Lydia A. Conlay

Current practice patterns for adult perioperative transesophageal echocardiography in the United States.

TRANSESOPHAGEAL echocardiography (TEE) was first introduced to the operating room in 1980 when M-mode measurements of left ventricular diameter were used to monitor changes in myocardial function. The subsequent development, in the mid 1980s, of transesophageal transducers capable of real-time, two-dimensional imaging and color Doppler flow mapping resulted in a powerful new tool for the determination of cardiac structure and function. Although these new TEE capabilities were initially limited to research centers, their applicability to the perioperative care of patients with complicated cardiovascular disease quickly became apparent. In a 1992 survey, Poterack found that TEE was being employed perioperatively in many of the academic anesthesiology programs in the United States. Since 1990, the use of perioperative TEE has spread beyond academic medical centers to the everyday care of cardiac surgical patients. Accordingly, today, many anesthesiologists have undertaken advanced training in the performance and interpretation of echocardiographic studies. Growing interest in this subject prompted the formulation of practice guidelines for perioperative TEE in 1996 by a joint task force of the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists (ASA/SCA). The recently defined standards for a comprehensive intraoperative TEE examination also included substantial contributions from the anesthesiology community. Despite these developments, there are no reports that describe the extent to which TEE has been incorporated into the daily perioperative care of patients across the spectrum of anesthesia practice environments existent in the United States. Similarly, no recent data are available regarding the credentialing standards that anesthesiologists have adopted or the training pathways they have chosen. We initiated the current study to determine the frequency with which TEE is currently employed in the perioperative care of surgical patients, to characterize the involvement of anesthesiologists in the provision of this service, and to describe the practice patterns of anesthesiologists who use TEE.

The impact of longer-than-average anesthesia times on the billing of academic anesthesiology departments.

Academic anesthesiology departments provide clinical services for surgical procedures that have longer-than-average surgical times and correspondingly increased anesthesia times. We examined the financial impact of these longer times in three ways: 1) the estimated loss in revenue if billing were done on a flat-fee system by using industry-averaged anesthesia times; 2) the estimation of incremental operating room (OR) sites necessitated by longer anesthesia times; and 3) the estimated potential gain in billed units if the hours of productivity of current anesthesia time were applied to surgical cases of average duration. Health Care Financing Administration average times per anesthesia procedure code were used as industry averages. Billing data were collected from four academic anesthesiology departments for 1 yr. Each claim billed with ASA units was included except for obstetric anesthesia care. All clinical sites that do not bill with ASA units were excluded. Base units were determined for each anesthesia procedure code. The mean commercial conversion factor (US

Induced hypertension for cerebral aneurysm surgery in a patient with carotid occlusive disease

45 per ASA unit) for reimbursement was used to estimate the impact in dollar amounts. In all four groups, anesthesia times exceeded the Health Care Financing Administration average. The loss per group in billed ASA units if a flat-fee billing system were used ranged from 18,194 to 31,079 units per group, representing a 5% to 15% decrease (estimated billing decrease of US

Performance Outcomes in Anesthesiology Residents Completing Categorical (Anesthesia) or Advanced (Nonspecific) Internship Training

818,719 to US

How old is your "bougie"?

1,398,536 per group). The number of excess OR sites necessitated by longer surgical and anesthesia times ranged from 1.95 to 4.57 OR sites per group. The potential gain in billed units if the hours of productivity of current anesthesia time were applied to surgical cases of average duration was estimated to be from 13,273 to 21,368 ASA units. Longer-than-average anesthesia and surgical times result in extra hours or additional OR sites to be staffed and loss of potential reimbursement for the four academic anesthesiology departments. A flat-fee system would adversely affect academic anesthesiology departments.

The history of office-based anesthesia

Elevations in systemic arterial pressure have been linked to the rupture of intracranial aneurysms (1). This association most likely reflects the relationship between systemic arterial pressure and the transmural pressure on the aneurysmal wall. Thus, blood pressure is carefully controlled in patients suffering subarachnoid hemorrhage and is frequently reduced intraoperatively with pharmacologic agents as an aneurysm is clipped (2-3). Although the judicious reduction of arterial pressure may benefit some patients by preventing aneurysmal rupture, such reductions could also prove injurious to patients with impaired cerebral perfusion (4). This report summarizes the course of a patient with an intracranial aneurysm and carotid occlusive disease who suffered a cerebral infarction after a iatrogenic reduction in arterial pressure in an intensive care unit. His neurologic symptoms partially resolved after the subsequent elevation of his arterial pressure; thus, arterial pressure was maintained at artificially high levels throughout his subsequent perioperative course.

Comparing clinical productivity of anesthesiology groups

Background: The internship or first year (PGY 1) of anesthesiology training may be categorical (within anesthesiology), or obtained in more diverse settings. Revisions recently proposed in the training requirements incorporated the PGY 1 into the existing curriculum. Purposes: We studied whether this change improved measurable outcomes. Methods: There were 518 residents studied retrospectively from four institutions that offered entry following both “Categorical” and “Other” internships. Thus the training in clinical anesthesia was identical. Results: No differences were observed in percentile scores on the Anesthesiology In-Service Training Examination during clinical anesthesia training, the receipt of awards, board certification or time to certification, or in reports of unsatisfactory performance to the American Board of Anesthesiology. “Categorical” residents were more frequently appointed chief resident. Conclusions: Easily accessible performance measures may function as valuable aids in decision making, particularly when significant changes in curricula are contemplated. Data do not support the proposed changes in anesthesiology.

Malignant Hyperthermia during a Prolonged Anesthetic for Reattachment of a Limb

To the Editor As anesthesiologists, the proper functioning of airway devices is among the most important equipment concerns that we face. During a recent difficult tracheal intubation, a plastic tracheal tube introducer—“bougie” 15F 70-cm coude tip lot no. 04-2999 (SunMed, Largo, FL) broke while the tracheal tube was being introduced over it into the trachea, requiring retrieval of the broken tip from the esophagus. As a result of this event, all remaining tracheal tube introducers at our institution were examined. Of the approximately 75 introducers in our operating rooms and storage locations, only 5 had the same serial number and of these 5, 1 broke in the described incident, 2 had been taped to the side of the anesthesia carts for storage and broke as the packaging was untaped from its secured location (Fig. 1), 1 was intact but broke with minimal pressure to the device, and 1 remained fully intact. All of the introducers were still in their original packaging from the manufacturer at the time of examination. The remaining introducers had expiration dates printed on the manufacturer’s packaging. No breaks were found in any introducer labeled with an expiration date. According to the manufacturer, this particular type of introducer has been labeled with an expiration date since 2005, indicating a production date of the introducer in this incident before 2005. It seems reasonable to conclude that the cause of the equipment failure described in this report is related to its age, with decreased flexibility of the plastic material resulting in fragility and breaking. With no expiration date on the packaging, there was nothing to alert the anesthesiologist to the age of this device, or to its potential for failure. This case demonstrates the importance of systems-based coordination in patient safety. In 2003, our hospital expanded to include a new surgical location at an institution across town where the reported event occurred. There was no central supply of anesthesia equipment, and no system in place to identify outdated anesthesia supplies without an expiration date on the original package. Monitoring anesthesia supplies that were used infrequently depended on the vigilance of individual anesthesia providers to check availability of equipment, and to reorder any needed items through the nursing service. A second lesson from this case is the importance of attention to seemingly minor equipment-related details as institutions expand to new locations. Subsequent to this incident, a process has been developed in which centrally located anesthesia technicians regularly monitor all anesthesia supplies and equipment throughout the institution. Short-lived equipment and supplies without expiration dates included on the original packaging are removed from service.

Increasing the value of time reduces the lost economic opportunity of caring for surgeries of longer-than-average times.

Abstract The history and evolution of office-based anesthesia are described, with particular emphasis on the role of the dental anesthesia community in the development of this style of practice.