Nicholas Sadovnikoff

Anesthesia for patients with severe chronic obstructive pulmonary disease.

Purpose of review Patients with chronic obstructive lung disease experience an increased risk of perioperative pulmonary complications. This review presents an evidence-based approach to perioperative care designed to optimize management. Recent findings Recent research has provided guidance regarding intraoperative and postoperative administration of oxygen and the selective use of volatile agents. The significance of preoperative malnutrition and postoperative epidural analgesia on outcomes has also been explored further. The opportunity for anesthesiologists to engage in tobacco interventions and the benefits of addressing smoking cessation have been studied. Summary Optimization for surgery includes preoperative treatment of reversible airway obstruction and respiratory infections, smoking cessation, and possibly nutritional interventions. Meticulous intraoperative monitoring combined with a sound understanding of pathophysiological mechanisms underlying air trapping will help clinicians strike a balance between permissive hypercapnia and adequate ventilation.

Neuromuscular blocking agents in the emergency department

Neuromuscular blocking agents (NMBAs) are utilized frequently in the emergency department (ED). We begin with a brief history of neuromuscular blockade, then review the indications and guidelines for its use in the emergency department setting. The relevant agents will be discussed focusing on dosage, side effects, and adverse reactions. Special attention will be paid to succinylcholine, the drug most commonly employed in the ED setting, followed by a summary of the nondepolarizing agents currently available, in particular the four shorter-acting agents that are most appropriate for administration in the ED.

Propofol for sedation in neuro-intensive care

Interventions in the intensive care unit often require that the patient be sedated. Propofol is a widely used, potent sedative agent that is popular in critical care and operating room settings. In addition to its sedative qualities, propofol has neurovascular, neuroprotective, and electroencephalographical effects that are salutory in the patient in neurocritical care. However, the 15-year experience with this agent has not been entirely unbesmirched by controversy: propofol also has important adverse effects that must be carefully considered. This article discusses and reviews the pharmacology of propofol, with specific emphasis on its use as a sedative in the neuro-intensive care unit. A detailed explanation of central nervous system and cardiovascular mechanisms is presented. Additionally, the article reviews the literature specifically pertaining to neurocritical care use of propofol.

CARBON MONOXIDE POISONING : AN OCCULT EPIDEMIC

Carbon monoxide poisoning is a significant health threat in the United States. Smoke inhalation from fires is the most common source. History of carbon monoxide exposure and elevated carboxyhemoglobin levels should alert physicians to the diagnosis of acute poisoning. When there is no history of exposure, carbon monoxide poisoning must be considered when two or more patients are similarly or simultaneously sick. The diagnosis must be excluded by a directed history and physical examination. If suspicion remains, carboxyhemoglobin levels should be determined and oxygen therapy should be started empirically while laboratory results are pending. Prompt administration of hyperbaric oxygen may reduce the risk of death. If carbon monoxide poisoning is confirmed, the source must be identified and recommendations for correction or avoidance should be made.

Chest tube suction-associated unilateral negative pressure pulmonary edema in a lung transplant patient.

We describe a 29-yr-old male, status post-bilateral lung transplant, who developed unilateral negative pressure pulmonary edema induced by chest tube suction in association with bilateral bronchial anastomotic strictures. We conclude that negative pressure pulmonary edema may occur secondary to high levels of negative pressure applied to the intrapleural space via chest tubes in the presence of partial large airway obstruction. Post-lung transplant patients may be especially at risk because of compromised lymphatic drainage.

The Association Between Preoperative Patient Characteristics and Both Clinical and Economic Outcomes After Abdominal Aortic Surgery

OBJECTIVE To evaluate the association between patient characteristics and both clinical and economic outcomes in patients having abdominal aortic surgery in Maryland between 1994 and 1996. DESIGN Retrospective study using an administrative data set. SETTING All Maryland hospitals that performed abdominal aortic surgery from 1994 through 1996 (n = 46). PARTICIPANTS All patients who had abdominal aortic surgery in Maryland from 1994 through 1996 (n = 2,987). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors obtained discharge abstracts from the Maryland Health Services Cost Review Commission for patients with a primary procedure code for abdominal aortic surgery. Primary outcome variables were in-hospital mortality, hospital length of stay, and intensive care unit (ICU) days. The authors evaluated the following groups of independent variables: demographic characteristics, severity of illness, comorbid disease, and preoperative admission days. In multivariate analysis, independent predictors of in-hospital mortality were age 61 to 70 years (odds ratio [OR], 3.1; confidence interval [CI], 1.4 to 6.9), age 71 to 84 years (OR, 7.2; CI, 3.7 to 14.1), age 85 years or older (OR, 9.3; CI, 3.9 to 21.9), ruptured aneurysm (OR, 5.3; CI, 3.5 to 8.2), urgent operation (OR, 2.3; CI, 1.1 to 5.2), emergent operation (OR, 3.0; CI, 1.9 to 4.7), mild liver disease (OR, 4.6; CI, 2.0 to 10.9), and chronic renal disease (OR, 6.9; CI, 3.9 to 12.1). Hospital admission 1 to 2 days preoperatively was not associated with a difference in in-hospital mortality but was associated with a 31% increase in hospital days (CI, 23% to 40%) and a 38% increase in ICU days (CI, 19% to 60%). CONCLUSION In patients having aortic surgery, several patient characteristics such as mild liver disease and chronic renal failure, were associated with increased in-hospital mortality and length of stay. The practice of admitting patients to the hospital 1 to 2 days before surgery should be reevaluated because this was not associated with reduced in-hospital mortality but was associated with increased hospital and ICU stay.

Hypothermia: Saving patients from the big chill

Although hypothermia is a serious and sometimes fatal condition, prompt recognition and institution of appropriate rewarming techniques may save even profoundly affected persons. The diagnosis of hypothermia should be considered when patients present with alterations of cerebral function without apparent explanation, especially in the presence of underlying predisposing illnesses and conditions. When hypothermia is suspected, an accurate core temperature must be obtained. Application of rewarming techniques appropriate to the degree of hypothermia may be lifesaving. Conservative use of pharmacotherapy is warranted.

Perioperative acute renal failure.

Although significant advances in the perioperative and intraoperative care of patients undergoing major vascular and cardiac surgery have been achieved over the last several decades, the occurrence of perioperative acute renal failure (PARF) continues to plague the postoperative course of these patients. The magnitude of this problem is substantial when it occurs because it is associated with marked increases in morbidity and mortality. Anesthesiologists often use intraoperative strategies with the intention of providing renal protection; however, no substantive scientific evidence has validated any such intervention. Consequently, the commonly used practices aimed at preserving the kidney are based on small studies, anecdotal information, or personal experience. In fact, the incidence of PARF in this population and its impact on outcome have changed little in the last 20 years. The purpose of this article is to summarize the statistics regarding the incidence and consequences of PARF, review what is known about the pathophysiology of PARF, evaluate the techniques currently used to provide renal protection, and scan the horizon for evidence of more effective therapies to prevent this complication in the future.

Why are we doing this case? Can perioperative futile care be defined?

Purpose of review The present review addresses the question of whether perioperative futility can be defined. Recent findings Although attempts have been made to define futility in medicine, all proposed definitions are inadequate and as a result there has been a shift to a procedural conflict de-escalation approach to addressing clinical questions of futility. Informed consent is central to the problem of deciding whether an operative procedure may be futile and the criteria for adequate consent by either a patient or surrogate decision-maker are reviewed. An adequately informed patient or surrogate may, nevertheless, desire to proceed with a procedure considered futile by some members of the medical team as a result of conflicting values. The basis for this and the ‘economy of hope’ in which extremely ill patients with few treatment options are invested, is explored. The particular role of the anesthesiologist in deciding whether an operative procedure may be futile is examined. Three potential positions are suggested: the anesthesiologist as service provider, consultant, or gatekeeper. Summary The present review will provide anesthesiologists with critical insight into the historical scholarship and current recommended process to address questions of perioperative futility.

Contemporary Multidisciplinary Care—Who Is the Captain of the Ship, and Does It Matter?

This is the battle cry most often heard in the intensive care unit (ICU) when physicians reach loggerheads about who should be directing care. The captain of the ship doctrine, although now largely discredited in medicolegal status, was first applied to medical practice in McConnel vs Williams.1 We argue that times have changed and changed permanently. In an era of team-based care, the question of who is captain of the ship is too often a distraction and, more importantly, does not contribute to good patient management. To be clear at the onset, we are not advocating for an abdication of personal responsibility. It is unarguable that patients feel best when they have a strong bond with a principal in the delivery of their care and can trust that individual to provide consistent oversight and be mindful of their preferences. That said, it is our contention that delivering on these commitments requires skill in teamwork, communication, and consensus-building and less focus on minute-to-minute management and “who is in charge.” Indeed, any time spent arguing the latter point subtracts from the more important actions at hand. The reason for this shift in emphasis is reflected in the way that medical practice has evolved. Physicians do not generally provide the same type of continuous care to their patients as they have in previous eras. For example, in operative or other invasive interventions, the attending surgeon of record is mandated to be present for the “critical portion” of any procedure and be available for urgent needs throughout. Still, when challenging procedures are completed, care is nearly always handed over to an ICU team that carefully monitors and treats a wide range of issues, albeit with input from the proceduralists. Such ICU environments involve a complicated dance of overlapping team-based care activities incorporating intensivists, fellows, residents, midlevel professionals, nurses, pharmacists, physical therapists, nutritionists, and others. We submit that this is just how it should be. Procedures have become more complex, and the patients undergoing them are sicker. Sick patients require constant care. The risks of fatigue and burnout mandate that one person cannot and should not do it all. To enable the best outcomes and the most sophisticated management, a reliable system of care is needed, with organizational characteristics that favor successful integration of multiple skill sets and rapid resolution of any conflicts. Most simply, physicians with highly specialized skills must interact in a collegial but nonhierarchical fashion. What accounts for the persistence of the captain of the ship doctrine and attendant conflicts over it? Two observations inform this question. The first is that identification of who is directing all care only becomes controversial when there are breakdowns in communication. It is no coincidence that perhaps the most intense disagreements about who is in charge occur in ICUs, where the most complex patients receive care from the largest number of overlapping specialties. Such conflicts are rarely the result of irreconcilable differences in opinion about how care should be delivered. They are almost always the result of a violation of what the medical sociologist Charles Bosk labeled the “rule of no surprises.”2 This occurs when something unexpected has happened, or care has been delivered in a way that surprises a physician who reasonably had an expectation of being informed or participating in the decision-making process (a “normative” deviation, in Bosk’s classification). The actual decision making and delivery of care may be flawless, but the surprise element drives the conflict. The response then becomes misdirected, focusing on the question of who is in charge instead of why communication broke down. Importantly, the root cause of failure in such instances is not a leaderless system, but one in which coordination of care has been disrupted. The demand to know who is in charge rarely occurs when patients are receiving the multidisciplinary care they need and the various health care professionals involved are communicating and coordinating with each other. The second reason that the captain of the ship philosophy is still invoked has to do with the nature of the informed consent conversation. Instead of including all of the physicians who will be involved in care, it is generally conducted only by the one physician planning on performing a procedure. This too is a historical artifact. The doctrine of informed consent as we use it today was formulated at a time when medical practice was simpler and the physician-patient dyad was the fundamental model of care. The legal scholar and physician Jay Katz lamented in 1998 that physicians had failed to fashion the “doctrine” in a way that was responsive to the realities of practice(s), as had been the intent of the judges who originally promulgated the concept in case law.3 If that was true in 1998, it is even more so now. Patients ought to be informed that they will be entering into a matrix environment in which multiple professionals will provide care at differing stages of treatment and recovery. In the case of a patient scheduled for surgery, this includes at a minimum the surgeon, anesthesiologist, their residents, physician assistants, nurses, and anyone else who plays a role in ensuring the success of an operation. The patient should be cognizant of VIEWPOINT