Sheila R. Barnett

Preventing postoperative complications in the elderly.

Postoperative complications are directly related to poor surgical outcomes in the elderly. This review outlines evidence based quality initiatives focused on decreasing neurologic, cardiac, and pulmonary complications in the elderly surgical patient. Important anesthesia quality initiatives for prevention of delirium, the most common neurologic complication in elderly surgical patients, are outlined. There are few age-specific quality measures aimed at prevention of cardiac and pulmonary complications. However, some recommendations for adults can be applied to the geriatric surgical population. In the future, process measures may provide a more global assessment of quality in the elderly surgical population.

Polypharmacy and Perioperative Medications in the Elderly

Polypharmacy is a significant and complex problem affecting more than 40% of the geriatric population. Accurate medication histories may be difficult to obtain, but must include over-the-counter remedies as well as prescription. Physiologic changes occur with aging that predispose elderly patients to adverse drug events. At a minimum, medications with significant anticholinergic properties should be recognized and avoided in the perioperative period.

Propofol versus traditional sedative agents for advanced endoscopic procedures: A meta-analysis

The optimum method for sedation for advanced endoscopic procedures is not known. Propofol deep sedation has a faster recovery time than traditional sedative agents, but may be associated with increased complication rates. The aim of the present study was to pool data from all available studies to systematically compare the efficacy and safety of propofol with traditional sedative agents for advanced endoscopic procedures.

Risk of Topical Anesthetic–Induced Methemoglobinemia: A 10-Year Retrospective Case-Control Study

IMPORTANCE Methemoglobinemia is a rare but serious disorder, defined as an increase in oxidized hemoglobin resulting in a reduction of oxygen-carrying capacity. Although methemoglobinemia is a known complication of topical anesthetic use, few data exist on the incidence of and risk factors for this potentially life-threatening disorder. OBJECTIVE To examine the incidence of and risk factors for procedure-related methemoglobinemia to identify patient populations at high risk for this complication. DESIGN AND SETTING Retrospective study in an academic research setting. PARTICIPANTS Medical records for all patients diagnosed as having methemoglobinemia during a 10-year period were reviewed. EXPOSURES All cases of methemoglobinemia that occurred after the following procedures were included in the analysis: bronchoscopy, nasogastric tube placement, esophagogastroduodenoscopy, transesophageal echocardiography, and endoscopic retrograde cholangiopancreatography. MAIN OUTCOMES AND MEASURES Comorbidities, demographics, concurrent laboratory values, and specific topical anesthetic used were recorded for all cases. Each case was compared with matched inpatient and outpatient cases. RESULTS In total, 33 cases of methemoglobinemia were identified during the 10-year period among 94,694 total procedures. The mean (SD) methemoglobin concentration was 32.0% (12.4%). The methemoglobinemia prevalence rates were 0.160% for bronchoscopy, 0.005% for esophagogastroduodenoscopy, 0.250% for transesophageal echocardiogram, and 0.030% for endoscopic retrograde cholangiopancreatography. Hospitalization at the time of the procedure was a major risk factor for the development of methemoglobinemia (0.14 cases per 10,000 outpatient procedures vs 13.7 cases per 10,000 inpatient procedures, P < .001). CONCLUSIONS AND RELEVANCE The overall prevalence of methemoglobinemia is low at 0.035%; however, an increased risk was seen in hospitalized patients and with benzocaine-based anesthetics. Given the potential severity of methemoglobinemia, the risks and benefits of the use of topical anesthetics should be carefully considered in inpatient populations.

Capnographic Monitoring of Moderate Sedation During Low-Risk Screening Colonoscopy Does Not Improve Safety or Patient Satisfaction: A Prospective Cohort Study

Objectives:Appropriate monitoring during sedation has been recognized as vital to patient safety in procedures outside of the operating room. Capnography can identify hypoventilation prior to hypoxemia; however, it is not clear whether the addition of capnography improves safety or is cost effective during routine colonoscopy, a high volume, low-risk procedure. Our aim was to evaluate the value of EtCO2 monitoring during colonoscopy with moderate sedation.Methods:We conducted a prospective study of sedation safety and patient satisfaction before and after the introduction of EtCO2 monitoring during outpatient colonoscopy with midazolam and fentanyl using the validated PROcedural Sedation Assessment Survey (PROSAS). Complications of sedation and PROSAS scores were compared among colonoscopies with and without capnography.Results:A total of 966 patients participated in our study, 465 in the pre-EtCO2 group and 501 in the EtCO2 group. On multivariate analysis, patients and nurses reported higher levels of procedural discomfort after adoption of capnography (1.71 vs. 1.00, P<0.001). No serious adverse events were seen, and minor sedation-related adverse events occurred with similar frequency in both groups (8.2% pre-EtCO2 vs. 11.2% EtCO2, P=0.115). The cost of implementing EtCO2 in our unit was

Risk Factors and Outcomes of Reversal Agent Use in Moderate Sedation During Endoscopy and Colonoscopy.

40,169.95 and added

The “Hidden Costs” of Graduate Medical Education in the United States

11.68 per case.Conclusions:Colonoscopy with moderate sedation is a low-risk procedure, and the addition of EtCO2 did not improve safety or patient satisfaction but did increase cost. These data suggest that routine capnography in this setting may not be cost effective and that EtCO2 might be reserved for patients at higher risk of adverse events.

Sedation and Monitoring

Background: Moderate sedation has been standard for noninvasive gastrointestinal procedures for decades yet there are limited data on reversal agent use and outcomes associated with need for reversal of sedation. Aim: To determine prevalence and clinical significance of reversal agent use during endoscopies and colonoscopies. Methods: Individuals with adverse events requiring naloxone and/or flumazenil during endoscopy or colonoscopy from 2008 to 2013 were identified. A control group was obtained by random selection of patients matched by procedure type and date. Prevalence of reversal agent use and statistical comparison of patient demographics and risk factors against controls were determined. Results: Prevalence of reversal agent use was 0.03% [95% confidence interval (CI), 0.02-0.04]. Events triggering reversal use were oxygen desaturation (64.4%), respiration changes (24.4%), hypotension (8.9%), and bradycardia (6.7%). Two patients required escalation of care and the majority of patients were stabilized and discharged home. Compared with the control group, the reversal group was older (61±1.8 vs. 55±1.6, P=0.01), mostly female (82% vs. 50%, P<0.01), and had lower body mass index (24±0.8 vs. 27±0.7, P=0.03) but received similar dosages of sedation. When adjusted for age, race, sex, and body mass index, the odds of reversal agent patients having a higher ASA score than controls was 4.7 (95% CI, 1.7-13.1), and the odds of having a higher Mallampati score than controls was 5.0 (95% CI, 2.1-11.7) with P<0.01. Conclusions: Prevalence of reversal agent use during moderate sedation is low and outcomes are generally good. Several clinically relevant risk factors for reversal agent use were found suggesting that certain groups may benefit from closer monitoring.

Anesthesia for Common Nonoperating Room Procedures in the Geriatric Patient

The cost of graduate medical education in the United States is subsidized by the federal government through direct and indirect Medicare payments. These payments are intended to cover the portion of resident salaries, teaching expenses, and indirect hospital costs associated with the academic mission attributable to the care of Medicare beneficiaries, using a complex allocation formula. However, there are other program expenses associated with medical education that are not reimbursed by Medicare and still significantly affect the competitiveness and quality of the educational programs. Although most educators recognize the amount of extra work and money required to run high-quality training programs, there are few analyses demonstrating the actual amount and effect of these extra expenditures on graduate medical education.1-4 Programs often spend significant amounts on recruitment efforts, including interviews, travel reimbursements, and orientation days. They purchase resource education materials for residents, such as books, simulation training, digital resources, association and membership dues, and in-service examinations to support their education. For scientific meetings and events, they often pay for travel and lodging expenses, program application fees and food; graduation ceremonies, awards, and certificates add to the expenses of running a program. Other items purchased for trainee support include laboratory coats, office supplies, computer hardware and software, parking, meal cards, and pagers. As fiscal pressures intensify for academic medical centers and associated faculty practice plans, it is essential to identify the magnitude and distribution of these “hidden costs” of residency training. As part of a strategic review of education and budgets, the 8 core Accreditation Council for Graduate Medical Education (ACGME) residency programs (comprising 461 trainees) at an academic medical center reported all nonsalary costs of training residents. The programs were asked to identify the costs by category of expenditure (using the 4 categories noted above) and the source of the funding: hospital cost center, physician practice plan, or special funds (eg, philanthropy, grants). The total annual hidden costs for resident education at that institution were

Geriatric Anesthesiology: Where Have We Been and Where Are We Going?

1,865,016. Approximately 70% (