Adam B. King

Enhanced recovery after surgery, perioperative medicine, and the perioperative surgical home: current state and future implications for education and training.

Purpose of reviewThe purpose of this review is to summarize the current state of perioperative medicine, including the perioperative surgical home (PSH) and enhanced recovery after surgery pathways (ERAS) as well as the educational implications of these concepts for current and future anesthesiology trainees. Recent findingsAlthough there is significant, ongoing discussion surrounding the structural concept of the PSH, there remains little clinical evidence to support its development. On the other hand, publications surrounding ERAS principles continue to show clinical benefit in reducing length of stay, cost, and perioperative complications for a variety of surgical populations. In this milieu, perioperative medicine is increasingly being recognized as its own specialty in perioperative care that encompasses, but is larger than, ERAS. SummaryThere is sufficient evidence to support widespread adoption of ERAS principles, although the specifics of local implementation may vary from site to site. There is significant uncertainty as to what the PSH actually is. However, perioperative medicine is a defined specialty in medicine that overlaps significantly with anesthesiology core training and practice and will be a significant focus in future education, research, and clinical care provided by anesthesiologists.

Disruptive Education: Training the Future Generation of Perioperative Physicians.

<zdoi;10.1097/ALN.0000000000000978> Anesthesiology, V 125 • No 2 266 August 2016 T issue of Anesthesiology contains a collection of articles describing “care redesign” in health care. This term encompasses many interpretations of the goals and objectives for redesigning the perioperative or periprocedural health care. An example of a circumscribed care redesign initiative was the operating room (oR) of the Future Project from the last decade. The goal of the oR of the Future Project was to examine the operating room systems to make them more efficient and improve utilization. The project was notable because it analyzed, among other things, the impact on its stakeholders, including participants.1–5 healthcare organizations continue actively seeking solutions, such as the oR of the future, to improve the operational performance under the pressure of declining reimbursements. A prominent current care redesign initiative is the Perioperative surgical home (Psh). The Psh aims to transition focus from the intraoperative period to the entire perioperative period, expanding the role of the consultant anesthesiologist in assisting our surgical colleagues to provide higher-quality and more cost-effective care. The oR of the future, the Psh, and the projects described in this issue represent the substantial efforts to redesign how we provide care. These projects all represent significant departures from previous thought, and they provoke us to reflect whether the current content and structure of anesthesiology education is suited to facilitate such innovation. The implicit expectation is that care redesign will improve the value for patients by improving quality and/or reducing cost, but many questions are unanswered even as healthcare organizations scramble to adapt to face new pressures. For example, how and why do care redesign initiatives arise in healthcare organizations? how are they managed, evaluated, and concluded? how do clinicians learn to participate in and lead such projects? Change in a technological environment involves altering the way people, processes, and technology work together. Does our current system of education in anesthesiology prepare clinicians to be the agents (and subjects) of change in the complex healthcare environment as we focus on improving value? Are residency training programs responding to this paradigm shift by changing curricula? Are we training residents to actively embrace and manage change, and importantly, to evaluate the outcomes? We would assert, based on the experiences like the oR of the future, that until now there has been little formal medical education on the topics of initiating, leading, and assessing the outcomes of care redesign in medicine. training the next generation of anesthesiologists to participate in the planning and leadership of new innovations in a value-driven care must become an important element of our training programs. if the Psh is in fact the future of our specialty, how should anesthesiology residency programs teach concepts to move the specialty from current state to the Psh? Currently, anesthesiology training is largely conducted in silos; residents receive training in intensive care units, pain management clinics, and in the operating room, without a unifying experience to tie the arc of periprocedural patient care together. Furthermore, the skills needed Disruptive Education

Heparin Resistance and Anticoagulation Failure in a Challenging Case of Cerebral Venous Sinus Thrombosis

We report a challenging case of cerebral venous sinus thrombosis (multiple etiologic factors) that was complicated by heparin resistance secondary to suspected antithrombin III (ATIII) deficiency. A 20-year-old female previously healthy and currently 8 weeks pregnant presented with worsening headaches, nausea, and decreasing Glasgow Coma Scale/Score (GCS), necessitating mechanical ventilatory support. Imaging showed extensive clots in multiple cerebral venous sinuses including the superior sagittal sinus, transverse, sigmoid, jugular veins, and the straight sinus. She was started on systemic anticoagulation and underwent mechanical clot removal and catheter-directed endovascular thrombolysis with limited success. Complicating the intensive care unit care was the development of heparin resistance, with an inability to reach the target partial thomboplastin time (PTT) of 60 to 80 seconds. At her peak heparin dose, she was receiving >35 000 units/24 h, and her PTT was subtherapeutic at <50 seconds. Deficiency of ATIII was suspected as a possible etiology of her heparin resistance. Fresh frozen plasma was administered for ATIII level repletion. Given her high thrombogenic risk and challenges with conventional anticoagulation regimens, we transitioned to argatroban for systemic anticoagulation. Heparin produces its major anticoagulant effect by inactivating thrombin and factor X through an AT-dependent mechanism. For inhibition of thrombin, heparin must bind to both the coagulation enzyme and the AT. A deficiency of AT leads to a hypercoagulable state and decreased efficacy of heparin that places patients at high risk of thromboembolism. Heparin resistance, especially in the setting of critical illness, should raise the index of suspicion for AT deficiency. Argatroban is an alternate agent for systemic anticoagulation in the setting of heparin resistance.

Randomized trial of a novel double lumen nasopharyngeal catheter versus traditional nasal cannula during total intravenous anesthesia for gastrointestinal procedures

STUDY OBJECTIVE Patients undergoing general anesthesia routinely experience episodes of hypoxemia. There are multiple causes of procedural oxygen desaturation including upper airway obstruction and central hypoventilation. We hypothesize that oxygen supplementation via nasopharyngeal catheter (NPC) will decrease the number of episodes of hypoxemia as compared to traditional NC oxygen supplementation in patients undergoing general anesthesia provided by an anesthesia provider for gastrointestinal endoscopy procedures. DESIGN Randomized control trial. SETTING Endoscopy suite. PATIENTS Sixty patients undergoing intravenous general anesthesia for endoscopic gastrointestinal procedures that did not require endotracheal intubation were enrolled. INTERVENTIONS Patients were randomized to receive supplemental oxygen by either a standard nasal cannula or a nasopharyngeal catheter. Initial oxygen flow rate was 4l/min and titrated at the anesthesia providers discretion. Intravenous anesthetic consisted of a propofol infusion. MEASUREMENTS Hypoxemia was defined as a pulse oximetry reading of <92%. Secondary outcomes included number of airway assist maneuvers such as jaw lift or other airway interventions. MAIN RESULTS Of the 60 enrolled patients; three subjects in the NPC group were excluded from further analysis. There was no difference between group in age, ASA classification, Body Mass Index, oropharyngeal classification or total propofol dose. Patients who received nasopharyngeal oxygen supplementation were less likely to experience a clinically significant oxygen desaturation event 3 of 27 (11.0%) versus 12 of 30 subjects (40.0%), p=0.013. Interventions to assists with airway management were required for fewer patients in the NPC group 4 (14.8%) versus the NC group, 17 (56.7%), p=0.001. CONCLUSION Oxygen supplementation via a nasopharyngeal catheter during intravenous general anesthesia resulted in significantly fewer episodes of hypoxemia and number of airway assist maneuvers. Future studies are needed to assess the utility of NPC in other clinical environments where supplemental oxygen is required in the setting of potential airway obstruction.

Creation and Execution of a Novel Anesthesia Perioperative Care Service at a Veterans Affairs Hospital

Physician-led perioperative surgical home models are developing as a method for improving the American health care system. These models are novel, team-based approaches that help to provide continuity of care throughout the perioperative period. Another avenue for improving care for surgical patients is the use of enhanced recovery after surgery pathways. These are well-described methods that have shown to improve perioperative outcomes. An established perioperative surgical home model can help implementation, efficiency, and adherence to enhanced recovery after surgery pathways. For these reasons, the Tennessee Valley Healthcare System, Nashville Veterans Affairs Medical Center created an Anesthesiology Perioperative Care Service that provides comprehensive care to surgical patients from their preoperative period through the continuum of their hospital course and postdischarge follow-up. In this brief report, we describe the development, implementation, and preliminary outcomes of the service.

Proceedings of the American Society for Enhanced Recovery/Evidence Based Peri-Operative Medicine 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine

Table of contentsA1 Effects of enhanced recovery pathways on renal functionCharles R. Horres, Mohamed A. Adam, Zhifei Sun, Julie K. Thacker, Timothy J. Miller, Stuart A. GrantA2 Economic outcomes of enhanced recovery after surgery (ERAS)Jeffrey HuangA3 What does eating, drinking and mobilizing after enhanced recovery surgery really mean?Kirstie McPherson, Sanjiv Patel, Su Cheen Ng, Denise Veelo, Bart Geerts, Monty MythenA4 Intra-operative fluid monitoring practicesSu Cheen Ng, Mark Foulger, Tim Collins, Kirstie McPherson, Michael MythenA5 Development of an integrated perioperative medicine care pathwayMark Edwards, Denny Levett, Tristan Chapman, Imogen Fecher – Jones, Julian Smith, John Knight, Michael GrocottA6 Cardiopulmonary exercise testing for collaborative decision making prior to major hepatobiliary surgeryMark Edwards, Thomas Sharp, Sandy Jack, Tom Armstrong, John Primrose, Michael Grocott, Denny LevettA7 Effect of an enhanced recovery program on length of stay for microvascular breast reconstruction patientsAdam B. King, Kye Higdon, Melissa Bellomy, Sandy An, Paul St. Jacques, Jon Wanderer, Matthew McEvoyA8 Addressing readmissions associated with an enhanced recovery pathway for colorectal surgeryAnne C. Fabrizio, Michael C. Grant, Deborah Hobson, Jonathan Efron, Susan Gearhart, Bashar Safar, Sandy Fang, Christopher Wu, Elizabeth WickA9 The Manchester surgical outcomes project: prevalence of pre operative anaemia and peri operative red cell transfusion ratesLeanne Darwin, John MooreA10 Preliminary results from a pilot study utilizing ears protocol in living donor nephrectomyAparna Rege, Jayanth Reddy, William Irish, Ahmad Zaaroura, Elizabeth Flores Vera, Deepak Vikraman, Todd Brennan, Debra Sudan, Kadiyala RavindraA11 Enhanced recovery after surgery: the role of the pathway coordinatorDeborah WatsonA12 Hospitalization costs for patients undergoing orthopedic surgery treated with intravenous acetaminophen (IV-APAP) + IV opioids or IV opioids alone for postoperative painManasee V. Shah, Brett A. Maiese, Michael T. Eaddy, Orsolya Lunacsek, An Pham, George J. WanA13 Development of an app for quality improvement in enhanced recoveryKirstie McPherson, Thomas Keen, Monty MythenA14 A clinical rotation in enhanced recovery pathways and evidence based perioperative medicine for medical studentsAlexander B Stone, Christopher L. Wu, Elizabeth C. WickA15 Enhanced recovery after surgery (ERAS) implementation in abdominal based free flap breast reconstructionRachel A. Anolik, Adam Glener, Thomas J. Hopkins, Scott T. Hollenbeck, Julie K. Marosky ThackerA16 How the implementation of an enhanced recovery after surgery (ERAS) protocol can improve outcomes for patients undergoing cystectomyTracey Hong, Andrea Bisaillon, Peter Black, Alan So, Associate Professor, Kelly MaysonA17 Use of an app to improve patient engagement with enhanced recovery pathwaysKirstie McPherson, Thomas Keen, Monty MythenA18 Effect of an enhanced recovery after surgery pathway for living donor nephrectomy patientsAdam B. King, Rachel Forbes, Brad Koss, Tracy McGrane, Warren S. Sandberg, Jonathan Wanderer, Matthew McEvoyA19 Introduction and implementation of an enhanced recovery program to a general surgery practice in a community hospitalPatrick Shanahan, John Rohan, Desirée Chappell, Carrie ChesherA20 “Get fit” for surgery: benefits of a prehabilitation clinic for an enhanced recovery program for colorectal surgical patientsSusan VanderBeek, Rebekah KellyA21 Evaluation of gastrointestinal complications following radical cystectomy using enhanced recovery protocolSiamak Daneshmand, Soroush T. Bazargani, Hamed Ahmadi, Gus Miranda, Jie Cai, Anne K. Schuckman, Hooman DjaladatA22 Impact of a novel diabetic management protocol for carbohydrate loaded patients within an orthopedic ERAS protocolVolz L, Milby JA23 Institution of a patient blood management program to decrease blood transfusions in elective knee and hip arthroplastyOpeyemi Popoola, Tanisha Reid, Luciana Mullan, Mehrdad Rafizadeh, Richard Pitera

An enhanced recovery program for bariatric surgical patients significantly reduces perioperative opioid consumption and postoperative nausea

BACKGROUND Patients frequently remain in the hospital after bariatric surgery due to pain, nausea, and inability to tolerate oral intake. Enhanced recovery after surgery (ERAS) concepts address these perioperative complications and therefore improve length of stay for bariatric surgery patients. OBJECTIVES To determine if ERAS concepts increase the proportion of patients discharged on postoperative day 1. Secondary objectives included mean length of stay, perioperative opioid use, emergency department visits, and readmissions. SETTING A large metropolitan university tertiary hospital. METHODS A quantitative before and after study was conducted for patients undergoing bariatric surgical patients. Data were collected surrounding length of stay, perioperative opioid consumption, antiemetic therapy requirements postoperatively, multimodal analgesia compliance, emergency department visits, and hospital readmission rates. Wilcoxon rank-sum and χ2 test were used to compare continuous and categorical variables, respectively. A secondary analysis was performed using Aligned Rank Transformation and Cochran-Mantel-Haenszel χ2 tests to account for an increase in sleeve gastrectomies in the intervention group. RESULTS The 2 groups had clinically similar baseline characteristics. Comparison group (N = 366) and ERAS group (N = 715) patients underwent a primary bariatric surgery procedure. There was an increase in the number of patients undergoing a laparoscopic sleeve gastrectomy in the intervention group. After accounting for this increase, the percentage of patients discharged on postoperative day 1 was unchanged (79.8% non-ERAS versus 83.1% ERAS, P = .52). ERAS length of stay was statistically significantly lower for gastric bypass (P<.001) and robotic gastric bypass (P = .01). Perioperative opioid consumption was reduced (41.0 versus 16.2 morphine equivalents, P<0.001), and fewer ERAS patients required postoperative antiemetics (68.8% versus 46.2%, P<.001). Emergency department visits at 7 days were reduced (6.0% versus 3.2%, P = .04), but hospital readmission rates were unchanged. CONCLUSIONS Implementing ERAS did not reduce the percentage of patients discharged on postoperative day 1 in a bariatric surgery program with historically low length of stay, but it led to significant reductions in perioperative opioid use, decreases in postoperative nausea, and early emergency room visits.

Intraoperative Management of the Kidney Transplant Recipient

Purpose of ReviewThe purpose of this study was to review current literature on the intraoperative management of the kidney transplant recipient in terms of preoperative evaluation, anesthetic agents of choice, monitoring needs, intraoperative fluid and hemodynamic management, and perioperative pain control options.Recent FindingsMore recent literature regarding intraoperative kidney management suggests less aggressive volume loading with a balanced crystalloid solution, particularly in regard to albumin and blood products, with increased consideration for multimodal therapies for nausea and pain control.SummaryPerioperative kidney management is crucial to immediate- and long-term outcomes for graft and patient survival. Surgical and anesthetic techniques should continue to be honed to allow for ideal renal perfusion intraoperatively. Considerations for intraoperative optimization for renal transplantation include the appropriate types and volume of fluid based on cardiac risk factors with the increasing number of elderly recipients, the avoidance of vasoconstrictive agents, and a reduction in perioperative cardiac-depressing agents for pain that may be managed by multimodal therapies.

Dexmedetomidine for the treatment of hyperactive delirium refractory to haloperidol in non-intubated patients

Delirium is reported to occur in up to 89% of patients admitted to the intensive care unit (ICU) (1), and delirium is an independent risk factor for increased costs, longer hospital stays, neuropsychological dysfunction, and mortality (2-4). As such, the effective treatment of delirium represents a way to not only improve patient safety and outcomes but also to decrease costs and increase hospital throughput. Multiple modalities, including both typical and atypical anti-psychotics, are available as off-label use to treat the symptoms of delirium.

Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery

Delirium is a common morbidity after surgery and in patients admitted to the intensive care unit (ICU). The development of delirium is associated with increased hospital costs, prolonged hospital stays, and increased in-hospital mortality (1-3). Consequences of delirium continue to afflict patients even after hospital discharge.