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General Anesthesia Linked to Language Problems in Children San Diego—Surgery with general anesthesia in youngg children may well lead to diminished language abilitiess and cognition, not to mention long-term regional voluu-metric alterations alte in brain structure, recentt research h suggests. Whether these findd-ings aare due to the anesthesia or somee otheer mitigating factor, howeverr,, rem mains to be determined in a pro speective trial. Animal studies have shown n th hat anesthetic exposure early in n liffe leads to structural and funcc-tiional abnormalities of the brain n.. But epidemiologic studies havee been unable to determinee

or a specialty that prides itself on the primacy of good data, aneesthesiology has been woefullly lacking in a key area: studies compaaring outcomes for patients who receivve care from physician anesthetists or their nurse counterparts. Evidence demonstrating that doctoorled care provides a safety advantagg e would be an important weapon in th he effort by the specialty to ward off whaat

see brain page 20 0

see outcomes page 14

Rovenstine Lecture cites lack of data On MD- versus CRNA-directed care

Older Patients Likely Overdosed With Inhaled Anesthetics New studies show that age-adjusted guidance largely ignored

nesthesiologists may be giving older patients significantly more volatile anesthetic during surgery than they require, new studies in both animals and people indicate. In one study, increasing age was associated with higher levels of delivered volatile anesthetics than the expected adjustment for age of minimum alveolar concentration (MAC). In another study, older rats experienced prolonged emergence from anesthesia and required a lower dose to lose their righting reflex—a measure of recovery.

“It’s pretty clear that we are relatively overdosing our elderly patients. Whether or not that has any adverse consequences is not yet clear,” said Alec Rooke, MD, PhD, professor of anesthesiology and pain medicine at the University of Washington Medical Center, in Seattle. “If, as some studies suggest, deeper levels of volatile anesthetics are found to increase the risk for postoperative cognitive dysfunction, then we see age page 18

PAIN MEDICINE

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Make An Educated Decision Information You Need To Be Informed and Stay Competitive Anesthesia Business Consultants (ABC) believes the more you know, the better the decisions you can make. ABC places the highest value on continuing education. As the health care world continues to evolve, offering new technological advances and business models, along with changing laws and regulations, it’s imperative to keep informed. We provide our clients and associates regular updates on what is happening in the world of anesthesiology through our weekly eAlerts. These Alerts highlight the very latest in developments, changing requirements and opportunities and are a complimentary service. If you are interested in receiving these Alerts just send your name, e-mail address, the name of your practice or company, city and state to info@anesthesiallc.com. ABC is also pleased to offer the Communiqué, our quarterly newsletter, to interested individuals. It is available electronically as well as in print. The Communiqué features articles written by industry leaders focusing on the latest hot topics in group management, compliance and future business models for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators. We look forward to providing you with many more years of practice management news through the Communiqué and our weekly Alerts. Please log on to ABC’s web site at www.anesthesiallc.com and click on the “Publications” link to view the electronic version of the Communiqué online or to see copies of our previous Alerts. ABC does not share this list with any third parties nor use it for purposes other than distributing the Alerts, the quarterly Communiqués and the very occasional special announcement. If you have any questions or would like additional information please call 517-787-6440 x 4113, send an email to info@anesthesiallc.com, or visit our website at www.anesthesiallc.com. This communication is for educational informational purposes only and is not intended or offered as legal advice.

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Comment on these and other articles @ AnesthesiologyNews.com.

Heard Here First:

December 2013

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

What this studyy has done is

q quantify the benefits of a method of placement confirmation that was first described in the 1800s. This is the

1. Study Probes Anesthesia-Erection Link 2. Propofol Dosing By Weight May Shortchange Obese Patients 3. High Incidence of Residual Paralysis Found in Canadian Study 4. Misconduct May Take Bloom off β-Blocker Rx 5. ASA Blasts Proposed Change to VA Nursing Guidelines

systematic validation of the first

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C OR R E SP O NDENCE To The Editor: read with interest the article titled “Operating Room Noise May Pose Risks to Clinicians, Patients” (October 2013, page 11). This concept is not new, but still bears addressing. The researchers are justifiably correct in being concerned about OR noise and patient safety. A recent article in Anesthesiology demonstrated that increased visual attentional load and auditory background noise resulted in a 17% reduction in the ability of anesthesia residents to

detect a decrease in simulated oxygen saturation from 99% to 98%.1 What is so disconcerting about this is that study participants were anesthesia residents in their late 20s or early 30s. Physicians today are working well into their 60s, and often into their 70s. The demographics raise concerns about what the actual reduction in detection of a decrease in oxygen saturation would be among practicing anesthesiologists, and whether 17% underestimates the true value.

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It is well known that aging involves sensory and neurocognitive changes. Common age-related sensory changes include impairment of hearing, visual acuity, depth perception and color discrimination.2 Continuous performance testing (CPT) often is used to demonstrate attention deficits. Mani and colleagues used CPT to demonstrate attention deficits in individuals ranging in age from 19 to 82 years under clear and noisy conditions.3 They found that under both conditions, accuracy of the tests decreased with age. False alarms and omission errors increased with age, suggesting a decline in selective attention and the ability to distinguish relevant from irrelevant information. The loss of selective attention can weaken inhibitory control, which in turn may increase the vulnerability to distraction.4 However, controversy on this subject does exist, as some researchers have found sustained attention to be equal between the different ages.5,6 Anesthesiology often is compared to aviation. In 1981, the Federal Aviation Administration enacted regulations (FAR 121.542 and FAR 135) in an attempt to reduce accidents during takeoff and landing, when pilots are most vulnerable to attention-related errors.7 These regulations, referred to as the “sterile cockpit” rule, prohibit the performance of nonessential chores and requires crew members to focus on the current duty at hand— safely operating the aircraft. Disregard of this rule continues to be a contributing factor in fatal accidents.8 The majority of anesthesia-related accidents do not result from a single error but instead arise from the accumulation of multiple small errors.9 Responses are notably slower in the presence of high attentional load and noise. The aviation industry has set the precedent. Operating room noise affects our ability to provide the best and the safest patient care. Just as ORs across the country have embraced the silent pause to conduct the safe surgery checklist, now is the time to institute a silent pause during times of high acuity that could be initiated by any member of the team at any time. —Tania Haddad, DMD, MD Dr. Haddad is an anesthesiologist in Arizona.

References 1. Stevenson RA, Schlesinger JJ, Wallace MT. Effects of divided attention and operating room noise on

©201 ©2 013. 3. Pai aid d fo forr by the Uni nite ted d St Stat ates ess Arm rmy. y. Al Alll ri righ ghts ts res eser erve ved.

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COR R E SPON D E N CE To The Editor: read with interest the article in the October 2013 edition, “Patient Opioid Disengagement” (page 76). I would like to make an observation about one of their recommendations related to discharging an opioidtolerant pain patient. The authors state: “Providing a final 30-day opioid prescription or a tapering dose to the patient may be appropriate to prevent withdrawal symptoms. This also should provide the patient adequate time to locate and establish care with a new provider, so that they cannot make ‘abandonment claims.’” If a physician thinks the patient should not be on opioids, then giving that patient more opioids and sending them out the door could be considered poor medical practice. If the patient has obtained opioids from multiple providers, the physician has no way of knowing if the patient has a potentially lethal stockpile of opioids at home. Giving more opioids could be seen as contributing to the patient’s death should an overdose occur. If the patient never has opioids in their urine drug confirmation tests, then they may not be taking their medications but rather selling their drugs. If you think a patient is selling their drugs and you give them more drugs, this could make you a partner in their

perception of pulse oximeter pitch changes. Anesthesiology. y 2013;118:376-381. 2. Greenfield LJ, Proctor MC. When should a surgeon retire? Adv Surg. 1999;23:385-393. 3. Mani TM, Bedwell JS, Miller LS. Age-related decrements in performance on a brief continuous performance test. Arch Clin Neuropsychol.l 2005;20:575-586. 4. McDowd JM, Oseas-Kreger DM, Filion DL. Inhibitory processes in cognition and aging. In: Dempster F, Brainerd C, eds. New Perspectives on Interference and Inhibition in Cognition. New York, NY: Academic Press; 1995:363-400.

crime. If the patient has developed the disease of addiction, then it is illegal to give a month’s supply of opioids to the patient (you may administer, not prescribe, a one-dayy supply of opioid for up to three consecutive days to bridge the patient into an addiction treatment program). There are many reasons a physician will need to discontinue opioid treatment. Many of those reasons would lead the prudent clinician not to offer a month’s supply of opioids to the

departing patient; to do so would risk being sued for wrongful death or malpractice, or arrested for drug dealing or maintaining a patient’s addiction. To avoid being sued for abandonment, the physician can do as the authors suggest: Offer to continue to treat the patient and wean them off their opioids. It seems odd to me that a physician would tell a patient that they should not be on opioids and then give the patient a prescription for a month’s supply of opioids as they send them

out the door. This is a little like telling the patient that they should quit smoking and handing them a pack of cigarettes as they leave the office. Sincerely, —Donald R. Taylor, MD, Marietta, Ga. Dr. Taylor is a diplomate of the American Board of Anesthesiology (with added qualifications in pain medicine), and a diplomate of the American Board of Addiction Medicine.

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5. Berardi A, Parasuraman R, Haxby JV. Overall vigilance and sustained attention decrements in healthy aging. Exp Aging Res. 2001;27:19-39. 6. Parasuraman R, Nestor P, Greenwood P. Sustainedattention capacity in young and older adults. Psychol Aging. 1989;4:339-345. 7. Sumwalt RL The sterile cockpit. http://asrs.arc. nasa.gov/publications/directline/dl4_sterile.htm. Accessed November 2013.

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8. U.S. Department of Transportation, Federal Aviation Administration. SAFO Safety Alert for Operators. http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo. Accessed November 2013. 9. Allnutt MF. Human factors in accidents. Br J Anaesth. 1987;59:856-864.

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P A IN M E D I C I NE

Will Opioid Scrutiny Spur NSAID Overuse?

n the wake of FDA changes to labels for extended-release/ long-acting opioid pain relievers, clinicians and patients may be looking elsewhere for ways to manage moderate pain. Nonsteroidal antiinflammatory drugs (NSAIDs) offer a potential alternative, but some clinicians are urging that a possible increase in NSAID consumption

should be met with caution. “We hope the impact will not be great,” said Daniel Brzusek, DO, vice chair of the Alliance for Rational Use of NSAIDs. “But we think that not only physicians, but the lay public will rely on NSAIDs.” Michael Carome, MD, director of Public Citizen’s Health Research Group, said it’s “hard to say” if the

new FDA labeling will influence NSAID use. He cited the variety of pain relief options that could be used in lieu of opioids or NSAIDs. “NonNSAIDs, like Tylenol, may be reasonable for some patients,” Dr. Carome said. “And frequently, these are underutilized.” Both Dr. Carome and Dr. Brzusek noted that there are ways to relieve

“It doesn’t make sense, every other parameter indicates good cerebral oxygenation.” Logic dictates that acceptable blood pressure and pulse oximetry readings correlate to adequate oxygenation in the brain. But logic doesn’t apply

pain that do not rely on pharmaceuticals, such as exercise and behavioral therapy. Dr. Brzusek also cited acupuncture as “a safer, zero-risk alternative” to NSAIDs. In the United States, an estimated 23 million people use NSAIDs for daily pain relief. Although considered safe when used properly, these drugs may result in adverse effects, such as cardiovascular events and gastrointestinal (GI) bleeding. A recent meta-analysis of the adverse effects of NSAIDs found that, compared with placebo, for every 1,000 patients per year receiving a coxib or diclofenac, there would be three additional vascular events, of which one would be fatal. The meta-analysis also reported an increase in upper GI complications compared with placebo—most frequently, bleeding—at relative risks of 1.81 for coxibs (P=0.0070), 1.89 for diclofenac (P=0.0106), 3.97 for ibuprofen (P<0.0001) and 4.22 for naproxen (P<0.0001) (Lancet 2013;382:769-779). Patients who use NSAIDs should take the “least dose possible for the shortest period of time,” Dr. Brzusek said. “That’s a maximum of 10 days.” Dr. Brzusek begins with a minimal dose—for example, 200 mg of ibuprofen three times daily, 75 mg of diclofenac daily or 250 mg of naproxen twice daily—and titrates up the dosage every three days until there is no additional positive response. How big a problem NSAIDs pose is a matter of debate. Lynn Webster, MD, president of the American Academy of Pain Medicine, has said that deaths from GI bleeding linked to NSAIDs “rival deaths from opioids, according to some estimates.” This statement provoked a strong response

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PA IN M E D ICIN E

Rapid Opioid Detox Method Linked To Hospitalizations, Deaths

rug rehabilitation clinics should no longer administer a controversial opioid detoxification method, government health officials have said. An investigation by the New York City Department of Health and Mental Hygiene found that anesthesiaassisted rapid opioid detoxification (AAROD) put patients at risk for serious adverse events, including cardiac arrest, vomiting, pulmonary edema and death. Between January and September 2012, 75 patients underwent AAROD procedures at a New York City outpatient clinic, according to a recent report from the Centers for Disease Control and Prevention (CDC; MMWR R 2013;62:777-780). Seven patients (9.3%) experienced adverse events that required hospitalization. Of these adverse events, two were fatal. In one case, the autopsy indicated cardiomegaly and pulmonary edema; in the other, the autopsy revealed anoxic encephalopathy and coronary atherosclerosis, and “hypokalemia and cardiac arrhythmia following

from Andrew Kolodny, MD, president of Physicians for Responsible Opioid Prescribing, who wrote on Twitter that Dr. Webster’s remark was “false” and should be corrected. Estimates of deaths from GI bleeding range from a high of 16,500 ((J Rheumatol Suppl 1999;56:18-24) to a more conservative 2008 report from the Centers for Disease Control and Prevention, which cited 3,400 deaths. In contrast, the agency recorded 14,800 deaths from opioids in 2008. When asked about the number of deaths from NSAIDs compared with the number of opioid-related deaths, Dr. Brzusek said he did not believe deaths from NSAIDs are quite so high. “There are definitely a lot of deaths from bleeding,” he said, “but hospitalizations are more common.” According to the Alliance for the Rational Use of NSAIDs, NSAIDs contribute to at least 100,000 hospitalizations per year. Dr. Carome emphasized that he is not opposed to the reasonable administration of NSAIDs. “All drugs have problems,” he said. “Patients need to be made aware of that.” —Ben Guarino

anesthesia-assisted rapid opiate detoxification” as the cause of death. During AAROD, general anesthesia and medication, such as clonidine and antidiarrheal and antiemetic agents, are used to reduce withdrawal symptoms. Patients at the New York City clinic received IV naloxone (median dose, 80 mg) or intramuscular injections of naltrexone (median dose, 133

mg) to precipitate opioid withdrawal. In 2005, the American Society of Addiction Medicine stated that use of AAROD in clinical settings is “not supportable” because of its “uncertain risks and benefits.” A 2010 Cochrane Library review of 1,109 patients receiving opioid agonists and anesthesia found that heavy sedation significantly increased the risk for adverse

events compared with light sedation (risk ratio, 3.21; P=0.003). P The CDC report recommended that clinics use medication-assisted treatment with opioid agonists, such as methadone or buprenorphine, as a safer alternative to AAROD for detoxification. —Ben Guarino

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Reference: 1 4th National Audit Project of the Royal College of Anesthetists and the Difﬁcult Airway Society: Major complications of Airway Management in the United Kingdom. Report and ﬁndings: March 2011. Editors: Dr. Tim Cook, Dr. Nick Woodall, and Dr. Chris Frerk.

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P A IN M E D I C I NE

Balky Payors Undermine Cost-Effectiveness Of Spinal Cord Stimulation Toronto—Myopic health care spending by insurers is threatening to make spinal cord stimulation (SCS) inaccessible to patients as a first-line treatment for certain types of neuropathic pain, experts told attendees at the recent 2013 International Congress on

Neuropathic Pain. “SCS is a cost-effective treatment for certain neuropathic pain patients, but it has a high up-front cost and takes longer to pay off than the time frame payors are concerned with,” Richard North, MD, emeritus

professor of neurosurgery, anesthesiology and critical care medicine at Johns Hopkins University School of Medicine, in Baltimore, said at the meeting. Dr. North shared preliminary findings from an international,

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multicenter, randomized trial he led that compared the efficacy and cost of SCS with reoperation in patients with failed back surgery syndrome (FBSS). He presented findings from the first 42 patients, at a mean follow-up of 3.1 years. Those data showed 62% of the FBSS patients (13 of 21) randomized to undergo reoperation failed to respond to surgical treatment and subsequently required an SCS implant. In contrast, 26% of those (five of 21) initially treated with SCS experienced refractory symptoms and subsequently underwent reoperation. None of the SCS patients requiring reoperation and 38% of crossovers from reoperation to SCS subsequently experienced treatment response. Dr. North said his team’s initial analysis showed the mean perpatient cost was $34,371 for those

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AnesthesiologyNews.com I 11

PA IN M E D ICIN E randomized to SCS and $36,341 for those randomized to undergo reoperation. “SCS was more effective and, given the high failure rate in the reoperation group, incrementally less expensive than reoperation in selected FBSS patients,” Dr. North said. “SCS should be the initial therapy of choice for these selected individuals with FBSS.” More data supporting the costeffectiveness of SCS have come out of a study led by Krishna Kumar, MBBS, MS, clinical professor of neurosurgery at the University of SaskatchewanRegina General Hospital in Canada. Dr. Kumar, who also spoke at the meeting, conducts research focusing on the cost of quality-adjusted lifeyears (QALYs), a measure that takes into account both the number of years added to a life and the quality of those added years. A broadly acceptable cost to payors for each additional QALY is $50,000, he said. To document the QALYY related costs of SCS, Dr. Kumar and his colleagues looked at medical charts from 313 patients with FBSS, complex regional pain syndrome (CRPS), peripheral arterial disease (PAD) and refrac-tory angina pecto-ris (RAP), who had received either an SCS implant and optimal medical

management (OMM) or OMM alone. OMM consisted mainly of pharmacotherapy. Based on their findings, which were recently published online (Pain Med 2013; doi:10.1111/pme.12146), the average cost for a QALY with combined SCS and OMM ranged from roughly $7,300 for FBSS to approximately $9,600 for CRPS patients. “The more you pay, the more you get in terms of net cost–benefit,” he said. “In this case, SCS with OMM is

cost-effective, and the incremental cost of an additional QALY falls well below the threshold payors are willing to pay.” Brett Stacey, MD, director of the Comprehensive Pain Center at Oregon Health & Science University in Portland, and professor of anesthesiology and perioperative medicine at the university, said cost-effectiveness studies like these are essential to staving off cuts to SCS reimbursement. “Anything that can demonstrate overall cost-effectiveness is helpful

in ensuring SCS is available to our patients,” said Dr. Stacey, y who was not involved in the studies. —David Wild Dr. Kumar is a consultant for Boston Scientific and Medtronic. Dr. North is an unpaid officer for the Neuromodulation Foundation, Inc., a nonprofit that has received sponsorship funding from Boston Scientific, Medtronic and St. Jude Medical, Inc. He also owns equity in and is a consultant for Algostim, LLC. Dr. Stacey reported no conflicts of interest.

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12 I AnesthesiologyNews.com

DECEMBER 2013

P A IN M E D I C I NE

Neuropathology in Skin May Be Source of Fibromyalgia

iopsies of the palms of fibromyalgia patients have revealed an anatomic distinction that may explain the symptoms of the condition. Researchers have found an excess of sensory fibers innervating arteriole-venule shunts (AVS), structures involved in temperature regulation, in these patients. “We’re asking about sensory innervation to vasculature: Could it underlie the pain, fatigue, poor sleep and cognitive issues characteristic of fibromyalgia?” asked lead author Phillip J. Albrecht, PhD, assistant professor in the Center for Neuropharmacology & Neuroscience at Albany Medical College, in Albany, N.Y. In the study (Pain Medd 2013;14:895-915), Dr. Albrecht and his colleagues compared a cohort of 24 women diagnosed with fibromyalgia with a cohort of 23 healthy women. The AVS profiles in the palmar, hypothenar and glabrous skin biopsies of fibromyalgia patients were larger than in control subjects (P<0.001), and the overall average innervation area of AVS profiles was twice as great as in control subjects (P<0.001). The proportions of vasodilatory sensory and vasoconstrictive sympathetic fibers were altered in fibromyalgia patients, with the sensory axons disproportionately represented (P<0.0001). The authors noted that the glabrous skin of the hands and feet is not only involved in thermoregulation, but also in apportionment of blood to other tissues, including skeletal muscle, when metabolic demand is high. The AVS pathology might contribute to tenderness and pain in the hands, Advertisement Airway Mobilescope (MAF), From Olympus

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‘We’re asking about sensory innervation to vasculature: Could it underlie the pain, fatigue, poor sleep and cognitive issues characteristic of fibromyalgia?’ —Phillip J. Albrecht, PhD

dysregulation of blood flow to the muscles and compromised circadian blood flow regulation—leading to the widespread deep pain, fatigue, sleep disturbances and cognitive dysfunction characteristic of fibromyalgia. Serotonin-norepinephrine reuptake inhibitors that are FDA-approved for fibromyalgia may act by targeting the sensory and sympathetic innervation of the AVS. Dr. Albrecht said he did not expect the findings to have an immediate clinical impact. “I doubt that clinicians will do anything different,” he said. However, he did expect more studies to follow. “Part of the excitement of doing science is to perform a study where the results open up new questions,” he said. Next steps include increasing the patient base, studying males who have fibromyalgia and determining the role of stress, he added.

who was not associated with the paper, said in an interview, “It’s an interesting contribution, very preliminary. Perhaps it’s done well at the laboratory level, but the reporting is not done well. It jumps to conclusions. It needs to be followed-up in studies, preferably not funded by drug companies.” The researchers’ grant support from Eli Lilly and Forest Laboratories, Dr. Wolfe said, was a conflict of interest. Dr. Wolfe also wondered whether other patients with severe pain, such as low back pain, would have shown similar findings. Finally, he said, the researchers have merely shown an association, not a cause-effect relationship. “You can’t determine the direction of causality from such data,” he said. Dr. Albrecht denied that the funding was a conflict of interest. “This was an investigator-initiated proposal,” he said. “This particular discovery is not a promotion of use for any specific class of drugs.” Response From Experts Dr. Albrecht agreed that studying other groups An editorial (Pain Medd 2013;14:777-778) accom- of patients would be important “to determine if the panying the study called it “masterful” and said it nature of this pathology is specific to fibromyalgia emphasized “the importance of peripheral pain gen- or chronic pain in general. ... However, regardless of erators in determining the clinical expression of these study issues, the alterations in the cutaneous pain.” vascular innervation are clearly present.” But Frederick Wolfe, MD, director of the National —George Ochoa Data Bank for Rheumatic Diseases, in Wichita, Kan.,

Protect your hard-earned reputation by managing risk. Since 1987, Preferred Physicians Medical (PPM) has exclusively insured anesthesiologists and their practices. Our policyh holders also own PPM, so helping our physician owners manage their risk iss a cornerstone of what makes us unique. PPM maintains a substantial database of more th han 11,000 adverse anesthesia events and uses this information to identify areass of risk, monitor developing loss trends, and provide cutting-edge, timely and practical anesthesia-specific risk management advice and strategies like: 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.

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14 I AnesthesiologyNews.com

DECEMBER 2013

P OLI C Y & M A NAGEMENT OUTCOMES

CONTINUED FROM PAGE 1

it perceives as mounting gains by certified registered nurse anesthetists (CRNAs). So it is somewhat surprising that only a small handful of such studies exist—not all of which were commissioned by anesthesiologists. Georgia anesthesiologist John Neeld Jr., MD, hopes to correct that. Dr. Neeld, a past president of the American Society of Anesthesiologists (ASA), recently challenged the group to put up $1 million to study the differences in outcomes between physicianand CRNA-directed care. That number came not from thin air, he added, but from consultation with experts in the sort of large-scale studies necessary to generate statistically meaningful data. At the heart of what Dr. Neeld called his funding “appeal” is a 1989 study of anesthetic safety by John Eichhorn, MD, and his colleagues published in Anesthesiology (70:572-577)—or, rather, what Dr. Neeld said was a widespread misinterpretation of those data. The Eichhorn study found the risk for death associated with anesthesia to be about one per 200,000 exposures. However, that rate applies only to relatively healthy patients classified as ASA status 1 or 2. The risk for fatal harm among patients with an ASA status of 3, 4 or 5, Dr. Neeld said, is substantially greater, on the order of one per 13,000. To compare outcomes of physician- and nurse-led care between ASA 1 and 2 patients would require millions of participants—at prohibitive expense. “But if it’s one in 13,000, a much smaller study should suffice,” Dr. Neeld said. The ASA said it was unaware of Dr. Neeld’s call for funding before he delivered his remarks at the Emery Rovenstine Memorial Lecture at the society’s 2013 annual meeting in San Francisco in mid-October. Advertisement Contiplex® C from B. Braun Medical Inc.

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Table. Death and Complications From Anesthesia by Provider Mortality

Complications

Opt-Out States

Non–OptOut States

Before Opting Out

After Opting Out

Non–OptOut States

Before Opting Out

After Opting Out

Anesthesiologist alone

1.00

0.797

0.788

1.00

0.824

0.818

CRNA alone

0.899

0.651

0.689

0.992

0.798

0.813

Team

0.959

0.708

0.565

1.067

0.927

0.903

CRNA, certified registered g nurse anesthetist. Source: Health Aff Aff.f. 2010;29:1469 2010;29:1469-1475. 1475.

ASA president Jane Fitch, MD, said “Dr. Neeld’s request for $1 million in funding for an outcomes study was not addressed with ASA leadership prior to” the meeting. “At this point, Dr. Neeld’s request will likely be assigned to a committee to make a recommendation to ASA’s board of directors for consideration at its next meeting.” The next board meeting is scheduled for March 2014. Dr. Neeldd said the amount of money involved would almost certainly need approval from the society’s House of Delegates, which won’t convene again until the annual meeting next October in New Orleans. ‘Winning the War’ In his talk, titled “Winning the War,” Dr. Neeld, formerly of Northside Hospital in Atlanta, argued that CRNAs have been waging an effective political battle against anesthesiologists to supplant physicians whenever possible. One of their most potent weapons has been the paucity of evidence that physician-directed care is better—or that nurse-directedd care is worse. The most salient study comparing anesthesiologists with CRNAs was published in 2010 in Health Affairs—a paper that physician anesthetists would prefer to ignore. The article, by Brian Dulisse and Jerry Cromwell, of the Research Triangle Institute, in North Carolina, and funded by the American Association of Nurse Anesthetists (AANA), found no differences in patient outcomes across some 481,000 cases when physicians were directing the anesthetic or in states that had opted out of a Medicare requirement of such supervision. But Dr. Neeld said people generally misinterpret those findings, too. “Both mortality and complications among patients cared for by CRNAs practicing solo increased after the opt-out, whereas mortality and complications decreased among patients cared for by anesthesiologists alone or the anesthesiologist-directed care team,” he said (Table). Even so, the ASA would prefer to cite a 2000 study in Anesthesiology (2000;93:152-163), by a group from the University of Pennsylvania. The researchers, led by pediatrician Jeffrey H. Silber, MD, used Medicare billing records to assess outcomes in 194,430 cases in which anesthesiologists directed treatment, and 23,010 cases in which CRNAs worked alone. They found a small but statistically significant increase in death and failure-to-rescue for the undirected patients—corresponding to an estimated 2.5 excess deaths per 1,000 patients, and 6.9 excess deaths per 1,000 patients with complications, they said. “Both 30-dayy mortality rate and mortality rate

‘Anesthesiologists and nurse anesthetists do different jobs, and I think ASA should invest in demonstrating this difference. ... The care team model of physicians supervising nurses has evolved because it is a safe and flexible way to manage anesthesia services.’ —Richard Dutton, MD, MBA

after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. These results suggest that surgical outcomes in Medicare patients are associated with anesthesiologist direction, and may provide insight regarding potential approaches for improving surgical outcomes,” they reported. Doubts About Health Affairs Study Richard Dutton, MD, MBA, executive director of the Anesthesia Quality Institute (AQI), said, “Anesthesiologists and nurse anesthetists do different jobs, and I think ASA should invest in demonstrating this difference. In particular, anesthesiologists are trained to supervise individual anesthetics, multiple cases at the same time, OR suites and even whole-facility anesthesia programs. The care team model of physicians supervising nurses has evolved because it is a safe and flexible way to manage anesthesia services.” Although the AQI has not looked specifically at provider-specific outcomes, the National Anesthesia Clinical Outcomes Registry (NACOR), which it oversees, does have data that can help shed light on the question. In particular, Dr. Dutton said, the “vast majority” of NACOR cases involve care team coverage, including those billed as “QZ”—the code for unsupervised care. That’s a critical point, he noted, because “a large percentage of cases billed as QZ are really done in a care team model with low ratios of coverage,” such as a single physician overseeing more than four nurse anesthetists. In a recent study, Dr. Dutton and his colleagues surveyed 100 facilities that had reported a high see outcomes page 17

16 I AnesthesiologyNews.com

DECEMBER 2013

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Video Laryngoscopy and the Difficult Airway: A Q&A With Carin Hagberg, MD Q. How does the newly revised American Society of Anesthesiologists’ (ASA) Difficult Airway Algorithm affect intubation practices? A. The new and revised ASA Difficult Airway Algorithm continues to provide the practitioner with organized, preplanned strategies to facilitate management of the difficult airway and reduce

the likelihood of adverse outcomes. The most significant modification of the 2013 guidelines is inclusion of video laryngoscopy, as either an initial approach to intubation—awake or following the induction of general anesthesia—or following failed intubation in which face mask ventilation is adequate. Equally significant is that the practitioner should consider not only difficulties with mask ventilation and intubation, but also difficulties

with supraglottic airway placement, laryngoscopy and the performance of a surgical airway, when making an initial airway assessment and formulating an airway management plan.

Q. How do video intubation devices enhance patient safety and improve patient outcomes?

A. The inability to visualize the vocal cords when performing direct laryngoscopy is a common factor that prevents successful tracheal intubation. Video laryngoscopes are a relatively new addition to the armamentarium of airway devices available to the airway manager. In difficult airway management, they offer a larger, brighter and higher resolution image, improve laryngoscopic grade and achieve the same or a higher intubation success rate, often in less time, than direct laryngoscopes. Video laryngoscopy is widely accepted in the management of difficult airways; however, a flexible intubation scope is still required in many cases.

Q. How do multiple video intubation technologies on a single cart drive procedural efficiencies? A. Use of video intubation techniques in surgical practice has become common for a range of procedures, simplifying both routine and emergency airway management. When a difficult airway is encountered, there is limited time to locate necessary intubation tools and supplies. An airway management cart that provides rapid access to a variety of intubation tools, including video techniques, can facilitate intubation success and improve procedural efficiencies.

Q. In your experience, how has the adoption of video technology improved training? A. Both video laryngoscopy and video flexible intubation technologies enable the instructor to see what the trainee is visualizing in “real time” and allows for instruction and demonstration to multiple viewers. An assistant can visualize the effects of laryngeal manipulation, if needed, and the procedure can be recorded and reviewed later in presentations or discussions. Direct laryngoscopy also may be taught with certain video laryngoscopes, such as the KARL STORZ Berci DCI® and C-MAC® technologies, GlideScope® Direct (Verathon Medical) and McGrath® MAC (Aircraft Medical/Covidien).

Q. Is there a single optimum solution or set of solutions for airway management? A. There is really not one optimum technology solution for every difficult airway management setting. Each airway device has unique properties that may be advantageous for certain situations, yet limiting for others. Specific airway management techniques are greatly influenced by individual disease and anatomy, and successful management requires combinations of devices and techniques. Nonetheless, clinical judgment born from experience is crucial to their application. Dr. Hagberg is the Joseph C. Gabel Professor and chair of the Department of Anesthesiology at the University of Texas Medical School at Houston, and executive director of the Society for Airway Management.

DECEMBER 2013

AnesthesiologyNews.com I 17

POL ICY & M A N A G E ME N T OUTCOMES

CONTINUED FROM PAGE 14

percentage of QZ cases. They asked three questions: 1) Is an anesthesiologist in the building when these cases are being done? 2) Does an anesthesiologist participate in case assignment (e.g., who does which case)? 3) Is an anesthesiologist available for rescue when a clinical crisis—such John Neeld Jr., MD as an unexpected difficult airway—occurs? Of the 100 facilities studied, 99 answered yes to all three questions. In other words, Dr. Dutton said, there’s good reason to doubt the Health Affairs study. “NACOR is clearly a biased sample, since participation is free to ASA members but would cost money for an all-CRNA practice. But these findings do call into question the CMS [Centers for Medicare & Medicaid Services] data,” he said. “My perception of reality is that ‘supervision’ of anesthesia is a smooth curve with lots of grey areas, rather than a series of easily divided buckets,” Dr. Dutton continued. “In any practice, easy cases get less supervision and hard cases require more hands, and the practice tends to adjust on the fly as needed. The overall goal is patient safety— which is almost universally achieved, and thus hard to demonstrate as being different between facilities. Billing decisions come after the fact. Because low supervision ratios mean no extra money, lots of groups simply bill these cases as QZ rather than complete the documentation to justify AS coding.” A Gamble Of course, an outcomes study comparing physician- and CRNA-directed care could backfire. “That is the risk of doing the study,” Dr. Neeld acknowledged. But not a likely one. As chairman of one of the busiest anesthesia practices in Georgia, “I saw day in and day out how anesthesiologists intervened to prevent serious injury,” he said. “As good as the CRNAs and anesthesia assistants [AAs] are, they’re not MDs. They have more of a technical background; they’re algorithm-driven. When we do the studies, we will find we are important, particularly to ASA 3, 4 and 5 patients.” But what if the data prove unfriendly? That’s an opportunity for change. “Let’s say we find that we don’t make a material difference. Then the question is why don’t we? Why is our education not making a difference?”

Although Dr. Neeld said he did not notify the ASA leadership about his call for funding, the AANA got word of the speech beforehand and issued its own rallying cry to its members. “How sad that the ASA is using its premier lecture, the Rovenstine Lecture,

to wage war not for patient safety, or against patient suffering, or against health care cost growth but against CRNAs,” the letter stated. It closed with an appeal for money of its own: “We must also make our voice heard among the policymakers … on Capitol Hill.” But Dr. Neeld said his intention was not—and never has been—to drive a wedge between CRNAs and physician anesthetists. Rather, he said, in his experience, the best care occurs when

anesthesiologists lead a care team that includes nurses and AAs. “I think that’s the model for the future. What I would like to see is the one-on-one practitioner step back” and let the team model predominate, he said. At Northside, “we employ over 100 nonphysician practitioners, about evenly split between CRNAs and AAs. I think that’s the way to go to spread care across the country.” —Adam Marcus

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DECEMBER 2013

PRN CONTINUED FROM PAGE 1

need to be concerned that we may be administering unnecessarily deep levels of anesthesia to our elderly patients.” Dr. Rooke and his colleagues presented their findings at the 2013 annual meeting of the American Society of Anesthesiologists (ASA; abstract 3056). Older patients tend to require lower doses of volatile anesthetics, and Dr. Rooke’s group sought to evaluate

how well anesthesia providers adhere to guidelines for age-adjusted MAC (aaMAC). They reviewed electronic medical records for all general anesthetics provided to adults at the University of Washington in 2012, including more than 8,500 single inhaled volatile anesthetics. Patient age was associated with an increasing predicted aaMAC. The rate of increase was 0.0036 per year (95% confidence interval [CI],

0.0033-0.0039) and decreased to 0.0012 per year (95% CI, 0.0003-0.0022) for those aged 65 and older (Figure 1). Clinicians are only partly correcting MAC for age, Dr. Rooke said. “We were able to show that considerably more anesthetic is used on elderly patients compared with what the studies would predict would be needed,” he told Anesthesiology News. “I

Read the #1 anesthesiology publication in the country anywhere, anytime.

1.0

0.9

SITE HMC UWMC

0.8

25 30 35 40 45 50 55 60 65 70 75 80 85 90

Age (Years)

Figure. Predicted relationship between age and age-adjusted MAC, with and without BIS monitoring. MAC, minimum alveolar concentration. Courtesy of Alec Rooke, MD.

1.0

anesthesiologynews

@anesthesianews

% Isoflurane

AGE

Predicted aaMAC (±95% Prediction Interval)

18 I AnesthesiologyNews.com

0.8 0.6 0.4 0.2

6 mo

24 mo

Age of rat

Figure 2. Minimum dose of isoflurane for loss of righting. Courtesy of Ken Solt, MD.

December 2013 pg. 1 of 40

think part of the issue is that we as anesthesiologists don’t see any adverse consequences of using a little more than what we might need—at least we know we’re not underdosing. We don’t want to push the envelope toward too little. But there is no reason that older patients should need relatively more anesthetic than younger patients to achieve such goals.” Increasing age, male sex, total dose of fentanyl and use of desflurane were associated with increased aaMAC. Bispectral index monitoring (Covidien) was used in 35% of cases and was associated with slightly lower doses of anesthetics. Concomitant regional or neuraxial anesthesia, ASA physical status 3 or 4 and use of isoflurane also were associated with lower aaMAC. Rodent Data Show Delayed Emergence in Older Animals Another study presented at the meeting seems to reinforce those findings. The study, by researchers at Harvard University and Massachusetts General Hospital, in Boston, evaluated the effect of age in rats on emergence from general anesthesia with isoflurane and propofol (abstract 3057).

DECEMBER 2013

AnesthesiologyNews.com I 19

PR N

Safety Council Report: Few States on Top of Prescription Drug Abuse

nly three states are doing an effective job of combating the growing problem of prescription drug abuse, according to a new report from the National Safety Council (NSC). The report, “Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic,” credits only Kentucky, Vermont and Washington for meeting standards in four areas identified by the nonprofit education and advocacy group as necessary for combating the escalating prescription painkiller problem: prescribing and overdose education and prevention programs, prescription drug monitoring programs, responsible painkiller prescribing, and state leadership and action. “[Forty-seven] states must improve existing standards if they are to reduce the number of deaths

Young rats in the study emerged from anesthesia with propofol and isoflurane (in separate experiments) much more quickly than their older cage mates, who also required far lower doses to become anesthetized (Figure 2). In another experiment using electroencephalography (EEG), all of the aged rats, but none of the young animals, were in burst suppression during a steady state of 2% isoflurane. Ken Solt, MD, assistant professor of anesthesia at Harvard Medical School, said, “Delayed emergence in aged animals is not unique to a specific anesthetic agent. It’s not a pharmacokinetic issue either because the aged rat requires less anesthetic to stay unconscious. It’s not due to muscle weakness in the aged rat because the EEG suggested that at the same dose of isoflurane, the aged rats’ brains were in a much deeper level of anesthesia. There’s a fundamental difference in anesthetic sensitivity: The aged brain in more sensitive. So the next question is, why is that the case?” The message from both studies, Dr. Solt said, is the same: “We are probably overdosing our elderly patients. But even if you adjust, there is still something different about the elderly brain. The classical end point used to determine anesthetic sensitivity and dosing has been MAC. The problem is that general anesthesia is a constellation of end points; it’s not just immobility. We need to study loss of consciousness as a distinct end point.” —Mandy Armitage, MD

involving prescription drug overdoses,” the council said in a statement. “NSC is calling on states to take immediate action to improve the prescribing, monitoring, treatment and availability of opioid pain relievers.” The report identified 14 states—Arizona, Delaware, Hawaii, Iowa, Maine, Nebraska, New Hampshire, Pennsylvania, South Carolina, South Dakota and

Wyoming—as having failed to meet any of the standards. According to the NSC, prescription pain relievers are responsible for 45 deaths daily, with the amount prescribed in 2010 alone capable of medicating the entire U.S. adult population 24 hours a day for a month. “For the first time since World War II, something other than motor vehicle

crashes is the leading cause of unintentional injury deaths for Americans ages 25 to 64,” said John Ulczycki, vice president of strategic initiatives at NSC. “Countless lives already have been lost. NSC will be working to confront this issue on a national level.” For a copy of the full report, visit nsc. org/rxreport. —AN Staff

20 I AnesthesiologyNews.com

DECEMBER 2013

PRN BRAIN

CONTINUED FROM PAGE 1

whether this phenomenon also occurs in humans. Andreas W. Loepke, MD, PhD, and his colleagues from Cincinnati Children’s Hospital Medical Center, compared children who were exposed to anesthesia before their fourth birthday (n=52) with those not exposed to the agents (n=52). Groups were matched for age, sex, handedness and family income. Neurocognitive assessments included tests of language skills and intelligence. Structural brain evaluations were performed using T1-weighted MRI scans. “Most were [ear-nose-throat] procedures done under halothane or sevoflurane,” said Dr. Loepke, associate professor of anesthesiology at the University of Cincinnati, who presented the findings at the 2013 annual meeting of the International Anesthesia Research Society (IARS; abstract S-316). “The exposure was usually between the first and second years of life, and all of the patients were generally healthy.” The researchers found that although average test scores for both groups were within population norms, the previously exposed children scored lower in all tests (Table 1). More specifically, exposed patients were statistically significantly worse with respect to listening comprehension, expressive language and measures of IQ. “We then used an overlay of the patients’ MRIs to examine clusters of brain cells that were different between the exposed and unexposed cohorts,” Dr. Loepke said. The volume of gray matter was sporadically reduced in posterior brain regions of previously exposed children; lower IQ correlated with reduced gray matter volume in the precentral gyrus. Although the findings seem to indicate that exposure to general anesthesia in early childhood leads to diminished language abilities and cognition,

Dr. Loepke was uncomfortable making a causal relationship based on his group’s data. “We still don’t know if these findings are due to anesthetic exposure, postoperative pain or the inflammatory response to the surgery,” he explained. “This is just a retrospective analysis, so we just have to take it as another piece in the puzzle.” Dean B. Andropoulos, MD, chief of anesthesiology at Texas Children’s Hospital in Houston, cited yet another possible confounder. “There is a paper from the [ear-nose-throat] literature recently that says if a child suffers prolonged obstructive sleep apnea [OSA] during surgery, it has a detrimental effect on long-term neurodevelopmental outcomes,” Dr. Andropoulos said. “So we need to keep looking at confounding variables. Don’t leap to the conclusion that these results are purely due to the anesthetic agent itself. And obviously we know that a young child having a tonsillectomy will usually have a certain degree of OSA.” If exposure to general anesthesia appears to raise a child’ss risk for downstream cognitive problems, child problems spi spinal anesthesia (SA) seems to be relatively benign, according to results from another study researchers presented at the IARS meeting (abstract S-319). A team from the University of Vermont found no evidence of learning difficulties

Table 2. Students Scoring Below the Fifth Percentile on Vermont Standardized Test

Reading

Exposed To Spinal Anesthesia

Not Exposed To Spinal Anesthesia

P Value

7% (18/257)

4.8% (37/771)

0.17

7.3% (18/246)

6.1% (46/738)

0.55

or academic performance in 265 girls and boys in that state who had received SA for hernia repair, circumcision and other surgeries as infants (Table 2). “This first examination of cognitive outcome after infant SA supports the long-term safety of infant SA and implies that cognitive dysfunction seen after exposure to [general anesthesia] in previous studies may be related to effects from anesthesia and not demographics of the patient population,” they wrote. —Michael Vlessides

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Table 1. Neurologic Test Results for Children Exposed or Not Exposed to Anesthesia Test

Exposed (n=52) Not Exposed (n=52) Differences P Value Mean±SD Mean±SD Mean±SD (=)

95% Confidence Interval

OWLS Listening

101.19±12.92

107.15±11.50

5.96±16.86

0.013

1.31-10.6

OWLS Oral Expression

108.06±13.31

111.40±15.50

3.34±21.20

0.257

-2.5-9.18

OWLS Oral Composite

104.66±12.23

110.11±13.77

5.45±19.17

0.043

0.17-10.74

WISC/WAIS Verbal

111.55±12.72

114.89±12.99

3.34±18.01

0.183

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108.32±14.53

114.72±13.08

6.40±17.66

0.011

1.53-11.26

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110.89±13.41

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22 I AnesthesiologyNews.com

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

Contiplex® C: The New Catheter-Over-Needle System for Continuous PNB From B. Braun Q. What is Contiplex® C? A. Contiplex C is a catheter-over-needle system for placement of the peripheral nerve block (PNB) catheter. The design concept is similar to that of an IV catheter. The needle and catheter are inserted together at the same time. Once in the appropriate location,

the needle is removed leaving the catheter in place. This differs from the traditional approach of first inserting a needle, then threading a catheter. By simplifying the catheter placement process and reducing potential complications (such as leakage at the insertion site), Contiplex C could improve the experience

for existing providers and empower a new generation, so that more patients benefit from continuous PNB.

Q. What are the advantages of Contiplex C over traditional catheter-through-needle systems?

Contiplex® C

D E NEW XC LU S

IVE

Echogenic Catheter-Over-Needle System for CPNB

A. Leakage can be reduced because of the catheter-over-needle design. The puncture created with Contiplex C is the same size as the catheter, resulting in a tighter seal. Traditional catheter-through-needle systems result in a smaller gauge catheter seated inside a larger gauge puncture, sometimes leaving room for fluid to backtrack to skin level. Because the catheter is inserted linearly at the same time as the needle, Contiplex C’s echogenic catheter body can stay fully in the ultrasound plane, and placement is similar to a single-shot procedure. This allows deliberate control over the final location of the catheter tip. There is no need to thread the catheter. Threading a catheter from a catheter-through-needle system can make the catheter tip difficult to locate once it exits the tip of the Tuohy needle. Once Contiplex C’s catheter tip is directed to the desired location, the needle is simply removed to place the catheter in one step. Securement of the shorter, 18.7-cm Contiplex C catheter can be easier to accomplish when compared with longer catheters.

Q. How can Contiplex C help my practice?

Deliberate catheter placement. Catheter can be purposely directed to an exact location, without the need to thread.

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A. There are fewer steps involved, and placement is similar to a single shot, therefore placement time may be reduced and blocks simplified. Patient outcomes may improve for two reasons: 1) because of a potential reduction of catheter leakage due to the catheter-over-needle design; and 2) improved comfort due to the 25-gauge needle (compared with 17- or 18-gauge Tuohys). Residents and practitioners experienced with single-shot PNB may benefit. Contiplex C’s deliberate, one-step catheter placement can help reduce the learning curve by eliminating the need to thread a catheter and making catheter placement more familiar—like placing a single-shot block. Practitioners with an established catheter technique may still see a benefit for certain block applications where there is a need to further reduce leakage and/or placement time, or to help train inexperienced practitioners within an anesthesia group.

AN 13-4029 C 10/13 KE

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AnesthesiologyNews.com I 23

PR N

Gloves and Gowns Decrease MRSA, but not VRE, Transmission

loves and gowns may help prevent the spread of methicillinresistant Staphylococcus aureus (MRSA), but they do not stop vancomycin-resistant enterococci (VRE) transmission, researchers at the University of Maryland recently found. The combined rate of MRSA and VRE infections in ICUs also remained unaffected by these contact precautions. “We thought this was a fairly aggressive intervention, which had been only tested before during outbreaks,” said Daniel J. Morgan, MD, MS, professor at the University of Maryland School of Medicine, in Baltimore, and the senior author of the study, which was published online in the Journal of the American Medical Association. “The results were a bit surprising.” Taken together, MRSA and VRE cause more than 100,000 infections and 12,000 deaths each year in the United States, according to the Centers for Disease Control and Prevention (CDC). “In intensive care units, infections are a leading cause of death and morbidity,” Dr. Morgan said. The researchers randomly divided 20 medical and surgical ICUs into two groups. Staff in the control group (n=10) followed CDC recommendations, wearing gloves and gowns only during interactions with patients who had clinically identified MRSA or VRE. Health care workers in the intervention group (n=10), donned gloves and gowns whenever they had patient contact or entered patients’ rooms. Over a three-month baseline period and a nine-month study period, clinicians collected more than 92,200 swabs from 26,180 patients in ICUs. Researchers grew MRSA and VRE cultures from the swabs and used polymerase chain reaction to detect antibiotic resistance genes. Wearing gowns and gloves during all patient contact did not significantly reduce MRSA or VRE acquisition compared with the control measures. For MRSA acquisitions alone, however, the additional contact precautions significantly decreased transmission rates compared with the control group (10.03 to 6.00 acquisitions per 1,000 patient-days vs. 6.98 to 5.94 acquisitions per 1,000 patient-days, respectively; P=0.046). The intervention did not have a significant effect on VRE transmission in comparison with the control. Gowns and gloves may have been more effective barriers to MRSA than VRE because the organisms inhabit separate areas of the body. MRSA resides primarily in the nose and on the skin,

Dr. Morgan said, whereas VRE colonizes the gastrointestinal tract. If a health care worker is wearing gloves and a gown, the potential for MRSA to spread via skinto-skin contact is reduced, but transmission of gut-dwellingg VRE may remain unaffected. Errors in determining baseline VRE infections may have influenced the results, said Preeti N. Malani, MD, a

professor of internal medicine at the University of Michigan, in Ann Arbor, in an accompanying editorial. An effective way to reduce transmission of MRSA and VRE, according to Dr. Morgan, is to bathe patients with chlorhexidine. A recent study found that chlorhexidine baths significantly cultures in ICUs reduce MRSA-positive (N Engl J Med 2013;368:2255-2265).

And, compared with putting on gowns and gloves before patient contact, a chlorhexidine bath “is a lot easier, and it’s only done once a day,” Dr. Morgan said. “If implemented, gloving and gowning should be just part of an overall strategy that includes efforts to optimize hand hygiene and prudent use of antimicrobials.” —Ben Guarino

For the Management of Postsurgical Pain

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Pivotal studies have demonstrated the safety and efficacy of EXPAREL in patients undergoing bunionectomy and hemorrhoidectomy procedures. The clinical benefit of the attendant decrease in opioid consumption was not demonstrated. EXPAREL is a liposome formulation of bupivacaine indicated for administration into the surgical site to produce postsurgical analgesia.

Important Safety Information: EXPAREL is contraindicated in obstetrical paracervical block anesthesia. EXPAREL has not been studied for use in patients younger than 18 years of age. Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. Other formulations of bupivacaine should not be administered within 96 hours following administration of EXPAREL. Monitoring of cardiovascular and neurological status, as well as vital signs should be performed during and after injection of EXPAREL as with other local anesthetic products. Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations. In clinical trials, the most common adverse reactions (incidence ≥10%) following EXPAREL administration were nausea, constipation, and vomiting. Reference: Gorfine SR, et al. Dis Colon Rectum. Dec 2011;54(12):1552-1559.

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Separating Signal From Noise in Ultrasound-Guided RA Boston—Ultrasound guidance has become the standard of care for regional anesthesia. And why not? It’s clear that use of the technology significantly improves outcomes for patients. Or does it? A group of regional anesthesia experts met recently to discuss the evidence supporting ultrasound-guided regional anesthesia (UGRA). Their conclusions:

Safety and Efficacy In 2009, the American Society of Regional Anesthesia and Pain Medicine (ASRA) joined with the European Society of Regional Anaesthesia and Pain Therapy (ESRA) to publish recommendations on UGRA. Since then, a number of studies have focused on ultrasound for neuraxial blocks. “Four years ago, there was very

little out there,” said Anahi Perlas, MD, associate professor in the Department of Anesthesia at the University of Toronto, in Canada. Today, she said, evidence supports a variety of claims. For example, class I/level B evidence demonstrates that ultrasound increases the accuracy of assessing lumbar space and accurately measures the depth of epidural/

intrathecal space. This designation means that a procedure is useful and effective based on evidence from a single randomized trial or nonrandomized studies. Class I/level A evidence shows ultrasound increases the efficacy of neuraxial blocks, meaning that it should be recommended based on data derived from multiple randomized clinical trials or meta-analyses. Class IIb/level B evidence from a limited evaluable population supports that it might contribute to enhanced safety. Joseph M. Neal, MD, a staff anesthesiologist at the Virginia Mason Medical Center, in Seattle, said few recent studies have focused on UGRA and patient safety. Two studies have compared peripheral nerve injury in patients receiving UGRA or peripheral nerve stimulation (PNS) and identified no differences in paresthesia, late deficits or documented injury (Reg Anesth Pain Med 2012;37:577-582; Reg Anesth Pain Medd 2012;37: 478-482). A metaanalysis of randomized controlled trials concluded that ultrasound reduces vascular puncture compared with electrical neurostimulation for peripheral nerve blocks (PNBs; Br J Anaesth 2009;102:408-417). Initial studies were inconsistent as to whether ultrasound decreased the incidence of seizures from errant blocks (RAPM M 2009;34:534-541; RAPM 2009;34:251-255). However, an analysis of 25,336 PNBs from the Australia and New Zealand Registry of Regional Anesthesia demonstrates that ultrasound reduces systemic local anesthetic toxicity incidence by 65% compared with PNS (Reg Anesth Pain Med 2013;38:289-297). Level IA evidence shows that for interscalene block (ISB), ultrasound reduces the frequency and severity of hemidiaphragmatic paresis, but not predictably (Br J Anaesth 2008;101:549-556; Reg Anesth Pain Med 2009;34:498-502; Reg Anesth Pain Med 2009;34:595-599; Reg Anesth Pain Medd 2011;36:17-20). Needle/Nerve Proximity Richard Brull, MD, associate professor of anesthesia at the University of Toronto, focused on the evidence regarding needle/nerve proximity. The 2009 UGRA recommendations listed 10 tasks that are helpful in performing an ultrasound-guided nerve block, one of which was following the needle under real-time visualization as it

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AnesthesiologyNews.com I 25

TE CH N OL OG Y ‘We still don’t know what a dangerous intraneural injection looks like on ultrasound.’ —Richard Brull, MD

injected anesthetic inside nerves of roughly 60 patients without causing neurologic injury (Anesthesiology 2006;105:779-783; Anesthesiology 2009;110:1235-1243). “We still don’t know what a dangerous intraneural injection looks like on ultrasound,” Dr. Brull said.

study of 20 adult patients scheduled for ambulatory arthroscopic or open shoulder surgery receiving an ultrasoundguided ISB. For the first block, the needle tip was outside, but in contact with, the brachial plexus sheath, between C5 and C6. Based on whether a block was successful, for each consecutive patient, they increased the distance Horseshoes, Hand Grenades from needle tip to sheath by 2 mm. The ... and Nerve Blocks maximum effective distance to produce At the ASRA meeting (abstract 59), a successful block in 50% of patients Dr. Brulll and his colleagues presented a was 8.4 mm.

“We backed up and we backed up, and patients kept having successful blocks,” Dr. Brull said. Currently, he said, clinicians can conclude that ultrasound is better than nerve stimulator and paresthesia guidance in reliably determining how far away the needle is from the nerve. However, “ultrasound can’t really tell us precisely how close we are when we get into the danger zone, that is, what is too close to the nerve,” he said. —Kate O’Rourke

Rationale, Reversal, and Recovery of Neuromuscular Blockade Part 1: Framing the Issues advances toward the target (Reg Anesth Pain Medd 2009;34:40-46). “In reality, however, it is not quite straightforward. Four variables have to be in sync to reliably position the needle tip beside the target nerve,” Dr. Brull said. The machine has to reliably present the needle and the nerve to clinicians, while the clinician has to reliably interpret the image of the needle and the nerve. In a study in which investigators videotaped 520 nerve blocks, 93.6% were successful (Reg Anesth Pain Med 2007;32:107-115). The two most common errors were failure to visualize the needle before advancing it and unintentionally moving the probe. Clinicians often do not know the exact location of the needle tip, which is evidenced by reports of accidentally injecting anesthesia inside blood vessels and causing seizures, Dr. Brull said ( (Anesthesiology 2008;108:759-761). “The presentation of the nerve by the ultrasound machine is limited by the acoustic resolution of the machine, and we are not able to discern nerve microanatomy at this point in time,” Dr. Brull said. The thickness of the perineurium is approximately 5 microns—clinicians would need a microscope to see it. Over the years, various studies have suggested ways of confirming needle-tip position. Echogenic needles are likely the most useful solution so far, according to Dr. Brull. So, how close is too close when it comes to needle-to-nerve proximity? Researchers have intentionally

Case Study Harold is a 74-year-old man undergoing a video-assisted right upper lobectomy for stage I non-small cell lung cancer. Current Symptoms • Dyspnea • Coughing with hemoptysis • Chest pain Vital Signs • Height: 177.8 cm (70”) • Weight: 65 kg (143 lb) Signi¿cant Medical History • Hypertension • Chronic obstructive pulmonary disease (moderate) Current Medications • Metoprolol succinate ER 50 mg/d • Tiotropium bromide inhalation powder Laboratory Results • 2-cm lesion in right upper lobe revealed on chest computed tomography (CT) scan; malignancy con¿rmed with needle biopsy • No abnormal bronchopulmonary or mediastinal lymph nodes; brain CT, isotopic bone scan, abdominal ultrasonography negative for distant metastases • Forced expiratory volume in the ¿rst second: 43.6% of predicted value (1.44 L) • Carbon monoxide diffusing capacity: 71.7% of predicted values (20.19 mL/min/mmHg) • Cardiac ultrasonography: normal pulmonary artery pressure (22 mm Hg) At induction, Harold receives propofol 1.5 mg/kg and rocuronium 0.6 mg/kg. During the procedure, movement of the diaphragm interferes with surgery. This activity is jointly sponsored by Global Education Group and Applied Clinical Education. Supported by an educational grant from Merck.

Applied Clinical Education is pleased to introduce a new interactive 3-part CME series featuring challenging cases in neuromuscular blockade. Each activity will present a clinical scenario that you face in your daily practice. After reading the introduction to the case, consider the challenge questions, and then visit www.CMEZone.com/nmb1 to ¿nd out how your answers stack up against those of our multidisciplinary faculty panel. Access the activities on your desktop, laptop, or tablet to explore the issues surrounding safe, effective, neuromuscular blockade and reversal via a unique multimedia learning experience and earn 1.0 AMA PRA Category 1 Credit.™ Participate in the coming months as well to complete the whole series and earn a total of 3.0 AMA PRA Category 1 Credits.™ This activity’s distinguished faculty Jon Gould, MD Glenn S. Murphy, MD Chief, Division of General Surgery Alonzo P. Walker Chair in Surgery Associate Professor of Surgery Medical College of Wisconsin Senior Medical Director of Clinical Affairs Froedtert Hospital Milwaukee, Wisconsin

Clinical Professor, Anesthesiology University of Chicago Pritzker School of Medicine Director Cardiac Anesthesia and Clinical Research NorthShore University HealthSystem Evanston, Illinois

Challenge Questions 1. What would you do next? 2. What potential postoperative risks does this patient face?

Access this activity at www.cmezone.com/nmb1

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Smart Pump Launches Require the Whole Team Chicago—The launch of a new smart pump system should be a multidisciplinary effort, according to Erick Borkowski, PharmD, who has spearheaded such efforts as the manager of the Pharmacy Department at Northwestern Lake Forest Hospital (NLFH), in Illinois. In a presentation at the Hematology/ Oncology Pharmacy Association’s (HOPA) fall conference, Dr. Borkowski described how NLFH, in the process of launching its second smart pump system, learned how to plan more effectively based on the implementation of its first system more than four years ago. “It is critically necessary to engage everyone in the planning for the implementation,” he stressed, “so that everyone who works with the pumps plays a part in the implementation and maintenance process. I don’t think that was done the first time out. … Pharmacy alone did most of the planning, and we think that’s one of the reasons why nursing’s compliance with the pumps consistently averaged just over 50% and never exceeded 55% no matter what we tried.” In contrast, NLFH’s new smart pump system went live April 30, and it has been much more successful. “Compliance has been averaging 92% for the past three months,” Dr. Borkowski said. The implementation was made significantly easier, he added, because NLFH’s parent, Northwestern Memorial Hospital (NMH), in Chicago, had been using the same pump system for over five years. “There were a lot of things they had gone through that we were learning from.” For example, NLFH was able to leverage the library build that had been completed at NMH when they implemented their smart pumps, Dr. Borkowski noted. “Moving to a consolidated library within the pumps was a lot easier than it would have been without that earlier work.” Work that NLFH had done to standardize IV concentrations during their electronic medical record (EMR) conversion aided in the implementation of the new smart pumps. But NLFH did have to create a pediatrics database for the library from scratch because it was not part of NMH’s library. “Building a new pediatric library allowed us to scrutinize our current library as well as ensure that all orderable medications were available in the pump,” Dr. Borkowski said. “That was one of the biggest lessons we learned and one of the biggest

‘Whenever possible, we try to implement ... strategies for addressing drug library issues to make it difficult for nursing to program the entry incorrectly.’ —Wyndie Tse, PharmD improvements we made,” he said. Before the changes, “medications that were to be delivered by infusion would be in our EMR, but they might not have had analogous entries in the drug library for the pumps. So we made sure that if it could be ordered in the EMR, the corresponding medication also would be in the pump. That helped enhance compliance tremendously.” A great deal of the team’s time was focused on deciding what the dose range limits should be. “We wanted to make sure the limits were within reason from the nurse’s point of view,” Dr. Borkowski said. “We wanted to know what the nurses wanted to be able to see and do in the system.” In planning for the implementation, NMH’s pharmacy programmers developed processes that struck a fine balance between rules to ensure that an infused medication would be “safe” for the patient and rules that were not “overly restrictive,” for example, creating alarms when nurses tried to infuse a drug as a special procedure under circumstances that made that exception appropriate. “We tried to set alert limits in the software that would make alarms meaningful but with enough of a buffer that nuisance alarms weren’t being set off.” NMH and NLFH update the pumps quarterly, with pharmacy and nursing sharing information to try to ensure that all pumps are updated effectively. The Pharmacy Department also shares reports with nurses frequently to stay on top of issues and continually searches for new ways “to make it easy to use the pumps.”

In another presentation, Wyndie Tse, PharmD, a medication safety pharmacist at City of Hope National Medical Center, in Duarte, Calif., described ways for pharmacy to take a “proactive role” in smart infusion pump optimization. By “managing infusion pump data and evaluating smart pump alerts to identify potential drug library improvements, creating tools for nursing education and coordinating library updates with nursing,” she said, pharmacists can help enhance pump use. At City of Hope, the pharmacy now has the primary responsibility for analyzing smart pump utilization data to identify issues that need improvement. One problem area identified through the continuous quality improvement (CQI) review was that a significant number of nurses were overriding the duration limit for mycophenolate mofetil. Many nurses were confused by information on the patient label, which listed a diluent volume and a final volume. The nurses were entering the wrong volume when programming the pump. “It was a case of the label saying one thing and the software another,” said Dr. Tse, “so the nurses’ misinterpretation of that caused an alert to fire. The solution was to create prebuilt entries in the drug library software that made it unnecessary for the nurses to program volume.” The result was that the drug “fell off our top 5 override list” and error alerts decreased, she said, adding, “Whenever possible, we try to implement high-leverage strategies for addressing drug library issues to make

it difficult for nursing to program the entry incorrectly.” To begin the drug library updating process, Dr. Tse said she looked at “best practice guidelines for smart pumps—which included a review of our formulary to see what drugs were missing from our library and needed to be added—as well as reviewed CQI data, internal medication event reports involving infusion pumps and nursing staff feedback.” Quarterly internal compliance audits implemented starting last spring revealed that although compliance with the library to infuse medications met the 90% goal, compliance using the library to infuse hydrations was around 70%, Dr. Tse said. “By conducting the real-time audits,” she said, “we learned that nursing was not aware that hydrations should infuse using the fluid section of our library, which has rateprotectedd limits. In this case, education was very important.” Another best practice recently implemented at City of Hope is that pharmacy now coordinates library updates with nursing, rather than leaving the lead role responsibility to nursing alone. “Now pharmacy and nursing are equal partners, and the advantage is that process improvement changes will get done consistently and in a timely manner. “One of the lessons we learned is that you cannot set a smart pump and forget about it. We had been updating our library every one to two years before 2012. The recommendation from the [Institute for Safe Medication Practices] Summit on the Use of Smart Pumps is to update a minimum of quarterly. So we were a little bit behind. Now we are updating our library two to three times a year, so we are moving in the right direction.” City of Hope is a wireless environment, and Dr. Tse stressed that in optimizing smart pumps, hospitals have to keep in mind that “even in a wireless environment, there is still a significant investment of nursing time in performing the library update.” The drug library cannot be updated while the pumps are actively in use, she noted. “So pumps need to be powered off, turned back on and then the nurses need to select a new patient in order to receive the new library.” Many nurses did not realize they had to select a new patient to finalize the update. “So that was an education tip we emphasized to solve this issue, and it has [worked].” —Liz Parks

DECEMBER 2013

AnesthesiologyNews.com I 27

The following advertorial has been provided by Olympus and is intended to support the advertisement presented below.

Olympus and Fiber-Optic Intubation In airway management, Olympus has been focused on flexible fiber-optic intubation (FOI) endoscopes, offering a solution for difficult cases in which direct laryngoscopy and video laryngoscopes cannot complete the task of intubation. The Olympus products filling this niche are flexible fiber-optic and video endoscopes such as the LF Intubation Series, MAF Intubation Series and the new HD bronchoscopes. The introduction of the portable MAF allows the anesthesiologist to deal with any intubation, anywhere, anytime, resolving routine and difficult cases in the operating room, emergency room, ICU and on the wards.

emergency into a manageable event. Olympus portable intubation endoscopes can be there at a moment’s notice.

Q. What makes the new Olympus portable MAF intubation endoscope the right portable FOI solution? A. There are a number of characteristics that make it the right solution: • Thin design for intubation: The small

4.1-mm insertion tube diameter on the MAF-GM makes it ideally suited for intubation. It provides a path into the airway for ETT placement. • Versatile design: Equipped with a 5.2mm insertion tube and 2.6-mm diameter working channel, the MAF-TM can support suction, BAL and instrument use. • Visual confirmation during

placement: Featuring a 2.5-inch monitor, the MAF endoscope offers portable visualization of tracheal anatomy during endotracheal intubation. • Portable recording: The MAF-GM/TM’s recording device allows capture of still images and movie recordings, as well as image management.

Q. How can I schedule an evaluation? A. Visit medical.olympusamerica.com or call (800) 401-1086.

Q. How is FOI improving safety and efficiencies in treatment? A. Difficult intubation and failed intubation situations are unpleasant and they need to be addressed immediately. When no other intubation system is successful, it is usually the versatility of FOI that works. The new portable MAF intubation endoscope offers clear video imaging and FOI security.

Q. How is FOI improving procedure outcomes for patients? A. Portable intubation systems are available on the wards and in the emergency room for situations that need rapid response. Not only do FOI endoscopes intubate, but LF-TP and MAF-TM can suction and deliver therapeutic devices. For thoracic procedures on the lung such as lobectomy, wedge resection and biopsy, a special type of intubation is required. In this case, a double-lumen endotracheal tube is used for differential lung ventilation. During this procedure, the fiberscope is used to check the position of the bronchial lumen to ensure it is inserted properly into the lung to be collapsed. The fiberscope is used at the beginning of the procedure to place the tube but also during the operation to confirm that the bronchial lumen remains in the correct position, because these tubes tend to shift due to repositioning of the patient during the procedure.

Q. How is FOI reducing procedure time and costs? A. Normal intubations take seconds to complete and are routine procedures in the OR. Resolution of a difficult intubation is the difference between seconds and a Code Blue. FOI, in the hands of an experienced anesthesiologist, has the ability to turn a possible

MAF AIRWAY MOBILESCOPE A Versatile, Mobile Device for Difficult Intubation to be used in the OR, ER, ICU — Anywhere, Anytime.

For additional information scan here.

For more information, visit us at Olympus booth #326 at the 67th Annual PGA Assembly, December 13–17, 2013, New York, NY or call 800-548-5515 to speak to a sales representative © 2013 Olympus America Inc. Trademark or Registered Trademark of Olympus or its affiliate entities in the U.S. and/or other countries of the world. All patents apply. AD809-1112

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Ear Acupressure Eases PONV After Knee Surgery San Diego—Like its cousin acupuncture, acupressure also seems to have a place in modern anesthesiology, according to a study by a team of New York City researchers. The group found that auricular acupressure significantly decreases postoperative nausea in the postanesthesia care unit (PACU) and within the first 24 hours after general anesthesia for knee arthroscopy. “Postoperative nausea and vomiting [PONV] can be the cause of a prolonged PACU stay, increasing costs and decreasing efficiency,” said Cynthia L. Feng, MD, clinical assistant professor of anesthesiology at New York University Medical Center, who helped conduct the study. “Other studies have found acupuncture and manual acupressure to be efficacious in decreasing PONV, but they didn’t [assess] auricular acupressure.” Awake patients may perceive acupuncture to be uncomfortable, making acupressure a desirable alternative, she said. A total of 150 patients participated

in the prospective, ranandomized doubleblind study; all were nonsmokers at high risk for PONV and had a history of postoperative nausea/emesis and/ or motion sickness. Pregnant and lactating women were excluded, as weree chronic opioid users, patients with diabeh tes and those with an American Societty of Anesthesiologists surgical status of 3 or greater. Patients were randomomized to a test group (n=50) who received pellets attached to the ear at three points—zero, shenmen and subcortex—using an opaque adhesive; a sham group (n=47); or a placebo group (n=53).

“II chose these t points because they’ve been shown to decrease anxietty, pain and nausea,” Dr. Fengg explained. “Point zeero is the point that helps decrease [gastroh intestinal] stimulation. The shenmen point is to help decrease anxiety. And the subcortex point helps decrease anxiety and also has anti-nausea and antieemetic effects.” The sham cohort receeived pellets placed 5 mm ffrom the test points. The plaacebo group received the opaquue adhesives without the acupressure acupressu pellet. Patients then underwent knee arthroscopy under general anesthesia. Patients reporting persistent nausea and/or vomiting received 4 mg of IV ondansetron as rescue medication. As Dr. Fengg reported at the 2013 annual meeting of the International Anesthesia Research Society (abstract S-24), patients in the test group had significantly less nausea than those in the placebo group (P=0.000) in the

PACU and the first 24 hours after surgery. Patients in the sham group also reported significantly less nausea than those in the placebo group (P=0.033), although to a lesser extent. “We also measured other parameters, including pain and emesis,” Dr. Fengg said. “And even though they were lower in test-group patients, the difference wasn’t statistically significant.” Dr. Fengg said she didn’t include patient satisfaction data in the study. “But anecdotally, our patients were very happy. They felt that they were being proactive in preventing their postoperative nausea and we got very positive feedback,” she said. “Obviously there are some deficiencies in the study,” including failure to conduct a univariate analysis and the researchers’ failure to collect data on patient satisfaction, said Girish P. Joshi, MD, director of perioperative medicine and ambulatory anesthesiology at Parkland Anesthesiology and Pain Management, in Dallas. “But this is a very good start, and sheds some light on a noninvasive way to treat postoperative nausea and vomiting.” —Michael Vlessides

Combo Regimen Reduces PONV After Bariatric Surgery

ME/ /AnesthesiaC e m c ff e /j u d .jefferson.e ttp://jeffline

ombining different classes of antiemetic drugs is an effective way to decrease postoperative vomiting, according to a recent study by Philadelphia researchers. Patients who received aprepitant (Emend, Merck) and ondansetron after weight loss surgery, were less likely to experience postoperative vomiting than those who received ondansetron alone, although there was no change in the rate of postoperative nausea. “If you evaluate all patients having surgery, about 30% will have a problem with postoperative nausea and vomiting [PONV],” said Ashish Sinha, MD, PhD, professor of anesthesiology and perioperative medicine at Drexel University, who helped conduct the study. Vomiting after bariatric surgery is particularly concerning because it can stress the fresh suture lines on the stomach.

In the randomized, double-blind trial, clinicians treated patients with 40 mg of aprepitant orally (n=64) or administered an oral placebo (n=60) one hour after bariatric surgery. All patients received 4 mg of IV ondansetron to treat PONV. Investigators asked patients to assess nausea on a 10-point scale at seven intervals after surgery, from 30 minutes to 72 hours. During this time, clinicians recorded all occurrences of vomiting. Aprepitant significantly decreased the incidence of vomiting compared with placebo (3% of patients compared with 15%, respectively; P=0.02), although there was no difference in the assessment of nausea between the two groups. Dr. Sinhaa presented the results at the 2013 meeting of the American Society of Anesthesiologists (abstract 2300). see combo page 37

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AnesthesiologyNews.com I 29

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

Palpation Effective for Confirming ETT Placement

ometimes it just feels right. Using tracheal palpation to help place a breathing tube in pediatric patients is a safe, simple and effective method of confirming correct placement, Canadian researchers have found. The study, by a group from the University of Saskatchewan, in Saskatoon, found that tracheal palpation is a fast, accurate and virtually free way of determining when an endotracheal tube (ETT) is in the correct place— while obviating the need for ionizing radiation from imaging tests, said Jonathan Gamble, MD, who helped conduct the study.

98% proper placement with palpation method, versus 84% with PALS method. “We noted that in the operating room, nurses would often confirm ETT placement by feeling the neck, and so with a little research we found that we could replicate the method with reliable results,” Dr. Gamble said. Proper placement of an ETT is key to sufficient oxygenation during surgery, in critical care units or other hospital settings. If the tube is placed too high in the trachea, patient movement could result in accidental extubation. If placed too deeply, the tube may proceed past the point of tracheal bifurcation, resulting in oxygenation of only one lung. The usual clinical practice for placing an ETT relies on an age-basedd measurement formula from the Pediatric Advanced Life Support (PALS) guidelines, which may be used in conjunction with confirmatory techniques, including listening for lung sounds and xx ray. y “We don’t have an ideal way to confirm proper placement,” Dr. Gamble said. “Lung sounds can be inaccurate, and x rays are time-consuming, costly and xexpose young patients to ionizing radiation, adding to their lifetime exposure burden of this cancer-causingg energy.” Dr. Gamble and his colleagues examined the use of tracheal palpation to confirm proper ETT placement in 50 children, aged 2 to 10 years, who were undergoing elective surgeries requiring intubation. Using the suprasternal notch as a guide, investigators placed three fingers side by side upward to feel the ETT as it was advanced until it could be felt at the sternal notch. Investigators reported whether they were able to feel it “strongly,” “weakly” or

“not at all.” Final placement of the tube was confirmed by bronchoscopy. In 46 children, clinicians could feel the ETT strongly; in the remaining four, it was weakly felt, and the method led to correct ETT placement in 49 of 50 cases (98%). These results compare favorably to PALS-assisted placement, which has an average success rate of 84%, Dr. Gamble said.

“What this study has done is quantify the benefits of a method of placement confirmation that was first described in the 1800s,” said John E. Fiadjoe, MD, assistant professor of anesthesiology and critical medicine at the Children’s Hospital of Philadelphia. “This is the first systematic validation of the technique, which is what makes it useful and interesting.”

Many institutions currently use ETTs with a balloon on the leading end, which can be felt at the sternal notch in a technique similar to tube palpation. This method has been found to be sensitive for correct ETT placement in adult patients, but its use has not been systematically studied or validated in pediatric patients. “It is always see ETT page 34

CONTINUING MEDICAL EDUCATION

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

DECEMBER 2013

Lesson 307: Management of the Adolescent Patient With Complex Regional Pain Syndrome WRITTEN BY:

PROFESSIONAL GAPS:

Annie Lynn Penaco, MD Anesthesiology Resident Department of Anesthesiology Montefiore Medical Center Bronx, New York

Although most anesthesiologists and pain management specialists are aware of CRPS as a chronic condition in adults, existence and therapy in children are less well known. Only recently has the extent to which this crippling problem may occur in the pediatric population been realized.

Veronica Carullo, MD, FAAP Director, Pediatric Pain Management Montefiore Medical Center Assistant Professor of Anesthesiology & Pediatrics Albert Einstein College of Medicine Bronx, New York

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.

CALL FOR WRITERS

CASE HISTORY

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

LEARNING OBJECTIVES: At the end of this activity, the reader will be able to: 1. Recognize the signs and symptoms that support the clinical diagnosis of complex regional pain syndrome (CRPS). 2. Summarize the International Association for the Study of Pain (IASP) diagnostic criteria for CRPS. 3. Differentiate between CRPS types 1 and 2. 4. Recognize the differences in characteristics between adult and pediatric CRPS. 5. Describe the different stages of CRPS. 6. Review the epidemiology and theories on the pathophysiology of CRPS. 7. Understand the multidisciplinary stepwise approach to disease management. 8. Identify commonly used pharmacologic treatments available for CRPS. 9. Discuss the psychological techniques used in the treatment of CRPS. 10. Outline the prognosis for pediatric CRPS.

DISCLOSURE: The authors, editor, and reviewer have declared no conflict of interest related to financial disclosures, research, and written presentation of this manuscript.

An active 14-year-old girl with no significant past medical history was referred to a pain center with a complaint of left foot pain of several months’ duration. The pain developed gradually without any significant history of trauma, although she vaguely recalled falling off her bike a few days before the onset of symptoms. The pain involved the dorsal and plantar aspects of the left foot and was described as a constant, sharp, burning sensation, exacerbated by movement and light touch. She was able to ambulate initially but within days was unable to bear weight due to excruciating pain. The patient initially presented to her pediatrician with mild swelling and severe pain involving her left foot. She reported that her foot turned purple or red for periods throughout the day. She also reported that she had difficulty wearing a shoe on the affected foot and reported difficulty with ambulation. On physical examination, the patient displayed an antalgic gait, an adaptive mechanism to reduce weight bearing on the painful extremity. The patient’s left foot appeared erythematous with localized edema up to the level of the ankle and was markedly colder than the right. Range of motion of the ankle was limited secondary to pain. Strength was intact and equal bilaterally. Plain films of her left foot were performed and found to be unremarkable. The left ankle was then immobilized in a boot for a presumed ankle sprain. When her symptoms failed to resolve after 2 weeks, the patient was referred to an orthopedist. A magnetic resonance imaging scan was performed, which also was negative. A bone scan was then performed, which was essentially normal except for mild changes in blood flow to the affected foot. The patient was then referred to a neurologist. Hyperalgesia to pinprick was elicited throughout her left foot but otherwise neurologic examination was unremarkable. Nerve conduction studies also were within normal limits. At that point, the patient had missed many days of school and expressed immense sadness and frustration at her pain and disability over the preceding months. The patient was referred to the pediatric pain management division for further evaluation and treatment with a presumptive diagnosis of CRPS.

Introduction

RPS is characterized by persistent pain, sensory and motor impairment, and regional autonomic dysfunction.1 Although symptoms vary from patient to patient, the main characteristic of CRPS is the presence of pain disproportionate to an inciting event or, in some cases, the absence of trauma.2 The symptoms often occur in an extremity and do not follow a dermatomal distribution. Patients frequently describe the pain as sharp or burning

PREANESTHETIC ASSESSMENT Dr. Elizabeth A.M. Frost, who is the editor of this continuing medical education series, is clinical professor of anesthesiology at the Icahn School of Medicine at Mount Sinaii 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 September 30, 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: December 1, 2013 TERMINATION DATE: November 30, 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.

with associated hyperalgesia (increased sensitivity to a noxious stimulus), paresthesia (abnormal sensation), dysesthesia (unpleasant abnormal sensation), or allodynia (pain from a stimulus that normally does not provoke pain).3 This constellation of symptoms is accompanied by evidence of findings related to the autonomic nervous system including blood flow and temperature changes, diffuse edema, increased sweating, and abnormal hair growth.3 If untreated, patients with CRPS can develop muscle atrophy;

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.

CONTINUING MEDICAL EDUCATION

DECEMBER 2013

bony changes such as bone demineralization, and contractures may occur (Figure 1). CRPS was first described during the American Civil War by Silas Weir-Mitchell, a student of Claude Bernard, and initially referred to using terminology such as reflex sympathetic dystrophy (RSD), reflex neurovascular dystrophy, causalgia, Sudeckâ&#x20AC;&#x2122;s atrophy, neuro-algodystrophy, and shoulder-hand syndrome. These pain syndromes now are considered variants of a single medical entity.4-6 CRPS is a relatively new diagnosis, first published by the IASP in 1994. However, it is increasingly being recognized and diagnosed. CRPS occurs as one of two types.2 CRPS type 1, previously referred to as RSD, develops without a definable nerve lesion and accounts for a majority of cases. CRPS type 2, originally referred to as causalgia, arises in the presence of an apparent peripheral nerve lesion. The incidence of CRPS in the pediatric population is not well defined. Once considered rare in children, probably partly due to underdiagnosis, CRPS now is thought to be both not uncommon and on the rise in this population. The peak age of onset occurs between ages 9 and 15 years,1 although CRPS has been diagnosed in children as young as age 3. CRPS in children and adolescents differs in many respects from adult CRPS (Table 1). Pediatric CRPS appears to have a greater female-to-male sex ratio. Significant trauma as a precipitating event is seen less frequently than in adults. Pediatric CRPS has a greater propensity for lower rather than upper extremity involvement, with a ratio of 5:1, and a predilection for the foot, than does the adult form of the condition.2 Children also exhibit a better response with a more favorable prognosis using noninvasive treatment modalities5 that focus heavily on physical therapy and cognitive-behavioral therapy.

Diagnosis CRPS remains a clinical diagnosis based on the appropriate findings on history and physical examination. However, CRPS is a difficult entity to diagnose due to clinical variability in presentation and clinical course. With these diagnostic challenges under consideration, a consensus group

Table 1. Adult Versus Pediatric CRPS: Several Marked Differences Have Been Identified Adults

Children/Adolescents

Sex predominance

Female > Male

Extremity involvement

Upper > Lower

Lower > Upper

Prognosis

Variable

Favorable

sponsored by the IASP was assembled to establish a set of uniform diagnostic criteria (Table 2).7 The clinical diagnosis requires the presence of chronic pain with neuropathic characteristics that are out of proportion to an inciting event and are accompanied by evidence of autonomic dysfunction. Furthermore, it is a diagnosis of exclusion whereby orthopedic, rheumatologic, neurologic, vascular, or other diagnoses that may explain the symptoms must be excluded. Although the applicability of the IASP diagnostic criteria to pediatric cases has not been extensively studied, their use aids in awareness and recognition of the condition to more effectively diagnose CRPS and to have an effect on long-term management. Unfortunately, no single diagnostic test for CRPS is available. Plain radiographs may support the diagnosis when findings including bone resorption, demineralization, or osteopenia are present.5 Three-phase bone scans also may aid in diagnosis; however, sensitivity often varies widely. In a retrospective study of children with CRPS by Low et al, the mean time to diagnosis was 13.6 weeks.5 Despite increasing recognition and awareness of the disorder, delay in diagnosis from 3 months to 1 year is not uncommon. Children and adolescents on average are seen by 2.7 specialists5 (including the fields of pediatrics, emergency medicine, orthopedics, neurology, and rheumatology) before receiving a referral to a pain specialist. These findings become more problematic in that later diagnosis and delayed treatment almost certainly correlates with poorer outcomes.

Stages Historically, CRPS has been described to progress in a sequential manner that can be classified into 3 distinct stages (Table 3). Stage 1 (lasting 1-3 months) represents the acute/traumatic phase, characterized by intense burning pain at the site of injury. Stage 2 (lasting 3-6 months) involves the dystrophic phase in which the affected area along with an area of distal spread worsens in the severity of pain as well as in the degree of skin changes. Stage 3, the atrophic stage, reflects extensive irreversible structural damage. Although the stages described attempt to delineate the natural progression of the disease, not all patients will progress in this manner. In fact, most cases of CRPS tend to remain stable rather than to deteriorate progressively.8

Pathophysiology

Figure 1. CRPS of the left lower leg. Note the redness, deformity, and swelling.

The pathophysiology of CRPS is not completely understood. Numerous theories including central neural causes, peripheral neuropathy, and other mechanisms involving exaggerated inflammation of small nerve fibers have been implicated.6,9 CRPS also has more recently been thought to involve an abnormally prolonged and exaggerated response of the sympathetic nervous system to traumatic injury.

Table 2. International Association for the Study of Pain Diagnostic Criteria for CRPS (1994) 1. The presence of an initiating noxious event which may or may not be associated with immobilization. 2. Continuing pain, allodynia, or hyperalgesia disproportionate to inciting event. 3. Evidence of edema, changes in skin blood flow, or abnormal sudomotor activity. 4. The diagnosis is excluded by the presence of conditions which would otherwise account for the degree of pain or dysfunction. From: Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain. Seattle, WA: IASP Press; 1999: 118.

Management Early reports of children with CRPS that occurred with spontaneous resolution suggested that no treatment was warranted for such a self-limiting disease.5 However, more recent reports suggest the use of management techniques similar to those used in adults. A multidisciplinary approach to treatment is the mainstay of clinical management of the disease. Treatment programs often involve a combination of aggressive physical therapy, pharmacotherapy with neuropathic pain medications, and biobehavioral or psychological therapies. Although definitive resolution of symptoms may not always be achieved, the main goal is to recover the childâ&#x20AC;&#x2122;s functional state and to minimize the degree of longterm pain and disability.

Physical Therapy Although no single therapy has been found to be uniformly curative, physical therapy appears to be the primary modality that offers the greatest chance for resolution.7 Early mobilization and physiotherapy has proven beneficial in pain reduction and functional restoration. A study by Sherry et al in 1999, following 103 children in an intensive exercise program found initial resolution of symptoms in 92% of children and long-term resolution at 2 years in 88% of patients. The mean duration of exercise therapy was 14 days, a time span that decreased to 6 days over the 2-year period. Of those followed for more than 2 years, 43 (88%) were symptom-free; 15 (31%) of these patients had a recurrence, 5 (10%) were fully functional but had some continued pain, and 1 (2%) had functional limitations. The median time to recurrence was 2 months; 79% of the recurrences were during the first 6 months after treatment.1 Many practitioners support the notion that all other therapies may be prescribed simply for the facilitation of a physical therapy regimen. Physical therapy goals are

CONTINUING MEDICAL EDUCATION

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

Table 3. Stages of CRPS: Progression May Not Be Seen in All Patients Stage

Characteristics

Timing

I (acute phase)

Pain/sensory abnormalities (hyperalgesia/allodynia)

Within weeks of injury

II (dystrophic phase)

More marked pain/sensory abnormalities; development of 3-6 months after onset motor/trophic changes

III (atrophic phase)

Decreased pain; increased motor/trophic changes

typically achieved through an intensive outpatient physical therapy regimen. If outpatient treatment fails, referral to an intensive multidisciplinary day rehabilitation program or to an inpatient rehabilitation program should be made. A dayhospital interdisciplinary rehabilitation approach seems effective in reducing disability and improving physical and emotional functioning and occupational performance among children and adolescents with CRPS who have failed to improve with outpatient treatment.10

TENS Transcutaneous electrical nerve stimulation (TENS) also may be beneficial in easing chronic pain by applying electrical impulses to nerve endings in an affected extremity. TENS is a noninvasive therapy that is well tolerated by children and has been shown to be extremely safe to use, making the device a worthwhile component of an initial multidisciplinary treatment regimen.11

Pharmacotherapy Medical therapy in children with CRPS has not been studied in randomized trials and is derived from experience in adults, leading to a great deal of controversy as to what constitutes appropriate drug therapy. Proponents of intensive physical therapy argue that medications are not necessary and may lead to unnecessary potential side effects.1,2 Others begin conservatively with nonsteroidal antiinflammatory drugs (NSAIDs) and neuropathic pain medications in moderate doses to allow participation in a basic physical therapy program. Tricyclic antidepressants (ie, amitriptyline, nortriptyline, and desipramine) are prescribed widely for neuropathic pain. The chosen agent often is selected based on the development of side effects including insomnia and anticholinergic effects. Anticonvulsants (ie, gabapentin, carbamazepine, and clonazepam) also have proven extremely effective in neuropathic pain management. Newer drugs such as pregabalin (Lyrica, Pfizer) and duloxetine (Cymbalta, Eli Lilly) have been successfully used off-label in older children and adolescents. Other classes of medications used less frequently for CRPS include α- and β-adrenergic agonists, calcium channel blockers, systemic vasodilators, and bisphosphonates. Although opioids have been prescribed in the past for brief painful events, these drugs generally are not recommended for the treatment of neuropathic pain syndromes.

Psychological and Biobehavioral Therapies CRPS is frequently a psychologically related disease process and therefore the therapeutic approach must take this aspect of the syndrome into account. A review of children with CRPS by Stanton et al found that 83% revealed evidence of “significant emotional dysfunction” on psychological testing.2 More recently, Logan et al reviewed children

Within years after onset

with CRPS and found that as a group, clinic-referred children with CRPS may be more functionally impaired and experience more somatic symptoms compared with children with other pain conditions.12 Consequently, comprehensive assessment using a biopsychosocial framework is essential to understanding and appropriately treating children with symptoms of CRPS. Patients may have coexisting psychiatric conditions such as depression, anxiety, post-traumatic stress disorder, or somatoform illness, which interfere with the motivation to improve. These findings highlight the importance of a thorough psychological evaluation in CRPS patients in order to rule out comorbid psychiatric disease or psychological comorbidities and to treat them appropriately before pursuing more invasive management. Various psychological techniques such as cognitivebehavioral therapy (CBT) and biofeedback have been extremely useful in neuropathic pain management. CBT employs a variety of specific methods to reduce emotional distress and to mitigate the stress response, thereby reducing pain intensity. These techniques may involve the use of breathing exercises, progressive muscle relaxation, and imagery. Biofeedback, with monitoring of the body’s physiological stress response, also can be used in conjunction with CBT to direct the relaxation response through self-awareness. Relaxation-focused interventions effectively target pain management, stress reduction, school reintegration, and family functioning.13 Additional complementary techniques include problem solving and communication skills retraining. Structured individual and family counseling also aids in the development of appropriate coping mechanisms. Overall, the child can be empowered to use psychological resources to manage distress and contribute to decreased pain perception.

Sympathetic Nerve Blocks Sympathetic nerve blocks have gained an established place in the diagnostic and therapeutic management of intractable and recurrent pain due to CRPS.14 A subset of CRPS patients with sympathetically mediated pain (pain due to sympathetic efferent activity, circulating catecholamines, and increased sensitivity to α-adrenergic receptors), are excellent candidates for nerve blocks with local anesthetics. An IV Bier block entails venous drainage of an extremity, proximal placement of a tourniquet for approximately 30 minutes, and injection of local anesthetic into a distal vein. This technique provides total pain relief in some patients. Other alternatives include lumbar sympathetic blocks or epidural blocks in lower-extremity cases and stellate ganglion blocks or epidural blocks for upper-extremity involvement. Generally, continuous nerve block techniques are preferred over repeated single injections to allow for the administration of multiple doses and to minimize the

DECEMBER 2013

number of procedures and the exposure to radiation. Regional blocks are not only effective in controlling acute pain, but also are beneficial in facilitating physiotherapy and functional rehabilitation.

Neuromodulatory Techniques Children who fail to respond to the stepwise multidisciplinary approach may require more advanced techniques including spinal cord stimulation and sympathectomy, but only as a last resort if conventional therapies have been exhausted and have failed. Evidence suggests spinal cord stimulation can be helpful in adolescents with severe, incapacitating CRPS that is resistant to conventional therapy.15 Implantation of a spinal cord stimulator is a minimally invasive procedure, usually following trial stimulation with a temporary percutaneous device. Pain relief is achieved by electrical stimulation to the dorsal column of the spinal cord, which aims to inhibit painful input and cover the affected region with paresthesias without discomfort or motor dysfunction. Sympathectomy (chemical or surgical) also may be helpful in reducing sympathetically mediated pain, but this treatment is irreversible and generally reserved for cases involving impending loss of function.2 Chemical sympathectomy involves the injection of phenol into a sympathetic ganglion, aiming to destroy these nerve fibers. These procedures can prove to be problematic as patients typically get relief for a few weeks, only to have the pain return with greater intensity and covering a larger area of their body.

Recurrence Although CRPS in children has an excellent prognosis, patients remain at risk for recurrence particularly in the setting of any trauma or after a planned or unplanned surgical procedure. Preoperatively, patients with a history of CRPS can benefit from consultation with a pain management physician in order to thoroughly assess pain symptoms and behaviors, implement appropriate interventions such as preoperative neuropathic medications, and coordinate with anesthesiologists to select the optimal anesthetic for the surgical procedure. Generally, elective surgical procedures on an affected extremity are postponed as long as possible, until the signs and symptoms of CRPS have resolved. For individuals requiring urgent or emergency surgery, the use of regional techniques may prove advantageous. Furthermore, the value of multimodal analgesic techniques has been well supported, as this approach targets not just the surgical site, but also mitigates central nervous system hyperexcitability.16 The perioperative use of N-methylD-aspartate receptor antagonists such as ketamine and/or methadone also may improve postoperative outcomes. Use of these techniques, in conjunction with the early use of physical therapy and rehabilitation, makes the prevention of CRPS recurrence much more feasible.

Management of the Case Presented Upon thorough evaluation, a pediatric pain specialist confirmed a diagnosis of CPRS type 1. Multidisciplinary pain therapies consisting of pharmacotherapy with gabapentin, referral to physical therapy, and referral for CBT commenced immediately. Physical therapy focused on desensitization, lower-limb weight-bearing and fine motor skill retraining. Six weeks after treatment initiation, the patient reported moderate improvement of swelling and temperature changes of the foot, although significant pain

CONTINUING MEDICAL EDUCATION

DECEMBER 2013

was still present. At 12 weeks, the patient had full range of motion of the ankle and was able to ambulate independently. Despite continued pain, she was fully functional with no missed days of school. At 6 months, she reported resolution of pain. Three months after resolution of pain, gabapentin was slowly weaned. No recurrence of symptoms was noted at 1-year follow-up.

Conclusion Management of CRPS in the pediatric population presents unique and significant challenges to clinicians. Effective pain management begins with the understanding of the fundamental differences between adult and pediatric CRPS and its implications on clinical course and prognosis. Awareness of the signs and symptoms of CRPS and early diagnosis are of utmost importance in the management of this potentially debilitating pain disorder. Because physical therapy is regarded as the most effective therapeutic modality in CRPS management, the clinician’s primary goal should be to develop a stepwise, multidisciplinary approach to provide adequate analgesia to facilitate the rehabilitation process. Early mobilization with intensive physical therapy, in combination with appropriate pharmacotherapy to facilitate this regimen, reduces the degree of

pain and disability and subsequent development of musculoskeletal changes. Treatment begins with the least invasive modalities and advances as necessary. The potential for recurrence of CRPS also is of great concern. With this in mind, certain steps may be taken to minimize the risk for recurrence and to improve short- and long-term outcomes. Early referral to a pain specialist and implementation of a multidisciplinary therapeutic approach greatly assists children with CRPS in minimizing suffering and optimizing function.

References

Finniss DG, Murphy PM, Brooker C, et al. Complex regional pain syndrome in children and adolescents. Eur J Pain. 2006;10(5):767-770.

Bruehl S, Harden RN, Galer BS, et al. Complex regional pain syndrome: are there distinct subtypes and sequential stages of the syndrome? Pain. 2002;95(1-2):119-124.

Sherry DD, Wallace CA, Kelley C, et al. Short and long term outcomes of children with complex regional pain syndrome type I treated with exercise therapy. Clin J Pain. 1999;15(3):218-223.

10. Logan DE, Carpino EA, Chiang G, et al. A day-hospital approach to treatment of pediatric complex regional pain syndrome: initial functional outcomes. Clin J Pain. 2012;28(9):766-774. 11. Norris CF, Bingham PM, Butler RB, et al. Complex regional pain syndrome in pediatric patients with severe factor VIII deficiency. J Pediatr Hematol Oncol. 2001;23(9):620-622.

Goldschneider KR. Complex regional pain syndrome in children: asking the right questions. Pain Res Manag. 2012;17(6):386-390.

Stanton RP, Malcolm JR, Wesdock KA, Singsen BH. Reflex sympathetic dystrophy in children: an orthopedic perspective. Orthopedics. 1993;16(7):773–779.

12. Logan DE, Williams SE, Carullo VP, et al. Children and adolescents with complex regional pain syndrome: more psychologically distressed than other children in pain? Pain Res Manag. 2013;18(2):87-93.

Wilder RT, Berde CB, Wolohan M, et al. Reflex sympathetic dystrophy in children. Clinical characteristics and follow-up of seventy patients. J Bone Joint Surg Am. 1992;74(6):910-919.

13. Gold JI, Townsend J, Jury DL, et al. Current trends in pediatric pain management: from preoperative to the postoperative bedside and beyond. Semin Anesth Periop Med Pain. 2006;25(3):159-171.

Harden RN. Complex regional pain syndrome. Br J Anaesth. 2001;87(1):99-106.

14. Dadure C, Capdevila X. Continuous peripheral nerve blocks in children. Best Pract Res Clin Anaesthesiol. 2005;19(2):309-321.

Low AK, Ward K, Wines AP. Pediatric complex regional pain syndrome. J Pediatr Orthop. 2007;27(5):567-572.

Sethna NF, Meier PM, Zurakowski D, Berde CB. Cutaneous sensory abnormalities in children and adolescents with complex regional pain syndromes. Pain. 2007;131(1-2):153-161.

15. Olsson GL, Meyerson BA, Linderoth B. Spinal cord stimulation in adolescents with complex regional pain syndrome type I (CRPS-I). Eur J Pain. 2008;12(1):53-59.

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.

16. Reuben SS. Preventing the development of complex regional pain syndrome after surgery. Anesthesiology. 2004;101(5):1215-1224.

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

Post-Test 1.

Of the following, _____ best supports the diagnosis of CRPS. a. clinical history and physical exam findings b. laboratory testing c. plain radiographs d. 3-phase bone scan

_____ does not constitute one of the IASP diagnostic criteria for CRPS. a. Persistent pain out of proportion to an inciting event b. Evidence of autonomic dysfunction c. Exclusion of other diagnoses that may account for symptoms d. Evidence of bony changes such as demineralization

Which characteristic is more prevalent in pediatric CRPS compared with adult CRPS? a. Greater male-to-female ratio b. Greater lower extremity involvement c. Poor prognosis with noninvasive treatment modalities d. Precipitated by major trauma

Type 1 CRPS _____. a. was previously referred to as reflex sympathetic dystrophy b. was previously referred to as causalgia c. occurs in the presence of an apparent peripheral nerve lesion d. represents a minority of CRPS cases

Sympathetic nerve blocks _____. a. are the preferred primary treatment modality for most cases of CRPS b. do not provide any benefit in acute pain control c. include IV regional Bier blocks d. abolish the need for an intensive physical therapy program

Regarding CRPS staging, ____. a. stage 1 is characterized by minimal pain b. stage 2 is referred to as the traumatic phase c. stage 3 reflects extensive, irreversible damage d. a majority of patients follow this sequential progression

____ is the primary treatment modality that offers the greatest chance for resolution of CRPS. a. Physical therapy b. Medical therapy c. Psychological techniques d. Sympathetic nerve blocks

The class of medications successfully used in neuropathic pain management is _____. a. nonsteroidal anti-inflammatory drugs b. opioids c. steroids d. anticonvulsants

Which of the following is true regarding psychological treatment in CRPS? a. Psychological techniques such as cognitivebehavioral therapy are of limited value in patients with CRPS. b. Coexisting psychiatric illness must be evaluated for and treated in order to be able to address longterm treatment goals. c. Invasive disease management is first attempted before performing a comprehensive psychological assessment. d. Patients with comorbid psychiatric illness often manage pain and distress more adeptly than those without.

10. CRPS recurrence _____. a. occurs at one point in all patients diagnosed with CRPS b. may be precipitated by subsequent trauma c. is not affected by scheduled surgical procedures d. is intractable and refractory to conventional treatment

34 I AnesthesiologyNews.com

DECEMBER 2013

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

Falls a Rising Trend in Trauma-Related Fatalities

rauma centers in the United States are experiencing a major shift in the most common causes of trauma-related fatalitiesâ&#x20AC;&#x201D;changes that may necessitate new strategies for trauma prevention and treatment, according to experts. A new study showed that, if current trends continue, falls would soon account for more deaths than

either motor vehicle collisions or firearms. â&#x20AC;&#x153;This fact poses an interesting public health challenge, namely, preventing falls in the elderly,â&#x20AC;? said Christopher C. Baker, MD, chair of surgery at the Carilion Clinic in Roanoke, Va. He was the official discussant of the paper when it was presented at the opening session of

the 2013 annual meeting of the American Association for the Surgery of Trauma (AAST). The study showed that since 2002, deaths due to motor vehicle collisions have declined by 27% due to improvements in car safety, public awareness and medical care. But that drop has been offset by a marked increase in fatalities related to falls,

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the rate of which rose by 46% over an eight-year period. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s clear that the mix of injuries that are currently being seen are substantially different than 10 years ago,â&#x20AC;? said primary investigator Kristan L. Staudenmayer, MD, MS, assistant professor of surgery in trauma and critical care at Stanford University, in Stanford, Calif. Total trauma-related mortality decreased by 6% between the years 2002 and 2010 (P<0.01). The drop occurred despite an increase in the number of miles driven by Americans and a 10% increase in the number of firearm injuries. Researchers from Stanford examined different data sources for the years ranging from 2002 to 2010: the American College of Surgeonsâ&#x20AC;&#x2122; National Trauma Data Bank and the Centers for Disease Control and Preventionâ&#x20AC;&#x2122;s (CDC) National Center for Injury Prevention and Control and its Web-based Injury Statistics Query and Reporting System (WISQARS). The researchers used the Cochranâ&#x20AC;&#x201C;Armitage test for trend to analyze mortality trends by year. In 2002, motor vehicle collisions caused about 16 deaths per 100,000 people living in the United States. In the same year, falls caused only about six deaths per 100,000 people. But by 2010, the picture changed markedly. Falls caused almost nine deaths per 100,000 people, whereas motor vehicle deaths had fallen to 12 per 100,000. Deaths from firearms stayed relatively stable between 2002 and 2010 at 10 per 100,000. Firearm injuries were seen more frequently in hospitals, increasing from a reported 31 to 34 per 100,000 people.

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important to do a specific pediatric study,â&#x20AC;? Dr. Fiadjoe noted. â&#x20AC;&#x153;Our pilot study demonstrates that the palpation technique is a robust method for determining proper tube placement,â&#x20AC;? Dr. Gamble said. â&#x20AC;&#x153;Going forward, we would like to extend this research to look at younger children,, whose smaller anatomy makes proper placement all the more delicateâ&#x20AC;&#x201D;and critical. Additionally, we think the tech-nique requires little training for staff to become proficient, but this, too, needs to be studied.â&#x20AC;? â&#x20AC;&#x201D;Keelyy Savoie

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AnesthesiologyNews.com I 35

CL IN ICA L A N E STH E SIOL OG Y The study was not designed to examine variables like patient frailty or age. Even so, the results strongly suggest that the demographics of patients arriving in trauma bays have changed. Today, trauma patients are older and sicker than a decade ago. Dr. Staudenmayer said the changing demographics of patients need to be taken into account when apportioning future trauma resources and creating prevention strategies. “The big challenge is that we are going to be dealing with patients who are more frail and have more comorbidities. That’s going to mean that we have to provide not just surgical care, but increasingly more medical care to these patients,” Dr. Staudenmayer said. “As our population ages, we’re going to have to adjust our resources appropriately and keep close tabs on the trends in trauma-related mortality so we can continue to calibrate our resources against the needs of the population,” she added. The study confirmed earlier reports that deaths from motor vehicle collisions occur less frequently. Accidents that resulted in injuries also declined, with fewer injuries per accident in 2010 compared with 2002. This study was the first analysis of national trauma trends using these multiple data sources and the first analysis of its kind that depicted what trauma surgeons are seeing in their emergency rooms, according to the authors. Experts noted that the study had several significant limitations. The study investigators made comparisons

across four different data sets, but each data set had its own limitations and methodologies. Moreover, investigators could not identify the number of patients who did not seek or receive treatment, nor could they discern the frailty of patients before injury. Deaths from burns, drowning, poisoning, suffocation and adverse effects were excluded from the study. —Christina Frangou

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36 I AnesthesiologyNews.com

DECEMBER 2013

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

Liposomal Bupivacaine Boosts TAP Block

nesthesiologists may have an effective new anesthetic at their disposal for 72 hours or more of postoperative pain relief. Liposomal bupivacaine (Exparel, Pacira) has been found to be effective for postoperative pain relief following surgical procedures involving incisions of the mid- and lower abdominal wall, according to the results of a study

presented at the New York School of Regional Anesthesia (NYSORA) 2013 annual meeting on regional anesthesia, pain management and perioperative medicine. The study found that the drug, a recently approved extended-release form of liposomal bupivacaine, provided pain relief for up to 72 hours after surgery when injected by

infiltration of the transversus abdominis plane (TAP), along the fascial planes of the abdomen. Previously, using bupivacaine for TAP infiltration was found to provide pain relief for 12 to 18 hours after surgery involving incisions of the mid- and lower abdominal wall. “The results were confirmatory of what we had expected,” said Eduard

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Logvinskiy, DO, a pediatric anesthesiologist at Maimonides Medical Center, in New York City, who helped conduct the study. “We just didn’t know how well it was going to work. We thought it wouldn’t last that long—about a day— but it lasted about three days in most of the patients.” Three patients required oral analgesia within the first 12 hours or surgery, and three others reported taking pain medication 24 hours after discharge from the hospital, Dr. Logvinskiyy said. For their study, Dr. Logvinskiyy and his colleagues selected 13 patients undergoing open umbilical hernia repair under general anesthesia, with an incision length between 3 and 12 cm. Using ultrasound guidance, a bilateral TAP infiltration was performed at the end of surgery, but before the general anesthesia wore off. The patients were first injected with 5 mL of saline to identify the TAP. That was followed by 20 mL of liposomal bupivacaine that had been diluted with 10 mL of sterile saline, for a total injectate volume of 30 mL, 15 mL of which was injected into each patient on either side of the TAP. The patients, who ranged in age from 28 to 65 years, reported their level of pain on a scale of 0 to 10 before the injection and after, at regular intervals up to 120 hours after TAP block. “We also made daily phone calls up to four days post-op as part of their follow-up. The forms were submitted at the time of their surgical followup approximately two weeks later, and later were forwarded to our department,” Dr. Logvinskiyy said. Although one TAP infiltration failed immediately due to significant pain, the remaining 12 were successful, with mean satisfaction scores of 4.4 at discharge and 4.6 at the follow-up visit. The patients reported an average pain

DECEMBER 2013

AnesthesiologyNews.com I 37

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

CONTINUED FROM PAGE 28

Several factors contribute to aprepitant’s therapeutic value, according to the researchers. Aprepitant targets neurokinin-1 receptors in the brain, f life ranges from and the drug’s halfnine to 13 hours. Ondansetron, on the other hand, is a 5-HT3 receptor antagonist with a shorter halff life of four to six hours. One concern, however, is the drug’s cost. Generic ondansetron costs about $1 or less for a 4-mgg dose; a dose of aprepitant can cost patients on Medicare between $30 and $60. Dr. Sinha said he “did not expect to see synergy to this extent” when administering ondansetron and

score of 1.6 at 72 hours after the TAP infiltration, with a standard deviation of 1.4. None of the patients reported any serious adverse events or complica-tions as a result of the drug, according to the researchers. “This study demonstrates the excel-lent efficacy nonopioid analgesics can provide with minimal to no side effects,” said Christopher Gharibo,, MD, director of chronic pain management at New York University’s Lan-gone Center for Musculoskeletal Care in New York City. “The benefits here are cleaner, more functionally relevant pain relief that is also more convenient for the patient.” However, Dr. Gharibo, who was not involved in the study, had reservations about the study, noting that it had few w patients and lacked a control group. Dr. Logvinskiyy and his colleagues acknowledged that their study was not a randomized controlled trial. “We basically wanted to see if this would actually work,” he said. The results further suggest that nerve blocks have the potential to sup-plant local anesthetics for postsurgical pain relief for surgeries involving inci-sions of the abdominal wall between 3 and 12 cm. “As of now, we apply local anes-thetic for postoperative analgesia,”” Dr. Logvinskiy said. “With nerve blocks we insert catheters next to the bundle of nerves, connected to con-tinuous infusion pumps, where we insert medication. We have the associ-ated costs of filling the pumps, creat-ing the solution, nursing care—which can potentially be eliminated if you’re using a drug like liposome bupivacaine,, with a single injection.” Pacira funded the study. —Ajai Ajai Raj

aprepitant. “The drop [in postoperative vomiting] from 15% to 3% is impressive, and both statistically and clinically significant.” Less impressive, however, was the effect on nausea. “Some people believe that nausea and vomiting are entirely different entities, with different mechanisms,” Dr. Sinha said, “even though they tend to get lumped together.” Because aprepitant is an oral medication, Dr. Sinhaa said clinicians might hesitate to administer the drug before

surgery. But he likened an oral dose of aprepitant to a β-blocker, taken with a small sip of water, which is not contraindicated in the morning before surgery and might enhance patient recovery. “This protocol is safe and effective,” Dr. Sinha said, who received funding from Merck for the study. “We hope more and different surgical patients will benefit from this approach.”

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DECEMBER 2013

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What’s in a Word? ‘Anesthesia’ From Ancient Greece to 1846, and Beyond

ave you ever thought about the origin of that word you say so often, “anesthesia”? Like many English words, this one has a long and complicated history. In April 1755, Samuel Johnson’s monumental A Dictionary of the English Languagee was finally published; the Englishman had been working on it since signing the contract in 1746. Johnson’s dictionary was hardly the first such work in English, but it remained the most authoritative until the Oxford English Dictionary (OED) was finally completed in 1928. But the word “anaesthesia” did not appear in Johnson’s dictionary; it was in limited use in English at the time. The word had appeared in several Englishlanguage dictionaries before Johnson’s, including Phillips’ The New World of Words: or, Universal English Dictionary (6th ed., 1706), followed by Bailey’s Universal Etymological English Dictionary (1721); James’ Medical Dictionary (1743); and the New and Complete Dictionary of Arts and Sciences (1754). The word also was known to Western readers in Latin. On July 20, 1718, Johann Bernhard Quistorp (1692-1761) appeared in the great auditorium at the University of Rostock, in Germany, to submit to a public examination of his doctoral thesis, “De Anaesthesia.” Written in Latin, Quistorp’s dissertation was published in the same year. The work was translated into English by Ray J. Defalque, MD, in 1999. The only known appearance of the word in modern Western literature before Quistorp other than in Phillips’ 1706 dictionary was in Castelli’s “Lexicon Medicum Graeco-Latinum” published in 1713; his definition was “a privation of the senses.” Yet the word must have been used for some decades prior; Quistorp’s work consolidates the knowledge of his time about this physiologic state. He defines anaesthesia as “a spontaneous, deep, more or less persistent loss of sensation by the whole body, except by the organs supporting the pulse and respiration. The brain is plunged into a deep, strange, more or less pleasant trance.” He describes numerous causes, including that “Vapors (fumes) entering the body may produce anaesthesia.” He notes that the term “has become accepted in the Greek and Latin medical literature.” In Chapter 1 of his dissertation, Quistorp explores seven definitions and their corollaries important to his topic. The word was apparently coined between the 10th and fifth centuries BCE. Ancient Greek and Latin authors used it widely and with various definitions. Among the authors who used the word to denote deprivation of the senses or insensitivity to pain are Linnaeus, Epicurus, Hippocrates, Hippon and Demosthenes. Isocrates, Demosthenes and others also used the word to mean either stupidity or irresponsibility. Plato, who used the term 18 times in his writings, implied both meanings. In “Timaeus, s ” Plato used the word several times to indicate a condition in which an impulse does not reach the brain. Galen, a Greek physician from Asia Minor born in 141, used the word to describe “the dullness

Samuel Johnson c. 1772, painted by Sir Joshua Reynolds.

Plato: copy of portrait bust by Silanion.

Dioscorides receives a mandrake root, an illumination from the Vienna Dioscurides.

of those who think differently.” In his “Ethics,” Aristotle defined it as the opposite of “debauchery and prudence.” Pedanius Dioscorides, a first-century military physician under the Roman emperors Claudius and Nero, used the word to describe a mixture of wine and extract of the mandrake root helpful for treating insomnia, chronic pain and “during cutting and cautery.” Dioscorides’ “De Materia Medica,” in which this description appeared, remained in use well into the Renaissance, as did the works of Galen. Their influence in medical practice over so many centuries may account for the survival of the rather obscure word “anesthesia” and its association with a state of pain deprivation. Print of a portrait of Peter Mark Roget, from Medical Throughout the rest of the 18th and early Portrait Gallery by Thomas Pettigrew. 19th centuries, the word appeared in numerous medical dictionaries and other works. In Roget’s 1854 revised edition does not contain 1846, Oliver Wendell Holmes, in a famous letter, suggested the word to describe the state produced by “anaesthesia,” either. But by the 1879 edition, in the William Morton’s ether administrations at Massachu- general section on “Sensation,” the following list can setts General Hospital in October of that year. “This be found: signifies insensibility, more particularly (as used by Physical Insensibility.— N. insensibility, physical insensibility; Linnaeus and Cullen) to objects of touch,” Holmes wrote, referring to the ancient Greek writer and the obtuseness &c. adj.\ palsy, paralysis, anaesthesia; sleep &c18th-centuryy physician William Cullen. The first edition of Peter Mark Roget’s eponymous {inactivity) 683; moral insensibility thesaurus was published in England in 1852, and did &c. 823. not contain the word anesthesia. anaesthetic agent, opium, ether, chloroform, chloral; nitrous oxide, After graduation from medical school in Edinburgh, Roget spent 1799 in Bristol working with laughing gas; refrigeration. Thomas Beddoes and Humphry Davy on their famous nitrous oxide research. Roget later wrote the The word had finally entered common usage, Encyclopedia Britannica entry on Beddoes. Near the where it remains today. Its meaning has solidified, end of his life Roget published the work for which however; other meanings from the past have largely he is so well known and on which he had been work- fallen away. The OED currently defines it as “loss of ing since the early 1800s. (Roget, man of many tal- feeling or sensation,” but also notes metaphorical uses ents, also invented the slide rule and the pocket beyond those related to the physical body. chessboard and did research on vision physiology later used as the basis for motion pictures.) —Amos J. Wright, MLS

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