Brian P. McGlinch

Perioperative Care of Patients Undergoing Bariatric Surgery

The epidemic of obesity in developed countries has resulted in patients with extreme (class III) obesity undergoing the full breadth of medical and surgical procedures. The popularity of bariatric surgery in the treatment of extreme obesity has raised awareness of the unique considerations in the care of this patient population. Minimizing the risk of perioperative complications that contribute to morbidity and mortality requires input from several clinical disciplines and begins with the preoperative assessment of the patient. Airway management, intravenous fluid administration, physiologic responses to pneumoperitoneum during laparoscopic procedures, and the risk of thrombotic complications and peripheral nerve injuries in extremely obese patients are among the factors that present special intraoperative challenges that affect postoperative recovery of the bariatric patient. Early recognition of perioperative complications and education of the patient regarding postoperative issues, including nutrition and vitamin supplementation therapy, can improve patient outcomes. A suitable physical environment and appropriate nursing and dietetic support provide a safe and dignified hospital experience. This article reviews the multidisciplinary management of extremely obese patients who undergo bariatric surgery at the Mayo Clinic.

Is Physician Anesthesia Cost-Effective?

One of the most controversial issues in anesthesia is whether nonmedically directed nurse anesthetists are relatively more cost-effective than anesthesiologists in the provision of anesthesia care. We electronically surveyed anesthesia practices throughout the United States to estimate the range in anesthesia professional costs from the payer perspective. Using this survey data on anesthesia reimbursement and published outcomes studies, we developed an ad hoc model to estimate the cost-effectiveness of physician-directed anesthesia relative to a nonmedically directed nurse anesthetist model of care from the payer perspective. Cost-effectiveness ratios were defined as the ratio of incremental costs associated with physician anesthesia relative to the estimated incremental life expectancy gains with this model of care (i.e., dollars per year of life saved [

The Mayo Clinic World War II short course and its effect on anesthesiology.

/YLS]). Reference case results suggest that physician anesthesia is cost saving with an estimated incremental cost-effectiveness ratio of −

Emergency Cardiac Support With Extracorporeal Membrane Oxygenation for Cardiac Arrest

2,601/YLS for a younger privately insured patient and an estimated cost-effectiveness ratio of −

Perioperative Anesthetic Care of the Obese Patient

4,410/YLS for an elderly Medicare insured patient. Cost-effectiveness ratios ranged from −

FIRST YEAR'S EXPERIENCE WITH RAPID-SEQUENCE INTUBATION (RSI) IN A RURAL CITY OF 85,000

4,410 to

Tongue engorgement with prolonged use of the esophageal-tracheal Combitube.

38,778/YLS in univariate and multivariate sensitivity analyses across payer types. Results were most sensitive to assumed differences in reimbursement (commercial conversion factors) and to mortality rate assumptions by provider type. This analysis offers economic evidence in support of the physician anesthesia model of care.

Intranasal Nicotine Increases Postoperative Nausea and is Ineffective in Reducing Pain Following Laparoscopic Bariatric Surgery in Tobacco-Naïve Females: A Randomized, Double Blind Trial

WORLD War II changed American medicine. Physicians were recruited in unprecedented numbers because the armed services needed specialists to care for the troops both in and out of combat. The need for physicians who were able to administer anesthetics to injured soldiers was of paramount concern. To accelerate training, the armed services created postgraduate courses to teach the fundamentals of the specialty. These courses were set up across the United States in places like the University of Wisconsin in Madison, Wisconsin; Bellevue Hospital in New York City, New York; Harvard University in Boston, Massachusetts; and the Mayo Clinic in Rochester, Minnesota. These trainees returned to civilian medicine after the hostilities ceased. How were these courses set up? Did the graduates continue to practice anesthesia after the war? Were these physicians responsible for the tremendous postwar growth of anesthesiology, as has often been theorized?

Extreme tracheal compression due to substernal goiter: Surgical and anesthetic management

A 46-year-old woman with no major medical history presented to the emergency department with chest pain and evidence of anterior, anterolateral, and inferior ST-elevation myocardial infarction. Her condition quickly deteriorated into cardiogenic shock with ventricular arrhythmia. Despite revascularization of the left anterior descending artery and intravenous inotrope and antiarrhythmic therapy, her unstable hemodynamics and arrhythmias persisted. Early emergency initiation of venoarterial extracorporeal membrane oxygenation (ECMO) led to prompt hemodynamic and rhythm stability; however, adequate endogenous cardiac output did not ensue, and she was not able to be weaned from ECMO until hospital day 8. She subsequently recovered and continues to do well in the outpatient setting. This case demonstrates the remarkable hemodynamic and rhythm stability that early initiation of ECMO can provide in the setting of unstable myocardial infarction.

The law of unintended consequences can never be repealed: The hazards of random urine drug screening of anesthesia providers

The only available resource to provide cutting-edge, in-depth coverage of the links between obesity and anesthesia in surgery, the reader-friendly Handbook of Perioperative Anesthesia: Complications and Challenges of the Obese Patient guides the practicing anesthesiologist through each stage of surgery for the obese patient. This clinically relevant text thoroughly illustrates the unique challenges and complications the anesthesiologist faces when supervising and administering drug delivery during surgery. Practical and hands-on, this source also advises the anesthesiologist on how to avoid potential risks and ensure speedy patient recovery post-operation.