June 2013 by McMahon Group

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THE INDEPENDENT MONTHLY NEWSPAPER FOR ANESTHESIOLOGISTS AnesthesiologyNews.com • J u n e 2 0 1 3 • Volume 39 Number 6

Liver Transplant Anesthesia Guidelines A ‘Landmark’

Marathon Bombing Put Local Anesthetists to Grim Test

xperts are applauding new recommendations for the administration of anesthesia during liver transplant surgery that offer formal recognition that anesthesiologists are critical to optimizing transplant patient care. The document, from the Organ Procurement and Transplant Network (OPTN)/United Network for Organ Sharing (UNOS), set qualification requirements for directors of liver transplant anesthesia. “The recommendations are really a landmark development in

Boston—Anesthesiologists who treated victims of the Boston Marathon bombing in April could not bring themselves to find a silver lining. Terrorist attacks have no silver linings. But the clinicians who spoke with Anesthesiology Newss about their experiences allowed that if such an event were to happen, it could not have happened in a better place at a better time or in better weather. The finish line where the twin bombs exploded is within two miles of five worldclass trauma centers. The attack took place just before 3 p.m., shift change time at most of the hospitals, so many workers were just arriving while the previous shift was still on duty or nearby. It was Patriots’ Day,

see organs page 18

see Boston page 25

Breathing for Two: A Life in Anesthesiology

Drug shortages and medication errors a bad mix.

10 | PAIN MEDICINE Sternotomy pain after CABG can sap daily living.

EDUCATIONAL REVIEW

Perioperative Approach to Patients With Opioid Abuse and Tolerance, see insert at page 14.

16 | CLINICAL ANESTHESIOLOGY Common colds pose uncommon problems in pediatric heart surgery.

The second Viking term was fey, and this was new to me. Here is what Sandlin wrote: People now understand [ fey] to mean effeminate. Previously it meant odd, and before that uncanny, see breathing page 6

E-NEWSLETTER

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INSIDE 08 | PRN

The following is the third in a three-part - t installment of excerpts from Breathing for Two, o a new memoir on a career in anesthesiology, by Wolf Pascoe (a pen name). The book is available at http://www.amazon.com/dp/ 1939803012 and wolfpascoe.com. once read an essay titled “Losing the War” whose relevance will become apparent shortly. The author, Lee Sandlin, was writing about the psychology of war. The essay appeared in the Chicago Readerr in March 1997. In his essay, Sandlin proposed that the mindset of war could be best explained by two Viking terms. The first term was berserker, familiar to me as a man in battle who killed without restraint.

REUTERS/Jessica Rinaldi

Accompanies this issue

CME: PREANESTHETIC ASSESSMENT Lesson 304: Perioperative Pain Management Of the Patient With Chronic Pain—Part 1, see page 20.

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Heard Here First: Compared with a patient who develops an injury after a car accident, with surgical patients June 2013

The five most-viewed articles last month on AnesthesiologyNews.com 1. Suite Strife: Offing Older Anesthesiologists 2. Small Florida Pain Center Looms Large in Fight Against Chronic Pain 3. The Boldt Affair: A Quandary for Meta-Analysts 4. Another Benefit of Daily Aspirin: Better Outcomes After Trauma 5. Telomere Length Linked to Fibromyalgia Pain

we know when our patients are going to get injured, and we know what type of injury is going to occur: the surgery. So, I think our goal will be to study surgical patients and evaluate their pain responses when they don’t have this premeditated injury, then follow them through the postoperative period in the hope that we can

to predict

chronic postsurgical pain and the factors related to its development.

SEE ARTICLE ON PAGE 12.

Reader Survey Contest Winner

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Megan Gayeski, MD, has won a $500 American Express gift card for participating in the 2013 Readex reader survey. Dr. Gayeski is a CA-1 in the Categorical Anesthesia program at Rush University Medical Center, in Chicago.

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AD LIB BREATHING

CONTINUED FROM PAGE 1

fairylike. That was back when fairyland was the most sinister place people could imagine. The Old Norse word meant “doomed.” It was used to refer to an eerie mood that would come over people in battle, a kind of transcendent despair…. Sometimes men say afterward that the most terrifying moment of any battle is seeing a fey look on the faces of the soldiers standing next to them. I’ve never been in combat. When I read those words I had no feeling for what fey meant in a practical sense. It seemed to have nothing to do with me, as my life was far removed from a battlefield. But that was before the day I met Sam, with whose airway I fought a losing battle. This is what happened: Sam was to undergo a minor urology procedure. (What is it about urology procedures and airways? I don’t know.) Sam was a cheerful, healthy man of forty-six. I performed my usual preoperative physical exam. Although Sam was heavyset, nothing during my exam warned of a difficult airway. I planned to do the case with a mask, allowing Sam to breathe spontaneously. After I gave Pentothal, Sam stopped breathing. This was a normal and temporary side effect of the drug—the respiratory center on hold. I put an airway in Sam’s mouth and positioned the anesthesia mask over his face, pressing the mask down to seal it against the skin. I squeezed the bag to push some air into Sam’s lungs, my usual procedure. Nothing happened. I repositioned the mask and tried again, hooking one finger around the angle of Sam’s jaw and lifting to clear the airway. Still, no oxygen got to his lungs. Then I did something inexplicable. Instead of waiting for breathing to start up on its own (which it always does), I felt the soft tissue in Sam’s neck and decided he’d be easy to intubate. I gave him the standard paralytic agent, Anectine, to relax his airway muscles and facilitate intubation. I inserted my laryngoscope. To my surprise, I couldn’t find the vocal cords. The right angle of Sam’s airway was too severe. I couldn’t see around it. I shoved the tube in anyway, hoping it would find its way by blind luck. But it was obvious when I tried to ventilate through it that the tube was in the esophagus. Agitated now, I pulled the tube out and reapplied the mask. I still couldn’t ventilate Sam by mask. Neither could

I intubate him. And he was now completely paralyzed. Sam’s respiratory center by now had started up again and was signaling his diaphragm to breathe. But the Anectine was blocking the message from getting through. Can’t intubate, can’t ventilate, paralyzed patient—the most dire airway emergency. The oxygen saturation started to fall. Besides displaying the saturation on a monitor, pulse oximeters emit a short tone coincident with every heart beat. If the saturation is high, the tone pitch is high. If the saturation falls, the tone falls in pitch. The effect of hearing a beatby-beat drop in pitch is alarming, and it’s intended to be. The room now filled with a series of falling tones, the sound of Sam’s blood turning blue. “What can I do?” said the nurse. “Get help,” I said. My insides turned buttery as I began to grasp the magnitude of my error. It was cardinal and unforgivable: I had paralyzed a patient whom I couldn’t mask. It was something I’d been taught not to do, and I’d never done before or since. To this day, I can’t say precisely what provoked this lapse. But lapse is too kind a word. Hubris, the Greeks might have called it. Delirium is more like it. Had there been time to call a surgeon to do a tracheotomy, I would have considered it. But there was no time. I had four minutes before Sam’s brain cells would start to die. I’d already used up two of them. One available instrument might have helped, a flexible fiberoptic laryngoscope. This was a long, thin tube through which light could bend and around which an endotracheal tube could slide. With fiberoptics, reluctant vocal cords could sometimes be coaxed into view. But the fiberoptic laryngoscope was a new device, extremely difficult to use, and I wasn’t familiar enough with it. I’ve since learned to use the fiberoptic scope, and other similar airway tools that were about to come into existence. But face masks, ordinary laryngoscopes, and tracheotomies were pretty much the whole show then. Hardly an arsenal, you’d think, to justify overconfidence. Except in a fool.

The pitch of the pulse oximeter continued its dismaying fall. The saturation was now 60%. I continued trying to force air into Sam’s lungs without success. The room was a blur. The nurses probably continued to ask me ques-

hold sacred. How could I abandon my patient? How could I stop caring and stop trying? I can’t tell you how. I can only tell you that there was no defense against it. I understand now that what I was feeling was fey. And I also understand

tions and I might have answered, but I don’t remember. I groped for an idea, but none came, other than the idle thought that maybe the Anectine, which generally lasts five to ten minutes, would wear off before it was too late. But Sam still couldn’t breathe. He would die and I would be the cause. I looked at the saturation. It was 40%. I had never seen it that low. Sam’s blood was mostly empty of oxygen. But you didn’t need an oximeter to know that. Sam was blue now. The ship was going to the bottom. Then a strange thing happened. Something in my soul gave. I felt my heart slow and my head clear. The panic subsided, along with the desire to do anything at all. I watched Sam’s cyanotic body, the color of a moonlit sea, without alarm. There was nothing to be done. Sam would die. That was all right. None of this was a conscious decision on my part. I wasn’t trying to rationalize. It happened in my body. My body surrendered. It was a great relief. I was at peace. You might say it was the final humility. I had never felt this way before or since. The experience was singular. As I read what I’ve written, it seems terrible to me now—a breach of the Hippocratic oath, a denial of everything I

why the most terrifying thing in battle is to see a fey look on the soldier next to you. It’s total surrender to the unbearable. Fey is probably what happens to captains who go down with their ships. Lee Sandlin, whose essay I quoted from previously, thinks it happens to whole nations on the brink of losing a war. In the middle of that eerie doom the door of the room burst open. … In the last quarter of the twentieth century, two developments in

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particular have dramatically improved airway safety. The first, which I mentioned in connection with Sam, is fiberoptics, the technology of bending light. As ingenious as ordinary laryngoscopes have become, some airways remain impenetrable to them. It turns out that not all right-angled paths are alike. In some patients, the angle is less severe and the vocal cords at the end of the path are fairly easy to visualize. In other patients—Rose and Sam, for example—the turn is sharper, and the vocal cords cannot be coaxed into direct view by any laryngoscope blade. It’s hard to pass a breathing tube through a pathway you cannot see. But if a severely curved laryngoscope blade is constructed with embedded fibers that conduct light, then it becomes possible to see around an extreme airway bend. The vocal cords become visible by looking through the optical fibers.

The first fiberoptic laryngoscopes were crude and difficult to use, much as the first direct laryngoscopes were. But they got better. Today fiberoptic laryngoscopes, which come in various shapes and sizes, have a place on every anesthesiologist’s cart. One other late twentieth century airway development had an important impact on anesthesia safety. It was an improvement on the standard anesthesia mask, the kind of mask I used on Otto and Rose—and that didn’t work on Sam. You might suppose from the difficulties I’ve described that the standard anesthesia mask leaves something wanting in the way of airway management. After all, if it’s so easy to lose control of an airway using an anesthesia mask, why not simply put a full-fledged breathing tube in every patient? There are three reasons not to do this. First, the stories of Otto, Rose, and Sam are unusual. Most of the time, face masks work, at least for a while. Second, intubation is more invasive than masking. It irritates the trachea and calls for deeper anesthesia. You like to avoid it if you don’t really need it. Finally, a severe right-angled path makes some patients (such as Otto

and Rose, for example) very difficult to intubate. Dr. Archie Brain, an aptly named British anesthesiologist with an inventive streak, is in full agreement about the problems of the anesthesia mask. The mask had been around for the better part of a century when Dr. Brain began to think about improving it. But instead of simply tinkering, he had the idea to abandon it completely. What if, Dr. Brain reasoned, instead of applying a mask to the face to cover the mouth and nose, he applied a smaller mask insidee the mouth—all the way at the back of the throat—to go around the right angle and cover the larynx directly? Such a device would obviate the problem of the tongue falling back to obstruct the airway. Rather than being a face mask, the new gadget would be a laryngeal mask. A laryngeal mask wouldn’t pass between the vocal cords and into the trachea, like an endotracheal tube does. Instead, it would sit on top of the larynx without going in, just as a standard mask covers the face without going in the mouth. But it would protect the larynx from a fallen tongue. Dr. Brain began to experiment with

cadavers to see whether he could devise a shape that would work. He settled on an oblong form for his new mask— elliptical at one end, tapering to a point at the other. He attached an inflatable cuff around the perimeter and fastened a semi-rigid plastic tube to the mask. The tube ran from the mask (which sat just above the vocal cords), around the right-angled path of air, out the mouth, and connected to the breathing circuit. Archie Brain called the device the LMA—the laryngeal mask airway. An LMA is easy to put in. You don’t need a muscle relaxant. You insert it into the mouth of a sleeping patient and push it to the back of the throat until it dead-ends at the tracheal inlet over the vocal cords. Then you inflate the cuff. With the LMA you don’t need to see a thing. You don’t need to see around the right-angled path. You put it in by feel. The laryngeal mask provides a better path for air than a standard mask and does so consistently and reliably. The airway is better because with the LMA, it doesn’t matter if the tongue and mouth tissue fall back in the throat— oxygen is traveling through the plastic tube of the LMA. Introduced over two decades ago, the LMA became immediately popular with anesthesiologists. It’s such an improvement that I rarely do a case now with a face mask. In the years since I began using the LMA, I’ve had only one patient I couldn’t ventilate with it, and that was probably caused by my inexperience. I still use a face mask at the beginning of every general anesthetic, but only to ventilate with pure oxygen for a few moments before either intubating or putting in an LMA. If I can’t ventilate with a face mask, I immediately switch to an LMA, even if I eventually want to put in an endotracheal tube. You can count on the LMA in a way you could never count on a face mask. The laryngeal mask has smoothed out anesthesia for thousands—maybe millions—of patients. It’s also saved lives. I wish I’d had it as a resident. An LMA wouldn’t have solved Rose’s airway problem—she needed to be intubated. But it would have worked for Otto and Sam and rendered their stories mundane and boring. And mundane, boring stories—not interesting ones—are the ideal in an operating room.

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PRN

A Dangerous Interplay: Rx Shortages and Med Errors

uring two months starting in November 2010, more than 200 patients at seven hospitals in the MedStar Health system in the Maryland and Washington, D.C., region received double their prescribed concentration of potassium acetate. In response to a shortage of the usual stock dose of the drug (2 mEq/mL), MedStar acted to fill the gap by procuring vials containing a 4-mEq/mL solution. The wrong concentration was entered into the IV compounder software, which then identified the new vials as containing the lower dose, and the drug was administered to patients receiving total parenteral nutrition. No patients experienced injuries or medical abnormalities, which is one reason the mistake went undetected for so long. That the error occurred is disturbing, but unfortunately no longer surprising in a time when medication errors are rampant. Yet something sets this event apart beyond its scope and duration: MedStar chose to allow non-MedStar colleagues to observe its failings, its investigation and the changes it implemented to increase medication safety. “We knew this error could happen anywhere because the compounding device we used is common and the problems with drug shortages are everywhere,” said Bonnie Levin, PharmD, MBA, corporate assistant vice president of pharmacy services at MedStar Health. “We didn’t want this happening at another hospital; we want others to learn about the approach we took to identify and fix the problem and prevent it from happening again.” The incident was central to a session at a meeting in December of the American Society of Health-System Pharmacists (ASHP) that explored the link between drug shortages and medication errors and how hospitals can mitigate their negative impact. In addition to Dr. Levin, the speakers at the session included Michael R. Cohen, RPh, MS, ScD, president of the Institute for Safe Medication Practices (ISMP), and Terry Fairbanks, MD, associate professor of emergency medicine at Georgetown University, in Washington, D.C., and director of the National Center for Human Factors Engineering in Healthcare (NCHFEH), a division of MedStar Health. Rapid Response Team “This is a rare situation where an entire health system allowed its staff to step forward and teach others what

they went through,” Dr. Cohen said. “I’m sure it was embarrassing to go public with this event and I hope they get credit for stepping up like this.” ISMP representatives, Dr. Fairbanks and other consultants from the NCHFEH were part of a response team summoned by MedStar within a day or two after the error was discovered. They worked closely with hospital clinicians and administrators to determine the cause of the error, examine IV compounding policies and procedures, and offer recommendations to decrease the risk for future errors. The ISMP reviewed every step of the

a prominent role. For instance, Dr. Cohen and his ISMP colleagues found that staff members were not always aware of the reasons for changing processes within the IV admixture service, and that a systematic approach to communication about shortages and product changes with staff was lacking. “Communication always turns out to be a major issue when the ISMP conducts consultations,” Dr. Cohen said. “Everything from the way orders are communicated by computers, the way drugs are listed on a screen, lookk alike drug names, handwriting problems, abbreviations, verbal orders, telephone

IV admixture process, from drug procurement, labeling and packaging, to communication issues, staffing competency and education. Among their findings: • Pharmacy staff focused on the ingredient name and the volume of the container, but not the concentration. Moreover, a high level of trust among the staff led to expectations that mistakes would occur at an unrealistically low level, which can lead to cursory checks of drug and patient information. • Buyers did not routinely inform the pharmacy supervisor when alternate products were purchased. • The purchased strength was not contained on log sheets and an assumption was made that 2 mEq/mL was received. • Most items stored in the drug room are high-alert medications; therefore, labeling them as such does not provide any additional safety benefit. • There was no standardized process that incorporated a printed checklist to validate that whatever changes are made to the databases are correct. Communication lapses played

orders, the way we speak with one another—all that falls under communication. In this case, the health system’s purchasing department knew it was buying the higher concentration because that’s all they could obtain, but that information never reached the people who make the adjustments in the automated compounder system.” Dr. Cohen urged health systems to use the ISMP’s “Ten Key Elements” of the medication-use system when evaluating pharmacy processes. “The Ten Key Elements offers a template for designing an interlocking system of safety checks and balances that is very helpful when alternative drugs are brought in,” Dr. Cohen said. “Hospitals will want to know what it has to teach the medical and nursing staffs about a drug in order to monitor it because it’s different.” ‘Inattentional Blindness’ To Blame Dr. Cohen also discussed the role of “inattentional blindness” in medication errors. The phenomenon occurs when someone performing a task fails to see what should have been plainly visible.

Later, the individual cannot explain the lapse. Inattentional blindness certainly played a part in the MedStar incident, because clinicians repeatedly looked at the stock drug vial but did not register the new drug concentration on the label, Dr. Cohen said. Inattentional blindness has been the culprit in many errors documented by the ISMP, such as when a nurse pulled a vial of heparin from an automated dispensing cabinet, read the label, prepared the medication and administered it intravenously to an infant, despite the heparin concentration being 1,000 times greater than prescribed. The child died. In another event, a pharmacist entered a prescription for methotrexate into the pharmacy computer daily. A dose warning appeared on the screen, which the pharmacist read and bypassed, leading to a fatal overdose. According to a 2009 ISMP Medication Safety Alert, “In many cases, people involved in the errors have been labeled as careless and negligent. But these types of accidents are common—even with intelligent, vigilant and attentive people. The cause is usually rooted in inattentional blindness, a condition all people periodically exhibit.” Dr. Fairbanks identified root causes of the MedStar incident from the vantage point of safety engineering. He found, for example, that the staff exhibited decreased sensitivity to changes after long-term drug shortages; to facilitate bar-code scanning, vials at the compounding station were hung upside down with labels turned away from the operator; and nonformulary drug concentrations were stored on formulary drug shelves. He also noted that a change in a drug’s concentration is a rare and, therefore, unexpected event— one that individuals are unlikely to detect unless forewarned. Among his group’s recommended corrective actions were measures to restrict access to the IV compounder database; define a formulary list in the drug purchasing system (purchasing outside of which required the buyer to involve the pharmacist); procedural review and revision; staff retraining and re-education; and promoting a culture of continual feedback among staff. More broadly, he emphasized that the success of medication safety hinges on designing systems that compensate for inevitable human error—a tenet that is central to human factors engineering. “The key to designing

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PR N safe systems is to design them around human performance and failings,” he said. “You can’t teach humans to not make mistakes; they’re an underlying fact of life, so we design systems to mitigate for inevitable errors.”

ignoring policies can still result in dis- Culture and transparency within MedStar that empowered the people ciplinary action. “If the leadership changes the way involved in the incident to openly disthey approach safety, then front-line cuss errors and system shortcomings people will change their approach as with managers without fearing unfair well,” Dr. Fairbanks said. “It’s a huge repercussions, Dr. Fairbanks said. change of culture and it allows people “Our hospital isn’t different from any Lessons From Other to be more comfortable talking about other, and this could happen anyIndustries their errors, which allows for learning where,” he said. “We didn’t injure a For decades, human factors engi- and mitigation of those errors. It alters patient, but someone else could injure neering has been a fixture in high- the entire tone of discussion and the a patient, so we have a duty to report it and talk about it.” risk, high-consequence fields like environment.” aviation, nuclear power and the milIt was the intersection of Just Another reason that human factors itary. Only recently has it begun to rise within health care, Dr. Fairbanks said. “Health care has not become any safer since the 1999 Institute of Medicine report, To Err is Human, probably because we continue to take the misguided approach that if there’s a human error involved in an adverse event we can prevent it from happening again by telling other clinicians not to make that same mistake, or by disciplining or punishing the person who made the mistake.” A far more realistic and effective strategy, he noted, is to approach safety breaches with the attitude that if it happened once it will happen again, then take steps to make sure that when the error is repeated it won’t affect the patient. To make the case that safety improvements need to be targeted toward systems and not individuals, Dr. Fairbanks, a licensed pilot, noted that an average of four communications errors occur between pilots and air traffic controllers every hour on every commercial airliner. “Yet we hardly ever crash a plane anymore” because aviation safety adjusts for human imperfection, he noted. But changing the entrenched way of thinking about safety will take some time. “It’s hard to change the culture in health care, where we really want to blame someone and punish them when something goes wrong,” Dr. Fairbanks DISPOSABLE PAIN PUMPS said. “If our answer to patient safety is to stop humans—even those who are ® ® Introducing the ARROW FLEXBLOCK very well trained—from making mistakes, we’re going to fail.” echogenic continuous peripheral nerve block catheter

are so important in health care, noted Medstar Health’s Dr. Levin, is because “we have cobbled together over the years a collection of different technologies that don’t integrate with each other very well. At each point, there is an opportunity for a human intervention, and, therefore, an error. Human factors looks at the whole picture and tries to understand all of it, identify where the weak points are and strengthen them.” —Steve Frandzel

Post-Op Pain Has met its match

A Just Culture One approach is to adopt the concept of Just Culture, in which individuals are provided with the knowledge to act safely and are encouraged—even rewarded—for upholding safety standards, including reporting their own errors. In other words, people must feel secure that there will be no disproportionate consequences for doing the right thing. Yet they will still be held accountable for their actions, and ongoing infractions or purposefully

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Pain Post-CABG Sternotomy: Prevalent and Relevant to Patients Miami Beach, Fla.â&#x20AC;&#x201D;Nearly one-third of patients experience moderate to severe chronic pain following coronary artery bypass graft surgery with sternotomy, a long-term followw up survey has found. Many of these patients do not seek medical attention to manage their pain, which they often describe as burning, shooting or constant aching. For this and other reasons, post-sternotomyy pain after coronary artery bypass graft (CABG) procedures may be underrecognized and undertreated, researchers said. â&#x20AC;&#x153;We donâ&#x20AC;&#x2122;t ask, the patients donâ&#x20AC;&#x2122;t offer and weâ&#x20AC;&#x2122;re more interested in outcomes like strokes, deaths and recurrence of angina or heart-related chest pain,â&#x20AC;? study co-author Dimitri Petsikas, MD, attending surgeon at Kingston General Hospital in Ontario, Canada, told Anesthesiology News. â&#x20AC;&#x153;Surgeons donâ&#x20AC;&#x2122;t see it as an issue, whereas the patients do see it as an issue because it affects them every day,â&#x20AC;? said Dr. Petsikas, who also is associate professor of surgery at Queens University in Ontario. Dr. Petsikas and his colleagues called 100 patients six to 18 months after they underwent CABG with sternotomy at their institution in 2011. Thirty patients (30%) reported chronic poststernotomyy pain. The researchers asked about post-sternotomyy pain and use of health care. They also assessed pain severity and its effect on daily activities using the Short-Form McGill Pain Questionnaire and the Brief Pain Inventory interference subscale. The researchers defined chronic poststernotomyy pain as pain at the surgical site that persisted for six months or more and was distinct from preoperative pain. Pain scores greater than 4 on a 0 to 10 rating scale were considered moderate to severe. Of the 30 patients who reported chronic pain, 11 (37%) reported moderate to severe pain as their worst level of discomfort in the previous 24 hours. In addition, half described moderate to severe pain during movement. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s distinct from angina-type pain,â&#x20AC;? Dr. Petsikas said. â&#x20AC;&#x153;It is not exerciserelated and is more movement-related, in the sense that it can come on spontaneously but itâ&#x20AC;&#x2122;s not related to any exertion.â&#x20AC;? Patients report post-sternotomy pain emanating from the shoulder, neck and/or anywhere in their chest. â&#x20AC;&#x153;Patients move their arm a certain way or shift positions a certain way [and feel the pain],â&#x20AC;? Dr. Petsikas said. â&#x20AC;&#x153;It can also be a chronic, low-grade, smoldering

discomfort that they just pass off and figure itâ&#x20AC;&#x2122;s part of the game.â&#x20AC;? Dr. Petsikas recommended that clinicians counsel patients that they might experience chronic pain months after CABG with sternotomy and to seek medical attention if they do. Daniel Mok, a medical student at Queens University, presented the study findings at the 2013 annual meeting of

the Society of Cardiovascular Anesthesiologists (abstract 2). â&#x20AC;&#x153;Patients might expect itâ&#x20AC;&#x2122;s a normal or expected part of the healing process,â&#x20AC;? Mr. Mokk said at the meeting. â&#x20AC;&#x153;There is considerable interference with daily activities from this pain syndrome,â&#x20AC;? Mr. Mokk said. More than 30% of those with chronic pain described moderate to severe interference with

INDICATIONS ULTIVAÂŽ (remifentanil HCl) for Injection is indicated for intravenous administration: t "T BO BOBMHFTJD BHFOU GPS VTF EVSJOH UIF JOEVDUJPO BOE NBJOUFOBODF PG HFOFSBM BOFTUIFTJB GPS JOQBUJFOU BOE PVUQBUJFOU QSPDFEVSFT t 'PS DPOUJOVBUJPO BT BO BOBMHFTJD JOUP UIF JNNFEJBUF QPTUPQFSBUJWF QFSJPE JO BEVMU QBUJFOUT VOEFS UIF EJSFDU TVQFSWJTJPO PG BO BOFTUIFTJB QSBDUJUJPOFS JO B QPTUPQFSBUJWF BOFTUIFTJB DBSF VOJU PS JOUFOTJWF DBSF TFUUJOH t "T BO BOBMHFTJD DPNQPOFOU PG NPOJUPSFE BOFTUIFTJB DBSF JO BEVMU QBUJFOUT

general activity (nine patients), sleep (11) and normal work (12) activities. Even so, 63% (19) did not consult their primary care physician for treatment. James H. Abernathy III, MD, MPH, associate professor of anesthesiology at the Medical University of South Carolina, in Charleston, said that some patients in the study responded â&#x20AC;&#x153;noneâ&#x20AC;? when asked about their worst pain in

6-5*7" JT B SFHJTUFSFE USBEFNBSL PG (MBYP (SPVQ -JNJUFE 5IF .ZMBO MPHP JT B SFHJTUFSFE USBEFNBSL PG .ZMBO *OD

IMPORTANT RISK INFORMATION $POUJOVPVT JOGVTJPOT PG 6-5*7" TIPVME CF BENJOJTUFSFE POMZ CZ BO JOGVTJPO EFWJDF *7 CPMVT BENJOJTUSBUJPO PG 6-5*7" TIPVME CF VTFE POMZ EVSJOH UIF NBJOUFOBODF PG HFOFSBM BOFTUIFTJB *O OPOJOUVCBUFE QBUJFOUT TJOHMF EPTFT PG 6-5*7" TIPVME CF BENJOJTUFSFE PWFS UP TFDPOET *OUFSSVQUJPO PG BO JOGVTJPO PG 6-5*7" XJMM SFTVMU JO SBQJE PGGTFU PG FGGFDU 3BQJE DMFBSBODF BOE MBDL PG ESVH BDDVNVMBUJPO SFTVMU JO SBQJE EJTTJQBUJPO PG SFTQJSBUPSZ EFQSFTTBOU BOE BOBMHFTJD FGGFDUT XJUIJO UP NJO VQPO EJTDPOUJOVBUJPO PG 6-5*7" BU SFDPNNFOEFE EPTFT %JTDPOUJOVBUJPO PG BO JOGVTJPO PG 6-5*7" TIPVME CF QSFDFEFE CZ UIF FTUBCMJTINFOU PG BEFRVBUF QPTUPQFSBUJWF BOBMHFTJB QBSUJDVMBSMZ XIFSF QPTUPQFSBUJWF QBJO JT BOUJDJQBUFE 7JUBM TJHOT BOE PYZHFOBUJPO NVTU CF DPOUJOVPVTMZ NPOJUPSFE EVSJOH 6-5*7" BENJOJTUSBUJPO 6-5*7" QSPEVDFT BEWFSTF FWFOUT UIBU BSF DIBSBDUFSJTUJD PG Ă§ PQJPJET

ÂŞ .ZMBO *OTUJUVUJPOBM

6-5 +"

JUNE 2013

AnesthesiologyNews.com I 11

PA IN M E D ICIN E the previous 24 hours. â&#x20AC;&#x153;There is a large portion of people for whom their pain does not seem to interfere with their daily life,â&#x20AC;? Dr. Abernathyy said. Dr. Abernathy asked if researchers identified any predictors of which patients are most likely to experience more significant pain, but they did not do so, Mr. Mokk said.

On Off

Some surgical risk factors for this pain syndrome are not modifiable, including female sex and obesity. However, surgeons could reduce the risk with their choice of bypass graft, Dr. Petsikas said. Use of the internal thoracic artery, for example, is associated with a greater likelihood of poststernotomyy pain.

The study was single-center, retrospective research, Dr. Petsikas said. â&#x20AC;&#x153;It would be good if [it was] done across multiple institutions, but itâ&#x20AC;&#x2122;s a small pilot study.â&#x20AC;? Another limitation is that pain is subjective. â&#x20AC;&#x153;Some people may not be bothered by large amounts of pain and others might be crawling the walls from small amounts of pain,â&#x20AC;? he said. Use of reliable, validated pain questionnaires is a strength of the research, he added.

when you want it. when you donâ&#x20AC;&#x2122;t.

Anesthesia providers identiďŹ ed more than 150 procedures for Remi*.1 Providers interviewed recommend Remi for more than 150 procedures.1 Where could Remi beneďŹ t your practice?

NEUROLOGICAL/ EVOKED POTENTIAL

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HEAD & NECK

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Remi gives you predictable control of depth and duration of analgesia when you need it most2 t Rapid onset of 1 to 2 minutes2 t Rapid response to dose adjustment within 5 to 10 minutes2 t Rapid offset within 5 to 10 minutes results in rapid dissipation of effect and rapid recovery2 t Unique organ-independent metabolism provides rapid elimination with no accumulation2

Visit www.aboutULTIVA.com to see where Remi could work for you. Please see Indications and Important Risk Information below and accompanying brief summary of Prescribing Information on next page for all precautions, warnings, contraindications, and adverse events.

TVDI BT SFTQJSBUPSZ EFQSFTTJPO BQOFB UBDIZDBSEJB CSBEZDBSEJB IZQPUFOTJPO IZQFSUFOTJPO BOE TLFMFUBM NVTDMF JODMVEJOH DIFTU XBMM SJHJEJUZ #FDBVTF UIFTF FGGFDUT BSF EPTF EFQFOEFOU BOE DBO PDDVS SBQJEMZ DPOUJOVPVT NPOJUPSJOH JT OFDFTTBSZ ULTIVA TIPVME OPU CF VTFE BT B TPMF BHFOU CFDBVTF MPTT PG DPOTDJPVTOFTT DBOOPU CF BTTVSFE BOE CFDBVTF PG B IJHI JODJEFODF PG BQOFB NVTDMF SJHJEJUZ BOE UBDIZDBSEJB 6-5*7" TIPVME CF VTFE XJUI DBVUJPO JO QFEJBUSJD HFSJBUSJD BOE NPSCJEMZ PCFTF QBUJFOUT EVF UP IJHI WBSJBCJMJUZ JO QIBSNBDPEZOBNJDT BOE EPTF SFTQPOTF *OUSBPQFSBUJWF BXBSFOFTT IBT CFFO SFQPSUFE XJUI DPODPNJUBOU BENJOJTUSBUJPO XJUI QSPQPGPM JOGVTJPO Ăľ NDH LH NJO 'BJMVSF UP BEFRVBUFMZ DMFBS UIF *7 UVCJOH UP SFNPWF SFTJEVBM 6-5*7" IBT CFFO BTTPDJBUFE XJUI UIF BQQFBSBODF PG SFTQJSBUPSZ EFQSFTTJPO BQOFB BOE NVTDMF SJHJEJUZ VQPO UIF BENJOJTUSBUJPO PG BEEJUJPOBM n VJET PS NFEJDBUJPOT UISPVHI UIF TBNF *7 UVCJOH

%VF UP UIF QSFTFODF PG HMZDJOF JO UIF GPSNVMBUJPO ULTIVA is contraindicated for FQJEVSBM PS JOUSBUIFDBM BENJOJTUSBUJPO 6-5*7" JT BMTP DPOUSBJOEJDBUFE JO QBUJFOUT XJUI LOPXO IZQFSTFOTJUJWJUZ UP GFOUBOZM BOBMPHT 6-5*7" 4)06-% #& 64&% */ 5)& $"3&'6--: .0/*503&% 4&55*/( #: 41&$*'*$"--: 53"*/&% 1&340/4 /05 */70-7&% */ 5)& 463(*$"- 03 %*"(/045*$ 130$&%63& 09:(&/ 4"563"5*0/ *4 50 #& $0/5*/6064-: .0/*503&% 3&464$*5"5*7& "/% */56#"5*0/ &26*1.&/5 09:(&/ "/% "/ 01*0*% "/5"(0/*45 .645 #& 3&"%*-: "7"*-"#-& 3FNJGFOUBOJM JT DPNNPOMZ SFGFSSFE UP BT 3FNJ CZ BOFTUIFTJB QSPWJEFST References: 1. Data on ďŹ le. Canonsburg, PA: Mylan Institutional; 2012. 2. ULTIVA [package insert]. Rockford, IL: Mylan Institutional LLC; 2011.

Dr. Petsikas said his group plans to study if spreading the breastbone apart more slowly could reduce postoperative sternotomy pain. Traditionally, surgeons use a retractor to separate the breastbone quickly, which does not allow time â&#x20AC;&#x153;for your ligaments to stretch in your back or between your spine and ribs to stretch. Itâ&#x20AC;&#x2122;s like doing aggressive stretching exercises without warming up first.â&#x20AC;? â&#x20AC;&#x201D;Damian McNamara

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Progress, If No Breakthroughs, in Chronic Post-op Pain Washington—The emerging recognition that many patients develop chronic pain after surgery has spurred a host of behavioral and anatomic research. So far, these studies have yet to produce any breakthroughs in the understanding, and more importantly for patients, the treatment of the problem. But during a session at the 2012 annual

ULTIVA® for Injection

meeting of the American Society of Anesthesiologists, experts said the question was not whether, but when, those treatments would arrive. “Not surprisingly, chronic postsurgical pain has become a popular topic,” said Timothy Brennan, MD, PhD, the Samir Gergis Professor and Vice Chair for Research at the University of Iowa’s Roy J. and Lucile A. Carver School

(remifentanil hydrochloride) For IV Use Only Rx only Brief Summary: The following is a brief summary only. Before prescribing, see complete ULTIVA prescribing information. CONTRAINDICATIONS Due to the presence of glycine in the formulation, ULTIVA is contraindicated for epidural or intrathecal administration. ULTIVAA is also contraindicated in patients with known hypersensitivity to fentanyl analogs. WARNINGS AND PRECAUTIONS Continuous infusions of ULTIVA should be administered only by an infusion device. IV bolus administration of ULTIVA should be used only during the maintenance of general anesthesia. In nonintubated patients, single doses of ULTIVA should be administered over 30 to 60 seconds. Interruption of an infusion of ULTIVA will result in rapid offset of effect. Rapid clearance and lack of drug accumulation result in rapid dissipation of respiratory depressant and analgesic effects upon discontinuation of ULTIVA at recommended doses. Discontinuation of an infusion of ULTIVA should be preceded by the establishment of adequate postoperative analgesia. Injections of ULTIVA should be made into IV tubing at or close to the venous cannula. Upon discontinuation of ULTIVA, the IV tubing should be cleared to prevent the inadvertent administration of ULTIVA at a later point in time. Failure to adequately clear the IV tubing to remove residual ULTIVA has been associated with the appearance of respiratory depression, apnea, and muscle rigidity upon the administration of additional fluids or medications through the same IV tubing. USE OF ULTIVA IS ASSOCIATED WITH APNEA AND RESPIRATORY DEPRESSION. ULTIVA SHOULD BE ADMINISTERED ONLY BY PERSONS SPECIFICALLY TRAINED IN THE USE OF ANESTHETIC DRUGS AND THE MANAGEMENT OF THE RESPIRATORY EFFECTS OF POTENT OPIOIDS, INCLUDING RESPIRATORY AND CARDIAC RESUSCITATION OF PATIENTS IN THE AGE GROUP BEING TREATED. SUCH TRAINING MUST INCLUDE THE ESTABLISHMENT AND MAINTENANCE OF A PATENT AIRWAY AND ASSISTED VENTILATION. ULTIVA SHOULD NOT BE USED IN DIAGNOSTIC OR THERAPEUTIC PROCEDURES OUTSIDE THE MONITORED ANESTHESIA CARE SETTING. PATIENTS RECEIVING MONITORED ANESTHESIA CARE SHOULD BE CONTINUOUSLY MONITORED BY PERSONS NOT INVOLVED IN THE CONDUCT OF THE SURGICAL OR DIAGNOSTIC PROCEDURE. OXYGEN SATURATION SHOULD BE MONITORED ON A CONTINUOUS BASIS. RESUSCITATIVE AND INTUBATION EQUIPMENT, OXYGEN, AND AN OPIOID ANTAGONIST MUST BE READILY AVAILABLE. Respiratory depression in spontaneously breathing patients is generally managed by decreasing the rate of the infusion of ULTIVA V by 50% or by temporarily discontinuing the infusion. Skeletal muscle rigidity can be caused by ULTIVA and is related to the dose and speed of administration. ULTIVA may cause chest wall rigidity (inability to ventilate) after single doses of >1 mcg/kg administered over 30 to 60 seconds, or after infusion rates >0.1 mcg/kg/min. Single doses <1 mcg/kg may cause chest wall rigidity when given concurrently with a continuous infusion of ULTIVA. Muscle rigidity induced by ULTIVA should be managed in the context of the patient’s clinical condition. Muscle rigidity occurring during the induction of anesthesia should be treated by the administration of a neuromuscular blocking agent and the concurrent induction medications. Muscle rigidity seen during the use of ULTIVA in spontaneously breathing patients may be treated by stopping or decreasing the rate of administration of ULTIVA. Resolution of muscle rigidity after discontinuing the infusion of ULTIVA occurs within minutes. In the case of life-threatening muscle rigidity, a rapid onset neuromuscular blocker or naloxone may be administered. ULTIVA should not be administered into the same IV tubing with blood due to potential inactivation by nonspecific esterases in blood products. PRECAUTIONS Vital signs and oxygenation must be continually monitored during the administration of ULTIVA. General: Bradycardia has been reported with ULTIVA and is responsive to ephedrine or anticholinergic drugs, such as atropine and glycopyrrolate. Hypotension has been reported with ULTIVA and is responsive to decreases in the administration of ULTIVA or to IV fluids or catecholamine (ephedrine, epinephrine, norepinephrine, etc.) administration. Intraoperative awareness has been reported in patients under 55 years of age when ULTIVA has been administered with propofol infusion rates of ≤ 75 mcg/kg/min. Rapid Offset of Action: WITHIN 5 TO 10 MINUTES AFTER THE DISCONTINUATION OF ULTIVA, NO RESIDUAL ANALGESIC ACTIVITY WILL BE PRESENT. However, respiratory depression may occur in some patients up to 30 minutes after termination of infusion due to residual effects of concomitant anesthetics. Standard monitoring should be maintained in the postoperative period to ensure adequate recovery without stimulation. For patients undergoing surgical procedures where postoperative pain is generally anticipated, other analgesics should be administered prior to the discontinuation of ULTIVA. ULTIVA should not be used as a sole agent for induction of anesthesia because loss of consciousness cannot be assured and because of a high incidence of apnea, muscle rigidity, and tachycardia. Pediatric Use: The efficacy and safety of ULTIVA as an analgesic agent for use in the maintenance of general anesthesia in outpatient and inpatient pediatric surgery have been established in controlled clinical trials in pediatric patients from birth to 12 years. In clinical trials, the clearance rate observed in neonates was highly variable and on average was two times higher than in the young healthy adult population. While a starting infusion rate of 0.4 mcg/kg/min may be appropriate for some neonates, an increased infusion rate may be necessary to maintain adequate surgical anesthesia, and additional bolus doses may be required. The individual dose for each patient should be carefully titrated (see ULTIVA Prescribing Information [PI], DOSAGE AND ADMINISTRATION, Table 11). ULTIVA has not been studied in pediatric patients for use as a postoperative analgesic or as an analgesic component of monitored anesthesia care. Geriatric Use: Of the total number of subjects in clinical studies of ULTIVA, 486 were in the age range 66 to 90 years. While the effective biological half-life of remifentanil is unchanged, elderly patients have been shown to be twice as sensitive as the younger population to the pharmacodynamic effects of remifentanil. The recommended starting dose of ULTIVA should be decreased by 50% in patients over 65 years of age. Use in Morbidly Obese Patients: As for all potent opioids, caution is required with use in morbidly obese patients because of alterations in cardiovascular and respiratory physiology. Long-term Use in the ICU: No data are available on the long-term (> 16 hours) use of ULTIVA as an analgesic in ICU patients. Carcinogenesis, Mutagenesis, Impairment of Fertility: Animal carcinogenicity studies have not been performed with remifentanil. Remifentanil did not induce gene mutation in prokaryotic cells in vitroo and was not genotoxic in an in vivoo rat assay. No clastogenic effect was seen in hamster or mouse studies. In the in vitroo mouse lymphoma assay, mutagenicity was seen only with metabolic activation. Remifentanil has been shown to reduce fertility in male rats when tested after approximately 40 times the maximum recommended human dose (MRHD). The fertility of female rats was not affected at IV doses as high as 1 mg/kg when administered for at least 15 days before mating. Pregnancy Category C: Teratogenic effects were not observed in either rats or rabbits following administration of remifentanil at doses up to 400 times and 125 times the MRHD, respectively. Administration of radiolabeled remifentanil to pregnant rabbits

of Medicine, in Iowa City. “Compared with a patient who develops an injury after a car accident, with surgical patients we know when our patients are going to get injured, and we know what type of injury is going to occur: the surgery. So, I think our goal will be to study surgical patients and evaluate their pain responses when they don’t have this premeditated injury, then

and rats demonstrated significant placental transfer to fetal tissue. There are no adequate and well-controlled studies in pregnant women. ULTIVA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Administration of remifentanil to rats throughout late gestation and lactation at IV doses up to 400 times the MRHD in terms of mg/m2 of body surface area, had no significant effect on the survival, development, or reproductive performance of the F1 generation. Animal Toxicology: Intrathecal administration of the glycine formulation without remifentanil to dogs caused agitation, pain, hind limb dysfunction, and incoordination. These effects are believed to be caused by the glycine. Glycine is a commonly used excipient in IV products and this finding has no relevance for IV administration of ULTIVA. Labor and Delivery: Respiratory depression and other opioid effects may occur in newborns whose mothers are given ULTIVA shortly before delivery. The safety of ULTIVA during labor or delivery has not been demonstrated. Placental transfer studies in rats and rabbits showed that pups are exposed to remifentanil and its metabolites. In a human clinical trial, the average maternal remifentanil concentrations were approximately twice those seen in the fetus. In some cases, however, fetal concentrations were similar to those in the mother. The umbilical arteriovenous ratio of remifentanil concentrations was approximately 30% suggesting metabolism of remifentanil in the neonate. Nursing Mothers: It is not known whether remifentanil is excreted in human milk. After receiving radioactive-labeled remifentanil, the radioactivity was present in the milk of lactating rats. Because fentanyl analogs are excreted in human milk, caution should be exercised when ULTIVA is administered to a nursing woman. ADVERSE EVENTS In controlled clinical trials in approximately 2770 adult patients, ULTIVA produced adverse events characteristic of μ-opioids, such as respiratory depression, bradycardia, hypotension, and skeletal muscle rigidity. These adverse events dissipated within minutes of discontinuing or decreasing the infusion rate of ULTIVA. Table 1: Adverse Events Reported in ≥ 1% of Adult Patients in General Anesthesia Studies* at the Recommended Doses† of ULTIVA Induction/Maintenance Adverse Event Nausea Hypotension Vomiting Muscle rigidity Bradycardia Shivering Fever Dizziness Visual disturbance Headache Respiratory depression Apnea Pruritus Tachycardia Postoperative pain Hypertension Agitation Hypoxia

ULTIVA (n=921)

Alfentanil/ Fentanyl (n=466)

Postoperative Analgesia ULTIVA (n=281)

Morphine (n=98)

After Discontinuation ULTIVA (n=929)

Alfentanil/ Fentanyl (n=466)

8 (<1%) 178 (19%) 4 (<1 % ) 98 (11%)‡ 62 (7%) 3 (<1%) 1 (<1%) 0 0 0

0 30 (6%) 1 (<1%) 37 (8%) 24 (5%) 0 0 0 0 0

61 (22%) 0 22 (8%) 7 (2%) 3 (1%) 15 (5%) 2 (<1%) 1 (<1%) 0 1 (<1%)

15 (15%) 0 5 (5%) 0 3 (3%) 9 (9%) 0 0 0 1 (1%)

339 (36%) 16 (2%) 150 (16%) 2 (<1%) 11 (1%) 49 (5%) 44 (5%) 27 (3%) 24 (3%) 21 (2%)

202 (43%) 9 (2%) 91 (20%) 1 (<1%) 6 (1%) 10 (2%) 9 (2%) 9 (2%) 14 (3%) 8 (2%)

1 (<1%) 0 2 (<1%) 6 (<1%) 0 10 (1%) 2 (<1%) 0

0 1 (<1%) 0 7 (2%) 0 7 (2%) 0 0

19 (7%) 9 (3%) 7 (2%) 0 7 (2%) 5 (2%) 3 (1%) 1 (<1%)

4 (4%) 2 (2%) 1 (1%) 0 0 3 (3%) 1 (1%) 0

17 (2%) 2 (<1%) 22 (2%) 10 (1%) 4 (<1%) 12 (1%) 6 (<1%) 10 (1%)

20 (4%) 1 (<1%) 7 (2%) 8 (2%) 5 (1%) 8 (2%) 1 (<1%) 7 (2%)

*Does not include adverse events from cardiac studies or the neonatal study. See ULTIVA PI, Tables 6, 7, and 8 for cardiac information. † See ULTIVA PI, Table 10 for recommended doses. Not all doses of ULTIVA were equipotent to the comparator opioid. Administration of ULTIVA in excess of the recommended dose (i.e., doses >1 and up to 20 mcg/kg) resulted in a higher incidence of some adverse events: muscle rigidity (37%), bradycardia (12%), hypertension (4%), and tachycardia (4%). ‡ Included in the muscle rigidity incidence is chest wall rigidity (5%). The overall muscle rigidity incidence is <1% when remifentanil is administered concurrently or after a hypnotic induction agent. In the elderly population (> 65 years), the incidence of hypotension is higher, whereas the incidence of nausea and vomiting is lower. DRUG ABUSE AND DEPENDENCE ULTIVA is a Schedule II controlled drug substance that can produce drug dependence of the morphine type and has the potential for being abused. OVERDOSAGE As with all potent opioid analgesics, overdosage would be manifested by an extension of the pharmacological actions of ULTIVA. Expected signs and symptoms of overdosage include: apnea, chest-wall rigidity, seizures, hypoxemia, hypotension, and bradycardia. In case of overdosage or suspected overdosage, discontinue administration of ULTIVA, maintain a patent airway, initiate assisted or controlled ventilation with oxygen, and maintain adequate cardiovascular function. If depressed respiration is associated with muscle rigidity, a neuromuscular blocking agent or a μ-opioid antagonist may be required to facilitate assisted or controlled respiration. Intravenous ﬂuids and vasopressors for the treatment of hypotension and other supportive measures may be employed. Glycopyrrolate or atropine may be useful for the treatment of bradycardia and/or hypotension. Intravenous administration of an opioid antagonist such as naloxone may be employed as a speciﬁc antidote to manage severe respiratory depression or muscle rigidity. Respiratory depression from overdosage with ULTIVA is not expected to last longer than the opioid antagonist, naloxone. Reversal of the opioid effects may lead to acute pain and sympathetic hyperactivity. ULTIVA is a registered trademark of Glaxo Group Limited. US Patent Nos. 5,019,583; and 5,866,591 Version C, 07/2011 Manufactured for Mylan Institutional LLC, Rockford, IL 61103 Manufactured by Hospira, Inc. Lake Forest, IL 60045

follow them through the postoperative period in the hope that we can learn to predict chronic postsurgical pain and the factors related to its development.” Several studies have associated the development of chronic postsurgical pain and other unfavorable long-term outcomes with somatic and psychological predictors. A 2007 Dutch investigation ((Ann Surg 2007;245:487-494) in 625 patients, for example, found that psychological factors such as fear of long-term consequences and lack of optimism were predictors of persistent pain, disability and low quality of life after surgery. “I think, sometimes, functional limitations and lower quality of life may impact a patient’s perception of their pain and certainly the development of persistent pain afterward,” Dr. Brennan noted. “This reminds us that there are many psychological factors associated with the development of persistent pain.” More recently, a team of Norwegian researchers followed more than 12,000 patients, 2,043 of whom had undergone surgery within three months of the start of the study (Pain 2012;153:1390-1396). Persistent pain in the area of surgery was reported by 40.4% of the patients. The researchers also found strong associations between sensory abnormalities and persistent pain. “Broad studies such as these cast a wide net, and are certainly continuing to point to this relevant problem of disability after surgery and significant pain reports,” Dr. Brennan said. Few studies, however, have shed as much light on the anatomic changes that occur in response to pain as a longitudinal investigation by Baliki and colleagues, reported last year in Nature

JUNE 2013

AnesthesiologyNews.com I 13

PA IN M E D ICIN E Neuroscience (2012;15:1117-1119), to determine the mechanism of brain reorganization as pain moves from acute to chronic. The researchers followed patients with subacute back pain for more than a year, stratifying them into those whose pain did not resolve and those whose pain improved, and also compared them with a group of healthy controls. Patients whose pain persisted showed decreases in the density of gray matter in the brain. “The researchers also looked at the connectivity between various parts of the pain network and what I call the emotional network,” Dr. Brennan said. They found that an initially greater level of connectivity between a section of the brain called the nucleus accumbens, which is critical to the sensation of pleasure, and the prefrontal cortex predicted pain persistence. This increased connectivity, they inferred, suggests that corticostriatal circuitry is causally involved in the transition from acute to chronic pain. “The medial prefrontal cortex is one of those areas in the brain that signals the affective component of pain,” Dr. Brennan explained. “When pain is well connected to the nucleus accumbens, pain pathways are strongly linked to psychological pathways. This link was found to be an accurate predictor of the transition from subacute to chronic pain. Now, whether or not this applies to a perioperative situation certainly remains to be seen,” he continued. “We know that there are similarities between back pain patients and postsurgical patients, but more research needs to be performed.” For clinicians, of course, the physiology of how postoperative pain becomes chronic is most important if it leads to ways of preventing the transformation. “The literature suggests it may not be that easy,” Dr. Brennan said.

Eugene R. Viscusi, MD, professor of anesthesiology and director of acute pain management at Thomas Jefferson University, in Philadelphia, noted that the magnitude of chronic postsurgical pain is vastly underestimated by most anesthesiologists and surgeons. “I agree with Dr. Brennan that a link with severe acute pain alone is probably too simplistic,” said Dr. Viscusi, a member of the editorial board of Anesthesiology News. “My opinion is that since the causes are likely

multifactorial, there will not be a single solution. What’s more, some patients may just have an inherent risk. Nevertheless, several interesting studies support that preoperative and postoperative pregabalin [Lyrica, Pfizer] and ketamine may reduce longer-term pain after surgery. The best current evidence suggests that a multimodal analgesic approach and adjustment of surgical technique may make a difference.” —Michael Vlessides

@anesthesianews

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Sedative Before Surgery May Blunt Post-op Cognitive Dysfunction Washington—Although sevoflurane anesthesia can cause functional declines in short-term cognitive function after surgery in elderly patients, the infusion of dexmedetomidine before surgery can mitigate these effects. Patients who receive the combination treatment return to preoperative levels of cognitive function quicker than with sevoflurane alone, researchers have found.

“We know that postoperative cognitive dysfunction is a common postoperative complication in the elderly,” said Hui Xu, MD, consultant anesthesiologist at the University of Science and Technology in Wuhan, China, who led the study. “Dexmedetomidine [Precedex, Hospira] is promising in this regard, but there are few studies that show that dexmedetomidine can

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

improve postoperative cognitive function in conjunction with sevoflurane anesthesia in older patients.” Dr. Xu and her colleagues enrolled 60 patients (aged 65-75 years) into the randomized, double-blindd trial; all were American Society of Anesthesiologists (ASA) physical status 1 or 2 and were scheduled for elective surgery. Before undergoing anesthesia with sevoflurane,

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

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

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

half the patients received an infusion of 1 mcg/kg dexmedetomidine over 15 minutes, the other half received saline. Both groups underwent an otherwise identical standardized anesthetic regimen. As part of that regimen, 0.6 mg/kg of rocuronium was used to facilitate tracheal intubation. Anesthesia was induced with sevoflurane and a single IV injection of 5 mcg/kg of fentanyl. Rocuronium was titrated throughout the procedure as needed. The researchers evaluated cognitive function using the Mini-Mental State Examination (MMSE), assessing patients preoperatively and one, three, six, 24 and 72 hours postoperatively. A postoperative decline of at least 2 points in at least two of the tested domains was defined as cognitive function decline. As Dr. Xu reported at the ASA’s 2012 annual meeting (abstract 149), the time to eye opening and extubation were comparable between groups. However, the time to react on command occurred sooner in patients given dexmedetomidine-sevoflurane than in those receiving only sevoflurane (P<0.05). MMSE scores showed no statistically significant differences between groups before surgery. Although these scores decreased significantly in both groups at one and three hours postoperatively (P<0.05), they were significantly lower in the sevoflurane-only group (P<0.05). MMSE scores took six hours to recover to preoperative levels in the dexmedetomidine-sevoflurane group compared with 24 hours in the sevoflurane-onlyy group. Two markers of brain injury, serum 100B and C-reactive protein (CRP), also appeared to be elevated in patients who received sevoflurane alone (P<0.05). “These results show that although sevoflurane anesthesia can cause shortterm postoperative cognitive dysfunction, dexmedetomidine is effective at improving cognitive function associated particularly with respect to return to preoperative levels,” Dr. Xu said. John W. Devlin, PharmD, associate professor of pharmacy practice at Northeastern University, in Boston, noted that mounting evidence suggests that inhalational anesthetics may be neurotoxic to the aging brain, leading to postoperative cognitive dysfunction that can persist long after surgery. “In their rigorous, double-blindd study, Dr. Xu and see cognitive page 16

11-2724_AN_5/13_BB

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CL IN ICA L A N E STH E SIOL OG Y

Etomidate Linked to Worse Post-op Outcomes vs. Propofol Risk for death more than doubled for critically ill in retrospective study Washington—Anesthesiologists tempted to use etomidate instead of propofol to induce anesthesia in critically ill patients might think twice after considering the results of a retrospective analysis by researchers at Cleveland Clinic. The analysis concluded that noncardiac patients given etomidate were two to three times more likely than those given propofol to die within 30 days. “Although etomidate is sometimes used for general anesthesia induction in critically ill patients, the drug is known to cause prolonged adrenal impairment by blocking cortisol release,” said Ryu Komatsu, MD, a resident at the Ohio institution. “As we might suspect, worse outcomes have been reported in association with etomidate use in critically ill patients. However, the potential link between etomidate and worsened postoperative outcomes has not been systematically studied in general surgical patients.” Dr. Komatsu and his colleagues evaluated the electronic records of 31,148 adult patients who underwent noncardiac surgery under general anesthesia requiring at least one night of hospitalization at the institution between 2005 and 2009. Anesthesia was induced with etomidate in 2,616 patients; 28,532 received propofol. The researchers performed propensity score matching for 2,143 patients who received etomidate and 5,231 given propofol using a host of potential demographic and intraoperative confounders. The matched groups were compared with respect to duration of postoperative hospitalization and 30-dayy mortality. Dr. Komatsu’s group found that 139 patients who received etomidate died within 30 days of surgery, compared with 134 in the propofol group (odds ratio, 2.3; 97.5% confidence interval, 1.73-3.06; P<0.001). The mean length of stay was seven days for patients given etomidate (range, three to 13) and six days for those who received propofol (range, two to 11). Patients who received etomidate were 18% less likely to be discharged from the hospital at any time after surgery than were those treated with propofol. “We also looked at the systolic blood pressure profile during surgery,” added Dr. Komatsu, who reported the findings at the 2012 annual meeting of the American Society of Anesthesiologists (abstract 015). “We found that from intubation to incision, propofol

patients had lower systolic blood pressure, with mean difference of 8 to 9 mm Hg, which I think could be clinically significant.” Dr. Komatsu acknowledged the limitations of the retrospective database analysis. “We could only show an association between worse outcomes and

etomidate use,” he said. “Randomized controlled trials are necessary to determine if there is another relationship between etomidate use and outcomes, as well as to define precisely the effect of etomidate. In the meantime, however, physicians should use etomidate judiciously, considering that

etomidate’s improved hemodynamic stability at induction might be accompanied by substantially worse longerterm outcomes.” Jesse Ehrenfeld, MD, assistant professor of anesthesiology and biomedical informatics at Vanderbilt see etomidate page 16

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Common Cold Adds Complications, Costs to Peds Heart Surgery

nfants who undergo heart surgery while infected with human rhinovirus (HRV) remain in the hospital longer and experience more respiratory complications than uninfected children, researchers have found. The study, by a group at Nationwide Children’s Hospital and the Ohio State University Wexner Medical Center, in Columbus, underscores the need to establish a standard of care and preoperative protocol for pediatric surgical patients, who typically experience five to six colds in their first year of life. “I think that it was remarkable the impact that rhinovirus infection had on patients in terms of their length of stay and overall morbidity,” said Peter Winch, MD, a pediatric cardiac anesthesiologist at Nationwide Children’s, who helped conduct the study. “We are talking about big surgeries in patients who are at considerable risk for postoperative respiratory complications.” Respiratory complications during and after surgery increase the length of time that patients require mechanical ventilation, which can lead to further complications requiring additional care and medications. “You end up needing a lot more care and a higher complexity of care the longer you stay on the ventilator.” Dr. Winch’s group presented the results at the 2013 annual meeting of the Society for Pediatric Anesthesia (NM-322). The researchers reviewed data for all infants admitted for surgery to repair congenital cardiac anomalies at the two Ohio State hospitals. In nine children who tested positive for HRV (average age, 5 months; range, 1-9 months) undergoing a variety of cardiac repair surgeries, the median hospital stay was 97 days. For 24 HRVV negative children undergoing comprehensive stage II surgeries, the median hospital stay was 14 days; 28 uninfected infants undergoing complete atrioventricular canal repair had a median hospital stay of six days. The study builds on previous work in which the team retrospectively compared postoperative care and costs of two patients who had tested HRVV positive with the average care and costs for uninfected patients. “The cost of their care compared with [uninfected patients] was three times greater,” Dr. Winch said. For an HRVV positive patient who underwent stage II palliation, the cost of treatment was $788,462, compared with $273,834 for a typical patient not infected with the virus. For an HRVV positive patient who underwent complete repair of a valve defect, the cost was $642,679 compared with $100,423 for a typical uninfected child (Table). In neither case did the infected children show signs of a lower respiratory infection during the preoperative period. When the hospital subsequently implemented a screening test, using the polymerase chain reaction (PCR), for patients admitted with respiratory symptoms and as a preoperative screening protocol for cardiac patients under 1 year old and those deemed to be high-risk, the new protocol revealed another unexpected finding: 17.4% of “entirely asymptomatic” patients tested positive for HRV. How

Table 1. Infection With Rhinovirus Drives up Health Care Costs for Pediatric Surgery Patient A (Comprehensive Stage II)

Patient B (Atrioventricular Canal)

Length of stay (days)

Average length of stay (days)

23 (24 patients)

21 (28 patients)

Median length of stay (days)

14 (24 patients)

6 (28 patients)

Mechanical ventilation (days)

Noninvasive ventilation (days)

Time on ionotropes (days)

Max inotropic score (days)

31.5

Inhaled nitric oxide (days)

Total cost of hospitalization for HRV+

$788,462

$642,679

Average

$281,180 (24 patients)

$274,036 (28 patients)

Median

$273,834

$100,423

Range

$45,192—$711,635

$58,407—$3,233,556

HRV, human rhinovirus

asymptomatic infection might affect these patients is unclear, Dr. Winch said. “Now that we have very sensitive viral diagnostics, we need prospective, systematic studies using similar PCR tests for these viruses to better define the epidemiology, including risk factors, clinical syndromes and the overall burden of rhinoviruses in pediatric patients,” said Monica Ardura, DO, MS, an infectious disease specialist and assistant professor of pediatrics at Nationwide Children’s. “As our molecular diagnostic testing improves and we’re detecting more of these viruses, we’re beginning to better understand their epidemiology and recognizing that [HRV] is not ‘just’ a virus that causes the common cold in some children.”

COGNITIVE

CONTINUED FROM PAGE 14

colleagues report that a high dose of dexmedetomidine administered prophylactically over a short period before sevoflurane anesthesia leads to faster postsurgical cognitive recovery,” Dr. Devlin said. “The fact that postoperative serum CRP and serum 100B concentrations were lower in the dexmedetomidine-treatedd patients suggests that the drug may exert a protective effect against the effects of inhalational anesthetics in the brain through both anti-inflammatoryy and decreased blood–brain permeability mechanisms. “While additional, larger studies are needed to evaluate the safety of dexmedetomidine in this setting and the benefits of its administration on longer-term cognitive and clinical outcomes,” Dr. Devlin added, “this important study suggests that the prophylactic use of dexmedetomidine may play an important role in improving short-term outcome in elderly patients who require surgery with an inhalational anesthetic.” —Michael Vlessides

Dr. Winch and his colleagues are currently working toward determining the best course to take in balancing the need for surgery with emerging knowledge about postoperative outcomes. “Ultimately, we want to optimize outcomes for these patients and establish a guideline for best practices for preoperative testing,” he said. “When you are taking a patient to the operating room for a large surgical procedure involving multiple hours under anesthesia and a period of bypass where the lungs are not being ventilated for possibly several hours, the question is how to optimize their postoperative course and minimize respiratory complications.” —Keely Savoie

ETOMIDATE

CONTINUED FROM PAGE 15

University School of Medicine, in Nashville, Tenn., said that although the authors did the best analysis they could with the available data, the study was hardly definitive. “While their propensity analysis adjusted for a number of important variables shown to impact mortality and length of stay, it is still unclear in this retrospective study what the potential impact of unmeasured confounding might be,” Dr. Ehrenfeldd said. “In my experience, most clinicians choose to use etomidate in sicker patients under particular clinical scenarios,” Dr. Ehrenfeldd told Anesthesiology News. “And without a prospective randomized trial, those unaccounted-for circumstances cannot be controlled for. It therefore would not be appropriate at this time to attribute the excess mortality seen in the study to use of etomidate alone. I congratulate the authors for investigating this important subject, and hope that their efforts and this study will lead to future, more conclusive, work.” —Michael Vlessides

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Rediscovered Local Holds Promise for Spinal Anesthesia

literature review suggests 2-chloroprocaine, a local anesthetic recently approved in Europe for intrathecal use, offers distinct clinical advantages for brief lower-body surgical procedures. This anesthetic appears to carry a much lower risk for transient adverse neurologic effects than lidocaine, a concern that drove many anesthesiologists away from spinal anesthesia for these procedures. “I have been using 2-chloroprocaine offf label for several years,” said Arthur Atchabahian, MD, associate professor of anesthesiology at New York University School of Medicine, in New York City. “I found the medication extremely useful and had, in my own clinical experience, no side effects.” After finding no review article on 2-chloroprocaine spinal anesthesia, Dr. Atchabahian decided to conduct his own review. Along with Elyse Goldblum, MD, an anesthesiology resident, he searched scientific databases for reports on 2-chloroprocaine for spinal anesthesia. Although a paucity of data published from 1966 until April 2012 prevented a full systematic review, they discovered some promising findings from retrospective and randomized controlled studies, which they reported in a paper published in May in Acta Anaesthesiologica Scandinavica (2013;57:545-552). Although other researchers have reported a 10% to 40% rate of transient neurologic symptoms associated with lidocaine for spinal anesthesia, a group in Montreal found a prevalence of less than 2% (one in 53 patients) with 2-chloroprocaine in their randomized double-blind trial (Can J Anesth 2011;58:384-391). In addition, a retrospective review at Virginia Mason Medical Center, in Seattle, found that of 503 outpatients who received 2-chloroprocaine, none experienced this adverse outcome ((Acta Anaesthesiol Scandd 2011;55:267-272). “Some of my colleagues still use mepivacaine, which still has between a 6% to 30% incidence of transient neurologic symptoms,” Dr. Atchabahian said. Use of 2-chloroprocaine for spinal anesthesia could be “of great value for anesthesiologists” in the United States, said Jacques Chelly, MD, PhD, MBA, professor of anesthesiology at the University of Pittsburgh School of Medicine. “I would not be surprised if an application would be submitted

to the FDA to get approval in this country.” Approved indications for 2-chloroprocaine now vary by formulation—with or without preservatives—and include local infiltration, peripheral nerve blocks and/or epidural anesthesia. The review turned up other benefits of 2-chloroprocaine, including shorter

time to recovery and earlier discharge than with other local anesthetics. “The main priority at this time is pharmacovigilance once the medication is available for widespread use, in order to detect any issues or adverse effects that were not seen in the limited number of patients and subjects included in this review,” Dr. Atchabahian said.

Only preservative-free 2-chloroprocaine was used in all studies; therefore, it is not advisable to use preservative-containing 2-chloroprocaine, Dr. Atchabahian said. Concomitant use of epinephrine is not recommended because it has been associated with flulike symptoms, he added. —Damian McNamara

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Paxton JH, Knuth TE, Klausner HA. Proximal humerus intraosseous infusion: a preferred emergency venous access. The J Trauma 2009;67(3):606-11. Research sponsored by Vidacare Corporation. For alert and conscious patients responsive to pain, consider IO 2% lidocaine without preservatives or epinephrine (cardiac lidocaine). A Medical Director must authorize appropriate dosage range. As with any vascular access site, the IO insertion site should be monitored frequently. IO should only be used when landmarks can be clearly identiﬁed.

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liver transplant anesthesia (see OPTN Bylaws, Appendix B, Attachments I-XI - : that they urge closer cooperation and Accessed March 29 at URL: http:// goodwill between the transplant and optn.transplant.hrsa.gov/policiesandanesthesia communities and address bylaws2/bylaws/optnbylaws/pdfs/ the best interests of our patients,” said bylaw_162.pdf ). They also specify Susan Mandell, MD, PhD, professor the educational and transplant experiof anesthesiology at the University of ence that such directors should have in Colorado Health Sciences Center, in order to be appointed to the position, Aurora. as well as their duties in the position The recommendations, passed as an (sidebar). OPTN/UNOS bylaw, call for transAlthough the recommendations plant centers to appoint a director of are not binding, if OPTN/UNOS CONTINUED FROM PAGE 1

determines that lack of adherence to the guidelines contributes to poor outcomes at a center, it can recommend that the directorship guidelines be implemented. In addition, the Centers for Medicare & Medicaid Services has authority to decertify programs if they have poor outcomes, especially if recommended guidelines were not followed, Dr. Mandell explained. While Dr. Mandell welcomed the new bylaw, she said it does not introduce new practices—a conclusion she

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arrived at after she and several of her co-investigators surveyed adult academic transplant centers and private programs and compared the recommendations with current practice (Liver Transpll 2013;19:425-430). The 42 adult academic centers that responded to the survey indicated they already had a director in place before the recommendations were issued. Although most centers did not have formal directorship criteria, the majority of directors had the specialized liver transplant education and the experience in liver transplantation or a related highacuityy care specialty that the guidelines call for, Dr. Mandell said. Furthermore, most directors performed similar administrative duties to those specified in the OPTN/UNOS bylaw (Table). Anesthesiologists “Essential” To Transplant Care “The importance of these guidelines is really in their recognition of anesthesiologists as essential to achieving the best care possible for liver transplant patients,” Dr. Mandell said. “They support the emerging leadership in liver transplant anesthesia and bring greater uniformity to the directorship position.” Table. Selected Survey Responses From Academic Liver Transplant Centers

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On-site risk management seminars for our policyholders and their staff presented by PPM in-house claims attorneeys. Exclusive online access to best practice prrotocols and documentation; white papers; current and archived issuess of Anesthesia & Law, our risk management newsletter; and other usefull information. Immediate email notiﬁcation via Anesthessia Alerts of issues such as widespread drug contamination, drug sho ortages and signiﬁcant changes h tto ASA standards. t d d 24/7/365 telephone access to our experien nced attorneys and claims specialists for the expert risk management advice you need, wheneever you need it. Call PPM today to learn more about how our exten nsive risk management program can help you protect your reputation.

Response (N=42)

Centers with directors of anesthesia for liver transplantation

100%

Centers with written criteria describing the directorship position

38%

Directors who completed a fellowship in liver transplantation

Centers requiring a specific number of liver transplant cases to qualify as director

4.3%

Centers requesting that directors have post-graduate liver transplant experience

82%

Directors at small, medium and large centers earning ≤5 CME credits annuallya

47%, 35% and 31%

Directors attending transplant patient selection committees

65%

Centers with anesthesiologist-developed liver transplant patient care protocol

80%

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Center size defined by annual volume of liver transplants. Small: 10-49; 0 9; medium: ed u 50-99; 50 99; large: a gge >100 > 00

JUNE 2013

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CL IN ICA L A N E STH E SIOL OG Y

Selected Points From OPTN/ UNOS Director of Liver Transplant Anesthesia Recommendations • The director will be responsible for establishing internal policies for anesthesiology participation in perioperative transplant patient care. • The policy must establish a clear communication channel between the transplant anesthesiology service and other liver transplant disciplines. • The director should have fellowship training in critical care medicine, cardiac anesthesiology or liver transplant, including perioperative care of at least 10 liver transplant recipients or experience in the perioperative care of at least 20

The recommendations strengthen a multidisciplinary model of liver transplantation by calling for directors to be involved in all aspects of care: perioperative consults, transplant candidate selection, morbidity and mortality conferences, postoperative patient visits and development of intraoperative guidelines. Several studies have demonstrated that specialized liver transplant anesthesia teams can improve patient outcomes. For example, researchers at the University of Wisconsin showed that liver transplant anesthesiologists reduce the need for blood transfusions and shorten intensive care unit stays following liver transplantation (Liver ( Transpl 2009;15:460-465). “This was one of the pieces of evidence that OPTN/UNOS considered in its deliberations about the role of anesthesiologists in the integrated care model,” Dr. Mandelll said. Fostering Partnerships David J. Reich, MD, professor and chief of the Division of Multiorgan Transplantation and Hepatobiliary Surgery, at Drexel University College of Medicine and Hahnemann University Hospital, in Philadelphia, co-authored the survey study with Dr. Mandell and her colleagues. He said the guidelines “should improve liver transplant anesthesia support and partnership between transplant and anesthesia teams.” “This can only bolster safety and high-qualityy outcomes,” said Dr. Reich, a past member of UNOS’ Liver and Intestine Transplant Committee and immediate past chair of the Standards Committee of the American Society

liver transplant recipients within the past five years. • The director should earn a minimum of eight hours of credit in transplant-related educational activities within the three years preceding appointment. —D.W.

of Transplant Surgeons (ASTS). “In every discipline, clinical programs are stretched in terms of resources. Because these guidelines have been issued by a governing organization, they provide transplant anesthesiologists with a strong case to ask hospital leadership for adequate resources so that they can ensure they meet the recommendations.” Although the survey did not include low-volume and private liver transplant centers, if the reaction from Porter Adventist Hospital, in Denver, is an

indication of the broader response from this subset of programs, the guidelines should not be onerous. “The OPTN/UNOS guidelines are reasonable and manageable,” said Alan Qualls, MBA, the hospital’s director of Oncology, Robotics, and Transplant Services. His private medical center recently restarted its program and performs 10 to 15 liver transplants annually. “If the director is trained at a major center with a liver program, the see organs page 27

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CONTINUING MEDICAL EDUCATION

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

JUNE 2013

Lesson 304: Perioperative Pain Management of the Patient With Chronic Pain—Part 1 WRITTEN BY: David B. Turk, MD Anesthesiology Resident Department of Anesthesiology Einstein College of Medicine/Montefiore Medical Center New York, New York

Karina Gritsenko, MD Assistant Professor Department of Anesthesiology Pain Medicine and Regional Anesthesiology Division Einstein College of Medicine/Montefiore Medical Center New York, New York

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

DISCLOSURES The author and reviewer have no conflicts of interest to disclose nor is unapproved use of any drugs discussed.

toxicity will be delineated and perioperative adjuvants discussed. Additional sections will deal with the special concerns of postoperative analgesia in the obese patient and drug interactions caused by concomitant administration of St. John’s wort. Finally, the differences between addiction, pseudoaddiction, tolerance, and secondary gain will be presented.

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

LEARNING OBJECTIVES At the conclusion of the lesson, the reader will be able to: 1. Classify types of pain 2. Be conversant with definitions of pain terminology 3. Conduct a preoperative evaluation of a chronic pain patient 4. List the pros and cons of various intraoperative anesthetic options 5. Explain the concept of multimodal analgesia 6. Understand opioid analgesic conversions 7. Differentiate between neuropathic and nociceptive pain 8. Subdivide acute pain according to anatomic origins 9. List adverse effects (AEs) related to polypharmacology in chronic pain management 10. Be aware of the differences between spinal cord stimulators and intrathecal pumps

TARGET AUDIENCE

CASE HISTORY

Anesthesiologists

A 65-year-old man was scheduled for multilevel laminectomies and instrumentation. Suffering from severe back pain for years, he had been receiving chronic methadone therapy, opioid patches, and oxycodone/acetaminophen. His pain specialist had prescribed several antidepressants, and the patient reported that he also self-administered several herbal preparations, including St. John’s wort. His underlying disease limited his exercise tolerance. Although there was no formal diagnosis of obstructive sleep apnea, his wife reported that he snored loudly and often stopped breathing for a few seconds at night. He weighed 265 lb (120 kg) and was 69 inches (175.26 cm) tall. He was very concerned about pain and postoperative pain control.

PROFESSIONAL GAPS This 2-part series reviews the perioperative management of pain. Part 1 will define pain and the descriptors of pain terminology. Appropriate evaluation of the chronic pain patient is outlined and alternatives for anesthetic plans presented. The concept of multimodal analgesia is discussed and a conversion table for commonly used analgesic agents is presented. In Part 2 (available at www.mssm.procampus.net in July 2013), narcotic metabolism and

he International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”1 This definition acknowledges the many facets of the human experience with regard to pain: the sensory and physiologic components, the subjective aspect, and the emotional and psychological components. Pain can be acute or chronic. Acute pain generally results from nociceptive pathways, whereas chronic pain often also involves behavioral and psychological phenomena that must be addressed in order to provide the patient with an all-encompassing, effective therapy. Pain also can be characterized as nociceptive or neuropathic. Nociceptive pain, such as the pain of surgical

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

A COURSE OF STUDY FOR AMA/PRA CATEGORY 1 CREDIT Read this article, reflect on the information presented, then go online (www.mssm.procampus.net) and complete the lesson posttest and course evaluation before May 31, 2014. (CME credit is not valid past this date.) You must achieve a score of 80% or better to earn CME credit. TIME TO COMPLETE ACTIVITY: 2 hours RELEASE DATE: June 1, 2013 TERMINATION DATE: May 31, 2014 ACCREDITATION STATEMENT The Icahn School of Medicine at Mount Sinai is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

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

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incision, is modulated by activated or sensitized receptors and transmitted by peripheral neurons to the central nervous system (CNS). Neuropathic pain, such as diabetic neuropathy or radiculopathy from bone metastasis in a patient with cancer, occurs secondary to injury or damage sustained by the peripheral or CNS anatomy. Acute pain can be further classified as to its anatomical origin, somatic versus visceral; somatic pain can be further subdivided as “superficial” or “deep.” Superficial somatic pain arises from pain receptors in the skin, subcutaneous tissues, and mucous membranes, whereas deep somatic pain originates in the muscles, tendons, joints, or bones. Superficial somatic pain often is described by patients as having sharp, stabbing, or throbbing qualities, whereas deep somatic pain usually is described as having a dull, aching quality that is poorly localized. Visceral pain arises from the internal organs and/or the overlying fascia, pleura, or peritoneal tissues. Visceral pain, therefore, can be described as “true” visceral or parietal in nature, and can be further categorized as local or referred. Alternatively, visceral pain can be described as dull and diffuse or as sharp, stabbing, and localized, with its intensity and localization varying to some extent based on the degree of involvement of parietal coverings. For example, pain may arise from the pancreas and be referred to a distant site such as the shoulder. Pain also can be characterized by its etiology, including postoperative pain, neuropathic pain secondary to a systemic illness, chronic low back pain resulting from a herniated disk, cancer pain resulting from inflammatory cytokine release, and mass effect on adjacent structures.

Descriptors of Pain Terminology Descriptive terms used in pain management help to further define the patient’s symptomatology, which can sometimes be confused by the patient’s own subjective psychological experience, emotional factors, and language barriers (Table 1).

pharmacotherapy. Opioid therapy may include shortacting analgesics such as oxycodone as needed; longacting analgesics such as sustained-release morphine, a fentanyl patch, or methadone; or partial-agonist agents such as buprenorphine. The dose, strength, frequency, and route of administration must be documented clearly and verified with the patient’s primary care physician or pharmacy, or by inspecting medication bottles. Reactions to specific narcotics should be documented to avoid inadvertent use in the postoperative setting. Drug interactions also may result from therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), antispasmodic agents such as baclofen, antidepressants (particularly tricyclic antidepressants [TCAs] such as nortriptyline), anticonvulsants such as pregabalin, and other therapies. It is important to differentiate between AEs and true allergic reactions. Pharmacogenetic differences among patients should be considered. Not all drugs work equally well for all patients, and some individuals may benefit from continuing the opioid regimen that has been working well for them.2,3 For example, a patient who has been managed well on chronic morphine therapy may state a preference for morphine over the hydromorphone that is on the hospital formulary. Pharmacologic interventions are only part of the therapeutic repertoire. Spinal cord stimulators deliver analgesia via electrical pulses from electrodes implanted in the epidural space and their anatomic location must be noted. Intrathecal pumps deliver small quantities of medication, such as baclofen, morphine, or ziconotide, directly into the spinal fluid, which in theory minimizes but does not eliminate the side effects associated with higher systemic dosages of these drugs. Neuraxial devices can limit the options for neuraxial anesthesia and can be important depending on the surgical procedure planned, as there

can be untoward complications from inadvertent device manipulation, including catheter fracture or dislodgement on the operating table and a subsequent postoperative pain crisis.

The Anesthetic Plan A preoperative conversation with the patient regarding choice of anesthetic—general anesthesia (GA), neuraxial anesthesia (NA), peripheral regional anesthesia (RA), or a combination—entails discussion of the risks and benefits of each, especially the assessment of expected pain control. General Anesthesia GA often is the default option in many patients’ minds for surgery. Its benefits include good intraoperative analgesia, amnesia, and unconsciousness. These factors may serve the patient well in cases where surgical intervention is of variable or unknown duration. Drawbacks may include unreliable postoperative analgesia (unless a plan has been set up in advance, eg, patient-controlled analgesia [PCA]); reliance on opioids and/or other IV agents for analgesia with accompanying side effects (ie, depressed consciousness, urinary retention, pruritus, constipation, and ileus), as well as shivering and nausea in the postanesthesia care unit (PACU). Neuraxial Anesthesia NA includes spinal, epidural, and caudal blocks. Depending on the case, NA may be used as the sole anesthetic, in conjunction with GA, or for postoperative analgesic plan. NA has an excellent safety profile; studies show reductions in perioperative morbidity and mortality, and decreased risk for deep venous thrombosis and pulmonary embolism in many instances in which NA is used.4,5

Table 1. Common Pain Descriptors Used in the Pain Management Lexicon

Managing the Chronic Pain Patient: Preoperative Evaluation The patient with chronic pain poses unique challenges in the perioperative setting. In addition to the usual anesthetic considerations, these patients can present with complex narcotic regimens at high doses, alternative delivery modalities (ie, intrathecal pump therapy), and implanted interventional devices such as spinal cord stimulators. Each situation presents unique risks, including AEs secondary to polypharmacy, tolerance to anesthetics, or narcotic withdrawal (eg, a patient on buprenorphine provided with acetaminophen/oxycodone postoperatively). In preparation for the narcotictolerant patient, the pain physician, surgeon, and anesthesiologist should devise a multimodal perioperative plan and present it to the patient. Such a plan must combine both the chronic analgesic requirements of the patient and address new acute pain needs. Initial assessment of a patient with chronic pain should employ a systematic approach. First, a global history and physical examination should be explored to document pain generators, psychosocial stressors, and comorbidities. A complete medication list should be compiled, including both long- and short-acting opioid

Term

Definitiona

Allodynia

Perception of a normally nonpainful stimulus as painful

Analgesia

Absence of the perception of pain

Anesthesia

Absence of all sensations

Anesthesia dolorosa

Pain in an area lacking sensation

Dysesthesia

Adverse or abnormal sensation with or without a stimulus

Hypoalgesia (hypalgesia)

Decreased response to painful stimulus

Hyperalgesia

An exaggerated or extreme response to painful stimulus

Hyperesthesia

Increased sensitivity to any stimulus (eg, pain, heat, cold, or touch)

Hyperpathia

Presence of hyperesthesia, hyperalgesia, and allodynia, typically accompanied by persistence of the sensation after removal of the stimulus

Hypoesthesia

An abnormally reduced sense of sensation (eg, touch, pressure, or temperature)

Neuralgia

Pain caused by damage to or malfunctioning of a nerve and often following the course of the involved nerve(s)

Paresthesia

Abnormal sensation without an apparent stimulus

Definitions are adapted from International Association for the Study of Pain (IASP) taxonomy site.

CONTINUING MEDICAL EDUCATION

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Table 2. Pain Sensation, Transmission, Modulation, and Perception: Potential Pharmacologic Interventions Anatomy

Action

Examples of Analgesic Agents

Brain

Perception of pain

Opioids α₂-agonists TCAs SSRIs SNRIs

Spinal cord descending modulation

Modulation of pain transmission; may augment or inhibit

TCAs SSRIs SNRIs

Spinal cord ascending modulation

Transmission of pain from peripheral nerves to CNS

Local anesthetics Opioids

Tissue peripheral nociceptors

Transduction of pain via nociceptors to peripheral nerves

Local anesthetics Capsaicin Anticonvulsants NSAIDs, ASA APAP

APAP, acetaminophen; ASA, aspirin; CNS, central nervous system; NSAID, nonsteroidal anti-inflammatory drug; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant

NA may mitigate the hypercoagulable state associated with surgery, provide for better tissue blood flow, and suppress the neuroendocrine response.4,5 In a 2003 review of NA, Moraca et al found significant reductions in several areas, including cardiac morbidity, pulmonary infections, and pulmonary embolism.5 NA, particularly epidural PCA, may be associated with shorter duration of mechanical ventilation after surgery, reductions in intensive care unit and hospital lengths of stay (LOS), and subsequent decreased hospitalization costs,6 as well as greater patient satisfaction and decreased use of opioids.7 Contraindications to NA may include the use of certain anticoagulant regimens,8 a history of coagulopathy or bleeding diathesis, infection at proposed spinal injection site, severe aortic or mitral stenosis, elevated intracranial pressure, and severe hypovolemia. Relative contraindications may include sepsis, preexisting neurologic deficits or demyelinating lesions, stenotic valvular heart disease, severe spinal deformities, and history of trauma or back surgeries. In this particular vignette involving a patient for multilevel laminectomies, NA would not commonly be used for several reasons (prone position, variable operating time, different approaches, fluid shifts), although there are case–control analyses discussing use of intrathecal medications in lieu of GA for lumbar decompression.9 However, the technique is not popular, and is even less so in this patient due to possible difficulty with placement of an intrathecal dose in an obese patient, as well as long surgery with greater hemodynamic instability and blood loss. Potential AEs of NA include backache, urinary retention, “high” block, total spinal anesthesia, anterior spinal artery syndrome, nerve injury, intraspinal bleed or epidural hematoma, dural puncture, catheter retention, infection, and local anesthetic drug toxicity. Peripheral Nerve Blocks Peripheral RA, like NA, may offer superb targeted anesthesia and decreased use of systemic opioids.

Patients receiving nerve blocks report greater overall satisfaction, and may demonstrate decreased cognitive impairment.10 Use of continuous peripheral nerve blocks may improve anesthesia-related workflow and reduction of time spent in the PACU compared with GA. Anesthesia-related costs also may be reduced, as a result of reduced rates of postoperative nausea and vomiting, and fewer in-hospital days.11 Complications of RA include local anesthetic toxicity, blockade of the wrong nerve, and nerve damage. Relative contraindications to peripheral nerve blocks include uncooperative patients, bleeding diathesis, disseminated infection, and peripheral neuropathy. Multimodal Analgesia Pain transmitted from peripheral nociceptors is perceived in the CNS, which also might further modulate pain sensation and development of chronic pain syndromes (Figure 1). Chronic pain mechanisms involve transduction, transmission, modulation (and changes in neuroplasticity), and perception by the CNS. Selecting modes of analgesia based on pain mechanisms may help in multimodal management of acute-on-chronic pain (Table 2). Prevention of acute pain is important, not only for the short-term postoperative experience, but also to prevent the development of long-term chronic pain syndromes because development of chronic pain conditions can affect activities of daily living and cause inability to return to work. Acute pain exacerbations might lead to neural sensitization and release of neuroendocrine mediators, both peripherally and centrally.12 Multimodal analgesia occurs when multiple drugs, including analgesics or adjuvants, are given in combination to relieve acute or chronic pain. This therapy may include acetaminophen, short-term NSAID use, ketamine, and/or dexmedetomidine. Multimodal analgesia also may involve agents such as gabapentin, pregabalin, and injectable capsaicin; indeed some studies have found an

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analgesic effect from the preoperative administration of gabapentin.13 Pain control can be achieved through 3 approaches: 1. Modulating the pain transmitted to the CNS using local anesthetics, NSAIDs, acetaminophen, anticonvulsants, and capsaicin. 2. Mitigation of CNS pain perception using opioids, α2-agonists, and TCAs. 3. Regulation of descending inhibitory pathways using tramadol, selective serotonin reuptake inhibitors, and clonidine. Nevertheless, insufficient data exist to prove definitively that multimodal analgesia significantly improves postoperative outcome. This may be due in part to an insufficient number of cases to detect statistically significant differences in currently low incidences of postoperative complications.14 Alternatively, drug–drug interactions may exert deleterious effects on patient outcomes. For example, the sedative effects of methadone and diazepam can be exacerbated as both are metabolized by the same cytochrome P450 enzymatic system. In geriatric patients, age-related changes in pharmacokinetics and drug metabolism also may play a role. Providing an elderly patient with even a small amount of opioid analgesia in combination with TCA therapy can bring about clinically significant constipation.15 Multimodal analgesia, therefore, might best be conceived as part of a balanced approach to postoperative care, with additional multidisciplinary inputs, such as physical therapy and postdischarge rehabilitation.

Converting Between Opioid Agents When deciding on choice of opioid and dose, several questions may arise. For example, if the patient’s home medication list includes 35 mg of oxycodone per day, should the postoperative dose simply be increased to account for acute perioperative pain? An important concept to emphasize is that unimodal treatment of opioid-tolerant patients is not the best approach for postoperative pain. Studies suggest that undertreating acute pain may decrease analgesia subsequently derived from opioid analgesics, frustrating future pain control.16 Thus, daily opioid treatment requirements must be met before attempting to achieve analgesia. No predictions of opioid requirements can be made for individual patients. Even patients requiring modest opioid doses preoperatively may require more than twice the amount of opioids typically used for adequate pain control in opioid-naive patients, increasing the likelihood of opioid-induced AEs such as sedation and respiratory depression. In a unimodal analgesia paradigm, the preoperative needs of an opioid-tolerant patient should first be tabulated; equianalgesic doses of other opioids can then be substituted, depending on the analgesic plan of the provider (Table 3). The clinician also should consider the oral and IV conversion for a particular drug when calculating perioperative requirements. Patients on chronic methadone or buprenorphine often require special consideration. Oral methadone doses often are reduced significantly when given intravenously. When acute-on-chronic opioid treatment is involved, providers should be wary of the potential for opioid overdose to

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Table 3. Opioid Conversion Table, Relative Potency Compared With Morphine

Opioid Agent

Potency vs Morphine t ½

Initial Dose in OpioidNaive Patient

Side Effects; Special Comment

Long-acting Methadone

Buprenorphine

Pentazocine

~2 to 3.5 - 20+ Dose conversion highly variablea

Duration of analgesia ~8 h May increase to 24-48 h after repeated dosage

5-10 mg IV; Low cost. NMDA antagonist effects may 20 mg PO provide additional analgesic benefit. 24-h oral morphine/ Risk for QT prolongation methadone ratio: <30 mg 2:1 31-99 mg 4:1 100-299 mg 8:1 300-499 mg 12:1 500-999 mg 15:1 1,000-1,200 mg 20:1 >1,200 mg CONSIDER CONSULT (1.5 mg oral dose): 2 mg methadone PO=1 mg methadone IV

~20+

2.2-3 h IV duration lasts ~6 h

0.3 mg every 6-8 h as needed

0.3

30 mg

Agonist-antagonist; can precipitate withdrawal. Should not be given to patients on traditional opioids. Risk for QT prolongation at higher doses. Pain specialist or physician familiar with its use should be consulted Agonist-antagonist; partial agonist at κ, μ, δ receptors; can precipitate withdrawal. Slow dissociation from receptors causes long duration of action

Intermediate-acting Morphine

Meperidine

0.1

2-4 h

2.5 h

5-10 mg IV every 4 h as needed

ER formulations may provide analgesia for 8-24 h. Active metabolite; provider should consider alternative agents (eg, hydromorphone) in patients with renal failure

1.1-2 mg/kg IM or SubQ Reduced dose (eg, 0.8 mg/kg) may be given IV

Accompanied by sympathomimetic effects such as tachycardia. Should be given with caution to patients on serotonergic agents to avoid precipitating life-threatening serotonin syndrome. Active metabolite can accumulate with repeated doses, hepatic or renal insufficiency

Hydromorphone 5-7

2-3 h

0.2-1 mg every 3-4 h as needed

Commonly given PCA; oral ER formulations also available

Oxymorphone

Duration of analgesia 3-6 h

~0.5 mg IV

Chemically similar to hydromorphone

30-60 min

1-2 mcg/kg or 25-100 mcg/dose

Short-acting, but increased duration of dose results in increased duration of effects (context-sensitive half-life)

~100

Remifentanil

200-500

10-20 min

0.02-0.1 mcg/kg/min Titrate as needed

Ultrashort-acting; decays rapidly in blood irrespective of amount given

Sufentanil

500-1,000

10-20 min

0.01-0.1 mcg/kg/min May also be given epidurally in local anesthetic solution

Short-acting but intermediate to fentanyl and remifentanil. After prolonged administration, elimination half-life can increase significantly

ER, extended release; IM, intramuscular; NMDA, N-methyl-D-aspartate; PCA, patient-controlled analgesia; SubQ, subcutaneously a

Management of the Case Presented Please see Part 2 of this series, available at www.mssm. procampus.net in July 2013.

Conclusion The plan for postoperative pain management in the chronic pain patient must start well before the day of surgery and involve many disciplines. The regimen should be individualized to the patient according to his or her medical history and current pain management protocols. Multimodal techniques should be explored and discussed as a team and approved by the patient. Because various schemes can prove ineffective in some patients, equivalent medications should be sought and substituted.

References 1.

International Association for the Study of Pain, list of taxonomy. http://www.iasp-pain.org.

Cohen M, Sadhasivam S, Vinks AA. Pharmacogenetics in perioperative medicine. Curr Opin Anaesthesiol. 2012;25(4):419-427.

Droney J, Riley J, Ross J. Opioid genetics in the context of opioid switching. Curr Opin Support Palliat Care. 2012;6(1):10-16.

Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. BMJ. 2000;321(7275):1493.

Moraca RJ, Sheldon DG, Rhirlby RC. The role of epidural anesthesia and analgesia in surgical practice. Ann Surg. 2003;238(5):663-673.

de Leon-Casasola OA, Parker BM, Lema MJ, et al. Epidural analgesia versus intravenous patient-controlled analgesia. Differences in the postoperative course of cancer patients. Reg Anesth. 1994;19(5):307-315.

Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology. 2005;103(5):1079-1088.

Horlocker T, Wedel D, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (3rd Edition). Reg Anesth Pain Med. 2010;35(1):64-101.

McLain RF, Kalfas I, Bell GR. Comparison of spinal and general anesthesia in lumbar laminectomy surgery: a case-controlled analysis of 400 patients. J Neurosurg: Spine. 2005;2(1):17-22.

10. Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011;113(4):904-925. 11. Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract. June 2012.

Short-acting Fentanyl

develop as acute pain wanes. Different classes of analgesics using different routes of administration may be preferable.

Data accrued from several sources in the literature; conversion may vary depending on source.

12. Vadivelu N, Mitra S, Narayan D. Recent advances in postoperative pain management. Yale J Biol Med. 2010;83(1):11-25. 13. Parikh HG, Dash SK, Upasani CB. Study of the effect of oral gabapentin used as preemptive analgesia to attenuate post-operative pain in patients undergoing abdominal surgery under general anesthesia. Saudi J Anaesth. 2010;4(3):137-141. 14. Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg. 2007;104(3):689-702. 15. Mao J, Gold M, Backonja M. Combination drug therapy for chronic pain: a call for more clinical studies. J Pain. 2011;12(2): 157-166. 16. Alford D, Compton P, Samet J. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127-134.

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

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

Post-Test 1.

Rank the following opioids in terms of their potency, from greatest to least: a. Hydromorphone, oxymorphone, morphine, meperidine b. Oxymorphone, hydromorphone, meperidine, morphine c. Hydromorphone, morphine, oxymorphone, meperidine d. Morphine, hydromorphone, meperidine, oxymorphone

A patient’s home opioid regimen includes 30 mg of morphine 6 times per day. What would be a comparable dose if the patient were converted to methadone? a. Ratio is 2:1. Give the patient 15 mg of methadone 6 times per day. b. Ratio is 2:1. Give the patient 15 mg of methadone 3 times per day. c. Ratio is 8:1. Give the patient 20 mg of methadone over a 24-hour period. d. Ratio is 8:1. Give the patient 20 mg of methadone twice daily.

An 85-year-old woman is scheduled for pelvic floor surgery and requests an epidural. She appears healthy. Physical exam is notable for a chronic heart murmur. Her hematocrit is 33. She has not taken clopidogrel for almost 2 weeks, but takes aspirin 81 mg daily. What additional study would most assist the anesthesiologist preoperatively? a. Clotting studies b. Echocardiogram c. Hemoglobin electrophoresis d. Electrocardiogram A 35-year-old volunteer fireman is brought to the emergency room sustaining third-degree burns to his hands. He does not appear upset and says it only hurts “a little.” A concerned nurse taps his hand lightly and he reports sensation. This is an example of _____. a. hypoesthesia b. hypoalgesia c. analgesia d. anesthesia A patient is complaining of constant burning pain on the left side of her face for the past several months after a procedure to treat her trigeminal neuralgia. The primary medical doctor palpates and lightly pricks her face to assess sensation but the patient reports numbness. This is an example of _____. a. dysesthesia b. anesthesia dolorosa c. hyperalgesia d. paresthesia

A patient with unresectable pancreatic cancer reports sharp, stabbing pain in her shoulder and occasional severe nausea. Physical exam reveals an apparently normal-appearing shoulder; range of motion is normal and shoulder x-ray is normal. Full body magnetic resonance imaging is significant for non-contourdeforming pancreatic mass and omental spread. The etiology of her pain is likely _____. a. metastatic spread of tumor to shoulder joint b. deep superficial pain from muscular spread c. visceral pain from the parietal coverings d. withdrawal from opioids

Neuraxial anesthesia for perioperative pain control in opioid-tolerant patients is associated with all of the following except _____. a. decreased cost b. decreased risk for urinary retention c. decreased length of in-hospital recovery d. decreased pulmonary infections

A histrionic, morbidly obese 45-year-old woman presents for laminectomy and fusion of multiple herniated disks. She states that due to her chronic back pain she has been taking morphine 240 mg per day, and low-dose thioridazine (75 mg) for anxiety, but now wants a more potent analgesic. How much methadone should she be placed on perioperatively? a. Ratio is 24:1, dose 10 mg. b. Ratio is 12:1, dose 20 mg. c. Ratio is 8:1, dose 30 mg. d. This patient is at risk for adverse effects and should not be placed on methadone.

For which patient would neuraxial anesthesia likely be contraindicated? a. A 25-year-old man with history of gum bleeding requiring transfusion after wisdom tooth removal; hematocrit today is 35%. b. An 80-year-old woman with history of aortic stenosis, now status post-valve replacement with normal echocardiographic studies. c. A 34-year-old man positive for HIV with history of meningitis 3 years ago but no sequelae. d. A 45-year-old Korean-speaking woman who initially refused spinal anesthesia but after discussion with a hospital interpreter has now consented.

10. A 66-year-old man with glioblastoma multiforme on chemotherapy describes burning pain in the right buccal region. He says he feels constant sharp pain, worsened by eating, drinking, talking, and swallowing. Pricking the face with a probe elicits tremendous pain, as does light palpation. Five minutes later, he is still wincing from pain. This is an example of _____. a. hyperalgesia b. hyperpathia c. hyperesthesia d. dysesthesia

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like “images of the Civil War, when there were so many amputations,” Dr. Ortega added. “But this movie that was being played before my eyes was in color, high-definition.”

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April 15, a state holiday in Massachusetts, so elective surgeries were at a minimum with freed-up space in the emergency rooms and recovery units. And because temperatures were in the 50s—about 30 degrees cooler than the year before—first responders were not busy treating heat exhaustion victims and more wheelchairs were available. “A series of favorable circumstances allowed us to respond so fast and with so many people,” said Rafael Ortega, MD, professor of anesthesiology at Boston University School of Medicine and Boston Medical Center. “Had it been at 1 in the afternoon, all the rooms would be up and running,” said Scott Segal, MD, anesthesiologistin-chieff at Tufts Medical Center. “Had it happened at 7 o’clock [p.m.], we would have been down to our call teams. On the anesthesiology side, we were very lucky.” The anesthesiologists agreed that another stroke of good fortune was the skill with which first responders treated and prepared victims before they arrived at Scott Segal, MD the hospitals. Because of the number of victims (three dead, more than 250 injured) and the seriousness of the injuries, emergency medical technicians (EMTs) at the scene and in ambulances knew timing was critical, so they prepared vital medical information in case the victims lost consciousness. “They were writing on people’s chests,” said Joan E. Spiegel, MD, an instructor in anesthesia at Beth Israel Deaconess Medical Center. “They just wrote what happened to them on a chest with a marking pen. It was a very good idea.” Hospitals conduct drills for disasters, but the anesthesiologists were unprepared for the types of injuries they encountered after the blasts. Although some victims had wounds and burns to the face and hands, most injuries affected the lower extremities—atypical for a major city during peacetime. “Most of us are set up for civilian trauma—blunt trauma and penetrating gunshot wounds—but not blast injuries,” Dr. Segal said. The rooms looked

Heightened security at Tufts Medical Center.

Entering a ‘War Zone’ While the clinicians raced to prepare themselves for surgery, the operating rooms (ORs) filled with patients at an astonishing, and dismaying, rate. “I went to the locker room and I changed,” Dr. Ortegaa recalled. “It must have taken a minute. Within that minute, when I got into the ER, it was as if I had entered a war zone.” Routine bookkeeping procedures weren’t a consideration. “The consent

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C LIN I C A L A N ES THES IO LO G Y BOSTON

Most victims were young and healthy. “We physically sent anesthesiologists down to the Emergency Department to get information to the OR so we’d know what we were getting,” Dr. Segall said. “A lot of what was done at the beginning

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issue didn’t even cross my mind,” Dr. Ortegaa said. “I will deal with that some other time.” “Time was of the essence,” said Joshua Vacanti, MD, medical director of the postanesthesia care unit at Brigham and Women’s Hospital. “People communicated what they needed to communicate by whatever means worked. We circumvented the computerized version” of patient records. Doctors also had to work without the benefit of cell phones, which were not working during the height of the chaos, either because the devices were shut off by authorities or the telephone circuits were overwhelmed. “We used pagers and landlines—old school,” Dr. Segall said. All patients arrived at Tufts in a conscious state, which Dr. Segal said helped with communication. Doctors and nurses were able to determine quickly whether they had major drug allergies that would make anesthesia

was stabilization. In the immediate time period, it’s trauma. You get them in, get them, stabilize them, and get things fixed.” Things moved as smoothly as possible under the circumstances, even though the OR had to be evacuated at one point because of a

An injured person is transported to Tufts Medical on April 15. Christopher Evans/Boston Herald

administration difficult or deadly. Dr. Spiegel, a member of the Anesthesiology Newss editorial board, said she was told of one patient at her facility who “came in with a giant piece of paper that said ‘malignant hyperthermia.’”

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CL IN ICA L A N E STH E SIOL OG Y if small-scale bombs become a weapon of choice for terrorists. But all in all, they were proud of how well they, their patients, the patients’ loved ones and first responders performed. Dr. Ortegaa said the Boston hospitals were “well-oiled machines.” He said he had written a paper for a journal years ago about treating blast injuries, “but never from a terrorism attack.” Now, he said, he has a new chapter to write, and “now it was from reality.” —John Dillon

Boston Medical Center personnel wait for victims from the marathon bombings to arrive. Jim Davis/ Globe Staff

bomb scare, Dr. Segall said. Doctors and patients alike had to deal with not only injuries but “seeing people in full Kevlar suits and automatic weapons walking around the hospital,” he said. As severe as some of the injuries were, Dr. Vacanti said they were easier for an anesthesiologist to deal with. The wounds largely did not involve the thorax, heart or abdomen, “which would have made for sicker patients,” he explained. Such injuries “are more difficult to diagnose and involve more instability. That would have been more challenging to resuscitate them,” he said. Pain management “was certainly an issue,” Dr. Vacanti added. “Several had anesthetics that were supplemented with regional anesthesia—single-shot nerve blocks—and gases.” Peripheral nerve catheters were applied to patients who had to undergo amputations. “Phantom limb pain is a big issue immediately postoperatively and down the road,” he said. At Beth Israel, anesthesiologists took advantage of portable ultrasound devices to assess vascular injury to limbs, Dr. Spiegel said. The hospital performed 14 surgeries on blast victims, she said, many of which were amputations. Like at the other hospitals, doctors had time to ask no more than three or four questions. “I was surprised by how coherent, how calm they were,” she said. “We had patients with gruesome injuries, and they seemed to have been well-prepped for the hospital room. There were no hysterical patients whatsoever.” Clinicians said there will be lessons to be learned from the attack, especially

ORGANS

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requirements should already be in practice. Our director of liver transplant anesthesia already actively participates in the selection committee and clears patients medically with the primary liver surgeon during the evaluation process.” The feedback Dr. Reich received to date has focused on requests for more continuing medical education (CME) opportunities so that

directors can meet the CME requirement stipulated in the guidelines. “The ILTS [International Liver Transplantation Society] has a one-day program for transplant anesthesiologists and the ASTS is increasing educational offerings to anesthesiologists,” he added. “We welcome collaboration with anesthesiologists and are trying to advertise educational opportunities, such as at the American Transplant Congress.” —David Wild

Less pain. Less opioids. From the start. OFIRMEV® provides significant pain relief*1 • OFIRMEV 1 g (Q6h) + patient-controlled analgesia (PCA) morphine demonstrated significant pain relief vs placebo + PCA morphine (P<0.05 over 6 h)1 • OFIRMEV 1 g (Q6h) + PCA morphine showed greater reduction in pain intensity over 24 h (SPID24)† compared to placebo + PCA morphine (P<0.001)2

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

OFIRMEV from the start • Consider administering the first dose of OFIRMEV PreOp or post-induction • Schedule OFIRMEV Q6h for first 24 h and continue as clinically warranted

Indication ndication OFIRMEV is indicated for the management of mild to moderate pain; the management of moderate to severe pain with adjunctive opioid analgesics; and the reduction of fever. Important Safety Information OFIRMEV is contraindicated in patients with severe hepatic impairment, severe active liver disease or with known hypersensitivity to acetaminophen or to any of the excipients in the formulation. Acetaminophen should be used with caution in patients with the following conditions: hepatic impairment or active hepatic disease, alcoholism, chronic malnutrition, severe hypovolemia, or severe renal impairment. Do not exceed the maximum recommended daily dose of acetaminophen. Administration of acetaminophen by any route in doses higher than recommended may result in hepatic injury, including the risk of severe hepatotoxicity and death.

OFIRMEV should be administered only as a 15-minute 15 minute intravenous infusion. infusion 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. y 2005;102:822-831. 2. Data on file. Cadence Pharmaceuticals, Inc.

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Perioperative Approach to Patients With Opioid Abuse and Tolerance BENJAMIN VAGHARI, MD

JAIME L. BARATTA, MD

KISHOR GANDHI, MD, MPH, CPE

Clinical Instructor Jefferson Medical College Thomas Jefferson University Department of Anesthesiology Philadelphia, Pennsylvania

Assistant Professor Director, Fellowship in Regional Anesthesia and Acute Pain Jefferson Medical College Thomas Jefferson University Department of Anesthesiology Philadelphia, Pennsylvania

Associate Professor Director, Regional Anesthesia Jefferson Medical College Thomas Jefferson University Department of Anesthesiology Philadelphia, Pennsylvania

The authors report no relevant financial conflicts.

ubstance abuse in the United States is

increasing. Most of the rise in illicit drug use has been attributed to marijuana,

with the use of heroin remaining relatively stable over the past 10 years. Yet although heroin use has plateaued, overall use of opioid analgesics has increased dramatically.1 Sales of prescription opioids quadrupled between 1999 and 2010.2

Enough of these substances were prescribed in 2011 to medicate every American adult with a standard dose of 5 mg of hydrocodone every 4 hours for a month. In 2010 alone, 12 million Americans reported nonmedical use of prescription pain killers in the past year.2 As the use and abuse of opioids increases, the likelihood of an anesthesiologist encountering these patients during clinical practice also will increase. The anesthetic and analgesic implications of increased opioid use are 2-fold. First, as both illegal and prescription use of opioids increases, anesthesiologists will encounter more patients exhibiting opioid tolerance. Second, as abusers of opioids seek treatment for their addiction, the numbers of patients receiving long-term opioid therapy for their addiction also will increase. Long-term medical therapy for opioid dependence introduces several issues in the management of patients that clinicians must consider when forming an anesthetic and analgesic plan.

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All anesthetic and analgesic plans can be divided into preoperative considerations, intraoperative management, and postoperative recovery and analgesia. For patients with known or suspected opioid abuse, this strategy is no different. Optimal patient care always begins in the preoperative period with the patient assessment. Obtaining information about patient drug use and potential ongoing treatment is critical in constructing an appropriate plan. If the patientâ&#x20AC;&#x2122;s history with opioids is limited or unknown to the anesthesia care team, patient care and satisfaction are likely to be compromised. Understanding and performing appropriate screening and assessment is paramount in these cases.

Patient Evaluation Screening and assessment of opioid use can be broken down into 2 main categories: subjective and objective data. Subjective data are gathered by the practitioner at time of interview, either in preadmission

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testing or in the preoperative holding area. Objective data largely are related to urinalysis and blood testing. The interviewing clinician will benefit from realizing that many patients with a history of abuse of or dependence on prescription opioids—including oxycodone, hydrocodone, fentanyl, and other drugs—will be evasive about that history or will attempt to minimize their use of these drugs. A helpful strategy when collecting the patient history is to focus on specific questions while preserving a nonjudgmental environment. For example, “What is the most you have ever used in a day,” can provide more useful information than simply asking about average daily use. Whenever possible, the interviewer should determine the time of the last dose of opioids and, if applicable, who is prescribing these medications. To help with this difficult task, several drug screening questionnaires have been developed. Some of these validated screening tests can involve many questions, which may be impractical for daily use by anesthesiologists, who must make efficient use of their limited time. However, 2 such questionnaires are short enough to be practical for everyday use by anesthetists.

CAGE-AID The CAGE-AID (Adapted to Include Drugs) is a modification of the common 4-question tool used to detect potential alcohol abuse (Table 1).3 A second, and perhaps easier, validated screening test is the single question: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”4 Regardless of which strategy anesthesiologists use in their own practice, most patients are unlikely to volunteer this important information without direct questioning. Drug screening, specifically urine drug screening (UDS), is an important tool in obtaining objective information about a patient’s use of opioids. However, these tests have several important limitations (Table 2).5 Immunoassay screening, which is the most common UDS, can detect the presence of specific opioids and their metabolites but frequently returns false-positive results and typically findings must be confirmed by gas

Table 1. The CAGE-AID Questionnaire Have you ever felt that you ought to Cut down on your drinking or drug use? Have people Annoyed you by criticizing your drinking or drug use? Have you ever felt bad or Guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995;94(3):135-140. Adapted from reference 3.

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chromatography-mass spectroscopy—a time-consuming process. Also, a UDS, and even serum testing, have difficulty detecting fentanyl use. Finally, UDS cannot detect past abuse. Nevertheless, drug testing can provide useful objective information as long as clinicians are aware of these limitations.

Long-Term Opioid Therapy When collecting patient information in the preoperative period, the clinician likely will encounter patients who have been taking opioids chronically. These include the opioid agonists methadone and buprenorphine-naloxone (Suboxone, Reckitt Benckiser), as well as the opioid antagonist naltrexone (Vivitrol, Alkermes). Having at least a working knowledge of these medications is helpful in understanding their anesthetic and analgesic implications.

METHADONE Methadone is by far the most commonly used longterm opioid treatment and has been widely available since the 1960s. Methadone is a long-acting opioid agonist with some activity as an N-methyl-D-aspartate antagonist. The major function of methadone is to suppress withdrawal symptoms, which in most patients can be achieved with as little as 30 to 40 mg per day. It is only available in outpatient treatment programs and is dispensed on a daily basis. If a patient reports having received methadone, clinicians should verify the dose by contacting the methadone clinic by telephone. The verified dose then can be administered. Administering methadone without the supervision of a methadone clinic is illegal. For that matter, treating opioid withdrawal with opioids is against guidelines from the Drug Enforcement Administration. The administration of opioids, including methadone, by an anesthetist or other clinician is reserved exclusively for treating pain and must be thoroughly documented in patients’ medical records.

BUPRENORPHINE Unlike methadone, buprenorphine is a partial opioid agonist. Buprenorphine relieves drug cravings without producing the “high” and dangerous side effects of other opioids. Suboxone is a combination of buprenorphine and naloxone that received FDA approval in 2002.6 If Suboxone is injected intravenously, the naloxone component will precipitate withdrawal symptoms. Its increased therapeutic window and deterrence of IV use allow Suboxone to be prescribed by certified physicians outside the context of a specialized treatment clinic and without the need for daily supervision. Given its relative ease of use for those seeking treatment, prescription use of this medication has been increasing steadily in recent years. Although opioid agonists, whether full or partial, are the most commonly used treatment modality by far, some opioid-dependent patients opt for therapy with an opioid antagonist. Historically, the main treatment was naltrexone, similar to naloxone. As a once-daily treatment, poor patient compliance limited the effectiveness of this

agent. However, Vivitrol, an extended-release form of naltrexone, has gained acceptance as treatment for patients with dependence on alcohol, opioids, or both. Given as a monthly injection, this medication has clear advantages over once-daily dosing in terms of patient compliance.

Intraoperative Management With appropriate data collection and assessment in the preoperative period, intraoperative management of patients with opioid dependence or abuse relies heavily on 3 areas: managing intoxication, preventing or treating withdrawal, and achieving effective analgesia. Although many patients will not present for elective surgery when they are acutely intoxicated, urgent or emergent situations involving these patients often occur. In these incidents, monitoring respiratory rate and oxygen saturation is critical. Antagonist therapy should be reserved for patients with potentially life-threatening respiratory depression, as precipitating withdrawal in such a patient may make both anesthetic and analgesic management more difficult. Although patients not receiving established agonist therapy, like methadone, cannot be given opioids to treat withdrawal symptoms directly, they can be managed in other ways. First, patients on long-standing prescription opioids can be directed to take these medications as they normally would on the morning of surgery. Second, patients at risk for or entering withdrawal can have their symptoms managed. Clonidine commonly is used to treat symptoms of opioid withdrawal and can be given at a starting dose of 0.1 mg twice daily. Other medications, such as loperamide, also can be administered to target specific withdrawal symptoms. Analgesia strategies for patients with significant histories of opioid use should focus less on opioids as a foundational, single-agent therapy and more on opioidsparing or multimodal techniques with nonopioid agents such as IV acetaminophen (Ofirmev, Cadence Pharmaceuticals) or liposomal bupivacaine (Exparel, Pacira Pharmaceuticals). Many of these agents can be initiated in the preoperative or intraoperative phases and continued into the postoperative period. Nonopioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs, regional anesthesia when possible, α-2 agonists, and ketamine can have profound analgesic effects, particularly when used in combination. Pregabalin (Lyrica, Pfizer) and gabapentin also can be useful for managing neuropathic pain, which often is poorly controlled by opioids in general. An emphasis on multimodal analgesia is paramount in these patients and should be continued through surgery and into the postoperative period. Goals for the postoperative period can be divided into 2 main categories: comfort and safety. Patient comfort consists of providing adequate analgesia and continued prevention or management of opioid withdrawal. Patient safety is equally important, as this population typically manifests significant opioid tolerance. Patients with opioid tolerance generally will require at least 2 to 3 times

Table 2. Potential Limitations Of Urine Drug Screening for Opioids Standard UDS and tests used for pain management differ greatly in complexity Standard UDS frequently reported only as positive for opiates Oxycodone, oxymorphone, methadone, and buprenorphine often must be checked specifically Fentanyl: cannot be detected in-office UDS, urine drug screening

more opioids than an opioid-naive patient. Yet despite their analgesic tolerance, they appear to be at risk for respiratory side effects. During the postoperative period, clinicians must continue to manage both a patient’s potential withdrawal symptoms and his or her analgesic needs. For opioiddependent patients, these 2 aspects often intersect. Opioid withdrawal, either real or potential, can complicate pain assessments; patients may overreport pain to obtain increased opioid dosages. Reassuring patients that their withdrawal symptoms will be managed, either with their current opioid agonist or by easing of their symptoms, is a good first step. Even patients on high doses of opioids in the postoperative period may suffer intermittent withdrawal symptoms given the waxing and waning effects of short-acting opioids. If appropriate, combining a long-acting opioid analgesic with shorter-acting agents, such as hydromorphone by patient-controlled analgesia during periods of breakthrough pain may help to alleviate patients’ withdrawal fear or symptoms. However, this strategy can be used only when treating pain and not for the management of withdrawal symptoms, which are not life-threatening. In addition to managing a patient with opioid tolerance, patients on some type of long-standing opioid medical therapy require modifications to the analgesic plan. For those receiving methadone maintenance, management is relatively straightforward. After verifying the dose with a methadone clinic, the drug can be continued during the postoperative period. The dose can be divided into a 3-times-daily regimen to take advantage of methadone’s analgesic properties, which are much shorter than its withdrawal-preventing effects. Management can be significantly more complicated for patients receiving buprenorphine-naloxone therapy. As a partial μ-opioid agonist, buprenorphine has what is known as a ceiling effect. Similar to full agonists, morphine, or methadone, initially increasing buprenorphine dosage will heighten both its analgesic properties and its unwanted side effects. Unlike full agonists, as the dose of buprenorphine increases, the effects will plateau, at which point further doses have no effect7—widening the drug’s therapeutic window by broadening its safe dosing range. Coupled with its long half-life, these attributes help

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to make buprenorphine both relatively safe and effective in managing long-term opioid dependence.8 In the context of managing acute pain, however, buprenorphine is more difficult. The drug has a high affinity for μ receptors, about 1,000 times higher than that of morphine.9 With its long halflife and high receptor affinity, buprenorphine will persist on the receptor even when more potent, short-acting opioids are introduced in an attempt to provide analgesia. And because buprenorphine is only a partial agonist, effective analgesia will be difficult to provide. Given this profile, 4 recommendations for acute pain generally exist when dealing with buprenorphine.10 First, maintenance therapy can be continued and short-acting opioids can be titrated to effect.11 One must recognize that with buprenorphine present on the receptor sites, the patient likely will require higher than usual doses of a short-acting opioid to achieve an expected effect. A second option is to divide buprenorphine into 3-times-daily dosing to take advantage of its inherent analgesic properties in much the same way as methadone.12 This strategy may be helpful if the surgery or procedure is not likely to be particularly invasive or painful. A third option is to discontinue buprenorphine therapy and treat the patient with full opioid analgesics, while being mindful of potential withdrawal.11 A caveat here is for the clinician to realize that buprenorphine can continue to be present on the receptor up to 5 days after the last dose. Finally, a fourth option with buprenorphine is to convert to methadone at 30 to 40 mg per day. This total daily dose is usually sufficient to prevent withdrawal symptoms.13 However, because methadone cannot be prescribed for withdrawal outside a methadone clinic, this strategy requires the standard 3-times-daily dosing of methadone, and its primary purpose would need to be documented as treating pain, not managing withdrawal.

Also, if buprenorphine has been held, clinicians should contact the prescribing physician for assistance, as administration of buprenorphine can precipitate mild withdrawal symptoms.14 For the few patients on once-monthly extended-release naltrexone, acute pain management can be extremely difficult. The effect of opioid administration in the face of competitive antagonism is hard to predict.15,16 Further complicating management is the fact that response to opioids can vary depending on where the patient is in the dosing cycle. For example, more antagonism may be present soon after a dose than toward the end of the monthly period.17 Also, if patients missed a dose or recently finished a dosing regimen, they may be more sensitive to opioids. For these reasons, if a reasonable pain regimen would likely include opioids, then the safest option may be to postpone elective surgery until the patient is no longer undergoing treatment. If surgery cannot be delayed, use of nonopioid medications and techniques are of utmost importance. Although the competitive antagonism can be overcome with continued administration of opioids, effective dosages will be unpredictable, and careful titration and monitoring are recommended.

Conclusion Patients with significant opioid use histories represent an increasingly large part of the anesthesiologist’s caseload. Appropriate preoperative data collection and assessment are crucial for deciding effective analgesic plans and alleviating the effects of withdrawal. As opioids are less effective for this population, multimodal analgesia is an important strategy in managing these patients in the perioperative period. Although certainly challenging, with some background information and awareness, patients with known and unknown opioid use and abuse can be managed effectively and safely through the perioperative period.

References 1.

Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012.

2. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008, Centers for Disease Control and Prevention analysis. MMWR Morb Mortal Wkly Rep November 4, 2011. 60(43);1487-1492. 3. Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995;94(3):135-140. 4. Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170(13):1155-1160.

9. Bryson EO, Lipson A, Gevirtz C. Anesthesia for patients on buprenorphine. Anesthesiol Clin. 2010;28(4):611-617. 10. Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127-134. 11. Mitra S, Sinatra RS. Perioperative management of acute pain in the opioid-dependent patient. Anesthesiology. 2004;101(1):212-227. 12. Moa G, Zetterström H. Sublingual buprenorphine as postoperative analgesic: a double-blind comparison with pethidine. Acta Anaesthesiol Scand. 1990;34(1):68-71. 13. Fultz JM, Senay EC. Guidelines for the management of hospitalized narcotics addicts. Ann Intern Med. 1975;82(6):815-818.

5. Moeller K, Lee K, Kissack J. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83(1):66-76.

14. Center for Substance Abuse Treatment. Clinical Guideline for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS publication no. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004.

6. Ling W. Buprenorphine for opioid dependence. Expert Rev Neurother. 2009;9(5):609-616.

15. Vivitrol Full Prescribing Information. Waltham, MA: Alkermes, Inc; rev October 2010.

7. Johnson RE, Fudala PJ, Payne R. Buprenorphine: considerations for pain management. J Pain Symptom Manage. 2005;29(3):297-326.

16. Vivitrol Medication Guide. Cambridge, MA: Alkermes, Inc.; November 2010.

8. Walsh SL, Eissenberg T. The clinical pharmacology of buprenorphine: extrapolating from the laboratory to the clinic. Drug Alcohol Depend. 2003;70(2 suppl):S13-S27.

17. Dunbar JL, Turncliff RZ, Dong Q, Silverman BL, Ehrich EW, Lasseter KC. Single- and multiple-dose pharmacokinetics of long-acting injectable naltrexone. Alcohol Clin Exp Res. 2006;30(3):480-490.

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AURAONCE

KING VISION Address: 6740 Baymeadow Dr., Glen Burnie, MD 21060 Phone: (800) 262-8462 Fax: (800) 262-8673 Email: purchase_orders@ambu.com Website: www.ambuusa.com

Product Description: AuraOnce has a special curve that carefully replicates natural human anatomy. Molded directly into the tube, the unique shape makes correct insertion easy without abrading the upper airway. AuraOnce’s curve also ensures that the patient’s head remains in a natural supine position when the mask is in use without extra stress on the upper jaw. Moreover, AuraOnce is specially designed to give the airway tube the flexibility needed to adapt to individual anatomical variances and a wide range of head positions. AuraOnce has a D-shaped airway tube to give a firm and ergonomic grip during insertion. In short, positioning is fast and accurate, with the least possible internal pressure.

Special Supplement I June 2013

Address: 6740 Baymeadow Dr., Glen Burnie, MD 21060 Phone: (800) 262-8462 Fax: (800) 262-8673 Email: purchase_orders@ambu.com Website: www.ambuusa.com Product Description: The King Vision is an affordable, durable and portable video laryngoscope. It is designed for indirect laryngoscopy, difficult endotracheal intubations as well as routine intubations. The King Vision accommodates minimum mouth openings of 13mm for the standard blade and 18 mm for the channeled blade, making it effective for the majority of patient populations.

AnesthesiologyNews.com

BUYER’S GUIDE Summer/Fall 2013 AIRWAY MANAGEMENT

C-MAC –

CLARUS MEDICAL, LLC CLARUS ADULT AND PED SHIKANI STYLET SCOPES

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

Address: 1000 Boone Ave. N #300, Minneapolis, MN 55427 Phone: (763) 525-8450 Fax: (763) 525-8656 Email: admin@clarus-medical.com Website: www.clarus-medical.com/airway Product Description: Clarus Shikani line offers a superbly portable and durable fiber-optic stylet for the smallest to biggest patient. With the Shikani’s superb view from the tip of the ET tube, navigate through difficult airways and confirm placement. Use Shikani alone or as a vital accessory to DL, VL, supraglottics, DLTs and Crics. The Shikani’s malleability allows for use in routine or difficult cases such as awake intubations, difficult DL, anterior or small mouths, Treacher-Collins syndrome, Pierre Robin syndrome, etc. Why guide your tube blindly when you can affordably add visualization for every intubation?

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CLARUS MEDICAL, LLC CLARUS FLEXIBLE POCKET SCOPE Address: 1000 Boone Ave. N #300, Minneapolis, MN 55427 Phone: (763) 525-8450 Fax: (763) 525-8656 Email: admin@clarus-medical.com Website: www.clarus-medical.com/airway Product Description: The Clarus Pocket Scope is a portable alternative to the traditional fiber-optic bronchoscope. This reusable fiber-optic scope is ideal for confirming the placement, position or patency of an ET tube or LMA. Instead of calling for the FOB tower, and running the risk for breakage and repair, use the Pocket Scope for simple confirmation. Conveniently sized, easy to clean and cost-effective, the Pocket Scope is an essential tool for the OR, MRI or ICU.

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CLARUS MEDICAL, LLC CLARUS LEVITAN FPS STYLET SCOPE Address: 1000 Boone Ave. N #300, Minneapolis, MN 55427 Phone: (763) 525-8450 Fax: (763) 525-8656 Email: admin@clarus-medical.com Website: www.clarus-medical.com/airway

C-MAC® Pocket Monitor

Miller Blades

Product Description: The Clarus Levitan is a malleable fiber-optic intubating stylet. The Levitan’s view from the tip of the ET tube allows you to confirm and steer through difficult and routine intubations. Use this versatile Levitan alone or as a vital accessory to other devices such as DL, VL and supraglottics to navigate anterior airways and small mouth openings. Carry this durable, portable, low-cost difficult airway scope to every intubation!

Flexible Intubation Video Endoscope

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CLARUS MEDICAL, LLC CLARUS VIDEO STYLET SCOPE Address: 1000 Boone Ave. N #300, Minneapolis, MN 55427 Phone: (763) 525-8450 Fax: (763) 525-8656 Email: admin@clarus-medical.com Website: www.clarus-medical.com/airway Product Description: The Clarus Video Scope is a malleable stylet with a digital camera at the distal end. With visualization from the end of the ET tube, steer through a difficult airway and confirm placement. Use the CVS alone or as an essential accessory to existing techniques such as DL, VL and supraglottics for anterior airways, small mouth openings and awake intubations. There’s even a red LED to transilluminate as a lighted stylet!

800-421-0837 www.karlstorz.com

4 A-0112002

Special Supplement I June 2013

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HOVERTECH INTERNATIONAL

KARL STORZ ENDOSCOPY-AMERICA, INC.

HT-WEDGE™ ADJUSTABLE POSITIONING DEVICE

FLEXIBLE INTUBATION VIDEO ENDOSCOPE

Address: 513 S. Clewell St., Bethlehem, PA 18018 Phone: (610) 694-9600 Fax: (610) 694-9601 Email: info@hovermatt.com Website: www.HoverMatt.com

Address: 2151 E. Grand Ave., El Segundo, CA 90245 Phone: (800) 421-0837 Fax: (800) 321-1304 Email: communications@karlstorz.com Website: www.karlstorz.com Product Description: The KARL STORZ Flexible Intubation Video Endoscope (FIVE) incorporates a video chip and LED light source in the distal tip of the scope for optimal visualization and lightweight design. It is compatible with the C-MAC® platform, plugging into either the C-MAC® monitor for a highly portable solution or the C-HUB® module, which works within any integrated OR setting.

Product Description: The HT-Wedge™ Adjustable Positioning Device inflates to lift and position the head and chest of a supine patient. The dual chamber design allows the patient’s head and chest to be adjusted separately, making it easier to achieve ear to sternal notch positioning regardless of the patient’s body type. When deflated, the HT-Wedge features a low profile, which allows the product to be left underneath the patient in between uses for maximum convenience.

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INTERSURGICAL INC.

KARL STORZ ENDOSCOPY-AMERICA, INC.

ENDOFLEX

LARYNGOBLOC™ Address: 417 Electronics Pkwy., Liverpool, NY 13088 Phone: (800) 828-9633 Fax: (315) 451-3696 Email: support@intersurgicalinc.com Website: www.intersurgical.com

Address: 2151 E. Grand Ave., El Segundo, CA 90245 Phone: (800) 421-0837 Fax: (800) 321-1304 Email: communications@karlstorz.com Website: www.karlstorz.com Product Description: The LARYNGOBLOC™ is a single-use, fiber-optic LED laryngoscope. Its “one-piece” blade and handle design makes it more robust than conventional single-use blades and prevents contact of blade tip with the handle. The reusable LED insert is completely protected within the single-use handle. The laryngoscope is disposed of after use, eliminating both reprocessing time and cross-contamination risks.

Product Description: EndoFlex enables rapid, safe manipulation and control of the distal tip into position without switching tubes or adding stylets. EndoFlex provides enhanced use of video laryngoscopes of all types as well as standard laryngoscopes. This control is provided without the use of stylets that pose a risk during insertion, can be difficult to remove and may even require cleaning and tracking. EndoFlex gives you control in a simple, cost-effective and easy-to-use device. Quality, innovation and choice!

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KARL STORZ ENDOSCOPY-AMERICA, INC.

MERCURY MEDICAL®

C-MAC® FAMILY

AIR-Q® Address: 2151 E. Grand Ave., El Segundo, CA 90245 Phone: (800) 421-0837 Fax: (800) 321-1304 Email: communications@karlstorz.com Website: www.karlstorz.com

Address: 11300 49th St. North, Clearwater, FL 33762 Phone: (800) 237-6418 Fax: (727) 571-3922 Email: sbarlowe@mercurymed.com Website: http://mercurymed.com/catalog2/index2.php

Product Description: The C-MAC® system is designed as a complete video intubation platform and is more than just a video laryngoscope. The C-MAC® offers a full line of blade sizes to accommodate neonate through adult patients. In addition to video laryngoscopy, this system allows the use of flexible intubation (video and fiber) scopes and optical stylets using the C-CAM® camera head.

Product Description: The air-Q® Disposable Masked Laryngeal Airways are available in six sizes, 1.0, 1.5, 2.0, 2.5, 3.5 and 4.5. The new design has evolved into a superior airway for ease of placement, better seal in everyday use and improved intubation success. The everyday disposable airway designed to facilitate intubation.

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KARL STORZ ENDOSCOPY-AMERICA, INC.

MERCURY MEDICAL®

C-MAC® POCKET MONITOR

AIR-Q® BLOCKER

Address: 2151 E. Grand Ave., El Segundo, CA 90245 Phone: (800) 421-0837 Fax: (800) 321-1304 Email: communications@karlstorz.com Website: www.karlstorz.com Product Description: The highly portable C-MAC® Pocket Monitor is an ideal solution for emergency, trauma and field-based difficult intubations. This portable Video Laryngoscope offers virtually no learning curve since it uses the C-MAC® standard Macintosh and Miller blades to accommodate neonate through adult patients. The adjustable LCD screen can be folded to the side of the laryngoscope for transport and storage.

Special Supplement I June 2013

Address: 11300 49th St. North, Clearwater, FL 33762 Phone: (800) 237-6418 Email: sbarlowe@mercurymed.com Website: http://mercurymed.com/catalog2/index2.php

Fax: (727) 571-3922

Product Description: The air-Q® Blocker Masked Laryngeal Airway offers a new design, with integrated channel to access the esophagus. Clinicians can now place a nasogastric tube through the air-Q Blocker channel. Designed and developed by an anesthesiologist, for use with confidence!

AnesthesiologyNews.com

BUYER’S GUIDE Summer/Fall 2013 AIRWAY MANAGEMENT 21

MERCURY MEDICAL® AIR-QP SP® Address: 11300 49th St. North, Clearwater, FL 33762 Phone: (800) 237-6418 Fax: (727) 571-3922 Email: sbarlowe@mercurymed.com Website: http://mercurymed.com/catalog2/index2.php

Request a DEMO at www.airtraq.com

Product Description: Introducing the air-Q SP. Safe. Simple. Self-pressurizing. Eliminates the guesswork and problems that occur with mask cuff overinflation.

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MERCURY MEDICAL FLOW-SAFE® II Address: 11300 49th St. North, Clearwater, FL 33762 Phone: (800) 237-6418 Fax: (800) 990-6375 Email: sbarlowe@mercurymed.com Website: http://mercurymed.com/catalog2/index2.php Product Description: The Flow-Safe II Disposable CPAP System from Mercury Medical is the only one that has so many advantages, it gives you an advantage in life-saving emergencies. The Flow-Safe II is a revolution in emergency care. Advantage 1: Consumes 50% LESS oxygen. Advantage 2: Built-in manometer and pressure relief valve. Advantage 3: Nebulizer (in-line capability). Advantage 4: Advanced mask design for patient comfort. Faster. Safer. More comfortable. More convenient. More efficient than other disposable CPAP devices.

$ 12.90 Total Cost per Use

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TELEFLEX MEDICAL INCORPORATED

Zero capital to amortize Zero repair costs

LMA CLASSIC® AIRWAY Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Fax: (919) 361-3914 Email: CS@teleflex.com Website: www.lmana.com Product Description: The LMA Classic® Airway is a safe, hands free alternative to tracheal intubation or the face mask, and is a general-purpose airway for routine, elective inpatient and outpatient surgical procedures. The LMA Classic Airway is supplied non-sterile and must be cleaned and sterilized before initial use and before each subsequent use. It may be used a maximum of 40 times before being discarded.

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TELEFLEX MEDICAL INCORPORATED LMA CLASSIC EXCEL® AIRWAY Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Email: CS@teleflex.com Website: www.lmana.com

Fax: (919) 361-3914

Product Description: Including all of the features of the LMA Classic® Airway, the improved design of the LMA Classic Excel® Airway makes this airway reusable up to 60 times. Enhanced features help facilitate intubation in the event of an unforeseen airway complication.

Two sizes

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TELEFLEX MEDICAL INCORPORATED

LMA EID™ ESOPHAGEAL INTUBATION DETECTOR

LMA® MADDY® PEDIATRIC MUCOSAL ATOMIZATION DEVICE

Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Fax: (919) 361-3914 Email: CS@teleflex.com Website: www.lmana.com

Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Email: CS@teleflex.com

Product Description: The LMA EID™ Device offers first responders proper ETT placement. A patented o-ring design prevents inadvertent air leaks and false readings. The LMA EID™ Device is more accurate than colorimetric end-tidal CO2 in emergency intubation studies, and helps reduce errors in clinical judgment and aspiration risk. Accurate, cost-effective and reliable.

Product Description: Introducing the LMA® MADdy® Device—the ideal pediatric device to deliver topical solutions across the nasal and oropharyngeal mucous membranes. The MADdy® delivers intranasal and intraoral medications in a fine mist with rapid absorption and transport across mucosal membranes to the bloodstream.

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Fax: (919) 361-3914 Website: www.lmana.com

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TELEFLEX MEDICAL INCORPORATED

LMA FASTRACH® AIRWAY

LMA® MADETT® ENDOTRACHEAL TUBE MUCOSAL ATOMIZATION DEVICE

Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Fax: (919) 361-3914 Email: CS@teleflex.com Website: www.lmana.com

Product Description: Included in the Difficult Airway Algorithms of the AHA and ASA, the LMA Fastrach® Airway is the ideal choice for the anatomically difficult airway. Designed to facilitate blind intubation without moving the head or neck and allowing for onehanded insertion, the LMA Fastrach® Airway allows continuous ventilation between intubation attempts. Available as single-use or reusable devices, in sizes 3, 4.

Product Description: The LMA® MADett® Device—the pulmonary drug delivery solution that sprays medications directly into your patients’ lungs during ventilation.

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TELEFLEX MEDICAL INCORPORATED

LMA FLEXIBLE® AIRWAY

LMA® MADGIC AIRWAY™ INTUBATING AIRWAY WITH MUCOSAL ATOMIZATION AND OXYGEN DELIVERY

Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Fax: (919) 361-3914 Email: CS@teleflex.com Website: www.lmana.com

Product Description: When a patient is undergoing a delicate sinus, eye, ear or other ENT procedure, laryngeal mask airway benefits—minimal hemodynamic response, reduced intraocular pressure, fewer drugs and smooth emergence from anesthesia— are essential. That’s why the LMA Flexible® Airway is designed with a pliable, wire-reinforced airway tube to improve surgical access without compromising airway seal.

Product Description: Introducing the LMA® MADgic Airway™ Device, the most innovative choice to create a temporary airway to facilitate fiber-optic intubation. For your difficult and awake airways requiring a fiber-optic scope, the MADgic Airway™ Device can come to the rescue, combining atomized topical anesthetic and oxygen delivery in an innovative and elegantly designed fiber optic–compatible oral airway.

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TELEFLEX MEDICAL INCORPORATED

LMA® MAD NASAL™ INTRANASAL MUCOSAL ATOMIZATION DEVICE

LMA® MADGIC® LARYNGO-TRACHEAL MUCOSAL ATOMIZATION DEVICE

Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Fax: (919) 361-3914 Email: CS@teleflex.com Website: www.lmana.com Product Description: Introducing the LMA® MAD Nasal™ Device, the safe and painless way to deliver medication with rapid absorption and transport across mucosal membranes to the bloodstream without an IV line. When IV delivery is less than ideal, the MAD Nasal™ Device can come to the rescue, delivering safe, painless and rapidly effective treatment with minimal resource use.

Special Supplement I June 2013

Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Fax: (919) 361-3914 Email: CS@teleflex.com Website: www.lmana.com Product Description: Introducing the LMA® MADgic® Device, a versatile choice to administer medication across the entire upper airway and beyond the vocal cords. For all of your difficult and awake intubations, bronchoscopies, transesophageal echocardiograms and endoscopies, the MADgic® Device will have you and your patients breathing easier with innovative features that are easy to swallow.

AnesthesiologyNews.com

Airway devices have evolved...

BUYER’S GUIDE Summer/Fall 2013 AIRWAY MANAGEMENT 33

TELEFLEX MEDICAL INCORPORATED LMA® MADGICWAND® PHARYNGEAL TISSUE RETRACTOR/ ATOMIZER

HAVE YOU?

Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Fax: (919) 361-3914 Email: CS@teleflex.com Website: www.lmana.com Product Description: For your difficult intubations, cervical spine injury intubations and bronchoscopies, the LMA® MADgicWand® Device allows thorough topicalization and precise anesthetic placement.

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TELEFLEX MEDICAL INCORPORATED LMA® MADOMIZER® REFILLABLE BOTTLE ATOMIZER Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Email: CS@teleflex.com Website: www.lmana.com

i-gel

Product Description: The LMA® MADomizer® Refillable Bottle Atomizer—the simple, effective and targeted topical medication delivery system that helps clinicians control the risk for cross-contamination.

is ®aissecond generation i-gel a second supraglottic airwayairway generation supraglottic a non-inflating withwith a non-inﬂating anatomical anatomical cuff.

Fax: (919) 361-3914

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TELEFLEX MEDICAL INCORPORATED

i-gel® provides reduced trauma, improved seal pressures, gastric access, an integral bite block and is a conduit for intubation!

LMA SUPREME® AIRWAY Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Fax: (919) 361-3914 Email: CS@teleflex.com Website: www.lmana.com Product Description: The LMA Supreme® Single-Use Airway combines the best features of all previous LMA masks and is designed for safety and ease of use. Whether for a routine procedure or to manage a higherrisk patient, it is designed to channel fluids away from the airway in the unlikely event of active or passive regurgitation and allows for diagnostic testing and verifiable positioning.

A truly unique range of adult and pediatric supraglottic airways

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TELEFLEX MEDICAL INCORPORATED LMA UNIQUE® AIRWAY

www.i-gel.com

Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Fax: (919) 361-3914 Email: CS@teleflex.com Website: www.lmana.com Product Description: The LMA Unique® Single-Use Airway can be used for a wide range of routine applications, from general anesthesia to emergency use, or as a resuscitation device. Made from a soft, flexible material, the LMA Unique® Airway is designed to minimize soft tissue and dental trauma, and lessen the potential for sore throat. Available in a full range of sizes from neonate to adult.

Quality, innovation and choice www.intersurgical.com support@intersurgicalinc.com 800-828-9633

Special Supplement I June 2013

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TELEFLEX MEDICAL INCORPORATED

DRÄGER

RUSCH® EZ-BLOCKER™ ENDOBRONCHIAL BLOCKER

FABIUS TIRO

Address: 2917 Weck Dr., Research Triangle Park, NC 27709 Phone: (866) 246-6990 Fax: (919) 361-3914 Email: CS@teleflex.com Website: www.ez-blocker.com

Address: 3135 Quarry Rd., Telford, PA 18969 Phone: (800) 437-2437 Fax: (215) 723-5935 Email: info.usa@draeger.com Website: www.draeger.com Product Description: Fabius Tiro combines the latest ventilation and gas-delivery technologies with an ergonomic and compact design. Adding the ability and functionality of the Dräger Infinity patient monitoring range allows you to create a workplace environment that is a good investment for the future. The open modular architecture and the software and hardware upgrade options ensure that your anesthesia workplace meets your expectations, even if you are not in the main operating room.

Product Description: The EZ-Blocker™ Endobronchial Blocker is the next generation of one-lung ventilation products designed to enhance outcomes during selective procedures. The EZ-Blocker Endobronchial Blocker was designed by anesthesiologists for use by anesthesiologists to provide an improved device for lung isolation, with a unique Y-shaped distal end that mirrors the bifurcation of the trachea.

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DRÄGER

APOLLO

FABIUS TIRO M Address: 3135 Quarry Rd., Telford, PA 18969 Phone: (800) 437-2437 Fax: (215) 723-5935 Email: info.usa@draeger.com Website: www.draeger.com

Address: 3135 Quarry Rd., Telford, PA 18969 Phone: (800) 437-2437 Email: info.usa@draeger.com

Product Description: A highly efficient anesthesia workstation, the Apollo helps manage your increasingly complex workflow. The high-speed piston ventilator works with great precision to supply a maximum peak flow far in excess of any bellows ventilator, resulting in the kind of performance previously only seen in the ICU. Its unique “Low Flow Wizard” is designed to support optimal low and minimal flow settings, which can significantly reduce the cost of inhalational anesthetic agent.

Product Description: The Fabius Tiro M was designed to provide a fullfeatured anesthesia machine in a compact, easy-to-assemble package for use in military medical installations in the field. The modular design allows all standard system components to be stored in a single container so that assembly and disassembly of the unit is easily accomplished.

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Fax: (215) 723-5935 Website: www.draeger.com

ANESTHESIA MACHINES 43

DRÄGER

GE HEALTHCARE

FABIUS GS PREMIUM

AESPIRE VIEW

Address: 3135 Quarry Rd., Telford, PA 18969 Phone: (800) 437-2437 Fax: (215) 723-5935 Email: info.usa@draeger.com Website: www.draeger.com

Address: PO Box 7550, Madison, WI 53707 Phone: (800) 345-2700 Fax: (608) 347-2699 Email: annmarie.preece@med.ge.com Website: www.gehealthcare.com

Product Description: Fabius GS Premium combines time-tested design concepts with the comfort and utility of modern digital technology. It’s an anesthesia workstation built for today and ready for the future. Export gas flows, concentrations and waveforms to our Infinity Patient Monitoring System™ and Innovian™ Anesthesia system to enhance monitoring, charting and networking power. Its intuitive user interface, common to Dräger workstations, enables fast and precise adjustments.

Product Description: Clarity of view—clarity of decision. Advanced anesthesia delivery in a compact, cost-effective system ideal for hospitals and outpatient surgery centers. With its 12-inch color ventilation display and five ventilation packages, the Aespire View lets you tailor ventilation for each patient. The small breathing system responds to fresh gas changes rapidly even during low-flow anesthesia.

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DRÄGER

GE HEALTHCARE

FABIUS MRI

AISYS CARESTATION Address: 3135 Quarry Rd., Telford, PA 18969 Phone: (800) 437-2437 Email: info.usa@draeger.com

Fax: (215) 723-5935 Website: www.draeger.com

Product Description: Increased diagnostic capability with state-of-theart ventilation in the Fabius MRI anesthesia system. Specifically designed for use in magnetic environments, the Dräger Fabius MRI is certified for field strengths of up to 40 mTesla or 400 Gauss. Provides reliable ventilation with 1.5 and even 3 Tesla MRI systems. The Fabius MRI incorporates a servo-controlled piston ventilator capable of delivering higher inspiratory flows than the traditional bellows ventilator, with more accurate volume delivery.

Special Supplement I June 2013

Address: PO Box 7550, Madison, WI 53707 Phone: (800) 345-2700 Fax: (608) 223-2497 Email: gina.petry@med.ge.com Website: www.gehealthcare.com Product Description: The Aisys Carestation now features Lung Ventilation Procedures and Neonatal Ventilation Capabilities with the recent version 8.0 software release. Responsive and reliable, the Aisys Carestation delivers sophisticated anesthesia therapy, advanced ventilation and dynamic patient monitoring through its innovative digital platform. AIMS-ready design suited for EMR. Add Navigator Application Suite to analyze drug therapy to help model and predict the effect of anesthesia-related drugs.

AnesthesiologyNews.com

BUYER’S GUIDE Summer/Fall 2013 ANESTHESIA MACHINES 45

An ETView Product

GE HEALTHCARE AVANCE CS2

See the Possibilities ess

Single Lung Isolation

Address: PO Box 7550, Madison, WI 53707 Phone: (800) 345-2700 Email: gina.petry@ge.com

Constant Visualization and Airway Control

Fax: (608) 223-2497 Website: www.gehealthcare.com

Product Description: Avance CS2 features a 15” touchscreen ventilator display. The optional ecoFLOW feature provides a graphical display of oxygen flow and anesthetic agent use. ecoFLOW shows your pre-set target and calculates the cost of agent used. Clinicians can use this information to avoid unnecessarily high fresh gas flow rates for potential environmental and economical benefits when waste gases are reduced.

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MAQUET MEDICAL SYSTEMS USA FLOW-I ANESTHESIA DELIVERY SYSTEM Address: 45 Barbour Pond Dr., Wayne, NJ 7470 Phone: (888) 627-8383 Website: www.maquetusa.com

Fax: (973) 807-1683

Product Description: FLOW-i is designed with the changing needs of patients and clinicians in mind. An innovative re-breathing technology replaces both the traditional bag-in-bottle and piston for quick and precise wash-in and wash-out of anesthetic agent while providing high-performance ICU-quality ventilation for all patient categories including the most challenging cases. Thanks to its innovative design, FLOW-i has been shown to save up to 26% in anesthetic agent use compared with a leading competitor (data on file). Open architecture supports the patient monitor of choice and the fully electronic platform is EMR ready. FLOW-i is ergonomically designed, height-adjustable, and can be configured to satisfy a variety of workflow requirements.

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SPACELABS HEALTHCARE ARKON Address: 35301 SE Center St., Snoqualmie, WA 98065 Phone: (425) 396-3300 Email: marketing@spacelabs.com Website: www.spacelabshealthcare.com

PRECISION

CONTINUOUS VIEW

CONFIDENCE

Enables accurate placement with unparalleled control

Provides visual assurance during intubation

Facilitates fast, efficient intubation

ETView Medical presents its VivaSight airway management portfolio, providing the surgical team with next-generation lung isolation products. VivaSight™-SL and VivaSight™-DL permit continuous airway monitoring with uninterrupted visualization for accurate positioning and precise placement.

Product Description: Welcome to ARKON®: the high-performance anesthesia delivery system that offers the maximum in functionality, comfort and control. Rather than look to functionality and reliability as ends in themselves, we saw them as the points of entry and asked, “How could we make it even better?” The answer—ARKON.

See the possibilities with VivaSight, the fully integrated imaging/ventilation systems for total airway management. Caution: US Federal Law restricts this device to sale by or on the order of a physician.

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SPACELABS HEALTHCARE BLEASEFOCUS Address: 35301 SE Center St., Snoqualmie, WA 98065 Phone: (425) 396-3300 Email: marketing@spacelabs.com Website: www.spacelabshealthcare.com

For more information visit www.etview.com, or call us at (567)-248-4820, email sales@etview.com.

Product Description: BleaseFocus provides excellence in versatility and value and does not compromise on performance or features. An open platform that is flexible in design, it enables you to configure it to suit your requirements and budget. As a result, the BleaseFocus is an ideal solution for your outpatient surgery center operating rooms offering ease of use, efficiency and proven technology.

VivaSight, VivaSight-SL, VivaSight-DL, VivaSight-EB, and other VivaSight products are the registered trademark of ETView Medical Ltd. VivaSight products clearance/certiﬁcation: FDA, CE (MDD 93/42/EEC), ISO 9001:2000, ISO 13485:2003. ETView products are extensively protected by both US and international patents, both issued and pending. Europe: EP15551277 // China: Zl200380101369.1 // India: 207888 // Korea: 10-1060944. Patents pending in Canada, United States, Japan, and Australia.

www.etview.com ETView Ltd. Trendlines Building | Misgav Bus. Park | M P Misgav 20174 Israel Sales and Product Information, United States: +1.567.248.4820 | Israel: +972.72.260.7060

Special Supplement I June 2013

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INFORMATION MANAGEMENT SYSTEMS 53

AMBU INC

DRÄGER

KING FLEX2

INNOVIAN ANESTHESIA Address: 6740 Baymeadow Dr., Glen Burnie, MD 21060 Phone: (800) 262-8462 Fax: (800) 262-8673 Email: purchase_orders@ambu.com Website: www.ambuusa.com

Address: 3135 Quarry Rd., Telford, PA 18969 Phone: (800) 437-2437 Email: info.usa@draeger.com

Product Description: Innovian® Anesthesia is Dräger Medical’s next-generation perianesthesia information solution. Innovian has proven success in more than 130 hospitals and 3,000 users worldwide. Innovian Anesthesia is designed to optimize and address the specific challenges of the perianesthesia process, from preop to intra-op and post-op/recovery, while simultaneously increasing throughput, accuracy and completeness to help you maintain a distinct competitive advantage. Innovian Anesthesia provides a comprehensive overview of a patient’s medical story, enabling patientcentric care, improved staff and patient satisfaction, and the ability to track, measure and manage outcomes for improved clinical and financial results.

Product Description: The King Flex2 co-axial single-limb anesthesia breathing circuit incorporates all of the best features of King Systems’ other breathing circuits into one innovative product. It is also flexible so it can expand, compress and hold its shape to accommodate the widest range of clinical applications from the operating room through transport to either PACU or CCU.

BREATHING CIRCUITS 50

Fax: (215) 723-5935 Website: www.draeger.com

INFUSION SYSTEMS 54

ARC MEDICAL

CODAN WALRUS® BY CODAN®

CIRCUITGUARD™ Address: 4296 Cowan Rd., Tucker, GA 30084 Phone: (800) 950-2720, ext. 272 Fax: (404) 373-8385 Email: arcinfo@arcmedical.com Website: www.arcmedical.com

Address: 3511 West Sunflower Ave., Santa Ana, CA 92704 Phone: (714) 545-2111 Fax: (714) 545-9111 Email: info@codanuscorp.com Website: www.codanuscorp.com

Product Description: FDA-cleared as a hygienic alternative to decontamination of anesthesia equipment. circuitGuard™ filter’s exclusive unitized construction protects anesthesia circuits and equipment (ETCO2, etc.) from contamination and protects patients from contaminated circuits and equipment. Used by thousands of facilities nationwide. Save time, money, space. OPS—top 10 ways to reduce costs.

Product Description: Walrus® by CODAN® High Flow Blood Set with 170 micron filter and 50 cc Cylinder Pump with 2-gang High Flow Stopcock Extension Set. This high-flow Blood/ Trauma Set will deliver 3 to 4 units of blood at maximum flow rates. Complete all-in-one Specialty Anesthesia Sets and Blood Sets made in the USA. Custom Sets, sterile and non-sterile samples available upon request.

BREATHING CIRCUITS 51

MONITORING SYSTEMS & DEVICES 55

PALL MEDICAL

BLUESTAR ENTERPRISES, INC.

PALL MULTIPLE-PATIENT-USE ANESTHESIA SYSTEM AND ULTIPOR® 25 FILTER

TOF-WATCH Address: 3406 S 184th Ave., Omaha, NE 68130 Phone: (402) 861-8750 Fax: (402) 861-8751 Email: info@bluestarent.com Website: www.bluestarent.com

Address: 25 Harbor Park Dr., Port Washington, NY 11050 Phone: (866) 347.3428 Email: hospitalfilters@pall.com Website: www.pall.com/reuse

Product Description: TOF-Watch is a portable instrument belonging to the TOF-Watch range of neuromuscular transmission monitors. Utilizing acceleromyography principles, it objectively measures neuromuscular block produced by the administration of an NMBA. Also can be used in locoregional anesthesia.

Product Description: The Pall Multiple-Patient-Use Anesthesia System has been validated for use on an unlimited number of patients for up to 24 hours, as long as each new patient receives a fresh Pall patient kit (consisting of a mask, elbow and Ultipor® 25 Filter). Pall’s system helps to protect patients, staff and equipment while increasing efficiency, and reducing costs and medical waste.

CARTS 52

MONITORING SYSTEMS & DEVICES 56

ARMSTRONG MEDICAL INDUSTRIES

COVIDIEN

ALUMINUM WIRELESS AUTO-LOCKING CART

BIS™ BRAIN MONITORING TECHNOLOGY

Address: 575 Knightsbridge Pkwy., Lincolnshire, IL 60069 Phone: (800) 323-4220 Fax: (847) 913-0138 Email: csr@armstrongmedical.com Website: www.armstrongmedical.com

Address: 6135 Gunbarrel Ave., Boulder, CO 80301 Phone: (855) SENSING or (855) 736-7464 Website: www.covidien.com/rms

Product Description: The new Aluminum Wireless Auto-Locking Cart from Armstrong Medical features keyless entry, an LCD display (shows date, time of day, current battery life and programmable menu-driven display system), integrated 802.11g wireless capabilities with wireless antenna, up to 5,000 user codes, supervisor code for programming and manual or automatic locking. The Aluminum Wireless Auto-Locking Cart is available with Optional Prox Reader and Optional Controlled Substance Drawer.

Product Description: The BIS™ System monitors the patient-specific effects of anesthetics and sedatives on the brain. It also provides objective insight to help you make more informed decisions about titration of sedative drugs, thereby optimizing the comfort, safety and quality of care for patients.

Special Supplement I June 2013

AnesthesiologyNews.com

-!1 #OPYRIGHT¬-!15%4¬-E EDICAL¬3YSTEMS¬53!¬OR¬ITS¬AFFILIATES ¬s¬ #!54)/. ¬&EDERAL 53 ¬LAW¬RESTRICTS¬THIS¬DEVICE¬TO¬SALE¬BY¬OR¬O E¬ N¬THE¬ORDER¬OF¬A PHYSICIAN ¬2EFER¬TO¬ )NSTRUCTIONS¬FOR¬5SE¬FOR¬CURRENT¬INDICATIONS ¬WARNINGS ¬CONTRAI TRA NDICATIONS ¬AND¬PRE ECAUTIONS

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Anesthesia Delivery And The True Cost Of Ownership )N¬TODAY S¬EVER CHANGING¬HEALTHCARE¬REIMBURSEMENT¬ENVIRONMENT ¬HOSPITALS¬AND¬OUTPATIENT¬ SURGERY¬CENTERS¬DEMAND¬SUPERIOR¬TECHNOLOGY¬WITH¬LONG TERM¬COST¬CONTAINMENT ¬0ARTNER¬WITH¬ -!15%4¬AND¬DISCOVER¬THE¬TRUE¬COST¬OF¬YOUR¬CURRENT¬ANESTHESIA¬PLATFORM ¬COMPARED¬TO¬THE REVOLUTIONARY¬&,/7 I¬SYSTEM ¬AND¬MAKE¬THE¬RIGHT¬CHOICE¬FOR¬YOUR¬PATIENTS¬AND¬YOUR¬BUSINESS Call us at 888-627-8383 or email marketing@maquet.com to trial the revolution in anesthesia delivery technology — FLOW-i.

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www.maquetusa.com

BUYER’S GUIDE Summer/Fall 2013 MONITORING SYSTEMS & DEVICES 57

MONITORING SYSTEMS & DEVICES 61

COVIDIEN

DRÄGER

CAPNOSTREAM® 20

INFINITY® OMEGA-S SOLUTION

Address: 6135 Gunbarrel Ave., Boulder, CO 80301 Phone: (855) SENSING or (855) 736-7464 Website: www.covidien.com/rms

Address: 3135 Quarry Rd., Telford, PA 18969 Phone: (800) 437-2437 Fax: (215) 723-5935 Email: info.usa@draeger.com Website: www.draeger.com

Product Description: Delivers effective airway management by providing early indication of airway compromise. Provides an accurate and reliable assessment of a patient’s respiratory status. Measures EtCO2 and SpO2. Integrated Pulmonary Index™ (IPI) provides a single number that represents adequacy of ventilation. 72-hour trend data. Oridion Smart Capnography™ SARA algorithm reduces clinically insignificant alarms. Facilitates detection of respiratory changes caused by opiates.

Product Description: Designed for monitoring at the point of care, Infinity Omega-S features an Infinity Kappa patient monitor with a 20-inch-wide Infinity C700 for IT workstation display. The touchscreen feature allows you to quickly gain fingertip access to critical patient information. Combined with a Dräger anesthesia workstation, Infinity Omega-S integrates live anesthesia device data with patient data management and clinical applications to support on-the-spot decision making.

MONITORING SYSTEMS & DEVICES 58

MONITORING SYSTEMS & DEVICES 62

COVIDIEN

EDWARDS LIFESCIENCES

INVOS™ CEREBRAL SOMATIC OXIMETRY SYSTEM

EV1000 CLINICAL PLATFORM

Address: 6135 Gunbarrel Ave., Boulder, CO 80301 Phone: (855) SENSING or (855) 736-7464 Website: www.covidien.com/rms

Address: One Edwards Way, Irvine, CA 92614 Phone: (800) 424-3278 Email: criticalcare@edwards.com Website: www.edwards.com/criticalcare

Product Description: The INVOS™ System provides site-specific assessments on perfusion adequacy and perfusion distribution across the brain and body. Continuous monitoring of site-specific perfusion provides an early warning of developing pathology and deteriorating patient condition. The INVOS™ System provides realtime measurement and display of regional oxygen saturation (rSO2), a measure of blood oxygen saturation in the microvasculature after tissues have consumed what they need.

Product Description: The EV1000 Clinical Platform presents the physiologic status of the patient in an entirely new, intuitive and meaningful way. Offering scalability and adaptability for both the OR and ICU, the EV1000 Clinical Platform works with the FloTrac sensor and PreSep oximetry catheter—giving you the choice of parameters you want, how you want to view them.

MONITORING SYSTEMS & DEVICES 59

MONITORING SYSTEMS & DEVICES 63

COVIDIEN

EDWARDS LIFESCIENCES

NELLCOR™ BEDSIDE RESPIRATORY PATIENT MONITORING SYSTEM

FLOTRAC SENSOR Address: One Edwards Way, Irvine, CA 92614 Phone: (949) 250-2500 Email: criticalcare@edwards.com Website: www.edwards.com/criticalcare

Address: 6135 Gunbarrel Ave., Boulder, CO 80301 Phone: (855) SENSING or (855) 736-7464 Website: www.covidien.com/rms

Product Description: The FloTrac sensor is the easy and reliable solution for tailored perioperative hemodynamic optimization. Less invasive, the FloTrac sensor attaches to an existing arterial catheter and automatically calculates key flow parameters such as continuous cardiac output, stroke volume, stroke volume variation and systemic vascular resistance.

Product Description: Continuous SpO2, pulse rate and respiration rate in an easy-to-read and flexible monitoring platform. Incorporates real-time and trending data, helping clinicians make better-informed treatment decisions. State-of-the-art, lightweight and versatile design. Easy-to-read touchscreen with color display and custom screen layouts. Multiple connectivity options. Modular software, expandable parameters, including Nellcor™ Respiration Rate Software.

MONITORING SYSTEMS & DEVICES 60

MONITORING SYSTEMS & DEVICES 64

COVIDIEN

EDWARDS LIFESCIENCES

NELLCOR™ FOREHEAD SPO2 SENSOR Address: 6135 Gunbarrel Ave., Boulder, CO 80301 Phone: (855) SENSING or (855) 736-7464 Website: www.covidien.com/rms Product Description: Nellcor™ Forehead SpO2 Sensors: • Provide reliable information • Give readings when conventional finger sensors fail • Show accurate readings • Have readings that are correlated with blood gas analysis and are not affected by vasoconstriction • Offer fast response • Can detect changes in SpO2 earlier than conventional sensors

Special Supplement I June 2013

PRESEP OXIMETRY CATHETER Address: One Edwards Way, Irvine, CA 92614 Phone: (949) 250-2500 Email: criticalcare@edwards.com Website: www.edwards.com/criticalcare Product Description: The PreSep oximetry catheter continuously monitors central venous oxygen saturation (ScvO2) and provides the security of an early warning by detecting critical changes in hemodynamic status earlier.

AnesthesiologyNews.com

BUYER’S GUIDE Summer/Fall 2013 MONITORING SYSTEMS & DEVICES 65

MONITORING SYSTEMS & DEVICES 69

EDWARDS LIFESCIENCES

MASIMO

SWAN-GANZ CATHETER

PATIENT SAFETYNET™ REMOTE MONITORING AND CLINICIAN NOTIFICATION SYSTEM

Address: One Edwards Way, Irvine, CA 92614 Phone: (800) 424-3278 Email: criticalcare@edwards.com Website: www.edwards.com/criticalcare

Address: 40 Parker, Irvine, CA 92618 Phone: (800) 851-3810 Email: manacone@masimo.com

Product Description: Setting the gold standard in cardiac output monitoring, the advanced technology of the Swan-Ganz catheter (CCO, SvO2, RVEDV, REVEF) provides a complete picture of right heart function and insight into the balance of oxygen delivery and consumption for your most critical patients.

MONITORING SYSTEMS & DEVICES 66

Website: www.masimo.com

Product Description: The Patient SafetyNet* System combines Masimo SET® measure-through motion and low perfusion pulse oximetry with optional ventilation monitoring and clinician notification via pager or IP phone. With demonstrated reductions in rapid response team activations, ICU transfers and sentinel events—as well as significant opportunity cost savings—Patient SafetyNet helps hospitals comply with recommendations for postoperative patient monitoring from the Joint Commission and the Anesthesia Patient Safety Foundation (APSF). *The use of the trademarks Patient SafetyNet and PSN is under license from University HealthSystem Consortium.

MONITORING SYSTEMS & DEVICES 70

EDWARDS LIFESCIENCES

MASIMO

TRUWAVE PRESSURE TRANSDUCER AND VAMP CLOSED BLOOD SAMPLING SYSTEM

RAD-87™ PULSE CO-OXIMETER® WITH UPGRADABLE RAINBOW® TECHNOLOGY

Address: One Edwards Way, Irvine, CA 92614 Phone: (800) 424-3278 Email: criticalcare@edwards.com Website: www.edwards.com/criticalcare

Address: 40 Parker, Irvine, CA 92618 Phone: (800) 851-3810 Email: manacone@masimo.com

Product Description: Accurate and safe solutions for pressure monitoring and blood sampling, the TruWave pressure transducer and VAMP closed blood sampling system may be used independently or combined for a precise and reliable system.

MONITORING SYSTEMS & DEVICES 67

Website: www.masimo.com

Product Description: Featuring upgradable Masimo rainbow® technology and a built-in radio for wireless communication with Masimo’s Patient SafetyNet™ system, the Rad-87™ Pulse CO-Oximeter® noninvasively and continuously measures total hemoglobin (SpHb®), oxygen content (SpOC™), carboxyhemoglobin (SpCO®), methemoglobin (SpMet®), Pleth Variability Index (PVI®), acoustic respiration rate (RRa™), oxyhemoglobin (SpO2), perfusion index (PI) and pulse rate.

MONITORING SYSTEMS & DEVICES 71

GE HEALTHCARE

MASIMO RADICAL-7® WITH TOTAL HEMOGLOBIN (SPHB®) AND PLETH VARIABILITY INDEX (PVI®)

CARESCAPE MONITOR B650 Address: PO Box 7550, Madison, WI 53707 Phone: (800) 345-2700 Email: annmarie.preece@med.ge.com Website: www.gehealthcare.com

Fax: (608) 347-2699

Address: 40 Parker, Irvine, CA 92618 Phone: (800) 851-3810 Email: manacone@masimo.com

Product Description: From the OR to the PACU, GE®’s newest streamlined CARESCAPE solution can adapt to any patient need, helping to improve patient flow and deliver exceptional decision support across beds and units. Plus, the user-friendly interface and easy connectivity to hospital data take pressure off IT staff, bringing clinical intelligence to the bedside for more informed decisions at the point of care.

MONITORING SYSTEMS & DEVICES 68

Website: www.masimo.com

Product Description: The new Radical-7 leverages Masimo’s breakthrough noninvasive measurements and functionality to automate the process of care, enabling clinicians to instantly adapt to changing monitoring needs in different care areas. As a 3-in-1 monitor (bedside, handheld, transport), the Radical-7 comes with integrated wireless communication, Masimo SET® measure-through motion and low perfusion pulse oximetry, and upgradable rainbow® measurements including total hemoglobin (SpHb) and pleth variability index (PVI) to help clinicians with both blood and fluid management as well as bleeding detection.

MONITORING SYSTEMS & DEVICES 72

GE HEALTHCARE

MASIMO

CARESCAPE MONITOR B850

SEDLINE® BRAIN FUNCTION MONITOR

Address: PO Box 7550, Madison, WI 53707 Phone: (800) 345-2700 Fax: (608) 223-2497 Email: gina.petry@med.ge.com Website: www.gehealthcare.com

Address: 40 Parker, Irvine, CA 92618 Phone: (800) 851-3810 Email: manacone@masimo.com

Product Description: The product that launched GE®’s new era in modular patient monitoring, CARESCAPE Monitor B850 is designed to help provide exceptional decision support for high-acuity OR procedures and throughout the continuum of therapy. Advanced parameter technologies help you tailor anesthesia and detect potential problems early. The Citrix interface is designed to integrate with existing hospital networks.

Product Description: With 4 simultaneous channels of high-quality EEG data, SedLine provides continuous information about both sides of the brain and provides information about a patient’s response to anesthesia. SedLine enables individualized titration of sedation, while offering reliable monitoring during challenging conditions such as electrocautery. The Density Spectral Array (DSA™) provides immediate detection of asymmetrical activity. And the Patient State Index (PSI™) has been shown to help clinicians manage patients to significantly faster emergence from anesthesia and recovery.

Special Supplement I June 2013

Website: www.masimo.com

AnesthesiologyNews.com

BUYER’S GUIDE Summer/Fall 2013 MONITORING SYSTEMS & DEVICES 73

MONITORING SYSTEMS & DEVICES 75

MASIMO

SPACELABS HEALTHCARE XPREZZON®

UNIVERSAL RESPOSABLE™ SPO2 SENSOR SYSTEM Address: 40 Parker, Irvine, CA 92618 Phone: (800) 851-3810 Email: manacone@masimo.com

Address: 5150 220th Ave. SE, Issaquah, WA 98029 Phone: (425) 657-7200 Website: www.spacelabshealthcare.com/en/product/xprezzon

Website: www.masimo.com

Product Description: Our ReSposable sensor system was created after more than 10 years of research and development with feedback from hundreds of clinicians on what they wanted most in a sensor— less waste, more value and superior performance. The new Universal ReSposable sensor system offers the performance and comfort of a single-use disposable sensor with the cost-effectiveness and environmental advantages of a reusable sensor. While many hospitals are turning to reprocessing in an attempt to reduce costs, quality and performance suffer. ReSposable offers a lower-cost option while offering less waste and smaller carbon footprint than traditional reprocessing programs.

Product Description: The future of connecting clinicians with patient information starts here. XPREZZON combines a legacy of proven performance with the ultimate fusion of form and function. XPREZZON provides easy access to patient data, creating an expansive “information gateway” at the point of care for the clinician. Visually rich Custom Trends can be displayed continuously or sized and arranged as preferred.

MONITORING SYSTEMS & DEVICES 74

NONIN MEDICAL, INC.

CLARUS MEDICAL, LLC

LIFESENSE™ AND RESPSENSE™ PORTABLE CAPNOGRAPHS

PAIN MANAGEMENT 76

NUCLEOTOME® PERCUTANEOUS DISCECTOMY SYSTEM

Address: 13700 1st Ave. North, Plymouth, MN 55441-5443 Phone: (800) 356-8874 Fax: (763) 553-7808 Email: info@nonin.com Website: www.nonin.com

Address: 1000 Boone Ave. N #300, Minneapolis, MN 55427 Phone: (763) 525-8403 Fax: (763) 525-8656 Email: admin@clarus-medical.com Website: www.clarus-medical.com

Product Description: Nonin’s portable LifeSense™ and RespSense™ capnographs are ideal for endotracheal tube placement verification, waveform trend monitoring, detecting changes in ventilation, continuous monitoring for airway integrity, procedural sedation monitoring and sleep studies. MedAir EtCO2 technology delivers early indication of an adverse event in the breathing function of a patient in multiple environments.

Product Description: The Nucleotome percutaneous discectomy kits are indicated for patients with contained herniated disks following failed conservative treatment. The system’s unique design allows physicians to safely aspirate and extract enough tissue to sufficiently decompress the disk. This is achieved through a small probe without removing bone or disturbing the epidural space. With the Nucleotome, you can visualize and quantify the tissue removed. Sterile disk access components are included in one convenient tray.

Special Supplement I June 2013

BUYER’S GUIDE Summer/Fall 2013 PAIN MANAGEMENT 77

REGIONAL ANESTHESIA 81

HAVEL’S INC.®

AMBU INC

ECHOGENIC MICRO LASER ETCHED NEEDLES (MLE™)

ACTION BLOCK PAIN PUMP

Address: 3726 Lonsdale St., Cincinnati, OH 45227 Phone: (800) 638-4770 Fax: (800) 628-3458 Email: jbarrett@havels.com Website: www.havels.com

Address: 6740 Baymeadow Dr., Glen Burnie, MD 21060 Phone: (800) 262-8462 Fax: (800) 262-8673 Email: dct@ambu.com Website: www.ambuusa.com

Product Description: Havel’s Echoline™ includes the EchoBlock® PTC30 Needles for ultrasound-guided PNBs. The Micro Laser Etching (MLE™) near the tip creates multiple surfaces to reflect sound waves back to the transducer. The MLE™ is also on the EchoBlock® PTC for shoulder, hip and knee injections, as well as the new EchoTuohy™.

Product Description: The ACTion Block Pain Pump provides a continuous, stable delivery of local anesthetic solution to the nerve block catheter and enables the anesthesiologist to tailor the infusion strategy to best match each individual patient’s unique pain needs throughout the course of treatment. Fill to any volume from 50 to 650 mL. Flow consistency ±5%. Latex-free. Smart Technology—Smart Choice—ACTion Block.

PATIENT SAFETY 78

REGIONAL ANESTHESIA 82

HY-TAPE INTERNATIONAL

HAVEL’S INC.®

HY-TAPE

NEW IMPROVED 4X4 ECHOGENIC CORNER CUBE REFLECTOR NEEDLES (CCR®)

Address: P.O. Box 540, Patterson, NY 12563 Phone: (800) 248-0101 Email: seanhiggins@hytape.com

Fax: (845) 878-4104 Website: hytape.com

Address: 3726 Lonsdale St., Cincinnati, OH 45227 Phone: (800) 638-4770 Fax: (800) 628-3458 Email: jbarrett@havels.com Website: www.havels.com

Product Description: Hy-Tape surgical tape dramatically reduces dressing changes for wound care, plastic surgery and, especially, ostomy securement. It can withstand the bodily secretions, oils, moisture and hair that can cause adhesive breakdown. It’s durable, flexible and washable. And yet, Hy-Tape’s latex-free adhesive formula is remarkably gentle on bandaged skin. Visit our website for a free sample.

Product Description: Havel’s EchoLine™ includes the marketleading EchoStim® for ultrasound-guided PNBs. Corner Cube Reflectors (CCR®) near the tip create multiple angled surfaces to reflect sound back to the transducer, even at steep insertions. The CCR® are also on the EchoBlock® for PNBs using ultrasound only, and EchoBlock® MSK, for joint injections.

PATIENT SAFETY 79

REGIONAL ANESTHESIA 83

MERCURY MEDICAL®

NONIN MEDICAL, INC.

FACE-CRADLE®

EQUANOX ADVANCE® ADULT SENSOR

Address: 11300 49th St. North, Clearwater, FL 33762 Phone: (800) 237-6418 Email: sbarlowe@mercurymed.com Website: http://mercurymed.com/catalog2/index2.php

Address: 13700 1st Ave. North, Plymouth, MN 55441-5443 Phone: (800) 356-8874 Fax: (763) 553-7808 Email: usequanox@nonin.com Website: www.nonin.com

Fax: (800) 990-6375

Product Description: The Nonin EQUANOX Advance® Model 8004CA Adult Sensor provides absolute accuracy at 4.1 Arms in patients at risk for compromised oxygen saturation to the brain or other organs. Four-wavelength capabilities ensure that rSO2 values reflect true patient physiology. This level of unmatched accuracy provides critical threshold values in cerebral and somatic applications.

Product Description: The only one fully adjustable prone support system. The Face-Cradle is for use in prone-position surgeries offering clinicians greater visibility of the patient’s face. The Face-Cradle System consists of a mirror, a base and a soft, contoured foam set. Advantages include simple setup, “no waiting.” Fully adjustable cushion set accommodates most adult head sizes and greater visibility of patient’s eyes and ET tube. “When Vision Matters … You Have Control.”

PATIENT SAFETY 80

REGIONAL ANESTHESIA 84

VOSS MEDICAL POSITIONING, INC.

NONIN MEDICAL, INC.

VOSS PRONE POSITIONER

EQUANOX ADVANCE™ NEONATAL/PEDIATRIC SENSOR®

Address: 4235 Centergate, San Antonio, TX 78217 Phone: (800) 247-6294 Fax: (210) 650-8032 Email: vosstec@aol.com Website: www.vossmedicalproducts.com

Address: 13700 1st Ave. North, Plymouth, MN 55441-5443 Phone: (800) 356-8874 Fax: (763) 553-7808 Email: usequanox@nonin.com Website: www.nonin.com

Product Description: The unique design of the Voss Prone Positioner provides clearance for the eyes, nose and mouth while evenly distributing the weight over the rest of the positioner. Features also include a v-channel for the endotracheal tube and easy access to confirm clearance and massage contact points to maintain blood flow.

Product Description: Nonin’s EQUANOX Advance® Neonatal/Pediatric Sensors 8004CB Series are designed and clinically validated with pediatric-specific algorithms, spacing and footprint to provide pediatric values you can act on. These sensors deliver rSO2 absolute values of noninvasive arterial and venous measurements and are for use on patients weighing less than 40 kg. FDA 510(k) pending.

Special Supplement I June 2013

AnesthesiologyNews.com

BUYER’S GUIDE Summer/Fall 2013 REGIONAL ANESTHESIA 85

REGIONAL ANESTHESIA 87

PAJUNK MEDICAL SYSTEMS L.P.

CHIBA SONO

TAP BLOCK SONO KIT Address: 6611 Bay Circle, Ste. 100, Norcross, GA 30071 Phone: (770) 493-6832 Fax: (678) 514-3388 Email: richard.fischer@pajunk-usa.com Website: www.sonoplexusa.com

Address: 6611 Bay Circle, Ste. 100, Norcross, GA 30071 Phone: (770) 493-6832 Fax: (678) 514-3388 Email: richard.fischer@pajunk-usa.com Website: www.sonoplexusa.com Product Description: PAJUNK® has developed the Sono range of cannulae, designed specifically to optimize cannula tip visibility. Ultrasound-guided TAP blocks and rectus sheath blocks increasingly are being used for the management of postoperative pain from abdominal surgery, but cannula tip visibility always has been a problem.

Product Description: PAJUNK® has developed a new-generation cannula that facilitates soft tissue biopsy using its innovative quality together with the latest in ultrasound technology. The construction and build of the cannula tip are designed so that the user can focus attention on the tip of the cannula during the complete biopsy.

REGIONAL ANESTHESIA 86

TEMPERATURE MANAGEMENT 88

PAJUNK MEDICAL SYSTEMS L.P.

CINCINNATI SUB-ZERO

SPROTTE®

WARMAIR AND FILTEREDFLO Address: 6611 Bay Circle, Ste. 100, Norcross, GA 30071 Phone: (770) 493-6832 Fax: (678) 514-3388 Email: richard.fischer@pajunk-usa.com Website: www.pajunkadvantage.com

Address: 12011 Mosteller Rd., Cincinnati, OH 45241 Phone: (513) 772-8810 Fax: (513) 772-9119 Email: cszinc@cszinc.com Website: www.cszmedical.com Product Description: The WarmAir® warming system is a compact, lightweight unit that delivers gently moving warm air using a low-velocity blower. All air is filtered through the WarmAir® unit and the FilteredFlo® blankets. The filtered air warming method minimizes air currents that may spread contaminants to the patient.

Product Description: The “Original” PAJUNK®—SPROTTE® cannula is turning “33.” Celebrate with us and start ordering directly from the “Original Manufacturer.” SPROTTE®—a class of its own in spinal anesthesia and lumbar puncture.

TEMPERATURE MANAGEMENT 89

FUTUREMED ASTOTHERM PLUS & ASTOFLO PLUS Address: 15700 Devonshire St., Granada Hills, CA 91344 Phone: (818) 830-2500 Fax: (818) 891-4755 Email: info@futuremed.com Website: www.futuremed.com Product Description: Astotherm Plus and Astoflo Plus are unique, environmentally friendly warmers that bring blood and IV fluids to normal temperatures with little to no disposable. Astotherm Plus uses an economical tubing extension set, and Astoflo Plus warms fluids directly within the patient’s standard tubing. The lack of disposables eliminates waste and adds up to significant savings. Both warmers are fast and easy to set up, and have intuitive keys for temperature adjustment. Multiple independent sensors and an audio-visual alarm ensure accurate temperature control and patient safety. For more information, visit www.futuremed.com or call (800) 222-6780.

BUYER’S GUIDE Summer/Fall 2013

Optimized for your mobile device and always available at

VASCULAR ACCESS 90

VIDACARE EZ-IO® INTRAOSSEOUS VASCULAR ACCESS SYSTEM Address: 4350 Lockhill Selma Road, Shavano Park, TX 78249 Phone: (210) 375-8500 Fax: (210) 375-8537 E-mail: customerfeedback@vidacare.com Web site: www.vidacare.com Product Description: The EZ-IO® Intraosseous Vascular Access System provides fast, safe, efficient vascular access for any qualified healthcare provider to deliver essential medications and fluids when time is critical.

Special Supplement I June 2013

INTUBATION IS EASY UNTIL IT ISN’T

ONCE YOU’VE USED YOUR FIRST PASS, THERE IS NO GETTING IT BACK As an anesthesiologist or CRNA, you can’t count on anything being simple. That’s why the McGRATH® MAC enhanced direct laryngoscope works like the direct laryngoscope you use every day, but offers more–an anterior camera. So, when your patient is on the table, you are better prepared for the unexpected.

Learn more at Covidien.com/YourNewPlanA6

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 Directive 93/42/EEC concerning medical devices. The device is regulated in the USA under FDA Regulation Number 868.5540 and device listed under the name “McGRATH MAC”. “McGRATH” and “Aircraft” are registered trademarks of Aircraft Medical Limited. “CameraStick” is a trademark of Aircraft Medical Limited. 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 Covidien company. © 2013 Covidien. 13-AW-0007

Dräger Anesthesia.

Rated #1 for system performance and system reliability.*

Providing clinicians the performance and reliability to meet today’s OR challenges For more than a century, Dräger has been providing anesthesia technology clinicians can count on. Our experience has led to innovations such as piston ventilation technology, which allows clinicians to deliver highly accurate therapies for improved patient outcomes. From anesthesia machines to anesthesia monitors to anesthesia information management systems, no other company is more focused on anesthesia care than Dräger.

VISIT WWW.DRAEGER.COM/PERFORM TO LEARN ABOUT OUR ANESTHESIA WORKSTATIONS *MD Buyline User Ratings, Q1 2013