Alan David Kaye

Clinical performance feedback and quality improvement opportunities for perioperative physicians

Clinical performance feedback is an important component of the ongoing development and education of health care practitioners. For physicians, feedback about their clinical practice and outcomes is central to developing both confidence and competence at all stages of their medical careers. Cultural and financial infrastructures need to be in place, and the concept of feedback needs to be readily embraced and encouraged by clinical leadership and other stakeholders. The “buy-in” includes the expectation and view that feedback occurs on a routine basis, and those engaged in the process are both encouraged to participate and held accountable. Feedback must be part of an overarching quality improvement and physician education agenda; it is not meant to be an isolated, fragmented initiative that is typically undermined by lack of resources or systemic barriers to gaining improvement within programs. Effective feedback should be an integral part of clinical practice. Anesthesiologists and other perioperative physicians are identifying specialty-specific indicators that can be used when creating a broader quality improvement agenda. Placing a more immediate formal feedback strategy that focuses on goal-oriented behavior is rapidly becoming a mainstay. Physicians may use their individual feedback reports for reflection and designing personal development plans as lifelong learners and leaders in improving patient care.

Perioperative Considerations of Patients with Pulmonary Hypertension

Pulmonary hypertension (PH) is a devastating and potentially life-threatening condition that results from a heterogeneous group of diseases. PH is characterized by a sustained increase of mean pulmonary artery pressure (PAP) of 25 mmHg or greater due to any etiology [1]. PH is the manifestation of abnormal pulmonary vascular bed anatomy, abnormal vasoconstrictive status, and pulmonary parenchymal abnormalities which result in obstruction to pulmonary blood flow, cardiac diseases which may impede venous return from the lungs, or a combina‐ tion of the above. Although many different causes exist, hypertension in the pulmonary circulation is the result of increased vascular resistance, increased vascular bed flow, or a coexistence of both. Initially the signs and symptoms of PH are usually subtle and nonspecific, often ignored by the patients. If left untreated, however, these patients with PH will develop progressive symptoms of dyspnea, fatigue, poor exercise tolerance and right heart failure culminating in a markedly shortened survival [2]. The mechanism for the pathogenesis of pulmonary arterial hypertension (PAH) is not completely understood. There is a conceptual transition in recent decades from the traditional view of mechanical obstruction of blood flow leading to elevated pressure in the pulmonary circulation to cellular growth and vascular remodeling causing increased resistance in pulmonary vasculature resistance [3][4]. Though uncommon, there are patients with PH scheduled for various surgical procedures and requiring anesthetic care perioperatively. In recent years some emerging strategies in the management of PH are potentially applicable to anesthesia practice intraoperatively. From the

Clinical Laser/Light Applications in Anesthesiology Practice

Lasers in surgery and medicine have evolved into a specialized area with increasing use and innovative techniques requiring anesthesia providers to be familiar with the historical, technical, and procedural aspects of laser applications. Lasers applications in surgery include a variety of procedures with various laser types and specific anesthetic considerations. Currently, anesthesia providers commonly encounter use of lasers in many procedures including airway surgery, cutaneous and cosmetic surgeries, urologic, endoscopic and ophthalmology procedures. Anesthesia for procedures involving laser use in specialized patient populations such as pediatrics and obstetrics requires the anesthesia provider to be familiar with the procedure and special needs of the patient. Development of an anesthetic plan that is safe and satisfactory to the surgeon and patient necessitates knowledge of the procedure and patient characteristics. Laser applications for surgery are widespread and include excisions of dermatologic lesions, treatment of laryngeal lesions, treatment of prostatic hypertrophy, Barrett’s esophagus and cataracts. Use of laser in cosmetic and cutaneous procedures is generally well tolerated with monitored anesthesia care supplemented with topical or local anesthesia. Laser use in prosthetic reduction surgery is common and often patients are elderly presenting with multiple co-morbidities influencing choice of anesthetic technique. With the use of lasers in the operating becoming more common in recent years, awareness and adherence against health hazards to both the patient and personnel are essential. Laser safety includes vigilance on the part of the anesthesia provider to prevent laser induced fires, avoid eye injury and burns, as well as, prevent electrical hazards. Procedures involving lasers and the airway represent a special challenge to the anesthesia provider including risk of airway fire, aspiration, injury, and inadequate ventilation and oxygenation. As laser technology continues to evolve in the fields of medicine and surgery benefits to the patient as it relates to anesthesia are apparent in some areas and require further study in others. Laser safety programs are required nationally in all hospitals and office based surgical facilities using lasers.

Anesthetic Considerations in Robotic Cardiac Anesthesia

Robotic assistance enables cardiac surgery to be performed without a median sternotomy (rCABG). In the case of coronary artery bypass grafting (CABG), the robot is used to harvest one or both internal mammary arteries and the distal anastomoses can then be performed by hand in a procedure called minimally invasive direct coronary artery bypass grafting (MIDCAB) or they can be performed with the robotic instruments, known as totally endoscopic CABG (TECAB) (Poston 2008, Bonaros 2014). In the case of mitral valve surgery, it is used to gain visualization and dexterity around the valve in a way that improves the reliability of complex mitral repairs over what is possible using open techniques (Suri R 2015). In both of these operations, the avoidance of a sternotomy helps minimize blood loss and improve recovery time. Many patients report a quicker resolution of wound pain and cosmetically superior results.

Anesthesiologists’ Role in Disaster Management

The field of anesthesiology provides life-supporting care regardless of the etiology or circumstances. The anesthesia provider occupies a crucial and essential role in initiating effective and efficient health care, serving as a link between surgical services and the Intensive Care Units (ICUs) in the provision of medical care and the coordination and/or implementation of a disaster response strategy. Given the anesthesiologist’s familiarity with the two specialties, it is of little doubt that the specialty of Anesthesiology should embrace a key primary role in the event of a disaster. The responsibilities of the anesthesiologist would include, but not be limited to, frequently coordinating the care of patients in nearly all fathomable settings/scenarios, analyzing and problem solving, performing a systematic triaging of patients, providing or supervising optimal anesthesia for best patient outcomes, and helping to improve upon previous areas of deficiency as a region begins the process of rebuilding. The sheer essence contained with the definition of a disaster are the circumstances which prove that these instances are usually unforeseen and similarly exert catastrophic damage as a result from inappropriate preventative or preparative measures. In the face of disaster, the implementation of the aforementioned responsibilities of the anesthesiologist ultimately will attempt to save lives by blunting the associated morbidity and mortality common during disaster circumstances.

Essentials of Pediatric Anesthesiology: Index

In undergoing this life, many people always try to do and get the best. New knowledge, experience, lesson, and everything that can improve the life will be done. However, many people sometimes feel confused to get those things. Feeling the limited of experience and sources to be better is one of the lacks to own. However, there is a very simple thing that can be done. This is what your teacher always manoeuvres you to do this one. Yeah, reading is the answer. Reading a book as this essentials of pediatric anesthesiology and other references can enrich your life quality. How can it be?

Essentials of Pediatric Anesthesiology: Frontmatter

In undergoing this life, many people always try to do and get the best. New knowledge, experience, lesson, and everything that can improve the life will be done. However, many people sometimes feel confused to get those things. Feeling the limited of experience and sources to be better is one of the lacks to own. However, there is a very simple thing that can be done. This is what your teacher always manoeuvres you to do this one. Yeah, reading is the answer. Reading a book as this essentials of pediatric anesthesiology and other references can enrich your life quality. How can it be?

Essentials of Pediatric Anesthesiology: Contents

In undergoing this life, many people always try to do and get the best. New knowledge, experience, lesson, and everything that can improve the life will be done. However, many people sometimes feel confused to get those things. Feeling the limited of experience and sources to be better is one of the lacks to own. However, there is a very simple thing that can be done. This is what your teacher always manoeuvres you to do this one. Yeah, reading is the answer. Reading a book as this essentials of pediatric anesthesiology and other references can enrich your life quality. How can it be?