Alexander A. Hannenberg

Gastric Distention and Rupture from Oxygen Insufflation during Fiberoptic Intubation

SINCE its introduction in 1986, 1,2 the use of oxygen insufflation during fiberoptic intubation is recommended by nearly all authorities on airway management: 3,4, ?,,∥ The beneficial effects of oxygen administration through the fiberscope include (1) supporting the patients oxygenation, (2) clearing secretions from the tip of the instrument, and (3) defogging the viewing channels optics. We report a case in which gastric distention and rupture complicated this technique.

Improving perioperative temperature management

Daniel I. Sessler, MD† Numerous randomized outcome trials have demonstrated that even mild hypothermia triples the risk of morbid myocardial outcomes, triples the risk of surgical wound infection, increases blood loss and transfusion requirement, and prolongs recovery and duration of hospitalization in a wide variety of surgical procedures. This literature forms the basis for the practice guidelines in this area, including the recently updated American Heart Association-American College of Cardiology “2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery.” This evidence-based guideline includes a Level 1 recommendation for maintenance of perioperative normothermia. Quality-based payment systems have proliferated in the past decade. In 2005, more than 80% of Health Maintenance Organizations enrollees were in a plan featuring performance-based provider payment and more than two-thirds of employers required their health insurance carriers to incorporate such features in their contract. These efforts are strongly promoted by large collaborative of health care purchasers, such as the Leapfrog Group, Bridges to Excellence, and the Pacific Business Group on Health. Beginning with the Tax Relief and Healthcare Act of 2006, the federal government incorporated a precursor of performance-based physician payment into Medicare with its Physician Quality Reporting Initiative. The Center for Medicare and Medicaid Services has committed

Anesthetic practices in ambulatory aesthetic surgery.

1.35 billion to continue a 1.5% pay-for-reporting bonus in 2008. A Medicare demonstration of performance payments for hospitals distributed almost

The registry imperative.

9 million among 115 hospitals with encouraging improvement in 27 quality metrics. *In 2006, Massachusetts Blue Cross Blue Shield earmarked almost

Risk stratification index: an important advance in comparing health care apples to oranges.

180 million for quality incentive payments; and in the West, the California Integrated Healthcare Association† distributed

10 years in, why time out still matters.

55 million among 200 medical groups on the basis of medical quality, patient satisfaction and information technology deployment. In the United Kingdom, up to 20% of physician earnings are tied to performance measures. It is thus apparent that purchasers, whether we like it or not, now intend to pay for quality, not quantity. Anesthesiology, now more than ever, is faced with the choice of bringing quality measures to the table or watching the associated funding flow to other disciplines. Redirection of physician payment funds to quality improvement efforts is motivated by the belief that medical care lags far behind established best practices. A widely cited study by the RAND Corporation, for example, documented that patients with a variety of common conditions received care consistent with well established, evidence-based standards less than half the time. The capacity of measurement and incentives to accelerate adoption of improved practices is also suggested by the impact of Joint Commission and National Committee for Quality Assurance attention to postmyocardial infarction blocker administration. For example, -blockers, conclusively demonstrated to improve postmyocardial infarction outcomes in 1982, were seldom prescribed even 15 yr after guideline From the *Department of Anesthesiology, Tufts University School of Medicine at Newton-Wellesley Hospital, Newton, Massachusetts; and †Department of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio. Accepted for publication May 23, 2008. Supported by NIH Grants GM 061655, DE 17706, and AG 029656 (Bethesda, MD) and the Joseph Drown Foundation (Los Angeles, CA). In recent years, Dr. Sessler’s department received research funding from numerous companies including Hospira, Nova Nordisk, Progenics, Arizant, Ogenix, MGI, Dynatherm, and Kimberly Clark. Dr. Sessler is a consultant for Cardinal Health Care, MGI, and Johnson & Johnson. Dr. Hannenberg does not have a personal financial interest in any company related to this editorial. Address correspondence and reprint requests to Daniel I. Sessler, MD, Department of Outcomes Research, The Cleveland Clinic—P77 Cleveland, OH 44195. Address e-mail to ds@or.org or www.or.org. Copyright

Negligence in supervision: a case of failed resuscitation4

Although ambulatory aesthetic surgery is commonly practiced and information concerning methods of anesthesia is readily available, little is known about the prevalence of various anesthetic practices and whether such practices differ according to the location of surgery. To obtain this information, we sent a carefully structured, 16-page, 69-item questionnaire to the members of the American Society for Aesthetic Plastic Surgery. Six hundred four (76.6 percent) of the 789 actively practicing members returned questionnaires, an exceptionally high response rate. Of interest are the following findings. More than 50 percent of the respondents operate in their offices half or more of the time. About one-half never perform aesthetic surgery in the hospital. Free-standing ambulatory surgical facilities are used less frequently. A wide range of laboratory studies are ordered routinely, regardless of the location of surgery or age of the patient. Local anesthesia with intravenous sedation is widely used in all settings. When employed for office surgery, neither a nurse anesthetist nor an anesthesiologist is present about one-third of the time. General anesthesia is used in half of the office surgical units and is administered by dedicated anesthesia personnel. About half of the time it is administered by an anesthesiologist and about half of the time by a nurse anesthetist. The intensity and methods of patient monitoring are similar in the office, in the hospital, and in a free-standing ambulatory surgical facility. Preoperative laboratory evaluation, monitoring, and the use of anesthetic agents are similar regardless of the surgical setting.

Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers

Editor’s Note: This is the fourth in a series of four Editorial Views on long-term outcomes after anesthesia and surgery. This series adds to other recent Editorial Views in ANESTHESIOLOGY and includes a discussion of broadening our research outside of the operating room to prevention of wound infections, cancer spread, cardiovascular morbidity and mortality, chronic postsurgical pain, and rare complications. ANESTHESIOLOGY will sponsor special sessions in 2010 on the topic of long-term outcomes at annual meetings of the Japanese Society of Anesthesiologists, the European Society of Anesthesiology, and the American Society of Anesthesiologists.

Extending the Acute Care Surgery Paradigm to Global Surgery

This article has been selected for the ANESTHESIOLOGY CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue.

The World Health Organization safe surgery checklist as a catalyst for system improvement

n January, The Joint Commission’s Universal Protocol for the Prevention of Wrong Site, Wrong Procedure, and Wrong Person SurgeryTM turned 10 years old. During the past decade, the Universal Protocol has become widely adopted and is nearly synonymous with patient safety. Its three fundamental components are preprocedure verification, site marking, and time out. Perioperative practitioners who use the Universal Protocol to prevent medical errors have learned that process alone does not provide a safety net for preventing wrong-person, wrong-site, or wrong-procedure events in the surgical setting. According to The Joint Commission, failures in leadership, communication, and human factors were the top three causes of more than 900 wrong-site surgeries reported from 2004 to 2013.