Fred E. Shapiro

Dexmedetomidine in Aesthetic Facial Surgery : Improving Anesthetic Safety and Efficacy

Background: Dexmedetomidine is an &agr;2-agonist anesthetic with several properties that are advantageous in aesthetic facial surgery. By attenuating sympathetic nervous system activity, it induces sedation and analgesia while lowering blood pressure and preventing pain-induced hemodynamic fluctuations. It spares the respiratory drive and decreases the need for supplemental oxygen, thus reducing the fire risk of electrocautery. It decreases narcotic use, thereby further improving respiratory safety and decreasing postoperative nausea and vomiting. This retrospective study evaluated the safety and efficacy of dexmedetomidine in rhytidectomy. Methods: Records were reviewed for 155 consecutive face lifts performed under sedation by one surgeon over 3.5 years. Intraoperative and postoperative parameters and outcomes were compared for 78 patients sedated with dexmedetomidine (dexmedetomidine group) and 77 sedated without dexmedetomidine (no-dexmedetomidine group). Results: Intraoperatively, the dexmedetomidine group had lower mean systolic and diastolic blood pressures and heart rate (p < 0.001). Fewer dexmedetomidine group patients had oxygen desaturation below 92 percent (p < 0.05) and fewer required antihypertensives (p < 0.01), although more required vasopressors (p < 0.01). The dexmedetomidine patients needed less midazolam (p < 0.01) and fentanyl (p < 0.001). Postoperatively, the dexmedetomidine group again had lower mean systolic and diastolic blood pressures and heart rate (p < 0.001). In addition, fewer patients in this group needed postoperative antiemetics (p < 0.05). Immediate postoperative hematomas occurred in two patients in the dexmedetomidine group and one patient in the no-dexmedetomidine group. Conclusions: Dexmedetomidine lowered blood pressure, decreased the frequency of oxygen desaturations, and reduced narcotic, anxiolytic, and antiemetic use. When compared with conventional sedation, dexmedetomidine appears to improve anesthetic safety and efficacy for rhytidectomy patients.

Anesthesia for outpatient cosmetic surgery.

Purpose of review American Society of Aesthetic Plastic Surgery statistics show outpatient cosmetic procedures increased from 3 to 11 million (1997–2007), an increase of 457%, and

Office-based anesthesia: safety and outcomes

13 billion was spent. Exponential growth, complexity of cases and patients, and media attention to high-profile untoward events are accompanied with concerns for patient safety and development of safer anesthesia practices. Recent findings Improved safety and efficacy in aesthetic facial surgery include oral sedation and local anesthesia, addition of dexmedetomidine to intravenous anesthesia, and defining the ‘safest’ dose of lidocaine with epinephrine. A nasopharyngeal tube can be used to deliver a concentration of oxygen commensurate with recent American Society of Anesthesiologists Task Force Practice Advisory for the prevention and management of operating room fires. Analgesia for breast surgery including instillation of bupivicaine, paravertebral block, and combination dexamethasone with nonsteroidal anti-inflammatory drugs can decrease narcotic requirement and recovery time. Risks of combined gynecologic and plastic surgical procedures are not greater than those seen with either procedure alone. A coordinated team approach for patient management is essential. Pulmonary embolism remains the greatest cause of mortality. Summary The methods presented improve patient safety. The number of cosmetic procedures will continue to grow exponentially and evolve additional patient safety concerns. This larger population is the foundation for prospective trials to develop evidence-based anesthesia for cosmetic surgery.

Patient safety and office-based anesthesia.

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.

Initial Results from the National Anesthesia Clinical Outcomes Registry and Overview of Office-Based Anesthesia

Purpose of review Office-based anesthesia is a new and growing subspecialty within ambulatory anesthesia. We examine major developments in office-based anesthesia and how patient safety can be maintained. Recent findings The emergence of office-based anesthesia as a subspecialty of ambulatory anesthesia is a result of economic and social factors, and is also due to the development of better surgical techniques and anesthestic drugs. There is still a dearth of primary literature that addresses patient safety in the office-based setting. Some existing literature points to increased risk in the office, although others suggest that proper provider credentialing, qualifications, and appropriate facility accreditation can improve patient outcomes compared to surgicenters and inpatient facilities. There is a lack of state and federal oversight of office-based facilities. Increased regulation and standardization of care, such as the use of check lists and professional society guidelines, can help promote safer practices. Summary There is no uniform standard of care for performing procedures in the office-based setting. Healthcare providers are facing the challenge of creating a safer, efficient, cost-effective and patient-centered environment. Available data show that the office-based practice can be as safe as any ambulatory surgicenter or hospital, as long as patients, regulators, and physicians become educated advocates of safer practices. In addition, procedures can be performed safely with general anesthesia or conscious sedation, provided that there are properly trained personnel and adequate equipment and facilities. Moreover, physicians should be credentialed to perform the same procedure in a hospital that they perform in an office.

A Comparison between office and other ambulatory practices: Analysis from the National Anesthesia Clinical Outcomes Registry.

Safe office-based anesthesia practices dictate proper patient and procedure selection, appropriate provider qualifications, adequately equipped facilities, and effective administrative infrastructure. Analysis of patient outcomes can help reduce mortality and morbidity by identifying high-risk patients and procedures. We analyzed data from the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry. Analysis included patient demographics and outcomes, procedure and anesthesia type and duration, and case coverage by provider. Increased regulation and standardization of care, such as the use of checklists and professional guidelines, can advance safe practices. There is increasing emphasis on continuous quality improvement, electronic health records, and outcomes data reporting.

Analysis of patient injury based on anesthesiology closed claims data from a major malpractice insurer

Ambulatory and office-based surgery is expanding rapidly. While growth continues, there are lingering patient safety concerns. To this end, the American Society of Anesthesiologists (ASA) created the Anesthesia Quality Institute (AQI), which collected patient and procedural characteristics on 23,341,130 anesthetics from all health care settings from 2010 to 2014. Of these, 179,618 office and 4,627,379 ambulatory cases were isolated and compared. Our findings show that although both settings are often grouped together, there are statistically significant differences in patient demographics, procedure types, and reported adverse events. Among these reports, inadequate postoperative pain control and nausea/vomiting are the most common issue. More serious events such as death, cardiac arrest, and vision loss occurred but were rare.

Administrative issues to ensure safe anesthesia care in the office-based setting.

INTRODUCTION The analysis of malpractice claims can provide risk managers with a detailed view of patient mortality and morbidity. The data comes from many institutions, encompasses a diverse group of practitioners and practice settings, and contains detailed clinical information. Analysis can help identify patterns of injury, risk factors, and rare and sentinel events. METHODS We examined most recent anesthesia closed claims data collected by The Doctors Company, a large national malpractice insurer. We analyzed data from claims closed between 2007 and 2012. Each claim underwent a review by physician and nurse experts, and was then coded using the Comprehensive Risk Intelligence Tool. Injury distribution and association between the injury and patient comorbidity were also examined. RESULTS A total of 607 claims were analyzed. Most frequent injuries were teeth damage (20.8%), death (18.3%), nerve damage (13.5%), organ damage (12.7%), pain (10.9%), and arrest (10.7%). Obesity was most frequently identified as a contributing factor leading to a claim. Injury-to-claim rates were highest in hospitals with fewer than 100 beds, while ambulatory surgery centers had the lowest death-to-claim rate (12%). Average indemnity for an anesthesia claim was

Putting the Patient Into Patient Safety Checklists

309 066, compared to

Checklist Implementation for Office-Based Surgery: A Team Effort

291 000 for all physician specialties. CONCLUSIONS The most frequent claims were death and nerve damage when teeth damage was excluded. Obesity impacted anesthesia outcomes more frequently than did other comorbidities. Although there were fewer claims from the smaller hospitals, those claims had higher rates of mortality and nerve damage compared to larger-size hospitals. Further analysis is needed to evaluate these trends as well as impact of specific patient comorbidities on anesthesia outcomes.