged 15-19 years attributable to prescription drugs rose from 1.7 to 3.3 per 100,000 people between 2000 and 2009, according to new data from the Centers for Disease Control and Prevention. By 2009, accidental poisoning accounted for 824 deaths among Americans age 19 and under, up from 442 in 2000. The annual death rate fell from 15.5 to 11.0 per 100,000 people during the study period. The rate for motor vehicle accidents, the leading killer, fell from 9.3 to 5.5 per 100,000 people.

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Stormy Passage: How a Pregnancy Survived the Tornado of the Century

t 3 in the afternoon of April 27, 2011, Amanda Berry, then 24, looked out the window of her home in Phil Campbell, Ala., to a see a darkened sky. A newsflash was reporting a severe thunderstorm warning when the power went off. Amanda, her

husband and her mother scrambled into the bathroom, the only inner room in the house, as the tornado struck. Amanda has trouble remembering what happened next. Her ears ached from the sudden drop in atmospheric pressure. Shards of glass and plywood

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shot through the air like bullets. The floor trembled, and the wall she braced herself against suddenly buckled, fracturing her right leg above the ankle. As AP Photo/The Tuscaloosa News, Dusty Compton her feet lifted off the ground, the sky opened into a chasm of blackness. She was whirled violently in the air, colliding with objects caught in the twister. A string of barbed wire entangled her legs. She held her belly with one hand and her mother with the other. Her mother shouted, “I love you,” as she was pulled away; Amanda would never see her alive again. When Amanda landed, she found herself lying in a ditch 50 feet from where her house had stood moments ago. Her husband lay near her in the grass, moaning incoherently. Both of them were naked, their clothes ripped off by the lashing winds. Amanda would later remark on the surreal nature of the situation: “I kept thinking, ‘Is this really happening?’” She watched a washing machine tumble overhead like an autumn leaf. Hail rained down as she hid beneath a cabinet door, a makeshift shelter provided by a passing stranger. Nearly an hour passed before she heard the voices of the first rescuers. Three months later, Wendy (not her real name), a nurse anesthetist from Florence, was recounting this story to an audience of medical volunteers on a mission trip to Guatemala. We had been exchanging stories to pass the evenings in the remote village of Montellano. Everyone had heard of the tornadoes that leveled towns across northern Alabama, and this tale clearly trumped all others. To me, the details sounded strangely familiar. Wendy first saw Amanda and her husband when they were brought emergently to the operating room. A foreign object had struck him in the face, entering next to his eye and exiting through his ear. “It looked like a grenade had exploded by his head,” Wendy “The McGRATH MAC video laryngoscope complies with EN 60601-1 and EN 60601-1-2 safety standards. The CE mark indicates that it meets the requirements of European Council said. While one surgeon worked on Directive 93/42/EEC concerning medical devices. The device is regulated in the USA under that wound, another repaired his fracFDA Regulation Number 868.5540 and device listed under the name “McGRATH MAC”. tured left ankle. Still another member “McGRATH” and “Aircraft” are registered trademarks of Aircraft Medical Limited. “CameraStick” is a trademark of Aircraft Medical Limited. of the surgical team closed the lacerations scattered over his body. Amanda was in the neighboring operating room, where surgeons were repairing the wound in her right leg, an open tibia-fibula fracture. After Amanda was anesthetized, Wendy COVIDIEN, COVIDIEN with logo, Covidien logo and positive results for life are U.S. and internationally registered trademarks of Covidien AG. Other brands are trademarks of a removed a six-inch sliver of wood burCovidien company. ©2012 Covidien. All rights reserved. 12-AW-0264f ied under the skin of her back. “It was ®

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AnesthesiologyNews.com I 11

COMME N TA R Y as long as a tent spike,” Wendy told us. “She was literally covered in sawdust.” It finally clicked; I recognized this patient. But there was something Wendy had not mentioned. I interrupted her to ask about the most dramatic detail of all. “Was she pregnant?” “Yes!” Wendy said. “How did you know?” “I took care of her, too.” We pieced together the rest of the story. Amanda had been 21 weeks pregnant when catastrophe struck. Immediately after the tornado, she dilated to 5 cm and was leaking amniotic fluid. To receive the appropriate care, she was moved to three different hospitals and finally transferred 90 miles north to my institution, Vanderbilt University Medical Center, in Nashville, Tenn. I met Amanda three weeks after the storm when the acute pain service was consulted for pain management. She had undergone multiple surgeries on her leg and was awaiting another for amputation. The severity of her pain, and the fragility of her pregnancy, prevented Amanda from receiving the traditional regimen of narcotics. I introduced myself to Amanda and discussed treatment options. With some difficulty, she was placed in a sitting position. Her back looked like it had been flogged. Shrapnel continued to emerge from her flesh. After some searching, I found a small clearing in her low back, and placed an epidural at the L4-5 interspace. Over the next several minutes, Amanda told me what had happened. She was a survivor of the deadliest tornado in the United States in 37 years, Alabama’s largest natural disaster since 1932. In her hometown of 1,100 people, 21 had been killed. The May 8 edition of The Huntsville Times led simply with the facts: “32 miles. 210 mph winds. 70 lives lost.” The death toll would be increased to 238 in Alabama alone. The next week I rotated off the pain service and lost track of Amanda. Wendy didn’t know what had happened to her, either. As anesthesia providers, we are used to caring for patients in the acute setting; long-term follow-up is a privilege we often do without. But both of us were touched by Amanda’s story, and the fact that we connected in Guatemala of all places seemed more than coincidental. Were we being reminded to follow-up on Amanda? It certainly felt that way. When I got back home, I was determined to find her to see how she was recovering. I was able to track Amanda down

with a few phone calls, and she brought me up to date. She had been discharged home in stable condition after her last surgery. The trauma team at Vanderbilt managed to salvage her leg, and already she was able to get around with a walker. Her husband had returned from rehabilitation and was making progress. Amanda said it’s a miracle they survived. The greatest miracle of all occurred on Sept. 2, 2011, when Amanda gave birth to a healthy boy. To the shock of her obstetrical care providers, her

preterm labor had halted and her cervix closed after the initial trauma of her injuries. From that point forward, her pregnancy was uneventful. The obstetric nurses nicknamed the boy “Stormy” to commemorate his turbulent passage into this world. Today, Amanda and her husband are raising their son in a temporary apartment as they piece their lives back together. Motherhood, she said, is a pleasant distraction from all her troubles. Her son’s name is Kaden, a

compromise of her mother’s choice of Kade and her own of Aiden. And that blending is appropriate—a double tribute to a loved one lost and to the miraculous arrival of another. When she looks at her baby boy, Amanda repeats her mother’s last words: “I love you.” —Stephen Harvey, MD Dr. Harvey is assistant professor of anesthesiology at Vanderbilt University Medical Center, in Nashville, Tenn.

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

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C OMM E NT A R Y

Calif. Ruling on CRNA Practice Promises Nationwide Tremors

s if competition for exclusive contracts is not fierce enough already, on March 15, 2012, the California Court of Appeal upheld a trial court ruling that nurse anesthetists in the state do not require physician supervision. The California Society of Anesthesiologists and the California Medical Association filed the lawsuit, and the

appeal, to block the governor’s decision to opt out from Medicare’s physician supervision rule. The associations had asserted that California law does not permit independent practice by certified registered nurse anesthetists (CRNAs). In its opinion, the appeals court relied on the specific California statute defining the practice of nursing, which

states that the Board of Registered Nursing, and no other agency, is vested with the power to define the scope of nursing practice. The court noted that the board has repeatedly expressed its view that physician supervision of CRNAs is not required. The court also pointed out that there is specific statutory authority for the fact that CRNAs may

administer anesthesia to implement a treatment ordered by a physician—in other words, the surgeons “order” the anesthesia and the fulfillment of that request is up to the CRNA. The associations urged the court to consider “ordered by a physician” as requiring physician oversight. They found no support for that interpretation. The California Society of Anesthesiologists has announced that it will file a petition for review, the first step in an appeal to the California Supreme Court. Pandora’s Box Why were judges at both the trial and appellate levels skeptical of the argument by the two associations? A look at California’s Nursing Practice Act reveals a clue. The act, which specifies the scope of practice and duties for registered nurses, states, “the Legislature recognizes that nursing is a dynamic field, the practice of which is continually evolving to include more sophisticated patient care activities. It is the intent of the Legislature in amending this section at the 1973-74 session to provide clear legal authority for functions and procedures that have common acceptance and usage. It is the legislative intent also to recognize the existence of overlapping functions between physicians and registered nurses and to permit additional sharing of functions within organized health care systems that provide for collaboration between physicians and registered nurses …” (emphasis added). This language is a treasure trove for CRNAs as well as other nurses who

Figure. The 16 “opt-out” states (green).

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COMME N TA R Y will clearly benefit economically as hospitals, payers and the government exert increasing pressure to expand the scope of nursing. For example, several years ago, the California Board of Registered Nursing issued a letter endorsing the complete independent practice by CRNAs, including performance of procedures to treat both acute and chronic pain. That letter was withdrawn when the California Society of Anesthesiologists attacked it as an improperly adopted regulation. However, the latest ruling underscores the fact that had the nursing board gone through the proper channels to push its position in the form of a regulation, not an informal yet public letter, it would now be viewed as consistent with California law. What Next? Whether you are an anesthesiologist or a CRNA, if you practice in California competition for exclusive contracts, both at ambulatory surgery centers and at hospitals, will increase as CRNA groups begin to seek those arrangements. To be sure, specific medical staff bylaws may be more or less permissive in terms of the scope of CRNA practice at a given facility. Similarly, a particular insurance or managed care plan may not reimburse for unsupervised CRNA charges. Still, those issues are likely to be resolved relatively quickly— and in a manner consistent with the expanding role of nurses. If you are an anesthesiologist practicing in a non–opt-out state (Figure), political pressure is sure to mount within your state for both an optout and, if necessary, an expansion of the definition and role of nursing to accommodate it. In other words, competition is destined to get tougher for you, too. Explore Your Options The competitive landscape for anesthesiologists is dynamic and rapidly changing. Competition, once limited to a somewhat benign concern that a group from across town would scoop up a stray ambulatory surgery center or seek to displace your group as the holder of its sole exclusive contract, has burgeoned.

In addition to aggressive local groups, truly national groups are seeking to expand across the country; staffing services and anesthesia management companies are masquerading as groups, seeking to do the same thing; and now, in opt-out states such as California—one of 16—CRNA groups will be seeking those same opportunities for themselves. These trends further underscore the fact that groups must adopt actual

business structures and seek to provide unique value—what I have called an “experience monopoly”—to their facilities, referring surgeons, patients and the larger medical staff and community. Simply continuing to provide a service to the hospital, even a clinically competent service, is equivalent to providing a commodity, one that will be provided for less or with more panache by one of the many new competitors in a race to the lowest bottom line.

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

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C LIN I C A L A N ES T H ES IO LO G Y

Half Full? Anesthesiologists Vastly Overstate Surgical Bleeding Study finds estimates 40% higher than real loss Chicago—Estimates of blood loss during surgery by anesthesia personnel may lead to excess transfusion, according to a recent study, which found that estimated loss exceeded measured loss by more than 40% during spine

procedures. “Interpretation of intermittent measurements of hemoglobin levels is often complicated by fluid shifts, intravenous volume infusions and transfusions,” said John Stover, MSN, a nurse

1000 900 800

practitioner at Duke University Medical Center, in Durham, N.C., who helped conduct the study. Increases in hemoglobin following transfusion of allogeneic red blood cells make changes in perioperative

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Estimated Actual Blood Loss, mL Blood Loss, mL

Figure. Discrepancy between estimated and actual blood loss.

hemoglobin unreliable markers of blood loss, Mr. Stover said. Previous studies have shown that clinicians in the operating room are poor judges of blood loss. As a result, a less subjective assessment—such as direct measurement of the hemoglobin mass lost from the surgical field—may better quantify surgical bleeding. However, few trials have compared anesthesiologist estimates of intraoperative blood loss with measured hemoglobin loss. As part of a larger study, the Duke investigators analyzed data from 60 patients undergoing multi-level posterior lumbar instrumentation and fusion. During each case, heparinized saline was added to suction containers to prevent clotting of any blood aspirated from the surgical field. Blood in surgical sponges was recovered by immediately soaking the sponges in a container of citrated saline. Before processing red blood cells from the cell salvage device, collected blood was mixed by agitating the collection container. The hemoglobin concentration was measured from an aliquot of salvaged blood through a sampling port inserted at the base of the collection chamber using sterile technique. At the end of each operation, all surgical sponges soaked in citrated saline were wrung into the soak container. The soak solution was then added to the sanguineous solution in the wall suction containers. After mixing, the hemoglobin concentration and total volume of the wall suction containers were measured. The hemoglobin loss in surgical sponges and wall suction was then calculated. see bleeding page 17

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CL IN ICA L A N E ST H E SIOL O G Y

Early Epidurals No Advantage for Blunt Thoracic Injury Houston—Early thoracic epidural analgesia does not reduce pulmonary complications in patients with a blunt chest injury compared with patientcontrolled analgesia with opioids, a new study suggests. The study, in patients with at least three rib fractures, casts doubt on the benefit of thoracic epidural anesthesia (TEA) in these cases, said Julin Tang, MD, clinical professor of anesthesia and critical care medicine at the University of California, San Francisco School of Medicine, who led the study. “People have thought that early epidural analgesia would result in fewer pulmonary complications and shorter ICU [intensive care unit] stays and hospital length of stay, but this turned out to be a negative study. It was really surprising,” said Dr. Tang, whose group presented the findings at the 2012 annual meeting of the Society of Critical Care Medicine (abstract 116). Mark Stafford-Smith, MD, professor of anesthesiology at Duke University Medical Center, in Durham, N.C., said some data show that TEA after chest surgery improves patient outcomes and reduces complications. However, whether the benefit holds in the uncontrolled trauma of blunt injury with rib fracture is not well-studied. “The findings of the study should be used thoughtfully in considering the use of TEA for blunt thoracic trauma patients with rib fractures, but they are too preliminary to guide practice change,” said Dr. Stafford-Smith, who was not involved in the research. Dr. Tang’s group reviewed medical records of 187 non-intubated patients with blunt thoracic injury who were seen at San Francisco General Hospital over a five-year period. Early epidural analgesia was used in 18% of cases. The average delay between hospital arrival and epidural insertion was roughly 18 hours (±13.2 hours) and the average duration of epidural use was approximately 98 hours (±69.4 hours). Patients treated with an epidural more often had bilateral rib fractures (32% vs. 15% treated with opioids; P=0.026) and a greater number of fractured ribs (seven vs. five; P<0.001). Early TEA failed to reduce the incidence of pulmonary complications compared with patient-controlled analgesia with opioids (11.1% vs. 11.8%, respectively; P=1.000). Patients who received an early epidural stayed longer in the ICU (median, one day vs. no days; P<0.001) and hospital (seven

vs. five days; P=0.006). Pulmonary complications were more common in older patients (P=0.029) and those who required chest tubes (P=0.012), regardless of anesthesia type. Dr. Stafford-Smith said the retrospective nature of the study made it impossible to determine why some patients received TEA and others did not. Notably, TEA subjects had

more rib fractures, and more bilateral rib fractures, than non-TEA patients. “This suggests that TEA patients may even have been sicker by some criteria. Hence, a similar or slightly delayed recovery profile would not be inconsistent with benefit from TEA,” he said. Dr. Tang is in the process of designing a prospective study to compare early epidural analgesia in blunt thoracic

injury with opioid analgesia. The surprising results of the initial study have made him rethink the design. “We have to sit down and decide how early is ‘early,’” Dr. Tang said. “Can we do the epidural three days later [after injury] if patients are still complaining about pain? Can we do it at day 1, day 2 or day 3?” —Kate O’Rourke

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OFIRMEV reduces opioid consumption*1 • OFIRMEV 1 g (Q6h) + PCA morphine significantly reduced morphine consumption vs placebo + PCA morphine (–46% over 6 h, P<0.01; –33% over 24 h, P<0.01)1 • The clinical benefit of reduced opioid consumption was not demonstrated

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Discontinue OFIRMEV immediately if symptoms associated with allergy or hypersensitivity occur. Do not use in patients with acetaminophen allergy. The most common adverse reactions in patients treated with OFIRMEV were nausea, vomiting, headache, and insomnia in adult patients and nausea, vomiting, constipation, pruritus, agitation, and atelectasis in pediatric patients. OFIRMEV is approved for use in patients ≥2 years of age. The antipyretic effects of OFIRMEV may mask fever in patients treated for postsurgical pain. To report SUSPECTED ADVERSE REACTIONS, contact Cadence Pharmaceuticals, Inc. at 1-877-647-2239 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.com. Please see Brief Summary of Prescribing Information on adjacent page or full Prescribing Information at OFIRMEV.com.

*Randomized, double-blind, placebo-controlled, single- and repeated-dose 24-h study (n=101). Patients received OFIRMEV 1 g + PCA morphine or placebo + PCA morphine the morning following total hip or knee replacement surgery. Primary endpoint: pain relief measured on a 5-point verbal scale over 6 h. Morphine rescue was administered as needed. †SPID24=sum of pain intensity differences, based on VAS score, from baseline, at 0 to 24 h.

References: 1. Sinatra RS, Jahr JS, Reynolds LW, Viscusi ER, Groudine SB, Payen-Champenois C. Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. Anesthesiology. 2005;102:822-831. 2. Data on file. Cadence Pharmaceuticals, Inc.

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C LIN I C A L A N ES T H ES IO LO G Y

Center Cuts Ventilation Time for CABG Patients Protocol improves outcomes, and likely bottom line

rolonged ventilation is linked to pneumonia and other serious complications, but is early extubation safe in the intensive care setting? One institution’s experience with a fast-tracking protocol for patients on mechanically ventilation after coronary artery bypass graft (CABG) surgery

suggests that departments can significantly reduce ventilation times without sacrificing outcomes. Ravi S. Tripathi, MD, assistant professor of critical care medicine at Ohio State University Medical Center, in Columbus, said he and his colleagues decided to start the protocol when they

noticed the median time on mechanical ventilation for the 68 CABG patients in the first quarter of 2010 was 12.8 hours—far above the national average of 7.9 hours. After initiating the protocol, Ohio State’s figure for the 58 CABGs performed a year later fell to 7.2 hours. The incidence of prolonged

ventilation—the patient’s breathing tube still in place 24 hours after arrival to the intensive care unit (ICU)—also declined, from 27.8% to 8.6%, as did the number of patients ventilated less than six hours: 41% to 19.2%. Roadblocks to Early Extubation “The biggest hurdle was getting everyone on the same page and showing them it was possible to extubate earlier,” Dr. Tripathi said. “They thought we needed to let patients rest. But we presented them data showing it’s better for patients if we keep things moving.” Along with unstandardized extubation practices, the other roadblock to decreasing ventilation time was use of non–goal-directed sedation and analgesia. “Before the study, we provided five different medications postoperatively, and the doctors and nurses could pick and choose which to use,” Dr. Tripathi told Anesthesiology News. “Unfortunately, some were using all of the medications.” Now the medical staff chooses from IV hydromorphone and hydrocodone tablets, while the blood pressure medications available are sodium nitroprusside and hydralazine. Others are looking at what it might take to further decrease ventilation time. “Some centers extubate cardiac surgery patients in the operating room prior to going to the ICU,” said Elizabeth A. Martinez, MD, MHS, associate professor of anesthesia, critical care and pain medicine at Massachusetts General Hospital, in Boston. “However, this practice requires a robust system that is prepared to manage patients both intraoperatively and postoperatively in a manner that makes it safe to extubate them in the OR.” Jeanine Wiener-Kronish, MD, anesthetist-in-chief at Mass General agreed. “Not every patient can be fasttracked,” Dr. Wiener-Kronish added. The elderly, smokers, patients with lung disease or complications from surgery may not be good candidates for early extubation. Less Ventilation Saves Time, Resources in ICU For most cases, early extubation is better for the health of patients, according to the Ohio State study.

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CL IN ICA L A N E ST H E SIOL O G Y Bleeding continued from page 14 Using the mean starting hemoglobin concentration for the study patients, measured hemoglobin loss was converted into volume of whole blood lost from the surgical field, then compared with estimates of whole blood loss as documented by the anesthesia team. “We were surprised to find that the estimated blood loss given by the anesthesiologists was higher than the actual calculated blood loss by 40%,” Mr. Stover said. This difference (860 vs. 611 mL; P<0.0001), he added, likely relates to the inability to visibly determine hemoglobin concentration of sanguineous solutions in suction canisters and surgical sponges. “The ramification of higher estimated blood loss may be that patients receive excessive IV fluid administration, which may worsen the

Re-intubation of patients decreased 11.8% to 3.4%, and the incidence of postoperative pneumonia decreased from 5.9% to 1.7% with the lower ventilation rates. “Early extubation speeds up the recovery process,” Dr. Tripathi explained. “Having a breathing tube in place takes away the patients’ ability to cough and clear throat secretions. That’s why the pneumonia rates decreased with early extubation.” The next step is to conduct a cost analysis, Dr. Tripathi said. “Less ventilation time probably saves money because of the lower pneumonia and re-intubation rates, along with shorter hospital stays,” he said. Dr. Tripathi and his colleagues presented their findings at the 2012 annual meeting of the Society of Critical Care Medicine (abstract 508). John F. Dombrowski, MD, a pain specialist at the Washington Pain Center in Washington, D.C., said, “If you can shorten the average stay in the ICU from 12 to six hours, that translates into a significant savings. That’s the ‘so what’ factor.” Dr. Dombrowski, a member of the American Society of Anesthesiologists board of directors, added that “the fact that anesthesiologists are taking the lead here shows the critical role of anesthesiology not only in keeping patients safely asleep during surgery, but also helping them recover faster during the post-op period.”

hemodilution effect, thereby putting them at higher risk for unnecessary transfusions,” Mr. Stover explained. “We feel that better bedside measurements—which could give a better visual estimation of the hemoglobin loss during the surgery—and possibly continuous hemoglobin monitors, may help to decrease the effect of overestimation of blood loss.” Martin London, MD, professor of clinical anesthesia at the University of California, San Francisco, noted that

the process of estimating blood loss as described by the authors seemed “labor-intensive.” Mr. Stover, who presented the data at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 054), concurred. “It’s not only labor-intensive, but care must also be taken to avoid bone fragments that may be in the sponges,” he said. “I think the problem is that we still use visual estimation of hemoglobin loss, and it’s very difficult to determine the

actual hemoglobin concentration. So at this point there’s not a silver bullet that will give us an exact number.” Richa Dhawan, MD, assistant professor of anesthesiology and critical care medicine at the University of Chicago School of Medicine, said she saw “a role for teaching in terms of looking at the field, sponge counts and the canisters, and estimating blood loss from that, as well as the other parameters.” —Michael Vlessides

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CLI NI CA L A NEST H E SIOL O G Y Stroke continued from page 1 approach in which neuroanesthesiologists are fully integrated into patient care. Staff members say the arrangement is essential to maximizing the potential of the growing armamentarium of clinical tools. This sea change grabbed the attention of Elisabeth Abramowicz, MD, director of neuroanesthesiology at Montefiore. “When I arrived four years ago it became apparent that intra-arterial stroke treatment technology would only grow,” Dr. Abramowicz said. Consequently, she worked with the neuro-interventional radiologists and neurologists to foster collaboration. “This is a completely new area of clinical engagement for neuroanesthesiology. We’ve embraced that here and have become full partners in the organization.” Until recently, options were slim for patients who suffered ischemic stroke (about 87% of strokes). The IV therapy available was limited to smaller clots and had to be administered quickly to be effective. This changed in 2004, when the FDA approved a device that enabled the manual removal of the clot with the aid of a catheter threaded up to the brain from the leg, widening the treatment window from within three hours of symptom onset to eight hours or more. In March, the FDA approved the Solitaire Flow Restoration device (Covidien) for mechanical thrombectomy, bringing to three the number of approved instruments for this type of clot removal. Daniel Labovitz, MD, a vascular neurologist who joined Montefiore as director of Stern Stroke Center shortly after Dr. Abramowicz’s arrival, was impressed by the high level of collaboration. “I’ve never had this situation before, where anesthesiologists are willing to take a specific focus on stroke the way they have here,” he said. “Stroke is a very dynamic and ever-changing set of problems. Having people who know how to talk to each other and understand the goals makes for better outcomes.” Communication became a priority. Now all parties—vascular neurologists, neuro-interventional radiologists, neurosurgeons and neuro-anesthesiologists— meet regularly. “We call it our interdisciplinary stroke task force and we discuss everything that pertains to the management of the patients, including how long it takes to get to the table, and impediments,” Dr. Abramowicz said. The group also realized that the previous practice of having any of the approximately 30 Montefiore campus anesthesiologists who worked on

call involved with stroke patients was unwieldy. From Dr. Abramowicz’s point of view, this meant anesthesia needed to be handled by a small, dedicated team. “As of January of this year, we streamlined this to involve only the five of us on the neuroanesthesiology team, and someone is available 24/7. This way, it’s easy to adhere to protocol and takes no time to disseminate changes as we implement them.” The team uses a stroke page system. When someone identifies a possible candidate for intra-arterial treatment, everyone is notified at once, including the neuroanesthesiologist on call. Allan Brook, MD, director of interventional neuroradiology at Montefiore, said that once the decision is made to use intra-arterial methods (mechanical thrombectomy, thrombolysis, angioplasty or stenting) to remove or break up the clot, “it’s crucial to have the anesthesiologist as we decide how to restore blood flow, so the patient is not moving, and to protect the airway and keep the blood pressure and vital signs optimized. If the patient is moving, we can’t see the intricate small blood vessels. The procedure time is lengthened and is more dangerous for the patient when the stability is not managed.” With the center’s focus on intraarterial treatments, Dr. Labovitz said, “having a neuroanesthesiologist is mission critical. They understand the need to keep blood pressure up, help decide whether to intubate a patient or not, and provide a tremendous amount of direct management of vascular control above and beyond just keeping the patient sedated. In stroke in particular, managing blood pressure is important. You need it high before recanalization and low after successful recanalization. Having a good understanding among the people who work on this together is important and the extra time it takes to invest in this really pays off.” More General, Less Local Citing the new procedures, such as mechanical thrombectomy, being embraced at Montefiore and elsewhere, some experts have argued for wider availability and use of general anesthesia in response to technical advances in endovascular stroke treatment. Caspar Brekenfeld, MD, co-author of a 2010 article in Stroke titled “General Is Better Than Local Anesthesia During Endovascular Procedures” (41:2716-2717), said that the availability and engagement level of anesthesiology varies greatly. “In my opinion, there is no standardized treatment concept for acute

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CL IN ICA L A N E ST H E SIOL O G Y the access sheath as the source of arte- immobilized supine patient who starts minutes—and this is completely changrial tracing fails as more catheters are vomiting,” she said. ing the way we operate as a group.” inserted through its lumen,” she said. Stroke is merely one part of the neuDr. Abramowicz hired two neuroanAnother area of focus for the team roanesthesiologists’ workload, but esthesiologists in 2010 to take her team is the criteria they apply for decid- with the number of patients growing to the current five. She is recruiting ing who is a candidate for sedation. “It and the time involved in their care, for another, but finding well-trained cliniMembers of the Montefiore stroke team (from sounds trivial, but there may be conse- Dr. Abramowicz and her colleagues cians has not been easy. “Young people left): Drs. Angelika Kosse, Elisabeth Abramowquences to converting a sedation to a it is becoming increasingly significant. don’t consider this a career path very icz, Matthew Wecksell and Allison Spinelli. general anesthetic if the patient’s neu- “These procedures are complex and tie often but there’s going to be a growing endovascular interventions at the rological condition deteriorates and us up for hours. We have to show up need for these services,” she said. “I don’t moment,” said Dr. Brekenfeld, a neuro- the patient becomes uncooperative, quickly and the equipment has to be know where we’re going to get these radiologist at the University Hospital or, even more serious, how to be ready ready. This is akin to having a cesar- people from.” Hamburg-Eppendorf, in Hamburg, Ger- to prevent aspiration in an awake but ean section room ready —within 30 —Jennifer Hanawald many. “In some centers you might have well-organized pathways and enough resources to allow for an anesthesiology team from the beginning of diagnostic procedures and interventions. In these situations, time loss due to intubation is minimal. However, there are many other centers where you have to fight to get support from anesthesiology and the whole process of ordering, discussing and finally preparing the patient might waste a lot of time. Consequently, some colleagues prefer to proceed quickly and to perform these interventions in awake patients. The patient gets treatment faster, but due to movement the intervention becomes more dangerous and might be prolonged or even impossible to perform. But does the more efficient approach translate into saved lives? The Montefiore group would not share its results, but Dr. Abramowicz said the answer is yes. “We treated nine strokes with intraarterial therapy in January and everyPreferred Physicians Medical (PPM) formed in 1987 to exclusively insure anesthesiologists and their practices. From day one, each new policyholder one’s perception is that we’ve done a also became an owner of PPM, so it’s no surprise that protecting our terrific job—variability is no longer physicians’ professional reputation is at the core of everything we do. there,” she said. “We know exactly what needs to be done. We as a group have Our substantial database of more than 11,000 adverse anesthesia events developed an expertise that would have collected over the last quarter of a century arms our physician owners with practical, anesthesia-speciﬁc strategies to effectively identify and manage taken much longer if we had 20 people.” risk, including: The team tracks its performance on stroke therapy with several meaOn-site, anesthesia-speciﬁc risk management seminars sures, including time from arrival in Exclusive online access to timely and useful risk management resources the angiography suite to when the procedure starts, vital signs during treatA subscription to Anesthesia & the Law, our industry-respected risk management newsletter ment, whether a patient is intubated and patient outcomes. “Our practice is In-house Claims Attorneys and Claims Specialists skilled in using this data to effectively develop defense strategies and resolve constantly evolving and we are improvclaims without indemnity payment ing, but I prefer not to publish the data,” Don’t wait another year. Take ownership of your own reputation by Dr. Labovitz said. calling PPM today. Dr. Abramowicz said that internal evaluations of stroke procedures have led to important changes in care, as have monthly roundtables to review cases and the latest studies. “We are reviewing the newest published data in an attempt to narrow down the anesthetic protocols: For example, does every patient need a pre-procedure arterial line? Does that delay the intervention or can it be inserted simultaneAdd your good name to our growing list of ASA “standard of care” clinicians. Call us toll free today at 800.562.5589 and join other select anesthesiologists who have already secured ownership in their professional reputations. ously with the start of the procedure? We have already decided that using

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Current Concepts In the Management Of the Difficult Airway

Carin A. Hagberg, MD Joseph C. Gabel Professor and Chair, Department of Anesthesiology The University of Texas Medical School at Houston Director of Advanced Airway Management Memorial Hermann Hospital–Texas Medical Center Houston, Texas Executive Director 2009-present, Society for Airway Management

Dr. Hagberg is a member of the speakers’ bureaus for Ambu A/S, Cook Medical, Covidien, and LMA North America; and has received equipment support from Aircraft Medical, Ambu A/S, Cook Medical, Karl Storz Endoscopy, King Systems, LMA North America, Mercury Medical, and Verathon Medical.

anagement of the difficult airway remains one of the most relevant and challenging tasks for anesthesia care providers. This review focuses on several of the alternative airway management

devices/techniques and their clinical applications, with particular emphasis on the difficult or failed airway. It includes descriptions of many new airway devices, several of which have been included in the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm (Figure).

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also may become the standard for routine intubations as the equipment and users’ skills improve and the cost of the devices decreases, with the potential for important savings in time and decreased morbidity in patients. It is beyond the scope of this review to discuss all of the laryngoscopes that have been manufactured; thus, only some of the most recently developed blades will be described (Table 3).

Indirect Rigid Fiber-Optic Laryngoscopes

Figure. The ASA Difficult Airway Algorithm. (Anesthesiology 2003;98:1269-1277) The algorithm can be viewed at: www.asahq.org/ publicationsAndServices/practiceparam.htm.

Alternative Airway Devices A common factor preventing successful tracheal intubation is the inability to visualize the vocal cords during the performance of direct laryngoscopy. Many devices and techniques are now available to circumvent the problems typically encountered with a difficult airway using conventional direct laryngoscopy.

Endotracheal Tube Guides Several endotracheal tube (ET) guides have been used to aid in intubation or extubation, including both reusable/disposable and solid/hollow introducers, stylets, and tube exchangers (Table 1).

Lighted Stylets In the past decade, many lighted stylets have been developed, including light wands, which rely on transillumination of the tissues of the anterior neck to demonstrate the location of the tip of the ET—a blind technique, unless combined with direct laryngoscopy, and visual scopes, which use fiber-optic imagery and allow indirect visualization of the airway. They also can be used alone or in conjunction with direct laryngoscopy (Table 2).

Rigid/Video Laryngoscopes Video-assisted techniques have become pervasive in various surgical disciplines, as well as in anesthesiology. As more video laryngoscopes are introduced into clinical practice, and as airway managers become more skillful with the technique of video-assisted laryngoscopy, it could well become standard procedure for patients with known or suspected difficult airways. It

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These laryngoscopes were designed to facilitate tracheal intubation in the same population that would be considered for flexible fiber-optic bronchoscopy, such as patients with limited mouth opening or neck movement. Relative to the flexible fiber-optic bronchoscopes (FOBs), they are more rugged in design, control soft tissue better, allow for better management of se-cretions, are more portable (with the exception of the new portable FOBs), and are not as costly. Intubation can be performed via the nasal or oral route and can be accomplished in awake or anesthetized patients (Tables 4 and 5).

Supraglottic Ventilatory Devices The Laryngeal Mask Airway (LMA, LMA North America, Inc.) is the single most important development in airway devices in the past 25 years. Since its introduction into clinical practice, it has been used in more than 200 million patients worldwide with no reported deaths. Other supraglottic ventilatory devices are available for routine or rescue situations. The most recently developed supraglottic ventilatory devices have a gastric channel or are intended to be used as a conduit for fiberoptic guided intubation (Table 6).

Special Airway Techniques Awake Intubation For managing patients in whom a difficult airway is suspected or anticipated, securing the airway before induction of general anesthesia adds to the safety of anesthesia and helps minimize the possibility of major complications, including hypoxic brain damage and death. To perform awake intubation, the patient must be adequately prepared for the procedure. Good topical anesthesia is essential to obtund airway reflexes and can be provided by various topical agents and administrative devices (Table 7). Other relatively new devices can be used to best position patients and maintain an open airway during awake intubation (Table 8). Atomizing devices currently available for delivering topical anesthesia to nasal, oral, pharyngeal, laryngeal, and tracheal tissues include the DeVilbiss Model 15 Medical Atomizer (DeVilbiss Healthcare), the Enk Fiberoptic Atomizer Set (Cook Medical), and the LMA MADgic Laryngo-Tracheal Atomizer (LMA North America, Inc.). Although any technique of tracheal intubation can be performed under topical anesthesia, flexible fiber-optic intubation is most commonly used.

Flexible Fiber-Optic Intubation Flexible fiber-optic intubation is a very reliable approach to difficult airway management and assessment. It has a more universal application than any other technique. It can be used orally or nasally for both upper and lower airway problems and when access to the airway is limited, as well as in patients of any age and in any position. Technological advances—including improved optics, battery-powered light sources, better aspiration capabilities, increased angulation capabilities, and improved reprocessing procedures have been developed. Additionally, a completely disposable system, the aScope (Ambu) has recently been developed. Rescue techniques, such as direct laryngoscopy and placing a retrograde guidewire through the suction channel, may be used if the glottic opening cannot be located with the scope, or if blood or secretions are present.17 Insufflation of oxygen or jet ventilation through the suction channel may provide oxygen throughout the procedure, and allow additional time when difficulty arises in passing the ET into the trachea.

length. A 6 Fr reinforced fluorinated ethylene propylene Emergency Transtracheal Airway Catheter (Cook Medical) has been designed as a kink-resistant catheter for this purpose. Percutaneous cricothyrotomy involves using the Seldinger technique to gain access to the cricothyroid membrane. Subsequent dilation of the tract permits passage of the emergency airway catheter. Surgical cricothyrotomy is performed by making incisions through the cricothyroid membrane using a scalpel, followed by the insertion of an ET. This is the most rapid technique and should be used when equipment for the less invasive techniques is unavailable and speed is particularly important.

Tracheostomy

Retrograde intubation (Table 7) is an excellent technique for securing a difficult airway either alone or in conjunction with other airway techniques. Every anesthesia care provider should be skilled in employing this simple, straightforward technique. It is especially useful in patients with limited neck mobility (that is associated with cervical spine pathology, or in those who have suffered airway trauma). Cook Medical has 2 retrograde intubation sets: a 6.0 Fr for placing tubes of 2.5 mm or greater ID, and a 14.0 Fr for placing tubes of 5.0 mm or greater ID.

Tracheostomy (Table 10) establishes transcutaneous access to the trachea below the level of the cricoid cartilage. Emergency tracheostomy may be necessary when acute airway loss occurs in children under 10 years of age or children whose cricothyroid space is considered too small for cannulation, as well as in individuals whose laryngeal anatomy has been distorted by the presence of pathologic lesions or infection. Percutaneous dilatational tracheostomy is the most commonly performed tracheostomy technique, yet it is still considered invasive and can cause trauma to the tracheal wall. Translaryngeal tracheostomy, a newer tracheostomy technique, is considered to be safe and cost-effective, and it can be performed at the bedside. It may be beneficial in patients who are coagulopathic. Surgical tracheostomy is more invasive, and should be performed on an elective basis and in a sterile environment.

Transtracheal Jet Ventilation

Conclusion

Transtracheal jet ventilation (TTJV) is a well-accepted method for securing ventilation in rigid and interventional bronchoscopy, and there are several commercial manual jet ventilation devices available (Table 7). The Enk Oxygen Flow Modulator (Cook Medical) is a device recommended for use when jet ventilation is appropriate but a jet ventilator is not available. The Wadhwa Emergency Airway Device (Cook Medical), which also can be used for TTJV, is several devices in one (Table 7). It has an emergency nasopharyngeal airway catheter; a large-diameter transtracheal needle for a cricothyrotomy procedure with the option for TTJV; and the main body of the device acts as a blow tube or 15-mm adapter.

Most airway problems can be solved with relatively simple devices and techniques, but clinical judgment born of experience is crucial to their application. As with any intubation technique, practice and routine use will improve performance and may reduce the likelihood of complications. Each airway device has unique properties that may be advantageous in certain situations, yet limiting in others. Specific airway management techniques are greatly influenced by individual disease and anatomy, and successful management may require combinations of devices and techniques.

Retrograde Intubation

Cricothyrotomy Cricothyrotomy (Table 9), a lifesaving procedure, is the final option for “cannot-intubate, cannot-ventilate” patients according to all airway algorithms, whether they concern prehospital, emergency department, intensive care unit, or operating room patients. In adults, needle cricothyrotomy should be performed with catheters at least 4 cm and up to 14 cm in

Recommended Reading 1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98(5):1269-1277. 2. Miller CG. Management of the difficult intubation in closed malpractice claims. ASA Newsletter. 2000;64(6):13-19. 3. Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: a review. Anesth Analg. 2000;90(3):745-756. text continues on page 28

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Table 1. Endotracheal Tube Guides Name (Manufacturer)

Description

Length, cm

Aintree Intubation Catheter (Cook Medical)

Polyethylene 19 Fr AEC allows passage of an FOB through its lumen. Has 2 distal side holes and is packaged with Rapi-Fit adapters. Color: light blue.

Arndt Airway Exchange Catheter Set (Cook Medical)

Polyethylene 8 and 14 Fr AEC with a tapered end, multiple side ports, packaged with a stiff wire guide, bronchoscope port, and Rapi-Fit adapters. Color: yellow.

50, 65, 78

Cook Airway Exchange Catheter EF (Cook Medical)

Polyethylene 11 and 14 Fr EF AEC that facilitates exchange of DLT of 4.0 mm or larger ID. Also comes in a soft-tip version. Colors: EF, green; soft-tip version, green with purple tip.

100

Frova Intubating Introducer (Cook Medical)

Polyethylene 8 and 14 Fr AEC with angled distal tip with 2 side ports. Has hollow lumen and is packaged with a stiffening cannula and removable Rapi-Fit adapters. 14 Fr also packaged in box of 10. Colors: 8 Fr, yellow; 14 Fr, blue.

35, 65

GlideRite Auto Stylet (Verathon Medical)

Reusable, sterilizable, semirigid stylet that conforms to GlideScope blade angulation; adjustable for ETs of various lengths.

Accommodates ETs ≥6.0 mm ID.

GlideRite DLT Stylet (Verathon Medical)

Reusable, sterilizable, semirigid stylet designed to enable placement of a double-lumen ET.

Designed for use in double-lumen ETs ≥6.0 mm ID.

GlideRite Rigid Stylet (Verathon Medical)

Reusable, sterilizable, semirigid stylet that conforms to GlideScope unique blade angulation; provides improved maneuverability in ET placement.

Accommodates ETs 6.0-10.0 mm ID. Overall length is 32.34 cm (12.73 in).

VBM Introducer Single-use 15 Fr introducer with coudé tip and (VBM Medizintechnik GmbH) hollow for oxygenation. Color: orange.

Muallem ET Tube Stylet Single-use 8, 12, 14 Fr stylet; malleable, but with (VBM Medizintechnik GmbH) soft and atraumatic coudé tip. Color: green.

40, 65

OptiShape Stylet (Truphatek International Ltd.)

Reusable, sterilizable, semirigid stylet with optimal shape memory for indirect intubation procedures.

4 sizes; accommodates ETs 2.5-3.5, 4.0-5.5, 5.0-6.5, and 7.0-9.0 mm ID.

Portex Venn Tracheal Tube Introducer (Smiths Medical)

15 Fr ET introducer made from a woven p olyester base, with a coudé tip (angled 35 degrees at its distal end). Also known as the gum elastic bougie. Color: golden brown.

RadLyn Stylet R-100 (RadLyn LLC)

Single-use, semirigid dilating stylet employing malleable guide tip and soft, dilating balloon.

Single size only. Accommodates ETs 7.0-10.0 mm ID.

Single-Use Bougie (Smiths Medical)

15 Fr, PVC ET introducer with coudé tip. Has a hollow lumen that discourages reuse and is provided sterile. Color: ivory.

VBM Tube Exchanger Single-use 11, 14, and 19 Fr tube exchanger that is (VBM Medizintechnik GmbH) hollow to allow oxygenation. Color: blue. Abbreviation key for all tables is on page 13.

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Clinical Applications

Special Features

Exchange of SGAs for ETs ≥7.0 mm using an FOB. Its hollow Large lumen (4.7 mm) allows passage of FOB. Rapi-Fit lumen allows insertion of an FOB directly through the cath- adapters allow both jet ventilation and ventilation with 15-mm adapter (anesthesia circuit or Ambu bag). Single use. eter so that the airway can be indirectly visualized. Exchange of LMAs and ETs using an FOB.

Tapered end and multiple side ports. Rapi-Fit a dapters allow both jet ventilation and ventilation with 15-mm adapter (anesthesia circuit or Ambu bag). Single use.

Exchange of DLTs.

EF with 2 distal side holes. The soft-tip version offers a more flexible tip to help minimize tracheal trauma. Rapi-Fit adapters as above, but should be used primarily for jet ventilation because of length. Single use.

Facilitates endotracheal intubation and allows simple ET exchange. Can also be used by placing it first in the ET, with its tip protruding, or placing it directly into the glottis and then placing the ET over it.

Can be used in pediatric population for ETs as small as 3.0 mm. Hollow lumen allows oxygenation/ventilation in all sizes. Single use.

Designed to work with GlideScope AVL, CVL, Cobalt, and Ranger video laryngoscopes to facilitate intubations in OR, ED, and emergency settings.

Reusable, durable stainless steel; easy to clean; adjustable for ETs of various lengths (including cut tubes).

Designed to work with GlideScope video laryngoscopes to facilitate intubation by helping overcome obstructions such as vocal cords, arytenoids, and the cricothyroid membrane depression.

Reusable, durable stainless steel; easy to clean and sterilize in an autoclave.

Designed to work with GlideScope AVL, GVL, Cobalt, and Ranger video laryngoscopes to facilitate intubations in OR, ED, and emergency settings.

Reusable, durable stainless steel; easy to clean and sterilize in an autoclave.

Difficult intubation with oxygenation possibility.

Supplied with unique removable connector to allow oxygenation with 15-mm connector or jet. Graduation marks for insertion depth.

Difficult intubation.

Malleable stylet with soft coudé tip and graduation marks for insertion depth.

Facilitates smooth passage of ET in both routine and difficult intubations. Especially useful in combination with the variety of video laryngoscopes that employ >42-degree angles. Designed with the ideal curve to closely follow the blade shape and ensure successful passage of ET through vocal cords.

Easily adjustable to a variety of ET sizes. Suitable for use in combination with a variety of video laryngoscopes that employ >42-degree angle of vision.

Proven useful in patients with an anterior larynx (grades 2b, 3, and 4) and those with limited mouth opening. Can be used by slightly protruding through the ET, or placing it directly into the glottis and then placing an ET over it.

Nondisposable and reusable. Size 5 Fr is single use. Has memory properties. Coudé tip effectively detects “tracheal clicks” to confirm correct placement. Part of a range of introducers, stylets, and guides for adults and pediatrics. Can be reused after cold-water disinfection.

Tapered, dilating balloon facilitates mechanical dilation Combines the functionality of a coudé tip bougie with a of the laryngeal anatomy for less traumatic passage of traditional wire stylet into a single, easy-to-use device. the ET. Facilitates smooth passage of ET in routine intubations; when the laryngeal inlet is distorted, edematous, or narrowed; when vocal cords are reactive (ie, nonparalyzed); or when Cormack-Lehane grade III/IV view is encountered. Single-use product reduces the risk for cross-contamination. Otherwise, same as Portex Venn Tracheal Tube Introducer.

Similar to Portex Venn Tracheal Tube Introducer, but hollow lumen allows oxygenation/ventilation. Single use.

Exchange of tracheal tubes.

Similar to Muallem ET Tube Introducer.

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Table 2. Lighted Stylets Name (Manufacturer)

Description

Size

Aaron Surch-Lite (Bovie Medical Industries, Inc.)

10” sterile, single-use, flexible stylet.

Adult

AincA Lighted Stylet (Anesthesia Associates, Inc.)

Easily malleable, lighted stylet with adjustable ET holder. Shapes and guides ET while forwardly illuminating the passage. Completely reusable device consisting of removable handle with xenon bulb.

Adult and children (ETs ≥5 mm). Infant (ETs ≥3 mm).

air-Vu Plus Fiber-optic Stylet (distributed by Mercury Medical)

High-resolution, stainless steel, rigid stylet. Incorporates an adjustable tube stop and optional oxygen port for oxygen insufflation.

Adult (ETs ≥5.5 mm).

Bonfils Retromolar Intubation Endoscope (Karl Storz Endoscopy)

3.5- and 5.0-mm OD. ET must be High-resolution rigid fiber-optic stylet with a fixed ≥0.5 mm larger to fit. 40-degree curved shape at the distal end. Available with a standard eyepiece or with a direct coupling interface to endoscopic camera system. Can be used within the C-MAC system while using the portable monitor of the C-MAC video laryngoscope.

Brambrink Intubation Endoscope (Karl Storz Endoscopy)

High-resolution semiflexible fiber-optic stylet with a 40-degree curved shape at the distal end, 40× magnification, a fixed eyepiece, a movable ET holder, and an insufflation port.

2.0-mm OD. ET must be ≥0.5 mm larger to fit.

Clarus Video System 30000-V (Clarus Medical)

Malleable (shapeable) stylet with a digital camera; USB for recharging lithium ion battery and connecting to wireless notebook or monitor; red LED for transillumination. Optional detachable flexible scope and laryngoscope blades available.

5-mm OD. ETs ≥5.5 mm.

Levitan GLS (Clarus Medical)

High-resolution optics, malleable (shapeable) stainless steel stylet that protects the illumination optic fibers. Comes in a preformed hockey-stick shape that can be changed, if necessary. Built-in tube stop to hold ET in place with integral oxygen port for oxygen insufflation during intubation.

Adult (ETs ≥5.5 mm ID).

PocketScope (Clarus Medical)

Conveniently sized, easy to clean, and cost-effective (reusable) flexible stylet that has a patented, deflected, nondirectable tip.

Adult (ETs ≥4.0 mm ID).

Rüsch Trachlight Stylet & Tracheal Light Wand (Teleflex Medical)

Consists of 3 parts: a reusable handle, a flexible wand, and a stiff, retractable stylet.

Available in 3 sizes: adult, child, and infant. Accommodates ETs from 3.0- to 10.0-mm ID.

SensaScope (Acutronic Medical Systems AG)

Hybrid S-shaped, semirigid fiber-optic intubation video stylet. Has a 3-cm steerable tip that can Similar to AincA lighted stylet be flexed in sagittal plane for 75 degrees in both directions with lever at proximal end of device. Quality of optics is similar to flexible fiber-optic and rigid endoscopes, but has no working channel.

6.0-mm OD. ET must be >0.5 mm larger to fit.

Shikani Optical Stylet (SOS; Clarus Medical)

High-resolution, stainless steel, malleable (shapeable) fiber-optic stylet that comes in a preformed hockey-stick shape. Has an adjustable tube stop and integral oxygen port for oxygen insufflation.

Adult (ETs ≥5.5 mm ID). Pediatric (ETs 2.5- to 5.0-mm ID).

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Clinical Applications

Special Features

Although usable for routine blind intubations or additional illumination during laryngoscopy, it is especially useful when the FOB is unavailable (eg, outside locations or ambulances), or when bronchoscopy is difficult to perform (eg, obscured airway or limited head motion allowed).

Can be used alone or in conjunction with other techniques. System is completely disposable. Intended for single-use. Individually packaged in boxes of 3.

Same as Aaron Surch-Lite.

Can be used alone or in conjunction with other techniques. Handle-mounted xenon light source is always on and keeps stylet tip cold. Uses 2 AA batteries. System is completely reusable and sterilizable.

Allows for visualization during intubation through an air-Q laryngeal mask.

A portable, durable rigid stylet that allows for a fiber-optic view during intubation through the air‑Q. Light source options include GreenLine laryngoscope handle or fiberoptic light source (4 AA batteries).

Able to elevate a large, floppy epiglottis and navigate through the oropharynx of patients with excessive pharyngeal soft tissue, midline obstruction, limited mouth opening, or fragile veneers on incisors.

Fixed-shape shaft with an adjustable eyepiece that allows ergonomic movement during intubation, in addition to an adapter for fixation of ETs and oxygen insufflation. Portable, rugged, and better maneuverability than the flexible FOB. Used with a battery-powered or fiber-optic light source.

Similar to Bonfils Retromolar Intubation Fiberscope.

Available with a standard eyepiece or a DCI for video cameras.

ET intubation, confirmation, extubation (with video); LMA placement, positioning, and intubation with certain LMAs. Provides access with limited mouth opening; malleable stylet provides shaping to reduce cervical movement.

Red LED provides better illumination than the white LED, and better transillumination when used like a light wand in cases when use of the scope is contraindicated because of blood or vomit.

Originally designed as an adjunct to direct laryngoscopy. Many use it as a stand-alone device similar to the Shikani for intubation, cric/trach tubes, LMAs, and intubation through LMAs or just positioning or checking placement of the same.

GreenLine laryngoscope handle or a Turbo LED can be used for light sources. Very similar to the SOS, but requires the user to cut the ET because it does not have a movable tube stop.

Allows for visualization during intubation through ILMA or quick confirmation of SGA, DLTs, or ET placement/ positioning patency. May also be used for extubation.

This device has been modified with a patented deflected tip that allows it to be used for viewing while performing nasal intubation.

Although it can be used for routine intubations, it is especially useful in situations in which the FOB is unavailable (eg, in ambulances or outside locations), or in which bronchoscopy is difficult to perform (eg, when an airway is obscured by blood or secretions or when a patient’s head cannot be flexed or extended).

Blind technique that can be used alone or in conjunction with other techniques.

Similar to Brambrink Intubation Endoscope.

Offers an improved view of glottis, simultaneous direct and endoscopic views, full visual control over passage of ET, and confirmation of final position. No need for extreme head extension or forced traction of laryngoscope. Can be rapidly assembled to use immediately.

Similar to flexible FOB. Can be used alone or as an adjunct to laryngoscopy and is especially useful for those unable to maintain skills with a bronchoscope.4

Has the simple form of a standard stylet, plus the advantage of a fiber-optic view and maneuverability of its tip. Portable, rugged, and able to lift tissue. Light source options are light cable, Turbo LED or GreenLine laryngoscope handle with adapter. table continues on next page

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Table 2. Lighted Stylets Name (Manufacturer)

(continued)

Description

Tube-Stat Lighted Intubation Similar to AincA lighted stylet Stylet (Medtronic) Vital Signs Light Wand Illuminating Stylet (GE Healthcare)

Similar to AincA lighted stylet

Size Nasotracheal: 33 cm shaft Orotracheal: 25 cm shaft Adult

Table 3. Video Laryngoscopes Name (Manufacturer)

Description

Size

Berci-Kaplan DCI Video Laryngoscope System (Karl Storz Endoscopy)

Video laryngoscope system with interchangeable laryngoscope blades. Handles allow a DCI camera head to snap onto any standard eyepiece fiberscopes (flexible or semirigid). Required components include a camera control unit, xenon light source, and monitor. Telepack portable combination video/light source/monitor unit is also available for use with this system.

MAC 2 – 4, Miller 0, 1, 4, Doerges universal blade and D-Blade for difficult anterior airways.

C-MAC Video Laryngoscope (Karl Storz Endoscopy)

Instant on, battery-powered video laryngoscpe with standard shaped interchangeable Macintosh and Miller blades for obese adults through neonates as well as a difficult airway blade (D-Blade) for anterior airways. Blades house high-resolution CMOS distal chip and LED technology. Real-time viewing on 7-inch LCD monitor.

MAC 2–4, Miller 0 and 1, MAC 3 and 4 with channel for suction, D-Blade.

C-MAC PM (Pocket Monitor) fits directly on all blades; 2.4 inches LCD high resolution screen works in direct sunlights; rechargeable battery lasts one hour; screen can be moved in serveral directions, folded away for transportations; fully immersible. Dörges D-Blade (Difficult Airway Blade, Karl Storz Endoscopy), has angle of view that is approximately 80 degrees; acute curvature design.

1 adult size only.

CoPilot VL (Magaw Medical)

Next-generation video laryngoscope with an acutely Adult sizes 3 and 4. Pediatric sizes available in late angled blade and C-shaped channel for a bougie; a 2011. 14-Fr suction catheter, LTA kit, or FOB also fit. The lithium polymer internal battery provides over 2 hours of continuous use. No buttons or settings.

GlideScope AVL (Advanced Video Laryngoscope; Verathon Medical)

Portable advanced video laryngoscope features a digital color monitor and digital camera for DVD clarity. Also includes integrated real-time recording, onboard video tutorial, and anti-fogging mechanism to resist lens clouding and secretions. Reusable and single-use options available.

6 disposable blades ranging in size from 0 through 4. Reusable blades in four sizes: GVL 2-5.

Direct Intubation Trainer combines the characteristics of a standard Macintosh blade with AVL video technology. Digital video camera near end of blade and digital AVL color monitor. Embedded antifogging mechanism.

Comparable to a 3.5 Macintosh blade.

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Clinical Applications

Special Features

Ideal for difficult intubations, teaching.

Minimizes neck flexion and head hyperextension in trauma cases.

Clinical Applications

Special Features

Useful for anterior airways, obese patients, and patients with limited mouth opening or neck extension. Additionally useful for teaching purposes, verification of ET position, aiding application of external laryngeal manipulation, or passage of an intubating introducer. Recommend styletted or special ET. May also be used for nasal intubation and ET exchange.

The wide-angle camera allows improved visualization and video documentation of laryngoscopy and intubation. Extreme positioning of the head is unnecessary. MACÂ 3 and 4 blades provide 45- and 60-degree angles of view, respectively.

Same as DCI.

Built-in still and video image capture on memory card. Angled distal lens provides 45- to 60-degree angle of view. Inherent anti-fog design. Unit can be pole-mounted, inserted into waterproof field bag, or freestanding on easelback clamp. No special ETs or stylets needed. Can be used concurrently with battery charging. On-screen toggle brightness control facilitates use in low and bright ambient light conditions.

Designed for intubation of anterior airways that cannot be intubated with a standard or video Macintosh blade.

Has a familiar blade design and 80-degree field of view.

Same as DCI.

Patent-pending Bougie Port was designed to enhance glottic entry. A 14 Fr suction catheter, FOB, reusable rigid stylets, or regular malleable stylets may also be used via this port. A built-in heating mechanism helps prevent fogging.

DVD-quality airway view enables swift intubation in a wide range of adult and pediatric patients, including preterm/small child and morbidly obese, bloody or anterior airways, and patients with limited neck mobility. Optimized for demanded applications in the OR, ED, ICU, and NICU. Can be used for teaching purposes.

Real-time recording, onboard video tutorial, antifog mechanism to resist lens contamination, advanced resolution output to an external monitor, intuitive user controls and status icons, lightweight and easily transportable, impactresistant, durable polycarbonate-coated video screen. Disposable blades allow quick turnaround and help limit the possibility of cross-contamination.

Designed to facilitate instruction of classic DL. Digital video camera near the end of the blade and digital AVL monitor allow instructors to watch and guide a DL intubation. Ideal for performing video-guided DL in a clinical setting.

Compatible with AVL and GVL video laryngoscopes. Available in reusable and single-use configurations.

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Table 3. Video Laryngoscopes

(continued)

Name (Manufacturer)

Description

Size

GlideScope Ranger and Ranger Single Use Video Laryngoscopes (Verathon Medical)

Portable video laryngoscope designed for EMS and Reusable Ranger offers 2 blade military paramedics. Compact and rugged. Opera- sizes, 3 and 4 (patient sizes, 22 lb to morbidly obese). Ranger Sintional in seconds. gle Use is offered with 6 disposable Stats ranging in size from 0 through 4.

GlideScope Video Laryngoscope (GVL) (Verathon Medical)

Video laryngoscope that includes high-resolution camera, antifogging mechanism to resist lens contamination, nonglare color monitor, and unique blade angulation.

6 disposable blades, sizes 0 through 4. Reusable blades: GVL 2-5.

King Vision Video Laryngoscope (King Systems)

Durable, fully portable digital video laryngoscope with a high-quality reusable display and disposable blades. Display is in-line with blade, ergonomic handle is integrated into blade, the disposable blades incorporate the camera and light source, antifog coating on distal lens. Channel is soft, allowing for easy ET detachment.

One size, 2 versions, correlating to size 3 laryngoscope. Channeled blade allows use of 6.0 to 8.0 mm ET and min mouth opening of 18 mm. Standard blade requires min mouth opening of 13 mm.

McGrath MAC (Aircraft Medical Ltd; distributed by Covidien)

Portable video laryngoscope designed for everyday use in the OR, ICU, and ED. Uses disposable MacIntosh shaped blades. Durable (drop tested up to 2 m).

Blade sizes 3 and 4.

McGrath Series 5 Video Laryngoscope (Aircraft Medical Ltd; distributed by LMA North America, Inc.)

Portable video laryngoscope with adjustablelength single-use disposable blade that can be disarticulated from the handle to further assist with difficult airways. The flatscreen monitor is located on the handle to remain in a more natural line of sight with the patient.

Adjusts to fit many adult and pediatric sizes.

The McGrath Series 5 HLDi is the new “High Level Disinfection Immersible” system that is entirely waterproof. Pentax Airway Scope (Pentax Medical; distributed by Ambu Inc.)

Wireless video laryngoscope with disposable transparent blade (Pblade) that has a suction port. Has a 12-cm cable with CCD camera and 2.4-in LCD color monitor.

One size only.

Truview PCD Video and Optical Laryngoscope (Truphatek International Ltd.)

Fully portable, lightweight and compact system with interchangeable laryngoscope blades. New 5-in LCD color monitor with picture capture device. Video output for remote display and recording. Rechargeable battery pack.

5 blade sizes: pediatric 0, 1, and 2; regular adult 3; large adult 4.

Venner AP Advance Video Laryngoscope (Venner Capital S.A.)

Fully portable video laryngoscope with 3 .5-in monitor that attaches to a reusable handle. Self-containing LED light source. Built-in antifogging mechanism.

Mac 3 and 4, and Difficult Airway Blade.

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Clinical Applications

Special Features

Ideal for EMS (ground and air), military, ED, ICU, and crash cart settings. Offers same benefits as the GVL and Cobalt systems.

Ranger models are compact, rugged, portable, and built to military and EMS specifications. Powered by rechargeable lithium polymer battery; 1.5 lb. Awarded US Army Airworthiness and US Air Force Safe-to-Fly certifications. Reusable and disposable.

Useful for a wide range of adult and pediatric patients, including preterm/neonatal and morbidly obese, bloody or anterior airways, and patients with limited neck mobility. Optimized for applications in the OR, ED, ICU, and NICU. Also can be used for instruction.

Offers improved visualization and allows video documentation of laryngoscopy and intubation.

Facilitates both routine and difficult intubations.

Can be used alone or in conjunction with other techniques. Powered by 3 AAA batteries. OLED screen allows wideangle viewing in various lighting conditions. Video out availabe for connection to external display or video capture device.

Its dual capability combines the benefits of a video-supported anterior view as well as a direct visualization to support a wide range of airways from routine to more difficult cases.

Does not require additional training. Supports direct and indirect visualization due to video support. Blade is very slimline for improved agility. Blade shape requires less tube curvature than other video laryngoscopes for easier insertion and a stylet is not always required. Highly portable and lightweight. Does not require an electrical outlet and thus is ideal for settings outside the OR. Uses disposable blades for quick turnaround between uses and for limiting crosscontamination. The monitor is located on the handle to remain in a more natural line. Entirely waterproof.

Useful in patients with limited mouth opening or head and neck movement, anterior airways; obese patients; in patients in whom an increased hemodynamic response is a concern; and for teaching purposes.

Highly portable and lightweight. Uses disposable blades for quick turnaround between uses and for limiting crosscontamination. An adjustable blade allows use of different blade lengths on the spot. Low-profile blade and disarticulating handle can accommodate patients with very limited mouth opening and severely limited movement of the head and neck. The monitor is located on the handle to remain in a more natural line of sight with the patient.

Similar to McGrath Video Laryngoscope. Useful for patients with limited neck mobility. Does not require alignment of the oral, pharyngeal, and laryngeal axis. Ideal for prehospital use. Monitor permits viewing from various positions to facilitate all methods of intubation. Additionally useful for teaching purposes.

Green target symbol on monitor display indicates direction of the tracheal tube tip. The Pblade comes with 2 channels: one allows safe placement and insertion of ET, and the other has a suction port through which a suction catheter can be passed. ET is attached to right side of the blade. The device, powered by 2 AA alkaline batteries, is portable with a 1-hour run time and 5-minute low-battery warning.

With a 42- to 47-degree blade angle, used in difficult pediatric and adult intubations of all grades, including patients with limited neck extension or mouth opening. Provides improved visualization of airway and tube placement. Delivers oxygen to prevent fogging and manages secretions. The image can be exported via USB or RCA output as a teaching tool.

Preformed memory stylets with ideal shape for indirect intubation technique provided in each set. Reusable. Versatile and rugged system can be used with unaided vision through eyepiece, or with customized camera attachment and monitor.

Similar to CMAC video laryngoscope.

Can be used as traditional laryngoscope and converted to video laryngoscope by attachment of monitor.

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Table 4. Alternative Rigid Laryngoscope Blades Clinical Applications

Name (Manufacturer)

Description

Size

Special Features

Dörges Emergency Laryngoscope Blade (Karl Storz Endoscopy)

Developed in Europe as a universal blade that combines features of both the MAC and Miller laryngoscope blades.

One size only for patients >10 kg.

Blade is inserted into the oropharynx to the appropriate depth, which correlates with the patient’s size.

Has 10-kg and 20-kg markings on the blade.

Flexible tip or levering fiber-optic MAC laryngoscope blades are designed with a hinged tip controlled by a lever at the proximal end. Designed to fit standard handles.

Adult sizes 3 and 4. Pediatric size 2.

Controlled manipulation of large or floppy epiglottis. Also useful in patients with a recessed mandible and decreased mouth opening.

A lever controls the tip angle through 70 degrees during intubation to lift the epiglottis, if necessary, to improve laryngeal visualization.5

Adult sizes only.

Useful in patients with a recessed mandible and decreased mouth opening.

Modified MAC Blades AincA Flex-Tip FiberOptic Laryngoscope Blade (Anesthesia Associates, Inc.)

Flipper (Teleflex Medical) Heine Flex Tip Fiber‑Optic Laryngoscope Blade (Heine USA, Ltd.) AincA Macintosh Viewing Prisms (Anesthesia Associates, Inc.)

An optically polished viewing prism for attachment to most M acintosh laryngoscope blades (conventional OR fiberoptic). Effectively repositions the practitioner’s viewpoint to the forward portion of the Mac curve via a 30-degree refraction without inverting the image. Clips to the vertical flange of the Mac to “look around the curve of the blade.”

Sizes 2, 3, and 4 for use on Macintosh laryngoscope blades of sizes 2, 3, and 4.

Allows viewing of the vocal cords even in a patient with an anterior airway position. Also useful during nasal intubation (with impaired view) and for postoperative examination of the larynx.

A built-in clip on each prism allows attachment to any Macintosh-type laryngoscope blade that has a standard thickness vertical flange. Usable on both conventional and fiberoptic type Mac blades. Reusable and sterilizable.

Rüsch Truview EVO (Truphatek International Ltd.; distributed by Teleflex Medical)

Indirect rigid laryngoscope with specially designed 42-degree blade curvature; fits onto all standard endoscopic camera heads. Provides clear, unmagnified view of the glottis. Oxygen channel for demisting, clearing secretions, and insufflation.

Adult, smalladult, and infant sizes.

Useful for difficult adult and infant airways, including patients with an anterior airway and limited neck extension.

Rugged, portable, easy to maintain. Depth lines on the blade to guide insertion. Can be used with all fiber-optic laryngoscope handles. Designed to provide indirect laryngoscopy with continuous oxygen insufflation. Infant size features an LED light and rechargeable battery.

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Table 5. Indirect Rigid Fiber-Optic/Optical Laryngoscopes Name (Manufacturer)

Description

Size

Clinical Applications

Airtraq (Prodol Meditec SA, Spain; distributed by Airtraq LLC)

Disposable optical laryngoscope that provides a magnified angular view of the glottis without alignment of oral, pharyngeal, and tracheal axes. Includes a guiding channel to hold ET and direct it toward the vocal cords. Optional snap-on camera can be attached for viewing on external wireless monitor, which has display, record, and playback functions compatible with all Airtraq models.

7 color-coded sizes available: regular adult for ET 7.0-8.5 mm; small adult for ET 6.0-7.5 ediatric mm; p for ET 4.05.5 mm; infant for ET 2.5-3.5 mm; nasotracheal (adult and infant); and double-lumen endobronchial tubes.

Intended to facilitate intubation in both routine and difficult airway situations. Useful in all cases where ET tube intubation is desired. ppropriate Also a for emergency settings, cervical spine immobilization, fiberscope guidance, tube exchange, and foreign body removal.

Totally self-contained disposable advanced airway device with built-in antifog system, and low-temperature light source. Can be used with standard ETs. Integral tracking channel allows ET to be directed without a stylet or bougie.

Airtraq Avant (Prodol Meditec SA, Spain; distributed by Airtraq LLC)

Reusable optic piece (up to 50 intubations). Disposable blade and eyecup.

Regular: 7.0– 8.5, Small: 6.0–7.5

Same as Airtraq but limited to adult patient use.

Optics fully isolated from patient, preventing cross contamination.

Bullard Elite Laryngoscope (Gyrus ACMI)

Most recent version of the Bullard laryngo scope and the only indirect fiber-optic laryngoscope that incorporates attachable metal stylets.

Adult and pediatric sizes (newborn/ infant and child).

Six methods of intubation have been described.8,9 Useful for anterior airways and patients with limited neck extension.

Has a working channel for oxygen insufflation, suction, and instillation of local anesthetics. Can be used with a conventional laryngoscope handle or fiberoptic light source.

Special Features

Abbreviation Key AEC AHA ASA CCD CMOS CPAP CPR DCI DISS DLT ED EF EMS ENT ET FOB Fr ICU ID ILMA

airway exchange catheter American Heart Association American Society of Anesthesiologists charge-coupled device complementary metal oxide semiconductor continuous positive airway pressure cardiopulmonary resuscitation direct coupled interface diameter index safety system double-lumen tube emergency department extra firm emergency medical services ear nose and throat endotracheal tube fiber-optic bronchoscope French intensive care unit internal diameter intubating laryngeal mask airway

ISO LCD LED LMA LT LTA MAC NICU NTSC OD OR PEEP PPV PVC PVP SGA Stat TFE TTJV USB

International Organization for Standardization liquid crystal display light-emitting diode laryngeal mask airway laryngeal tube laryngeal tracheal anesthesia Macintosh neonatal intensive care unit National Television System Committee outer diameter operating room positive end-expiratory pressure positive pressure ventilation polyvinyl chloride polyvinylpyrrolidone supraglottic airway sterile single-use blade tetrafluoroethylene transtracheal jet ventilation universal serial bus

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Table 6. Selected Supraglottic Ventilatory Devices Name (Manufacturer)

Description

Size

AES The Guardian CPV (AES, Inc.)

All silicone laryngeal mask with a vented gastric tube and CPV that constantly monitors cuff pressure.

Adult sizes 3, 4, 5.

AES Ultra (AES, Inc.)

All-silicone laryngeal mask with standard cuff valve.

Adult sizes 3, 4, 5, 6.

AES Ultra Clear (AES, Inc.)

Silicone cuff and PVC tube, laryngeal mask with standard cuff valve.

Adult sizes 3, 4, 5, 6.

AES Ultra Clear CPV (AES, Inc.)

Silicone cuff and PVC tube, laryngeal mask with cuff pilot valve (CPV) which constantly monitors cuff pressures.

Pediatric to adult sizes 1, 1½, 2, 2½, 3, 4, 5, 6.

AES Ultra CPV (AES, Inc.)

All-silicone laryngeal mask with CPV that constantly monitors cuff pressures.

Pediatric to adult sizes 1, 1½, 2, 2½, 3, 4, 5, 6.

AES Ultra EX (AES, Inc.)

All-silicone, multiple-use laryngeal mask (40 uses).

Pediatric to adult sizes 1, 1½, 2, 2½, 3, 4, 5, 6.

AES Ultra Flex CPV (AES, Inc.)

Wire-reinforced, silicone cuff and tube with CPV which constantly monitors pressure changes in the cuff.

Pediatric to adult sizes 1, 1½, 2, 2½, 3, 4, 5, 6.

AES Ultra Flex EX (AES, Inc.)

All-silicone, wire-reinforced, multiple-use laryngeal mask (40 uses).

Pediatric to adult sizes 1, 1½, 2, 2½, 3, 4, 5, 6.

air-Q Blocker Disposable Laryngeal Mask (Cookgas LLC; distributed by Mercury Medical)

Combines the features of air-Q Disposable Laryngeal Mask, with an additional soft flexible guide tube located to the right of the breathing tube.

Sizes (2.5, 3.5, and 4.5) that can accommodate standard ETs up to 8.5 mm. Also available in kits with syringe and lubricant packet.

air-Q Disposable Laryngeal Mask (Cookgas LLC; distributed by Mercury Medical)

Same features as air-Q Reusable Laryngeal Mask, except disposable.

Sizes (1.0, 1.5, 2.0, 2.5, 3.5, and 4.5) that can accommodate standard ETs up to 8.5 mm.

air-Q Reusable Laryngeal Mask (Cookgas LLC; distributed by Mercury Medical)

Hypercurved intubating laryngeal airway that resists kinking, and removable airway connector. Anterior portion of mask is recessed; a larger mask cavity allows intubation using standard ETs. Air-Q removal after intubation is accomplished by using air-Q reusable removal stylet.

Sizes (2.0, 2.5, 3.5, and 4.5) that can accommodate standard ETs 5.5–8.5 mm.

air-Q SP (Cookgas LLC; distributed by Mercury Medical)

Combines the features of the air-Q disposable and reusable laryngeal masks with the added advantage of a self-pressurizing mask. No inflation line or pilot balloon is needed.

Sizes (1.0, 1.5, 2.0, 2.5, 3.5, 4.5) that can accommodate standard ET tubes up to 8.5 mm.

Ambu AuraFlex (Ambu Inc.)

Disposable wire-reinforced flexible laryngeal mask airway.

Adult and pediatric sizes 2-6.

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Clinical Applications

Special Features

Similar to LMA Supreme, but with built-in CPV to minimize postoperative sore throat. Color indicator bands provide instant feedback regarding pressure changes.

The CPV detects changes caused by temperature, nitrous oxide levels, and movement within the airway, enabling clinician to maintain a recommended cuff pressure of 60 cm H2O. Single use.

Standard all-silicone SGA.

All silicone. Single use.

Combines all-silicone cuff with PVC tube for cost savings.

All-silicone cuff with PVC tube. Single use.

Similar to AES Ultra CPV.

Similar to LMA Classic, but with built-in CPV to minimize postoperative sore throat. Color-indicator bands provide instant feedback regarding pressure changes.

The CPV detects changes caused by temperature, nitrous oxide levels, and movement within the airway, enabling clinician to maintain a recommended cuff pressure of 60 cm H2O. Single use.

Reusable, standard SGA.

40 uses.

Wire-reinforced SGA that accommodates repositioning of the head and neck. Color-indicator bands provide instant feedback regarding pressure changes.

Single use. The cuff pressure indicator detects changes caused by temperature, nitrous oxide levels, and movement within the airway. The CPV enables the clinician to maintain a recommended cuff pressure of 60 cm H2O.

Reusable, wire-reinforced SGA, designed to accommodate repositioning of the head and neck during surgery.

40 uses.

Enhanced version of the standard air-Q. It is indicated as a primary airway device when an oral endotracheal tube is not necessary or as an aid to intubation in difficult situations.

The soft guide tube allows access to the posterior pharynx and esophagus by supporting and directing medical instruments beneath the air-Q mask and into the pharynx and esophagus. Medical instruments especially suited are suction catheters, nasal gastric tubes up to size 18.0 Fr, and the newly designed air-Q Blocker tubes. The Blocker tubes are designed to suction the pharynx, or suction, vent and block the upper esophagus during use of the air-Q Blocker airway. Removable color-coded connector allows intubation with standard ETs up to 8.5 mm.

Same as air-Q Reusable Laryngeal Mask.

Removable color-coded connector allows intubation with standard ETs up to 8.5 mm.

Similar to both LMA Classic and LMA Fastrach. Allows easy access for flexible fiber-optic devices. Use as routine masked laryngeal airway. Removable connector allows intubation with standard ETs up to 8.5 mm.

Designed to minimize folding of the cuff tip on insertion. Same use and benefits as LMA Classic and LMA Fastrach. Integrated bite block reinforces the tube while diminishing the need for a separate bite block. Color-coded removable connectors are tethered to the airway tube avoiding episodes of misplaced connectors.

Same as regular air-Q but eliminates the need for mask inflation.

Positive pressure ventilation self-pressurizes the mask cuff. On exhalation, mask cuff decompresses to the level of PEEP. Removable connector allows intubation with standard ET tubes.

Designed for use in ENT, ophthalmic, dental, and torso surgeries.

Integrated pilot tube, and high flexibility enables positioning away from the surgical field, without a loss of seal. Single use. EasyGlide texture and extra-soft cuff ease insertion and removal. Convenient depth marks for monitoring correct position of the mask. table continues on next page

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Table 6. Selected Supraglottic Ventilatory Devices

(continued)

Name (Manufacturer)

Description

Size

Ambu Aura-i (Ambu Inc.)

Laryngeal mask with built-in bite blocker designed as a conduit for endotracheal intubation.

Adult and pediatric sizes 1-6.

Ambu AuraOnce (Ambu Inc.)

A laryngeal mask with a special built-in curve that replicates natural human anatomy. It is molded in 1 piece with an integrated inflation line and no epiglottic bars on the anterior surface of the cuff.

Adult and pediatric sizes 1-6.

Ambu AuraStraight (Ambu Inc.)

Similar to the LMA Unique but without epiglottic bars on the anterior surface of the cuff.

Adult and pediatric sizes 1-6.

Ambu Aura40 (Ambu Inc.)

Same design as the Ambu AuraOnce, but reusable.

Adult and pediatric sizes 1-6.

Ambu Aura40 Straight (Ambu Inc.)

Similar to the LMA Classic. No epiglottic bars on the anterior surface of the cuff.

Adult and pediatric sizes 1-6.

CobraPLA (Pulmodyne)

Large ID laryngeal tube, which is soft and flexible with a tapered, striated tip. Now has an improved distal curve, softer tube, and softer head. It has a high-volume, low-pressure oropharyngeal cuff.

Adult and pediatric sizes 1⁄2-6.

CobraPLUS (Pulmodyne)

Similar to the CobraPLA. Includes temperature monitor (all sizes) and distal gas sampling (pediatric sizes only: 1⁄2, 1, and 11⁄2).

Adult and pediatric sizes 1⁄2-6.

Esophageal Tracheal Combitube (Covidien)

A disposable DLT that combines the features of a conventional ET with those of an esophageal obturator airway. Has a large proximal latex oropharyngeal balloon and a distal esophageal low-pressure cuff with 8 ventilatory holes in between.

Two adult sizes. 41 Fr: height >5 ft. 37 Fr: height 4-6 ft.

i-gel (Intersurgical Inc.)

Supraglottic airway with a noninflating cuff, designed to mirror the anatomy over the laryngeal inlet, with an integral bite block, buccal cavity stabilizer and a gastric channel. It also incorporates a wide-bore airway channel that can be used as a conduit for intubation with fiber-optic guidance (sizes 3, 4, and 5).

Adult sizes (3-5) and pediatric sizes (1-2.5). Adult sizes accommodate ET sizes 6.0-8.0 mm.

KING LAD (King Systems)

Family of disposable silicone and flexible laryngeal masks.

Adult and pediatric sizes 1-5 in silicone and 2-5 in flexible.

KING LT (King Systems)

Multiuse, latex-free, single-lumen silicone tube with oropharyngeal and esophageal low-pressure cuffs, 2 ventilation outlets, insertion marks, and a blind distal tip (almost like a single-lumen, shortened Combitube).16 Color-coded connectors for each size.

Sizes 3-5 available worldwide; sizes 0-2 currently available only outside the United States and Canada.

KING LT-D (King Systems)

Same design as the KING LT, except disposable.

Adult sizes 3-5 and pediatric sizes 2, 2.5.

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Clinical Applications

Special Features

Combines everyday routine use of supraglottic airway with direct intubation capability in case of difficult airway situations.

Anatomically correct curve designed as Ambu AuraOnce and Ambu Aura40 but specially designed as a conduit for intubation. Compatible with standard ETs.

Allows easy access for flexible fiber-optic devices. For use in both anesthesia and emergency medicine.

Anatomically correct curve facilitates placement. One-piece mold. EasyGlide texture for ease of insertion. Convenient depth marks for monitoring correct position of the mask. MRI safe. Extra-soft cuff. If intubation becomes necessary or desired, recommend intubation over Aintree AEC. S ingle use.

For use in both anesthesia and emergency medicine.

Single-use, one-piece mold. EasyGlide texture for ease of insertion. Convenient depth marks for monitoring correct position of the mask. MRI safe. Extra-soft cuff.

Same as LMA Classic.

Same as LMA Classic, but reusable.

Same as LMA Classic.

Reusable. Available only in the United States.

Same as LMA Classic.

Disposable. If intubation becomes necessary or desired, will accommodate ET up to 8.0 mm. Single use.

Same as LMA Classic. An added benefit is the ability to measure core temperature. In addition, distal CO2 can be monitored in pediatric patients.

Similar to CobraPLA, but CobraPLUS allows monitoring of the patient’s core temperature. In neonatal and infant patients, CobraPLUS has the ability to increase the accuracy of end-tidal CO2 and volatile gas analysis. If intubation becomes necessary or desired, will accommodate ET up to 8.0 mm. Single use.

Same as LMA Classic but not contraindicated in nonfasting patients. Appropriate for prehospital, intraoperative, and emergency use. Especially useful for patients in whom direct visualization of the vocal cords is not possible, patients with massive airway bleeding or regurgitation, limited access to the airway, and patients in whom neck movement is contraindicated.

Ventilation is possible with either tracheal or esophageal intubation. Distal cuff seals off the esophagus to prevent aspiration of gastric contents. Allows passage of an oro gastric tube when placed in the esophagus. Single use.

Indicated for use in routine and emergency anesthesia and resuscitation in adult patients. i-gel is not indicated for use in resuscitation in children. Can be used as a conduit for intubation with fiber-optic guidance (sizes 3, 4, and 5). The gastric channel provides an early warning of regurgitation, allows for the passing of a nasogastric tube to empty the stomach contents and can facilitate venting of gas from the stomach (except size 1).

The noninflating cuff allows easy and rapid insertion, provides high seal pressures and minimizes the risk for tissue compression. Gastric channel provides an early warning of regurgitation. Buccal cavity stabilizer reduces the risk for rotation or displacement and the integral bite block prevents occlusion of the airway channel. The wide-bore airway channel also allows for use as a conduit for intubation with fiber-optic guidance (sizes 3, 4, and 5).

Similar to LMA Classic but disposable.

All silicone.

Same as LMA Classic, but with ventilatory seal characteristics like those of LMA ProSeal.

Easily inserted, possible aspiration protection, and allows both PPV and spontaneous breathing. Reusable (up to 50 times).

Same as KING LT.

Also available in a kit. Single use.

table continues on next page

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Table 6. Selected Supraglottic Ventilatory Devices

(continued)

Name (Manufacturer)

Description

Size

KING LTS (King Systems)

Double-lumen laryngeal tube that incorporates a second (esophageal) lumen posterior to the ventilation lumen.

Adult sizes (3-5) and pediatric sizes (0, 1, 2, 2.5) currently available only outside the United States and Canada.

KING LTS-D (King Systems)

Same as KING LTS, except disposable.

Adult sizes (3-5).

LMA Classic (LMA North America, Inc.)

Supraglottic ventilatory device that consists of an oval inflatable silicone cuff in continuity with a wide-bore tube that can be connected to an Ambu bag or anesthesia circuit. Designed to fit the pharynx of patients of various weights.

Adult and pediatric sizes 1-6, accommodating ET 3.5-7.0 mm.

LMA Classic Excel (LMA North America, Inc.)

The Classic Excel has the benefits of LMA Classic and an improved design to facilitate intubation.

Adult and pediatric sizes 3-5.

LMA Fastrach (LMA North America, Inc.)

Adult sizes 3-5 that can accomConsists of a mask attached to a rigid stainless steel tube curved to align the barrel aperture to the modate special ETs 6.0-8.0 mm. glottic vestibule. The set includes an LMA with a stainless steel shaft covered with silicone (reusable version) and a single movable epiglottic elevating bar, ET stabilizer, and silicone wire-reinforced ET. The single-use Fastrach is made from PVC and includes a disposable wire-reinforced ET.

LMA Flexible (LMA North America, Inc.)

Original LMA cuff design attached to smaller diameter, flexible armored tube that allows repositioning of the tube without cuff displacement. New single-use version is easier to insert.

Adult and pediatric sizes 2-6.

LMA ProSeal (LMA North America, Inc.)

Designed with a modified cuff and dual tubes to separate the respiratory and alimentary tracts. Has a built-in bite block.

Adult and pediatric sizes 1-5.

LMA Supreme (LMA North America, Inc.)

Adult and pediatric sizes 1-5. Has a gastric drain tube designed to suction the stomach, channel gases and fluids away from the airway, and confirm placement of the tip of mask at upper esophageal sphincter. The airway tube has a gentle curve and oblong shape to allow easier insertion and more stable placement.

LMA Unique (LMA North America, Inc.)

Original, disposable LMA design. Sterile, latex-free, available with or without syringe and lubricant. Soft cuff and airway tube allow for conformity to patients’ natural anatomy.

Rüsch Easy Tube (Teleflex Medical)

Disposable LT that combines the features of a con- Small 28 Fr; large 41 Fr. ventional ET with those of an esophageal obturator airway similar in design to the Combitube.

Soft-Seal Laryngeal Mask (Smiths Medical)

Adult and pediatric sizes 1-5. Similar in shape to the LMA Unique, but differs in its 1-piece design, in which the cuff is softer and there is no “step” between the tube and the cuff, an integrated inflation line, no epiglottic bars on the anterior surface of the cuff, and a wider ventilation orifice.

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Adult and pediatric sizes 1-5.

Clinical Applications

Special Features

Same as KING LT, except that it has a second lumen for gastric access, similar to LMA ProSeal.

Allows easy passage of a gastric tube to evacuate stomach contents. Distal tip reduced in size to facilitate insertion. Reusable.

Same as KING LTS.

Allows passage of 18 Fr gastric tube. Also available in a kit.

Although originally developed for airway management of routine cases with spontaneous ventilation, it is now listed in the ASA Difficult Airway Algorithm as an airway ventilatory device or a conduit for endotracheal intubation.1,13 Can be used in both pediatric and adult patients in whom ventilation with a face mask or intubation is difficult or impossible. Can also be used as a bridge to extubation14 and with pressure support or PPV.15

Reusable.

Same as LMA Classic.

Removable connector and epiglottic elevating bar to facilitate intubation. Works with ET up to 7.5 mm. Reusable up to 60 times.

Useful for ventilation and intubation. Designed for blind orotracheal intubation but can be used in conjunction with lighted stylets, FOB, or Flexible Airway Scope Tool. FOB recommended when using PVC ET.

Both reusable and disposable versions now available. Can be utilized as a blind or visually guided technique. Benefits include ability to intubate with larger ET and remove the device easily over the ET.

Particularly useful in ENT/head and neck procedures.

Both reusable and disposable versions now available. Airway tube resists kinking and cuff dislodgment, and thus may be positioned away from the surgical field without loss of seal.

Same as LMA Classic except drain tube also allows for evacuation of stomach contents.

Second cuff allows tighter seal for PPV. Reusable.

Same as LMA ProSeal.

A single-use LMA with a redesigned mask that achieves a 50% higher seal pressure than the Classic or Unique. Similar to all LMAs, the Supreme is designed to protect the airway from epiglottic obstructionâ&#x20AC;&#x201D;in this model with molded fins in the bowl of the mask.

Same as LMA Classic. Included in AHA 2000 Guidelines for CPR and Emergency Medicine Cardiovascular Care.

Single use.

Same as Esophageal Tracheal Combitube.

Similar to Combitube with following differences: single lumen at distal tip, soft latex-free cuff, open proximal second lumen allows use of fiber-optic device or passage of a suction catheter or tube exchanger. Single use.

Same as LMA Classic. Allows easy access for flexible fiber-optic devices.

If intubation becomes necessary or desired, will accommodate ET up to 7.5 mm. Single use.

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Table 7. Devices for Special Airway Techniques Name (Manufacturer)

Description

Size

DeVilbiss Model 15 Medical Atomizer (DeVilbiss Healthcare)

Metal atomizer; includes glass receptacle (for liquid), pair of metal outlet tubes extending from metal atomizing nozzle, and adjustable tip for directing spray to inaccessible areas of the throat. Can be used with or without RhinoGuard tip cover.

Length: 10.5 in.

Enk Fiberoptic Atomizer Set (Cook Medical)

Device for atomizing small doses of local anesthetics. Atomizer set consists of a pressure-resistant oxygen tube and a connecting tube attached by a 3-way side-arm fitting with a small flow control opening. The set also contains an introducer catheter and 2 syringes (1-mL).

EZ-Spray (Alcove Medical)

Disposable atomizer device which comprises a plastic receptacle, atomizer nozzle, and gas inlet tube. Tubing is connected from an air or o xygen flowmeter nipple to the gas inlet tube on the device.

LMA MADdy Pediatric Mucosal Atomization Device (LMA North America, Inc.)

Pediatric Mucosal Atomization Device delivers intranasal/intraoral medications in a fine mist that enhances absorption and improves bioavailability for fast and effective drug delivery.

Typical particle size: 30 microns. System dead space: 0.12 mL (with syringe), 0.07 mL (device only). Tip diameter: 0.19 in (4.8 mm). Applicator length: 4.5 in (11.4 cm).

LMA MADgic Laryngo-Tracheal Atomizer (LMA North America, Inc.)

Mucosal atomization device that incorporates a small flexible, malleable tube with an internal stiffening stylet that connects to a 3-mL syringe.

Typical particle size: 30-100 microns. System dead space: 0.25 mL and 0.13 mL. Tip diameter: 0.18 in (4.6 mm). Applicator length: 8.5 in (21.6 cm) and 4.5 in (11.4 cm).

LMA MADgic Airway (Intubating Airway With Mucosal Atomization and Oxygen Delivery; LMA North America, Inc.)

Combines atomized topical anesthesia and oxygen delivery in a fiber-optic oral airway.

Typical particle size: 30-100 microns. System dead space: 0.25 mL.

LMA MAD Nasal-Intranasal Mucosal Atomization Device (LMA North America, Inc.)

Disposable, compact atomizer for delivery of medi- Typical particle size: 30-100 cations to the nose and throat in a fine, gentle mist. microns. System dead space: 0.13 mL and 0.07 mL. Tip diameter: 0.17 in (4.3 mm). Applicator length: 1.65 in (4.2 cm).

Awake Intubation

Retrograde Cook Retrograde Intubation Set (Cook Medical)

Available as a complete set in 6.0 Fr or 14.0 Fr and includes Arndt Airway Exchange Catheter with Rapi-Fit adapter.

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6.0 Fr=50 cm; 14.0 Fr=60 cm.

Clinical Applications

Special Features

Intended for the application of topical anesthetics to the nose, oropharynx, and upper airway of patients, at the direction/discretion of a clinician.

Includes glass receptacle for dispensing the liquid; adjustable swivel top and vented nasal guard attached to a hand bulb. Can be used with all types of oil or water solutions that are compatible with rhodium metal plating. The allmetal top can be autoclaved. Reusable.

To apply topical anesthetics to laryngotracheal area through the working channel of a bronchoscope using oxygen flow. Designed and intended to be used by those trained and experienced in techniques of flexible fiber-optic intubation.

Device is an accessory to a bronchoscope. Delivery form is a fine spray mist using oxygen flow through the working channel bronchoscope. Sterile. Single use.

Application of topical anesthetic to the nose, oropharynx, and upper airway of patients, at the direction/ discretion of a clinician.

Trigger-valve system provides controlled release of compressed gas to an atomizing nozzle, creating a liquid spray. Gas flow is adjusted to the desired setting. Use with either oil- or water-based solutions. Nonsterile. Single use.

Application of topical anesthetics to oropharynx and upper airway region. Fits through vocal cords, down LMA, or into nasal cavity.

Child-friendly and no sharps (bright colors in a toy-like presentation make the procedure less scary for young patients). Flexible (internal stylet provides support, malleability and memory). Disposable (single patient use, eliminates risk for cross-contamination). Practitioner-controlled (patient needs targeted specially by medication, concentration, position, and location).

Application of topical anesthetics to oropharynx and upper airway region. Fits through vocal cords, down LMA, or into nasal cavity.

Malleable applicator retains memory to adapt to individual patient’s anatomy. Delivery of a fine spray mist is generated by a piston syringe. Luer connection adapts to any luer lock syringe. Nonsterile. Single use.

Allows retraction of soft tissue while applying topical anesthesia in a fine, gentle mist. Used to apply topical anesthetic to the airway before awake intubation.

Device blade positioned along floor of the mouth can be directed immediately in front of laryngeal inlet to generate a fine mist by a piston syringe. Nonsterile. Single use.

Intranasal medication delivery offers a rapidly effective method to deliver selected medications to a patient without the need for a painful shot and without the delays in onset seen with oral medications.

Rapidly effective (atomized nasal medications absorb directly into blood stream, avoiding first-pass metabolism, atomized nasal medications absorb directly into the brain and CSF via olfactory mucosa to nose-brain pathway, achieves medication levels comparable to injections). Controlled administration (exact dosing, exact volume, titratable to effect [repeat if needed], atomizes in any position, atomized particles are optimal size for deposition across broad area of mucosa).

Technique used for securing a difficult airway, either alone or in conjunction with other alternative airway techniques. Especially useful in patients with limited neck mobility or patients who have suffered airway trauma. 6.0 Fr places tubes ≥2.5 mm ID; 14.0 Fr places tubes ≥5.0 mm ID.

Packaged as a complete kit with everything needed to perform a retrograde intubation. The recently added Arndt Airway Exchange Catheter allows for patient oxygenation and facilitates placement of an ET. Disposable.

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Table 7. Devices for Special Airway Techniques Name (Manufacturer)

(continued)

Description

Size

Reusable, contoured, good sealing facemasks with special capped port containing flexible silicone diaphragm that allows for endoscopy without interruption of ventilation.

Child, small adult, and large adult.

Face Mask Ventilation AincA Patil-Syracuse Mask (Anesthesia Associates, Inc.)

Endoscopy Mask Face mask with diaphragm to allow simultaneous (VBM Medizintechnik GmbH) ventilation and endoscopy.

Newborn, infant, child, and adult.

ErgoMask (King Systems)

Face mask with contoured finger/thumb grip.

Medium adult size.

Boussignac CPAP System (LMA North America, Inc.)

Open CPAP with an integral pressure-relief system. The CPAP device has 2 ports: a green one with integral oxygen connecting tube, and a colorless port for controlling pressure, monitoring CO2, and adding oxygen.

Small, small adult, medium adult, and large adult.

Single device that looks similar to a pen. At one end of the “pen” is a needle with a 9 Fr cricothyrotomy catheter; on the other end is a nasopharyngeal airway catheter.

Cricothyrotomy catheter: 6.0 cm. Nasopharyngeal catheter: 9.5 cm (7.0 mm ID).

AincA Manual Jet Ventilator (Anesthesia Associates, Inc.)

Portable jet ventilation device with thumb depression mechanism which initiates a controlled burst of oxygen flow. Customizable assembly includes DISS inlet connection, 5 ft of inlet tubing, flow control knob, on/off thumb control, internal filter, back pressure gauge, and 2 ft of outlet hose ending in a Luer-Lok male fitting. Connects to any tool or port that has a Luer-Lok female connection (ie, malleable stylets, various adapters, etc).

Jet ventilation catheters of malleable copper with Luer fittings accommodate adults, children, and infants. Adapters allow direct connection to bronchoscope or ET.

AincA MRI Conditional 3.0 Tesla Manual Jet Ventilator (Anesthesia Associates, Inc.)

Similar to AincA Manual Jet Ventilator but MRI compatible.

Jet ventilation catheters of malleable copper with Luer fittings accommodate adults, children, and infants.

Enk Oxygen Flow Modulator Set (Cook Medical)

Complete set including 15-gauge needle with reinforced fluorinated ethylene propylene catheter, syringe (5 cc), connecting tubing, and Enk oxygen flow modulator with tracheal catheter connector.

7.5 cm (2.0 mm ID).

Manual Jet Ventilator (Instrumentation Industries)

Complete set includes an on/off valve, 6 ft of highpressure tubing, and 4 ft of small-bore tubing.

Jet ventilation catheter size 13G can accommodate adults, and 14G children.

All in One Wadhwa Emergency Airway Device (Cook Medical)

Transtracheal Jet Ventilation

Manujet III Complete set including 4-m pressure hose, Luer(VBM Medizintechnik GmbH) Lok connecting tubing, bronchoscope adapter, Endojet adapter with Endojet catheter, and jet ventilation catheter.

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Jet ventilation catheters can accommodate adults, children, and infants.

Clinical Applications

Special Features

Simple technique that allows leak-free endoscopy while maintaining minimal interference with mask ventilation. Useful for identifying anatomic landmarks, obstructions, conditions and growths. Often used in conjunction with an oral airway (Patil-Syracuse, Williams, or other) to aid endoscopy.

Choice of 3 durable materials (latex, neoprene, and silicone), available in various sizes and seal types. Silicone seal of the special port is extremely durable, but replaceable if damaged. When capped, functions like a normal mask. Reusable and sterilizable.

• • • •

Available in different sizes and with different sized diaphragms for a perfect seal during endoscopy. Special Bronchoscope Airway available to protect equipment and aid endoscopy.

Fiber-optic intubation Airway endoscopy Gastroenterology Transesophageal echocardiography

Intended to facilitate 1-handed mask ventilation. Encourages proper chin lift to open airway. Allows improved control of mask seal.

Ergonomically designed for better hand placement. Ventilation port off-center facilitates use with small hands and improves mask seal.

Provides respiratory assistance to patients breathing spontaneously. Effective postoperatively in obese patients with sleep apnea.

Compatible with all face masks, ETs, and tracheostomy tubes. Mask head harness is designed for patient comfort.

Can be used for a needle cricothyrotomy, for TTJV, or as a nasal catheter.

The components require some preassembly. Once assembled, it is easy to transport to offsite locations and is intended for use in emergencies. The main body of the device acts as a blow tube or 15-mm adapter. Disposable.

Manual Jet Ventilation for oxygen saturation maintenance and usable for emergency direct TTJV and for laser throat surgery (elimination of plastic ET in laser path).

Easy factory customization available for hose lengths and oxygen source connection type (DISS vs various quickdisconnect types) as well as optional pressure regulator (with gauge) and standard or custom regulator-to-source connection hoses. Adapters, fittings, and connectors available. Completely reusable and sterilizable.

Similar to the AincA Manual Jet Ventilator, but fully certified for use in MRI suites with coil strength to 3.0 Tesla. Allows emergency oxygen saturation maintenance while determining how to solve airway issues.

Easy factory customization available for hose lengths and oxygen source connection type (DISS vs various quickdisconnect types). Adapters, fittings, and connectors available. Completely reusable and sterilizable.

Similar to the AincA Manual Jet Ventilator. Recommended for use when jet ventilation is appropriate but a jet ventilator is unavailable.

Packaged as a complete set with everything needed to perform TTJV. Disposable.

Same as Manujet III. Can also be used in unobstructed difficult airway management.

Offered with and without an adjustable pressure regulator to accommodate use on various-sized patients. Reusable.

Well-accepted method for securing ventilation in rigid and interventional bronchoscopy. Because airflow is generally unidirectional, it is important that air has a route to escape (unobstructed airway).

Packaged as a complete kit with everything needed to perform TTJV. The Endojet adapter allows jet ventilation on an ET, LMA, or face mask. The catheter can be pushed forward through the ET or LMA as far as required, and can be fastened with a screw. Includes a pressure regulator. Reusable.

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Table 8. Positioning Devices Name (Manufacturer)

Description

Chin-UP (Dupaco Inc.; distributed by Mercury Medical)

Hands-free airway support device used to lift up the patient’s chin and hold it in position to keep the airway open.

JED Jaw Elevation Device (Hypnoz Therapeutic Devices; distributed by LMA North America, Inc.)

New hands-free, noninvasive device that helps clinicians maintain an open airway during any procedure in which a patient is sedated and the airway may be compromised.

RAMP Rapid Airway Management Positioner (Airpal Patient Transfer Systems, Inc.)

Air-assisted medical device that can be inflated to transfer and position patients for various procedures.

Troop Elevation Pillow (Mercury Medical)

Foam positioning device that quickly achieves the head- elevated laryngoscopy position (HELP). Includes many accessories (head cradle, arm board pads, addition pillow).

Table 9. Cricothyrotomy Devices Name (Manufacturer)

Description

Size

6 Fr reinforced fluorinated ethylene propylene catheter.

5.0 and 7.5 cm.

Melker Cuffed Emergency Cricothyrotomy Catheter Set (Cook Medical)

Same as Melker Emergency Cricothyrotomy Catheter Set.

9.0 cm (5.0 mm ID).

Melker Emergency Cricothyrotomy Catheter Set (Cook Medical)

Complete set including syringe (10 cc), 2- to 18-gauge introducer needles with TFE catheter (short and long), 0.038-in diameter Amplatz extrastiff guidewire with flexible tip, scalpel, curved dilator with radiopaque stripe, and PVC airway catheter. Also available in a Special Operations kit, which includes all of the above in a slip peel-pouch and 2 airway catheters.

Standard kit: 3.8 cm (3.5-mm ID), 4.2 cm (4.0-mm ID), and 7.5 cm (6.0-mm ID). Special kit: 4.2 and 7.5 cm.

Pertrach Emergency Cricothyrotomy Kit (Pulmodyne)

Contents include 2 splitting needles, cuffed or uncuffed Trach tube, dilator with flexible leader, twill tape, syringe, extension tube, and scalpel (optional).

Adult: 6.8 cm (5.6 mm ID). Child: 3.9 cm (3.0 mm ID), 4.0 cm (3.5 mm ID), 4.1 cm (4.0 mm ID), and 4.4 cm (5.0-mm ID).

Needle Cricothyrotomy Emergency Transtracheal Airway Catheter (Cook Medical) Percutaneous Cricothyrotomy

Complete kit includes airway catheter, stopper, Quicktrach Emergency needle, and syringes that come preassembled. Cricothyrotomy Device (VBM Medizintechnik GmbH)

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Adult (4.0 mm ID) and child (2.0 mm ID).

Clinical Applications

Special Features

Aids during monitored anesthesia care and total intravenous anesthesia sedation procedures.

Disposable polyurethane foam cushions.

OR procedures, MRI, recovery, FOB intubation, and interventional radiology, oral surgery, and endoscopy procedures.

Assists provider in maintaining an open airway in sedated or anesthetized patients without the need for additional instrumentation. Frees medical personnel from the need to hold the jaw manually in sedated patients. When left in place after a procedure, reduces postoperative airway complications. Noninvasive and easy to use. Reusable device with disposable pads.

Allows for the positioning of a patient for direct laryngoscopy, extubation, and central venous access. Enhances the safe apnea period, bag valve mask ventilation, and chest wall excursion.

Base of the RAMP is integrated with an Airpal platform (air-assisted lateral patient transfer and positioning device). Inflates and deflates, thus can remain in place during surgery and reinflate for extubation. Reusable.

Aids airway management for obese patients by aligning upper airway axes, and facilitating mask ventilation, laryngoscopy, direct laryngoscopy, and central venous access. Allows patients to breathe more comfortably during preoxygenation and regional anesthesia.

Available in disposable and reusable formats. Troop Elevation Pillow may be added for super morbidly obese patients.

Clinical Applications

Special Features

A lifesaving procedure that is the final option for “cannot-ventilate, cannot-intubate” patients in all airway algorithms.

Designed to be kink-resistant specifically for the purpose of needle cricothyrotomy.

Same as Melker Emergency Cricothyrotomy Catheter Set.

Same as Emergency Transtracheal Airway Catheter. Intended to be used with the Seldinger technique via the cricothyroid membrane; however, it has the capability to be used as a surgical cricothyrotomy.

Packaged as a complete kit with everything needed to perform a percutaneous cricothyrotomy. The Special Operations kit comes in a slip peel-pouch for easy transport to offsite locations. Also can be used in the OR. It comes with 2 differently sized airway catheters to reduce the number of kits needed in the field. Disposable.

Use in failed orotracheal or nasotracheal intubation and/ Serves as an emergency cricothyrotomy or tracheostomy device that uses a patented splitting needle and dilator to or fiber-optic bronchoscopy. Immediate airway control in patients with maxillofacial, cervical spine, head, neck, perform a rapid and simple procedure. and multiple trauma. Also used when endotracheal intubation is impossible and/or contraindicated. Immediate relief of upper airway block. Same as Melker Emergency Cricothyrotomy Catheter Set.

Packaged as a complete kit with everything needed to perform a percutaneous cricothyrotomy—even the neck tape and connecting tube. The removable stopper is used to prevent a “too-deep” insertion and avoid the possibility of perforating the rear tracheal wall. The conical needle tip allows for the smallest necessary stoma and reduces the risk for bleeding. Easily transported to offsite locations. Disposable. table continues on next page

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Table 9. Cricothyrotomy Devices Name (Manufacturer)

(continued)

Description

Size

Surgical Cricothyrotomy There is no special kit for a surgical cricothyrotomy. It is performed by making an incision through the cricothyroid membrane using a scalpel, followed by the caudad insertion of an ET. This is the most rapid technique and should be used when equipment for the less invasive techniques is unavailable and when speed is particularly important. Combination Percutaneous and Surgical Cricothyrotomy Melker Universal Emergency Cricothyrotomy Catheter Set (Cook Medical)

Same as Melker Cuffed Emergency C ricothyrotomy 9.0 cm (5.0-mm ID). Catheter Set for percutaneous technique. Also includes for surgical technique: tracheal hook, safety scalpel, Trousseau dilator, and blunt curved dilator.

Table 10. Tracheostomy Devices Name (Manufacturer)

Description

Size

Percutaneous Dilatational Tracheostomy Ciaglia Blue Dolphin Balloon Percutaneous Tracheostomy Introducer (Cook Medical)

Complete kit with size-specific Blue Dolphin balloon dilator. Available with or without Shiley 6 or 8 PERC tracheostomy tubes. A tray version is available that includes lidocaine/ epinephrine, 15-mm swivel connector, chlorhexidine skin prep, drape, and suture.

21, 24, 26, 27, 28, 30 Fr introducers.

Ciaglia Blue Rhino Percutaneous Introducer Set (Cook Medical)

Complete kit includes 24.0, 26.0, and 28.0 Fr loading dilators and Shiley 6 or 8 PERC disposable dual-cannula tracheostomy tube. A tray version is available that includes lidocaine/ epinephrine, connector, chlorhexidine skin prep, drape, needle driver, and suture.

74 mm (6.4-mm ID); 79 mm (7.6-mm ID).

Portex Ultraperc Percutaneous Dilatational Tracheostomy Kit (Smiths Medical)

Complete set with or without a tracheostomy tube.

70.0 mm (7.0-mm ID); 75.5 mm (8.0-mm ID); 81.0 mm (9.0-mm ID).

Shiley TracheoSoft XLT Extended-Length Tracheostomy Tubes (Covidien)

Available in 4 ISO sizes (5.0-, 6.0-, 7.0-, and 8.0-mm ID). Each size offers the choice of cuffed or uncuffed stylets, and proximal or distal extensions. Disposable inner cannula; replacements sold in packages of 10.

90 mm (5.0-mm ID); 95 mm (6.0-mm ID); 100 mm (7.0-mm ID); 105 mm (8.0-mm ID).

Surgical Tracheostomy Surgical tracheostomies are performed by making a curvilinear skin incision along relaxed skin tension lines between sternal notch and cricoid cartilage. A midline vertical incision is then made dividing strap muscles, and division of thyroid isthmus between ligatures is performed. Next, a cricoid hook is used to elevate the cricoid. An inferior-based flap or Bjork flap (through second and third tracheal rings) is commonly used. The flap is then sutured to the inferior skin margin. Alternatives include a vertical tracheal incision (pediatric) or excision of an ellipse of anterior tracheal wall. Finally, the tracheostomy tube is inserted, the cuff is inflated, and it is secured with tape around the neck or stay sutures.

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Clinical Applications

Special Features

Same as Melker Emergency Cricothyrotomy Catheter Set.

One-half of the tray is the same as Melker Cuffed Emergency Cricothyrotomy Catheter Set for the percutaneous technique. The other half of the tray includes all items necessary to perform a surgical emergency cricothyrotomy.

Clinical Applications

Special Features

One-step dilation and tracheal tube insertion. Establishes transcutaneous access to the trachea below the level of the cricoid cartilage by Seldinger technique.

Unique balloon-tipped design combines balloon dilatation and tracheal tube insertion into one step. Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy.

Same as Portex Ultraperc Percutaneous Dilatational Tracheostomy Kit.

Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy. The single dilator with a hydrophilic coating and flexible tip results in a simpler, less traumatic insertion. The wire guide has a SafeT-J tip to reduce trauma. Disposable.

Establishes transcutaneous access to the trachea below the level of cricoid cartilage. Allows for smooth insertion of the tracheostomy tube over a Seldinger wire.

Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy. The dilator is single-staged and prelubricated with an ergonomic handle to facilitate insertion. Disposable.

Flexible dual cannula tube for patients with unusual anatomy. Proximal length extension for thick necks; distal length extension for long necks, tracheal stenosis, or malacia.

The only fixed-flange extended-length tube with disposable inner cannula. Flexible inner cannula conforms to the shape of the outer cannula. Sixteen configurations to fit a wide variety of patients. Disposable.

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24. Wong EK, Bradrick JP. Surgical approaches to airway management for anesthesia practitioners. In: Hagberg CA, ed. Handbook of Difficult Airway Management. Philadelphia, PA: Churchill Livingstone; 2000;209-210.

14. Brimacombe J, Keller C, Hörmann C. Pressure support ventilation versus continuous positive airway pressure with the laryngeal mask airway: a randomised, crossover study of anesthetized adult patients. Anesthesiology. 2000;92(6):1621-1623.

25. Gibbs M, Walls R. Surgical airway. In: Hagberg CA, ed. B enumof’s Airway Management. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2007:678-696.

15. Dörges V, Ocker H, Wenzel V, Schmucker P. The laryngeal tube: a new simple airway device. Anesth Analg. 2000;90(5):1220-1222.

26. Sarpellon M, Marson F, Nani R, Chiarini L, Bradariolo S, F onzari C. Translaryngeal tracheostomy (TLT): a variant technique for use in hypoxemic conditions and in the difficult airway [in Italian]. Minerva Anestesiol. 1998;64(9):393-397.

I ndependently developed b y M c Ma h on P u b lis h in g

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CL IN ICA L A N E ST H E SIOL O G Y

ACTs Shortened With Less Protamine for Heparin Reversal Chicago—Anesthesiologists using traditional dosage regimens of protamine to reverse heparin after cardiopulmonary bypass may be missing the mark, researchers have found. The investigators found that compared with normal doses of protamine, lower doses were associated with shorter clotting times. “This study was prompted by the question of what the appropriate protamine dose for heparin reversal is after separation from cardiopulmonary bypass,” said Adrienne B. Warrick, MD, anesthesiology resident at University of Florida in Gainesville, who helped conduct the analysis. “Some anesthesia providers at our institution were noticing that when giving less than traditional protamine doses for heparin reversal, the post-protamine ACT [activated clotting time] values were close to baseline values, or sometimes even lower.” Dr. Warrick and her colleagues reviewed the charts of 68 patients who underwent cardiac bypass surgery at the institution between July 2009 and July 2010. Half received the normal dose of 1 to 1.3 mg of protamine per 100 units of heparin; a lowdose group received 0.5 to 0.7 mg of protamine per 100 units of heparin (n=34). “Our null hypothesis was that there would be no difference between the two protamine-dosing groups in terms of post-protamine ACT values,” Dr. Warrick said. The results were presented at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 056). “The low-dose group received an average of approximately 0.6 mg of protamine per 100 units of heparin,” Dr. Warrick said. “By comparison, the normal-dose group received approximately 1 mg of protamine per 100 units of heparin.” Patients in the low-dose group had lower post-protamine ACT values (129.0±15.6 vs. 138.6±18.7; P<0.048). After controlling for age, sex, weight and other variables, the low dose was still associated with a shorter postprotamine ACT (P=0.0045). However, the researchers observed no statistically significant differences between the two dosing groups in intraoperative and postoperative requirements for packed red blood cells, fresh frozen plasma and platelets, or ICU length of stay and 48-hour chest tube output. Dr. Warrick acknowledged that the

number of participants was a chief limitation of the study, but said the findings suggest that a lower dose of protamine is at least as effective and safe as a normal dose of protamine for heparin reversal. Dr. Warrick also noted that the heparin was used only to get to bypass. “We did not include any of the heparin that was given while on pump. So,

the protamine dose used to calculate our ratio was just the pre-bypass heparin,” she said. But was it an overdose? “The protamine dose [used in the study] is what’s written in the books,” said Martin London, MD, professor of clinical anesthesia at the University of California, in San Francisco. “The state of the art is so poorly written that

a lot of anesthesiologists do overdose people.” Nevertheless, Dr. London called the findings “really great pilot data for a randomized double-blind trial. ... This is pilot data that should prompt a prospective trial; there’s no reason not to do it.” —Michael Vlessides

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P OLI C Y & M A NA G EMENT ASCs continued from page 1 “Overall, we’re very pleased that CMS put a national quality reporting program in place, and it’s gratifying to see that CMS, in its proposed and final rule, adopted most of the quality measures proposed by [a coalition of affected societies, including the ASCA and other specialty societies],” said David Shapiro, MD, a Florida-based anesthesiologist and president of ASCA. The CMS proposals require ASCs to report data through three different sites. The national association representing the centers has asked CMS to simplify the reporting process in the future. “We would like to minimize the burden on ASCs because most are small businesses,” Dr. Shapiro said. The quality reporting program will eventually require centers to provide data on eight measures that CMS has deemed important for patient outcomes. Right now, CMS has not established how the method for payment penalties to centers that do not report will be calculated. A proposal is expected in the next year. Data collection for five quality measures will start on Oct. 1, 2012, and will affect 2014 payment

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determinations. These measures include patient burns; patient falls; wrong site, side, patient, procedure and impact; hospital transfer/admission and timing of prophylactic IV antibiotics. This first set of measures will be reported through claims-based mechanisms. Over the next two years, CMS will add three additional measures, including use of a safe surgery checklist, ASC facility volume data for selected procedures and a National Healthcare Safety Network infection control measure that calls for influenza vaccination coverage among health care personnel. ASCs will need to report their use of a safe surgery checklist during 2012 through a CMS Webbased tool that will be available between July 1, 2013, and Aug. 15, 2013. ASCs also will need to report their 2012 all-patient volume data for some procedure codes using the same tool during the same period. CMS has not specified a specific surgery checklist. The Association of Perioperative Registered Nurses, the World Health Organization and SafeSurgery.org have suitable versions. A measure for vaccination coverage is still being finalized and will affect payments for 2016, with data collection beginning in October 2014. In other changes, federal regulations that restricted ASCs from hosting operations on the same day that physicians and patients scheduled the procedures were lifted in December. This allows ASCs to offer same-day services that patients could alternatively receive in the hospital outpatient department.

The CMS also is finalizing its proposed policy to make data that an ASC has submitted for the quality reporting program available on a CMS Web site after providing an ASC an opportunity to preview the data to be made public. The changes will have an important effect on physicians working at these centers, particularly anesthesiologists, general surgeons and gastroenterologists who perform surgical and endoscopic procedures. Only six new procedures were added to the ASC list of covered surgical procedures for 2012, although 232 procedure codes were reviewed. The new procedures are primarily vascular and include transcatheter therapy, transcatheter placement of intravascular stents and vessel mapping for hemodialysis access. Dr. Shapiro said physicians who work at ASCs would like to see more procedures added to the list and want CMS to increase the transparency of the selection process for procedures. “The current system is a bit of a black box. They [CMS] are not mandated to tell us what exclusionary criteria they use,” he said. “We’re often put in a position that we can no longer do things in an ASC when a patient turns 65 even though they’re commonly done at ASCs for younger patients.” The changes to 2012 reimbursement rates for surgical and endoscopic procedures performed at ASCs are mixed. Overall, surgical specialists who treat the digestive system are expected to receive a 4% increase in payments under the revised payment system, according to a summary statement prepared by the AGA and Hart Health Strategies, a bipartisan consulting and lobbying firm specializing in legislative and regulatory health care issues. Many commonly performed procedures will have an estimated modest increase in aggregate Medicare payments under the revised ASC payment system. Approximately 5,000 ASCs in the United States participate in Medicare. —Christina Frangou

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POL ICY & M A N A G E M E N T Cancelled continued from page 1

OR SCHEDULE

nearly $1 million that year alone. Because surgeries bring in approximately 60% of the PATIENT PROCEDURE ROOM TIME STATUS hospital’s entire revenue, that HERNIA REPAIR CANCELLED loss has a major effect on the GALL BLADDER CANCELLED bottom line, said study author Sabrina Bent, MD, MS, cliniKIDNEY STONE CANCELLED cal associate professor of anesCHOLECYSTECTOMY CANCELLED thesiology and director of research at the Tulane University Department of Anesthesia, in New Orleans. rooms at once, other equipment fails that the cost of cancellation varies with “People need to recognize that there or the intensive care units happen to specialty, with the highest loss in neuis a cost to cancelled surgeries that is be full, leaving no place for patients to rosurgery and urology (Table). Start not insignificant,” said Dr. Bent, who recover following procedures. with these high-revenue subspecialpresented the findings at this year’s Dr. Bent and her team found that ties, she said, and analyze and develop American Society of Anesthesiologists cancellations were more likely among ways to curb those losses. “Maybe you Conference on Practice Management patients who did not have a preoper- cannot fix everything right away, but (abstract PM23). ative clinic visit with the anesthesiol- maybe there is something you can do The bulk of the cost from cancelled ogist—nearly 11% of these surgeries to improve the efficiency and lack of surgery stems from “opportunity costs,” were ultimately cancelled compared cancellations in specialized groups.” Dr. Bent said. When surgeries are can- with less than 4% of surgeries preceded The rate of cancellations in the celled on short notice, hospitals are by a clinic visit. study “makes sense,” said David Glick, unable to swap in other procedures As a result, Dr. Bent recommended MD, MBA, associate professor of anesthat would bring in lost revenue. that hospitals ensure all patients receive thesia and critical care at the UniHospitals cancel surgeries at the last a preoperative visit to verify patients versity of Chicago, who conducts minute for various reasons, Dr. Bent are medically ready for surgery and similar research. The total cost for noted. More than 30% of patients in her that they receive the proper preoper- Tulane probably exceeded $1 million, study failed to show up at the time of ative instructions for the day of the surgery because of transportation prob- procedure. lems, confusion over the date of the “That is a major factor that should procedure, forgetting about the appoint- be achievable,” she told Anesthesiolment or for other reasons, she said. ogy News. Other ways to reduce canAmong the minority of cancellations cellations include improving the besides no-shows for which the rea- allocation of equipment and resources, son was recorded, nearly one-third of and increasing efficiency to help the procedures were cancelled because patients move through the hospital of issues at the hospital itself, such as a faster, she added. “All of these things lack of beds or equipment. Although it are multifactorial and take time, thus is not in the hospital’s interest to can- are hard to address easily.” cel planned surgeries, these issues arise, Consequently, Dr. Bent recomDr. Bent said. Scheduling errors can mended that hospitals focus in areas occur when one piece of expensive where they could have the most impact. equipment is needed in two operating For instance, she and her team found

however, Dr. Glick said, because the hospital has a relatively small volume and cancelled surgeries also result in a loss of money when disposable equipment is opened and then must be thrown out. “There can be significant losses to the medical centers when they lose cases because of cancellations,” Dr. Glick said. “I think their findings are useful, insofar as they provide justification for greater financial investment by hospitals to decrease cancellations.” For instance, Dr. Glick’s own research also showed that patients who have preoperative visits in the anesthesia clinic are less likely to delay or cancel their surgeries (Anesthesiology 2005;103:855-859). Although these visits are largely not reimbursed, it may be in the hospital’s interest to support them financially. “I think this study suggests that it is reasonable for medical centers to bear a significant cost to maintain the anesthesia preoperative clinic,” Dr. Glick said. “It enables them to save more money down the line, when surgeries are not cancelled.” —Alison McCook

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Table. Revenue Loss by Specialty Specialty

Total revenue Total, n loss, $

Average revenue loss per case, $

General surgery

102

200,478

1,965

Neurosurgery

41,735

5,962

Ophthalmology

46,828

2,927

Orthopedics

71,807

2,779

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Otolaryngology

87,840

4,623

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Pediatrics

15,900

1,325

Plastic surgery

9,039

2,260

Radiology

33,449

2,787

Thoracic surgery

84,160

4,208

Urology

66,614

4,758

Total

225

657,850

2,924

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24 I AnesthesiologyNews.com

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P A IN M E D I C INE

N.H. Pain Center Strives for the Best Individualized Care

he Richard Barrett Pain Management Center at DartmouthHitchcock Medical Center in Lebanon, N.H., is named after the state’s first practicing anesthesiologist—Richard H. Barrett, MD—who came to the hospital in the 1940s and worked there for more than 34 years. “At a time when pain was often disregarded, he was a visionary in

understanding that people in pain should actually be treated for it,” said Gilbert Fanciullo, MD, MS, Barrett Center’s current director. Today, the center carries on Dr. Barrett’s legacy by providing comprehensive care for acute, chronic, cancer and end-of-life pain, using a thoughtful, interdisciplinary approach that offers patients individually tailored

treatment plans. Its long history of commitment to patients has made it one of the preeminent pain clinics in the United States, an American Pain Society Center for Excellence award winner and a vital pain management resource in New Hampshire and Vermont. “Our mission is to provide the right care to the right patient at the right time, all the time,” Dr. Fanciullo said.

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Treatment Vectors The Richard Barrett Pain Management Center attacks pain with a variety of strategies. “We believe there are four treatment vectors for patients with pain,” Dr. Fanciullo explained. “One is surgery and injections; another is medication; a third is behavioral interventions; and the last is physical medicine approaches. We strive for a balance of each of these therapies in treating patients.” For example, a recent patient— a police officer—was seriously hurt while making an arrest. “He was so severely injured that a bone from his face severed his pituitary gland,” Dr. Fanciullo said. To alleviate the man’s excruciating facial pain, Barrett clinicians treated him aggressively with drugs, counseled him for post-traumatic stress syndrome, and eventually implanted supraorbital and infraorbital nerve stimulators to control his pain. Today, the officer is back working on a full-time basis. “We use any means necessary to help patients,” Dr. Fanciullo said. The Barrett Center provides its comprehensive services regardless of a patient’s ability to pay. “We don’t deny services to someone we think we can help just because they are unlucky and don’t have a job that provides health insurance,” Dr. Fanciullo said. “Our mission is: ‘We advance health through research, education, clinical practice and community partnerships, providing each person the best care in the right place at the right time, every time.’ Nowhere in that statement is there a qualifier about having the right insurance.” Although a commendable policy, it does beg the question of what effects such an approach has on the bottom line. “It is a challenge,” Dr. Fanciullo said. “What we focus on is value. All of our decisions and initiatives have to do with improving the quality of the care we provide and decreasing the costs per unit of service.” Innovative Programs With two outreach clinics at Mt. Ascutney Hospital and Health Center in Windsor, Vt., and New London Hospital in New London, N.H., the center improves pain care by providing a wide variety of programs offering noninterventional and interventional treatment options. One example is its nationally recognized functional restoration program (FRP).

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P ain M e d icine

The Richard Barrett Pain Management Center medical staff, front row, from left, Dawn Sparks, DO; Tabitha Washington, MD, MS; Khalilah Brown, MD; and Bert Fichman, MD; back row, from left, John Corey, MD; Gilbert Fanciullo, MD, MS; Robert Rose, MD; Ralph Beasley, MD; and Keith Scarfo, DO.

“A big part of the problem people have with pain, especially back and neck pain, is that they are functionally limited or even disabled by it,” said Rowland G. Hazard, MD, director of the program. “Our functional restoration program is designed not so much to reduce symptoms, but to help people get back to work and resume daily living activities.” FRP is an intensive 14-day, eighthour-a-day program that provides physical training and behavioral counseling. It educates patients about pain, how pain affects them and how to cope with it so they can lead more active lives and limit future treatments. “The Cochrane Reviews said that multidisciplinary care with functional restoration has the best track record for helping people in pain get back to being able to perform daily activities,” Dr. Hazard said. The pediatric PainFree Program at Children’s Hospital at DartmouthHitchcock Medical Center provides sedation and stress control to any child requiring therapeutic or diagnostic procedures at the center. In the program, anesthesiologists, anesthesia residents and certified registered nurse anesthetists work with registered nurses, a patient care technician, a child life specialist and an administrative assistant in a dedicated sedation suite that includes a patient intake area, admissions bed, a fully equipped procedure room and two recovery beds. “When you try to do a procedure on a child, there are two challenges— the stress and the pain,” said Joseph P. Cravero, MD, the program’s medical director. “We felt there was inadequate sedation for children undergoing procedures here, so we created this program to provide ideal sedation for any child having any procedure anywhere in our hospital.” Today, a child with leukemia undergoing repeated bone marrow biopsies or lumbar punctures has the procedures performed under an IV bolus of

propofol to eliminate pain and discomfort. “When the children come in, they don’t look at a procedure as a negative,” Dr. Cravero said. “They know they’ll just fall asleep and wake up when it’s done.” Currently, the program, which treats approximately 200 children per month, also incorporates the nonmedical virtual distraction techniques, such as digital entertainment—music, DVDs and three-dimensional movies—to help kids through procedures.

“Some children can get pain-free with those types of things alone,” Dr. Cravero said. “We’re always looking for alternatives to medications.” Barrett’s renowned palliative care program, which began 15 years ago, works closely with DartmouthHitchcock’s Cancer Center to provide a wide range of services, including inpatient consultations, outpatient clinic follow-ups, family education, bereavement support and more, to patients facing end-of-life issues.

“If you look at palliative care parameters, such as patients in their last six months of life, and how many days they spend in a hospital, and how many doctors they see, we have the lowest totals of all the medical centers in the United States,” Dr. Fanciullo said. Virtual Tools To Combat Pain Innovation at Barrett isn’t limited to programs. The center has been at the forefront of developing virtual tools to see Barrett page 26

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P A IN M E D I C INE Barrett continued from page 25

way to measure the effectiveness of its interventions and determine how well assess and treat pain. It has created the patients are doing. Computerized Dynamic Assessment “With POET, we can graphically disof Pain and Interactive Computer- play a patient’s pain, quality of life and ized Quality of Life tools to determine functional scores, so we can understand how much pain patients are suffering what’s going on,” Dr. Fanciullo said. “As and how it affects their lives. Its patient- POET grows, along with other mediand clinician-generated Pain Outcomes cal integration software, such as EPIC, Evaluation Tool (POET) is a database we will collect data on thousands more containing information on more than patient visits, giving us an enormous 15,000 patient visits. Launched in 2007, database to determine which intervenPOET gives the center an objective tions are useful and which are not.”

Barrett Pain Management Center’s PainFree Program: Director Joseph Cravero, MD, prepares a pediatric patient for anesthesia prior to surgery.

The Richard Barrett Pain Management Center staff

Tackling Opioid Abuse

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A new initiative on the horizon at the Barrett Center is a protocol, education-based, mid-level provider– directed, cost-neutral opioid clinic that will focus on assessing and monitoring patients on opioid pain relievers. “If you look at the states with the biggest prescription opioid abuse problems, five are in the Northeast,” Dr. Fanciullo said. “With our new clinic, we want to make sure patients who benefit from these drugs continue to receive them safely and effectively, and at the same time, identify people who may be prone to addiction and would do better with treatments other than prescription opioids.” Dr. Fanciullo said he hopes the clinic will make a dent in the serious prescription opioid abuse problem in Vermont and New Hampshire. If it does its job correctly, he said, the clinic may become the sole prescriber of these drugs in the two states. “We believe primary care physicians and other providers would be happy to have somebody else assume this burden, especially if we can do it safer and more efficiently than they can,” he said. The Barrett Clinic also is gearing up for what it sees as changes coming to the pain management market. “We are focusing on accountable care, part of the health care reform package, which offers doctors and hospitals financial incentives to provide good quality care to patients, while keeping down costs,” Dr. Fanciullo said. “A good example is the Kaiser Permanente system in the western United States, where providers are given a certain sum of money to manage a group of patients consistent with ‘best value’—excellent care at the lowest possible cost. “We believe there will be a transformation to this type of care,” he continued, “and we are preparing for it.” —Tom McDonough

Tribute Plan projections are not a forecast of future events or a guarantee of future balance amounts. For additional details, see www.thedoctors.com/tribute.

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P ain M e d icine

Pain Education Lacking in Medical Schools

ain education in North American medical schools is “limited and fragmentary,” according to a study of 117 medical schools in the United States and Canada (J Pain 2011;12:1199-1208). The researchers found that vital curricular pain content is presently going unaddressed. “The more we come to know about what’s being taught in pain, the more glaringly obvious the gap between theory and practice becomes,” said co-author Beth B. Murinson, MD, PhD, associate professor and director of pain education at Johns Hopkins School of Medicine, in Baltimore. Chronic pain affects at least 116 million U.S. adults, many of whom receive inadequate assessment and treatment, according to the Institute of Medicine. The researchers discovered that pain is most often taught in the context of a more general required course that is not focused on pain—an approach the researchers called fragmentary. Among U.S. medical schools,

only 3.8% reported having a required pain course. An additional 16.3% of U.S. medical schools offered a designated pain elective. The total number of pain sessions taught at a single school ranged from one to 28, with a mean of nine and a median of seven. A large number of U.S. medical schools did not report teaching any pain courses and an equally large number commit fewer than five hours to pain education over four years. Steven D. Passik, PhD, professor of psychiatry and anesthesiology at Vanderbilt University Medical Center, in Nashville, Tenn., said, “It is lacking in almost every respect—not enough time spent, not enough breadth of the psychological and other complications of pain, not nearly enough casebased understanding. Given that pain is the most common reason people go to the doctor, it is a travesty that more time is not spent on it.” Areas particularly underserved, said Dr. Murinson, are pediatric pain, cancer pain and medicolegal issues

pertaining to opioids. “There’s literally almost nothing on these topics,” she added. “Kids should not suffer needless pain. And, clearly, cancer patients should not endure untreated pain.” Geriatric pain also is not addressed sufficiently, according to the study. Pain education currently focuses on basic science, but more pragmatic education is needed, according to Dr. Murinson. “There’s a groundswell for more clinically focused education,” she said. The authors recommend that the number of required, integrated, painfocused courses be increased, as part of a more organized, formal delivery of pain education. Dr. Murinson has developed a curriculum for pain, an 18-hour course at Johns Hopkins. Her personal mission is “to understand better how medical students grow and develop as clinicians.” Emotional as well as intellectual skills are important. “We’re asking how to facilitate students’ progress toward becoming

highly compassionate physicians,” she said. Carol Aschenbrener, MD, chief medical education officer at the Association of American Medical Colleges (AAMC), said the new study was limited by the great variability in the extent of data reported by medical schools. (Data from AAMC were used in the study.) “There are many areas where we can improve, and [pain education] is one of them, but we shouldn’t focus just on medical school,” she said. The Journal of Pain study is important, said Dr. Passik, because “it documents just how bad the problem is and gives a recent perspective, i.e., that this problem has been known for a long time. If anyone was laboring under the misconception that it had improved with all the attention to pain that has characterized recent years, this [study] demonstrates that it has not.” —George Ochoa

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T E C H N OL O G Y

Electronic Reminders Improve Accuracy of AIMS-Based Billing

little digital prodding can lead to “tremendous” increases in revenue, researchers have found. By sending the electronic reminders through their facility’s anesthesia information management system (AIMS), researchers at the University of Michigan, in Ann Arbor, tripled clinicians’ compliance with proper documentation of anesthesia start times

and boosted annual reimbursement by more than $450,000. Stephen D. Pratt, MD, chief of the Division of Quality and Safety, and assistant professor in the Department of Anesthesia, Critical Care and Pain Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, said demonstrating that a behavior can be changed

by simple intervention is important. Although reminders were effective in increasing reporting, the paradox is that inaccurate reporting of anesthesia start times is a problem that may be created by an AIMS. “With AIMS, the anesthesia record can only be started by a computer, and in the vast majority of cases, this means that it is not started until the patient

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enters the room,” said Dr. Pratt, who was not involved in the study. “Thus, the prep time needs to be manually adjusted back by up to 30 minutes prior to the room time. On a paper record, boxes exist for prep and operating room and PACU [postanesthesia care unit] entry and exit. These can be completed any time and are less likely to be missed.” Although the Centers for Medicare & Medicaid Services (CMS) specifies that perioperative anesthesia care begins with anesthesia induction preparation, some clinicians underreport the services they provide, said study leader Robert Freundlich, MD, research fellow in the University of Michigan’s Perioperative Outcomes Research Center, part of the Department of Anesthesiology. To improve documentation, Dr. Freundlich’s team sent electronic reminders for accurate start-time documentation in AIMS during 2,091 randomly selected surgeries, including general adult, cardiovascular and pediatric surgeries conducted between March and April 2008. The alerts were sent at the time of surgical incision if the documented anesthesia start time was concurrent with, later than or more than 30 minutes earlier than the documented patient in-room time. Alerts reminded providers to correct the start time to reflect preoperative transport and medication administration time. The researchers compared compliance rates with CMS definitions see accuracy page 30

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TE C H N OL O G Y

AIMS Critical Event Data May Be Flawed, Experts Warn

ore than half of anesthesiarelated critical events requiring manual entry into an anesthesia information management system (AIMS) may go unrecorded, researchers have found. The researchers, who presented the findings from a retrospective analysis at the Society for Technology in Anesthesia’s 2012 annual meeting (abstract 54), said the results indicate AIMS records may not reflect the true incidence of critical events. Richard P. Dutton, MD, MBA, executive director of the Anesthesia Quality Institute (AQI), who was not involved in the study, said the findings confirm that “voluntary reporting of low-risk events is spotty, especially during busy moments in patient care. No system that requires active documentation of an event will ever be 100% accurate. If precise data are required for credible research, for example, then an independent observer is necessary. AIMS can make it easier to report,” Dr. Dutton added. “But compliance with active reporting will always be less than perfect.” Study leader Mohamed Rehman, MD, clinical associate professor in the Department of Anesthesiology and Critical Care Medicine at the University of Pennsylvania School of Medicine, in Philadelphia, said clinicians at his institution are required to report incidents of anesthesia-related critical events through AIMS and to submit continuous quality improvement (QI) reports in some cases.

However, it had been unclear before the study whether the AIMS and QI data accurately reflect the number of critical events. To determine the accuracy of the data, Dr. Rehman, who also oversees his department’s hospital information management system, and colleagues analyzed data from an earlier clinical trial they had conducted. In that study, research assistants

evaluated fasting gastric volumes and the incidence of nausea and vomiting among 995 day-surgery patients. The assistants also were expected to enter the data into AIMS and submit QI reports following institutional protocols. “Given the original study’s parameters, emesis recorded by the research assistants was a true indicator of the event and was used as the

standard of comparison,” Dr. Rehman explained. Dr. Rehman’s group found that the assistants documented eight episodes of induction-related emesis in the clinical trial records, but recorded only three of these in the AIMS. They submitted only one QI report. Statistical analyses determined that see critical page 30

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T E C H N OL O G Y Accuracy continued from page 28

Dr. Freundlich’s analysis, which he presented at the 2012 annual meeting using the reminder system with com- of the Society for Technology in Anespliance in 1,941 procedures con- thesia (abstract 51), showed that comducted during the same period for pliance rates rose from 33.5% (1,063 which no reminders were used. They of 3,169) at baseline to 86.9% (1,818 also included baseline data from of 2,091) with the reminder system. 3,169 cases performed before the In contrast, 40.5% (787 of 1,941) of intervention period, during which all control group participants accurately anesthesia staff received emails and documented anesthesia start times were urged at meetings to document compared with the intervention group anesthesia start times according to (P<0.001). The percentage did not CMS definitions. change meaningfully over time.

Compliance rates continued to rise, reaching 91.6% (2,676 of 2,921) during a two-month period following the randomization period, when all providers received alerts (P<0.001 compared with baseline). Furthermore, the intervention had significant residual effects, with 85.1% (3,319 of 3,900) of providers accurately documenting start times three years after the alerts were discontinued (P<0.001 compared with baseline). A financial analysis conducted by

the researchers showed that average billing time increased by more than five minutes per case, translating into an estimated $471,117 in additional annual revenue. The one-time cost of instituting the reminders, including the computer programmer, was about $1,400, Dr. Freundlich said. “The ability to generate automated reminders that result in significant increases in billing may lead even more practices to implement an AIMS,” he said, “particularly if their existing reservations about adoption are largely financial.” —David Wild

Critical continued from page 29

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AIMS was 38% sensitive (95% confidence interval [CI], 8.5%-75.5%) and 100% specific (95% CI, 99.6%-100%), and had a positive predictive value (PPV) of 100% (95% CI, 29.2%-100%). Quality improvement reports were 13% sensitive (95% CI, 0.3%-52.7%) and 100% specific (95% CI, 99.6%-100%), and had a PPV of 100% (95% CI, 2.5%-100%). There were not enough cases of emesis to determine the negative predictive value of AIMS, Dr. Rehman said. Given that the study used research assistants and not clinical anesthesiologists, the extent to which the current findings reflect AIMS and QI reporting practices among anesthesiologists requires further research, the investigator noted. However, he said, “Our results indicate there is under-reporting of significant events and suggest that user-dependent reports extracted from AIMS records may not be a reliable source for either realizing the occurrence of clinical events or conducting outcomes research. “One approach to improving the reporting rate might be to reduce the amount of text the user has to enter and to increase the amount of discrete data to include more binary questions, for example,” Dr. Rehman added. Dr. Dutton said “voluntary reporting will increase if clinicians appreciate that the data are being used in a non-punitive way to improve patient care. This is the goal of any quality management professional, namely to create a culture of safety in the practice.” —David Wild

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AnesthesiologyNews.com I 31

The following advertorial has been provided by APP Pharmaceuticals and is designed to support the advertisement presented below.

NAROPIN® is indicated for the production of local or regional anesthesia for surgery and for acute pain management. Q. How does NAROPIN compare with bupivacaine in terms of motor function? A. NAROPIN, at equipotent doses to bupivacaine, provides faster return of motor function with effective sensory block.1-3 Data shows that NAROPIN demonstrated 8 to 10 hours faster return of motor function vs bupivacaine (P<0.05).1

Q. In the labor and delivery setting, how does NAROPIN compare with bupivacaine?

concentrations of epidural ropivacaine for cesarean section. Anesthesiology. 1995;82:1346-1352. 5. Crosby E, Sandler A, Finucane B, et al. Comparison of epidural anaesthesia with ropivacaine 0.5% and bupivacaine 0.5% for caesarean section. Can J Anaesth. 1998;45:1066-1071. 6. Griffin RP, Reynolds F. Extradural anaesthesia for caesarean section: a double-blind comparison of 0.5% ropivacaine with 0.5% bupivacaine. Br J Anaesth. 1995;74:512-516.

7. Aşik I, Göktuğ A, Gülay I, Alkiş N, Uysalel A. Comparison of bupivacaine 0.2% and ropivacaine 0.2% combined with fentanyl for epidural analgesia during labour. Eur J Anaesthesiol. 2002;19:263-270. 8. 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. 9. Hickey R, Hoffman J, Ramamurthy S. A comparison of ropivacaine 0.5% and bupivacaine

0.5% for brachial plexus block. Anesthesiology. 1991;74:639-642. 10. Rawal N, Allvin R, Axelsson K, et al. Patient-controlled regional analgesia (PCRA) at home: controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia. Anesthesiology. 2002;96:1290-1296. 11. 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.

A. NAROPIN restores motor function faster3-8 and improves labor and delivery outcomes.3,7,8 • 51% of mothers who received NAROPIN had less intense motor block compared to 42% with bupivacaine (P<0.05)8 • NAROPIN patients experienced 96 minutes faster recovery of motor function after complete paralysis following C-sections vs bupivacaine (P<0.05)5 • NAROPIN produced effective onset of anesthesia, duration of sensory blockade, and quality of analgesia6 • An 18% higher proportion of spontaneous vaginal deliveries was observed in patients who received NAROPIN vs bupivacaine (P<0.05)8 • NAROPIN was associated with a 32% lower proportion of instrumented deliveries vs bupivacaine (P<0.01)8

Q: How does NAROPIN compare with bupivacaine in terms of efficacy of analgesia and patient satisfaction? A. NAROPIN, at equipotent concentrations to bupivacaine, delivers effective analgesia1,3,9-11 and greater patient satisfaction.3,10,11 • 18% to 52% faster onset of analgesia vs bupivacaine, with an equal mean duration of 13 to 14 hours9 • Significantly less initial morphine use (2.8 mg vs 5.9 mg) compared to bupivacaine patients in the postop recovery room (P<0.05)1 • Significantly more patients were satisfied with the analgesic efficacy of NAROPIN—an 81% satisfaction rate vs 52% for bupivacaine (P<0.05)10 • 93% of NAROPIN patients rated their overall anesthesia experience as excellent vs 73% of bupivacaine patients (P<0.05)11

NAROPIN® delivers effective analgesia and improves patient satisfaction vs bupivacaine.1-3 A Block Well Done.

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. Morrison LM, Emanuelsson BM, McClure JH, et al. Efficacy and kinetics of extradural ropivacaine: comparison with bupivacaine. Br J Anaesth. 1994;72:164-169.

93% of NAROPIN patients rated their overall anesthesia experience as excellent vs 73% of bupivacaine patients (P<0.05).2 To learn more about the clinical beneﬁts of NAROPIN, visit www.naropin-us.com.

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

3. NAROPIN® Prescribing Information. Data on file. 4. Datta S, Camann W, Bader A, VanderBurgh L. Clinical effects and maternal and fetal plasma

Using NAROPIN beyond recommended doses to increase motor block or duration of sensory block may negate its favorable cardiovascular advantages, in the event that an inadvertent intravascular injection occurs.

NAROPIN is indicated for the production of regional or local anesthesia for surgery and for acute pain management. References: 1. Rawal N, Allvin R, Axelsson K, et al. Patient-controlled regional analgesia (PCRA) at home: controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia. Anesthesiology. 2002;96:1290-1296. 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. NAROPIN Prescribing Information. Data on ﬁle. Naropin® and logo are registered trademarks of APP Pharmaceuticals, LLC. and APP ® are registered trademarks of APP Pharmaceuticals, LLC. ©2011, APP Pharmaceuticals, LLC. All Rights Reserved. 0191-NAR-05-5/11

WHY COMPROMISE?

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PRN

Heart Gene May Predict CABG Outcomes for Women Chicago—Increased expression of a key protein in heart muscle appears to aggravate the extent of damage to the organ during bypass surgery and may predict long-term survival after the procedure, at least in women, German researchers have found. The protein, myocardial Gq, transduces signals of angiotensin II, norepinephrine and other hormonal

regulators of cardiac function. Researchers from University Hospital Essen found that in women undergoing coronary artery bypass graft (CABG) surgery, increased expression of Gq was linked to sharply elevated levels of troponin I, a marker of myocardial damage (Figure 1). “Understanding gender differences in outcomes after CABG is important

Naropin

(ropivacaine HCl) Injection

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

for their health implications,” said Ulrich Frey, MD, assistant professor of anesthesia at University Hospital Essen, who led the study. “Our data shed new light on the pathophysiologic role of increased Gq expression in ischemic cardiac disease, and may help identify patients at high risk for cardiac death after CABG operations who may need additional treatment.”

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

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

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

Naropin total N=1661

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

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

Bupivacaine total N=1433

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

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

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

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

Naropin total N=1661

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

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

Bupivacaine total N=1433

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

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

APP Pharmaceuticals, LLC

0191-NAR-05-5/11

Rev. 11/08

In previous work, Dr. Frey’s group identified a polymorphism in the human GNAQ promoter gene. Th e y also showed that the polymorphism was linked to Ulrich Frey, MD cardiac hypertrophy—particularly in women. The latest study, presented at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 446), sought to test whether the GNAQ polymorphism is associated with sex-specific differences in myocardial Gq protein expression, myocardial damage after CABG and mortality one year after surgery. The investigators took tissue samples from the right atria of 48 patients undergoing CABG. Western blot analysis showed genotype-dependent Gq expression in women, but not men. Perioperative myocardial injury was investigated in 227 consecutive patients undergoing CABG. Baseline characteristics between GNAQ genotypes were similar. However, preoperative ejection fraction was significantly higher in women. Serum concentrations of troponin I before surgery did not differ between genotypes, regardless of sex. But postoperative analysis showed higher concentrations of the marker in women with the GC/GC phenotype, followed by GC/TT and TT/TT, with a gene-dose effect (P=0.03; Figure 2). “This was only true for female patients,” Dr. Frey noted. “We did not observe any differences in postoperative troponin I values in male patients.” In women, the area under the curve for troponin I serum concentrations more than 96 hours after CABG was almost three times as high in the GC/GC genotypes (643±700 ng/ mL) than in the GC/TT (280±223 ng/mL) and TT/TT genotypes (231±191 ng/mL; P=0.024). The researchers also sought to determine the effect of the Gq polymorphism on long-term survival. “When we looked at one-year survival, there were 11 deaths, ” Dr. Frey explained. “And we found a trend of genotype-specific survival in the different groups.” One-year mortality

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AnesthesiologyNews.com I 33

PRN Angiotensin II

Endothelin

Phenylephrine

EGF/PDGF

Confidence for Every Intubation

Ca2+

PLC-β

Gq/11

DAG

IP3

PKC

Ca2+

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Effectors

Leviitan Levitan FPS FP PS

Figure 1. Increased expression of Gq was linked to sharply elevated levels of troponin I. Men

Women GNAQ • GC/GC • GC/TT • TT/TT

cTnl, ng/mL

P=0.03

GNAQ • GC/GC • GC/TT • TT/TT

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Figure 2. After surgery, women wiht the GC/GC phenotype had the highest serum concentrations of troponin I. cTnI, change in troponin I

was significantly associated with genotype in women (GC/GC patients, 22%; GC/TT patients, 0%; TT/TT patients, 0%; P=0.026). Mark Stafford-Smith, MD, director of the cardiothoracic anesthesia fellowship at Duke University Medical

Center in Durham, N.C., noted that the researchers did not conduct a multivariable analysis that included relevant clinical factors, particularly ejection fraction.

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Anesthesiologist’s Manual of Surgical Procedures: Fourth Edition

Richard A. Jaffe; Stanley I. Samuels Lippincott Williams & Wilkins, February 1, 2009 This practical full-color reference is a comprehensive guide to the anesthetic and perioperative management of patients during all procedures performed by general and subspecialist surgeons.

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Anesthetic Management of the Obese Surgical Patient Jay B. Brodsky; Hendrikus J.M. Lemmens

Cambridge University Press, January 16, 2012 The management of obese and morbidly obese patients differs significantly from that of normal-weight patients undergoing the same procedure. Anesthetic Management of the Obese Surgical Patient discusses these specific management issues within each surgical specialty area.

Atlas of Ultrasound-Guided Regional Anesthesia: Expert Consult—Enhanced Online and Print

Andrew T. Gray, MD Elsevier/Saunders, October 15, 2009 Dr. Gray, a pioneer of ultrasound guidance in regional anesthesia, demonstrates step-by-step a full range of nerve block techniques designed to help you improve the quality and success rate of regional blocks. A companion Expert Consult site features videos of regional blocks performed under ultrasound guidance.

Basics of Anesthesia: Expert Consult: Online and Print, Sixth Edition

Ronald D. Miller; Manuel Pardo

First Aid for the Anesthesiology Boards

Himani Bhatt; Karlyn J. Powell; Dominique Aimee Jean McGraw-Hill, July 22, 2010 Written by a team of residents from St. Luke’s-Roosevelt Hospital Center, this is a guide to success on the anesthesia boards and in-service exams. The books presents quick, frequently tested, high-yield facts based on the most recently administered exams. Students will find this helpful for initial and last-minute exam review and anesthesiologists will find it valuable as a refresher before recertification.

Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia

Admir Hadzic McGraw-Hill, December 7, 2011 Featuring sections that progress from the foundations of regional anesthesia to the clinical applications of nerve blocks, this book includes tips and insider perspectives from the leadership of The New York School of Regional Anesthesia and its academic affiliates. The book includes an atlas of ultrasound anatomy for regional anesthesia and pain medicine.

Handbook of Pain and Palliative Care: Biobehavioral Approaches for the Life Course

Rhonda J. Moore Springer, January 31, 2012 This book meets the needs of this growing field by taking both a biobehavioral and a lifespan approach to understanding long-term and chronic pain and intervening to improve patients’ optimal functioning.

Surgical Palliative Care and Pain Management, An Issue of Anesthesiology Clinics

Elsevier/Saunders, June 24, 2011

Geoffrey Dunn Elsevier/Saunders, March 28, 2012

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This issue of Anesthesiology Clinics covers the most important advances in surgical palliative care for anesthesiology intensivists. Topics covered include palliative care of patients on high doses of narcotics, trauma in the surgical ICU and care of the family in the surgical ICU. AN0512

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Scoring System Offers Clues to SICU Mortality