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Cardiac and respiratory complications, along with other problems not directly related to surgery, were the most common causes of unplanned hospital admissions after ambulatory surgery, according to a retrospective study at Duke University Medical Center, in Durham, N.C. Surgical-related reasons, including complications or necessary additional procedures, were the next most common. The study was presented at the 2011 annual meeting of the American Society of Anesthesiologists (ASA; abstract 849).

The investigators reviewed the charts of 28,456 patients who underwent ambulatory surgery between May 2006 and May 2010 at a freestanding surgical center adjacent to Duke University. They included all cases admitted directly after the procedure and cases from the ambulatory center’s 23-hour observation unit. Demographic variables were obtained from the medical center’s electronic records; hospital charges attributed to inpatient admissions were pulled from an internal financial database.

During the study period, unplanned hospital admissions accounted for 127 patients, a rate of 0.45%, which is comparable to previously published findings. The average age of the patients was 48 years; average body mass index was 30 kg/m². Fifty-one percent were classified as ASA physical status I/II; the remainder of the patients were classified as ASA III/IV and were obese.

Medical-related issues accounted for 32% of admissions (41 cases) and were associated with the highest total charges ($356,392); treating cardiac complications was the most expensive ($177,283). Surgical-related reasons accounted for 22% of admissions (28 cases) and were associated with the next highest charges ($311,311); treating surgical complications was the most expensive ($137,367).

Other reasons for admission included need for additional pain control (27 cases), postoperative antibiotics (13 cases), postoperative bleeding (11 cases), anesthesia-related complications (four cases) and adverse drug reactions (three cases).

Steve Melton, MD, assistant professor of anesthesiology at Duke and a co-author of the study, said the results were more confirmatory than surprising. “It shows we’re doing a better job of identifying appropriate patients for ambulatory surgery, and identifying and managing risk factors beforehand,” Dr. Melton said. Risk identification should be a team approach from surgeons and anesthesiologists, although “some of this stuff you can’t always prepare for,” he added.

A new tool that allows real-time, three-dimensional ultrasound may help cut down on errors while placing central lines, without adding precious time to the procedure, researchers have found. When anesthesiologists attempted the technique on a sample of 10 patients undergoing heart surgery, they cannulated the internal jugular vein in every patient—and, in nine of the 10 patients, with the first needle pass (Figure). No back wall passes or inadvertent punctures of the carotid artery occurred.

The cases required an average of 15 seconds to scan the blood vessels, and the average time to insert the needle into the internal jugular vein was 14 seconds, according to the study, which the researchers presented at the 2011 annual meeting of the Society of Cardiovascular Anesthesiologists, in Savannah, Ga.Traditional ultrasound techniques take approximately the same amount of time to find the vein, said David Auyong, MD, of Virginia Mason Medical Center in Seattle. The new technique “didn’t take longer, and it potentially showed that we could follow the needle better, by avoiding the back wall passes and arterial punctures.” However, one patient required six needle passes, likely because the internal jugular vein was relatively deep, Dr. Auyong said.

Many anesthesiologists now rely on ultrasound when inserting a central line, but the traditional technique cannot always rigorously track the tip of the needle, as evidenced by the lingering risk for complications such as pneumothorax and inadvertent arterial puncture.

The new “4-D” technique uses a probe that wobbles slightly (roughly four times per second) over a three-dimensional area such as the internal jugular vein, creating a three-dimensional image in real time—with time representing the fourth dimension, Dr. Auyong explained. “The ultimate goal here is a way to track the needle more reliably,” he said.

Dr. Auyong, who has lectured for SonoSite, which supplied the ultrasound equipment used in the study, said that the biggest hurdle for uptake of the technology is learning how to use it. When he demonstrates it to other anesthesiologists, he said they often struggle with having to follow four images simultaneously in order to track the needle. “It is not something that is necessarily intuitive the second you pick it up.” Dr. Auyong said he, too, struggled at first, but grew more comfortable after an estimated 10 practice insertions of a needle. Cost is another barrier, said Paul Barash, MD, professor of anesthesiology at Yale University School of Medicine, in New Haven, Conn., and a member of the Anesthesiology News editorial board. Ultrasound helps reduce the risk for complications associated with vascular catheterization, Dr. Barash said, but the physicians who do not use it often attribute their hesitation to the expense of the equipment.

Pregnant women undergoing a normal course of labor may be able to safely consume food or drink while receiving epidural anesthesia, thereby increasing their perception of satisfaction. Researchers at Magee-Womens Hospital of the University of Pittsburgh Medical Center, in Pittsburgh, found that laboring women who drank a high-protein shake reported more satisfaction than those who were allowed only ice chips, with no increase in complications. The study results were presented at the 2011 annual meeting of the Society for Obstetric Anesthesia and Perinatology (abstract 25).

A strict policy of nothing by mouth (NPO) is imposed during labor to reduce maternal morbidity and mortality, said senior author Manuel C. Vallejo, MD, professor and director of obstetric anesthesia at the Pittsburgh hospital. But the widespread use of regional anesthesia and improved general anesthetic techniques have significantly decreased the incidence of maternal aspiration, he said. Facilities in Northern Europe, including Switzerland, have adopted a less restrictive NPO policy.

All patients received patient-controlled epidural anesthesia of 0.08% bupivacaine with 2 mcg/mL of fentanyl. The researchers monitored the patients for episodes of nausea and vomiting at hourly intervals until delivery. After delivery, participants were asked to rate their overall satisfaction.

Overall, 21.4% of women in the protein-shake group had nausea, compared with 33.3% in the ice-chips group (P=0.43). In the protein-shake group, 10.7% of the women experienced vomiting, compared with 12.8% of the ice-chips group (P=0.91). Average satisfaction scores were 92 out of 100 in the protein-shake group and 90 out of 100 in the ice-chips group (P=0.05). Aspiration did not occur in any of the patients, and none required a general anesthetic. Two women in the protein-shake group and five women in the ice-chips group had a cesarean delivery.

Dr. Vallejo told Anesthesiology News that as long as women have a functioning epidural and normal progression of labor, “it’s probably OK to have something to eat or drink. It’s good for the women’s well-being, and it increases patient satisfaction.” He said the study is ongoing, and now includes about 107 women. Some patients who heard about the study have asked to participate, he said.

Women undergoing cesarean deliveries may require a smaller dose of anesthesia when administered through an intrathecal catheter, rather than a single spinal injection, according to a small study presented at the 2011 annual meeting of the Society of Obstetric Anesthesia and Perinatology.

Among a sample of 10 patients who received intrathecal catheters, the average woman required between 0.6 and 1.1 mL of 0.75% hyperbaric bupivacaine to experience a T4 to T6 block. That amount is between 25% and 50% less than published doses of the same medication delivered as a single spinal injection.

Based on these findings, study author J. Sudharma Ranasinghe, MD, associate professor of anesthesiology at the University of Miami Miller School of Medicine, recommended that clinicians opting for intrathecal catheters should use slow, incremental dosing to ensure patients do not receive excessive anesthesia.

“If an adequate block can be achieved with less local anesthetic, bolus injection of a spinal medication that was intended for single-shot spinal through a spinal catheter may lead to high spinal block with respiratory difficulty, aspiration risk and severe hypotension,” Dr. Ranasinghe told Anesthesiology News.

These findings have potentially important implications, said David Wlody, MD, professor of clinical anesthesiology at the State University of New York-Downstate Medical Center, in New York City. “I think it’s a good idea to look at this. I wouldn’t have necessarily thought that there would be a difference in dosing between an injection through a spinal needle and a catheter injection technique. I would usually use the same dose.”

However, with such few patients and a lack of a control group, modifying dosing based solely on these results would be premature, said Dr. Wlody, a member of the editorial board of Anesthesiology News. “It’s entirely possible that, when they complete the study, they’re going to get completely different results,” he said. “Let’s see what the final numbers are before we start changing practice.”

New York—An interview protocol used in the preanesthesia clinic aimed at addressing psychological stress associated with surgery improved patient satisfaction substantially, according to a new study.

The method is known as BATHE: Background, Affect, Trouble, Handling and Empathy. Samuel DeMaria Jr., MD, an instructor in anesthesiology at Mount Sinai Medical Center in New York City, said that his group came to think of the final part as Explain, as well. Dr. DeMaria, whose group presented its findings at the 2010 PostGraduate Assembly in Anesthesiology (abstract P-9082), called BATHE “a way of ensuring that the practitioner was meeting the psychological needs of the patient, so that they felt connected to their clinician.”

Dr. DeMaria and colleagues had taught five senior anesthesia residents the method. They interviewed 50 patients using BATHE and 50 without using the protocol. Half of the patients were scheduled for cardiac surgery, the rest for general surgical procedures.All patients responded to a survey to assess their interactions in Mount Sinai’s preanesthetic clinic. As expected, patients in the BATHE group were more likely to be asked questions about their mood, feelings about the impending surgery and how they had been handling such concerns.

Scores for patient satisfaction, based on survey responses, were somewhat higher in the BATHE group than in patients interviewed without the method (P<0.05). Use of the BATHE method was significantly related to satisfaction (r=0.40; P<0.01). A number of individual satisfaction survey questions also revealed improvements when employing the BATHE method. Patients in the BATHE group rated the friendliness and courtesy of their physician higher, and said their clinician showed greater concern for their worries (P=0.01 for both). Interestingly, BATHE patients also were more satisfied with the amount of time the doctor spent with them, although there were no actual differences in time spent between the two groups.

Still, she said, the method might help improve patient satisfaction in this setting. “The most important questions may be, ‘what questions do you have, and how can I help?’”

New findings suggest that a three-step test of assessing the placement of an endotracheal tube (ETT) is essentially foolproof, but that as a stand-alone test, the depth of the tube in the airway is a better measure than auscultation.

“If [clinicians] hear breath sounds on either side of the chest, they assume the tube is in the right position,” said David Alfery, MD, associate adjunct professor of anesthesiology at Vanderbilt University, in Nashville, Tenn., who was not part of the study. “But even an experienced anesthesiologist can be fooled.”

The new study “suggests that simply using tube insertion depth, which requires no judgment, better predicts appropriate tube position than the best clinical judgment even by experienced anesthesiologists,” said Daniel I. Sessler, MD, professor and chair of the Department of Outcomes Research at Cleveland Clinic, in Ohio, who helped conduct the research... researchers found that the optimal tube insertion depth is 20 cm in women and 22 cm in men. “Perhaps using a general 20/22 cm rule, with the possible exception of using 19 cm for smaller women with a higher body mass index, might be a safer approach,” Dr. Sessler suggested. Based on these results, he said, physicians should rely more on insertion depth than on auscultation.

However, combining all three tests—bilateral auscultation of the lungs, observation and palpation of the symmetrical chest movements, and referencing the ETT centimeter scale—provided the most sensitivity, hitting 100%, Dr. Sessler said. Still, tube depth, with a sensitivity of 88%, was significantly more sensitive for detecting endobronchial intubation than either auscultation (65%) or observation (43%) (P<0.001), the researchers found.

Anesthesiologists and other clinicians in Europe and the United States are re-evaluating their use of hydroxyethyl starch for fluid management in surgery as investigators continue to probe the veracity of nearly 90 studies authored by now-disgraced German anesthesiologist Joachim Boldt, MD, PhD.

On March 1, the Association of Surgeons of Great Britain and Ireland announced that citations referring to six studies authored by Dr. Boldt, who was forced out of his position at the Klinikum Ludwigshafen late last year, had been withdrawn from the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients.

“The references by Boldt should not now be regarded as valid evidence pending their review,” a statement posted on the association’s Web site read. “We shall undertake a thorough review of the recommendations of the guidelines to determine whether any adjustments to them are needed.”

In Europe, changes in practice are evolving, said Jukka Takala, MD, PhD, director of intensive care medicine at University Hospital Bern, Switzerland. But “it’s clearly too early to evaluate this in any objective manner,” he told Anesthesiology News.

Dr. Boldt, who has published nearly 350 articles, was a leading proponent of hetastarch (HES) as a volume expander for surgical and trauma patients. Many of his studies formed the basis of clinical guidelines for HES therapy worldwide. But other studies have documented adverse effects from HES, including increased risk for bleeding, heart and kidney failure and anaphylactic shock (Anesth Analg 2011:112:635-645). As a result, the debate over the efficacy and safety of colloid, crystalloid and even albumin solutions has been intense and long-standing.

Dr. Boldt was thrust into the research and publishing scandal in October 2010, when the journal Anesthesia & Analgesia retracted a 2009 article of his over concerns of data manipulation and ethical lapses. Since then, investigators have been reviewing his research results. In March, a German medical board released a list of 88 articles for which it could not find evidence that Dr. Boldt had obtained proper approval from an institutional review board.

An international group of 16 anesthesiology journals subsequently announced that it was retracting those papers (Anesthesiology News, March 2011, page 1). Dr. Boldt faces criminal charges for allegedly fabricating research results and forging the signatures of other scientists on submitted papers. Dr. Boldt has not responded to the allegations.