Susan H. Noorily

Monoamine oxidase inhibitors and cardiac anesthesia revisited

There are well-recognized adverse interactions between the monoamine oxidase inhibitors and anesthetic drugs, particularly narcotics. Patients having cardiopulmonary bypass procedures are commonly anesthetized using high-dose narcotic techniques. We describe an uneventful perioperative course in a parkinsonian patient who required urgent coronary artery bypass graft surgery while he was taking selegiline, a selective inhibitor of monoamine oxidase type B.

A patient-centered surgical home to improve outpatient surgical processes of care and outcomes

Preparing patients for surgery is critical for achieving the best possible surgical outcomes. To do this effectively, care must be coordinated across several types of specialists, and potentially across multiple settings. In this paper, we develop a Patient-Centered Surgical Home (PCSH) for outpatient surgery based on the concept of the Perioperative Surgical Home proposed by the American Society of Anesthesiologists. A key feature of the PCSH is to have an anesthesiology preoperative assessment clinic (APC) serve as system coordinator and information integrator. Based on a study of outpatient surgery at the University of Texas Health Science Center at San Antonio and its primary teaching hospital using statistical analysis and simulation, we demonstrate how this can be accomplished. We show that for the PCSH to succeed, APC must see the right patients with the right information by overcoming improper triaging of patients and patient information deficiencies. Our analysis shows that with the proper screening tool and modifications to the way triage is handled, it is possible to increase the number of patients that the APC sees each day with a modest increase in resources. Much of the potential benefits rest on the cooperation of the referring clinics as well as closing the gap between the current level of patient information and what is needed for optimizing medical decisions. Estimated cost savings are over one million dollars annually with a PCSH. Since APC-like clinics are common, our findings have great potential for widespread implementation of similar PCSH models with commensurate benefits.

A simulation analysis of a patient-centered surgical home to improve outpatient surgical processes of care and outcomes

The process of preparing patients for outpatient surgery is information intensive. However, medical records are often fragmented among different providers and systems. As a result, the preoperative assessment process is frequently prolonged by missing information, potentially leading to surgery delay or cancellation. In this study, we simulate an anesthesiology pre-operative assessment clinic to quantify the impact of patient information deficiency and to assist in the development of a patient-centered surgical home to mitigate this problem through better system-wide coordination.

Preoperative Anesthetic Evaluation and Clinical Decision Making

In the past decade alone, the portion of the US population aged 65 and over has grown to over 40 million people, representing a 15.1 % increase from 2000 to 2010, and comprising 13 % of the total population. In contrast, the portions of the population under age 18 and age 18–45 increased by only 2.6 % and 0.6 %, respectively. Given that half of all surgical procedures are performed in patients aged 65 years or older, healthcare providers involved in the perioperative treatment of patients must be familiar with the issues and concerns particular to geriatric patients. Patients undergoing urologic procedures tend to be older and have an array of complex comorbidities. This chapter will review key issues in the preoperative evaluation of older adults undergoing urologic surgical procedures.

The impact of a patient-centered surgical home implementation on preoperative processes in outpatient surgery

ABSTRACT Purpose: To report results of a pilot study quantifying the impact of a Patient-Centered Surgical Home (PCSH) implementation on preoperative processes in outpatient surgery at University Health System in San Antonio, TX. As a key feature of our PCSH model, an Anesthesia Preoperative Clinic (APC) served as system coordinator and information integrator. Materials and methods: Pre- and post-intervention statistical analyses were conducted on observational data, including patient volume, health condition, information deficiency, and clinic waiting time. Additional analyses were conducted on 63 months of APC patient volume data and 89 weeks of operating room (OR) first-case delays. Results: The average number of patients assessed by APC increased by 19% while APC average clinic time decreased by 9%. Operating Room (OR) patients assessed by APC increased from 45% to 59%. Patient information deficiency improved but the health condition of patients seen in-clinic at APC remained unchanged. OR first-case delay rates that the intervention was designed to impact decreased: anesthesia (69%), surgeon (43%) and patient (33.6%). OR first-case delay rates not impacted by the intervention, but attributable to the hospital, increased by 90%. Conclusions: The PCSH implementation improved several preoperative process metrics for outpatient surgery. Additionally, the study revealed opportunities for improvement.

55 Anesthetic Management of the Cardiac Transplant Recipient During Functional Endoscopic Sinus Surgery

Cardiac transplantation is now the treatment of choice for many patients with end-stage cardiac disease. Cardiac transplant recipients, because they are immunosuppressed, will come to the otolaryngologist for treatment of chronic sinusitis. We present an interesting drug response that occurred in a heart~ung transplant recipient who required functional endoscopic sinus surgery. After an uneventful anesthetic induction, local anesthetic agent (3 ml of 1% lidocaine with 1:100,000 epinephrine) was injected into the nasal septurn. The patient responded with sustained sinus tachycardia (>140 beats/min for 20 minutes) without hypertension. This case is demonstrative of the potential complications that can be encountered during the surgical care of a cardiac transplant recipient. The following discussion will describe necessary precautions to be taken when caring for these patients including the preferred topical and injectable local anesthetic agents, anesthetic techniques, and infection prevention. In addition, the physiology of the denervated myocardium will be discussed.