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Note: This publication contains

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Current Controversies in Adult Outpatient Anesthesia
Jeffrey L. Apfelbaum, M.D. Chicago,Illinois
Introduction
The fast paced world of ambulatory anesthesiology continues to present anesthesiologists with an ever-
changing array of challenges. This Refresher Course will provide an update on current controversial issues in adult
outpatient anesthesia, including fast tracking; preoperative assessment, evaluation, and preparation; recent changes
to ASA Basic Anesthesia Monitoring Standards; ramifications of recent changes to Interpretative Guidelines issued
by the Center for Medicare and Medicaid Services (CMS) on our practice; and Computer Assisted Personalized
Sedation (CAPS). Additionally we will consider a variety of breaking news areas of controversy which may
include topics such as patients with obesity/modified metabolic syndrome; advances in and recommendations to
enhance perioperative communication; treatment decisions for patients with coronary artery stents; opportunities to
incorporate ones personal outcomes data into your patient care plan and potential effect choice of anesthetic on
cancer recurrence rates.
Fast Tracking: Eliminating Intensive Post-Operative Care in Same Day Surgery Patients Using Short Acting
Fast Emergence Anesthetics
Many anesthetics have the pharmacokinetic and pharmacodynamic advantages of a shorter duration of
action and a more rapid rate of recovery which permit a faster emergence from anesthesia compared with their
predecessors. Less than 30 years ago, it was unthinkable that patients would be able to return home on the day of
surgery. Today, advances in surgery and anesthesiology make it possible to perform the vast majority of all surgical
procedures, safely and effectively on an ambulatory basis, with many patients ready to be reunited with their
families within minutes of emergence from anesthesia. In todays cost sensitive healthcare environment, the
processes of ambulatory surgical care must be continually re-evaluated to take advantage of advances in technology
and pharmacology and to optimize efficiency of the ambulatory surgical care without detriment to patient safety and
satisfaction.
Traditionally, ambulatory surgical patients go from the operating room to the postanesthesia care unit (PACU) or
recovery room (a highly specialized intensive care unit) for their immediate postoperative recovery from anesthesia
and then to a second stage recovery unit (SSRU) for preparation for home readiness. By its very nature as a
specialized ICU, the PACU is an expensive, labor-intensive environment. After a set of recovery criteria
1, 2, 3
are
met in the PACU, the patient is usually transferred to the SSRU. In the SSRU, the patient-to-nurse ratio is
considerably higher (i.e., nursing care in the SSRU is less labor intensive) than in the PACU. Only basic monitoring
and observation are performed as the patient and his or her escort are prepared for imminent discharge to home.
Because of the rapid recovery of patients undergoing anesthesia with the shorter acting, faster emergence
anesthetics, some have questioned if all ambulatory surgical patients need to receive intensive postoperative care in
the PACU setting or whether first stage recovery from anesthesia can be achieved safely while still in the
operating room (at least for some patients), thereby resulting in enormous potential savings.
The SAFE study evaluates the impact of selective patient bypass of the PACU on both the outcomes of
ambulatory surgical patients and the use of resources in the surgical arena.
4
This study was designed to evaluate the
rapid recovery of patients undergoing ambulatory surgery using short-acting, fast emergence anesthetic agents and
to determine if policies and procedures could be developed that would allow patients to safely bypass first stage

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post-anesthesia care units (PACU) and whether such changes in the recovery paradigm would result in financial
savings for the surgical center. Five community based facilities (hospitals or surgery centers) participated in this
prospective observational study. While in the operating room at the end of the surgical procedure, anesthesiologists
were asked to assess all ambulatory surgical patients for recovery using standardizing discharge criteria typically
used at the end of a PACU stay (Table 1). If the patient met the discharge criteria, they were transferred from the
OR directly to the less labor intensive second stage recovery unit (SSRU). Financial data were provided from all
five sites detailing all costs associated with the recovery process. Clinical data on every elective ASA 1, 2 and 3
ambulatory surgical patient were collected over a three month period. During month one, data collected established
a baseline of case mix, time stamps, adverse events, bypass rates, and financial profile. During month two, an
educational intervention was provided on a multi-disciplinary basis to all units in the surgical center discussing the
implications of the bypass paradigm. After implementation of the paradigm (month three) weekly feedback reports
were provided to the site featuring the key outcomes of the study, and these reports were distributed to the health
care providers. Nearly 5,000 patients were entered into the study. The overall bypass rate increased from 15.9% in
the baseline month to 58.9% in the month following the educational intervention (p < 0.0001). The change in
process in this study went beyond reducing time spent in the PACU to eliminating the time spent in the PACU while
not increasing the time spent in the operating room or SSRU. In fact, the average (SD) time spent in the SSRU was
significantly shorter for patients who bypassed the PACU than for those who did not bypass the PACU. There were
no significant differences in other parameters of patient outcome. Annualized savings ranged from $50,000 to
$160,000 per site.
The Hows And Whys Of Preoperative Evaluation
The continued growth of outpatient surgery has created new roles for the anesthesiologist which seemingly
demands skills in addition to "giving a good anesthetic." The times from induction to emergence are no longer the
only important role for the perioperative physician. Particularly in the freestanding and office environments, it is
often the anesthesiologist who is most involved in the direct medical care of the patient; we are the physicians who
must insure that the patient is appropriately screened, evaluated, and informed prior to the day of surgery. Indeed,
the anesthesiologist/patient relationship which sometimes develops often takes on a primary care quality. Although
sometimes difficult to arrange, the preoperative interview and evaluation by a consultant anesthesiologist
(particularly in high risk patients) can be extraordinarily beneficial. In addition to lessening anxiety about the
surgery and anesthesia, in most cases, the anesthesiologist will be able to identify potential medical problems in
advance, determine their etiology, and if indicated, initiate appropriate corrective measures. Additionally, the
ambulatory anesthesiologist can play a critically important role in assuring that the patient understands and complies
with preoperative instructions. In most facilities, the goal is to resolve preoperative problems well in advance of the
day of surgery, thereby minimizing the numbers of both cancellations and complications.
At the present time, there are several commonly used approaches to screening patients for ambulatory
surgery. These include: (1) facility visit prior to the day of surgery, (2) office visit prior to the day of surgery, (3)
telephone interviews/no visit, (4) review of health survey/no visit, (5) preoperative screening and visit on the
morning of surgery, (6) virtual visit via the internet/no physical visit, and (7) the use of telemedicine technology.
Each system has its own advantages and disadvantages.
Should Patient Age or ASA Physical Status Influence Case Selection?
Although the vast majority of individuals scheduled for outpatient surgery are relatively healthy (ASA
Physical Status 1 and 2), practitioners are constantly being pressured by third party payors to consider "simple
outpatient surgery" for patients with significant baseline co-morbidities. A survey of members of the Society for
Ambulatory Anesthesia (SAMBA) revealed that half the respondents felt that their practice pushes the envelope of
patient safety by performing outpatient surgery on patients with serious pre-existing conditions, and that 40% of
respondents felt that their practice pushes the envelope of patient safety by performing complex or lengthy surgical
procedures on outpatients. In the past, many individuals had arbitrarily stated that freestanding ambulatory surgical
facilities were severely limited in the type of patients they could anesthetize, particularly with regard to age and
physical status. Clinical experience, however, suggests otherwise. In a retrospective study of over 1,500 cases of
patients anesthetized for ambulatory surgery, Meridy
6
was unable to demonstrate an age-related effect on the
duration of recovery or the incidence of postoperative complications. With regard to the issue of physical status, in
a prospective study involving over 13,000 patients at a freestanding ambulatory surgical center, Natof
7
concluded

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that ASA 3 patients whose systemic diseases were well controlled preoperatively were at no higher risk for
postoperative complications than ASA 1 or 2 patients. Chung examined predictors of adverse events in ambulatory
surgery in the elderly, as well as factors contributing to prolonged stay after ambulatory surgery in elderly patients.
This data demonstrated that outpatient surgery is safe in this patient population, with elderly patients sustaining
more minor cardiovascular events than their younger counterparts, and less postoperative nausea and vomiting, pain,
and drowsiness.
8, 9
. It is clear that geriatric and higher risk (physical status 3 and 4) patients may be considered
acceptable candidates for outpatient surgery if their systemic diseases are well controlled and the patients medical
condition is optimized preoperatively.
The Inappropriate Patient - Who's OK And Who's Not
There are few data to reliably categorize the inappropriate adult surgical outpatient. As anesthesiologists
have become more experienced with the anesthetic management of the problem surgical outpatient, the list of
"inappropriate" patients has dwindled. We must individualize our decision with regard to each patient; with few
exceptions, the appropriateness of a case for outpatient surgery is determined by a combination of factors including
patient considerations, surgical procedure, anesthetic technique, and anesthesiologist's comfort level.
At the University of Chicago Medical Center, we have distinguished several groups of patients who may
not be appropriate candidates for ambulatory surgery. As one might expect, this list is frequently modified to adapt
to the ever-changing conditions of our social and medicolegal environment.
Unstable ASA Physical Status 3 and 4: At the present time we are reluctant to proceed with elective ambulatory
surgery in a medically unstable patient. Instead, we use our anesthesia perioperative medicine clinic (APMC) to
screen these patients, and together with the primary care surgeon or interventionalist, establish a plan to proceed
with the surgery or intervention after medical stabilization. Contrary to the original "ground rules" of ambulatory
surgery, studies involving hundreds of thousands of patients seem to suggest that neither increasing age nor the
presence of stable pre-existing disease affect the incidence of postoperative complications in the surgical outpatient.
Malignant Hyperpyrexia: In our facility, overnight hospitalization and observation is usually indicated for patients
with a history of malignant hyperpyrexia or with identified susceptibility to malignant hyperpyrexia. However,
patients who are well educated, have a good understanding of their disease process, and have ready access to
medical care may be treated as outpatients by some centers.
Complex Morbid Obesity/Complex Sleep Apnea: Although patients who have a history of sleep apnea or who are
morbidly obese without systemic disease are acceptable candidates for ambulatory surgery, we prefer overnight
hospitalization and postoperative observation for morbidly obese surgical patients with significant pre-existing
cardiac, pulmonary, hepatic or renal compromise or those patients with a history of complex sleep apnea. Practice
guidelines for the perioperative management of patients with obstructive sleep apnea have recently been developed
by the American Society of Anesthesiologists and offer recommendations for preoperative evaluation, preoperative
preparation, intraoperative management, postoperative management, and site of surgery (inpatient vs.
outpatient).
10

Acute Substance Abuse: Because of the increased likelihood of acute untoward cardiovascular responses when
one administers an anesthetic to a patient who has recently abused illicit drugs, we preoperatively counsel these
patients and inform them that any sign of recent drug abuse on the day of surgery will result in immediate
cancellation of their anesthetic. We tell them that no elective surgical procedure "is worth dying for" and encourage
their preoperative participation in a rehabilitation program.
Anesthesiology directed perioperative medicine clinics are increasingly used to optimize the medical
condition of a patient in preparation for surgery. These clinics have been shown to enhance patient safety
11
,
improve patient satisfaction
12,13
, minimize preoperative consultation
14
, and reduce day of surgery case cancellations
and case postponements.
15

Changes to the ASA Standards for Basic Anesthesia Monitoring

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For the first time in nearly a decade, there has been a significant change to the ASA Standards for Basic
Anesthesia Monitoring.
16
The standard for monitoring of ventilation has undergone significant revision:
VENTILATION: 3.2.4: During regional anesthesia (with no sedation) or local anesthesia (with no sedation), the
adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs. During moderate or
deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs
and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the
patient, procedure, or equipment. Many physicians have asked if these standards apply to cases where sedation is
administered in out of operating room locations. The Centers for Medicare and Medicaid (CMS) Revised Hospital
Anesthesia Services Interpretative Guidelines seemingly provide guidance on this issue. The first section in these
Interpretative Guidelines is entitled Types of Anesthesia Services and the first bullet in this section begins as
follows: Anesthesia services, which include both anesthesia and analgesia, are provided along a continuum,
ranging from the application of local anesthetics for minor procedures to general anesthesia for patients who
require loss of consciousness as well as control of vital body functions in order to tolerate invasive operative
procedures. This continuum also includes minimal sedation, moderate sedation/analgesia (conscious sedation),
monitored anesthesia care (MAC), and regional anesthesia.
CMS Issues Revised Hospital Anesthesia Services Interpretive Guidelines
CMS has recently issued significant revisions to the Anesthesia Services Interpretive Guidelines.
16
These
included significant revisions to the CMS compliance requirements for both pre and post anesthesia evaluations, as
well as a requirement that heretofore, ALL anesthesia and sedation services (including mild, moderate, and deep
sedation) , regardless of providers MUST be organized into a single anesthesia service under the direction of a
qualified doctor of medicine or doctor of osteopathy. Specific portions of these Interpretive Guidelines will be
addressed during the presentation.
Computer-Assisted Personalized Sedation (CAPS)
Ethicon Endo-Surgery, Inc. has developed a computer-assisted personalized sedation system (trade name
SEDASYS

) According to the manufacturer, the SEDASYS

System is the first computer-assisted personalized
sedation (CAPS) system designed for physician/nurse teams to provide minimal-to-moderate sedation levels with
propofol. By integrating drug delivery and patient monitoring, the SEDASYS

System enables physician/nurse

teams to deliver personalized sedation. It automatically detects and responds to signs of over-sedation (oxygen
desaturation and low respiratory rate/apnea) by stopping or reducing delivery of propofol, increasing oxygen
delivery and automatically instructing patients to take a deep breath.
On May 28, 2009, the Anesthesia and Respiratory Therapy Devices Advisory Committee of the US Food and
Drug Administration (FDA) concluded its deliberations and recommended to the FDA that the SEDASYS

device
be approvable for the administration of propofol by physician/nurse teams for the initiation and maintenance of
minimal to moderate sedation during screening and diagnostic procedures in patients undergoing colonoscopy and
esophagoduodenoscopy procedures with the following conditions:
1) The device may only be used in adult patients (ASA I, II, and III) 70 years old or younger;
2) The device may only be used in the presence of a 3 person clinical team where one person shall have the sole
responsibility of monitoring the patient, the device and managing the patient's airway. This dedicated person must
have advanced training and at least the skills of a nurse;
3) Physicians utilizing the device must complete training in advanced airway management, pharmacology of
propofol and opioids, patient selection, monitor training (such as SpO
2
monitoring), device set-up and maintenance
with the training provided by a clinician with credentials to provide deep sedation to general anesthesia. In addition,
there needs to be a program established for ongoing maintenance of training;
4) The manufacturer must complete all post-marketing studies as proposed at the time of the Advisory Panel
hearing.
5) The product launch is controlled.
On several occasions, representatives of the company have suggested that the device is compliant with
ASA guidelines on sedation/analgesia by non-anesthesiologists; as a result of this claim both medical professionals
and lay people have occasionally erroneously concluded that the device is consistent with ASA standards,
guidelines, statements and/or policies.
17
Indeed, some individuals have mistakenly concluded that ASA has

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endorsed the product. However, this conclusion is erroneous. In the AANA-ASA Joint Statement Regarding
Propofol Administration (April 14, 2004) the ASA position regarding the use of propofol is clearly stated as
follows:
18

Whenever propofol is used for sedation/anesthesia, it should be administered only by persons trained in the
administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic
procedures. This restriction is concordant with specific language in the propofol package insert, and failure to
follow these recommendations could put patients at increased risk of significant injury or death.
In April 2010, Johnson & Johnson, the parent company of Ethicon-Endo Surgery, Inc., announced that the
FDA sent the company a not approvable letter for the SEDASYS

Computer Assisted Personalized Sedation

System. The company had appealed this decision and on May 10, 2013 the company announced that the FDA had
granted PMA approval for the device. The SEDASYS

System is expected to be introduced on a limited basis

beginning in 2014. The company will collaborate with the gastroenterology, anesthesiology and nursing
communities to successfully integrate the SEDASYS

System, and conduct two post-approval studies to monitor the

use of the technology in actual clinical practice. During the session, we will review many of the specifics of this
device and present an update on its current approval status.
Summary
Today there is a continued trend to expand the indications for ambulatory surgery. Because outpatient
anesthesia is a break from our traditional training, we are constantly being confronted with the need for change in
our clinical practice patterns. We have recognized that the needs of the surgical outpatient may be very different
from the inpatient and are now trying to adapt our practice patterns to meet the psychologic and pharmacologic
requirements of the compacted perioperative management the outpatient receives. This Refresher Course has
focused on some of the controversial problems which we as practicing clinicians must deal with every day in our
practice of ambulatory anesthesia for adult patients.

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REFERENCES
1. Chung F: Are discharge criteria changing? J Clin Anesth 1993; 5:64S-68S.
2. Chung F: Recovery pattern and home-readiness after ambulatory surgery. Anesth Analg 1995; 80:896-902.
3. Aldrete JA: J Perianes Nurs 1998; 13(3):148-55.
4. Apfelbaum JL, et al: Anesthesiology 2002; 97:66-74.
5. Sandberg et al: Anesthesiology 2012; 117:4: 772-779.
6. Meridy HW. Anesth Analg 1982, 61:921-6.
7. Natof HE. Ambulatory surgery: Patients with pre-existing medical problems. Ill Med J 1984; 166(2):101.
8. Chung F, Mezeu G, Tong D. BJA 1999, 83(2): 262-70.
9. Chung F, Mezei G. Anesth Analg 1999, 89(6): 1352-9.
10. Gross JB, et al. Anesthesiology 2006; 104(5):1081-1093.
11. Parsa P, et al. Anesth Analg 2004; 100:S-147.
12. Parker BM, et al. J Clin Anesth 2000; 12:350-6.
13. Harnett, et al. Anesthesiology 2010; 112:66
14. Fischer SP. Anesthesiology 1996; 85:190-206.
15. Ferschl MB, et al. Anesthesiology 103(4):855-859.
16. http://www.asahq.org/For-Members/Clinical-Information/Standards-Guidelines-and-Statements.aspx
17. Pambianco, et al: GI Endoscopy 2008;68: 542-547
18. http://www.asahq.org/publicationsAndServices/standards/37.pdf




TABLE 1. DISCHARGE CRITERIA

Awake, alert, oriented, responsive (or return to baseline)
Minimal pain
No active bleeding
Vital signs stable (not likely to require pharmacologic intervention)
Minimal nausea
No vomiting
If nondepolarizing neuromuscular blocking agent used, patient can perform sustained five second head lift
Oxygen saturation of 94% on room air (three minutes or longer) OR return of oxygen saturation to baseline
or higher in order to be eligible to bypass Phase I recovery (PACU), the patient must meet ALL of the
above criteria, and in the judgment of the anesthesiologist, be capable of transfer to the step-down unit,
with appropriate care and facility for patient management at that location


Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

Refresher Course Lectures Anesthesiology 2013 American Society of Anesthesiologists. All rights reserved. Note: This publication contains
material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
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Preoperative Evaluation of the Adult Outpatient
Barbara S. Gold, M.D. Minneapolis, Minnesota
Introduction
Preoperative evaluation is a fundamental component of anesthetic delivery because it guides anesthetic management
and postoperative care. This is especially true in the ambulatory surgical setting where preoperative evaluation also
informs patient selection. Patient selection, in turn, is the cornerstone for safe and efficient ambulatory anesthesia
care.
In the outpatient setting the preoperative anesthesia assessment which exists in a variety of forms - is a key tool for
both optimizing medical and administrative outcomes. Proactive identification and management of medical
problems avoids last minute surprises that at best interrupt ambulatory surgery center patient flow and at worst
contribute to adverse medical outcomes. This lecture will review: 1) the basic requirements for preoperative
evaluation as determined by payers and regulators 2) models of preoperative evaluation and their merits and 3)
preanesthetic evaluation of selected co-morbidities which are particularly relevant to the outpatient setting such as
obesity, sleep apnea, cardiac disease, and insulin requiring diabetes.
Ground Rules
The ground rules that govern US hospitals as set forth by the Joint Commission state that prior to any operative or
other high risk procedure the patient receives a medical history and physical examination no more than 30 days prior
to surgery. (Standard: RC.02.01.03, PC.01.02.03, EP 5) The American Society of Anesthesiologists has adopted
standards (last amended in 2010) for preanesthesia care which is more specific http://www.asahq.org/For-
Healthcare-Professionals/Standards-Guidelines-and-Statements.aspx; accessed 5/13)
Basic Standards for Preanesthesia Care
The anesthesiologist, before the delivery of anesthesia care, is responsible for:
1. Reviewing the available medical record.
2. Interviewing and performing a focused examination of the patient to:
a. Discuss the medical history, including previous anesthetic experiences and medical therapy.
b. Assess those aspects of the patients physical condition that might affect decisions regarding perioperative
risk and management.
3. Ordering and reviewing pertinent available tests and consultations as necessary for the delivery of anesthesia care.
4. Ordering appropriate preoperative medications.
5. Ensuring that consent has been obtained for the anesthesia care.
6. Documenting in the chart that the above has been performed.
Furthermore the ASA Statement on Documentation (last amended in 2008) lists specific elements of the
preanesthesia evaluation that should be recorded and further states that this is the responsibility of an
anesthesiologist. (www.asahq.org/publicationsAndServices/sgstoc.htm, accessed 5/13) The content of this
evaluation is to include medical history, anesthetic history, medications, appropriate physical exam including vital
signs and documentation of airway assessment, review of objective diagnostic data and medical records, medical
consultations when applicable, assignment of ASA physical status, formulation of anesthetic plan and
documentation of risks and benefits of the plan including discharge issues when indicated. The Center for
Medicare and Medicaid Services (CMS) issued Revised Hospital Anesthesia Services Interpretive Guidelines in
December 2009 (with a clarification in January 2011) which reflect the ASA Statement for documenting
preoperative assessment.
What then is the best approach for satisfying these minimum requirements and professional society expectations?
Clearly, the answer depends on the type of facility, patient population and procedures. Patient selection criteria, and
hence evaluation paradigms, for a free-standing or office based practice will undoubtedly differ from a hospital

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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
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based practice in a tertiary care center. In spite of these differences, there are some unifying guiding principles that
apply to all settings.
For starters, the basic requirements as outlined above need to be satisfied in a manner that is consistent and efficient.
The goal is to determine who is fit for outpatient surgery and then to optimize those candidates. The extent and
focus of the preanesthesia assessment is determined by the patients co-morbidities and type of surgical procedure.
Secondly, a plethora of studies indicate that laboratory exams should be obtained for medical indication
only and that routine testing is of no value, especially in the ambulatory setting. (1-3) However, the information
gained from a thorough history and physical exam and clear communication with members of the perioperative team
is of considerable benefit. Investigators of the Australian Incident Monitoring Study database identified poor airway
assessment, communication problems, and inadequate preoperative evaluation as contributing factors in 197
preventable major adverse events (incidence 3.1%) including death and major morbidity. (4) While laboratory
exams may not be useful, basic patient evaluation and communication of salient features are still essential.
Over the past few decades, several models have been developed to facilitate preoperative communication,
triaging, and medical evaluation. All of these models have their strengths and weaknesses, depending on the facility
(free-standing center, office, hospital, etc.) and the patient population.

Models for Systematic Preoperative Evaluation
Patients can be evaluated on the day of surgery or seen in a preoperative evaluation clinic, or some hybrid version.
The preferred model depends on patient demographics and type of facility. Patients evaluated the day of surgery
have usually had a screening telephone interview with a preoperative nurse several days in advance of the procedure
with anesthesiologist consultation as necessary. This method can be quite effective and efficient if relevant patient
records (i.e., history and physical, laboratory values) are available at the time of the telephone screen, the nurses are
well trained at interviewing, and have algorithms for seeking physician consultation. At the other end of the
spectrum are preoperative evaluation clinics where patients are seen well in advance of surgery by an
anesthesiologist and/or advanced practice nurse. These clinics are usually found in larger tertiary medical centers
and face-to-face visits are reserved for patients with extensive co-morbidities. These clinics require institutional
support and delineated organizational infrastructure. (5)
Regardless of the method used, preoperative screening is cost effective and has the potential to yield
substantial dividends by minimizing delays, cancellations, and opportunity costs. (6-8) While data for ambulatory
surgery are limited, in a large urban medical center Ferschl and colleagues found same day surgery patients seen in
the preoperative evaluation clinic had a cancellation rate of 8.4% as compared with a cancellation rate of 16% for
same day patients who were not evaluated in clinic. Cancelations have significant negative financial impact, with
estimates of over $1500/hr of lost revenue for every hour the OR sits idle (contribution margin).
Data are beginning to emerge using preoperative assessment to predict future hospital costs. In the
National Surgical Quality Improvement Program (NSQIP), 51 preoperative risk factors such as Cr > 1.2 or previous
cardiac surgery, predicted post-operative cost variation due to complications and extended hospital stay. (9) The
authors speculate that preoperative optimization of these risk factors would mitigate the occurrence of postoperative
complications and hospital costs. This remains to be determined.
Whether telephone screens or preoperative clinic visits are used, the model chosen for ambulatory
anesthesia evaluation needs to emphasize patient selection using evidence-based algorithms developed by
anesthesiologists and broadly shared with surgeons and their offices. This will permit effective triaging of patients
and optimization of medical conditions preoperatively. For example, a patient with a drug-eluting cardiac stent
placed within the year who abruptly discontinued clopidigrel would not be an appropriate candidate for elective
surgery, irrespective of the venue. However, the same patient a year later may be perfectly appropriate for a
hospital-based surgery center but not an office setting, depending on the procedure and other co-morbidities.

Medical Evaluation
This discussion will encompass medical co-morbidities that have considerable relevance to the outpatient setting due
to the associated perioperative risks and dilemmas posed by discharging the patient within a few hours of surgery
and anesthesia. Areas of focus include cardiac disease with an emphasis on stents and implantable cardiac rhythm
devices, obesity and obstructive sleep apnea, and diabetes and perioperative glycemic control.

Cardiac
There is an abundance of data, guidelines and opinions to guide preoperative evaluation of cardiac risk. This section
will focus on key studies and guidelines that are applicable to outpatients since the type of surgery is usually limited

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in scope, with minimal fluid shifts. However, most studies, which form the backbone of current guidelines, were
extrapolated from (in) patients having extensive procedures.
In guideline parlance, outpatient procedures are generally considered low risk however, lumping these
procedures can be misleading (i.e., a cataract repair is not equivalent to a rigid bronchoscopy). Consequently, it
becomes incumbent on the anesthesiologist to sort out which patients are at risk and require more extensive
evaluation. Risk stratification methods are useful but they all have their limitations, namely they are often
observational studies at a single institution. Nevertheless, common themes emerge.
A landmark study of 4315 patients over 50 years having noncardiac elective surgery was used to identify
independent risk factors, comprising the Revised Cardiac Risk Index (RCRI). (10) Although major cardiac
complications were rare (2%) six independent risk factors were identified:
High risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular)
History if ischemic heart disease
History of congestive heart failure
History of cerebrovascular disease
Preoperative treatment with insulin
Preoperative serum creatinine > 2.0 mg/dL

The authors specifically note that (T)he Index is of uncertain generalizability in lower-risk populations, such as
patients who undergo minor procedures.. However, data specifically examining that population is lacking so this
risk index is widely used.
While risk indices can be quite useful, Reilly used a simple and practical - screening tool to predict
perioperative risk, namely self-reported exercise tolerance. Poor exercise tolerance, such as the inability to walk 3
blocks or climb 2 flights of stairs (< 4 METS), is an independent predictor of serious perioperative complications
(OR 1.94, CI 1.19-3.17). Moreover the likelihood of serious complications is inversely related to the number of
blocks walked or flights of stairs climbed. (11)
A decade later, in a single-center observational study, Kheterpal used NSQIP data to identify preoperative
and intraoperative predictors of adverse cardiac events. (12) Their findings are consistent with findings from a
decade earlier, with some modifications. Those independent predictors are:
Age > 68 yrs
Active CHF
BMI > 30 kg/m2
Emergency surgery
Previous cardiac intervention
Cerebrovascular disease
Hypertension
Operative duration > 3.8 hrs
Administration of one or more units of PRBCs
All of the aforementioned predictors except for two (emergency surgery and administration of > 1 unit of PRBC) are
commonly encountered in the ambulatory setting. On a related note, a supporting study by Correll and colleagues
found that age > 65 was an independent predictor of preoperative electrocardiogram abnormalities. (13)
The findings from the aforementioned studies and many, many others led to the most recent (2007)
American Heart Association/American College of Cardiology guidelines on perioperative evaluation for patients
having noncardiac surgery. (14) (These guidelines were updated in 2009 with respect to perioperative beta-
blockade.) There are some key points in these guidelines as they relate to ambulatory surgery. First, ambulatory
surgery is considered as one entity and all ambulatory procedures are considered low risk with reported cardiac
mortality < 1%. Secondly, in the absence of active cardiac conditions, interventions based on cardiovascular
testing in stable patients would rarely result in a change in management and it would be appropriate to proceed with
the planned surgery. In other words, in the absence of active cardiac conditions (unstable coronary syndromes,
decompensated heart failure, significant arrhythmias, and severe valvular disease), additional interventions would
rarely alter perioperative risk for low risk procedures. However, although additional testing may not be warranted
(because it would rarely lead to a meaningful intervention), a complete and thorough history and physical exam
which can probe the presence or absence of active cardiac conditions is essential. The AHA/ACC guidelines
recognize that there are clinical risk factors (which are based on Lees Revised Cardiac Risk Index cited earlier).
However, in the absence of active cardiac conditions, further action is rarely needed.


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Previous Coronary Interventions: Stents and Cardiac Rhythm Devices
Stents
Approximately two million patients per year in Western countries have cardiac stents placed and 90% of
those stents are drug eluting stents which will require long term antiplatelet therapy. About 5% of stented patients
will present for noncardiac surgery within the first year of stent placement. (15,16) The implications of cardiac
stents and antiplatelet therapy on preoperative assessment requires a clinical understanding of the associated risks
and well defined preoperative policies to guide patient selection and evaluation.
With any coronary stent, there are risks, especially during the period of re-endothelialization. Until the
period of re-endothelialization is complete, patients need to remain on dual antiplatelet therapy (i.e., aspirin and
clopidigrel). Bare metal stents (BMS) are layered with endothelial cells after about 4-6 weeks. However, there is a
risk that these stents are vulnerable to restenosis over time hence the development of drug eluting stents (DES).
DES are coated with agents which impair cellular proliferation. This can prevent restenosis but also results in a
longer period of time to stent re-endothelialization. During this period, patients must remain on dual antiplatelet
therapy.
Premature discontinuation of dual antiplatelet therapy, especially in the perioperative period, can be
catastrophic due to stent thrombosis. (17-22) If noncardiac surgery is performed immediately after stent placement
and without antiplatelet therapy, there is a 30% risk of perioperative MI and 20-40% of those are fatal. The risk of
MI and death is 5-10 times higher than waiting the appropriate amount of time.
Practice guidelines are unequivocal in stating that elective surgery be postponed until patients have
completed an appropriate course of antiplatelet therapy. (14,18,22) The duration of antiplatelet therapy is currently
estimated at minimum of 4 weeks for BMS and 12 months for DES, with aspirin continued indefinitely. However,
some patients may be more prone to thrombosis and may need to remain on antiplatelet therapy for longer periods.
Predictors of stent thrombosis are: bifurcated lesions, long stents, diabetes, renal failure and low ejection fractions.
However, until more data are available, the practice guidelines are unequivocal.
The ACC/AHA 2007 Perioperative Guidelines state: Elective procedures for which there is significant
risk of perioperative or postoperative bleeding should be deferred until patients have completed an appropriate
course of thienopyridine therapy (12 months after DES implantation if they are not at high risk of bleeding and a
minimum of 1 month for bare-metal stent implantation).(14) Similarly, an ASA Practice Alert affirms the position
of the ACC/AHA Perioperative Guidelines. (22)
Since ambulatory surgery procedures are usually elective, patients need to defer surgery until 4-6 weeks
after placement of a BMS and one year after DES. Aspirin should be continued in the perioperative period if at all
possible. To avoid confusion and compromised patient care, it is extremely useful for surgery centers to have
policies that reflect these guidelines.
Cardiac Rhythm Devices
The perioperative assessment management of the adult surgical outpatient with a cardiac implantable
electronic device (CIED) a pacemaker, an implantable defibrillator or both, is fairly common. This poses clinical
and administrative challenges. (23-25) Indeed, perioperative management of these devices is the topic of an updated
ASA Practice Advisory. (25)
The indications for the CIED should be fully appreciated, as this often reflects significant underlying
cardiac disease. (23) Permanent pacemakers are indicated for symptomatic third-degree heart block, type II second-
degree heart block, sinus node dysfunction, recurrent neurally mediated syncope as well as some forms of
cardiomyopathy. For example, biventricular pacemakers are considered in patients with significant heart failure
(ejection fraction <35%) despite medical therapy. Implantable Cardiac Defibrillators (ICDs) are indicated in
patients who have had a cardiac arrest that is not due to a temporary condition. This includes a wide array of
problems including ischemia, long QT syndrome, hypertrophic cardiomyopathy or familial cardiomyopathy. Thus
the first question to be asked is: WHY was THIS device placed? The second question is whether the patient (and
procedure) are appropriate for outpatient surgery given the status of the cardiac disease.
If the patient and procedure are appropriate for the facility, then basic information about the devices should
be obtained either during a preoperative visit or telephone call. This should be done well in advance of surgery, so
that there is time to 1) decide if device interrogation or reprogramming by appropriate personnel will be necessary
and 2) have enough time to coordinate personnel for preoperative and postoperative care.

Preoperatively, the following information should be obtained (ASA Practice Advisory):
1. Indication for CIED
2. Is patient device dependent?
3. Type of device and manufacturer (available from manufacturers identification card)

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4. Assess CIED function
Date of last interrogation and results
Current setting
Does the device capture when it paces?
Effect of magnet on pacemaker function (ie, defaults to DOO at # bpm)
Does CIED automatically reset to preoperative settings when a magnet is removed?

5. Likelihood of device interference
Will electromagnetic interference (EMI) be likely during the procedure? (EMI is unlikely if the
device is < 10 years old and bipolar cautery is > 15 cm from device lead or generator)
Based on the likelihood of EMI, is reprogramming the CIED to asynchronous mode or disabling
rate responsive function with a magnet or reprogramming indicated?
Should antitachyarrhythmia functions be suspended? (By whom?)

Appropriate arrangements need to be made preoperatively so that the device can be reprogrammed (if necessary) in
advance of the procedure and immediately after the procedure, without unduly inconveniencing patients or
providers. If the device required reprogramming by the cardiology service/manufacturers representative
preoperatively then original settings will need to be restored postoperatively and before discharge from PACU.
Until those settings are restored, patients need to have cardiac monitoring with the capability to defibrillate
immediately (i.e., defibrillator pads in place).

Obesity
Approximately 36% of the adult US population is obese and ~ 69% are overweight and obese
(http://www.cdc.gov/nchs/fastats/overwt.htm, accessed 5/13). Obesity poses considerable perioperative challenges,
and this is especially true in the outpatient setting where patients are expected to be discharged within a few hours
after surgery. Associated co-morbidities such as obstructive sleep apnea and pulmonary dysfunction impact
postoperative recovery/discharge and hence the patient selection process. A thorough understanding of the common
obesity associated co-morbidities is useful to help formulate not only ambulatory anesthetic management but also
patient selection criteria.
Cardiovascular
There is a direct and independent relationship between obesity and hypertension. (26-28) Furthermore,
obese patients without documented hypertension are prone to occult diastolic dysfunction, probably secondary to
increased circulating blood volume and chronic LV wall stress. (29) Systolic dysfunction associated with obesity is a
later development, and is most often seen among obese patients with body mass index (BMI) > 40kg/m2 for > 10
years. (30) Cardiac function can be difficult to assess preoperatively due to diminished functional capacity.
Consequently, non-invasive testing with appropriate modalities (such as stress echocardiography) may be required if
patients have multiple risk factors or have limited functional capacity. (31,32)
Reconciling the AHA/ACC cardiac evaluation and care algorithm for non-cardiac surgery in obese patients
having ambulatory surgery requires clinical judgment. Indeed, this issue was highlighted in the recent advisory
from the AHA regarding the cardiac evaluation of severely obese patients: (T)hese categorizatons (low,
intermediate and vascular surgery) are used in the decision algorithm for further testing but it is unknown if obesity
influences these categorizaitons. (33) Consequently, this AHA advisory recommends a preoperative ECG in
severely obese patients (BMI > 40 kg/m2) with one risk factor for heart disease. If there are signs of CV disease
(e.g., CAD, RVH consistent with pulmonary hypertension), additional workup based on functional capacity be
pursued if it will change management.
Obesity and obstructive sleep apnea are associated with pulmonary hypertension which poses considerable
perioperative risk. However, diagnostic criteria (such as signs of right heart failure) in the absence of an
echocardiogram are vague, especially in the morbidly obese. The associated postoperative mortality in patients with
pulmonary hypertension across several different inpatient procedures is estimated to be 7-10%. (35,36) Due to
several factors, including intense intra and postoperative monitoring, these patients may not be candidates for the
vast majority of ambulatory procedures and need to be carefully evaluated on a case by case basis.
Obstructive Sleep Apnea (OSA)
The prevalence of OSA in obese patients presenting for bariatric surgery is 71% -77%, depending on (BMI). (37)
OSA is usually not a solitary diagnosis in an obese patient; associated co-morbidities include:
hypertension and increased risk of cardiovascular disease (e.g., stroke and sudden death). (38-40) Sudden cardiac
death in (non-surgical) obese patients is associated with a nocturnal pattern, which is distinctly different than in

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other populations. A review of polysomnograms and death certificates from 112 persons who experienced sudden
cardiac death demonstrated that those with OSA had peak in sudden death from cardiac causes during sleeping hours
(midnight to 6am). In contrast, those without OSA had peak incidence of sudden death after 6am. (41)
In the perioperative setting, patients with OSA have an increased incidence of postoperative complications:
Hwang measured home nocturnal desaturations preoperatively in 172 subjects. Patients with > 5 desaturations/hr
had significantly higher rate of postop complications (15%) vs. those with < 5 events/hour (3%). Complications
were primarily respiratory. (42) Chung evaluated 177 patients deemed at risk for OSA by various screening tools
and then performed polysomnography. (43) Those with apnea-hypopnea index (AHI) >5 as confirmed by
polysomnography had postoperative complication rate that was more than double those with AHI < 5 (27% vs.
12%).
Discerning who actually has OSA is challenging, as the diagnostic gold standard is polysomnography, which
many patients do not obtain. Diagnosis based on screening questionnaires is unreliable. A meta-analysis of clinical
screening tests for OSA illustrates that it is possible to predict severe OSA with a high degree of accuracy.
However, aside from severe OSA, false negative rates range from 14-38% which will miss a significant proportion
of patients. (44)
Nevertheless, simple screening methods have been developed for preoperative use including the STOP-
BANG questionnaire which has a sensitivity from 84% (AHI>5) to 100% (AHI >30). Patients who answer yes to
three or more items are considered to be at high risk of OSA. (43) Other similar validated tools incorporate upper
airway anatomy to enhance predictive modeling. (45)

STOP-BANG (Chung 2008)
1. Snoring
Do you snore loudly (louder than talking or loud enough to be heard
through closed doors)?
5. BMI
BMI more than 35 kg/m2?
2. Tired Do you often feel tired, fatigued, or sleepy during daytime?

6. Age over 50 yr old?
3. Observed
Has anyone observed you stop breathing during your sleep?
7. Neck circumference greater than 40 cm?
4. Blood pressure
Do you have or are you being treated for high blood pressure?
8. Male gender?

A main concern for patients with OSA is their suitability for ambulatory surgery. Is it safe to send these patients
home to an unmonitored setting after anesthesia and surgery? Data are scant since important determinants such as
severity of OSA, type of anesthetic and type of procedure have not been individually examined. Instead, we have
expert opinions extrapolated from inpatient setting and used as guide. The ASA Practice Guidelines for the
Perioperative Management of Patients with OSA (2006) state that literature is insufficient to make recommendations
and those guidelines are based on consultant opinion. (46) Moreover, the clinical screening tool suggested in ASA
Guideline has not been clinically validated. The ASA Guidelines recommend that anesthesiologists determine
whether a given surgical procedure and individual patient with (or at risk for) OSA is appropriate for outpatient
setting. Factors to consider include:
(1) severity of sleep apnea status
(2) anatomical and physiologic abnormalities
(3) status of coexisting diseases
(4) nature of surgery
(5) type of anesthesia
(6) need for postoperative opioids
(7) patient age
(8) adequacy of postdischarge observation
(9) capabilities of the outpatient facility

Specifically in reference to outpatients, the ASA Guidelines recommends: These patients should not be
discharged from the recovery area to an unmonitored setting (i.e., home or unmoniotored hospital bed) until they are
no longer at risk for postoperative respiratory depression. The Guidelines also recommend observing patients
while breathing room air in an unstimulated environment and note that this may require a longer ambulatory stay
(i.e., 3 hours longer than non-OSA counterparts and median of 7h after last episode of airway obstruction or

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hypoxemia while breathing room air in an unstimulating environment). Practical application has been challenging
because patients frequently do not have formal preoperative diagnosis of OSA and severity is difficult to estimate.
Most likely, recommendations in this arena will continue to evolve as more relevant data become available.
Obesity Hypoventilation Syndrome
Obesity Hypoventilation Syndrome (OHS) exists in about 10-20% of patients with both obesity and OSA,
and is characterized by the triad of obesity, daytime hypoventilation and sleep disordered breathing. Findings in
patients with OHS include upper airway obstruction, restrictive chest physiology, blunted central respiratory drive,
pulmonary hypertension and increased mortality. The mainstay of treatment is continuous positive airway pressure
and weight loss. However, these patients are at higher risk for morbidity and mortality as compared to based who
are eucapneic and obese. There are limited data on the perianesthetic management of these high risk patients, in any
setting. (47)

Diabetes
Approximately 14% of US adults aged >20 years and ~27% of individuals >65years have diabetes or impaired
fasting glucose. (http://www.cdc.gov, accessed 5/13) In order to evaluate potential end-organ damage and maintain
metabolic homeostasis these patients require a focused assessment to a) gauge appropriateness for procedure on an
outpatient basis, with a focus on potentially difficult airway in patients with long-standing Type I diabetes and b)
guide preoperative fasting and insulin instructions.
Cardiovascular disease is the major cause of morbidity and mortality amongst patients with diabetes, with
the most common conditions being hypertension and dyslipidemias. The most recent American Diabetes
Association guidelines (2012) recommend that patients with diabetes be treated to a blood pressure < 130 mm Hg
systolic and < 80 mmHg diastolic. (48) Furthermore, it is recommended that all patients with diabetes have serum
creatinine measured and cardiovascular risk factors such as dyslipidemia, hypertension, smoking, positive history of
coronary disease and presence of mico- or macroalbuminemia assessed annually. This is part of routine health
maintenance and is independent of surgical need. Further cardiac testing irrespective of the need for surgery -
should be considered in diabetics with typical or atypical anginal symptoms or an abnormal resting ECG. (48)
Patients with diabetes may be on complicated regimens to achieve glycemic goals in order to reduce the
risk of micro and macrovascular complications. In addition to insulin and conventional oral hypoglycemic agents,
treatment may include relatively new classes of gastrointestinal hormones namely incretins and amylin which
impact glucose homeostasis. (49) In adults glycemic goals are: A1C < 7 % and preprandial glucose 70-130mg/dl
and peak postprandial glucose < 180 mg/dl. (48) Due to concerns about perioperative hypoglycemia as delineated in
the NICE-SUGAR study, perioperative glycemic goals as suggested by the ADA are in the range of 120 180
mg/dl. (48,52)
To achieve those targets and simplify preoperative instructions, ambulatory surgery centers usually have
protocols which address the type and quantity of insulin (and other hypoglycemic agents) to be administered
preoperatively, recommendations for monitoring blood sugar preoperatively and treating hypoglycemia while
adhering to NPO guidelines. A common feature in these protocols is to include a basal form of insulin on the day of
surgery (usually as a fraction of the typical intermediate acting insulin or long acting insulin) and withhold oral
hypoglycemic agents and incretins. (48-50) A basic understanding of the time course of commonly used insulins,
as outlined below, is integral to developing effective preoperative instructions.
Insulin Comparison
Action Generic name Onset Peak Duration
Rapid Insulin Aspart 15 min 45-90 min 3-5 hrs
Short Regular Human Insulin 30 min 2.5-5 hrs 8 hrs
Intermediate NPH Insulin 1.5 hrs 4-12 hrs ~24 hrs
Long Insulin Glargine ~1 hr - up to 24 hrs
Long Insulin Detemir ~3 hrs ~6-8 hrs up to 24 hrs
Mixtures Insulin Aspart Protamine, Insulin Aspart 60 min 1-4 hrs up to 24 hrs
Mixtures Insulin NPH/ Regular, 70/30 ~30 min 2-12 hrs ~24 hrs

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Summary
Outpatient evaluation is the basis for patient selection, which is fundamental for safe and efficient ambulatory
anesthetic management. Models of evaluation include: assessment on the day of surgery, telephone triage, or
preoperative clinic visit. Each model has its advantages, and adoption depends on the facility and patient
demographics. Irrespective of the method, patients are evaluated with discharge planning in mind. Patients should
be suitable for elective surgery with the expectation that they can be safely discharged home within a few hours of
their procedure. Several co-morbidities affect this process and serve to refine patient assessments and selection
criteria.





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Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

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Anesthesia for Outpatient Diagnostic or Therapeutic Radiology
Thomas W. Cutter, M.D. Chicago Illinois
Diagnostic radiology procedures are anatomic or functional, minimally to non-invasive, cause little
pain or discomfort, and are most frequently performed without anesthesia services. When anesthesia care is
requested, it is typically because of the patients unique physiological or psychological needs or desires.
Therapeutic techniques are often more invasive and more likely to require an anesthesiologist because of the
complexity of the procedure and the comorbidities and discomfort of the patient. All therapeutic procedures are
to some degree interventional, but many diagnostic procedures are not, although an interventional radiologist
may perform them. Conducting anesthetics in the radiology department can be challenging because of the
patients comorbidities, the procedure, the anesthetic, the radiology equipment, and the environment.
Anesthetics can be one of three types: monitored anesthesia care (MAC), regional anesthesia, or
general anesthesia. Selection depends on the procedure and the relative risks and benefits to the patient.
Monitored anesthesia care, the least invasive anesthetic, is indicated when a procedure may nominally require
deep sedation or increased monitoring.
1
The anesthesiologist administers intravenous sedation and analgesia; the
proceduralist may give an additional local anesthetic at the site. Monitored anesthesia care is a physician service
that is distinct from moderate sedation because the anesthesia provider must be able to apply resources to
support life and ensure patient comfort and safety during diagnosis or therapy.
2

Diagnostic Radiology
Iodinated contrast media is used in both diagnostic and interventional radiology and may cause adverse
(anaphylactoid) reactions or renal dysfunction. Adverse reactions involve direct cellular effects, including
enzyme induction and activation of the complement, fibrinolytic, kinin, and other systems.
3
Manifestations
range from relatively benign itching to life-threatening cardiovascular or ventilatory collapse. Prophylaxis and
treatment for the former include antihistamines and steroids, while advanced cardiac life support measures may
be needed for the latter. Anaphylaxis is quite rare and is probably not a result of the iodine in the contrast
material.
4

Patient-specific risk factors for renal complications include chronic renal disease, diabetes mellitus, heart
failure, older age, anemia, and left ventricular systolic dysfunction. Contrast-specific risk factors are high
osmolarity, viscosity, volume, and ionic media. For patients with renal disease, diabetes, proteinuria,
hypertension, gout, or congestive heart failure, serum creatinine levels should guide the radiologists
administration of the contrast material. Adequate intravascular volume, bicarbonate, and low volumes of iso- or
low-osmolar contrast are indicated. Diabetic patients with preexisting renal dysfunction who also take
metformin have developed severe lactic acidosis after an iodinated contrast study. Thus, metformin should be
discontinued at the time of or before the procedure, withheld for 48 hours subsequent to the procedure, and
reinstituted only after renal function has been re-evaluated and found to be normal.
5
Intravenous gadolinium for
magnetic resonance imaging (MRI) contrast studies is not problematic during the anesthetic. Ultrasound contrast
is achieved through the intravenous administration of echogenic microbubbles, which carry an FDA warning
that patients with pulmonary hypertension or unstable cardiopulmonary conditions be closely monitored during
and for at least 30 minutes after administration.
6
Although barium is not an intravenous contrast, it should be
mentioned because it may pose an aspiration risk after ingestion during deep sedation or general anesthesia.
Anatomic Imaging
The ASA has issued a specific practice advisory
7
emphasizing a location or position for optimal patient
observation and vigilance during delivery of anesthesia in the MRI. The American College of Radiologists and
the Joint Commission on the Accreditation of Healthcare Organizations have also established standards,
guidelines, and recommendations for the MRI suite.
8-10
Anesthesia equipment must conform to the criteria of
the American Society for Testing and Materials and the Food and Drug Administration.
Patient monitoring and the administration of an anesthetic in the MRI suite are difficult because the
anesthesia provider is physically separated from the patient during the study. The patient must be observed
continually, either through a window into the scanner room or with a camera trained on the patient and a video
monitor in the control booth. Vital signs must be monitored through a window or via a camera trained on a
monitor in the scanner room or a slave monitor in the control room.
Monitor placement and the length and routing of leads, wires, and tubing should be considered to prevent
entanglement or traction as the MRI tables moves. Coiling monitor wires (e.g., pulse oximeter,

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electrocardiogram) should be avoided because this can cause patient burns.
11
Patient temperature should be
monitored because it may increase from the heat of radiofrequency radiation within the magnetic field,
12
or it
may decrease by radiation, conduction, convection, and evaporation. Monitoring temperature intermittently
instead of continuously may avoid the possibility of burns from the thermistor during long sessions or in
critically ill patients.
13

Medical emergencies must be anticipated and a plan in place to treat them. Although advanced cardiac life
support may be instituted on a patient still in the scanner, prompt relocation outside the scanner room gives
better access to the patient and is safer for the staff. If an emergency requires the magnet to be shut down
quickly, (quenching)
14
the liquid cryogen boils off rapidly and releases enormous amounts of helium vapor, so
an evacuation plan must be in place. The scanner is noisy and there have been reports of patient hearing loss
following MRI scan, so some form of ear protection is advisable, even for unconscious patients.
15

Airway management must be scrupulous and conservative because of the distance and barriers between the
anesthesiologist and the patient. It may be best to secure the airway outside of the scanner room and then
transport the patient into the room.
Electromagnetic waves (X-rays) have been incorporated into a number of different imaging modalities,
including static two-dimensional X-rays, dynamic two-dimensional X-rays (fluoroscopy) and three-
dimensional computed tomography (CT). Major issues include the anesthesia providers radiation exposure and
distance from the patient. The former is addressed by distance, lead, and personal dosimetry; the latter, by
following protocols for monitoring similar to those in the MRI suite. The U.S. Occupational Safety and Health
Administration has established limits for the exposure of individuals to radiation in restricted areas,
16
and
institutional guidelines should adhere to these standards. Radiology equipment (e.g., C-arm or CT aperture) can
make airway management and access to the patient difficult, and the anesthesia equipment often adds to the
difficulty of maneuvering in the suite, as can the encumbrance of a lead apron. The configuration of the table
and other equipment means that patient positioning, especially lateral or prone, can be problematic.
For diagnostic fluoroscopy procedures, the contrast material may be ingested (e.g., barium swallow),
administered per rectum (e.g., barium enema), or injected intravenously (e.g., intravenous pyelogram) or
intrarterially (e.g., aortogram). Many procedures can be performed without anesthesia support, unless a patients
comfort, comorbidities, or cooperation requires it. For example, diagnostic angiography is often performed with
no or only light to moderate sedation and analgesia by cardiologists; percutaneous transhepatic cholangiography
may be performed by a radiologist using the same regimen.
Computed tomography is an easily tolerated procedure for most patients and is relatively safe for personnel
since the X-ray beam is tightly focused. Although studies are performed in a few seconds or minutes, they
require a still patient, so cooperation must be assured either through patient reassurance or medications.
Like diagnostic X-rays, diagnostic ultrasound imaging is noninvasive and easily tolerated. In the absence of
invasive techniques, anesthesia support is not warranted; if it is indicated, no encompassing techniques or
precautions are necessary.
Functional (Brain) Imaging
Functional brain imaging reveals blood flow, metabolism, or electrical activity. Electrical activity is
represented by the electroencephalogram (EEG), which directly measures the electrical potential between two
scalp electrodes. The EEG is spatially limited by the number of electrodes, a limitation that has been improved
by high-density arrays of over 120 electrodes.
17
Magnetoencephalography is a more sensitive technology that
records local magnetic fields produced by neuronal electrical activity in the brain via extremely sensitive
instruments such as superconducting quantum interference devices.
Other functional brain imaging techniques rely on the remarkably consistent relationship between regional
changes in the cellular activity of the brain and changes in the blood flow and metabolism of the region.
18
Blood
flow is revealed by functional MRI (fMRI), positron emission tomography (PET), and single-photon emission
computed tomography (SPECT). A functional MRI distinguishes between the distinct magnetic resonance
signals of oxygenated hemoglobin (diamagnetic) and deoxygenated hemoglobin (paramagnetic). A less common
technique uses arterial spin labeling to magnetically alter the protons in the water molecules of the arterial blood
in the neck and then identify them as they perfuse the brain. Functional MRI has been useful in determining the
functional relationship between tumors and surrounding tissues.
19

A PET scan involves injecting a radionuclide molecule that emits positrons which annihilate electrons and
produce gamma rays that are then detected by the scanner. The amount of imaged tracer reflects blood flow and
concomitant brain activity. Regional metabolic activity can be seen if the radionuclide molecule contains [F]-2-
fluoro-deoxy-d-glucose (FDG),
20
which concentrates in the more active areas. Positron emission tomography is
often combined with CT or MRI to correlate anatomy with function. Like PET, SPECT detects gamma rays but
the tracer material itself emits gamma radiation as it decays. More material indicates greater blood flow.
Metabolic activity also can be revealed through magnetic resonance spectroscopy, which detects signals
specifically from hydrogen or phosphorous to determine the concentration of brain metabolites in tissue; greater
levels indicate greater metabolic activity.

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These procedures are often performed on awake individuals, although occasionally a patients psychological
or physical condition may require the use of sedation or general anesthesia. Administering anesthetic
psychotropes may result in artifacts that disrupt the remarkably consistent relationship between regional
changes in the cellular activity of the brain and changes in its circulation and metabolism. Isoflurane is
associated with a relatively global reduction in brain glucose metabolism during PET with FDG.
21
Propofol
causes a larger absolute metabolic reduction, a greater suppression of cortical metabolism, and significantly less
suppression of basal ganglia and midbrain metabolism.
22
Propofol preferentially decreased cerebral blood flow
in brain regions previously implicated in the regulation of arousal, performance of associative functions, and
autonomic control and had more regional impact.
23
Using fMRI, morphine demonstrates a regional effect,
decreasing the signal in cortical areas as do propofol and midazolam, but activating endogenous analgesic
regions such as the periaqueductal gray, the anterior cingulate gyrus (decreased signal), and hypothalamus
(increased signal).
24
Midazolam impacts fMRI by significantly altering the signal in the brains auditory and
visual cortices.
25
Mechanical maneuvers can also influence imaging outcomes, such as an increased mean
airway pressure (e.g., continuous positive airway pressure) reducing the fMRI signal in the primary visual
cortex.
26

There are no strong recommendations for anesthetic technique for these diagnostic procedures. Indeed,
functional brain imaging techniques such as PET and fMRI have been used to study the effects of general
anesthesia on the brain, and a systematic baseline response to anesthetics has not yet been developed.
27-29
If an
anesthetic is required, the anesthesiologist should consider the anesthetics impact on cerebral blood flow,
metabolism, and electrical activity and choose agents with minimal effect, combine agents to minimize their
effects, and maintain steady-state anesthetic conditions during the study.
Therapeutic Radiology
Therapeutic radiology has grown from relatively simple percutaneous procedures for aspiration/drainage to
complex embolizations of arteriovenous malformations and the placement of arterial stents. It epitomizes the
adage, There is no body structure that cannot be reached with a number 14 needle and a good strong arm,
especially now that structures can be visualized in real time. Minor procedures such as biliary tube placement or
exchange, tunneled catheter placement, vascular interventions, and other catheter insertions have been
performed using moderate sedation, during which nurses, trained in critical care, monitor the patient and
administer low-dose midazolam and fentanyl.
30
Adverse events are few and minor without clinical impact.
30
Less rather than more sedation is the rule in Europe, although general anesthesia is more common in Europe
when anesthesia is utilized. In one East Coast academic center, MAC or general anesthesia was used for only
10% of cases for interventional radiology.
31

As it increases in volume and complexity, interventional radiology is more often being performed in emergency
settings and also includes more high-risk patients who cannot tolerate a more invasive (e.g., surgical)
intervention, making an anesthesiologist necessary.
32
The conditions for performing an anesthetic for
therapeutic radiology procedures include those for diagnostic radiology: monitoring from afar, avoiding
radiation exposure, working with radiology equipment and prohibiting ferrous materials in the MRI suites. The
choice of anesthetic technique for interventional radiology is procedure specific with wide variations, depending
on the patient and the skill sets of the interventionalist and associated personnel. The anesthetic presents more
challenges because the procedure is invasive and the patient may have several comorbidities. The goal of a
completely still patient, both for the success of the procedure and the safety of the patient, can sometimes be
attained by sedation and analgesia administered either by the proceduralist or an anesthesia provider. If a
predictable ventilatory pattern in the patient is desired, it can be achieved by the judicious administration of
medications to a cooperative patient or by general anesthesia with controlled ventilation. Some particularly
painful procedures (e.g., radiofrequency ablation of osteoid osteomas) require a subarachnoid block or general
endotracheal intubation by an anesthesiologist .
31
Other procedures associated with extreme fluid shifts (e.g.,
drainage of ascites fluid or blood loss during a uterine artery embolization) benefit from the presence of
someone who is well versed in intravenous access. Some procedures may require anticoagulation and the means
to measure its effects (e.g., activated coagulation time).
Fluoroscopy is the imaging modality typically used for endovascular stent placement. There is a significant
procedural potential for complications and the patient may have been considered too sick for open surgery.
33

Among the anesthetic techniques used for endovascular aortic repair are general, epidural, combined
epidural/spinal,
34
spinal, and continuous spinal.
35
Even when performed under MAC, one must be prepared for
significant blood loss and invasive monitoring.
36
Mild hypotension, and an immobile patient are important when
deploying the stent. Spinal cord injury may be decreased by limiting hypotension, monitoring evoked potentials
and cerebrospinal fluid (CSF) pressure, and measuring CSF proteins (S100 !) during thoracic aneurysm
stenting.
37
An intrathecal drain may be beneficial for thoracic aneurysm procedures,
38
but it may also lead to
catheter-related complications.
39

Carotid artery stenting may be superior to traditional carotid endarterectomy in patients who are at overall
increased surgical risk.
40
Aspirin and clopidrogel are often administered before the procedure and heparin is

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given intraoperatively while activated clotting time is monitored. Stenting may be performed in a patient under
MAC, with close attention paid to central nervous system changes and bradycardia,
33
or under general
anesthesia. General anesthesia depresses barorecepter reflex sensitivity and induces hemodynamic stability,
potentially decreasing complications.
41

Stenting to improve blood flow through iliac, popliteal, subclavian, or renal arteries does not mandate the
presence of an anesthesiologist
42
unless the patients comorbidities require it. Stenting of venous outflow has
been used for chronic nonmalignant or malignant obstruction of the femoroiliocaval vein,
43
and patients with
neoplastic superior vena cava syndrome have received palliative stents without sedation.
44

A transjugular intrahepatic portosystemic shunt relieves portal hypertension by using an expandable metallic
stent to create an artificial channel between the branches of the portal and hepatic veins. It is typically
performed under MAC or general anesthesia,
45
with the patients mental status, ability to tolerate the procedure
without moving, overall hemodynamic status, and ease of airway management dictating the type of anesthesia.
Significant comorbidities can include pathological shunting in vascular beds, leading to increased cardiac output
and heart failure. Ascites, pleural effusions, intrapulmonary shunting, pulmonary hypertension, hepatorenal
syndrome, encephalopathy, and coagulopathies are common in these patients. Because of hepatic insufficiency,
the anesthetic agents selected should not depend on the liver for clearance.
46
A cirrhotic cardiomyopathy is
prone to a prolonged Q-Tc interval, which may deteriorate into a torsades de pointes arrhythmia.
Thrombolysis results from the local infusion of tissue plasminogen activators that create plasmin with
ensuing fibrinolysis. Common agents include streptokinase, urokinase, and recombinant formulations.
Thrombolysis is used in patients with myocardial infarction, ischemic stroke, pulmonary embolism, thrombosed
dialysis access, portal vein thrombosis, and acute limb ischemia. Anesthesia is seldom required, but if it is, the
anesthetic depends on the patients comorbidities and avoiding trauma during airway maneuvers. Neuraxial
regional anesthesia is contraindicated.
47

Inferior vena cava filters are placed in patients who have a history of or who are at risk for deep vein
thromboses in the lower extremities. Access is obtained through the right internal jugular vein or a femoral vein.
The procedure may be performed without sedation, although anxiolysis or moderate sedation may be
administered by the interventional radiologist. General anesthesia or MAC is occasionally necessary.
In balloon angioplasty, a narrowed or obstructed blood vessel is widened with a balloon-tipped catheter.
Carotid angioplasty has been performed with deep cervical plexus blockade,
48
MAC, or general anesthesia. The
same concerns apply as for carotid stenting, which is often preceded by balloon angioplasty. Relatively minor
procedures, such as percutaneous transluminal angioplasty of the infrarenal aorta, can be safely performed with
only local anesthesia by the interventionalist.
49

Chemoembolization is currently limited to either primary or metastatic hepatic tumors,. A catheter is inserted
into the femoral artery and guided under fluoroscopy into the hepatic artery. Contrast material is then injected to
identify the arterial supply to the tumor. A chemotherapeutic agent such as doxorubicin is then injected,
followed by an embolic agent such as iodized poppy seed oil, which both limits the tumors blood supply and
traps the agent in close proximity to the tumor. Combination therapy with cisplatin, doxorubicin, and mitomycin
C often enhances the tumor-specific toxicity.
50
The procedure is typically performed without an
anesthesiologist. If anesthesia is requested, the primary anesthetic concerns are patient comorbidities,
coagulopathies, and hepatic insufficiency.
Vascular access is the placement of catheters in large veins for the infusion of medications (e.g.,
chemotherapy, parenteral feedings, antibiotics), dialysis, or blood sampling. Adults seldom require an anesthetic
for catheter placement, but if anesthesia is needed, special attention is given to the patients coexisting diseases
and to the risk of air emboli through an open, large-bore catheter during spontaneous ventilation.
Uterine fibroids, varicoceles, esophageal varices, and arteriovenous malformations can be embolized under
fluoroscopy. A catheter is inserted through a large artery or vein with the tip positioned near the structure to be
embolized. Particles (e.g., gelfoam or particulate agents such as gelatin-impregnated acrylic polymer spheres),
sclerosing agents (e.g., alcohols), metal coils, or liquid glue are used. The procedure is typically performed
without an anesthesiologist.
For uterine artery balloon occlusion in parturients at risk for hemorrhage, both general
51
and epidural
52
anesthesia have been utilized. An epidural catheter is placed before the balloon catheter is inserted to avoid
displacement of the balloon when the patient is positioned and to provide analgesia should the patient undergo a
cesarean section. Preparations should be in place for adequate intravenous access and invasive monitoring.
In percutaneous nephrolithotomy, medium-sized or larger kidney stones are removed from the urinary tract
with a nephroscope. The patient is placed prone and a track is created through a small incision above the kidney,
through which dilators and finally the nephroscope are inserted. If the stones are small, they may be removed
directly. For larger stones, percutaneous nephrolithotripsy can break up the calculi into manageable pieces; this
procedure typically requires a neuraxial block or general anesthesia.
53
Risks include excessive fluid absorption,
dilutional anemia, hypothermia, the potential for significant blood loss,
54
and renal insufficiency. Potential
complications are many and include pneumothorax or hydrothorax, pneumonia/atelectasis, paralytic ileus,

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nephrostomy tube dislodgment, urine drainage from the flank lasting more than 1 week, infection, urinoma
formation, renal pelvic laceration, ureteral avulsion, ureteropelvic or ureteral stricture, bowel injury, or escape of
stone fragments into the retroperitoneum.
55

Percutaneous biliary drainage may be performed with local anesthesia at the site of the drain tube and with
supplemental intravenous sedation and analgeisa. When pain is anticipated from large drainage catheters or
dilatation of the transhepatic tracts, epidural or general anesthesia is recommended.
56
Hepatic insufficiency and
the potential for blood loss should be considered.
Ablative therapies demand cross-sectional images for accurate needle, probe, or catheter placement, which is
accomplished with CT, MRI or ultrasound imaging. The same general imaging-specific caveats apply as for
other therapeutic and diagnostic procedures. Thus, radiation exposure in the CT suite is monitored, and
precautions against ferrous materials are taken in the MRI suite. The preanesthesia evaluation focuses on patient
comorbidities.
Hyperthermic ablation includes radiofrequency (RFA), microwave, or laser ablation. In RFA, the most
common procedure, electrical currents in the radiofrequency range heat an electrode that has been
percutaneously or directly placed within a tumor, with kidney, lung, breast, bone, and liver being common
targets. Because healthy tissue is better able to withstand heat, radiofrequency energy preferentially destroys the
tumor and only a small edge of normal tissue around its edge. The heat also cauterizes small blood vessels,
potentially reducing hemorrhage. Moderate sedation is often adequate for the percutaneous approach.
57
General
and epidural anesthesia are often used for RFA of renal cell tumors.
58
Since the ablation process produces heat,
precautions must be taken when the electrode is adjacent to critical structures. For example, during RFA for a
mediastinal lymph node, a temperature probe was applied to the endotracheal tube cuff to monitor the tracheal
temperature. When temperature rose, chilled saline was substituted for air in the cuff to prevent tracheal
trauma.
59

Cryoablation is used for tumors in the lung, liver, breast, kidney, or prostate. Liquid nitrogen or
gaseous argon destroys tissue by direct freezing, denaturation of cellular proteins, cell rupture, cell dehydration,
and ischemia. Patient comfort and safety have been provided with local or general anesthesia.
60
In lung
cryoablation, inflammation may result from the thawing phase of the ablated tissue. Cracking of a cryoablated
liver may cause significant hemorrhage.
50

Interventional Neuroradiology
Interventional neuroradiologists use imaging techniques combined with catheters and other devices to treat
vascular lesions in the central nervous system (CNS) and surrounding tissues. They either occlude blood flow
through abnormal vessels or increase blood flow in occluded vessels.
61
Cross-sectional imaging techniques
assist in diagnosis, and the procedures are performed under fluoroscopy.
Anesthesiologists are often needed because of the complexity of the procedure, the medical status of the
patient, or the need for immobility. The preanesthesia assessment focuses on the patients neurologic status and
comorbidities. An anesthetic plan must consider the potential for disease progression or iatrogenic
complications. Consultation with a neuroradiologist determines whether the patient must be responsive for
continuous CNS evaluation or whether rapid emergence from general anesthesia is preferred. Anesthetic
medications for a responsive (MAC) patient include propofol, dexmedetomidine, and fentanyl; for general
anesthesia, propofol, sevoflurane, and desflurane.
62
Nitrous oxide should be avoided because of the potential for
enlarging emboli. Laryngeal mask airways may be considered for airway management.
Intraprocedural concerns include elevated intracranial pressure, hemorrhage, blood pressure, and
cerebrovascular occlusion. Control of carbon dioxide may be necessary for certain procedures. Hypercapnia has
been used to vasodilate cerebral vessels for catheter entry, to enhance catheter propagation during superselective
cerebral catheterization, and to increase cerebral venous outflow, thereby favoring movement of an embolizing
agent away from intracranial drainage pathways.
63
Hypocapnia may be used to decrease cerebral blood flow and
lower intracranial pressure. Patient considerations include temperature, either warm for comfort or cool for
cerebral protection.
64
Bladder distention may be a concern because these are often lengthy procedures and
intravascular volume/renal perfusion must be maintained in the presence of a dye load.
In addition to routine monitors, an arterial line may be helpful if the procedure requires hypertension or
hypotension. An arterial line also enables the anesthesiologist to maintain the delicate balance between
intracranial pressure and cerebral perfusion pressure and to better diagnose and treat hemorrhage. If arterial
monitoring will be needed after the procedure, a peripheral site (e.g., radial artery) may be preferred to the side
port of the introducer sheath. Intravenous access should always be adequate and blood products should be
available as indicated.
Vertebroplasty and kyphoplasty are typically used to treat vertebral compression fractures. Patients are
typically elderly with significant comorbidities, including diminished pulmonary function associated with the
vertebral fracture. The procedures may be performed with general anesthesia or local anesthesia with sedation
and analgesia. After the patient is placed prone, trocars are inserted on each side of the involved vertebral body
under fluoroscopic or CT guidance. Polymethylmethacrylate (PMMA) is injected via a trocar into the medulla

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of the vertebral body under direct visualization. In kyphoplasty, a balloon is inserted through the trocar to
restore the intervertebral distance before PMMA is injected.
65
If PMMA leaks into perivertebral veins, it can
cause radiculopathy, embolization, or interference with pulse oximetry readings. The most severe complication
of PMMA leakage is spinal cord compression that requires immediate surgical decompression. Other
complications associated with PMMA leaks are hypotension, hypoxemia, cardiac arrhythmias, and pulmonary
embolism.
66

Anesthesia for the endovascular coiling of cerebral aneurysms ranges from none to general anesthesia. Many
radiologists prefer general anesthesia for patient comfort and safety and to obtain optimal conditions for
imaging, even though general anesthesia may mask the clinical signs that guide the progress of the procedure.
67

Patients with a subarachnoid hemorrhage because of a leaking or ruptured aneurysm are at risk for increased
intracranial pressure, cerebral ischemia, and hydrocephalus. Patients with a ventricular drain are at risk for
transmural pressure changes and re-bleeding with elevated arterial pressure.
62

Patients with an arteriovenous malformation (AVM), a steal phenomenon that may lead to the loss of
autoregulation in the surrounding brain tissue as chronic vasodilation compensates for the steal, may suffer
spontaneous hemorrhage and have seizures or other neurological symptoms because of ischemia or venous
hypertension.
68

General anesthesia is often preferred for embolization of an AVM because it facilitates visualization of
structures and prevents patient movement. Hypertension is controlled by reducing the anesthetic or
administering vasoactive agents that may help float a flow-directed catheter into the desired vessels. The most
common AVM embolic agent is the fast-polymerizing liquid adhesive n-butyl cyanoacrylate (n-BCA); a new
liquid agent, Onyx, has recently been introduced.
69
During injection, Valsalva maneuvers and controlled
hypotension may reduce the gradient across the AVM and diminish the amount of distal adhesive
embolization.
69
When the AVM is embolized and steal ceases, the surrounding brain may suffer hyperperfusion
injury unless the cerebral blood flow is aggressively controlled with nitroprusside or other agents.
Pial and dural arteriovenous fistulas (AVFs) are direct shunts between an artery and a vein and may be
associated with extremely high blood flow. Clinical characteristics include bruit, neurologic symptoms or
intracranial hemorrhage. Children may have concomitant high-output cardiac failure.
70
Transarterial
embolization for high-flow, single-hole fistulas is performed with balloons, coils, stents, or n-BCA.9
62

Cerebral thrombolytic procedures are most often performed on awake individuals, but their tenuous medical
status may mandate an anesthesiologists presence. Anesthesia concerns include altered mental status, airway
protection, control of patient movement, and management of intracranial pressure.
Embolization of cerebral tumors also may be associated with the consequences of a steal phenomenon
because of the hypervascular nature of these tumors. Hypotension should be avoided before embolization and
hypertension should be avoided after it. Other concerns include greater intracranial pressure from brain edema,
which may be treated with steroids.
Neurophysiologic monitoring helps gauge the progress of an intervention. In a patient under general
anesthesia, it signals impairment so that the insult may be reversed promptly. The EEG, somatosensory evoked
potentials (SSEPs), and brainstem auditory evoked potentials can be critical for the successful endovascular
treatment of cerebral aneurysms under general anesthesia.
71
Muscle motor evoked potentials can indicate spinal
cord perfusion in the anterior spinal artery during endovascular procedures and complement SSEPs.
72

Transcranial Doppler ultrasonography directly measures regional cerebral blood flow (rCBF) in arteriovenous
malformations, aneurysms, and arterial stenoses.
63
Other direct measures of rCBF include radionuclide CBF
(e.g., technetium) studies and xenon CT.
71
Since anesthetics often have an effect on measurements, the
anesthesiologist must be in close communication with monitoring personnel to distinguish between an
anesthetic artifact and a new neurologic deficit.
Two devastating complications of interventional neuroradiology procedures are intracranial hemorrhage and
thromboembolic stroke.
73
The incidence of these two complications during coiling of cerebral aneurysms is
2.4% and 3.5%, respectively; during embolization of arteriovenous malformation it is 1%8%.
74
Arterial
pressure can increase suddenly with acute intracranial hemorrhage and should be controlled immediately.
Heparin reversal may be necessary along with a decrease in arterial pressure. Hyperventilation and mannitol
should be considered to reduce intracranial pressure. Hemorrhage due to perforation can often be treated with
coiling, although emergency craniotomy and clipping may be required if coiling fails.
Occlusive events can be thrombotic, embolic, or vasospastic. For all, the arterial pressure should be raised to
increase collateral blood flow while normocarbia is maintained. Thrombi may be treated by mechanical lysis
with a guidewire, normal saline, or thrombolytics. Misplaced coils may be retrieved endovascularly or via
craniotomy. Vasospasm may be treated with papaverine or nicardipine,
75
cerebral angioplasty
76
or by
increasing arterial pressure and volume while decreasing blood viscosity through hemodilution.
62
Maintaining
hypotension with antihypertensive agents such as labetolol or esmolor may be beneficial after AVM
embolization to prevent cerebral edema and hemorrhage. Using phenylephrine or norepinephrine, a mean

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arterial pressure 20%30% above normal can maintain cerebral perfusion in patients with occlusion or
vasospasm.
62

Recovery
Recovery of any anesthetized patient is governed by the ASA standards for postoperative care.
1
Ideally, nursing care should conform to the Standards of the American Society of Perianesthesia Nurses, and
the facilities and equipment for recovery should be commensurate with the complexity of the patient. Medically
stable patients who have undergone innocuous procedures under MAC (MRI, inferior vena cava filter) can often
recover en suite, provided that the nurses are trained and an anesthesiologist is available. Patients who have
received regional or general anesthesia or who are at risk for pain (e.g., radiofrequency ablation for
hepatocellular carcinoma) or procedural complications (e.g., aortic stent graft) recover in a dedicated
postanesthesia care unit or an intensive care unit. Resuscitation equipment, oxygen, and monitors should be
available for transport from the radiology suite.
Summary
As radiologic interventions become more common, the need for anesthesia care will increase. While a
patients comorbidities are addressed and other concerns are similar to those in a surgical setting, the additional
requirements and constraints of the imaging environment and the procedure call for specific approaches and
techniques. Just as in the operating room, there is frequently no single best anesthetic technique for a given
procedure. The technique is designed and implemented according to the demands of the procedure and the skill
sets of the providers. Patient safety always takes precedence, and a location should never be permitted to
compromise care. In any case, the patient deserves care that is consistent with the parameters, guidelines, and
standards established by the various accrediting agencies and professional societies.
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contains material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using
individual refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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40. Touz E, Calvet D, Chatellier G, et al. Carotid stenting. Curr Opin Neurol. 2008; 21:56-63
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Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.
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The Geriatric Outpatient: Cognitive Dysfunction and Other Concerns
Kathryn E. McGoldrick, M.D. Valhalla, New York
Introduction
The elderly (!65 yr) are a rapidly growing demographic segment in the United States as well as in many other parts
of the developed world. This reality has profound implications for anesthesiologists and surgeons. Aging, for
example, increases the probability that an individual will require a surgical procedure. Whereas approximately 12%
of those aged 45 to 60 yr undergo surgery annually, this number increases to >21% in the elderly (1). Although
operative mortality has decreased in the geriatric population in recent decades, perioperative morbidity continues to
be more common in the elderly and perioperative mortality rates, especially in the presence of co-existing disease,
remain higher than those encountered with younger patients. Using the Cox proportional hazards model, the risk of
postoperative long-term mortality increases 1.42 times per decade of age (2). Clearly, as an ever-increasing
proportion of the surgical outpatient population falls into the geriatric category, anesthesiologists are becoming
geriatric subspecialists to a certain extent. Thus, it seems appropriate to summarize our current knowledge about the
physiology of aging and to discuss the implications of these issues for the perioperative management of the elderly
outpatient.
Physiology and Pathophysiology of Aging
Age alters both the pharmacokinetic and pharmacodynamic aspects of anesthetic management. As an individual
ages, he or she experiences a loss of reserve and a diminished ability to tolerate stress. The functional capacity of
organs declines and co-existing disease further contributes to this decline. Advanced age, in conjunction with
comorbidity, is a risk factor for increased perioperative mortality, and age itself may further amplify the negative
prognostic value of impaired physical status (3).
The effects of aging at the subcellular level are ubiquitous, and these effects are apparent when one considers organ
function in the elderly. In terms of cardiac function, it is well known that geriatric patients have reduced beta-
adrenergic responsiveness, and they experience an increased incidence of bradyarrhythmias and hypertension.
Fibrotic infiltration of cardiac conduction pathways and replacement of myocardial elastic fibers render the elderly
individual vulnerable to conduction delay and to atrial and ventricular ectopy. It is well known that postoperative
atrial arrhythmias, and atrial fibrillation (AF) and flutter specifically, are seen in 6.1% of elderly patients undergoing
noncardiothoracic surgery and in 10% to 40% of patients after cardiothoracic operations (4-7). Because reliance on
atrial kick is critically important for older adults, should we prophylactically treat high-risk patients to prevent
postoperative AF? If so, should we use rate control or rhythm control drugs? Elderly patients also have an increased
reliance on the Frank Starling mechanism for cardiac output. It is important, therefore, to consider fluid as a drug
that the elderly individual may or may not need. In the noncompliant older heart, small changes in venous return will
produce large changes in ventricular preload and cardiac output. Owing to reduced diastolic myocardial function,
baroreceptor-mediated heart rate control, adrenergic receptor responsiveness, and vascular compliance, the elderly
person compensates poorly for hypovolemia. Similarly, overtransfusion is also poorly tolerated.
COPD, pneumonia, and sleep apnea are common in the elderly. Closing volume increases with age, and FEV1
declines 8% to 10% per decade owing to reduced pulmonary compliance and muscle power (8). Arterial oxygen
tension decreases progressively with age-induced V/Q mismatch, diffusion block, and anatomical shunt (9). [Owing
to these abnormalities in gas exchange, it is recommended that elderly patients be transported to the PACU with 2-4
L/min of oxygen via nasal cannula, even after relatively minor ambulatory surgery (10)]. Given these deleterious
changes, it is not surprising that postoperative respiratory complications are common in geriatric patients. However,
the most important clinical predictor of adverse pulmonary outcome is the site of surgery, with thoracic and upper
abdominal surgery having the highest pulmonary complication rates (11, 12).

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Because the central nervous system is the target for so many of our drugs, age-related alterations in nervous system
function have extremely compelling implications for anesthetic management. Indeed, aging universally produces a
reduction in total nervous system tissue mass, neuronal density, and concentration of neurotransmitters, as well as
various receptors. Drug interactions are a very real concern in the elderly because senior citizens typically undergo
physiologic changes related to disease as well as to normal aging. Moreover, although elders represent
approximately 13% of the population in the United States, they consume one-third of all medications and are seven
times more likely to experience an adverse drug reaction than their younger counterparts. In fact, the elderly account
for 50% of all medication-related deaths. Important to an understanding of geriatric pharmacokinetics is an
appreciation of the role that reduced drug excretion plays in adverse interactions. With advancing age, the number of
functioning glomeruli declines, as do glomerular filtration rate and renal blood flow.

Intraoperative Management
Because of the pulmonary changes discussed previously, it is imperative to appreciate that desaturation occurs faster
in older adults. Additionally, elderly patients are more vulnerable to desaturation-related cardiac events. Therefore,
proper preoxygenation is critical. Benumof points out that maximal preoxygenation is achieved with 8 large breaths
of 100% oxygen within 60 sec with an oxygen flow of 10 L/min (13).
Advanced age is associated with a reduction in median effective dose requirements for all agents that act within the
central nervous system regardless of whether these drugs are administered via the oral, parenteral, or inhalational
route. Indeed, the ED50 equivalent for anesthetics falls linearly with age, such that the typical healthy 80-yr-old
will require only about two-thirds of the anesthetic dose needed to produce comparable effects in a young adult. An
octagenarian with notable comorbidities will require even lower doses. This reduction in anesthetic requirement is
agent-independent and probably reflects fundamental neurophysiologic changes in the brain, such as reduced
neuronal density or altered concentrations of neurotransmitters. Elderly patients require less propofol (and other
agents) for induction, and it is also important to appreciate that the concurrent use of midazolam, ketamine, and/or
opioids with propofol synergistically increases the depth of anesthesia. Even with an appropriate dose reduction of
propofol, hypotension is common. Less hypotension has been reported with appropriately titrated administration of
mask sevoflurane for induction compared with a propofol infusion (14). Interestingly, gender differences have been
described in the pharmacokinetics of propofol given by continuous infusion in elderly patients (15).
Several neuromuscular blocking agents, including vecuronium and rocuronium, have an increased onset time in
elderly patients, possibly as a result of a less dynamic circulation and, thus, an increased transfer time to the effector
site (16). The time required for clinical recovery from neuromuscular blockade is markedly increased in older adults
for nondepolarizing agents that undergo organ-based clearance from plasma, but is minimally different for
atracurium, cisatracurium, or mivacurium because they undergo hydrolysis in plasma. Those neuromuscular
blockers with prolonged duration of action in the elderly are associated with delayed elimination, which may be a
result of the reduced total body water and decreased liver mass that often accompany aging. The likelihood of
postoperative respiratory complications after long-acting muscle relaxants increases with advanced age. It is not
unusual for patients who meet rigorous extubation criteria in the OR to deteriorate in the PACU. Hence, it seems
advisable to administer a short- or intermediate-acting muscle relaxant to any elderly patient for whom extubation is
planned at the end of the surgical procedure. Importantly, sugammadex has been shown to facilitate rapid reversal
from moderate rocuronium-induced neuromuscular blockade in adults of all ages, but recovery to a train-of-four
ratio of 0.9 is 0.7 min faster in young and middle-aged adults compared with patients !65 yr (17).
In planning an expeditious emergence, anesthesiologists should be aware that end-tidal gas monitoring
underestimates the brain concentration of the more soluble agents. Failure to appreciate this hysteresis effect leads to
prolonged emergence. Moreover, MAC awake is more favorable if the vaporizer is turned down gradually rather
than turned off abruptly (18). Not surprisingly, it has been reported that use of shorter-acting drugs (propofol,
desflurane, sevoflurane), in conjunction with BIS monitoring, can provide more rapid emergence in geriatric patients
and facilitate PACU bypass (19). Whether this approach will have a favorable effect on longer-term outcomes
remains to be determined.
When one considers selection of anesthetic technique, it is important to appreciate that there are no controlled,
randomized studies in elderly patients to show that regional anesthesia is clearly superior to general anesthesia for
ambulatory surgery. In fact, neuraxial, plexus, or peripheral nerve blocks (PNBs) in the elderly may be associated
with an increased risk of persistent numbness, nerve palsies, and other neurological complications. It has recently
been demonstrated that age is a major determinant of duration of complete motor and sensory blockade with PNB,
perhaps reflecting increased sensitivity to conduction failure from local anesthetic agents in peripheral nerves in the
elderly (20). That said, PNBs offer some appealing features, especially in terms of postoperative pain control.
Clonidine is a valuable adjunct that enhances both local anesthetic and narcotic efficacy, and its addition to the local

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anesthetic mixture may afford some hemodynamic advantages compared with epinephrine. However, one should
select a dose of clonidine that will not produce postoperative sedation or hypotension. When administering epidural
blockade to elderly patients, it is important to remember that a given dose will produce a higher level of block in
seniors, and is typically accompanied by a greater incidence and degree of hypotension and bradycardia as well as a
longer duration of anesthesia (21). Sedation requirements are dramatically reduced under conditions of central
neuraxial block. Sensory input to the brain is attenuated and the BIS50 is shifted to a higher index. Although recent
data have supported a relaxation of the requirement for voiding before discharge after outpatient neuraxial blockade
with short-acting drugs for low-risk surgical procedures in low-risk patients, it is important to appreciate that elderly
patients do not meet these criteria (22). Current thinking is that elderly (!70 yr) patients who received neuraxial
block, regardless of the duration of the block, should be required to void before discharge.

Postoperative Management
Perioperative hypothermia is prevalent in both young and elderly surgical patients, but it is more frequent,
pronounced, and prolonged in the elderly, who have compromised ability to regain thermoregulatory control
quickly. Adverse consequences of postoperative hypothermia include cardiac ischemia, arrhythmias, increased
blood loss, wound infection, decreased drug metabolism, and prolonged hospitalization. Indeed, it has been shown
that maintaining normothermia decreases cardiac morbidity by 55 percent (23).
Postoperative pain increases the risk of adverse outcome in geriatric patients by contributing to tachycardia,
hypertension, cardiac ischemia, and hypoxemia. Effective analgesia can decrease the incidence of myocardial
ischemia and pulmonary complications, accelerate recovery, promote early mobilization, shorten hospital stay, and
reduce medical costs. However, postoperative pain control often is inadequate in the elderly because of concerns
about drug overdose, adverse response, drug interactions, and other issues. Pain control is further complicated by the
fact that the patients perception and expression of pain may be affected by changes in mental status. Current
postoperative analgesic techniques include the use of opioids by various routes, nonsteroidal anti-inflammatory
drugs, local anesthetic techniques (neuraxial, intra-articular, PNB, etc), and nonpharmacologic (transcutaneous or
percutaneous electrical nerve stimulation, acupuncture, acupressure, etc) methods. Pre-emptive, multimodal
approaches have been favored to minimize the risk of such opioid-related side effects as hypoxemia, constipation,
and pruritus. However, the recent discovery of data fabrication by a major researcher in the area of pre-emptive
analgesia has far-reaching and serious consequences. There is, for example, no longer unequivocal evidence
supporting the pre-emptive effect of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors.
Additionally, the ability of a multimodal pre-emptive analgesic regimen to prevent the development of chronic pain
after major orthopedic surgery remains unproven (24).

Postoperative Cognitive Impairment
Reports of postoperative cognitive deterioration in elderly patients surfaced several decades ago, and anesthesia
had often been implicated as a possible cause or contributing factor. Although improvements in surgical techniques
and anesthetic agents and methods have led to improved outcomes in the elderly, a troubling proportion of these
patients experience postoperative cognitive impairment (25-28), at least on a short-term (~3 months) basis.
The syndrome of postoperative cognitive impairment can be classified into two main categories: postoperative
delirium and postoperative cognitive dysfunction (POCD)(29). Delirium is defined as an acute change in cognitive
function that develops over a brief period of time, often lasting for a few days to a few weeks and typically having a
fluctuating course. It is characterized by inattention, as well as either disorganized thinking and/or altered
level of consciousness. Prospective studies have cited an incidence of delirium that ranges from 3% to >50% and is
dependent upon the type of surgery, the patient's preoperative physical and cognitive status, and the age of the
patient (29). Recently, Rudolph and Marcantonio reported an incidence of postoperative delirium ranging from 35%
to 65% for hip fracture repair, down to 4% for cataract surgery (30). In general, older patients undergoing
emergency or long, complex surgical procedures tend to have a higher frequency of delirium, which appears to be
less problematic in outpatients who recover in their familiar home environment. Delirium is a costly complication
that has been associated with increased postoperative morbidity and mortality. Although the risk factors for
postoperative delirium vary among studies, greater preoperative age, alcohol use, major comorbidities, and cognitive
impairment are generally thought to confer a higher risk of postoperative delirium. Recently, Smith et al (31)
reported that preoperative executive dysfunction and depression are independent risk factors for postoperative
delirium.The etiology of delirium is probably multifactorial and may include drug intoxication or withdrawal, drug
interactions, anticholinergic agents, metabolic disturbances, hypoxia, abnormal carbon dioxide levels, sepsis,
inadequate analgesia, and organic brain disease (32). Neurotransmitter imbalances involving acetylcholine,
dopamine, and gamma-aminobutyric acid appear to be heavily involved in the multifactorial pathophysiology of

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delirium. Recent evidence suggests that deregulation in the homeostasis of tryptophan, the precursor to serotonin,
may have a critical role in the pathogenesis of postoperative delirium (33). Because abnormalities in the regulation
of serotonin have consistently been linked with depression (34), this may have important implications for explaining
the association of depression with delirium. It has also been suggested that occult white matter damage to the
frontal-striatal areas of the brain predisposes some patients to develop delirium (31). It is perhaps possible that this
mild loss of white matter could manifest preoperatively as impaired executive performance and/or greater levels of
depression (31). Interestingly, the use of melatonin to treat delirium has produced some benefit, presumably by
resetting the circadian sleep-awake cycle of older surgical patients (35). Although common in the elderly, the
incidence of postoperative delirium may be reduced by protocol-driven perioperative treatment. Marcantonio and
colleagues reported a reduction in postoperative delirium in hospitalized patients by more than one-third, and of
severe delirium by more than one-half, by adherence to multifaceted recommendations that included elimination or
minimization of benzodiazepines, anticholinergics, antihistaminics, and meperidine, as well as encouraging early
mobilization and providing appropriate environmental stimuli (36).

POCD is defined as a deterioration of intellectual function in one or more neuropsychological domains that
often presents as impaired memory or concentration. Other neuropsychological domains, including executive
function, perceptual organization, language, attention, and psychomotor function, may be affected. Moller and
colleagues (25) evaluated cognitive function in patients aged 60 yr or older after major abdominal and orthopedic
surgery. These investigators found that approximately 25% of the patients had measurable cognitive dysfunction a
week after their surgery and 10% had cognitive changes 3 months postoperatively. This finding contrasted with a
3% incidence of cognitive deterioration in healthy control subjects in the same age range who did not undergo
anesthesia and surgery. Interestingly, neither perioperative hypoxemia nor hypotension correlated with the
occurrence of prolonged cognitive dysfunction. The identified risk factors for early (1 week) postoperative cognitive
dysfunction were increasing age and duration of anesthesia, low education level, a need for a second operation,
postoperative infection, and respiratory complications. The major risk factor for late (3 months) postoperative
cognitive dysfunction was age. Although the incidence of late postoperative cognitive dysfunction was 14% for
patients >70 yr, this rate decreased to only 7% for patients between the ages of 60 to 70 yr.
An additional large, prospective study conducted by Monk and colleagues evaluated the relationship of age to
POCD (28). Using the same methodology as the first multinational study (25), Monk and colleagues reported that
cognitive decline occurred in 16% of patients aged 60 yr or older at 3 months after major noncardiac surgery, but
was present in only 3% to 5% of younger patients (28). This study also determined that rates of cognitive decline
were higher in those >70 yr compared with younger elderly patients. More recently (2008), Monk explored the
predictors of cognitive dysfunction after major noncardiac surgery (37). Independent risk factors for POCD at 3
months after surgery were increasing age, lower educational level, a history of previous CVA without residual
impairment, and POCD at hospital discharge. Patients who had POCD at both hospital discharge and 3 months
after surgery were more likely to die in the first year after surgery, but whether this suggests a causal link or is
related to patients comorbidities is unknown (37).
There are few prospective studies on long-term cognitive outcomes after outpatient surgery, but an analysis of
cognitive recovery after major and minimally invasive surgery exists. Monk classified the type of surgical procedure
as minimally invasive (laparoscopic or superficial surgery), major intra-abdominal surgery, or orthopedic surgery
(28). The incidence of POCD was significantly greater for patients undergoing major abdominal or orthopedic
procedures compared with minimally invasive surgery. Because outpatient surgery is usually minimally invasive,
these results suggest that outpatients may have a better cognitive outcome than patients who require hospitalization.
The International Study of Postoperative Cognitive Dysfunction (ISPOCD) group, however, recently conducted a
longitudinal study comparing the incidence of POCD after inpatient versus outpatient surgery in patients older than
60 yr (38). At 7 days after surgery, the incidence of POCD was substantially lower in the outpatient group, but this
difference was not detected 3 months later. These results suggest that elderly outpatients have better cognitive
outcomes at discharge than elderly inpatients, but we currently have no explanation for the difference. Possible
explanations for the improved early outcome in outpatients include the healthier status of patients who qualify for
outpatient surgery, the briefer surgical and anesthesia times, the minimally invasive nature of most outpatient
procedures, or avoidance of hospitalization. Interestingly, a recent (2011) study by Evered et al found that POCD
was independent of the type of surgery and anesthetic (39). Specifically, at 3 months post procedure, 21% of
geriatric patients having coronary angiography under sedation had POCD. The incidence of POCD in geriatric
patients who underwent either total hip replacement or CABG surgery was 16% in each group.
It is important to understand that full return of cognitive function to preoperative levels may require several days,
even after ambulatory surgery in young, healthy patients (32, 40). Indeed, Lichtor (41) has suggested that even

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young adults may be sleepy for 8 hr after receiving IV sedation with midazolam and fentanyl, and the elderly
outpatient suffering from balance disturbances or age-related gait impairment may be at high risk of falling owing to
residual drowsiness. Nonetheless, it remains unclear which patient populations are most vulnerable and what the
causative factors might be for the serious problem of POCD. Although we have much to learn about postoperative
delirium and cognitive decline, it is clear that pre-existing subclinical decrements in functional status may become
evident during the perioperative period. Indeed, if a cognitive deficit is noted preoperatively, it may be a harbinger
of further postoperative decline. The data on the predictive value of preoperative cognitive status for the
development of delirium (42) and the ability of that assessment to result in successful intervention (as may be the
case with delirium) (36) offer compelling reasons to conduct a simple, brief mental status examination as part of the
preoperative interview. Indeed, Evered and colleagues recently identified that 20% of patients !60 hr having total
hip replacement had preexisting cognitive impairment, and 22% had amnestic mild cognitive impairment (MCI); 7%
had both (43). These findings underscore the need for a robust, reproducible, practical tool to assess preoperative
cognitive function in our elderly patients (44). Additionally, Vaurio and colleagues recently demonstrated that
elevated levels of preoperative pain and a postoperative increase in pain levels are independent predictors of
postoperative delirium in elderly surgical patients (45). These findings suggest that elderly surgical patients with
substantial preoperative pain should be targeted for more intensive pain control postoperatively.
Our current understanding of POCD suggests the etiology is multifactorial and may include the preoperative
status of the patient, as well as intraoperative events related to surgery (e.g., microemboli), and anesthetic factors.
The potential roles of inflammation and anesthetic depth remain to be more fully determined. However, recent
prospective studies that have combined neuroimaging, pain, and functional assessments have shown that when
surgery successfully treats chronic pain and inflammation, cognition improves and gray matter volume increases in
areas such as the dorsolateral prefrontal cortex, the anterior cingulate gyrus, and the amygdala (46). Although we
currently have no reliable neuroprotective intervention to offer our patients, a marker for POCD might influence the
decision to have such elective procedures as cosmetic surgery. Hopefully, future studies will lead to a clearer
definition of the incidence, mechanisms, and prevention of POCD (47).
Finally, it should be mentioned that interest has grown recently in exploring a potential relationship between
anesthesia and the onset and progression of such neurodegenerative conditions as Alzheimers disease (48). Our
knowledge in this area is limited, and anesthesia has been both implicated and exonerated. There is, however, some
laboratory evidence that anesthesia may affect the processing of amyloid beta peptide. It has also been speculated
that risk factors for POCD may overlap with those for Alzheimers disease, although any shared mechanism remains
conjectural. Available human studies on anesthesia and Alzheimers disease are inconclusive because they are
under-powered or confounded by coexisting disorders, independent risk factors for dementia, and, of course, surgery
(49-51). Increasingly, we are realizing that many of our elderly patients have MCI at baseline. The cognitive loss of
some of these patients may not be readily apparent preoperatively, and is unmasked by the perioperative experience.
Perhaps the concerning cognitive changes that are identified postoperatively indicate more about our patients than
about our anesthetic agents.
Interestingly, in April 2011, the first new diagnostic guidelines released in 27 years in the United States for
Alzheimers disease recognized MCI as a precursor to Alzheimers disease. The National Institute on Aging and the
Alzheimers Association now describe the disorder as a disease that occurs gradually over many years, starting with
changes in the brain, then mild memory problems, and finally progressing to florid dementia. This preclinical stage,
happening about a decade before dementia develops, may be the best place to intervene in the disease, with many
researchers believing that most Alzheimers drugs have been disappointing because they were tried in people whose
disease was too advanced to be halted or reversed. Although not yet ready for prime time, the development of new
imaging agents for PET scans, spinal fluid tests, and other biomarkers that predict or detect Alzheimers in its
earliest stages will be increasingly important to researchers, drug companies, and clinicians.

Summary

Elderly patients are uniquely vulnerable and particularly sensitive to the stresses of trauma, hospitalization, and
surgery/anesthesia in ways that are only partially understood. The ambulatory environment offers many potential
benefits for geriatric patients having elective procedures. Accordingly, minimizing perioperative risk in the
elderly population requires thoughtful preoperative assessment of organ function and reserve, meticulous
intraoperative management of coexisting disorders, maintenance of normothermia, and vigilant postoperative
monitoring and pain control.

References

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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
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Alzheimer disease. Neurology 2005;65:986-90.

Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

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Page 1
The Adult Patient With Morbid Obesity and/or Obstructive Sleep Apnea
For Ambulatory Surgery:An Update
Girish P. Joshi, MB BS, M.D., FFARCSI Dallas, Texas
Introduction
The prevalence of obesity is rapidly increasing worldwide. Pathophysiological changes associated with obesity
influence multiple organs and increase the risk of comorbidities [1]. One of the major co-morbidities associated
with obesity includes obstructive sleep apnea (OSA), reported in 60-70% of morbidly obese (body mass index
[BMI]>40 kg/m
2
) [2]. Therefore, this patient population is at a higher risk of perioperative morbidity and mortality.
This update discusses the current literature related to perioperative care of the obese, with emphasis on adult patients
with OSA, scheduled for ambulatory surgery.
Selection of Adult Obese Patients For Ambulatory Surgery
The suitability of ambulatory surgery in the obese and/or OSA patients remains controversial. Although it is
generally recommended that body weight or BMI alone should not be used as the sole indicator of suitability for
surgery or its location [3], most anesthesiologists use a body weight or BMI cut off in their ambulatory anesthesia
practice. In recent years, several large observational trials have evaluated the incidence of perioperative
complications in the obese population [4-8]. The factors contributing to increased adverse outcome include patient
characteristics (e.g., coexisting medical conditions such as presence of OSA, history of deep vein thrombosis (DVT)
or pulmonary embolism (PE), history of bleeding disorder, and impaired functional status) as well as surgical
characteristics (i.e., degree of invasiveness) and surgeons experience.
A recent systematic review of the literature addressing perioperative complications in adult obese patients
scheduled for ambulatory surgery included 23 studies (13 prospective and 10 retrospective studies), and one
systematic review [8]. A total of 106,119 patients (n=62,476 in the prospective trials and n=43,643 in retrospective
trials) were included in the analysis. Of these, 39,548 patients underwent laparoscopic gastric banding (not
including the systematic review of laparoscopic bariatric surgery, which included 2549 patients). This systematic
review revealed that BMI alone is not influence perioperative complications or unplanned admission after
ambulatory surgery. However, the patients undergoing non-bariatric surgical procedures had an average BMI of 30
kg/m
2
, which typically has a low burden of comorbidities. The patients undergoing bariatric surgery had BMI of
>40 kg/m
2
. However, the bariatric surgical population underwent screening for comorbidities, which were
optimized, preoperatively. This systematic review also revealed that super obesity (i.e., BMI >50 kg/m
2
) might be
associated with a higher risk of postoperative complications, particularly if these patients have significant
comorbidities such as OSA, obesity-related hypoventilation syndrome, pulmonary hypertension, resistant systemic
hypertension, significant coronary artery disease, resistant cardiac failure, bleeding disorder, and chronic renal
failure on dialysis [9].
Selection of Adult Patients With OSA For Ambulatory Surgery
The ASA-OSA practice guidelines propose a scoring system that may be used to estimate the perioperative risk
of complications and determine the suitability for ambulatory surgery [10]. However, this scoring system is not yet
validated. In addition, these guidelines also recommend that patients undergoing intra-abdominal and upper airway
procedures are not suitable for ambulatory surgery. However, numerous large observational case series have
reported that laparoscopic adjustable gastric banding (LABG) can be safely performed on an outpatient basis [11-
13]. Thus, invalidating the recommendation that intra-abdominal procedures are not suitable for ambulatory surgery.
A recent systematic review of published studies assessed the perioperative complications in patients with OSA
undergoing ambulatory surgery [11]. There were no differences between the OSA and non-OSA patients with
respect to anesthesia-related complciations and unanticipated hospital admission. However, it must be emphasized
that most studies used a protocol-based perioperative care, which may have contributed to a safe perioperative

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course. There was emphasis on limiting opioid dose and exercising caution in patients who develop prolonged and
frequent respiratory events (e.g., sedation analgesic mismatch with opioids, desaturation, and apneic episodes).
The predictors for surgical morbidity and mortality include age, male gender, coexisting medical conditions,
invasiveness of surgical procedure, surgeons experience, and postoperative opioid dose. Thus, preoperative
optimization of medical conditions and limiting opioid use is critical for patient safety. Overall, patients with
inadequately treated co-morbid conditions are not suitable for ambulatory surgery. Patients with a known diagnosis
of OSA (who are typically prescribed CPAP preoperatively) may be considered for ambulatory surgery if their
comorbid medical conditions are optimized and they are able to use a CPAP device in the postoperative period. It
appears that postoperative CPAP use may be protective against opioid-induced respiratory depression. Patients who
are unable or unwilling to use CPAP after discharge may not be appropriate for ambulatory surgery. Patients with a
presumed diagnosis of OSA, based on screening tools such as the STOP-Bang questionnaire, can be considered for
ambulatory surgery if their comorbid conditions are optimized and if postoperative pain relief can be provided
predominantly with non-opioid analgesic techniques. Of note, no guidance could be provided for OSA patients
undergoing upper airway surgery due to limited evidence. In addition, the ability of the facility to manage these
patients should also be taken into consideration.
Similar recommendations have been proposed recently by the American Society for Metabolic and Bariatric
Surgery, which also emphasized that the high risk population include males, age>50 years, BMI >60, and severe
OSA [13].

Preoperative Considerations
The comorbidities associated with obesity and OSA should be evaluated and optimized preoperatively. A
focused preoperative evaluation includes assessment of the airway, cardiovascular, respiratory, and endocrine
systems. In addition to assessment of functional status, patients should be questioned to determine symptoms of
angina, paroxysmal nocturnal dyspnea, orthopnea, and arrhythmia (i.e., palpitations). Because OSA is undiagnosed
in an estimated 60-70% of patients, screening for OSA should be part of routine preoperative evaluation. The STOP-
BANG screening tool is a user-friendly questionnaire that could be included in routine preoperative evaluation to
identify unrecognized OSA [14]. However, in contrast to original recommendations, use of 5 to 6 positive responses
out possible 8 questions on the STOP-BANG determine a possibility of moderate-to-severe OSA [15, 16]. If OSA is
suspected during preoperative evaluation, one could proceed with a presumptive diagnosis of severe OSA or obtain
a sleep study.

Preoperative Testing
It is well recognized that preanesthesia tests should be based on clinical indications and the invasiveness of the
surgical procedure. The American College of Cardiology (ACC) and American Heart Association (AHA) proposed
recommendations for perioperative care of morbidly obese patients undergoing surgery [17]. It is recommended that
ECG be obtained in patients with at least one risk factor for CHD and/or poor exercise tolerance. ECG signs of right
ventricular hypertrophy including right-axis deviation and right bundle-branch block would suggest pulmonary
hypertension, while a left bundle-branch block may suggest occult CHD. In addition, chest X-ray should be
obtained on all morbidly obese patients as it may suggest undiagnosed heart failure, cardiac chamber enlargement,
or abnormal pulmonary vascularity suggestive of pulmonary hypertension, which warrants further cardiovascular
investigation. Further testing, such as exercise and/or pharmacological stress echocardiography, may be performed
in presence of !3 risk factors of CAD (i.e., history of CHD, history of congestive heart failure, history of cerebro-
vascular disease, preoperative treatment with insulin, and preoperative serum creatinine levels >2 mg/dL).

Preoperative Medications
Obese patients may be on multiple medications including prescription and non-prescription (i.e., over-the-
counter or herbal diet drugs) that might have detrimental cardiopulmonary effects as well as adversely interact with
anesthetic drugs. Patients should be asked to continue their preoperative medications until the day of surgery,
except for antidiabetic therapy that might need some modification [18]. Because morbid obesity is one of the major
risk factors for the development of PE, prophylaxis for DVT, low dose heparin in combination with intermittent
pneumatic compression, are recommended [19]. Preoperative prophylaxis against acid aspiration (e.g., H
2
-receptor
antagonists and proton pump inhibitors) is commonly used. However, their routine use is questioned, as the risk of
regurgitation of gastric contents for the morbidly obese and the non-obese appears to be similar [20].




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Intraoperative Considerations
Although the surgical procedure and the need for postoperative opioids, rather than the choice of anesthetic
technique appear to be more important determinants of perioperative complications in the morbidly obese
particularly those with OSA, local or regional anesthesia should be preferred. Local/regional anesthesia obviates the
need for airway manipulation as well as avoids hypnotic-sedatives, opioids, and muscle relaxants. In addition, these
techniques provide postoperative analgesia and reduce postoperative opioid requirements.

Sedation and Analgesia in the Obese and OSA Patients
Because OSA surgery is not always successful, it is suggested that drug-induced sleep endoscopy (DISE) could
be used to assess the level and mechanism of obstruction and develop specific therapy [21-23]. Thus,
anesthesiologists will be involved in providing deep sedation/general anesthesia without a secured airway required
for DISE. Patients with OSA are more sensitive to sedative-hypnotics and opioids, which cause dose-dependent
upper airway collapse, respiration depression, and reduced respiratory responses to hypoxia and hypercapnia. Of
note, during sedation OSA may develop in previously unrecognized patients. Therefore, monitoring should include
continuous capnography as it allows detection of upper airway obstruction much prior to oxygen desaturation.
Because CPAP counteracts sedation-induced airway closure, it should be considered during moderate sedation,
particularly in patients using CPAP preoperatively.
Midazolam and propofol have a similar propensity for upper airway obstruction at similar levels of sedation
[24]. However, respiratory problems disappear more quickly (within 15 min) with propofol. Dexmedetomidine, a
highly selective alpha-2 adrenergic agonist with sedative, amnestic, analgesic, and sympatholytic properties with no
respiratory depression, can be used to provide sedation/analgesia. In addition, it reduces salivary secretions through
sympatholytic and vagomimetic effects. Of note, it is generally assumed that dexmedetomidine is a short-acting
drug; however, it may have prolonged sedative effects. Addition of low-dose ketamine (up to 1 mg/kg) to
dexmedetomidine may potentiate the analgesics effects and reduce the hemodynamic adverse effects with
influencing respiration [25].

General Anesthesia
The optimal general anesthetic technique would allow rapid and clear-headed recovery including early return of
the patients protective airway reflexes, which would allow maintenance of a patent airway. In addition, early
recovery should reduce postoperative cardiac complications due to residual anesthetic effects.

Pre-induction Considerations
Alterations in pulmonary function (e.g., reduced FRC and oxygen reserves) in the obese may result in severe
hypoxemia even after short periods of apnea. Positioning of the patient in the head elevated laryngoscopy position
(HELP), which can be achieved by stacking with blankets or a specially designed foam pillow, structurally
improves maintenance of the passive pharyngeal airway and may be beneficial for mask ventilation as well as
improve the success of tracheal intubation. Other techniques used to avoid post-induction hypoxemia include the
use of 10 cm H
2
O CPAP with the patient in head-up position [26]. The end point for preoxygenation should be to
achieve end-tidal oxygen concentration of at least 90%. Preinduction techniques followed by 10 cm H
2
O PEEP
during mask ventilation and after intubation have been shown to reduce post-intubation atelectasis and improve
arterial oxygenation [27]. Also, PEEP increases the pressure in the esophagus, which may act as a barrier against
regurgitation [28].

Airway Management
Because BMI alone is not a predictor of difficult intubation [29], awake tracheal intubation may not always be
necessary. Nevertheless, OSA has been reported to be a predictor of difficult airway [2]. Predictors of difficult
tracheal intubation include high Mallampati score (III or IV), neck circumference !40 cm, limited mandibular
protrusion, and severe OSA (AHI !40). If awake intubation is necessary, sedatives and opioids must be utilized
judiciously as they may cause airway obstruction before the airway is secured.

Induction of General Anesthesia
Because of concerns of regurgitation and difficult tracheal intubation, rapid sequence induction (RSI) of general
anesthesia is commonly performed in the morbidly obese. However, the need for RSI is increasing questioned [30].
Recent studies, in morbidly obese patients, have shown than the barrier pressure (lower esophageal pressure - gastric
pressure) remains positive throughout induction of anesthesia [20]. This suggests that the risk of gastric
regurgitation in the morbidly obese may be similar to that in the non-obese patients. Controlled induction of

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Page 4
anesthesia should allow adequate ventilation prior to intubation attempt and avoid hypoxia between induction and
tracheal intubation. Most anesthesia drugs including intravenous anesthetic drugs and opioids should be dosed
according to lean body weight (not actual body weight), except for neuromuscular blocking drugs, which should be
dosed according ideal body weight [31].

Maintenance of General Anesthesia
There is lack of evidence for superiority of a specific maintenance technique (e.g., inhalation vs. total
intravenous anesthesia). Nevertheless, inhalation anesthesia remains the mainstay of current anesthesia practice
because of the ease of titration. In addition, inhaled anesthetics exert some neuromuscular blocking effect, which
may reduce the need for muscle relaxants. Several studies have reported that in the morbidly obese, desflurane
allows earlier emergence compared with sevoflurane [32]. A study analyzing data from published randomized trials
as well as data from an electronic database found that desflurane reduced the average extubation time and the
variability of extubation time compared with sevoflurane. [33].
Because of its amnestic and analgesic properties, nitrous oxide (N
2
O) reduces anesthetic and analgesic
requirements and facilitates recovery. Nevertheless, the use of N
2
O is questioned due to concerns of increased
incidence of postoperative nausea and vomiting (PONV) and pressure effects through expansion of closed spaces.
However, a systematic review concluded that use of propofol for induction of anesthesia and antiemetic prophylaxis
(current standard of care for ambulatory surgery) [34]. Another benefit of N
2
O is that it facilitates the removal of
other inhaled anesthetics (i.e., second gas effect), and allows rapid emergence from anesthesia [35]. Furthermore,
the analgesic effects of N
2
O should reduce the need for intraoperative opioids and reduce opioid-related adverse
effects [36]. Thus, there is no convincing reason to avoid N
2
O.
Determining the optimal anesthetic concentrations that would parallel the varying surgical stimuli, while
preventing intraoperative awareness, remains challenging. Recent evidence suggests that titration of inhaled
anesthetic using end-tidal concentrations (0.7-1.3 minimum alveolar concentration [MAC] values) and propofol
TIVA using bispectral index (BIS) monitoring should prevent intraoperative awareness with recall [37].
Opioids continue to play an important role in anesthesia practice; however, opioid-related sedation, airway
obstruction, and respiratory depression are of concern in this patient population. Therefore, opioids should be used
sparingly. Remifentanil (titrated to hemodynamics) may be preferable in the obese because of its unique
pharmacokinetics and ultra-short duration. Opioid requirements in patients with OSA has been reported lower than
those without OSA probably because recurrent hypoxia observed in this patient population may affect endogenous
opioid mechanisms that may alter responsiveness to exogenous opioid administration [38]. Because lower opioid
doses may be sufficient to achieve adequate analgesia, opioid therapy in OSA patients should be individualized and
carefully titrated. Importantly, opioids should be administered according to lean body weight NOT actual body
weight [31].
Because even minor degree of residual neuromuscular blockade (usually not appreciated clinically), particularly
the obese and OSA patients, can increase postoperative morbidity such as inadequate ventilation, hypoxia, and the
need for reintubation, muscle relaxants should be used sparingly [39, 40]. Current evidence suggests that the dose of
neostigmine should be titrated to the intensity of neuromuscular blockade at the time of reversal [41, 42]. Of note,
patients having TOF monitoring of the eye muscles had a greater than 5-fold higher risk of postoperative residual
paralysis than those who had monitoring of the adductor pollicis [43].

Mechanical Ventilation
Obesity is associated with changes in pulmonary function (e.g., reduction in lung volumes, increase in peak
inspiratory pressures, and decrease in pulmonary compliance). Lung protective ventilation strategies in the obese
would include the use of pressure-controlled ventilation with low tidal volumes (6-8 ml/kg IBW) and PEEP of 5-10
cmH
2
O [44]. There appears to be no difference between pressure-controlled ventilation and volume-controlled
ventilation. Recruitment maneuvers are beneficial in obese patients and should be applied, particularly at the start
and end of surgery. It is important to avoid hyperventilation (and hypocapnia), as this may result in metabolic
alkalosis and lead to postoperative hypoventilation. Mild hypercapnia (i.e., ETCO
2
of 40 mmHg) can improve
tissue oxygenation through improved tissue perfusion resulting from increased cardiac output and vasodilatation as
well as increased oxygen off-loading from the shift of the oxyhemoglobin dissociation curve to the right [45].

Pain, Nausea and Vomiting Prophylaxis
Preventive analgesia with non-opioids (e.g., local/regional anesthetic techniques, acetaminophen,
NSAIDs/COX-2 specific inhibitors, and dexamethasone) should reduce perioperative opioid requirements and lower
opioid-related side effects as well as improve postoperative pain relief [46-48]. Incorporation of procedure-specific

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pain therapies in clinical pathways should improve compliance with protocols and thus improve perioperative
outcome as well as allow early return to activities of daily living [48].
Patients undergoing ambulatory surgery are at a higher risk of PONV and should receive prophylactic
multimodal antiemetic therapy (e.g., combinations of 5-HT
3
-receptor antagonists and dexamethasone). Although it
is recommended that the number of antiemetics be based on the patients level of risk as determined by risk factor
assessment, routine antiemetic prophylaxis is optimal for this patient population [49, 50].

Emergence From Anesthesia
Towards the end of surgery, it is common practice to reduce the respiratory rate in an effort to build up end-tidal
CO
2
levels and facilitate respiration. However, the reduced minute ventilation resulting from this practice may
delay removal of inhaled anesthetic, and thus delay emergence from anesthesia. Therefore, the primary aim at the
end of the surgery should be to maintain the minute ventilation in an effort to washout the inhaled anesthetic and
facilitate emergence [45]. One of the major concerns in obese patients, particularly those with OSA, is the risk of
airway obstruction after tracheal extubation [51, 52]. Thus, prior to tracheal extubation the patient must be fully
awake, alert, and follow verbal commands (i.e., deep extubation is not advisable). Importantly, coughing and reflex
movements of the hand towards the tracheal tube should not be confused as purposeful movements. Extubation
should be performed in a semi-upright (25-30 head-up) position, when possible. Also, use of a nasal airway, placed
before tracheal extubation, may avoid postextubation airway obstruction.

Postoperative Considerations
Potential postoperative complications include airway obstruction, respiratory failure, need for reintubation, life
threatening hypoxia as well as systemic hypertension, ischemia, and cardiac arrhythmia. Once in the PACU,
patients should be maintained in a semi-upright (25-30 head-up) position, if possible.

Postoperative CPAP/BiPAP
Although supplemental oxygen is beneficial for most patients, it should be administered with caution as it may
reduce hypoxic respiratory drive and increase the incidence and duration of apneic episodes. Because obese patients
might have unrecognized OSA, recurrent hypoxemia may be better treated with CPAP or bi-level positive airway
pressure (BiPAP) along with oxygen rather than oxygen alone. Because determination of optimal CPAP settings
may be difficult in patients who have not previously used the device, use of automatic self-adjusting or auto-
adjusting positive airway pressure (APAP) devices may be preferred in the postoperative period. The APAP devices
change the pressure level based on feedback from various patient measures such as airflow, pressure fluctuations, or
measures of airway resistance. The pressure titration with APAP devices allows for the changes in upper airway
pressures that might occur in the immediate postoperative period due to varying degrees of residual anesthetic and
muscle relaxant effects.

Post-PACU Discharge Care
Prior to discharge from the PACU the oxygen saturation on room air should return to baseline and the patient
should not become hypoxic or develop airway obstruction when left undisturbed in the recovery area. It has been
suggested that most significant postoperative complications in OSA patients usually occur within 2 hours after
surgery. Therefore, it may be worthwhile to observe these patients in the recovery room for at least 2 h. Of note,
complaints of postoperative shoulder, hip, or buttock pain along with unexplained elevations in serum creatinine and
creatine phosphokinase (>5000 IU/L) levels should raise suspicion of rhabdomyolysis [53].
Discharge home might be considered if the patient can maintain baseline oxygen saturation on room air, and the
propensity to develop airway compromise and respiratory depression no longer exists. The ASA-OSA Practice
Guidelines suggest that OSA patients be monitored for a median of 3 hours longer than their non-OSA counterparts
before discharge from the facility [10]. In addition, the monitoring should continue for a median of 7 hours after the
last episode of airway obstruction or hypoxemia while breathing room air in an unstimulated environment.
Unfortunately, the recommendations for longer postoperative stays are not based upon any scientific evidence. In
fact, recent studies in bariatric surgical population found that the time to discharge between the OSA and non-OSA
population was similar [54].

Patient Information
Education of the patients and their caregivers regarding the need for increased vigilance after discharge home is
critical [18]. Because opioids are the biggest culprits in post-discharge complications, patients should be advised
asked to limit opioid use. Patients on preoperative CPAP should be advised to use their CPAP device whenever

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sleeping even during the daytime, and for several days postoperatively. Also, patients should be advised against
sleeping in the supine position. Patients who are assumed to have OSA based on the screening questionnaire should
be advised to follow-up with their primary physician for possible sleep study. Because there is a possibility that
OSA patients may not always meet criteria for safe home discharge, the option of admission should be discussed
with the patient prior to surgery.

Post-Discharge Considerations
One of the major concerns after ambulatory surgery is nocturnal apnea with catastrophic consequences. Of
note, postoperative sleep disturbances appear to be related to the location and invasiveness of the surgical procedure
and opioid usage. Postoperative surgical stress response, anxiety, pain, and opioid use can cause sleep deprivation
and fragmentation, which may reduce REM sleep. Upon resolution of the stress response rebound REM sleep may
ensue [55], which may exacerbate sleep disorders and increase the potential airway obstruction and life-threatening
apnea. Because the risk of respiratory complications may last for several days after surgery, it is important that the
post-discharge instructions emphasize the potential for aggravation of OSA and the need to use opioids judiciously
for several days after recovery from the surgical procedure.

Summary
Obese patients, particularly those with OSA, are at a high risk of perioperative complications that might last for
several days after surgery. Because undiagnosed OSA is common and failure to recognize OSA preoperatively is
one of the major causes of perioperative complications, a focused history and physical examination can help identify
patients with OSA. Clearly, selecting a patient for an ambulatory procedure is a dynamic process, which depends on
the complex interplay between patient characteristics (i.e., coexisting medical conditions), invasiveness of the
procedure, and anesthetic technique as well as postoperative opioid requirements. Therefore, attempts to address
individual factors without consideration of others is fraught with flaws.
Prudent perioperative management should be guided by the awareness of the potential complications based on
the severity of comorbidities, invasiveness of diagnostic or therapeutic procedure, and requirement of postoperative
opioids. Use of fast-track anesthesia techniques with pain and PONV prophylaxis should allow rapid emergence,
reduce postoperative cardiopulmonary complications, and hasten recovery. Patients should be educated regarding
the deleterious effects of opioids and asked to limit their use. Patients on preoperative CPAP should be instructed to
use CPAP at night for several days postoperatively. Patients who are placed on OSA protocol based on clinical
indicators should be asked to follow-up with their primary physician for possible sleep study. Finally, developing
and implementing protocols (clinical pathways) is the best way to avoid adverse events and improve postoperative
outcome [62].

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refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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40. Brull SJ, Murphy GS: Residual neuromuscular block: lessons unlearned. part II: methods to reduce the risk of
residual weakness. Anesth Analg 2010;111:129-40.
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Disclosure
Pfizer, Self, Honoraria; Baxter, Self, Honoraria; Pacira, Self, Honoraria ; Cadence, Self, Honoraria, Edwards Life
Sciences, Honoraria
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Page 1
Effective Management of Pain, Postoperative Nausea and Vomiting and Opioid Related
Side Effects in Ambulatory Surgical Patients
Tong J. Gan, M.D., M.H.S. Durham, North Carolina
Postoperative nausea and vomiting (PONV) and pain are two of the most common and unpleasant side effects
following anesthesia and surgery. Although both are predictable part of the postoperative experience, inadequate
management of these symptoms is common and can have profound implications. Unrelieved postoperative pain
may result in clinical and psychological changes that increase morbidity, mortality, costs as well as decrease
quality of life and potentially increase the incidence of chronic pain
1
. Negative clinical outcomes resulting from
ineffective postoperative pain management include deep vein thrombosis and pulmonary embolism, coronary
ischemia and myocardial infarction, pneumonia, poor wound healing, insomnia and demoralization
2,3
. Associated
with these complications are economic and humanistic implications such as extended lengths of stay, readmissions,
and patient dissatisfaction with medical care.
4,5
A recent study suggests that pain in ambulatory surgical patients is
still undermanaged and the incidence of moderate to severe pain remains high.
6
The overall incidence of PONV has decreased from 60 % when ether and cyclopropane were used, to approximately
30% more recently.
7
However, in certain high-risk patients the incidence is still as high as 70%. It is estimated that
an episode of vomiting prolongs PACU stay by about 30 min.
8
Furthermore, it is estimated that approximately 0.2%
of all patients may experience intractable PONV, leading to unanticipated hospital admission following ambulatory
surgery, thereby increasing medical costs. The estimated cost of PONV to a busy ambulatory surgical unit was
estimated to range from $0.25 million to $1.5 million per year in lost surgical revenue.
9
The results of several studies suggest that patients not only rank the absence of PONV and pain as being important
10
but also rank it more important than an earlier discharge from an ambulatory surgical unit.
11
Because patients
convalesce at home after surgery, pain and nausea and vomiting must be effectively assessed, monitored, and
treated within the surgical setting and anticipated during the recovery at home. This article will discuss the
management of PONV and pain following ambulatory surgery, the use of an effective, multimodal and novel
therapy as well as recommendations for the prophylaxis and treatment of PONV and pain.
Management of Postoperative Pain
Pharmacological Options
Opioids
Opioids are effective analgesics for moderate to severe pain. They act on opioid receptors in the peripheral
12,13
and
central nervous system. However their efficacy is limited by side effects. Opioids and/or NSAIDs combined with
local anesthetic infiltration or regional block has proven to be a useful technique for controlling pain in patients
after ambulatory surgery and should be considered whenever possible. In most studies local anesthetic infiltration
with systemic opioids or NSAIDs showed improvement in analgesia, better recovery
14
and shortening of discharge
time from day surgery unit.
15,16
Acetaminophen
Acetaminophen (Paracetamol) is an effective analgesic for mild to moderate pain with favorable side effect profile.
17
It is an effective adjuvant to opioid analgesia and a reduction in opioid requirement by 20-30% can be achieved
when combined with a regular regimen of IV, oral or rectal acetaminophen. It has been shown that 1 g of
propacetamol results in significant reduction in postoperative morphine consumption over 6 h period.
18
A meta-
analysis of analgesic efficacy suggested that acetaminophen and tramadol is an effective analgesic combination in
324
Page 2

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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
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dental and post surgical pain. However, more patients experienced side effects like dizziness, nausea and vomiting
with this combination.
19
IV acetaminophen, commonly used in Europe, has the flexibility of being able to be used in
the perioperative period and may be a viable alternative to NSAIDs in minor surgery and a useful adjunct in
conjunction with other analgesics.
18,20


Non-Steroidal Anti-inflammatory Drugs and Cyclo-oxygenase (COX-2) Inhibitors
Non-steroidal anti-inflammatory drugs (NSAIDs) have become the cornerstone in the treatment of acute pain in
the early postoperative period because of its opioid sparing effect.
21
Administration of ibuprofen and oxycodone in
combination provides superior and effective analgesia in the postoperative period.
22
The combination of ibuprofen
and acetaminophen has also been reported to reduce the need for early analgesia up to 34% in children undergoing
tonsillectomy.
23
The use of COX-2 inhibitors have been shown to be an effective opioid adjunct in the
perioperative period without the increased risk of bleeding. Recently data suggest that oral regimen of ibuprofen
(1200 mg/d) or celecoxib (400 mg/d) improves analgesia and quality of recovery in ambulatory patients.
24
The
recent availability of IV ibuprofen may provide further option of administration in the perioperative setting.

Tramadol and Tapentadol
Tramadol is a synthetic, centrally acting analgesic with a weak opioid action. It also inhibits serotonin and
noradrenaline reuptake.
25
The tramadol metabolite, O-desmethyl tramadol is a more potent analgesic than
tramadol.
26
Unlike other opioids, it lacks the respiratory depressant effects and exhibits lower risk of bowel
dysfunction
27
at conventional doses. A meta-analysis
28
of acetaminophen and tramadol combination confirmed
superior analgesia without additional toxicity. The most common adverse effects noted were dizziness, headache,
nausea and vomiting. Combination of tramadol with acetaminophen increases tolerability.
29
More recently,
tapentadol has been approved in the US for the treatment of acute pain, It acts on opioid receptors as well as by
inhibiting norepineprine pathway. More studies are needed to define its clinical utility in an ambulatory setting.

Ketamine
Ketamine acts as an antagonist on the NMDA receptor. Used more widely as an anesthetic before the availability of
newer induction and maintenance agents, it has received renewed interest for its role in enhancing postoperative
analgesia. Several studies have focused on demonstrating use of subanesthetic doses of ketamine for various
surgical procedures to enhance pain relief and reduce total analgesic consumption.
30-35
Central excitatory
neurotransmitters acting on N-methyl-D aspartate receptor (NMDA) have been identified in the development and
perpetuation of pathologic pain states causing hyperalgesia and allodynia.
36


There is ample evidence to suggest that ketamine has opioid sparing effect and may confer advantage in patients
where large amount of postoperative opioid consumption is anticipated. At low doses ketamine can provide
analgesia in opioid resistant pain.
37
Continuous infusion of ketamine has been used perioperatively. Adam et
al., evaluated IV ketamine with an initial bolus (0.5 mg/kg) followed by continuous infusion of 3 mcg/kg/min
intraoperatively in combination with continuous femoral nerve block in patients undergoing total knee arthroplasty.
In this multimodal approach, ketamine group required significantly less morphine and tolerated early mobilization
of knee.
38
These drugs have to be used with caution in the ambulatory setting due to its potential side effects
including sedation and hallucinatory effects in some individuals, though administering only a bolus dose and
avoiding the infusion regimen can reduce the incidence of adverse events.

Wound infiltration with local anesthetics
Infiltration of surgical wound with local anesthetics is probably the simplest method of achieving wound analgesia.
This method has been shown to be effective in providing analgesia in patients undergoing inguinal hernia repair and
other ambulatory procedures. There is lack of evidence for any clinically useful effect for other more extensive
abdominal procedures.
39
For example, wound infiltration does not provide beneficial effect on pulmonary function
after surgery in one study.
40
Inadequate dosing and relatively short duration of action of the local anesthetics may
explain the poor results in some trials. Prolonged release technology of local anesthetics (e.g. depobupivacaine) has
recently approved for clinical use. In two pivotal studies, depobupivacine (Exparel

) would infiltration has been

shown to improve postoperative analgesia and reduced opioid consumption in bunionectomy and
hemorrhoidectomy surgery.
41,42
Further trials on its efficacy for peripheral nerve blocks are on-going. The role of
other adjuvants to local anesthetics is unclear. For example, wound infiltration of bupivacaine and ketamine has
not shown a decrease in pain score or the need for rescue analgesia but the duration of analgesia has been reported
to be prolonged by the addition of ketamine.
43

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Intra-articular analgesics
There are conflicting reports about the efficacy of intra-articular analgesics in the literature.
44-46
. In a systematic
review Moiniche S et al.
47
observed that the effect of intra-articular local anesthetics seemed to provide
moderate pain relief of short duration. Although the pain relief in the early postoperative period was statistically
significant, evidence was not overwhelming in favor of intra-articular local anesthetics because majority of the
studies did not demonstrate improved pain relief beyond the immediate postoperative period. Peripheral Nerve
Blocks (PNB)
Appropriate nerve blocks depending on the site of surgery are useful in providing short to intermediate-term pain
relief after surgery. Direct visualization of neural tissue with ultrasound technology and the utility of stimulating
catheters has made placement of indwelling catheters safer and more accurate. Continuous infusion of local
anesthetics through a peripheral nerve catheter is becoming increasingly popular in both hospital and ambulatory
setting to achieve prolonged analgesia.
48,49
For example, continuous femoral nerve block has been shown to reduce
duration of hospital stay and the frequency of serious complications.
50
Similarly, several other studies have
demonstrated the benefits of PNB including reduced length of stay and costs,
49
decreased incidence of PONV
51
and lower rates of unexpected hospital admissions after ambulatory surgery.
49,50,52
Systemic agents co-
administered during PNB such as opioids and clonidine have been found to enhance intraoperative and
postoperative analgesia. Two systematic reviews of 15 studies that used opioids as adjuvant, six reported a
statistically significant benefit in analgesia. Of the six studies that evaluated clonidine,
53
five found improvement
in analgesia.

Other Pharmacological and Non-Pharmacological Options
Numerous other adjunctive analgesia including gabapentin, pregabalin, corticosteroids, neostigmine, magnesium
have some usefulness in an ambulatory settings but more evidence need to be gathered to determine their specific
roles. A recent study suggests that patients anesthetized with propofol was associated with less pain compared to
sevoflurane anesthesia although the exact mechanism is not known.
54
Non-pharmacological therapy should be
considered as complimentary to pharmacological options for postoperative pain management. They may provide
additional benefits in reducing the total dose of analgesics required and therefore minimizing the adverse effects of
the analgesics. Techniques include acupuncture, hypnosis, relaxation, music therapy, etc.
55,56


Rationale for multimodal analgesia
The ideal analgesic regimen would provide effective pain relief, reduce opioid related side effects and surgical
stress response and improve clinical outcome e.g. morbidity, mortality and hospital stay. The concept of
multimodal analgesia was introduced to achieve these goals by combining various analgesic techniques and
different classes of drugs to improve postoperative outcome.
57
However, available data are conflicting and do not
necessarily resulted in improved outcome and concomitant reduction in adverse effects of opioids.
58-60
The
failure to improve clinical outcome may be due to inappropriate combination and dosing of analgesics. Apart from
adequate analgesia,
postoperative morbidity and hospital stay depend on other factors such as initiation of early nutrition, mobilization
and comprehensive rehabilitation program.
61
Although, there is insufficient evidence to recommend pre-emptive
analgesia routinely it is prudent to attenuate postoperative pain as effectively as possible during the intraoperative
period and initiating effective analgesic therapy in the early phase of perioperative period.

The effectiveness of individual analgesics is enhanced by the additive or synergistic effect of two or more drugs
acting by different mechanisms. For example, the synergism between alpha-adrenergic and opioid systems has been
demonstrated.
62
Similarly, combination of acetaminophen and non-steroidal anti-inflammatory drugs provides
additive analgesic effect in mild to moderate acute pain.
63
The addition of COX-2 inhibitors or NSAIDs reduces
opioid requirements by 20-30% with the reduction of opioid related side effects and better analgesia. Similarly,
ketamine has been shown to reduce the pain scores and lower analgesic requirement when added to a multimodal
epidural analgesia.
64
Adding ketamine in patient controlled epidural analgesia along with morphine, bupivacaine
and epinephrine has been demonstrated to result in enhanced analgesic effect. Chia et al.,
65
showed that the mean
visual analogue score in the ketamine group during movement and cough were lower than the control group. The
cumulative total analgesic consumption in the ketamine group was lower by 30% than the control group 24 h
following surgery. In another study, it was demonstrated that the combination of intraoperative ketamine and
epidural analgesia may confer a long-term benefit in reducing incidence of chronic pain.
66



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Management of PONV

Risk factors for PONV
Identification of patients at high risk for PONV enables targeting prophylaxis to those who will benefit most from it.
Universal PONV prophylaxis is not cost effective, is unlikely to benefit patients at low risk for PONV and would
put them at risk from the potential side effects of antiemetic agents. Patient, anesthesia, and surgery related risk
factors have been identified. Anesthesia related risk factors include the use of volatile agents
67
, nitrous oxide
68
,
opioids
67,69
and high doses of neostigmine (>2.5 mg) for the reversal of neuromuscular blockade.
70
Patient related
factors include female gender
69,71
, history of PONV or motion sickness
69,71,72
, and non-smoking status.
69,71
Highlevels of anxiety and postoperative pain, especially of pelvic or visceral origin, may also be associated with a
higher
incidence of PONV.
73-75


A recent systematic review of the results of all available studies suggest that the phase of the menstrual cycle has no
impact on the occurrence of PONV.
76
An increased Body Mass Index (BMI) is not a risk factor for PONV.
77
However, long surgical duration
71
and certain types of surgery also carry a greater risk of PONV.
71,78,79
In adults,
high incidences of PONV are found in intra-abdominal surgery, major gynecological surgery, laparoscopic surgery,
breast surgery, neurosurgery, eye and ENT surgery. Pediatric operations at high risk for PONV include strabismus,
adenotonsillectomy, hernia repair, orchidopexy, penile surgery and middle ear procedures.
80-82
However, in a
prospective validation study, an association between type of surgery and the risk of PONV was not apparent.
69
It
was suggested that the high incidence of PONV after certain operations might be caused by the involvement of
high risk patients. The incidence of PONV increases after the age of 3 years with a peak incidence of about 40 %
in the 11 14 year age group.
69,83,84
Prior to puberty, gender differences for postoperative vomiting have not been
identified.
85
A recent study suggests black South African as an independent factor in reducing PONV risk.
86


A number of PONV risk scoring systems have been developed. Apfel et al developed a simplified risk score
consisting of four predictors: female gender, history of motion sickness or PONV, non-smoking status and the use of
opioids for postoperative analgesia.
69
A recent study identifies five independent predictors for postdischarge nausea
and vomiting: female sex, age<50 years, history of PONV, opioid use in the PACU, and nausea in the PACU.
87


Reduction of Baseline Risks
There are several effective strategies which can be easily employed to reduce the baseline risk for PONV.
Adequate hydration is simple and inexpensive and has been shown to reduce the incidence of PONV.
88
Liberal
fluid regimen is associated with a lower incidence of vomiting and improved pulmonary function in patients
undergoing knee arthroplasty compared with restricted fluid regimen.
89
While earlier studies suggest a protective
effect of higher concentration of oxygen, a recent meta-analysis concluded that 80% FiO2 should no longer be
considered an effective or reliable method to reduce overall PONV.
90
Reducing the use of opioid by adding other
adjunctive analgesia, e.g. NSAID, COX-2 inhibitor, acetaminophen, local anesthetic infiltration, gabapentin etc
can lower incidence of PONV.
91
Avoidance of deep inhalational anesthesia guided by bispectral index has also
been shown to
reduce the risk of PONV. Dexmedetomidine infusion (0.20.8 !g " kg
1
" h
1
) has recently been shown to reduce
rescue antiemetic use in bariatric surgical patients.
92
Most importantly, the use of propofol as the maintenance
anesthetic have the greatest impact in further reducing the incidence.
93


Combination Antiemetic Therapy
There are at least four major receptor systems involved in the etiology of PONV. The concept of combination
antiemetic therapy was first introduced in 1988 in chemotherapy induced nausea and vomiting (CINV).
94
Its success
prompted similar research in the field of PONV. Over 100 randomized controlled trials have been published
comparing the relative efficacy of combination versus single agent antiemetic prophylaxis. Most of these studies
suggested better efficacies against PONV can be achieved by the use of two or more antiemetics acting at different
receptors compared with monotherapy.
95-97
The choice of combination is not critical. In a meta-analysis, Habib et al.
found no statistically significant difference in the incidence PONV when a 5-HT3 receptor antagonist was combined
with either droperidol or dexamethasone. Both combination regimens provided significantly better PONV
prophylaxis compared with 5-HT3 receptor antagonists alone.
98
.


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In a large prospective study using a multifactorial design, Apfel et al. evaluated 3 antiemetic interventions
(ondansetron 4 mg, droperidol 1.25 mg, dexamethasone 4 mg) and 3 anesthetic interventions (TIVA with propofol,
omitting nitrous oxide, and substituting remifentanil for fentanyl) for the prophylaxis of PONV. The data suggest
that antiemetics with different mechanisms of action have additive rather than synergistic effects on the incidence of
PONV. Each antiemetic reduced the risk of PONV by about 25 %. When combinations of interventions were used,
the benefit of each subsequent intervention was always less than that of the first intervention.
95
. Interestingly, a
recent study showed superior efficacy in reducing vomiting when aprepitant was combined with dexamethasone
instead of ondansetron-dexamethasone combination in neurosurgical patients.
99


Multimodal Approach
In addition to using a combination of anti-emetics acting at different receptor sites, the multifactorial etiology of
PONV might be better addressed by the adoption of a multimodal approach other than pharmacotherapy. This
is especially important in patients at high risk for PONV. Scuderi et al reported a multimodal approach to the
management of PONV in females undergoing outpatient laparoscopy. Their multimodal algorithm consisted of
total intravenous anesthesia with propofol and remifentanil, avoiding nitrous oxide and neuromuscular
blockade, aggressive intravenous hydration (25 ml/kg), triple prophylactic antiemetics (ondansetron 1 mg,
droperidol 0.625 mg and dexamethasone 10 mg), and ketorolac 30 mg. Multimodal management resulted in a
98% complete response rate (no PONV and no antiemetic rescue) in PACU.
100
More recently, a multimodal
approach incorporating TIVA with propofol, a combination of ondansetron and droperidol, and omitting nitrous
oxide, was associated with a higher complete response rate and greater patient satisfaction in the PACU,
compared to similar antiemetic prophylaxis with isoflurane/nitrous oxide based anesthetic.
98
A combination of
ondansetron and transdermal scopolamine (TDS) proves to be effective in reducing PONV up to 48 hours after
ambulatory surgery.
101
A recent meta-analysis suggests a similar effective reduction in PONV with both early
(the night before surgery) and late patch (same day of surgery) application. Apart from a higher prevalence of
visual disturbances after surgery with TDS, there was no difference in the other anticholinergic side effects
when compared to placebo.
102


Droperidol
Following the FDA black box warning on droperidol due to concerns of prolonged QTc interval, its use has
declined dramatically. A recently published pro and con debate weighed the justification of the FDAs action
103,104
.
Increasingly, clinicians begin to use haloperidol, another drug in the butyrophenone class, due to its lack of black
box warning. Haloperidol in doses of 1 mg has been shown to be effective without significant side effects.
105,106
Its efficacy is enhanced when combined with dexamethasone.
107


Novel Antiemetics

Neurokinin-1 Antagonists
Substance P, a member of the tachykinin family of neuropeptides, is an important neurotransmitter in afferent
pathways of emesis.
108
Substance P may be released from enterochromaffin cells in the stomach and intestine (e.g.
postoperative trauma) or from sensory neurons (e.g. radiation, chemotherapeutic agents).
108
Tachykinin peptide
activity is tied to at least three G-proteincoupled receptor subtypes found in the peripheral or central nervous tissue:
neurokinin receptor subtype 1 (NK1), type 2 (NK2), and subtype 3 (NK3). The NK1 receptors are located in the area
postrema and are thought to play a particularly important role in emesis. However, NK1 receptor antagonists (NK1
RAs) are thought to exert their mechanism of action on neurons in the afferent relay station situated between the
medial NTS and the central pattern generator for vomiting.
108
The potential NK1 receptor blocking activity located
deeper in the brain stem is thought to prevent both acute and delayed emesis, whereas 5-HT3 RAs are largely
effective against acute emesis,
108
leading to considerable interest in the use of NK1 RAs for prophylaxis of PONV.
NK1 receptor antagonists are effective for the prophylaxis and treatment of PONV.
109,110
In one study in females
undergoing gynecologic surgery, an NK1 receptor antagonist, CP-122,721 provided better prophylaxis against
vomiting compared with ondansetron. The combination of both agents also significantly prolonged the time to the
need for rescue compared with either drug alone, and was associated with a low incidence of emesis (2 %).
110

Aprepitant is the only NK-1 receptor antagonist currently approved by the FDA for the prophylactic management
for PONV. It is available in oral capsule in 40 mg to be administered between 1-3 hours before surgery. It has a long
half-live of about 48 hours. It appears to have better efficacy in the prevention of PONV when compared with
ondansetron. In two identically designed, randomized, double-blind, active-controlled studies, patients scheduled for
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mostly major gynecological surgery under general anesthesia were randomized to either aprepitant 40 mg, aprepitant
125 mg or ondansetron 4 mg. In the combined analysis, aprepitant 40 mg was superior to ondansetron for no nausea
(39.6% v 33.1%), no vomiting (86.7% v 72.4%), and no nausea, no vomiting, and no use of rescue (37.9% v 31.2%)
(p<0.05 for the odds ratio for each comparison).
111,112
Rolapitant, with a half-life of 180 h, also has superior efficacy
in the reduction of postoperative emesis when compared with ondansetron.
113
There are a number of other NK-1
antagonists currently under development.
114


Long Acting Serotonin Antagonist
Palonosetron has the longest elimination half-life of all the currently available serotonin antagonists at about 40
hours.
115
Its long duration of action can also be explained by its high binding affinity for 5-HT3 receptors.
116
Polanosetron was first introduced into the US market in for the management of (CINV) and it is also recently
approved for PONV. Recent studies suggest palonosetron 0.075 mg i.v. is effective for the reduction of the
incidence of nausea and vomiting in patients up to 72 h postoperatively. Palonosetron also reduces nausea severity
and interference in postoperative patient functioning due to PONV
117
. It would be interesting to see if the longer
half-life of this drug translates into prolonged clinical efficacy when compared with other serotonin antagonists.

Recommended strategy for PONV prophylaxis
The risk of PONV should be estimated for each patient. No prophylaxis is recommended for patients at low risk for
PONV except if they are at risk for medical consequences from vomiting e.g. patients with wired jaws, aesthetic
procedures or at patients request. For patients at moderate to high risk for PONV, regional anesthesia should be
considered. If this is not possible or contraindicated and a general anesthetic is used, strategies to minimize the
baseline risk of PONV should be adopted, e.g. minimize the use of opioids, avoid high dose neuromuscular reversal
drugs and the use of propofol maintained anesthesia. The use of combination antiemetic therapy and more
appropriately a multimodal approach in high-risk patients is recommended. However, the best available combination
and the optimum doses of antiemetic agents when used in combination are yet to be established. Ondansetron should
be considered in any prophylactic regimen as it is now generic and hence has a low acquisition cost.

Recommendations for the treatment of established PONV
There is a paucity of data on the use of antiemetics for the treatment of PONV in patients who failed prophylaxis or
did not receive prophylaxis. This is due to the difficulty in performing such studies since a large number of patients
would need to be recruited in order to obtain the required number of patients who eventually experience PONV.
The 5-HT3 receptor antagonists were the most commonly tested drugs in rescue clinical trials. Similar to their use in
PONV prophylaxis, the anti-vomiting efficacy of the 5-HT3 receptor antagonists is more pronounced than their anti-
nausea efficacy. There is no evidence of dose-responsiveness for these agents when used for rescue. As
ondasnetron is now generic, a 4 mg dose is recommended.

In patients who fail ondansetron prophylaxis, there is evidence to suggest that the use of ondansetron for rescue is no
more effective than placebo. A drug acting at a different receptor might be more effective in this case.
118
Droperidol
was not different from ondansetron when used for the treatment of established PONV.
119
On the other hand,
ondansetron 4 mg was more effective than metoclopramide 10 mg in this setting.
120,121


When evaluating PONV following surgery, the role of medication and mechanical factors should be considered
first. Such contributing factors might include opioids, blood draining down the throat, or bowel obstruction. Then
rescue therapy should be initiated as soon as possible. If PONV occurs within 6 hours postoperatively, patients
should not receive a repeat dose of the prophylactic antiemetic; a drug from a different class should be used for
rescue. Beyond 6 hours, PONV can be treated with any of the antiemetics used for prophylaxis except
dexamethasone and scopolamine, which are longer acting.

In summary, PONV and pain are very common following ambulatory surgery and should be managed
aggressively. The thorough understanding of the mechanism of these common symptoms and a careful assessment
of risk factors provide a rationale for appropriate management of PONV and pain. The adoption of a
comprehensive and multimodal approach for both symptoms will likely ensure success in the management.


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97. Tramer MR. Acta Anaesthesiol Scand 2001;45:14-9.
98. Habib AS, et al. Canadian Journal of Anaesthesia 2004;51:311-9.
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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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Disclosure
Merck, Funded Research ; Fresenius, Funded Research, Honoraria ; Pacira, Funded Research, Honoraria ;
Accel Rx
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Page 1
Ultrasound-guided Regional Anesthesia for Ambulatory Patients
Meg A. Rosenblatt, M.D. New York, New York
Introduction
Outpatient surgeries now account for more than two-thirds of all surgeries performed in the United States and after
GI endoscopies, and ophthalmologic procedures, orthopedic operations (surgery of the muscle, tendon, fascia and
bursa) are the next most frequently performed .
1
The advantages that regional anesthesia (RA) confers over general
anesthesia (GA), especially in the outpatient setting, are numerous. Specifically, orthopedic patients are the group
of ambulatory patients with the highest incidence (16.1%) of pain in the PACU.
2
Peripheral nerve blocks (PNBs)
offer predictable intraoperative anesthesia, as well as provide analgesia into the postoperative period, the
opportunity to bypass Phase I recovery, and the avoidance of airway manipulations. Ultrasound (US) imaging
permits direct visualization of peripheral nerves, needle location and distribution of local anesthetic. The use of US-
guidance to perform nerve blocks is associated with decreased time to onset and quality of block which is equal to or
better than PNBs performed with nerve stimulator (NS) techniques,
3,

4
and the use of US facilitates the placement
of blocks in patients who are obese, may be on anticoagulants and those with challenging external anatomy.
Since the mastery of US-guided PNBs frequently does not occur during residency, their successful incorporation
into practice requires that an anesthesiologist continues to acquire skills while often having to work in a rapid
turnover environment and meet high surgeon and patient expectations. Performing US-guided nerve blocks requires
an entirely new skill set for practitioners. Firstly, one must learn to operate ultrasound equipment and then use this
to identify anatomy as it appears on a two-dimensional screen. Secondly, one must be able to simultaneously use
both hands (one holding the ultrasound transducer and the other holding the block needle), watch the display screen,
and manipulate the needle into the nerve sheath. Lastly, it is necessary to learn to identify patterns of local
anesthetic spread that are associated with optimal plexus blockade. Smith designed a learner-centered curriculum
which describes the three elements that need to be acquired. They are the use of the US equipment (management of
the machine, choice of probe, medical record documentation), scanning techniques and sonoanatomy (performing
the exam, distinguishing anatomical elements, recognizing artifacts) and sonographic needle guidance
(understanding needle/probe orientation, optimizing needle visualization).
5

Enlisting the surgeon to introduce the concept of PNBs when they offer patients their preoperative instructions will
improve patient acceptance. Local anesthetics should be chosen to minimize onset times and limit the use of GA in
order to prevent operating room delays. Meticulous follow-up until resolution of all blocks along with
communication with the surgeons can add to overall satisfaction.
Local Anesthetics and Adjuvants
Local anesthetic (LA) agents should be chosen according to the desired duration of action and the required degree of
motor blockade. An insensate extremity in a patient whose procedure may not produce much post-operative
discomfort may be at risk for injury secondary to the loss of protective reflex to pain, or place the patient at risk
secondary to a loss of proprioceptionblocks of the longest possible duration are not always the wisest choice.
Whereas some practitioners combine LAs to decrease onset time while providing long duration, combining
chloroprocaine 2% and bupivacaine 0.5% causes pH changes that create a block that resembles one produced by
bupivacaine alone. Galindo concluded that mixing LAs leads to unpredictable blockade characteristics.
6
Gratenstein
looked at US-guided interscalene blocks with 30 mL in 3 different solutionsmepivacaine 1.5%, bupivacaine0.5%
and a 50:50 mixture of the two, and found that mixing the short and long-acting agents does not result in a
significant difference in onset time compared with either solution alone.
7
LAs diffuse into nerves and the rate of
diffusion is determined by the concentration, therefore higher concentrations of LAs result in more rapid onset of

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blockade. Ropivacaine 0.75% has been shown to have similar or shorter onset times for femoral, sciatic and
interscalene blocks, while providing significantly longer postoperative analgesia than mepivacaine and
bupivacaine.
8,9
The effect of alkalinization of agents on the speed of onset of the block is unclear. It has been shown
to offer no advantage in perivascular blocks with 0.5% bupivacaine,
10
but improvement in onset and quality of
analgesia in axillary blocks with 1.25% mepivacaine,
11
and in femoral and sciatic blocks with 2% mepivacaine has
been demonstrated.
12
Adding sodium bicarbonate to lidocaine has been shown to have no effect on the onset of
axillary block,
13
and in rats it has been shown to decrease the intensity and duration of the block.
14
In one study
fentanyl improved the sensory blockade achieved with an axillary block using 1.5% lidocaine, but the pH changes it
conferred delayed the onset of analgesia.
15
Other studies have not shown efficacy of either fentanyl or morphine in
the improvement of onset or quality of axillary blocks.
16,17
Clonidine, an !
2
-agonist, is known to prolong the
duration of sensory and motor blockade, particularly when added to local anesthetics of intermediate duration. One
study of 56 patients undergoing carpal tunnel release under axillary block with 1% lidocaine and varying amounts of
clonidine, showed a reduction in block onset time. However, even with doses as small as 30g, patients experienced
sedation. More than 50% of patients were reported to fall asleep intermittently at 140 minutes after performance of
the block.
18

Recently the utility of adding dexamethasone to upper extremity blocks. The addition of dexamethasone 8 mg to 30
mL mepivaciane has been shown to significantly prolong the duration of a supraclavicular block.
19
Eight mg of
dexamethasone was shown to prolong the duration of action of ropivacaine (11.8 vs 22.2 hrs) and bupivacaine (14.8
vs 22.4 hrs) when added to 30 mL of local anesthetic for interscalene anesthesia.
20
Tando and colleagues found no
difference in the duration of analgesia between adding 4 mg and 8 mg doses of dexamethasone to interscalene
blocks using 40mL bupivacaine.
21
There exact mechanism of this prolongation of action is yet to be elucidated.

The 5 US-Guided PNBs Every Ambulatory Practitioner Needs and When to Use Them
The following is a discussion of useful blocks and their specific applications for outpatients. Mastery of the
interscalene (ISB), supraclavicular, femoral, popliteal and transverses abdominis plane (TAP) blocks will be
adequate for almost all of the needs of the anesthesiologist who has an ambulatory-based practice. Learning the
infraclavicular block may be advantageous if the practitioner will be providing continuous postoperative analgesia
after surgery of the elbow, forearm or hand. All can be performed with a linear array probe which is 13 to 16 mHz
and 25 mm wide and a 22g, 50 mm needle.
Upper Extremity US-Guided Peripheral Nerve Blocks
This author is of the belief that one needs to master only two single-shot PNBs to be able to adequately anesthetize
the entire upper extremity for ambulatory surgeryISB and supraclavicular block. Both of these blocks can be
accomplished by learning a simple scanning technique. The patient is placed in the supine position with his or her
head flat on the bed (without pillows) and turned towards the contralateral shoulder. The region to be blocked is
sterilely prepped:
22

!" Identify the carotid artery and internal jugular vein, with the probe in the horizontal position, just above
the clavicle.
2) Moving the probe laterally along the clavicle and aiming the beam caudad, towards the first rib, the
subclavian artery is identified as the next pulsatile structure that is visualized. The brachial plexus at the level of the
divisions appears as a bag of grapes located lateral to the artery. To perform a supraclavicular block at that level, a
22 gauge block needle is inserted in-plane (parallel to the probe), until it reaches the location that is bordered by the
subclavian artery medially, the first rib inferiorly, and the divisions of the brachial plexus superior laterally--the
eight ball in the corner pocket position.
23
This block is ideal for all procedures of the elbow and distally. 30- 40 ml
of local anesthetic will be more than adequate to provide a block.
3) It is then possible to choose the largest of the nerves, appearing as a radiolucent circle and trace it
cephalad, as the probe is kept in the horizontal position. When the C-6 level is reached, this nerve and the others of
the brachial plexus are seen in a vertical orientation, between the anterior and middle scalene muscles. The 22-
gauge block needle is inserted either in-plane or out-of-plane and directed towards the previously identified nerve,
within the sheath. The out-of-plane approach may be preferable to an in-plane one for practitioners who have
experience with using a vessel finder for central venous line placement. Again, 30-40 ml of local anesthetic will
provide adequate anesthesia. In a study looking at 170 patients undergoing shoulder surgery, Spence sought to
describe the ideal location to inject LAeither peri-plexus (between the middle scalene muscle and brachial
plexus), or intra-plexus (injection within the brachial plexus sheath). After injecting 30 mL bupivacaine 0.5%, they

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looked for loss of shoulder abduction. Onset times and block quality were equal, but the intra-plexus blocks resulted
in statistically significantly longer block duration (2.6 hrs, p=0.03).
24


Data show that when 5mL vs. 20 ml of ropivacaine are used for in ISB combined with GA for the surgical
procedure, patients have fewer respiratory and other complications with no change in postoperative analgesia.
25

More recently this group showed that with the use of US, the minimum effective analgesic volume of ropivacaine
0.5% in an ISB required to provide analgesia in the immediate post op period is 0.9mL.
26
Although studies show
that much less LA can be used, the effect on the adequacy of these smaller volumes as the sole anesthetic for surgery
has not been described. Interestingly, 61 patients were undergoing US-guided ISB performed with insulated needles
for ambulatory shoulder surgery. After the needle tip was determined to be in the interscalene groove the nerve
stimulator was turned on and the lowest current eliciting a response was noted. The sensory analgesia achieved
between the groups with responses at <0.5 mA and >0.5 mA was similar, thus confirming that US-guided blocks
produce successful analgesia regardless of the motor stimulation evoked.
27


The use of US has been shown to speed the execution and improve the quality of supraclavicular blocks.
28
Perlas et
al described their experience with 510 consecutive US-guided supraclavicular blocks, and reported a 94.6% success
at achieving surgical anesthesia with a single attempt. Complications included symptomatic hemidiaphragmatic
paresis (1%), Horner syndrome (1%), vascular puncture (0.4%) and transient sensory deficit (0.4%). They
concluded that this US-guided block is a safe and effective technique.
29
A prospective registry of 1,169 US-guided
ISB and supraclavicular blocks for shoulder surgeries shows a 0% incidence of vascular puncture, 0.4%incidence of
short-term postoperative neurologic symptoms and a 0% incidence of permanent nerve injury.
30


Since Sauter used MRI to define the anatomic location of the cords of the infraclavicular brachial plexus, we know
that needle placement at the VIII oclock position adjacent to the axillary artery in the cranioposterior quadrant
and observing satisfactory spread of local anesthetic between the III oclock and IX oclock positions will predict
a successful infraclavicular block.
31
The use of US-guidance (with the probe in a sagital position medial to the
corticoid process and employing an in-plane technique) for single shot infraclavicular blocks yields high success
rates and trends toward improved block quality.
32


Practitioners who perform US-guided axillary blocks find that there is a greater success rate for achieving surgical
anesthesia and shorter performance times than when nerve stimulation or transarterial techniques are used.
33
Thirty
to 40 ml of local anesthesia is injected to ensure circumferential spread around the axillary artery. Mccairre
described using US-guided median and ulnar nerve blocks at the wrist to provide anesthesia for endoscopic carpal
tunnel release. Through a single injection site located 5 to 10 cm proximal to the wrist crease in the anterior
forearm, both nerves are blocked under direct vision, each with 4 ml of 1.5% mepivacaine. This is supplemented
with 1-2 ml of local anesthetic at the level of incision in the wrist crease in order to block the palmaris ramus of the
median nerve.
34

Lower Extremity US-guided Peripheral Nerve Blocks
US-guided blocks of the lower extremity that are useful in ambulatory practice include femoral, saphenous and
popliteal blocks. The femoral nerve is located by placing the linear probe in the inguinal crease. It is the dense
white structure, lateral to the hypoecoic pulsatile femoral artery and deep to both the fascia lata and fascia iliaca.
This can be blocked with a 22g needle in an in- or out- of plane approach and a successful block is anticipated when
local anesthesia spread is seen surrounding the nerve. This block is particularly useful for patients undergoing
repairs of the anterior cruciate ligament or surgical procedures involving the patella. Performing a fascia iliaca
block is an alternative to the femoral nerve block, and may be more successful for blocking the lateral femoral
cutaneous nerve and occasionally the obturator nerve. A line drawn between the anterior superior iliac spine and
pubic tubercle is divided in thirds. At the junction between the middle and lateral thirds an ultrasound probe is
placed in a transverse position and the fascia lata and iliaca are identified. The needle is placed under the fascia
iliaca, and 30 ml of local anesthetic is injected. Spread of local anesthetic in medial and lateral directions under the
fascia iliaca is evidence of correct needle placement.

For surgical procedures below the knee, the sciatic nerve in the popliteal fossa can be blocked either from a posterior
or lateral approach. The posterior approach requires placing the patient in a prone position and the hyperechoic
nerve is located at the midpoint between the tendons of the biceps femoris and the semitendinosus/semimembranosis
muscles. The popliteal artery is located medial and deep to the nerve, and is an excellent landmark from which to

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begin scanning superior and laterally. It is essential to identify the point of division of the sciatic nerve into the
common peroneal and anterior tibial nerves, and place the needle proximal to this point to ensure that both divisions
are blocked. US-guidance has been shown to increase success of block and decrease onset time compared to a NS
technique.
35
For the lateral approach, the patient remains in the supine position and it is helpful to have the patients
leg placed on a bolster, with the US probe placed underneath. A 100 mm needle is inserted parallel to the probe and
directed towards the hyperechoic nerve, again insuring that it has not yet divided. For either approach, 30 ml of local
anesthetic will ensure an adequate block.

To provide complete analgesia of the lower extremity with the popliteal block, anesthesia of the saphenous
distribution (medial side of the lower extremity) is necessary. And, in order to preserve quadriceps muscle function
(which would not be possible with a femoral nerve block), the saphenous nerve can be blocked at the level of the
tibial tuberosity. This can be accomplished by locating the saphenous vein in the short axis view, and then
delivering 5 ml of local anesthesia both medial and lateral to the vessel.
36
Because it may be difficult to identify the
saphenous nerve at this level, it may be easier to identify the nerve as it travels deep to the sartorius muscle, adjacent
to a descending branch of the femoral artery. With the patients lower extremity externally rotated at the hip, the
probe is placed perpendicular to the extremity 7 cm proximal to the popliteal crease. Using an in-plane approach, 10
ml of local anesthesia is deposited deep to the sartorious muscle anterior and superior to the artery, where the nerve
is visualized.
37


US is now being used to improve the success rate of PNBs nerve blocks at the ankle. The sural nerve has been
shown to lie adjacent to the lesser saphenous vein. Redborg placed his patients in a prone position with a tourniquet
around the proximal tibia, to allow easy identification of the vein, and using a 27 gauge needle in an out-of-plane
technique, injected 5 ml of local anesthetic. The endpoint was to observe the spread of local anesthesia completely
around the lesser saphenous vein. Although the US blocks took longer to perform than anatomically based ones
(172 sec vs. 70 sec), they were considered to be denser in quality.
38
She also described using US to block the tibial
nerve at the ankle. Again, patients were placed in the prone position, and the probe was placed in a horizontal plane
posterior to the medial malleolus. The nerve can be identified posterior to the posterior tibial artery. The flexor
hallucis longus tendon travels with the neurovascular structures at that level and may look like the nerve; therefore
the author suggests demonstrating motion of the tendon with movement of the great toe in order to differentiate it
from the nerve. Using 5 ml of local anesthetic and demonstrating circumferential spread around the nerve is
associated with block success.
39


Truncal Blocks
The TAP block is gaining popularity as a method for postoperative analgesia for procedures of the abdomen,
including laparoscopic appendectomy
40
and cholecystectomy.
41
The block is accomplished by placing a linear array
probe horizontally at the T10 level and moving laterally until it is possible to identify the following abdominal
layers: skin/subcutaneous tissue, external oblique muscle, internal oblique muscle, and transversus abdominis
muscle (below which is peritoneal cavity). Using a 22 gauge block needle and an in-plane approach, 20 ml of
0.25% bupivacaine is deposited on one or both sides, depending upon the location of the surgical incisions. This
block has been shown to reduce both the intraoperative and postoperative use of narcotic analgesics. US-guidance
has also been described to place ilioinguinal and iliohypogastric blocks to provide analgesia following outpatient
inguinal herniorrhaphy. After identifying the anterior superior iliac spine, the anterior abdominal muscle layers, and
the peritoneum, a needle is inserted into the fascial plane between the internal oblique muscle and transversus
abdominis muscle. Occasionally it is possible to identify the iliohypogastric nerve. Lastly, the rectus sheath block
has been described to block the lower thoracic nerves and provide analgesia for midline incisions and procedures
around the umbilicus. Needles are inserted 5 cm above and below the umbilicus and 5 cm bilaterally, and injecting
10 ml of local anesthetic in each quadrant between the anterior and posterior rectus sheaths.
42


Indwelling Catheter Techniques
For ambulatory practitioners who place indwelling catheters, US-guidance has proven to provide analgesia equal to
that achieved when a NS technique is employed, with statistically significant shorter time from needle placement
under to catheter insertion and lower catheter insertion pain scores.
43
For interscalene catheters, some advocate a
posterior approach to the interscalene groove, which provides postoperative analgesia and offers the advantages of
avoidance of the external jugular vein and placement of the catheter further away from the surgical field.
44
However
the use of GA is necessary since the nerves of the superficial cervical plexus and the skin around the shoulder are
not anesthetized. When placing catheters for forearm and hand procedures, an infraclavicular approach offers the

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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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advantage of a more secure position under both the pectoralis major and minor muscles. In this position there is less
leakage around the catheter than from more superficially placed ones (i.e., supraclavicular and interscalene
catheters). And US-guided infraclavicular catheters result in higher primary block success and decreased secondary
catheter failure when compared to traditional insertion techniques.
45


There are conflicting data regarding the ideal solutions for ambulatory catheters. For example, Lee found that low
concentrations of anesthetic at higher basal rate provided superior analgesia to patients with interscalene catheters.
46

Conversely, Ilfeld showed that for continuous popliteal-sciatic nerve blocks, concentrated solutions of small volume
provided excellent analgesia, with a lower incidence of insensate limbs.
47


Interestingly, Clendenen just reported a series of 5 cases of difficult removal of stimulating catheters placed in the
interscalene groove of ambulatory patients. In each case the polyurethane sheath sheared from stainless steel coil
and the coil was retained, requiring 4 of the patients to return to the hospital. Therefore, it may be prudent to avoid
the use of stimulating catheters in the ambulatory population.
48


Patient Instructions and Follow-Up
Whenever a regional anesthetic is performed, detailed instructions must be given to the patient,
49
offering an
expectation of the duration and extent of their block, the requirement to protect the insensate limb, and the need to
begin analgesic medications prior to his/her experiencing severe pain. Timely follow-up must be conducted to
ensure complete block resolution. Borgeat specifies in his study following 521 patients after interscalene block, that
sulcus ulnaris syndrome, carpal tunnel syndrome or complex regional pain syndrome must be excluded in the
presence of persistent paresthesia, dysesthesia or pain not related to the surgery, because specific interventions may
be necessary to treat those conditions.
45
Should any persistent neurologic deficit be discovered during a
postoperative interview, the patient should be reassured that it will resolve, and that the anesthesiologists
participation in the follow-up is certain. Discussion with the surgeon should include a plan for neurologic
evaluation.

Conclusions
The use of PNBs is associated with shortened post-procedure operating room, PACU and discharge times, provision
of postoperative analgesia, and a high level of patient satisfaction. Numerous techniques have been described in
order to provide anesthesia and analgesia for ambulatory surgical procedures. The introduction of US into the
practice of regional anesthesia offers new and exciting challenges for todays regionalists. Regional techniques
should be both encouraged and employed for procedures in outpatients.



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Fredrickson MJ, Ball CM Dalgleish AJ et al. Anesth Analg 2009;108:1695.
44
Mariano ER, Afra R, Loland VJ, et al. Anesth Analg 2009;108:1688-94.
45
Dhir S, Ganapathy S. Acta Anaesthesiol Scand 2008;52:1158-66.
46
Lee LT, Loland VJ, Mariano ER et al. Reg Anesth Pain Med 2008;33:518-525.
47
Ilfeld BM, Loland VJ, Gerancher JC. Anesth Analg 2008;107:701-06.
48
Clendenen SR, Robards CB, Greengrass RA, Brull SJ. Can J Anesth 2011;58:62-67.
49
da Conceicao DB, Helayel PE. Rev Bras Anestesiol;2008;58::51-4.

Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

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Outcomes and the ASC: the Role of the Medical Director and Measurement in Improving
Clinical and Business Outcomes
Douglas G. Merrill M.D. MBA Lebanon, New Hampshire
Its not what we dont know that hurts us.
Its what we know for sure that just aint so.
Mark Twain
Introduction
Measurements and analysis of financial and functional performance to support the achievement of individual and
organizational goals are required tools of management for any business enterprise. The use of outcomes to direct
strategic management decisions to attain goals is integral to the theory of knowledge management, a core aspect of
modern business management.
1
The learning organization theory grew from the need to respond to customer
demand with rapid process improvement. Defined by one writer
2
as the process whereby organizations understand
and manage their experiences, it includes the use of customer-focused data collection and assessment, employee-
centric management, benchmarking and best practice implementation and process re-engineering in response to
data.
3
This methodology is what Argyris and Schon defined as the employees response when they
4

experience a surprising mismatch between expected and actual results of action and
respond to that mismatch through a process of thought and further action that leads them
to modify their images of organization or their understandings of organizational
phenomena and to restructure their activities so as to bring outcomes and expectations
into line
A surprising mismatch is an apt description for the response of many physicians, nurses and other healthcare
providers when they first are given objective evidence of their patients perioperative experience. Most providers do
not know their specific, individual performance on the metrics that matter to their patients and to the success of the
business enterprise.
Before we go further, ask yourself if you know your personal nausea and vomiting rates (both) for the recovery
room (PACU) and also after discharge home. Do you know exactly how many of your patients would return to your
facility if the need arose, or to have you again as their provider, given a choice? These metrics are as important to
the health and survival of your practice as are market penetration or contribution margin, yet the majority of us do
not know them. PONV and PDNV top the list of patient concerns
5
and, with the increasingly competitive business
environment for healthcare, such data may be reflected in your profile on Angies List, Yelp, or on any of the
myriad physician grade websites.
Further, attempts to improve your facilitys clinical and financial performance are dependent upon your ability to
convince your physicians and nurses of the need to change. Given the highly intelligent and high degree of
resistance to change that characterizes most our professions, without data showing that a problem (the euphemistic
opportunity) exists, you will not be successful in gaining their support for change, and thus it will not occur. In
addition to the general human resistance to change, practitioners are susceptible to bias and more expert providers
may actually be more susceptible to all forms of bias.
6

7
The foundation of successful intentional process change
is credible measurement that reveals the gap between the current and the desired state to those who must
create and sustain the change.
In the past 50 years, this management by measurement has become an integral tactic to the administration of the
health care enterprise and has stimulated the large body of literature on healthcare quality as represented by
Donabedians work on quality improvement.
8

9
These techniques are now widely applied in healthcare.
10

11
Indeed,

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outcome measurement is critical to quality improvement.
12
However, collection of data and sharing with providers
so that they can experience a surprising mismatch is not widespread in perioperative practice. Here, we will
examine the value of such measurement and discuss the role of the Medical Director and her or his team in the
management of that data and its use in altering care, process, business and accreditation outcomes for the better.
Finally, we will discuss the potential positive impact of measurement as a means of changing the culture of an
institution, change that is extremely difficult but necessary to most facilities success (and survival).


The Role of the Medical Director
Inherent in this lecture is the assumption that the Medical Director serves as a leader in the ASCs management. In
most cases, the Medical Director in an ambulatory surgery center (ASC) has long since become an integral part both
of the medical team and the business team that manages the ASC. Gone are the days (we hope!) of the medical
director merely filling a daily role of waiting for the discharge of the last patient. Instead, he or she should expect to
fully participate in the creating of policies and procedures that will improve the safety of the patients and the high
quality of their surgical, anesthesia and nursing care. As well, the Medical Director is most often accountable for
decisions regarding marketing to and credentialing of surgeons and other providers, a significant part of the strategic
management of the ASC. It is the intent here to show the value of including the Medical Director in such decision
making and the reason that physicians should demand outcomes data access, if offered the opportunity to serve in
such a capacity.

Evidence Based Medicine and Clinical Outcome Measurement
Two complaints sometimes raised about Evidence-Based Medicine (EBM) are that it stymies care innovation by
encouraging standardized practice (care pathways) and is of little value in guiding much of routine clinical practice,
because the randomized controlled trials it requires have not or cannot be performed in many clinical situations.
However, the early proponents of EBM actually stated that, the practice of evidence based medicine means
integrating individual clinical expertise with the best available external clinical evidence from systematic
research.
13
In reality, EBM is actually a construct of expertise garnered locally, combined with the best that the
literature can offer. The cornerstone of EBM is actually its de-emphasis of expert opinion in favor of the lessons of
local experience. The appropriate means to garner accurate local experience in a useful format is the copious
collection of outcomes in a database. Then, the application of EBM is accomplished by the careful scrutiny of those
data, assessment for trends and linkages between practice and outcome, and a resulting focus on quality
improvement efforts unencumbered by anecdote or defensiveness.
14
Done well, with objective, equanimous and
open sharing of data, exchange of ideas and decisions on action followed by careful re-assessment and open
discussion of outcomes, this measurement can form the cornerstone of effective quality improvement efforts in any
perioperative environment.

Requirements of Measurement and Sharing of Data
To support the goals discussed here, the metrics chosen must meet certain criteria: accuracy, risk adjustment, regular
presentation to all stakeholders, and controllable by those providers who are being held accountable. As well, there
must be an ongoing tailoring of the metrics to meet changes in strategic goals of the organization.
The concept of publishing data and identifying responsible caregivers has been done with post-cardiac surgery
mortality data, but no effect upon improving outcomes was shown.
15
Mortality is a complex outcome, however,
created by a multiplicity of treatment and co-morbidity factors such that simply reporting it would be unlikely to
decrease its incidence. Of course, complex measures like mortality, stroke, MI and transfers are recorded to comply
with accreditation and licensing requirements in the outpatient surgery venue, but they otherwise rarely are caused
by variation in practice nor are they thankfully frequent. Therefore, they have little value as metrics to guide
quality improvement in an ASC.
However, open sharing and attaching names to providers data have been successful in this authors practice as a
means of generating process improvement through the magic of friendly competition that is aimed at the universal
success of all team members in the ASC. The metrics shared should include process outcomes (e.g., time in recovery
room, time of turnover, first case start on time history, etc.). Frequently that is the only type of information collected
and shared because it is easy to obtain. However, clinical outcomes must be included. Posting PONV and PDNV
outcome data with names attached has been particularly useful as a means of reducing this negative outcome that is
so pernicious to outpatients.
Posting of identified data should be done in a protected site (the clean core, med room, etc.) in a locked trophy
case where patients and families cannot see it and others cannot obtain it. It should not be emailed. There will be

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initial resistance to the concept of such data sharing and so it is ideal to discuss it in advance with staff and
physicians, giving an opportunity to discuss the reasons for its use. Some will feel that embarrassment is the goal
of such sharing, but repeated public emphasis on emulation of the best outcomes rather than focus on the stragglers
will improve outcomes and thereby convince most disbelievers.
This approach is different from that required for de-identified or Center outcome data, such as the Centers waiting
times, PONV rates, patient satisfaction, etc. These may be placed in a site where patients and families can see the
information (although still in a trophy case, so it cant be taken or copied). Employees and physicians rightfully take
pride in accomplishment of excellent outcomes and such transparency is of course welcomed by patients and
families.

Matching chosen metrics to goals
Our goals are threefold:
A. to exceed patient and family expectations,
B. to achieve superb clinical and financial outcomes, and
C. to create high provider (surgeon and staff) satisfaction.
To accomplish these, we craft our systems and improvement processes to focus on them. Thus, the metrics we
choose to measure and share must reflect them, as well.
Surveying patient and family satisfaction is a primary means of assessing customer satisfaction in healthcare and
is related to - but may not precisely reflect - the quality of outcomes delivered.
16
Given their baseline expectation of
safety in the ASC venue, patients and families value excellent service, the absence of PONV and PDNV, and respect
for their time.
1718
Measures that examine their satisfaction with each stage of their care and the people who provided
it, time measures (on-time starts, accuracy in scheduling case durations, and the absence of delays in turnover) and
PONV and PDNV are appropriate to choose, to be sure that the staff are keeping patient expectations in the forefront
of their daily work.
Clinical outcomes we measure include PDNV, PONV and pain scores, and adequacy of home pain medication.
Post-operative infection, unplanned transfers, unplanned urinary catheter placement, use of opioid or benzodiazepine
reversal agents, spinal headache, failed regional or neuraxial block, and prolonged stays in the PACU are relatively
easy to measure and are significant (if rare) indicators of quality of care. Individual practitioners vary in their
techniques of care and that will result in variation in outcomes
19
, so the process of identifying and emulating best
practice can be applied in this arena.
Financial measures include cost per case, such as supplies, implants and cost of FTE. Including the latter is
reasonable to help all practitioners to concentrate on decreasing that cost over time. However, when comparing
surgeon to surgeon on same-case data, eliminating the cost of FTE is reasonable as it should be considered
equivalent, unless overtime is routinely needed by a given practitioner. An exception would be if the facility sends
staff home without pay when the work is done. In that case, minutes in the O.R. should be tracked by surgeon.
Contribution margin (CM) is an excellent measure to track and useful for strategic planning as well as focusing all
on cost reduction. More so than utilization, CM is a reasonable metric upon which to base allocation of O.R. time
20
,
but the measurement of income and expense must be absolutely dependable and should be shared solely with the
surgeon and/or department involved. The measurements of capacity and utilization, combined with cost will
generate a pathway for reducing cost while increasing capacity.
21

Staff and provider satisfaction can be measured overtly by surveys, but also by staff retention rates and (for
surgeons) by the case volumes they bring to you (vs. those at competitor facilities, if you have those). Peer reviews
can be of great value in helping practitioners understand if they are outliers in comportment or collegiality. This data
is of great value in one-to-one counseling sessions.

Risk Stratification
In the simplest construct, risk stratification for clinical measures can be accomplished by categorizing outcomes by
surgical specialty. For instance, the PONV rate for an anesthesiologist or surgeon who performs pediatric cases
under general anesthesia cannot fairly be compared to the PONV generated by cataract cases done under local with
I.V. sedation. As the electronic health record (EHR) reaches more ASCs, the opportunities increase to use more and
more discrete metrics to stratify risk: e.g., ASA status, co-morbidities, age, CPT, duration of the case, etc. These
metrics can be automatically downloaded into local and national databases from an increasing number of EHRs (see
Table 1).



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Process Improvement and Benchmarking: AQI and SCOR!
As noted, measurement of the right outcomes can lead to improvement in the quality of practice.
2223
Measurement
of outcomes can reveal repetitive error in care choices, even leading to changing indications for surgery with
resulting decreases in morbidity and mortality.
24
A great tool in gaining consensus for improvement of care is
benchmarking with external but similar facilities. A single ASCs practice will most often not be large enough to
meet statistical significance when assessing trends, particularly for individual physicians.
25
Using external
benchmarks can provide risk stratified targets for the individual ASCs quality improvement when insufficient
numbers of a particular procedure or patient populations prevent identification of best practice within the Centers
own data. This can best be managed by joining a national database overseen by a professional society, such as

SAMBAs SCOR! (www.scordata.org ) or ASAs AQI (http://www.aqihq.org ), or both. The AQI has been
accepting data of all kinds for two years, with an early emphasis on administrative data but now taking clinical data
as well. SCOR! is exclusively collecting data describing outpatient surgical and anesthesia care. In SCOR!, outcomes
for individual caregivers can be monitored by the ASC, as well as aggregate reports. AQI and SCOR! are working
with several electronic health record vendors to provide direct download capability between a Centers system and
the AQI database. SCOR! and AQI are now linked with one another, so that entry of data into SCOR! will allow
measurement against the many outpatient cases in AQI, but with stratification by similar facility size and type (and
vice versa).

Business Decision Making
Data such as contribution margin should guide decisions regarding allocation of scarce resources, including
operating rooms and equipment purchases. An ASC can also make it clear to staff and physicians alike that
citizenship metrics are as important those that indicate income to the Center (such as APCs (Ambulatory Payment
Classifications) or RVUs (Relative Value Units)) in determining the ASCs willingness to provide investment
support. Providing resources to the practice of a surgeon who values teamwork and respects the staff is a far safer
investment than supporting a surgeon who is disrespectful of staff or patients time, showing up late or without
paperwork done in advance, for instance. The latter will not make a good long-term partner for the ASC. Counseling
of such a surgeon is made far easier with his or her personal data in hand.

Accreditation
The various accreditation organizations and CMS all value evidence of a cohesive quality assessment and
improvement program.
26
Showing that staff are provided with individual outcomes is particularly positive in the
eyes of an inspector who is seeking evidence of a patient-centric, employee-empowered just culture. As well,
proving that an ASCs administration is intent upon meeting its stated goals and supports this by matching metrics to
those goals is a significant positive to portray at the time of assessment. Professional accreditation (e.g., MOCA)
should also be supported by the practitioners access to such data.

Management by Outcomes: Culture change
Upon completion of residency, physicians have a body of knowledge that includes facts like medication doses and
expected ranges of patient physiologic responses to interventions. However, their education typically provides little
emphasis on the need for outcome measurement to be sure that patients respond to care in the ways we were taught
they would. In fact, for many physicians and other caregivers, it is a large leap to the conclusion that the facts we
were taught are not actually correct and that the best means to discover these new facts is to continuously review
the literature and to monitor our local outcomes. By not emphasizing the need to experience surprising
mismatches, our educational process has supported anecdotal care delivery.
Our professions reluctance to measure and share data has obstructed progress in care pathway creation, discovery of
best practice, self-discovery and accountability. Nonaka stated, knowledge is justified true belief. Individuals
justify the truthfulness of their beliefs based on their interactions with the world.
27
Twains much earlier
observation echoed our willingness to believe in self-swerving fictions. If our interactions with the world include no
information about the outcomes of our actions, then we lack justification for our beliefs. In business, it would be
unacceptable to make an investment in a particular service line or product without an understanding of its
profitability and ongoing assessment of its performance in the market place.
Yet healthcare has not embraced such measurement, so some of the safety assessment techniques long accepted in
business are only nascent in healthcare, including assessment of data and outcomes regarding practice techniques,
even though these are of clear value in improved patient safety.
28
Studies have shown that physicians do vary in
their ability to follow guidelines, based on gender, age, and type of facility and specialty but also on individual

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characteristics, even when they recognize that the guidelines are valid.
29
The need to tailor re-education to
individuals is obvious and such quality improvement would be aided by providing individual outcome data.
The literature on the topic of organizational culture is extensive, in business and as in healthcare where the topics of
patient-centered, change-oriented, and just culture behaviors and techniques are well reviewed.
30

31
Inherent to
all of these methodologies is the timely assessment and informing of providers of the outcomes of their actions,
acceptance of personal responsibility in a blame-free environment, empowerment to make change in your domain of
influence, and patient-centric behavior. The basis of successful change creation is repetitive and congenial decisions
to alter cherished beliefs about medical practice facts based on data.


Management by Outcomes: Financial Improvement
Providing data to staff and physicians about cost (of individual supplies, whole cases, patient types) will arm them to
focus on the opportunities for savings that can inform changes in purchasing or platform use that will decrease your
annual costs by 5% or more (a reasonable target). Offering alternative platforms for arthroscopy, for implants, etc. to
surgeons and staff with information about best pricing and the potential impact on annual costs can generate support
among those teams for change. At the very least, our surgeons, armed with such information, have been effective
advocates for best pricing in meetings with industry sales representatives. So, even if we didnt change platforms,
costs were reduced. This is particularly effective if staff and physicians have a stake in the financial outcome of the
facility (either via incentive bonuses, shareholder status, or the availability of capital for other desired purposes once
savings are known).

Management by Outcomes: the key to your success in the future
The best value of this transparent use of outcomes is the improvements in patient care quality and safety with lower
costs. The secondary value is the ability to stay in business, in the midst of the coming changes in healthcare
payment policies. Whatever facility you administer, it must grapple with the upcoming tenets of value-based
payment systems, embraced by the government and private payers alike. The requirements of these new models are
that facilities and physicians must prove that they are creating ever-improving outcomes AND at doing so at ever
lower cost. Establishing the outcomes measurement programs we have described will ready you, your group and
your facility to provide the data surrounding quality that you (not Yelp, not Angies List, not Healthgrades)
consider appropriate. The time to set these systems up is already passing by as you ready yourselves to succeed in
the next and potentially capricious and unpredictable iterations of healthcare payment policy.

Conclusions
The use of local outcomes combined with national benchmarking and review of the literature allows and ASC to use
the best evidence to identify best practice and to use that as a template to create care pathways. In the management
of individual patients, the evidence and pathways must be further leavened by patient choice and by the individual
practitioners skill and judgment. Outcome measures should be chosen to reflect the goals of the Center including
clinical, financial and citizenship metrics. In addition to guiding best practice, the collection of outcomes can allow
the Medical Director to focus investment and process improvement projects on those care systems that yield the
most value to patients and the Center. It is the ideal tool to manage a busy and complex care delivery system.

Bill James - writer, mathematician and baseball statistician - once observed that Education is the process of
opening minds to possibilities, souls to justice, and bodies to implementation.
32
Observing our own work is the
epitome of life-long learning, an attribute often cited in the definition of a physician. The difference between
children and adults, the difference between an educated and an uneducated populous is openness to or even the
ability to conceive of change. By observing the outcomes of our work, discussing them openly, and by crafting
means of improvement as a result of that data, we can educate ourselves. That education will improve the care
delivered to patients and the experience of its delivery for caregivers, and will create an environment that is the
safest and most efficient that it can be.



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Table 1: Useful Outcome Metrics to Consider for an Ambulatory Surgery Center

PATIENT SATISFACTION ASSESSMENTS
Would you refer a friend or family member to use our facility if they needed surgery and could have it here?
Would you return for surgery here if you were given the choice of another facility?
How would you rate your care today? (poor, fair, average, good, excellent) we only count excellent towards our
satisfaction rate.
Did anyone in particular provide notably excellent service to you or your family while you were here?
Did anyone in particular provide less than satisfactory service to you or your family while you were here?
Did you feel that we valued your time?
What could we do differently that would have made your experience here more positive?

FINANCIAL MEASURES
Days in accounts receivable and (if a stand-alone ASC) Days Cash on Hand.
Projected vs Actual Net profit (gross income less expenditure) by week, by month, by quarter
Cost (total operating expense) per case or per 100 O.R. minutes (used and available)
Full time equivalent (FTE) per case, or per 100 O.R. minutes (used and available)
Cost per FTE (total operating expense per month/total no. of FTEs per month) it may be useful to track both paid
hours and worked hours to elicit the burden of vacation and leaves.
Cost of supplies, implants, instruments, etc.
Total operating expenses (rolled up from Personnel vs. Non-personnel expense)
Cases per month (actual vs budgeted)
Gross charges (day, week, month, quarter, year to date)
Collection rate (budgeted vs actual)

OPERATIONAL MEASURES
Cases per day (average) actual vs. budget (take the overall case budget and divide by 252 working days/year)
this is a number that works well to help staff get a general sense of a good day vs. a slow day.
Turnover time, average, same surgeon following self (wheels out to wheels in)
Turnover time, average, all cases
Incidence of delay: location and causes ask Pre-op and O.R. RNs to keep a log (Excel) with delays and pre-chosen
categories (e.g., patient would refer to patient late arrival or lack of ride; paperwork, surgeon delay,
anesthesia delay, equipment or supply delay)
Minutes patient in room (MPIR) per room per day
Minutes of operation (MOO) (skin to skin) per room per day
MOO/MPIR
Minutes from room entry to skin incision
Minutes from skin closure to room exit
Utilization (MPIR/Blocked time allocated) by service or surgeon
Case time estimation accuracy: estimates that are either too long or too short (> <15% of actual case time)

CLINICAL MEASURES while the list below is large (and not exhaustive), only a few should be collected in the
absence of an electronic record. The Center should choose the measures in a collective and multidisciplinary
manner. Be willing to change those decisions if little is gained by the ones chosen (e.g., occurrence is too rare).
ASA Score
BMI
Smoker current or recent past (quit < 3mos ago)
CHF
CAD or Previous MI
AICD
Pacemaker
COPD
CRF
Previous difficult airway
OSA
Neurologic disease, pre-existing
HTN
CVA or TIA
Mental alteration pre-op
New Mental alteration PACU
On site nausea or vomiting
Post discharge nausea or vomiting
Highest pain score in PACU
Highest pain core in the first 48 hours
Did pain medication provided for home provide you
sufficient relief?
Use of opioid or benzodiazepine reversal agent OR
Opioid/benzodiazepine reversal agent PACU

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Use of opioid pre- or intra-op
Use of IV/IM/SQ atropine or epinephrine
Arrival in PACU with LMA or ET in place
RR below 10 in PACU
Failed intubation
Return to the OR
Re-intubation or airway device replacement
Nebulizer treatment in PACU, unplanned
Unexpected need to call or visit a physician in the
first 48 hours after surgery
Unexpected admission to the E.D. or hospital in the
30 days following discharge
Infection of the wound site in the 30 days following
discharge
Unexpected need for urinary catheter in the PACU
or at home
Did you experience any mental fogginess, memory
loss or dizziness that lasted longer than the day of
surgery?
CVA, TIA, PE or MI in the 30 days following
discharge
Unexpectedly prolonged numbness or dysfunction

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Moonesinghe SR et al. High-Risk Surgery: Epidemiology and Outcomes. Anesth Analg 2011; 112:891901.
25
Berwick DM. Measuring Physicians Quality and Performance: adrift on Lake Wobegon. JAMA 2009;302:2485-6.
26
Garcia JL, Wells KK. Knowledge-Based Information to Improve the Quality of Patient Care. J. Healthcare
Quality 2009; 31(1):30-35.
27
Nonaka I, von Krogh G. Tacit Knowledge and Knowledge Conversion: Controversy and Advancement in
Organizational Knowledge Creation Theory. Organ Sci 2009; 20 (3): 635652.
28
McDonald TB et al. Responding to patient safety incidents: the seven pillars. Quality & Safety in Health Care.
2010; 19(6):e11.
29
Mohan D et al. Sources of non-compliance with clinical practice guidelines in trauma triage: a decision science
study. Implementation Sci 2012;7:103-114.
30
Batt R. Managing customer services: human resource services, human resource practices, quit rates and sales
growth. Acad Manage J. 2002; 45 (3):587-97.
31
Gorenflo G. Achieving a culture of quality improvement. J Public Hlth Manage & Pract. 2010; 16(1):83-4.
32
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Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

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Office Based Anesthesia: Challenges and Success
Rebecca S. Twersky, M.D., MPH Brooklyn, New York
Introduction
Although there are no good national registries to accurately determine the amount of office based surgery (OBS),
performed in the United States, the projections have ranged from 17-24% of all elective ambulatory surgery [1, 2],
to an estimate in 2005 of 10 million elective procedures [1]. This phenomenon has paralleled and was certainly
driven by the huge increase in demand for cosmetic surgery over the past ten years. Newer surgical and anesthetic
techniques have allowed more invasive procedures to be performed in non-hospital settings. Economic advantages
and physician and patient convenience have driven the rapid growth of OBS and office-based anesthesia (OBA).
Other advantages of OBS include ease of scheduling, greater privacy, lower cost, no risk for nosocomial infection,
increased efficiency, and consistency in nursing personnel [3]. Despite these advantages, OBS is not for every
surgeon nor is it appropriate for every patient or every surgical procedure. In addition, OBA requires a different
approach than that is used in hospitals and ambulatory surgery centers (ASCs). This venue may not be suited for all
anesthesia providers. The rapid growth of OBA has not been uniformly accompanied by adherence to safety
standards used in hospitals or ASCs. This lecture will address the current status of OBA and challenges faced by the
office-based anesthesiologists regarding patient safety, patient and procedure selection, and anesthesia management
for adult patients.
Facility Considerations
Is OBS/OBA as safe as that is done at hospitals or ASCs? Media coverage of high profile liposuction deaths and
other tragic mishaps exposed OBA as the Wild, Wild West of Health Care [4]. Such press is more powerful than
the medical literature in the minds of patients. Lack of regulatory oversight of OBA is the fundamental difference
between OBS and surgery done at hospitals or ASCs. With minimal safety standards, OBS may be performed in an
environment with limited or outdated equipment, inadequate emergency resources, too few qualified healthcare
providers, or insufficient policies and procedures. In addition, quality of care plans for performance improvement,
peer review and emergency preparedness are often lacking in OBS. Office personnel may be untrained and
providers of anesthesia care may have varying levels of skill ranging from physician anesthesiologists, nurse
anesthetists, surgeons, dental anesthetists, to personnel without anesthesia training. Only 2% of Anesthesiology
residency programs provide formal training in OBA leaving a void in properly educating anesthesiologists on how
to prepare themselves for offices [5].
In response to this gap, ASA has established a framework from which clinicians can establish their own practice.
The ASA Guidelines for OBA underscore that the level of care in an office should be equal to that in a hospital [6].
Together with the ASA guidelines, the ASA-SAMBA OBA Manual on Office Based Anesthesia: Considerations
for Anesthesiologists in Setting Up and Maintaining a Safe Office Anesthesia Environment has addressed major
administrative and clinical aspects on OBA such as facility and safety, quality improvement and professional
liability, controlled medications, practice management, patient and procedure selection, perioperative care,
monitoring and equipment, pediatric and dental anesthesia, emergencies and transfers [7]. All ASA documents are
relevant to OBA practice (www.asahq.org/publicationsAndServices/sgstoc.htm accessed May 31, 2013).
Anesthesiologists must examine each practice with vigilance, and discuss with surgeons about steps needed to
provide safe perioperative care. Before agreeing to provide anesthesia, anesthesiologists should allow time to inspect
the office and evaluate the anesthesia work area and space requirements with focus on adequacy of facility design,
medication, equipment and supplies, perioperative patient flow, hospital transfer arrangement, emergency equipment
and protocols, competency and designated responsibilities of staff including credentialing and licensure of providers,

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malpractice coverage, and ongoing peer review and quality assurance. The practice should comply with all
applicable federal, state and local laws, building codes and regulation. Environmental safety features that are often
taken for granted should be verified in the office. These include fire safety, air handling, electrical systems and
alternate back-up power, inspection and preventive maintenance of all operative equipment, setup and maintenance
of medical gases, handling of controlled drugs, equipment disinfection and biohazardous waste and sharps [8].

The OBS infrastructure should support the safe delivery of anesthesia and surgery. In particular, anesthesiologists
and surgeons need to come to terms of agreement regarding the clinical and fiscal responsibilities of common
aspects of the practice. No anesthesiologist should provide services for a facility that demonstrates disregard for
standard of care for surgery, anesthesia and nursing care. Anesthesiologists would set a high bar for safety if they
practice only in accredited or licensed facilities. When not accredited, their anesthetic practice should at least reflect
accreditation and professional society standards. Anesthesiologists can distinguish themselves by assisting the
practice in becoming accredited.

Rules/Regulations/Accreditation
Improved state regulations may help to address patient safety problems in OBA, however, there are still many states
lacking any type of oversight of OBS/OBA and the regulations vary significantly from state to state. At present,
nearly 30 states have statutes, regulations or guidelines regarding OBA, and several states also require the reporting
of adverse events (www.asahq.org/Washington/rulesregs.htm,
www.fsmb.org/pdf/GRPOL_Regulation_Office_Based_Surgery.pdf accessed May 31, 2013). Accreditation is
another option to address OBA patient safety and is voluntary in most US states. Many third-party payers will only
reimburse the facility fee for procedures performed in accredited offices. Medicare reimburses professional fees but
not facility fees. Accreditation of office-based practices is conducted by three major accrediting organizations: The
Joint Commission (TJC, http://www.jointcommission.org/ accreditation/ accreditation_main.aspx), The
Accreditation Association for Ambulatory Healthcare (AAAHC, http://www.aaahc.org/en/accreditation/office-
based-surgery-centers/), and the American Association for Accreditation of Ambulatory Surgery Facilities
(AAAASF, http://www.aaaasf.org/pub/site/index-4.html) similarly address key components of OBS, however, they
differ in their requirements for adverse event (AE) reporting, peer review process, credentialing and privileging of
practitioners without hospital privileges and enforcement [9]. In addition, the American Medical Association (AMA,
www.ama-assn.org/ama/) identifies 10 core principles for establishing safety standards in offices, which has been
embraced by medical specialties and state medical boards.

Practice Management
By proactively making the experience pleasant for patients, staff, surgeons and other parties involved, the
anesthesiologist can help facilitate growing the practice Successful OBA practices hinge on certain business sense,
even more so than in other venues. Anesthesiologists that assume a management role will be in a better position to
align the financial incentives of surgeons with anesthesiologists. Providing extra services includes helping with
facility operations, providing drugs and supplies, staffing, and/or helping with accreditation issues, or including
everything as a turn-key approach. Competition will dictate which services to provide and how much to charge for
them. Anesthesiologists should be sensitive to potential kickback issues in connection with providing extra services
and ensure that they receive fair market value compensation not a bonus for the extra services they provide.
Examples of problematic practices include providing services at below-market rates or paying above-market rates to
rent an office in the surgeons building. Whether or not providing anesthesia drugs/supplies would be deemed to be
an illegal kickback depends upon the intent of the parties, and whether or not the person providing anesthesia
drugs/supplies received fair market value payment for such items [7]. Understanding federal and state regulations
affecting anesthesia practice and billing prior to starting an OBA practice is essential. Legal counsel should be
sought where appropriate. Probably one of the best known federal laws is Stark II which prohibits physicians from
making referrals to an entity that they, or a family member, has financial interest in. Other legal issues to consider
are exclusive contracts with hospitals, which may contain noncompete clauses [7].

Payment for services rendered is a key component of a successful OBA practice. There is no one single model for
reimbursement of anesthesia services, allowing each practice to determine the optimum arrangement. Billing for
anesthesia services should be clear to all participating parties during initial negotiations to provide service. The
anesthesia provider will need to decide which method to bill for its services and how much to charge. Recently, the
Office of Inspector General of the U.S. Department of Health and Human Services issued an advisory opinion on
certain types of anesthesia practices. The advisory warned that some anesthesia reimbursement arrangements had

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potential for prohibited remuneration under the Federal Anti-Kickback Statute, Federal False Claims Act, as well as
state laws prohibiting fee-splitting, self-referrals, and kickbacks. Appropriate counsel is recommended before
entering into any monetary arrangements, as violations can result in imprisonment, exclusion from federal health
care programs, and significant fines that can often be assessed per claim.( http://www.asahq.org/For-
Members/Advocacy/Washington-Alerts/Frequently-Asked-Questions-About-the-Company-Model.aspx (accessed
June 4, 2013)



Patient Safety in Office-Based Anesthesia
Notwithstanding the often-repeated advantages, death rates associated with OBA still precipitated significant
professional and public concern about the level of safety in this setting. Quality and safety in anesthesia is usually
monitored by analysis of perioperative morbidity-mortality (M & M) and incidents. To date, the largest QI database
(over 1 million outpatient procedures) from accredited facilities reports a mortality rate of 0.002% or 2.02 deaths per
100,000 procedures, with PE the most common cause of death (56.5%) [10]. In reviewing ASA closed claims
analysis of 63 office-based claims 1990-2009, Domino reported that the severity of injury for office-based claims
was greater than for other ambulatory anesthesia claims: 40% of office-based claims were for death, compared to
25% of ambulatory anesthesia claims. Respiratory events including airway obstruction, bronchospasm, inadequate
oxygenation-ventilation and esophageal intubation accounted for 29% of office based claims in 2009, with the
trends in complications changing. There has been a reduction in the claims for medication related claims (18%) yet
nearly three-fold increase for equipment reasons (17%) [K. Domino and K. Posner, ASA Closed Claims Database
project, Personal communication]. These events were judged to be preventable by monitoring, especially in the
postoperative period [11]. Several areas for improvement relevant to office based anesthesia safety were identified:
oversedation during MAC with failure to recognize and treat respiratory depression in a timely fashion, hazards of
anesthesia in nonoperating room locations, prevention of cautery-induced burns, and management of the difficult
airway particularly at extubation. Analysis of these rare events can improve practice and patient safety [12, 13].

A 2003 Florida Board of Medicine report cited causes of death due to poorly-trained personnel, inadequate
resuscitation equipment, deep venous thrombosis (DVT)/pulmonary embolus with inadequate prophylaxis, local
anesthetic overdose, airway mishap, and or failure to vigilantly maintain the same anesthetic monitoring techniques
used in the ASC or hospital [14]. More recent published reviews of the 10 years of prospective, independently
collected verifiable data on office surgery mortality in Florida concluded that office and other outpatient surgery are
safe if performed in an accredited facility by American Board of Medical Specialties, certified surgeons who are
credentialed for the same procedures in a hospital [15]. An NIH-funded conference concluded that evidence speaks
to the safety of OBS with even lower rates of adverse events and mortality (adverse event rate of 0.24/100,000 and
death rate of 0.41/100,000 procedures) [16]. This is supported further by Fleisher et al., in a comparative study of
outcomes in Medicare patients (> 65 yrs) by location of ambulatory surgery. They reported a death rate on day of
surgery /100,000 procedures of zero in offices, compared to 2.3 deaths in ASCs and 2.5 in hospital-based units.
Comparative admission rate/1000 procedures were 91 in office-based settings 8.4 for ASCs, and 21 in the hospital-
based ambulatory setting [17]. An extensive review of patient safety in OBS identified risk factors for adverse
events [18], urging more prospective research.

Anesthesiologists Role in Patient Safety
Much of the work on patient safety is reported from dentistry and oral and maxillofacial surgery, and focuses on
surgical outcomes, with almost no mention of anesthetic complications such as nausea and vomiting, pain, delayed
discharge, patient satisfaction or post-discharge symptoms. Recent data compiled from the SAMBA Committee on
OBA reported outcomes and complications in a database of 50,520 OBA cases from 6 practices for 2008-10. Deep
sedation without an airway device accounted for 83% of cases. Only 6% of cases required intubation, most from a
single, primarily dental OBA practice. Overall complication rates were very low with cancelations being the most
frequent event (3.3%). This higher rate than ASCs reflects more conservative approach for safe practice. The rates
for minor complications were all below 1%. Unplanned admission rates were 0.07%. Of note, there were 11
incidents of medication error, 4 aspirations, 2 wrong site surgeries, and 2 patients discharged without escort. No
deaths were reported. These sites showed that OBA compared favorably with safety and outcome data from
ambulatory, hospital-based practices [19, personal communication Michael T. Walsh, MD]. An OBA specific
checklist has been tested in several office sites and was reported to improve safety, documentation, and assessment
of patient satisfaction [20]. It is anticipated that with more participation in anesthesia registries, i.e. SAMBA

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Clinical Outcome Registry (SCOR) (http://www.scordata.org) and ASA Anesthesia Quality Institute (AQI) Data
Registry (http://www.aqihq.org) comparative benchmarks of anesthesia outcomes will become available.

The challenges for anesthesiologists are to collaborate with their surgical colleagues to improve the culture of safety
including educating patients to seek out the safest venue to have their surgery. The ASA-SAMBA OBA Manual
serves as a good companion for a quality driven and patient-safety oriented practice [7]. Familiarity with
professional guidelines of OBS specialties is helpful to ensure consistency with our clinical approach.
Anesthesiologists should actively participate in the OBS quality improvement (QI) plan. A review of anesthesia and
surgical morbidity and "adverse" or "sentinel" or outcome events should be integral to the plan. Examples include
patient deaths within 30 days, postoperative infection, transfer to a hospital/ ED for more than 24 hours,
unscheduled hospital admission within 72 hours of procedure, wrong site surgery or other serious or life threatening
events [7]. AE reporting should be standardized and registered on a national level to allow risk assessment by large
scaled studies. The low rate of anesthesia AE can be attained by ensuring trained anesthesia providers; careful
patient selection; utilizing full preoperative evaluation, intraoperative care and monitoring consistent with ASA
standards; and sufficient postoperative care to enable safe discharge.

Facility Readiness
As different anesthesiologists and surgeons might be providing care in the same offices on either a rotating or
permanent basis, all personnel, should be properly oriented to policies, procedures, physical layout, and the location
of emergency equipment. Facilities must establish written protocols for emergency management of rare but
catastrophic events and conduct regular drills that include the anesthesiologists and surgeons. Critical management
of emergencies most likely will require stabilization of the patient and quick transfer of the patient to an acute care
facility [7, 21]. Anesthesiologists should be comfortable with the qualifications of surgeon providers, especially
when performing the newer high-tech procedures. The office must be equipped to deliver positive pressure
ventilation with self-inflating resuscitation bag and there must be an identifiable source of oxygen. Suction may be
delivered via a portable or installed system. All anesthesia equipment should have a reliable back-up power source
in the event of equipment failure. Functioning resuscitation equipment and defibrillator, emergency airway
equipment, ACLS drugs and ACLS trained personnel must be available in the event of any emergency. A protocol
should be on hand to deal with the rare occurrence of malignant hyperthermia. A guide has been released to assist
the office practitioner in the event of this potentially catastrophic event and dantrolene must be readily available to
treat MH if triggering anesthetics are used [22]. Equipment should be maintained and inspected according to
manufacturers specifications. There should be sufficient space to accommodate all the necessary equipment,
adequate lighting and expeditious access to the patient. In locations administering only local anesthesia, intralipid
20%, other appropriate drugs, monitors and equipment should be on hand in the event of untoward reaction [7]. Fire
safety is also an emerging topic of interest in office based practice. Four of the 11 reported OBA ASA closed claims
for equipment involved cautery fires (personal communication, K. Domino and K. Posner, ASA Closed Claims
Database project, September 2012). Patients receiving oxygen under MAC for facial procedures are at risk for
surgical fires and anesthesiologists should take precautions to reduce airway fires. It is recommended that the
practice be compliant with National Fire Protection Agency and building code standards and have protocols and
policies in place to be followed in the event of a patient fire [23]. Regularly scheduled fire drills would also be
prudent. Clinicians should be mindful of using supplemental oxygen proximate to the surgical cautery [23, 24]

Patient Selection
As with all ambulatory anesthesia venues, not all patients or procedures are suitable for the office setting. When
evaluating patients to determine suitability for office procedures, surgeons should be alerted to those high risk
medical conditions that would exclude patients from OBA. Criteria of excluding patients from OBA include
unstable ASA 3 or greater, MI within 6 months; severe cardiomyopathy; uncontrolled HTN; brittle or poorly-
controlled diabetes mellitus; active multiple sclerosis; acute substance intoxication (drugs and alcohol); history of
malignant hyperthermia (MH); morbid obesity with poorly controlled comorbidities, severe COPD or obstructive
sleep apnea, pacemaker or AICD, end-stage renal disease, sickle cell disease, patient on transplant list, dementia (not
oriented), psychologically unstable (rage/anger problems), stroke within 3 months, myasthenia gravis or lack of
adult escort [21,25,26]. A list of exclusions from OBA should be shared with surgeons, and screening questionnaires
should be completed by patients. Office staff should confirm suitability of the patient for this venue and forward all
evaluations to be reviewed by anesthesiologists, preferably before the day of surgery. A review of prescription, non
prescription drugs and use of herbal and dietary supplements are important as drug interactions may occur.
Preoperative tests and consultations should be requested when indicated. Anesthesiologists, assuming the role of

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medical consultant, remain the best qualified professional to evaluate patients overall risk for OBA. However, since
most patients are seen for the first time by anesthesiologists on the morning of the procedure, surgeons must ensure
that patients have been adequately evaluated and undergone appropriate preoperative testing beforehand.
Oftentimes, this falls to the office staff, which needs clear direction from the surgeon providers.

Good communication between surgeons and anesthesiologists is crucial in determining accurate risk for patients
with older age or comorbidities. Surgeons should screen patients for potential difficult airway and the need for
further medical optimization. OBS staff should also ensure that patients receive proper preoperative instructions
regarding NPO and continuation of any chronic medications. The office surgeons should pay specific attention to
instructions for discontinuation of antiplatelet medications or other anticoagulation treatment; or whether
perioperative antibiotics are need, as the anesthesiologists will only evaluate the patient face-to-face on the morning
of surgery.

Types of Procedures
OBS procedures should be of duration and degree of complexity that will permit patients to recover and be
discharged from the facility as soon as possible. Anesthesiologists should ensure that OBS procedures are within the
scope of the physicians practice as well as the capabilities of the facility. As several OBA procedures are not
commonly done in the hospitals or ASCs, anesthesiologists must familiarize themselves with the physiological and
anesthetic implications of the newer and technologically updated surgical procedures [27]. Among the procedures
considered appropriate for OBA are cosmetic surgeries (liposuction, rhytidectomies, breast augmentation/reduction,
and rhinoplasty), ophthalmology, dental, gynecology, orthopedic, urologic and GI endoscopies. Procedures with
potential risk of significant blood loss such as major intra-abdominal, intrathoracic and intracranial surgeries are
inappropriate for OBA [8, 25, 28]. There are few prospective studies about using duration of surgery as a predictor
of adverse outcomes and results are still controversial. Some recommended that procedures not to exceed 6 hours to
decrease the risk of hypothermia and DVT, especially during high volume liposuction (> 5000 ml) combined with
other procedures [28, 29]. However, duration of surgery and anesthesia was not demonstrated to be an indicator of
patient morbidity and mortality in facial plastic surgery performed on 1200 patients lasting more than 4 hours in an
accredited OBS facility with board certified anesthesiologists [30]. A recent retrospective review of 2595
consecutive patients who had office-based cosmetic surgery in a single practice reported on the outcomes of patients
who received TIVA general anesthesia using propofol/remifentanil infusion with either LMA or endotracheal
intubation [31]. They found an increase in the occurrence of minor surgical complications such as PONV (2.8% vs.
5.7%, P = 0.0175) and urinary retention (0.7% vs. 7.6%, p < 0.0001) in the greater than 4-hour anesthesia duration
group. There were no statistically significant differences in major morbidity or mortality, including hospitalization
and reoperation rates in patients who received GA < or > than 4 hours.

Perioperative Care
The definition of appropriate level of anesthesia remains debatable in the non-anesthesia literature, though several
publications identify it as any safe technique provided by appropriate anesthesia professional in accredited facilities
[10, 32]. However, there is no one preferred technique. Choice of agents and techniques should be appropriate to
patients health and surgical procedures, the equipment, which might depend on whether the platform in the office is
fixed or mobile; and whether it allows a rapid recovery to normal function with minimal postoperative pain, nausea
and other side-effects. The same anesthetic techniques that are used in hospitals and ASCs can be used in OBA
(including local, monitored anesthesia care or MAC, regional or general anesthesia).


MAC with or without local anesthesia is more commonly used [33-36], though with increasing complexity there is
growing demand for general anesthesia (GA). GA may be preferable in complex or extended procedures because of
safety provided by airway protection, consistent level of anesthesia and the ability of allowing surgeons to
concentrate on procedures. Commonly utilized sedatives and anesthetics include midazolam, ketamine, fentanyl and
propofol, either alone or combined. Intravenous acetaminophen, ketorolac, ibuprofen, and other nonsteroidal anti-
inflammatory agents (NSAIDs) can be used as adjuvant non-opioid analgesics. Sevoflurane and desflurane are used
for inhalation anesthesia [37, 38]. Adjuvant treatment with clonidine or dexmedetomidine has been reported to be
beneficial in plastic surgery procedures [39]. In general, opioid use is minimized and substituted with generous use
of local anesthetic and NSAIDs to augment analgesia through the recovery period and avoid opioid-induced
postoperative nausea and vomiting (PONV).


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For GA, some practitioners prefer total intravenous anesthesia (TIVA) over inhalation agents for several reasons:
lack of capacity to deliver inhalation agents or nitrous oxide and need for adequate waste scavenging system;
avoidance of MH-triggering agents that would otherwise require the immediate availability of Dantrolene; improved
infusion pumps and computerized TIVA delivery systems. TIVA for OBA generally consists of propofol, preferably
with none or minimal opioids, with spontaneous or assisted patient ventilation, either with or without laryngeal mask
airway or other supraglottic device. Avoiding muscle relaxation permits muscle tone in the extremities which can
reduce DVT and subsequent PE. A recent retrospective chart review of over 2600 patients undergoing TIVA with
propofol and/or ketamine by board certified anesthesiologists or moderate sedation with midazolam and fentanyl by
plastic surgeons in AAAASF accredited facilities reported no deaths, cardiac events, or transfers to the hospital in
any patients, regardless of the type of sedation utilized [40]. Generally, muscle relaxants and endotracheal intubation
are used sparingly, although airway equipment for intubation must always be available during all cases of GA. It is
important that the equipment and machines used are maintained, tested and inspected on a regular basis and not
become a repository for obsolete equipment (http://www.asahq.org/For-Members/Standards-Guidelines-and-
Statements.aspx, http://www.apsf.org/newsletters/html/2004/winter/05guidelines.htm accessed May 31, 2013). The
bispectral index (BIS) system has been used in OBA to guide timing of intubation without neuromuscular blockers
[41].

Office-based practice, perhaps even more than others, has zero tolerance for PONV. Therefore, interventions against
PONV should be aggressively implemented [42]. New data have reported that postdischarge (PDNV) occurs in
patients who might not have experienced PONV. Apfel et al reported a 30-50% incidence of PDNV. Risk factors for
PDNV are similar to the ones for PONV with some differences [43]. History of nonsmoking and type of surgery
were not predictive for PNDV as they were for PONV. Patients who experienced nausea in the PACU had a 3-fold
increased risk of PDNV development [43]. Options for PDNV include long acting prophylactic antiemetics such as
dexamethasone, aprepitant, palonsetron, transdermal scopolamine, and even acupoint stimulation. More research in
this area is likely to emerge.

My recipe for OBA is premedication with antiemetic, intraoperative use of long acting local anesthetics, use of
anesthesia agents that minimize PONV, PDNV and pain and target toward a rapid emergence and ambulation.
Preventing or mitigating postoperative pain is a goal of OBA. Multimodal approaches that use multiple drugs and
combinations of techniques to improve pain relief and minimize side effects are growing in popularity. Clinical
studies have shown preoperative oral or intravenous co-administration of acetaminophen or nonsteroidal anti-
inflammatory drugs (NSAIDs) can decrease the use of opioids and opioid-related adverse effects and can be safely
used for the treatment of postoperative pain after ambulatory surgery [44-46].


Regardless of the type of OBA, patients must transition through the standard postoperative care. Traditional
stretchers are not used in the office setting; therefore patients must transfer directly from the operating table to a
lounge chair, wheelchair or walk with assistance to the designated recovery area. While the objective is to have the
patient fully awake to at the conclusion of the surgery, sometimes this is not feasible, given patients diverse age and
baseline condition [47]. Nonetheless, fast-tracking patients are met by selecting an intraoperative anesthetic
technique that maximizes rapid emergence with minimal side-effects. Postoperative recovery of patients in the office
should be provided by a qualified PACU nurse, freeing up the anesthesiologists to return to the procedure room;
although the anesthesiologists should remain responsible for overall postoperative recovery and discharge.
Discharge criteria for the office setting should use the same standards as for all ambulatory surgery settings.

Conclusion
OBA has undergone tremendous growth in the last ten years and is slowly becoming regulated and standardized.
As technology progresses, surgical techniques become less invasive and more cost conscious. Office-based facilities
will continue to perform more outpatient procedures. While safety has been questioned in the past, most OBA is
probably safe when performed by properly trained physicians working within their scope of practice and following
the standards and guidelines developed by professional societies. We should continue to advocate for outcomes
registries, uniform reporting of adverse events (AEs), allowing proper analysis and ongoing assessments of patient
outcomes. In the hands of skilled professionals, and with proper patient selection and perioperative care,
anesthesiologists can serve as pivotal leaders in ensuring that OBA can be as a safe as those done at hospitals or
ASCs.


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Structures Kept Pace with Care Delivery?
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2. AHA. TrendWatch Chartbook 2011.Trends affecting hospitals and health systems Chapter 3: Utilization and
Volume, p.36. Available at: http://www.aha.org/research/reports/tw/chartbook/2012/chart3-14.ppt. (Accessed
May 31, 2013).
3. Byrd HS, Barton FE, Orenstein HH, et al. Safety and efficacy in an accredited outpatient plastic surgery
facility: A review of 5316 consecutive cases. Plast Reconstr Surg 2003; 112 (2) 636-641.
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5. Hausman LM, Levine AI, Rosenblatt MA: A survey evaluating the training of anesthesiology residents in
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(Accessed May 31, 2013)
7. Twersky RS et al. ASA Committee on Ambulatory Surgical Care and the SAMBA Committee on Office-Based
Anesthesia. Office-based Anesthesia: Considerations for Anesthesiologists in setting up and maintaining a safe
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Florida data and 6 years of Alabama data reveal. Dermatol Surg 2012; 38: 171-7.
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multidsciplinary perspective. Dermatol Surg 2003; 29(1): 1-6.
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elderly patients. Arch Surg 2004; 139 (1):67-72.
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Chapter IV:Ambulatory safety in office-based surgery and anesthesia research. p 51-56. American Medical
Association, Chicago IL 2011. Available at: www.ama-assn.org/go/patientsafety. Accessed May 31, 2013
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Annual meeting of the American Society Anesthesiologists. A798.
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safety system on patient outcomes. Eplasty. 2012; 12:e59. Epub 2012 Dec 25.
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114: 94-100.
23. Apfelbaum JL, Caplan RA, Barker SJ, et al.: Practice advisory for the prevention and management of operating
room fires: An updated report by the American Society of Anesthesiologists Task Force on Operating Room
Fires. Anesthesiology 2013; 118:27190
24. Engel SJ, Patel NK, Morrison CM, et al. Operating room fires: Part II. Optimizing safety. Plast Reconstr Surg
2012; 130(3): 681-689.

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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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Anesthesia Handbook, 2nd edition. New York: Springer, Inc, 2008, p 283-324.
26. Iverson RE, Lynch DJ, Twersky RS and the ASPS Task Force on Patient Safety in Office-Based Surgery
Facilities. Patient safety in office-based surgery facilities: II. Patient Selection. Plast Reconstr Surg 2002; 110:
1785-90.
27. Pace MM, Chatterjee A, Merrill DG, Stotland MA, Ridgway EB; Local anesthetics in liposuction:
considerations for new practice advisory guidelines to improve patient safety Plast Reconstr Surg. 2013
May;131(5):820e-6e
28. Iverson RE, Twersky RS, and the ASPS Task Force on Patient Safety in Office-based Surgery Facilities. Patient
safety in office-based surgery facilities: I. Procedures in the office-based surgery setting. Plast Reconstr Surg
2002; 110:1337-42.
29. Iverson RE, Lynch DJ, and the ASPS Committee on Patient Safety. Practice advisory on liposuction. Plast
Reconstr Surg 2004; 113(5):1478-90.
30. Gordon NA, Koch ME: Duration of anesthesia as an indicator of morbidity and mortality in office-based facial
plastic surgery: A review of 1200 consecutive cases. Arch Facial Plast Surg 2006; 8: 47-53.
31. Phillips BT, Wang ED, Rodman AJ, et al: Anesthesia duration as a marker for surgical complications in office-
based plastic surgery. Ann Plast Surg. 2012 Oct; 69(4):408-11
32. Hoefflin SM, Bornstein JB, Gordon M. General anesthesia in an office-based plastic surgery facility: a report on
more than 23,000 consecutive office-based procedures under general anesthesia with no significant anesthetic
complications. Plast Reconstr Surg 2001; 107: 243-51.
33. Badrinath S, Avramov M, Shadrick M. The use of a ketamine-propofol combination during monitored
anesthesia care. Anesth Analg 2000; 90: 858-862.
34. Jourdy DN, Kacker A: Regional anesthesia for office-based procedures in otorhinoloaryngology. Anesthesiol
Clin 2012; 28: 457-68.
35. Olabi NF, Jones JE, Saxen MA et al. The use of office-based sedation and general anesthesia by board certified
pediatric dentists practicing in the United States. Anesth Prog 2012; 49: 12-7.
36. Hausman LM, Eisenkraft JB, Rosenblatt MA. The Safety and Efficacy of regional Anesthesia in an office-based
setting. J Clin Anesth 2008; 20 (4): 271-5.
37. Shapiro FE. Manual of office-based anesthesia procedures, ed. Lippincott Williams & Wilkins: Philadelphia,
PA, 2007, p.40-51.
38. Tang J, White PF, Wender RH, et al: Fast-track Office Based Anesthesia: A comparison of propofol vs.
desflurane with antiemetic prophylaxis in spontaneously breathing patients. Anesth Analg 2001; 92: 95-99.
39. Taghinia, AH, Shapiro FE, Slavin SA. Dexmedetomidine in Aesthetic Facial Surgery: Improving Anesthetic
Safety and Efficacy,Plast Reconstr Surg 2008; 121: 269-276.
40. Failey C, Aburto J, de la Portilla HG, et al. Office-based outpatient plastic surgery utilizing total intravenous
anesthesia. Aesthet Surg J. 2013 Feb 1; 33(2):270-4
41. Messieha ZS, Guirguis A, Hanna S. Bispectral index monitoring (BIS) as a guide for intubation without
neuromuscular blockade in office-based pediatric general anesthesia: a retrospective evaluation. Anesth Prog
2011; 58(1):3-7
42. Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia Guidelines for the Management of
Postoperative Nausea and Vomiting. Anesthesia and Analgesia, Dec 2007; 105(6): 1615-1628.
43. Apfel CC, Phillip BK, Cakmakkayya OS, et al. Who is at risk for postdischarge nausea and vomiting after
ambulatory surgery? Anesthesiology, Sep 2012; 117(3): 475-486.
44. Wininger SJ, Miller H, Minkowitz HS, et al: A randomized, double-blind, placebo-controlled, multicenter,
repeat-dose study of two intravenous acetaminophen dosing regimens for the treatment of pain after abdominal
laproscopic surgery. Clin Ther. 2010;32(14):2348-69
45. White PF, Tang J, Wender RH, et al. The effects of oral ibuprofen and celecoxib in preventing pain, improving
recovery outcomes and patient satisfaction after ambulatory surgery. Anesth Analg. 2011,112(2):323-329
46. Bookstaver PB, Miller AD, Rudisill CN, et al. Intravenous ibuprofen: the first injectable product for the
treatment of pain and fever. J Pain Res. 2010,25;3:67-79
47. Twersky RS, Sapozhnikova S, Toure B. Risk factors associated with fast-track ineligibility after monitored
anesthesia care in ambulatory surgery patients. Anesth Analg 2008; 106(5):1421-6.

Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.
Refresher Course Lectures Anesthesiology 2013 American Society of Anesthesiologists. All rights reserved. Note: This publication contains
material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
432
Page 1
Malignant Hyperthermia in the Outpatient Setting
Ronald S. Litman, D.O. Philadelphia, Pennsylvania
In this refresher course lecture, we will review basic principles of MH pathophysiology, susceptibility,
diagnosis, and treatment. We will also discuss unique aspects of treating acute MH in the ambulatory setting,
preparing your free-standing ambulatory center for potential MH, and anesthetizing the known MH susceptible
patient in a free-standing ambulatory center. Even in this current era of sophisticated means of detecting, diagnosing
and treating MH, mortality from MH in unsuspected individuals is not zero. In the past several years, at least ten
cases of MH-related death in ambulatory surgery patients are known to the Malignant Hyperthermia Association of
the United States (MHAUS). The incidence of acute MH in the general population is approximately 1:30,000
general anesthetics, but this doesnt account for unreported cases, or unrecognized, mild, or atypical reactions.
Furthermore, MH-susceptible patients may not develop the acute syndrome during any given anesthetic exposure.
Although acute MH may develop during the patients first exposure to a triggering agent, many MH-susceptible
patients will trigger upon subsequent anesthetic exposures.
Between 1996 and 2006, the rate of surgical procedures in a free-standing ambulatory surgery center
increased 300 percent. In 2006, approximately 53 million procedures were performed during 35 million ambulatory
surgery visits. Almost half of these visits occurred in a free-standing center.
1
Since malignant hyperthermia (MH)
susceptibility almost always occurs in phenotypically normal individuals, it is impossible to predict the risk of MH
in any given seemingly healthy ambulatory surgery patient.
MH Pathophysiology
MH susceptibility results from a familial or spontaneous mutation in a gene that encodes for one of the
components of a muscle cell that plays a role in regulation of intracellular calcium. The most commonly affected
structure is the ryanodine receptor, which regulates the movement of calcium from the sarcoplasmic reticulum into
the intracellular space of the myocyte.
2
The inheritance is autosomal dominant with variable penetrance. Affected
individuals are often healthy appearing, and, except for extremely rare cases of heat- or stress-related MH,
3
will only
develop signs of acute MH when exposed to one of the anesthetic triggering agents (i.e., volatile anesthetics or
succinylcholine). The specific mechanism by which anesthetics interact with these abnormal receptors to trigger an
MH crisis is unknown.
During an acute MH crisis, abnormal levels of calcium accumulate inside the muscle cell. This results in a
massive overload of actin-myosin cross-bridging, which leads to sustained muscle contracture, cellular hypoxia,
ATP depletion, and cell death (rhabdomyolysis). Hyperthermia results from the sustained muscle contraction, which
generates more heat than the body is able to dissipate.
Diseases Associated with MH
The gene for the ryanodine receptor, RYR1, is located on chromosome 19. The diseases that are known to
be linked with MH susceptibility are invariably also caused by mutations on chromosome 19 in the same region as
that which encodes for ryanodine. These are relatively rare and include central core myopathy,
4,5
multiminicore
myopathy,
6
King-Denborough syndrome,
7
Native American myopathy,
8
and possibly hypokalemic periodic
paralysis.
9

An interesting group of patients with possible MH susceptibility are those individuals with a history of
exercise- or heat-induced rhabdomyolysis.
10,11
Although many of these patients will not test positive, those with a
convincing history of severe heat- or exercise-induced rhabdomyolysis should probably be considered to be MH
susceptible unless proven negative by contracture testing.
A number of other diseases have been erroneously linked with MH susceptibility because patients have
developed rhabdomyolysis upon exposure to triggering agents. These include Duchenes and Beckers myopathy,
12

McArdles disease (glycogen storage disease, type V),
13
myoadenylate deaminase deficiency,
14
and carnitine
palmitoyltransferase type 2 (CPT-2) deficiency.
15
The mechanism of the relationship between these diseases and
anesthetic-induced rhabdomyolysis is unknown.
16


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Page 2
Additional diseases that are not associated with MH susceptibility include the mitochondrial myopathies,
Noonans syndrome, arthrogryposis, osteogenesis imperfecta, and neuroleptic malignant syndrome.

Clinical Features of Acute MH
MH manifests clinically as signs and symptoms of hypermetabolism and the sequelae of muscle
breakdown. An early important sign of hypermetabolism is hypercapnia that is out of proportion to increases in
minute ventilation. Tachycardia and hypertension may also occur. Spontaneously breathing patients will develop
marked tachypnea in an attempt to compensate for respiratory acidosis. Signs of ongoing rhabdomyolysis include
metabolic acidosis, localized or generalized rigidity (with or without neuromuscular blockade), hyperkalemia-
induced arrhythmias, myoglobinuria (tea-colored urine), and rapid temperature elevation. In some patients, masseter
muscle spasm in response to administration of succinylcholine is a harbinger of acute MH.
17
Death from MH almost
always results from acute hyperkalemia or hyperthermia-induced disseminated intravascular coagulation (DIC).
Muscular individuals appear to have the greatest risk of severe complications from MH, presumably because of the
relatively larger amount of muscle damage that contributes to hyperkalemia and hyperthermia.
18
They are also more
susceptible to recrudescence of MH following initial treatment with dantrolene.
19

Intraoperative or postoperative hyperthermia without additional signs of hypermetabolism is not an
observed presentation of acute MH.
20
In fact, the notion of acute MH first presenting several hours after completion
of the general anesthetic is unproven. Postoperative hyperthermia, even if striking, should prompt a search for other
causes unless accompanied by muscle rigidity or rhabdomyolysis. The most common mimic of acute MH is
hypercapnia caused by hypoventilation, from any one of a number of causes related to impaired ventilation.

Treatment of Acute MH
When clinical signs indicate a strong possibility of acute MH, the diagnosis should be confirmed by blood
gas analysis (when available), which shows the characteristic mixed respiratory and metabolic acidosis. In some
cases of severe acute MH, such as that seen with marked hypercapnia along with generalized rigidity, metabolic
acidosis may not yet be evident. Nevertheless, triggering agents should be immediately discontinued and the surgical
procedure should be aborted or completed as quickly as possible while administering intravenous (nontriggering)
anesthetics. An endotracheal tube should be placed if not already present, the minute ventilation should be increased
to offset respiratory acidosis, and the inspired oxygen should be increased to 100 percent. Simultaneously, all
available personnel are summoned, and the MH emergency cart (Table 1) is brought into the room. If the surgery is
being performed in a free-standing facility, plans for transport to the nearest full-service medical center should be
arranged. The concentration of the volatile gas remaining in the patient can be decreased most rapidly by increasing
fresh gas flows and by inserting into the anesthesia circuit a charcoal filter.
21

Immediate administration of dantrolene is the most important aspect of treatment of acute MH all
personnel should be focused on its administration as quickly as possible. Dantrolene is supplied as a lyophilized
powder (20 mg) and also contains 3 g of mannitol. It is reconstituted with sterile water, which when warmed will
enhance solubility.
22
A newer formulation manufactured by JHP Pharmaceuticals will solubilize within 20 seconds.
The initial dose of dantrolene is 2.5 mg/kg; subsequent bolus doses of 1 mg/kg should be administered until the
signs of acute MH begin to reverse. Some patients (e.g., muscular males) may require initial doses approaching 10
mg/kg; however, the need for higher than usual doses should prompt an exploration for alternative diagnoses. As
soon as feasible, the MH hotline should be called to speak with a knowledgeable expert who can assist with
diagnosis, treatment, and follow-up care (1-800-MH-HYPER).
The most important aspects of treatment of acute MH are listed in Table 2.

Preparing Your Ambulatory Surgery Center for Unexpected Acute MH
Since patients with significant neuromuscular disease are usually excluded from receiving general anesthesia in
an ambulatory facility, it is most likely that any patient that develops MH will be otherwise healthy. Therefore, each
facility should be optimally prepared to treat patients that unexpectedly develop acute MH. Each facility should have
a completely stocked MH cart (Table 1) and a readily available source of ice and cold intravenous fluids. A full
component of dantrolene (36 vials) should be available at every ambulatory facility that uses any anesthetic
triggering agent, and the facility should proactively identify a mechanism to rapidly attain additional dantrolene in
the event that the patient requires more than is immediately available. MH treatment drills should be performed at
least yearly. An in-service video and manual for management of MH in ambulatory centers is available from
MHAUS.



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Page 3
Anesthesia for MH Susceptible Patients in the Ambulatory Setting
MH susceptible patients are eligible for outpatient surgery in a free-standing facility. A non-triggering
technique should be used for general anesthesia after properly preparing the anesthetic machine according to the
manufacturers recommendations. Insertion of a charcoal filter into the anesthesia machine circuit allows rapid
clearance of residual anesthetic gases without prolonged flushing with fresh gas.
21
The patient should be carefully
monitored, especially with a focus on end-tidal carbon dioxide and core temperature. Prophylactic dantrolene is not
indicated. MH susceptible patients that receive a non-triggering anesthetic technique do not require extended
postoperative monitoring as long as their anesthetic course was uneventful. Following discharge, the patient is
instructed to call their physician or go to the emergency room if they develop elevated temperature or brownish
discoloration of their urine, which indicates myoglobinuria.

Case Example
During the RCL, I will discuss this recently encountered real case: A healthy 5 yr old girl presented for
tonsillectomy. Her paternal aunt (fathers sister) had a suspicious episode of MH in 1981 and has been treated as if
she is MH susceptible ever since. The aunt never had a biopsy or genetic testing. No one else in the family has ever
been tested but they have always considered themselves MH susceptible.

Questions:
Does the pt need a non-triggering technique?
Should she receive prophylactic dantrolene?
Postoperatively, do standard discharge criteria apply?
Can she have her surgery at a freestanding ASU?
Who should now be tested, and how?
What are the advantages/disadvantages of always considering the aunt (and family) MH susceptible?


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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
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432
Page 4
Table 1. Suggested Emergency MH Cart Supplies





Drugs
Dantrolene 20 mg vials 36 vials
Sterile water 2 1-liter bags
Sodium bicarbonate 8.4 percent, 50 mL 5 prefilled syringes or vials
Dextrose 50 percent, 50 mL 2 vials
Furosemide 10 mg/mL, 10 mL 2 vials
Calcium chloride 10 percent, 10 mL 2 vials
Lidocaine 2 percent, 5 mL 4 prefilled syringes or vials
Amiodarone 50 mg/mL, 3 mL 2 vials

Refrigerated drugs and solutions
Insulin regular 100 units/mL, 10 mL 1 vial
0.9% normal saline, 1000 mL for IV cooling 4 bags and sterile pour bottles
Cold packs 8 (freezer)

General equipment
Syringes, 60 mL to dilute dantrolene 5
Mini-spike or similar IV additive pins and transfer set to reconstitute
dantrolene.
2
IV catheters: 16G, 18G, 20G 2 inch, 22 g 1 inch, 24G ! inch (for IV
access and arterial line)
4 each
NG tubes Various sizes
60 cc irrigation syringes 2
Drip IV set, chamber, extension 4
Syringes (insulin, ABG, 60 mL, 10 mL, 3 mL) 4 to 6 each
18G needles 6
Charcoal filter (Vapor-Clean, Dynasthetics LLC, Salt Lake City, UT) 2

Monitoring equipment
Esophageal or tympanic temperature probes 2
Rectal or bladder and skin temperature probes 2

Nursing supplies
Large sterile Steri-Drape 1
Urine meter 1
Irrigation tray with piston (60 cc irrigation) syringe 1
Small and large clear plastic bags for ice 4 each
Bucket for ice 1
Test strips: urine analysis for hemoglobin and finger stick glucose 1 vial

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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
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432
Page 5
Table 2. Treatment of Acute MH


Initial Steps:
Call for help, dantrolene, and MH emergency supply cart.
Notify surgeon to abort or complete procedure rapidly.
Discontinue triggering agents and switch to non-triggering intravenous anesthetics if surgery ongoing.
Hyperventilate with 100% oxygen, place charcoal filter into breathing circuit; endotracheal intubation.
Administer dantrolene: dissolve 20 mg dantrolene in 60 mL sterile water; 2.5 mg/kg IV rapid push, and then 1
mg/kg every 10-15 minutes until reversal of acute signs of MH.
Place bladder catheter to monitor urine output and color.
If feasible, call MH Hotline during any part of treatment process: 1-800-644-9737 (1-315-464-7079 outside U.S.).

Ongoing Monitoring and Treatment:
Potassium, ABG, glucose levels at least every 20 minutes, CK levels every 6 hours for first 48 hours.
Treat hyperkalemia with hyperventilation, calcium chloride (10 - 20 mg/kg) or calcium gluconate (50 - 100 mg/kg).
Additional treatment of hyperkalemia: 10 units insulin IV push with 50 mL 50% dextrose glucose (for adults); 0.1
units insulin/kg IV push with 2 mL/kg 25% dextrose glucose (for pediatric patients).
Treat metabolic acidosis with sodium bicarbonate, 1-2 mEq/kg, IV push over 5 to 10 minutes.
Treat hyperthermia with cooling methods such as IV cold saline, ice to body surface, or cold lavage to open body
cavities; stop cooling when core body temperature decreases to 38
o
C.
Life-threatening dysrhythmias usually caused by hyperkalemia. Do not administer calcium channel blockers
(contraindicated with dantrolene treatment).
Maintenance dantrolene: 1 mg/kg every 4 to 6 hours, or 0.25 mg/kg/hr continuous infusion. Maintain for 24-48 hrs
after last sign of acute MH.
Treat myoglobinuria with induced diuresis (furosemide 1 mg/kg/dose) and sodium bicarbonate to alkalinize urine if
CK >10,000 IU/L.
Monitor coagulation studies for disseminated intravascular coagulation if rhabdomyolysis or hyperthermia severe.



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Page 6
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15. Wieser T, Kraft B, Kress HG: No carnitine palmitoyltransferase deficiency in skeletal muscle in 18 malignant
hyperthermia susceptible individuals. Neuromuscul Disord 2008; 18: 471-4
16. Litman RS, Rosenberg H: Malignant hyperthermia-associated diseases: state of the art uncertainty. Anesth
Analg 2009; 109: 1004-5

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refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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17. O'Flynn RP, Shutack JG, Rosenberg H, Fletcher JE: Masseter muscle rigidity and malignant hyperthermia
susceptibility in pediatric patients. An update on management and diagnosis. Anesthesiology 1994; 80: 1228-
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18. Larach MG, Brandom BW, Allen GC, Gronert GA, Lehman EB: Cardiac arrests and deaths associated with
malignant hyperthermia in north america from 1987 to 2006: a report from the North American Malignant
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2008; 108: 603-11
19. Burkman JM, Posner KL, Domino KB: Analysis of the clinical variables associated with recrudescence after
malignant hyperthermia reactions. Anesthesiology 2007; 106: 901-6
20. Litman RS, Flood CD, Kaplan RF, Kim YL, Tobin JR: Postoperative malignant hyperthermia: an analysis of
cases from the North American Malignant Hyperthermia Registry. Anesthesiology 2008; 109: 825-9
21. Birgenheier N, Stoker R, Westenskow D, Orr J: Activated charcoal effectively removes inhaled anesthetics
from modern anesthesia machines. Anesthesia & Analgesia 2011; 112: 1363-70
22. Mitchell LW, Leighton BL: Warmed diluent speeds dantrolene reconstitution. Can J Anaesth 2003; 50: 127-
30

Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

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Update on Cardiac Anesthesia
Glenn P. Gravlee, M.D. Aurora, Colorado
As for any physician in any specialty, new challenges and therapeutic options continue to emerge for cardiac
anesthesiologists. In particular, we are spending more and more time caring for patients undergoing nonsurgical or
combined surgical/nonsurgical interventions. Examples include thoracic endovascular aortic repairs and the
LARIAT procedure. In addition, a fibrinogen concentrate has been approved by the Food and Drug Administration
and introduced in the United States after considerable experience in Europe. This product might displace
cryoprecipitate and reduce activated Factor VII use. Finally, longstanding controversy about when to place stents vs
perform coronary artery bypass grafting (CABG) has heated up as a result of recent studies that may tip the scales
back toward CABG.
Thoracic Endovascular Aortic Repair (TEVAR)
Background. In recent years TEVAR has grown rapidly as an alternative to open descending thoracic aortic graft
placement. This experience has been the natural outgrowth of favorable results with abdominal aortic endovascular
repairs. Although the literature lacks randomized prospective clinical trials, retrospective or prospective case-
control studies strongly suggest TEVAR superiority over open descending aortic grafts for many important short-
and medium-term outcomes such as 30-day mortality, paraplegia, cardiac complications, blood transfusion, renal
impairment, pulmonary complications, and length of hospital stay (Cheng). Any survival benefit at one year and
beyond remains unproven, but this may change as long-term follow-up continues. The differences were risk-
adjusted for many important co-morbidities. TEVAR can be utilized for a variety of descending thoracic aortic
pathology including acute and chronic dissections, atherosclerotic aneurysms, and traumatic aortic disruptions.
Experience to date precludes any recommendation for aortic arch or ascending aortic aneurysms, and it appears that
most centers still approach these aneurysms with open surgery.
Preparation for surgery. These cases range in urgency from elective atherosclerotic aneurysms to acute traumatic
contained ruptures threatening to blow any minute. Common to all is the potential need to convert to open
thoracotomy because of free natural rupture or because the TEVAR intervention causes bleeding, creates new
downstream ischemia, or fails to correct the pathology. Consequently, it makes sense to prepare for substantial
blood loss and emergency open thoracotomy just in case. Many centers use a hybrid operating room for these
procedures, i.e., one that simultaneously permits state-of-the-art radiographic imaging while also allowing
thoracotomy and extracorporeal circulation if needed. Standard American Society of Anesthesiologists (ASA)
monitors plus one or more arterial catheters and large-bore IV catheters are baseline expectations (Ellard). Central
venous access of some type may be helpful as well. Transesophageal echocardiography may be helpful if there is
diagnostic uncertainty about ascending aortic dissection (or if needed for intra-anesthetic cardiac diagnosis and
management), but most often intravascular ultrasound fulfills the intraoperative needs of the surgeon. Rapid or
immediate availability of adjuncts such as autotransfusion, a rapid infuser, and fluid warmers are advisable. A
double-lumen endobronchial tube or bronchial blocker should be rapidly available in the event of conversion to
thoracotomy.
For patients with acute dissections and ruptures, preoperative hemodynamic stabilization with a beta-adrenergic
blocker such as esmolol and a vasodilator such as nitroprusside, clevidipine, or nicardipine will help prevent
extension of the dissection or rupture by reducing wall tension on the torn segment. For intraoperative use, the
same vasoactive drugs one would prepare for an open descending aortic or thoraco-abdominal aortic repair should
be immediately available. In addition, large doses of adenosine may be used during deployment of the stent.

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Another consideration is the potential need for a separate or simultaneous carotid-to-left subclavian bypass
procedure if the aortic stent landing zone will likely occlude the left subclavian artery ostium.

Anesthesia management: Arterial catheter placement varies in both number and site. Sometimes our surgeons
want bilateral radial artery catheters for a combination of monitoring and wire access. A right radial catheter may
facilitate endovascular graft placement in the descending thoracic aorta by mating from above with a retrograde
wire advanced from below. Sometimes anticipated left subclavian artery coverage (i.e., partial or complete
obstruction) precludes a left radial artery catheter while making the left hand a desired site for the pulse oximeter (as
a monitor for loss of signal) (Jazaeri). Depending upon the anticipated length of the stent graft and what may
already be known about a patients spinal cord blood supply, a spinal cord drain may be desired (Ullery). The closer
the anticipated distal end of the stent will be to the diaphragm and the longer the anticipated length of the
endovascular graft, the more likely the surgical team is to request a spinal drain. The benefit of spinal drains is
much less well substantiated for endovascular aortic stents than for open thoracic aortic or thoraco-abdominal aortic
grafts. If a spinal drain is used, the prevailing norm is to maintain cerebrospinal fluid (CSF) pressure at 8-12 mmHg
while limiting CSF drainage to 15-20 mL/hr.

Substantial retrospective data show better outcomes (mortality, pulmonary complications, length of stay, cardiac
complications) when regional anesthesia or local/MAC is chosen over general anesthesia for abdominal aortic
endovascular repair (Bakker, Cheng). One retrospective study suggests similar benefit for thoracic aortic
endovascular repairs, even to the extent of using the spinal drain to provide intermittent boluses of local anesthetic
drug and keeping the patient awake (Lee). General anesthesia currently is used exclusively for TEVARs at
University of Colorado Hospital. The potential need for deliberate short-term reduction in cardiac output during
proximal stent deployment complicates intraprocedural management. Techniques used to achieve this cardiac
output reduction include high-dose adenosine, rapid right ventricular pacing, and balloon inflation in the right
atrium. If used, these techniques offer less appeal in an awake patient than in an asleep, intubated one. Spinal
anesthesia would also render evoked potential monitoring ineffective, and could delay post-procedural neurologic
assessment.

Fibrinogen: Underappreciated Factor?

Fibrinogen concentrates are increasingly available in Europe, and are now available in the USA after FDA approval
for congenital deficiencies. Consequently, their use in intraoperative coagulopathies would be off-label;
nevertheless several studies report its use. Some show fibrinogen to be the first factor to diminish to the point of
deficiency during consumptive processes (as cardiopulmonary bypass can be) (Levy). Fibrinogen concentrate is
available as a lyophilized, reconstituted human product. As compared to fresh-frozen plasma, fibrinogen is much
more concentrated and expensive. As compared to cryoprecipitate, it is approximately the same concentration but
probably carries a lower risk of viral transmission and immunomodulation, and it is likely to be more rapidly
available (if it is locally available at all). As compared to recombinant factor VIIa, fibrinogen is less expensive and
is thought to require thrombin rather than generate it. In theory, the latter distinction suggests a lower risk of
hypercoagulable and hyperinflammatory states. Blome et al. correlated even low normal fibrinogen concentration
with post-cardiopulmonary bypass (CPB) bleeding (Blome). Karlsson et al. found that prophylactic fibrinogen
after CPB decreased 12-hr blood loss (Karlsson). Two nonrandomized studies found that fibrinogen administered
as the first intervention in post-CPB coagulopathy decreased transfusion of other components, one of which also
showed lower blood loss (Solomon, Rahe-Meyer). A recent editorial stated that fibrinogen concentrates have
replaced cryoprecipitate as a source of fibrinogen in several European countries. This same editorial noted that
dose-finding studies are needed, and that five prospective cardiac surgical clinical trials are ongoing (Ranucci).

Conclusive recommendations as to optimal use of fibrinogen concentrates in cardiac surgery cannot yet be made, but
in the meantime it appears reasonable to discuss these concentrates within your institution as a possible substitute for
cryoprecipitate when fibrinogen supplementation is indicated. It also seems reasonable to aggressively pursue a
diagnosis of hypofibrinogenemia in higher risk situations such as CPB times > 2 hours, redo cardiotomies, and
circulatory arrest procedures. In such cases, toward the end of CPB or immediately after protamine administration
one should strongly consider either traditional measurement of plasma fibrinogen concentration or a
thromboelastographic (TEG) equivalent such as ROTEM FIBTEM or the alpha-angle of a traditional TEG.
Whereas in the past a plasma fibrinogen concentration <100 mg/dL was considered to be the intervention threshold
for cryoprecipitate, currently the presence of coagulopathy in combination with a fibrinogen concentration < 200

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mg/dL supports administration of either cryoprecipitate (10 bags) or fibrinogen concentrate (approximately 4 grams)
as a primary intervention. There is insufficient evidence to support prophylactic administration of fibrinogen
concentrates after CPB.

LARIAT Procedure (and variants)

The LARIAT Procedure (device manufacturer SenterHEART, Inc) percutaneously lassoes the left atrial
appendage (LAA). This is typically performed by cardiologists with general anesthesia in an electrophysiology
procedure room, typically with a cardiac surgical team immediately available on standby. The principal indication
is chronic atrial fibrillation in a patient at high risk for thromboembolic phenomena who is also unable to receive
appropriate anticoagulants. The procedure involves placing a magnetized balloon catheter into the LAA via the
femoral vein and right atrium, then through the foramen ovale into the left atrium. A second catheter then is placed
percutaneously into the pericardium through a subxiphoid needle. A magnetic wire loop (LARIAT) is passed
through this introducer catheter to find the LAA via magnetic attraction to the balloon catheter. Once the LARIAT
has surrounded the LAA, it is guided to the LAA neck, the balloon catheter inside the LAA is inflated, the loop is
partially cinched down over the catheter, appropriate positioning is confirmed using ultrasound (often 3D
transesophageal echocardiography), the balloon is deflated and its catheter withdrawn, the lariat is tightened to
occlusion, and the pericardial catheter is withdrawn. Early studies suggest 95% efficacy in occluding the LAA,
which surprisingly is better than most reported surgical closure rates.

Obviously the biggest acute concerns are cardiac puncture during placement of the pericardial needle and rupture
of the left atrium while tightening the LARIAT. Because of the precision required for the procedure and its
attendant desire for short periods of apnea, most centers seem to be doing these procedures with general anesthesia,
although I could not find any series reported.

At least three experimental devices are being used to occlude the LAA from within. All are distensible devices
analogous to stents that, once deployed, have geometric shapes that variously resemble a parachute (WATCHMAN
device, Boston Scientific), a toadstool (Amplatzer device, St. Jude Medical), and a football (PLAATO device, ev3
Inc), respectively. Unlike LARIAT, these three devicets do not yet have Food and Drug Administration (FDA)
approval. Like LARIAT, hese devices have the potential for atrial rupture, but they also can migrate or embolize.
Here again, it appears that initially general anesthesia is being used predominantly, but it seems more likely that
these procedures could eventually move toward management with sedation than the LARIAT Procedure, because
they can be performed using femoral vein trans-septal access alone. Unlike LARIAT, the indwelling LAA occluder
devices require long-term anticoagulation, but possibly aspirin alone may prove adequate.

For all of these procedures, the anesthetic considerations are fairly obvious. The patients cardiac and other
comorbidities will play important roles in technique selection. Use of an arterial catheter seems very reasonable,
especially for the LARIAT procedure, and perhaps for the others as well at least initially.

CABG Comeback?

As recently as 10 years ago, coronary artery bypass grafting (CABG) was the dominant cardiac surgical operation
and one of the five most common surgical procedures in the US. How times have changed! Recent clinical studies
fuel a possible move back toward CABG for significant numbers of patients that have instead been undergoing
coronary stent placements in recent years. In a very large (190,000 patients) retrospective database study of
Medicare patients, Weintraub et al. compared outcomes in patients with 2- or 3-vessel coronary artery disease for
percutaneous coronary interventions vs surgical coronary artery bypass grafting (Weintraub). Inverse probability
weighting was used for risk adjustment. CABG patients had lower long-term mortality with a median follow-up of
2.67 years. Farkouh et al. found a lower long-term event rate after CABG in a prospective, randomized study of
1,900 diabetics with multivessel disease (Farkouh). The stent patients in this study predominantly received drug-
eluting stents, which allays concerns about the technology always staying ahead of the published studies.
There have been a number of interesting exchanges between invasive and noninvasive cardiologists about this latter
topic. In an accompanying editorial, Mark Hlatky, a noninvasive cardiologist, states, the comparative effectiveness
of CABG and PCIremains similar whether PCI is performed without stents, with bare-metal stents, or with drug-
eluting stentsMortality has been consistently reduced by CABG.The controversy should finally be settled.
Hlatky also opines that, Many percutaneous coronary interventions today are performed at the time of diagnostic

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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
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coronary with the same physician making the diagnosis, recommending the treatment, and performing the
procedure. This conflict of interest has seemed obvious for years, yet it appears that little has been done about it.
With ever-increasing regulation of health care in the US, including pre-procedural insurance approvals, it seems
possible that pre-approval for diagnostic cardiac catheterizations might cease to be accompanied by routine pre-
approval for coronary intervention, especially in elective scenarios and in diabetic patients. This could initiate a
CABG comeback time will tell.




References

TEVAR
Cheng D, Martin J et al, JACC 2010:55:986-1001.
Ellard L, Djaiani G, Anaesthesia 2013 68 (Suppl 1): 72-83.
Bakker EJ, van de Luijtgaarden KM et al, Eur J Vasc Endovasc Surg 2012;44:121-5.
Edwards MS, Andrews JS et al, J Vasc Surg 2011;54:1283-82.
Jazaeri O, Gupta R et al, Semin Cardiothorac Vasc Anes 2011;15:141-62.
Ullery B, Wang G et al, Semin Cardiothorac Vasc Anes 2011;15:123-40.
Lee WA, Daniels MJ et al, Circulation 2011;123:2938-45.

Fibrinogen

Levy JH, Anesth Analg 2012;114:261.
Blome M, Thromb Haemost 2005;93:1101.
Karlsson M, Thromb Haemost 2009;102:137.
Rahe-Meyer N, Brit J Anaesth 2009;102:785.
Solomon C, Scand J Clin Lab Invest 2012;72:121.
Ranucci M. J Thorac Cardiovasc Anes 2013;27:12.

Lariat Procedure

www.mymethodist.net/services/cardiovascular/lariat-procedure, accessed March 8, 2013.
Cheng A, Nonpharmacologic therapy to prevent embolization in patients with atrial fibrillation, UpToDate, April
29, 2013, accessed May 30, 2013.
Bartus K et al, Heart Rhythm 2011;8:188.
Shetty R, J Invasive Cardiol 2012:24:E289.

CABG Comeback?

Weintraub WS, NEJM 2012;366:1467
Farkouh ME, NEJM 2012;367:2375.
Hlatky MA, NEJM 2012;367:2437.



Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

Refresher Course Lectures Anesthesiology 2013 American Society of Anesthesiologists. All rights reserved. Note: This publication contains
material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
108
Page 1
Anesthesia for Patients With Valvular Heart Disease for Non-cardiac Surgery
Steven Konstadt, M.D., MBA, FACC Brooklyn, New York
INTRODUCTION
This talk will describe an approach to the patient with heart disease who is undergoing non-cardiac surgery.
Emphasis will be placed on the pathophysiology of the lesion, the pre-operative evaluation, anesthetic goals and
pertinent therapeutic options. Because of the time limitations of the presentation, not all cardiac conditions will be
addressed. Instead, this talk will focus on five important lesions that have been chosen because of their severity and
prevalence: aortic stenosis, hypertrophic obstructive cardiomyopathy, rheumatic mitral stenosis, and mitral valve
prolapse. In managing patients with valvular heart disease there are two important philosophies to remember. First,
"the enemy of good is better." Most valvular lesions cannot be completely treated by medical management. In other
words, don't over-treat these patients; aim for stability, not "normal" hemodynamics. Second for the reasons that will
become clearer in the discussion of aortic stenosis, in patients with multiple valvular lesions which may suggest
contradictory anesthetic goals, always give the highest priority to the aortic stenosis.
AORTIC STENOSIS
Aortic stenosis derives its position as the most important valvular lesion because of its potential for sudden
death(15-20%), and because of the inability to obtain adequate systemic perfusion by external cardiac massage
during a cardiac arrest. The three main etiologies of aortic stenosis are congenital, senile calcification and rheumatic
disease. The normal aortic valve is 2-3 cm
2
. As the valve orifice narrows, resistance to flow develops and a pressure
gradient across the valve also occurs. This pressure gradient leads to a pressure overload of the left ventricle.
There is compensatory concentric hypertrophy to normalize the wall stress, but other abnormalities persist:
increased oxygen demand, reduced oxygen delivery, and reduced diastolic relaxation and compliance. Symptoms ,

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i.e., angina, CHF, syncope, and sudden death, usually begin to occur when the valve area falls below 1 cm
2
.
Preoperative evaluation of a systolic ejection murmur will generally begin with an echocardiogram, and if the
symptoms or echo indicate, cardiac catheterization will be performed. The important measurements obtained during
catheterization are the aortic valve gradient, the aortic valve area, LVEDP, and LVEF. The main anesthetic goals are
to maintain normal sinus rhythm, adequate intravascular volume, and systemic vascular resistance. Perioperative
mortality in patients with critical aortic stenosis (AVA<.6cm
2
) has been reported as high as 11%. In addition to the
usual pharmacologic agents, there are two additional interventions to consider. One is the preoperative placement of
an IABP to improve coronary perfusion, and the other option in patients who are not candidates for aortic valve
replacement, is to perform percutaneous valve replacement to reduce the stenosis prior to non-cardiac surgery.

Hypertrophic Obstructive Cardiomyopathy(HOCM)
One rationale for including this lesion is that like aortic stenosis, HOCM can precipitate sudden death. It is
also included because of its unique dynamic physiology and unusual treatments. HOCM results in obstruction to LV
ejection in the LV outflow tract. Like aortic stenosis it also causes a pressure overload of the LV. In addition to the
pressure overload, systolic anterior motion (SAM) of the mitral valve induced by a Venturi effect, often precipitates
mitral regurgitation. Another possible physiologic mechanism of the LVOT obstruction relates to the position of the
papillary muscles. It is believed that the muscles can become anteriorly displaced and this moves the mitral valve
apparatus into the LVOT.



Factors such as hypovolemia, tachycardia, systemic vasodilation, and increased contractility all exacerbate
the obstruction. The clinical presentation includes angina, CHF, syncope and sudden death. Preoperative evaluation
includes baseline and provocative (Valsalva, or nitrates) echocardiography. The important measurements are the
LVOT diameter, the gradient across the LVOT, and the severity of the mitral regurgitation. The main anesthetic
goals are to maintain normal sinus rhythm, intravascular volume, systemic vascular resistance, and to avoid
hypercontractile states. In the acute perioperative period therapy is limited to pharmacologic agents, but in the
chronic care of HOCM, the synchronous contractile pattern induced by pacing may be therapeutic.



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Pulmonary Hypertension
Pulmonary hypertension (PHTN) can occur from a variety of causes including pulmonary disease, valvular
heart disease, and intrinsic vascular disease. Patients undergoing non cardiac surgery with pulmonary hypertension
usually do well intraoperatively but frequently have severe postop morbidity and mortality. In a retrospective review
of 145 patients with PHTN, there was a 7% periop mortality. Also the investigators identified several factors that
dramatically increased risk: history of pulmonary embolism, >class II NYHA, intermediate and high risk surgery,
and operations lasting more than 3 hours.
Rheumatic Mitral Stenosis
Mitral stenosis is a narrowing of the mitral valve orifice that results in left atrial hypertension, limited
filling of the LV, pulmonary congestion, and in moderate to severe cases, pulmonary arterial hypertension and right
ventricular pressure overload. Dyspnea is the most common presenting symptom, and many of the patients are in
atrial fibrillation. Echocardiography can demonstrate left atrial enlargement, mitral valve fibrosis and calcification,
and a gradient across the mitral valve. Cardiac catheterization will also determine the gradient across the valve, the
mitral valve area, LV function, and the right sided pressures. The anesthetic goals for patients with mitral stenosis
are to control the heart rate and if possible restore and preserve sinus rhythm, insure adequate intravascular volume,
and to prevent systemic arterial vasodilation. Additionally in patients with pulmonary hypertension, hypercarbia and
hypothermia, which may exacerbate the increased PVR should be avoided. Several special therapeutic options for
these patients exist. Balloon valvuloplasty may be performed, and cardioversion for atrial fibrillation may be useful.
There are also some new pharmacologic agents for treatment of refractory severe pulmonary hypertension: inhaled
prostacyclin and nitric oxide.
Mitral Valve Prolapse Syndrome (MVP)
MVP is the most common valvular abnormality occurring in 3 to 8 % of the population. Anatomically it is
characterized by billowing of one of the mitral valve leaflets into the left atrium. There may be minimal or
significant mitral regurgitation associated with this condition. In addition to the valvular abnormalities, there may be
an increased risk of autonomic dysfunction. Patients experience palpitations, chest pain, dyspnea, fatigue, and
orthostatic hypotension. Though there is some debate over the exact criteria to diagnose MVP, echocardiography is
still the diagnostic method of choice. Because of the leaflet abnormalities some of these patients receive anti-platelet
or other anticoagulant therapy. Other than infective endocarditis prophylaxis for those patients with abnormal
leaflets, there are few defined anesthestic goals for these patients.

References
1.Report of the American College of Cardiology/American Heart Association Task Forece on Practice guidelines
(Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Guidlines for perioperative
cardiovascular evaluation for noncardiac surgery JACC 27;910-48;1996
2.Cardiac Anesthesia, ed J.A. Kaplan, W.B. Saunders, Phila, PA 1993
3.Hayes et al, Palliative percutaneous aortic balloon valvuloplasty before noncardiac operations and invasive
diagnostic procedures. Mayo Clin Proc, 64:753-7,1989
4.Clinical Transesophageal Echocardiography, eds Oka and Konstadt, Lippincott-Raven, Phila PA, 1996.
5.O'Keefe et al, Risk of noncardiac surgical procedures in patients with aortic stenosis. Mayo Clin Proc, 64:400-
5,1989
6. Torsher et al: Risk of Patients with severe aortic stenosis in non-cardiac surgery. Am J Cardiol; 1998;81:448-52
7. Haering et al: Cardiac risk of non-cardiac surgery in patients with asymmetric septal hypertrophy. Anesthesiol;
1996;85:254-9
8. Jollis JG et al: Effects of Fen-phen, Circ 2000 101:2071-7
9. Kaluza et al: Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 2000
35:1288-94
10. Eagle et al: ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery
executive summary: A report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines JACC 39:542-53, 2002
11. Malouf et al: Aortic Stenosis and Pulmonary Hypertension. JACC 2002:40:789-9
12. Maron B et al: Effect of left ventricular outflow tract obstruction on clinical outcome in hypertrophic
cardiomyopathy, NEJM: 2003; 348(4):295-303
13. Maron B : Hypertrophic cardiomyopathy, JAMA 2002;287:1308-1320
14. Kertai et al: Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing
noncardiac surgery. AJMed January 2004, 8-13.
15. Poliac, et al: Hypertrophic Cardiomyopathy, Anesthesiology 104: 183-92, 2006.

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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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16. Cecchi, et al: Coronary Microvascular Dysfunction and Prognosis in Hypertrophic Cardiomyopathy. 349: 1027-
35, 2003
17. Amato, et al : Treatment Decision in asymptomatic aortic valve stenosis: role of exercise testing. Heart, 86:381-
6, 2001
18. ACC/AHA Guidelines for the management of patients with valvular heart disease. JACC 48: 1-148, 2006.
19.
Davenport DL, Ferraris VA, Hosokawa P, Henderson WG, Khuri SF, Mentzer RM.: Multivariable predictors of postoperative cardiac events
after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg 2007;204:1199-1210

20. Mittnacht, Fanshawe and Konstadt: Anesthetic considerations in the Patient with Valvular Heart Disease for Non
Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, Vol. 12, No. 1, 33-59 (2008)
21. Gautam Ramakrishna, MD, Juraj Sprung, MD, PHD, Barugur S. Ravi, MD, et al
Impact of Pulmonary Hypertension on the Outcomes of Noncardiac Surgery Predictors of Perioperative Morbidity
and Mortality, J Am Coll Cardiol
2005;45:16919


Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

Refresher Course Lectures Anesthesiology 2013 American Society of Anesthesiologists. All rights reserved. Note: This publication contains
material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
117
Page 1
Preconditioning the Heart:How it works and does it matter?
Judy R. Kersten, M.D. Milwaukee, Wisconsin
Objectives:
1) Identify the basic mechanisms of pre- and post-conditioning the heart against ischemic injury
2) Describe the evidence that supports or refutes the clinical use of anesthetics to protect the heart
3) Identify factors that interfere with clinical cardioprotection and strategies to mitigate the impact of disease
Preconditioning the heart against myocardial infarction was first described in 1986 by Murry, Jennings and
Reimer
1
. These investigators demonstrated that a brief period of myocardial ischemia that was insufficient to
damage myocardium protected against a more prolonged period of coronary artery occlusion and reperfusion in dogs
and infarct size was reduced by 50%. Subsequently, ischemic preconditioning (IPC) has been demonstrated in every
model and species in which it has been tested, including humans. Volatile anesthetics have also been shown to
precondition against myocardial ischemia and reperfusion injury
2
. These agents exhibited a memory period
during which myocardial protection persisted despite discontinuation of the anesthetic for up to 2 hr (anesthetic
preconditioning: APC) before index ischemia The protection of both IPC and APC waned and reappeared 24-48 hr
later during a second window or late preconditioning phase. A significant disadvantage of IPC and APC is that the
preconditioning stimulus must be applied before the period of index myocardial ischemia, thus limiting the clinical
utility of this approach. Interestingly, repetitive brief ischemia (stuttered reperfusion) or brief administration of
volatile anesthetics during the first seconds of reperfusion produced protection against ischemia and reperfusion
injury, a phenomenon referred to as post-conditioning (PoC). PoC has been shown to be equally efficacious as
compared to preconditioning strategies, and may be of greater clinical relevance as the period of prolonged ischemia
need not be anticpated. Recently, remote preconditioning (RIPC) has also become an attractive alternative to IPC
and PoC because coronary artery manipulation is avoided. During remote preconditioning, a regional ischemic
stimulus (e.g. limb ischemia and reperfusion) protected remote virgin myocardium against infarction
3
.
The mechanisms responsible for ischemic and anesthetic pre- and post-conditioning have been extensively
investigated in animal models. The mitochondrion appears to represent a final common pathway during
cardioprotection
4
. Mitochondria play essential roles not only in cellular energy metabolism, but also in signal
transduction, and regulation of apoptosis/cell death pathways. These organelles are an important source of reactive
oxygen species (ROS), that when released in small quantities, serve as triggers of IPC and APC. Conversely,
mitochondria are targets of injury during ischemia and reperfusion. For example, mitochondria play a critical role to
maintain intracellular calcium homeostasis. During ischemia and reperfusion, increases in cytosolic calcium lead to
mitochondrial calcium overload and excessive ROS production. These events provoke opening of the mitochondrial
permeability transition pore (mPTP), a large multi-protein channel connecting the inner and outer mitochondrial
membranes, resulting in collapse of the mitochondrial membrane potential and cell death. APC initiates a series of
intracellular signaling events including activation of membrane bound receptors, inhibitory G-proteins, intracellular
kinases, endothelial nitric oxide synthase (eNOS), and adenosine triphosphate-regulated potassium (KATP) channels
that ultimately attenuates opening of the mPTP and confer protection against ischemia and reperfusion injury. PoC
appears to protect the heart through similar reperfusion injury salvage kinase pathways, however, anesthetics also
have direct effects on mitochondria that are protective and do not require time-dependent signaling events. For
example, anesthetic PoC preserved an acidic mitochondrial matrix pH after reperfusion, an action that prevented
opening of the mPTP. Although the mechanisms involved in APC and APoC have been investigated in detail, much
less is known about the mechanism of RIPC. Blood borne mediators such as adenosine, nitric oxide, opioids, and
bradykinin have been suggested to play a role
5
.

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The potent cardioprotective effects of APC that were seen in animal studies were rapidly translated to use
in cardiac surgery where a well defined period of myocardial ischemia and reperfusion could be anticipated and
treated. Several small early studies indicated that troponin concentrations were reduced and left ventricular function
preserved in patients receiving volatile anesthetics compared to intravenous anesthetics
6
. However, not all studies
demonstrated a cardioprotective effect of volatile agents. It has been suggested that variations in mode of
administration, anesthetic concentration, presence of an anesthetic washout period (memory), and use of aprotinin
and other drugs all could have influenced the results. Thus, volatile anesthetics administered either throughout the
entire surgical procedure (evoking pre- and post-conditioning and anti-ischemic effects) or as a repetitive APC
stimulus may be most effective at decreasing myocardial injury
7
.
RIPC against myocardial infarction was first demonstrated in patients admitted with MI and randomized to
receive percutaneous coronary artery intervention either without or with RIPC (intermittent arm ischemia induced
with 4 cycles of 5 min blood pressure cuff inflations/deflations). Myocardial salvage was significantly improved by
RIPC
8
. RIPC has also been used to reduce troponin concentrations in patients undergoing cardiac surgery; however,
the results are conflicting. One study showed that RIPC was effective in isoflurane- but not propofol-anesthetized
patients
9
, while other studies have shown that RIPC does not modify myocardial injury in patients that are already
protected with volatile anesthetics. Lack of additional protection by RIPC during anesthesia with volatile
anesthetics
10
could be explained by activation of similar signaling pathways by RIPC or by decreased intensity of the
regional ischemic stimulus secondary to anesthetic effects on blood flow and oxygen consumption.
The beneficial effects of volatile anesthetics to protect against myocardial injury in patients at risk for
ischemia have been evaluated during non-cardiac surgery as well. For example, in a recent RCT of 385 patients,
sevoflurane did not decrease the incidence of myocardial ischemia compared to patients anesthetized with
propofol
11
. The evidence for a clear benefit of volatile anesthetics to protect myocardium against ischemic injury in
patients undergoing cardiac or non-cardiac surgery is equivocal despite overwhelming pre-clinical evidence that
volatile anesthetics possess potent cardioprotective effects. There are several important factors that may explain the
apparent lack of clinical cardioprotection in some studies
12
. The timing and mode of administration (stuttered versus
continuous), and dose of volatile anesthetic influences the efficacy of these drugs to reduce ischemic injury and was
not standardized in many investigations. Opioids have also been demonstrated to protect against myocardial
ischemia and reperfusion injury through activation of opioid receptor subtypes, including delta-, kappa-, and mu-
receptors. In addition, clinical studies frequently do not include an assessment of myocardium at risk for ischemic
injury. A recent consensus statement suggested that advanced myocardial imaging (e.g. SPECT) should be used to
precisely determine both risk area and the extent of myocardial injury during clinical trials that aim to determine the
efficacy of cardioprotective strategies. Asymptomatic myocardial ischemia is observed in nearly 50% of ambulatory
patients with stable coronary artery disease, and the degree of silent ischemia (frequency and severity) may be more
important in predicting cardiac events than the mere presence of ischemia. It has been suggested that the specific
anti-ischemic regimen that is utilized (that may include a variety of drugs such as beta blockers, statins, aspirin,
ACE inhibitors/ARBs) may be of less importance than insuring that heart rate is adequately suppressed.
Disease states or their treatment may influence the ability of anesthetics to modulate ischemia and
reperfusion injury
13
. APC and APoC were abolished by hyperglycemia, diabetes and in aged myocardium.
Sulfonylurea drugs used to treat diabetes stimulate insulin release by closing KATP channels in the beta cells of the
pancreas. They also blocked myocardial KATP channels and the beneficial effects of IPC and APC. Thus,
discontinuing sulfonylurea drugs 24-48 hrs before elective surgery is recommended.
Finally, statins are an important class of drugs that decrease cardiovascular morbidity and mortality, and
produce favorable actions to restore APC during hyperglycemia. The results of a meta-analysis highlight the
potential for statin therapy to positively impact cardiovascular risk reduction in patients undergoing cardiac and non-
cardiac surgery
14
. Additionally, evidence suggests that administration of statins to statin nave patients may be
beneficial in cardiac and non-cardiac surgery. Although there remains a small risk of rhabdomyolysis in patients in
whom statins are continued in the perioperative period, mortality rate may be substantially increased in patients in
whom statins are withdrawn
15
. Thus, patients who are chronically treated with statins should continue to receive
these drugs perioperatively.

In conclusion, volatile anesthetics produce potent effects to reduce myocardial ischemia and reperfusion
injury in experimental models but the benefits of these agents to decrease injury in patients during cardiac or non-
cardiac surgery are less clear. The results of clinical studies are difficult to interpret due to confounding factors such
as inability to accurately assess ischemic burden and area at risk for infarction. Concomitant treatment with other
drugs that significantly impacts cardiovascular outcome (e.g. statins, beta-blockers, ACE inhibitors, ARBs, alpha2-
agonists) also complicates the interpretation of clinical trial data. Although no single drug may be the magic bullet

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to improve cardiovascular outcome, the use of volatile anesthetics may be an important part of a multimodal
approach to protect the heart in patients with cardiovascular disease.

References

1.Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic
myocardium. Circulation 1986;74:1124-1136


2.Kersten JR, Schmeling TJ, Pagel PS, Gross GJ, Warltier DC: Isoflurane mimics ischemic preconditioning via
activation of KATP channels: Reduction of myocardial infarct size with an acute memory phase. Anesthesiology
1997; 87:361-370.

3. Przyklenk K, Bauer B, Ovize M, Kloner RA, Whittaker P. Regional ischemic preconditioning protects remote
virgin myocardium from subsequent sustained coronary occlusion. Circulation 1993;87:893899

4. Di Lisa F, Canton M, Carpi A, Kaludercic N, Menabo R, Menazza S, Semenzato M. Mitochondrial injury and
protection in ischemic pre- and postconditioning. Antioxidants & Redox Signaling 2011;14:881-890

5. Weiwei Shi and Jakob Vinten-Johansen. Endogenous cardioprotection by ischaemic postconditioning and remote
conditioning. Cardiovascular Research (2012) 94, 206216

6. De Hert, SG, Van der Linden, PJ; Cromheecke, S, Meeus, R, Nelis, A, Van Reeth, V, ten Broecke, PW, De Blier,
IG, Stockman, BA, Rodrigus, IE. Cardioprotective properties of sevoflurane in patients undergoing coronary
surgery with cardiopulmonary bypass are related to the modalities of its administration. Anesthesiology
2004;101:299310

7. Frdorf, Borowski, Ebel, Feindt, Hermes, Meemann, Weber, Mllenheim, Weber, Preckel, Schlack. Impact of
preconditioning protocol on anesthetic-induced cardioprotection in patients having coronary artery bypass surgery.
J Thorac Cardiovasc Surg 2009;137:14361442

8. Btker H, Kharbanda R, Schmidt M, Bttcher M, Kaltoft A, Terkelsen C, Munk K, Andersen N, Hansen T,
Trautner S, Flensted Lassen J, Christiansen E, Krusell L, Kristensen S, Thuesen L, Nielsen S, Rehling M, Srensen
H, Redington A, Nielsen T. Remote ischaemic conditioning before hospital admission, as a complement to
angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial.
Lancet 2010; 375:727-734

9. Heusch G, Musiolik J, Kottenberg E, Peters J, Jakob H, Thielmann M. STAT5 activation and cardioprotection by
remote ischemic preconditioning in humans. Circulation Research 2012;110:111-115

10. Lucchinetti E, Bestmann L, Feng J, Freidank H, Clanachan A, Finegan B, Zaugg M. Remote ischemic
preconditioning applied during isoflurane inhalation provides no benefit to the myocardium of patients undergoing
on-pump coronary artery bypass graft surgery. Anesthesiology 2012; 116:296-310

11. Buse G, Schumacher P, Seeberger E, Studer W, Schuman R, Fassl J, Kasper J, Filipovic M, Bolliger D,
Seeberger M. Randomized comparison of sevoflurane versus propofol to reduce perioperative myocardial ischemia
in patients undergoing noncardiac surgery. Circulation 2012;126:2696-2704

12. Kersten J. A recipe for perioperative cardioprotection: What matters most? The ingredients or the chef?
Circulation 2012; 126:2671-2673

13. Gu W, Pagel PS, Warltier DC, Kersten JR: Modifying cardiovascular risk in diabetes mellitus. Anesthesiology
2003; 98:774-9

14. Hindler K, Shaw AD, Samuels J, Fulton S, Collard CD, Riedel B: Improved postoperative outcomes associated
with preoperative statin therapy. Anesthesiology 2006; 105:1289-90

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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
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15. Schouten O, Hoeks SE, Welten GM, Davignon J, Kastelein JJ, Vidakovic R, Feringa HH, Dunkelgrun M, van
Domburg RT, Bax JJ, Poldermans D: Effect of statin withdrawal on frequency of cardiac events after vascular
surgery. Am J Cardiol 2007; 100:316-20

Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

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Regional Versus General Anesthesia for Vascular Surgery Patients
Peter Rock, M.D., MBA Baltimore, Maryland
Introduction
Vascular surgery patients are at increased risk for complications. These patients may have congestive heart
failure (CHF), a history of cigarette smoking, chronic obstructive pulmonary disease, hypertension, renal failure, and
diabetes (DM). There is an increased incidence of coronary artery disease (CAD) in this population and an increased
risk of myocardial infarction (MI) after vascular surgery. The AHA/ACC guidelines for patients undergoing non-
cardiac surgery categorize vascular surgery as high-risk [1]. Patients who are in jeopardy of developing
perioperative complications would benefit from anesthetic techniques that improve outcomes. Cardiac and
pulmonary complications, graft and deep venous thrombosis, gastrointestinal (GI) and central nervous system
(CNS) function, and mortality are important outcomes to evaluate. This review will address these issues, focusing on
major aortic and lower extremity arterial bypass surgery using general (GA) or regional anesthesia (RA) with either
spinal (SA) or epidural (EA) anesthesia. Since not all aspects of improvement in outcomes have been studied in
vascular surgery patients, it will be necessary to extrapolate to such patients the results of studies performed in other
surgical disciplines. There is conflicting data regarding whether regional analgesia results in superior outcomes
compared to other forms of analgesia. The line between intraoperative anesthesia and postoperative analgesia is
often blurred but the results of analgesic interventions are relevant to perioperative outcomes.
Potential Advantages and Disadvantages of RA and GA
RA does not require airway manipulation or neuromuscular blockade. Volatile agents are not used; there is
less effect on ventilatory control. A hypercoagulable state is seen after surgery. RA, by attenuating the stress
response to surgery, may modify the tendency to clot and decrease the incidence of postoperative venous, arterial,
and graft thrombosis [2, 3]. RA using local anesthetics (LA) and opioids can be administered continuously
postoperatively. RA may permit early ambulation, faster rehabilitation, and a decreased hospital length of stay
(LOS). EA provides better postoperative analgesia compared to intravenous patient-controlled analgesia (PCA) [4].
RA may be more time consuming than GA and is expensive if performed in the OR. Recent studies have
illustrated the risks associated with RA. A prospective study of 103,740 regional anesthetics (40,640 SA; 30,413
EA; 32,687 other) examined the incidence of adverse outcomes. [5]. There were 29 cardiac arrests, most of which
occurred during SA. Neurologic injury was reported in 34 patients. The risk of seizures after injection of LA was
2.2/10,000 and the risk of death was 0.7/10,000. A follow-up study confirmed the previous findings (56 major
complications in approximately 158,083 regional anesthetics) [6]. A recent study of over 1.7 million regional
anesthetics found 127 neurologic complications including permanent neurologic damage in 85 patients [7]. A review
of 8,210 epidural catheters inserted for postoperative pain control revealed a significant incidence of neuraxial injury
[8]. These studies should not discourage the use of RA but illustrate that all anesthetics are associated with
complications. Spinal or epidural hematoma may occur even in patients with normal coagulation function and can
result in devastating neurological consequences. Patients with vascular disease may receive anticoagulants or
antiplatelet agents, which increase the risk of neuraxial bleeding. The recent outbreak of fungal meningitis
associated with epidural steroid injection is an illustration of how seemingly low-risk procedures can be associated
with catastrophic adverse outcomes. Other potential drawbacks of RA include: airway control is assumed; airway
secretions cannot be suctioned; and there is no control over ventilation and oxygenation. But, GA requires airway
manipulation and can induce bronchospasm. Inhalational anesthetics attenuate the response to hypercarbia and
hypoxemia, and neuromuscular blockade is often employed.
RA might improve outcomes by attenuating the perioperative stress response; GA does not attenuate the
stress response as well as RA. Elevations in heart rate and blood pressure increase myocardial oxygen demand and
result in myocardial ischemia or infarct in individuals with CAD. Coronary vasoconstriction, as a result of an

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increase in circulating catecholamines, decreases coronary blood flow and myocardial oxygen delivery. EA ablates
the catecholamine response to lower extremity vascular surgery and attenuates the catecholamine response to
surgery above the umbilicus [9]. Postoperative norepinephrine correlates with postoperative hypertension [10].
Impaired fibrinolysis and increases in platelet aggregation after surgery might result in coronary artery thrombosis.

Meta-Analysis and Randomized Clinical Trials (RCTs)
Meta-analyses have suggested the superiority of epidural analgesia over other types of postoperative pain
relief, producing superior pain control and a reduction in the rate of postoperative MI [11]. However, it is possible
that adequate pain relief, regardless of how it is achieved, may reduce the rate of perioperative MI. Older studies
included in meta-analyses have flawed study design. They did not control hemodynamics, temperature, post-
operative care, and analgesic care, between RA and GA groups. Inclusion of such studies in a meta-analysis will
lead to false conclusions. Improvements in clinical practice over time may render the results of a meta-analysis
irrelevant to modern practice. Meta-analyses frequently do not agree with RCTs published on the same topic. One
study concluded if there had been no subsequent RCT the meta-analysis would have led to the adoption of an
ineffective treatment 32% of the time and to the rejection of a useful treatment 33% of the time [12]. New evidence
that changes conclusions of systematic reviews arises frequently within a short time [13]. But, RCTs alter usual
clinical care limiting the ability to generalize the results beyond the conditions of the trial. The MI rate is often lower
in RCTs, where clinical care is controlled, than in studies where perioperative management is not tightly controlled.

Deep Venous Thrombosis (DVT) and Graft Thrombosis
Surgery produces a hypercoagulable state. Increased levels of plasminogen activator inhibitor may result in
impaired fibrinolysis and predispose to arterial or venous thrombosis following surgery [2]. RA may attenuate this
response. Infusing stress hormones to normal subjects does not cause increases in procoagulant proteins and platelet
reactivity or decreases in fibrinolytic proteins [14]. Systemic inflammation and the acute phase response that
accompanies major surgery may lead to synthesis of coagulation proteins and inflammation-related changes in
platelet function. Anesthetic choice might not influence hypercoagulability after surgery.
Few studies in vascular surgery patients address the issue of whether there is an outcome advantage to RA
with respect to DVT. Patients undergoing endovascular abdominal aortic aneurysm surgery have a 6% incidence of
DVT without advantage for RA over GA [15]. An older meta-analysis suggested that RA is associated with a 31%
reduction in the incidence of DVT compared to GA in individuals undergoing hip surgery [16]. Although the
incidence of DVT was decreased, overall mortality was unchanged, and prophylaxis for DVT was not given
routinely or described. There was no standardization of perioperative care, anesthetic regimens or ambulation
protocols, which could have influenced the findings. It is probable that such a large difference in DVT incidence, if
there were a difference at all, would not be found in modern studies employing routine DVT prophylaxis. There are
still conflicting results in the literature regarding the effectiveness of RA over GA in terms of reducing DVT in
orthopedic patients [17, 18]. The overall incidence of DVT and pulmonary embolism is low in orthopedic patients
[19]. A recent Cochrane review suggested RA was superior to GA in reducing the incidence of DVT but noted this
conclusion is insecure due to possible selection bias in the subgroups in which this outcome was measured [20].
It has been proposed that a benefit of RA over GA is reduction in the incidence of graft occlusion, perhaps
through its ability to attenuate the hypercoagulable state that accompanies major surgery. Early studies suggested a
decrease in graft occlusion in vascular surgery patients receiving RA [3, 21]. Recent studies have failed to reveal a
benefit to RA with respect to graft occlusion [22, 23]. In one such study, patients (n=315) were randomized to
receive EA, SA, or GA, monitored with a pulmonary artery catheter (PAC), and admitted to an ICU for 48 72
hours after surgery [23]. There were no differences between the groups with respect to graft patency. In the real
world, it is unlikely that many vascular surgery patients receive a PAC and a three-day ICU stay.

Cardiac Outcomes
In 1987 Yeager published the results of a RCT of EA and light GA vs. GA in high risk surgical patients
(n=53) [24]. There was a decreased rate of cardiovascular complications in the EA group. Perioperative care (e.g.
invasive hemodynamic monitoring) and analgesia were not standardized (analgesia levels differed between groups).
In 1991, Baron reported a RCT in patients (n=173) receiving combined EA and GA vs. GA for abdominal aortic
surgery. There was no difference in cardiovascular morbidity between groups [25]. Tuman reported on the results of
a RCT involving major vascular surgery of the abdominal aorta and lower extremities [3]. Patients (n=80) received
either combined EA and GA or GA alone. Cardiovascular complications were reduced in the EA group. The EA
group had excellent pain control while pain scores were not measured in the control group. Christopherson reported
on a RCT in patients (n=100) receiving either EA or GA for lower extremity bypass grafting surgery [21]. Cardiac

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outcomes were similar between the two groups. There was standardization and optimization of patient care and
equal pain control was achieved in both groups. Bode reported a RCT in 423 patients receiving EA, SA, or GA for
peripheral vascular surgery [22]. Cardiovascular morbidity and mortality were not different between groups. The
low mortality rate, 3.1%, means it would have been necessary to study more than 24,000 patients to have sufficient
power to detect a 50% reduction in mortality between groups. Rigg reported the results of a RCT (n=915) in high-
risk patients (DM, renal failure, respiratory insufficiency, CHF, CAD) undergoing high-risk procedures (aortic or
major GI, genitourinary, or gynecologic surgery) and who received combined EA, GA and epidural analgesia or GA
and PCA [26]. There were no differences between groups with respect to cardiovascular events.


Anesthetic Techniques vs. Standardization and Optimization of Perioperative Care
Norris tested the hypothesis that reduction in variation in care and control and optimization of perioperative
pain management and hemodynamics can reduce morbidity and mortality to levels that eliminate the impact of
anesthetic technique. The primary endpoint was hospital LOS. Patients (n = 168) undergoing major aortic surgery
were randomized to one of four groups who received combinations of intraoperative anesthetic type and
postoperative analgesia (thoracic EA/light GA/epidural PCA; thoracic EA/light GA/iv PCA; sham thoracic
EA/GA/epidural PCA; sham thoracic EA/GA/iv PCA)[27]. Protocols standardized perioperative care. There were no
differences with respect to LOS, death, MI, pneumonia, or pain control. LOS is an integrated outcome measure;
an individual that suffered significant morbidity would presumably spend a longer time in the hospital. Perioperative
care rather than a specific anesthetic regimen may be the most important factor in outcome after surgery.

Regional Anesthesia and Analgesia and Postoperative Pulmonary Complications (PPCs)
Because RA does not require the use of neuromuscular blockade, airway instrumentation, or volatile
anesthetics, it might reduce PPCs. It has been difficult to demonstrate the benefits of RA over GA with respect to
reducing PPCs. Use of meta-analysis is problematic as there is no standard definition of a PPC and studies are not
comparable. Meta-analyses suggest that RA, especially epidural local anesthetics, decrease pulmonary infections
(pneumonia) and complications (poorly defined) [28-30]. Older RCTs did not demonstrate a significant
improvement in PPCs as a result of RA although they were not designed with PPCs as a primary outcome [3, 21,
25]. Jayr performed a RCT investigating the impact of analgesia and anesthesia (GA with postoperative parenteral
morphine or GA with postoperative epidural analgesia) on PPCs in patients (n=153) undergoing major surgery [31].
Despite better pain control in the RA group, no benefit could be attributed to RA with respect to LOS or PPCs in
either the group as a whole or in the subgroup of patients with underlying lung disease. In the PIRAT II study
(Norris) there were no differences between anesthetic groups with respect to PPCs [27]. PPCs in a RCT conducted
by Fleron were not reduced by regional analgesia in patients undergoing abdominal aortic surgery [32].
Rigg found that respiratory failure (prolonged ventilation, PaO
2
< 50 mmHg, or PaCO
2
> 50 mmHg) was
more common in the control group [26]. This definition of respiratory failure is problematic as few define a PPC as
a mild increase in PaCO
2
,

especially when associated with narcotic analgesia. Postoperative hypoxemia, common
after major abdominal surgery, has not been linked to more significant morbidity (e.g. increased ICU or hospital
LOS) or increased mortality. A recent re-analysis of Riggs data found there was a small reduction in duration of
postoperative ventilation (0.3 vs. 0.2 hours) but no difference in the number of patients requiring mechanical
ventilation > 24 hours in any subgroup [33]. The authors concluded there was no evidence that perioperative
epidural analgesia influences morbidity or mortality after abdominal surgery. A recent systematic review compared
PCA opioid therapy with epidural analgesia for pain control after intra-abdominal surgery in terms of side effects,
patient satisfaction and surgical outcome and found no differences in hospital length of stay or other adverse effects
[34]. Warner has written although regional techniques may provide excellent analgesia, it is not yet clear that they
consistently improve clinical respiratory outcome [35]. A recent systematic review concluded that the evidence
regarding the efficacy of regional analgesia and anesthesia in reducing PPCs is conflicting or insufficient [36].

Mortality
Yeagers study reported a decrease in mortality in patients receiving RA but the studies of Tuman, Baron,
Christopherson and Norris did not. The meta-analysis of Rogers found mortality at 30 days post-surgery was
reduced in the RA group [29]. However, that analysis included four trials with a much higher mortality rate than all
the others and which may have influenced the results. Park reported the results of a RCT in patients undergoing
aortic or major GI surgery suggesting that EA resulted in a lower mortality rate than patients receiving GA and
parenteral opioid therapy [37]. There were no protocols implemented and there was superior pain control in the RA
group. Hemodynamic monitoring and management was neither specified nor controlled. Urwin reported the results

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of a meta-analysis that demonstrated a difference in 1 month but not 3-, 6-, or 1-year mortality rates and concluded
there were marginal advantages for RA compared to GA in patients with hip fracture [18]. Peytons re-analysis of
Riggs data failed to demonstrate a mortality benefit of anesthetic technique in high risk patients [33]. Wu recently
reported on a nationally random sample of the Medicare database examining the effect of analgesia on outcome in
patients undergoing total hip arthroplasty. Epidural analgesia was not associated with a lower incidence of mortality
[38]. Using similar methodology not confined to patients undergoing hip surgery, Wu found a reduction in death at
seven days after surgery with EA [39]. Liu published a recent meta-analysis that did not demonstrate a reduction in
mortality in patients undergoing CABG as a result of thoracic EA [40].
Wijeysundera used administrative databases to perform a retrospective study of more than 259,000 patients
who underwent elective intermediate or high-risk non-cardiac surgical procedures. EA and epidural analgesia were
associated with a very small decrease in 30-day mortality (0.3% absolute reduction) resulting in a number needed to
treat of 477. They concluded our studydoes not provide compelling evidence that epidural anesthesia improves
postoperative survival [41]. Recently, Svircevic randomized 654 patients to either thoracic EA (TEA) or usual care
in patients undergoing cardiac surgery. The investigators were unable to demonstrate a benefit of TEA on the
frequency of major complications. Monk reported that duration of deep hypnotic time was an independent predictor
of one-year mortality after surgery but others have not confirmed this finding [42, 43]. Recently, Sessler investigated
the association between blood pressure, deep hypnotic time and anesthetic dose in 24,120 patients undergoing
noncardiac surgery. LOS and mortality was increased in patients having a "triple low" of low blood pressure, low
bispectral index, and low minimum alveolar concentration of volatile anesthesia [44]. In conclusion, there is
conflicting evidence regarding anesthetic technique-related differences in mortality.

Central Nervous System Function, Anesthesia And Surgery
GA, by definition, changes cerebral function while a patient is anesthetized. RA avoids that issue. It has
been proposed that GA may produce long-term alterations in brain function (post-operative cognitive dysfunction,
POCD) although some investigators question whether POCD even occurs [45]. No difference in POCD was
observed in a RCT (n=64; mean age 69) involving knee arthroscopy under RA or GA [46]. A report of 53 men
(mean age 71) undergoing prostate resection receiving GA or EA concluded that the type of anesthesia does not
result in POCD [47]. A RCT involving knee replacement (n=262; median age 69) found that the type of anesthesia
did not affect POCD [48]. The results of an investigation involving 1,218 patients undergoing major surgery found
POCD was present in 26% of patients one week after surgery and in 10% three months after surgery, compared with
3% of controls at the same time points [49]. Risk factors for POCD included age and duration of anesthesia but not
the type of anesthesia. An investigation of POCD (n=508; median age 51) found that risk factors for POCD
included: duration of anesthesia, administration of N
2
0, upper abdominal surgery, heart disease, and interestingly,
the use of epidural analgesia [50]. Two recent meta-analyses concluded the use of RA does not reduce the incidence
of POCD [51, 52]. Evered studied 678 patients and concluded that POCD is independent of surgical type and
anesthetic [53]. Heyer found the same rate of POCD in patients undergoing carotid endarterectomy under regional
block as those done under GA [54]. There is no evidence of POCD related to the type of anesthetic. However,
emerging evidence suggests that GA may result in long-term CNS changes or damage to the developing brain or in
older patients at risk for Alzheimers disease. Ikonomidou, Jevtovic-Todorovic, Xie, and Eckenhoff have variously
reported that GA results in apoptotic neurodegeneration and enhancement of amyloid beta oligomerization, a peptide
associated with Alzheimers disease [55-59].

Other Outcomes: GI Function; Cancer Recurrence; Surgical Site infections (SSIs); and Rehabilitation
Patients that receive EA using local anesthetics (LA) experience faster return of bowel function and meet
discharge criteria sooner than patients receiving parenteral opioids [60, 61]. Systemic absorption of LA could be
responsible for the improvement in bowel function observed after epidural administration of LA [62]. Anesthetic-
related differences in improvement in bowel function may also reflect the effect of opioids on gut motility. Selective
inhibition of gastrointestinal opioid receptors can counteract the effects of systemically administered opioids on the
GI tract while not interfering with pain relief. Their administration speeds recovery of bowel function and shortens
the duration of hospitalization [63]. These antagonists may thus minimize a potential advantage of RA over GA.
Patients undergoing colon surgery who receive EA get out of bed faster, have faster return of bowel function, greater
intake of food, and better exercise tolerance and health related-quality of life than a group receiving PCA at both 3
and 6 weeks after surgery whereas hip surgery patients receiving EA may not have enhanced rehabilitation [64, 65].
There are also intriguing reports suggesting regional anesthesia or analgesia may lessen the risk of cancer
recurrence [66, 67]. Other studies have been unable to confirm these findings [68, 69]. Cummings recently reported
that EA may improve survival in patients with nonmetastatic colorectal cancer undergoing resection but was unable

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to find an association between EA and decreased cancer recurrence [70]. Using an administrative database, Chang
investigated whether anesthetic type influences the development of SSIs [71]. In 3,081 patients undergoing total
joint replacement, those receiving GA had a higher risk of SSI compared with RA. A RCT might help further
elucidate the role of anesthetic type on SSIs and also suggests that anesthetic choice may have long-term
consequences deserving of further study.
It is not clear whether or how postoperative analgesia affects outcomes that are important to patients such
as quality of life, quality of recovery, and even patient satisfaction. One study suggested there is no evidence that
postoperative analgesia leads to improvements in patient-centered outcomes such as quality of life and quality of
recovery. The authors concluded modest reductions in pain scores do not necessarily equate to clinically
meaningful improved pain relief for the patient [72].

Vascular Surgery, Neuraxial Block, and Modification of the Coagulation System
Many vascular surgery patients undergo modification of the coagulation system to prevent thrombus
formation in diseased vessels, or to prevent graft occlusion or embolic events. When patients are on anticoagulants
or receiving anti-platelet agents, RA may be inadvisable because of the risk of neuraxial bleeding. Spinal or epidural
hematoma can occur spontaneously in relation to anticoagulation therapy and can also occur when there has been
vascular trauma related to attempts at neuraxial block [73]. The Society of Regional Anesthesia and Pain
Management has developed recommendations regarding the use of neuraxial techniques in patients receiving
anticoagulation [74]. The increasing use of agents that modify the coagulation system may make future comparisons
of RA vs. GA more difficult; it will be more difficult to achieve true randomization and changes in the coagulation
system may further reduce vascular events resulting in myocardial ischemia.

The Future
Perioperative beta-blockade (PBB) is thought to improve cardiac outcomes in patients at risk undergoing
major surgery [75, 76]. Questions remain regarding timing of therapy before surgery, target heart rate, duration of
treatment and optimal beta-blocker. A large retrospective study confirmed the benefit of PBB but the recent POISE
study demonstrated an increased rate of stroke and death in patients receiving PBB [77, 78]. These conflicting
results are likely to continue the controversy about indications for and the optimal dose and timing of PBB and result
in more cautious use of beta-blockade in the perioperative time period. Future studies of the ability of RA to
improve outcomes should be performed in the setting of PBB or pharmacologic interventions designed to prevent
DVT. Other outcomes should be examined to demonstrate value and cost-effectiveness of regional analgesia and
RA. Organizational characteristics of ICUs can improve outcomes, lower costs, and reduce length of stay [79-81]. It
will be important to reconcile conflicting results of meta-analyses regarding the role of epidural anesthesia and
analgesia in improving outcomes [82-85]. Efforts to improve outcomes should focus on global perioperative care
rather than on specific anesthetic techniques. It will be important to define the role of RA in improving outcomes in
real world settings where optimization of all aspects of perioperative care may not have been achieved.

Conclusions
Evidence in the literature suggests that RA and GA produce equivalent outcomes. Methodological flaws
bias older studies in favor of RA. Carefully conducted RCTs have not demonstrated improvements in cardiac
outcomes, mortality, or LOS with RA for vascular surgery. RA has not been demonstrated to result in superior
pulmonary outcomes, or decrease the incidence of POCD, even in high-risk groups, in carefully performed RCTs.
Demonstration of equivalent outcomes between RA and GA have been performed under the conditions of a tightly
controlled RCT, with protocol-driven management. Optimization and standardization of perioperative care may
result in improvements in outcome independent of the type of anesthetic. RA should be employed carefully in the
setting of perioperative modification of the coagulation system. It is possible that RA may offer advantages in
settings where optimization of care has not been achieved. In the real world, the choice of anesthetic may be
crucial. Clinical practice might change, perhaps in favor of RA, if a firm connection is established between GA and
neurotoxicity in humans, if it is conclusively demonstrated that the depth of anesthesia increases mortality after
surgery, or if evidence builds that regional techniques favorably influence cancer treatment. In the meantime, Royse,
in an editorial in Anesthesiology, suggested: Perhaps it is time to move away from trying to prove that anesthetic
interventions will reduce morbidity or mortality and to focus on tangible benefits to patients or their families.
Epidurals are used primarily to provide excellent analgesia, and any other benefits are a bonus [86].



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refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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Anesthesiology, 2004. 101: 703-9.

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Science, 1999. 283: 70-4.
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and shortens hospital stay in patients undergoing radical retropubic prostatectomy. Anesth Analg, 1998. 86: 235-9.
63. Taguchi, A., et al., Selective postoperative inhibition of gastrointestinal opioid receptors. N Engl J Med, 2001.
345: 935-40.
64. Carli, F., et al., Epidural analgesia enhances functional exercise capacity and health-related quality of life after
colonic surgery: results of a randomized trial. Anesthesiology, 2002. 97: 540-9.
65. Foss, N.B., et al., Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery:
a randomized, double-blind, placebo-controlled trial. Anesthesiology, 2005. 102: 1197-204.
66. Biki, B., et al., Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: a retrospective
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67. Exadaktylos, A.K., et al., Can anesthetic technique for primary breast cancer surgery affect recurrence or
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68. Gottschalk, A., et al., Association between epidural analgesia and cancer recurrence after colorectal cancer
surgery. Anesthesiology, 2010. 113: 27-34.
69. Wuethrich, P.Y., et al., Potential influence of the anesthetic technique used during open radical prostatectomy on
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70. Cummings, K.C., et al., A comparison of epidural analgesia and traditional pain management effects on survival
and cancer recurrence after colectomy: a population-based study. Anesthesiology, 2012. 116: 797-806.
71. Chang, C.C., et al., Anesthetic management and surgical site infections in total hip or knee replacement: a
population-based study. Anesthesiology, 2010. 113: 279-84.
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78. Devereaux, P.J., et al., Effects of extended-release metoprolol succinate in patients undergoing non-cardiac
surgery (POISE trial): a randomised controlled trial. Lancet, 2008. 371: 1839-47.
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Anesth, 2005. 17: 382-91.

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83. Liu, S.S. and C.L. Wu, Effect of postoperative analgesia on major postoperative complications: a systematic
update of the evidence. Anesth Analg, 2007. 104: 689-702.
84. Nishimori, M., J.C. Ballantyne, and J.H. Low, Epidural pain relief versus systemic opioid-based pain relief for
abdominal aortic surgery. Cochrane Database Syst Rev, 2006. 3: CD005059.
85. Choi, P.T., et al., Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst
Rev, 2003: CD003071.
86. Royse, C., Epidurals for cardiac surgery: can we substantially reduce surgical morbidity or should we focus on
quality of recovery? Anesthesiology, 2011. 114: 232-3.

Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

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Perioperative Myocardial Ischemia and Infarction in Non-cardiac Surgery
Peter Nagele, M.D., MSc St. Louis, Missouri
Myocardial infarction (MI) is a common and serious complication after non-cardiac surgery. This refresher course
will discuss the epidemiology, pathophysiology, preoperative risk stratification, prevention, management and
outcomes of perioperative myocardial infarction after non-cardiac surgery and highlight the role of cardiac
biomarkers.
Definition
Perioperative myocardial infarction is defined as suffering a new myocardial infarction in the immediate
pre-, intra- and postoperative period. Typically 30 days after non-cardiac surgery are considered the postoperative
period. The diagnosis of myocardial infarction is based on the Universal Definition of Myocardial Infarction which
was recently updated.
1
Accordingly, an MI is diagnosed when there is evidence of myocardial necrosis in a clinical
setting consistent with acute myocardial ischemia. In the perioperative setting, typically two criteria are most
commonly used: the rise (and/or) fall of a cardiac biomarker [preferably cardiac troponin] with at least one value
above the 99
th
percentile of the upper reference limit plus ECG changes consistent with acute myocardial ischemia
such as new ST-segment changes.
Epidemiology
Perioperative MI is often referred to as a hidden epidemic. It is estimated that among the 230 million
surgical procedures worldwide each year, more than 1 million patients suffer from perioperative MI or cardiac
death. A recent study among 85,000 inpatient surgeries showed an overall incidence rate of 0.5% for perioperative
MI, which was associated with a 30-40% mortality rate.
2
The risk for perioperative MI is at least on an order of
magnitude higher among patients with preexisting coronary artery disease undergoing major non-cardiac surgery
(reported risk: 5-6%).
3-5
When using sophisticated continuous monitoring methods such as 12-lead Holter ECG or
high-sensitivity cardiac troponin, it turns out that nearly all patients with pre-existing coronary artery disease
develop periods of myocardial ischemia in the perioperative period.
6,7

Pathophysiology
The majority of perioperative MI events are silent, i.e., not accompanied by specific symptoms such as
chest pain. The main reason for silent MIs is the presence of potent analgesic drugs that most patients receive after
surgery.
8
Two major causes of perioperative MI can be distinguished: (1) supply and demand mismatch resulting in
demand ischemia and (2) coronary thrombosis. More than 95% of all perioperative MIs are caused by demand
ischemia. It is caused by an imbalance between myocardial oxygen demand and supply. In the setting of stable
coronary artery disease with fixed atherosclerotic lesions, higher oxygen demands in the myocardium cannot be met
by the limited blood flow and subsequently lead to myocardial ischemia and infarction. Common reasons for high
myocardial oxygen demand and/or reduced oxygen supply in the perioperative period include tachycardia, acute
hemorrhage, hypotension, hypoxemia, hypertension (increased myocardial wall stress), fever, and sepsis syndrome.
In addition, endothelial dysfunction also plays a crucial role. Clinically, this type of perioperative MI often
resembles a non-ST segment elevation MI (NSTEMI) and is typically associated with a smaller increase in cardiac
biomarkers than an acute coronary occlusion due to a thrombus.
Acute coronary thrombosis is the cause for perioperative MI in approximately 5% of cases, but associated
with a markedly increased risk of cardiac death. Acute thrombosis occurs when an unstable vulnerable
atherosclerotic plaque ruptures followed by instantaneous acute coronary artery thrombosis, and subsequent
myocardial ischemia and infarction. Causes for plaque destabilization in the perioperative period are manifold, but
the most apparent are surgical stress resulting in hypertension, tachycardia and increased catecholamine levels, and

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hypercoagulability caused by surgical trauma. Patients who suffer from acute coronary thrombosis are often
symptomatic, become hemodynamically unstable and not infrequently undergo emergent coronary angiography.

Risk Stratification and Prevention
Several preoperative risk stratification models have been developed. The most commonly known and used
is the Lees Revised Cardiac Risk Index that integrates both pre-existing co-morbidities such as renal disease and the
magnitude of the surgical procedure.
9
Understandably, patients are at highest risk to develop perioperative MI when
they have several pre-existing cardiac risk factors and undergo major non-cardiac surgery. A classic example is a
patient with pre-existing ischemic cardiomyopathy undergoing open AAA repair. In this scenario, the risk may
exceed 25%. In order to improve pre-operative risk stratification, recent research has evaluated several biomarkers
such as brain natriuretic peptide [BNP]/N-terminal fragment of BNP [NT-proBNP], C-reactive protein (CRP), or
high sensitivity cardiac troponin. The relevance of these biomarkers in preoperative cardiac risk stratification is
currently unclear, but appears promising.
Prevention of perioperative MI has historically largely focused on the use of beta-blockers. Until the
publication of the POISE trial, beta blockers were considered the gold standard in the prevention of perioperative MI
and had a class I recommendation from the American Heart Association. Given the prominent influence of
myocardial stress in the pathophysiology of perioperative MI and the similarly prominent potency of beta-
blockers to reduce myocardial stress, it was only logical that perioperative beta-blockade became such a
cornerstone of perioperative MI prevention. The POISE trial, where more than 8,000 beta-blocker nave patients
were randomized to either extended-release metoprolol or placebo, showed that metoprolol was highly efficacious in
reducing the rate of perioperative MI but also significantly increased the risk of stroke and death.
10
Combined with
recent evidence, it appears that perioperative beta-blockade is a double-edged sword.
11
As long as the patient does
not experience hypotension and even more importantly significant hemorrhage, beta-blockade is predominantly
beneficial and leads to a marked reduction in perioperative cardiac risk. However, in the presence of hypotension
and hemorrhage, the tables are turned and now patients are at substantially increased risk of stroke and death,
probably because the presence of beta-blockers prevents the necessary increase in heart rate to maintain adequate
cardiac output.
12
At present, the role of perioperative beta-blockade is therefore unclear. Other drugs have been
sparsely investigated in the prevention of perioperative MI and no strong recommendations exist.

Management
During the last decades, the majority of research was focused on the prevention of perioperative MI and not
the treatment. It was assumed that postoperative patients who suffered from an acute MI should be managed in an
identical fashion to patients with an acute coronary syndrome in the emergency department or CCU. Thus, no
specific guidelines for the management of perioperative MI exist and until recently very limited research was
conducted to answer even the most basic questions. Two recent studies showed that even minor postoperative
cardiac troponin elevations, often referred to as troponin leaks, have significant prognostic importance and
identify patients at risk for long-term cardiac morbidity and mortality.
13,14
These troponin elevations that are much
more common when measured with a high-sensitivity assay are clearly not a major cardiac event in itself but
rather represent a red flag indicating a significantly elevated cardiac risk. At present, patients who develop
perioperative troponin elevation or MI are treated according to the most recent but generic AHA guidelines for the
treatment of acute coronary syndromes that include MONA (morphine, oxygen, nitrates, aspirin), possibly beta-
blockers, and in the case of a massive MI often emergent coronary catheterization.
15,16


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References:
1. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, The Writing Group on behalf of
the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction: Third
universal definition of myocardial infarction. Circulation 2012; 126: 2020-35
2. Ghaferi AA, Birkmeyer JD, Dimick JB: Variation in hospital mortality associated with inpatient surgery. N
Engl J Med 2009; 361: 1368-75
3. Badner NH, Knill RL, Brown JE, Novick TV, Gelb AW: Myocardial infarction after noncardiac surgery.
Anesthesiology 1998; 88: 572-8
4. Landesberg G, Mosseri M, Zahger D, Wolf Y, Perouansky M, Anner H, Drenger B, Hasin Y, Berlatzky Y,
Weissman C: Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST
depression-type ischemia. J Am Coll Cardiol 2001; 37: 1839-45
5. Le Manach Y, Perel A, Coriat P, Godet G, Bertrand M, Riou B: Early and delayed myocardial infarction
after abdominal aortic surgery. Anesthesiology 2005; 102: 885-91
6. Landesberg G, Luria MH, Cotev S, Eidelman LA, Anner H, Mosseri M, Schechter D, Assaf J, Erel J,
Berlatzky Y: Importance of long-duration postoperative ST-segment depression in cardiac morbidity after
vascular surgery. Lancet 1993; 341: 715-9
7. Nagele P, Brown F, Gage BF, Gibson DW, Miller PJ, Jaffe AS, Apple FS, Scott MG: High-Sensitivity
Cardiac Troponin T in Prediction and Diagnosis of Myocardial Infarction and Long-Term Mortality after
Non-Cardiac Surgery. American Heart Journal 2013; in press
8. Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS: Perioperative myocardial infarction.
Circulation 2009; 119: 2936-44
9. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson
MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L: Derivation and prospective validation of a simple
index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100: 1043-9
10. POISE Study Group, Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D,
Chrolavicius S, Greenspan L, Pogue J, Pais P, Liu L, Xu S, Mlaga G, Avezum A, Chan M, Montori VM,
Jacka M, P. C: Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery
(POISE trial): a randomised controlled trial. The Lancet 2008; 371: 1839-1847
11. London Mj HKSGGHWG: ASsociation of perioperative !-blockade with mortality and cardiovascular
morbidity following major noncardiac surgery. JAMA 2013; 309: 1704-1713
12. Le Manach Y, Collins GS, Ibanez C, Goarin JP, Coriat P, Gaudric J, Riou B, Landais P: Impact of
perioperative bleeding on the protective effect of beta-blockers during infrarenal aortic reconstruction.
Anesthesiology 2012; 117: 1203-11
13. Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study I, Devereaux PJ, Chan MT,
Alonso-Coello P, Walsh M, Berwanger O, Villar JC, Wang CY, Garutti RI, Jacka MJ, Sigamani A,
Srinathan S, Biccard BM, Chow CK, Abraham V, Tiboni M, Pettit S, Szczeklik W, Lurati Buse G, Botto F,
Guyatt G, Heels-Ansdell D, Sessler DI, Thorlund K, Garg AX, Mrkobrada M, Thomas S, Rodseth RN,
Pearse RM, Thabane L, McQueen MJ, VanHelder T, Bhandari M, Bosch J, Kurz A, Polanczyk C, Malaga
G, Nagele P, Le Manach Y, Leuwer M, Yusuf S: Association between postoperative troponin levels and
30-day mortality among patients undergoing noncardiac surgery. JAMA 2012; 307: 2295-304
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Myocardial Injury after Noncardiac Surgery and its Association with Short-Term Mortality. Circulation
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2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable
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AH, Yannopoulos D: Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for
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Disclosure
Roche Diagnostics, Self, Funded Research
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Page 1
Utility of Perioperative Transesophageal Echocardiography in Non-Cardiac Surgery
Stanton Shernan, M.D. Boston, Massachusetts
Since the introduction of intraoperative echocardiography into clinical practice in the 1980s, its popularity
has steadily increased. Although not as well established as for cardiac surgery, the benefit of perioperative
echocardiography for non-cardiac surgery is becoming increasingly more appreciated
1-3
. Selective or emergent
intraoperative transesophageal echocardiography (TEE) has been reported as beneficial in 40% to 80% of patients
respectively
4,5
. In over one-third of patients, intraoperative TEE may be associated with a change in medical
therapy, including treatment of myocardial ischemia, valvular pathology, and/or right ventricular (RV) and left
ventricular (LV) failure
4,5
. Furthermore, in approximately 25% of patients, intraoperative TEE has been associated
with a change in surgical procedure
4
. Based upon these findings, intraoperative echocardiography is rapidly
becoming recognized for its impact on perioperative decision-making during non-cardiac surgery.
Indications for Intraoperative Echocardiography
Indications for emergent TEE during non-cardiac surgery have included hemodynamic instability,
evaluation for chest trauma, hypoxemia, and pre-incision cardiac evaluation prior to emergent surgery
6
. In 1996
practice guidelines were published from the American Society of Anesthesiologists (ASA) and the Society of
Cardiovascular Anesthesiologists (SCA) Task Force on TEE
7
. Recommendations are divided into three categories
based on the strength of supporting evidence and/or expert opinion that TEE improves clinical outcomes. Category I
indications are supported by the strongest evidence or expert opinion that TEE is frequently useful in improving
clinical outcomes in these settings, and is often indicated. Category II indications are supported by weaker evidence
and expert consensus that TEE may be useful in improving clinical outcomes in these settings but absolute
indications are less certain. Category III indications have little scientific or expert support, and appropriate
indications are uncertain. An updated revision of this document authored by members of the ASA and SCA is
currently underway.
Although the ASA/SCA practice guidelines are perhaps most applicable for cardiac surgery, they also have
relevance for non-cardiac surgery. One of the most common Category I indications for the use of intraoperative TEE
during non-cardiac surgery, is the role of rescue TEE for the evaluation of acute persistent and life-threatening
hemodynamic disturbances in which ventricular function and its determinants are uncertain or have not responded to
treatment.
8
In a study investigating the usefulness of TEE during intraoperative cardiac arrest in non-cardiac surgery,
a primary suspected diagnosis of the underlying pathological process was established in 19 of 22 patients with TEE,
including 9 with thromboembolic events, 6 with acute myocardial ischemia, 2 with hypovolemia, and 2 patients with
pericardial tamponade
9
. A definitive diagnosis could not be made in 3 patients with TEE. In 18 patients, TEE
guided specific management beyond implementation of Advanced Cardiac Life Support protocols, including the
addition of surgical procedures in 12 patients. A related Category II indication includes the perioperative use of
TEE in patients with increased risk of hemodynamic disturbances. In several single center and multicenter studies,
intraoperative TEE for non-cardiac surgery has been to shown to influence surgical and anesthetic management in
30-40% of patients, including those who already had invasive hemodynamic monitors (i.e., radial arterial lines and
pulmonary artery catheters)
4,5,10,11
. Changes in management have been based upon confirming or invalidating a
prior diagnosis, detection of new diagnoses, and acquisition of pertinent information acquired during periods of
hemodynamic instability leading to changes in drug or goal-directed fluid therapy, unplanned surgical re-
interventions and further evaluation in the postoperative period. While many of the cases in the literature would be
considered Category I indications for the utility of intraoperative TEE, others have reported a consistent impact of
intraoperative TEE on perioperative clinical decision-making even for Category II indications among non-cardiac
surgical patients. Thus, in addition to earlier reports suggesting a primary benefit for intraoperative TEE as a

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diagnostic tool for evaluating myocardial ischemia during non-cardiac surgery
12
, more recent reports also confirm
its utility as a monitor of hemodynamic status and overall cardiovascular performance.

Perioperative Ischemia Monitoring

Ischemic changes detected by two-dimensional echocardiography include new systolic wall motion
abnormalities (SWMA) and decreased systolic wall thickening. Echocardiography is also useful for evaluating
complications of myocardial ischemia including myocardial infarction (MI), congestive heart failure (CHF),
valvular regurgitation, septal defects, thrombi, pericardial effusions, and ventricular free wall rupture. Controlled
studies have demonstrated a clear association between SWMA, coronary ischemia and cardiac events
13
. Data from
perioperative TEE studies have reported specificities and negative predictive values >90%. However, sensitivity
and positive predictive values for MI are less than 40%, possibly because not all ischemia results in MI
12
. In
addition, SWMA often overestimate the area of injury, and may result from etiologies other than ischemia including
myocardial stunning, hibernation and tethering as well as changes in loading conditions. While monitoring,
diagnosing and treating myocardial ischemia is important, it is not clear that routine TEE is either cost-effective or
more beneficial than ECG monitoring with ST segment analysis
14
. However, TEE may be a worthwhile monitor
and a diagnostic tool of choice for the initial assessment of myocardial ischemia or MI-related complications for
high-risk patients undergoing non-cardiac surgery.

Vascular Surgery

SWMA occur frequently during vascular surgery, but are less frequently associated with perioperative MI,
CHF, and cardiac death. In one study, 55% of patients undergoing aortic reconstruction experienced new SWMA at
the time of aortic clamping, with a greater incidence seen following supra-celiac clamping (92%) compared to
suprarenal (33%), and infra-renal (0%)
15
. In this particular series, only 1 patient (in the supra-celiac group) suffered
a perioperative MI.
As previously stated, SWMA may result from a variety of etiologies other than ischemia. Furthermore,
even if all SWMA were indicative of ischemia or ventricular dysfunction, ischemia does not always result in a
significant cardiac event. Anesthetic agents, metabolic changes, blood loss, and placement of the aortic cross clamp
are known causes of SWMA. Since these are transient processes, the occurrence of an adverse cardiac event is
reduced. The low positive predictive value of SWMA may also be associated with rapid detection and subsequent
prompt treatment. Nonetheless, the utilization of TEE during major vascular procedures may influence
perioperative management and outcome.
Liver and Lung Transplantation

Despite the presence of a coagulopathy and gastroesophageal varices, TEE has been used safely in patients
undergoing liver transplantation, with a reported bleeding complication rate of 1-2%
16
. During liver
transplantation, TEE monitoring has demonstrated new findings in > 50% of patients, improved hemodynamic
management, and has been shown to impact overall perioperative care in 11% of patients
16
. During lung
transplantation, TEE has been used to assess severity and etiology of pulmonary hypertension, intraoperative
ventricular function, and surgical anastomotic integrity. Diagnoses such as pulmonary artery (PA) thrombi, patent
foramen ovale, atrial septal and ventricular septal defects in 25% of patients, resulted in the requirement for
additional surgery in one study
17
. Furthermore, echocardiographic visualization of pulmonary vascular anastomoses
suggests that up to 30% may be abnormal, thus prompting additional surgical procedures
17
.

Orthopedics

Patients undergoing total hip replacement (THR) are vulnerable to perioperative cardiac complications due
to comorbidity and hemodynamic instability occurring during certain aspects of the surgical procedure. Emboli
released during preparation of the femur are readily diagnosed with TEE and have been associated with decreases in
blood pressure, increases in PA pressure, RV and LV SWMA, and occasionally cardiovascular collapse
18
. Emboli
have also been diagnosed in patients undergoing total knee replacement following thigh tourniquet release
19
.
However, in comparison to THR, the hemodynamic consequences of these embolic events may not be as severe
19
.
Although TEE may not be indicated for all patients undergoing orthopedic procedures, elderly patients and those

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with significant cardiovascular and pulmonary comorbidity may benefit from its utility as a monitor and diagnostic
tool for evaluating perioperative hemodynamics.
Neurosurgery

Hemodynamic instability during major neurological surgery is affected by a number of variables including
patient demographics, anesthetic agents and surgical techniques. Venous air embolism (VAE), which may cause
hemodynamic and pulmonary instability, occurs in 25-50% of neurosurgical procedures, and has been reported in as
many as 76% of craniotomies performed in the sitting position
20
. Although precordial Doppler echocardiography or
TEE is believed to be the most sensitive monitor for VAE, actual utilization varies from 25-87%
20
. Patients
scheduled to undergo craniotomy in the sitting position should have a pre-surgical echocardiographic evaluation
either preoperatively or immediately after induction of anesthesia to determine the presence of any intracardiac
shunts.
Obstetrics

It is becoming increasingly more common for high-risk obstetrical patients with cardiac disease including
congenital heart diseases, CAD, cardiomyopathies, and heart transplantation to present for peripartum care. In
addition, a number of pregnancy-related conditions, including pregnancy-induced-hypertension, pulmonary emboli,
hemorrhage, and peripartum cardiomyopathy have a significant influence on tolerance for the normal hemodynamic
changes associated with pregnancy. Although echocardiographic analysis during normal deliveries is not cost-
effective, use in assessing high-risk obstetric patients may be warranted
21
.

Trauma and Critical Care

Prompt and accurate diagnoses of traumatic cardiac injuries are crucial to improving survival. In one study
of penetrating chest injury, echocardiographic evaluation and diagnosis was achieved within 15 minutes, compared
to 42 minutes in the non-echo group. The survival was 100% in the former and 57% in the latter. Compared to
transthoracic echocardiography (TTE), TEE also significantly contributes to the diagnostic and hemodynamic
evaluation of cardiac and vascular injury, and can be performed in as quickly as 9-15 minutes
22,23
.
There is strong support for the use of echocardiography in critically ill patients
2,3
. Common indications for
postoperative echocardiography include evaluation of hypotension, LV and RV function, MR, prosthetic valves,
aortic injury, pericardial pathology, myocardial ischemia, complications following MI, cardiac masses and sources
of emboli or infection
24-28
. Echocardiographic evaluation of hemodynamic instability, trauma, and hypoxemia are
particularly common
23/24-27/28
.
When compared to clinical impression, echocardiography has been shown to provide new information in
80% of critically ill patients, changed medical management in 60%, and led to a surgical procedure in as many as
30% of patients
6,24
. Comparative analyses have shown that TEE improved cardiac evaluation compared to TTE in
as many as 50-70% of patients
20-28
.

National Board of Echocardiography Certification in Basic Perioperative TEE

In October of 2006, the ASA House of Delegates approved the development of a basic echocardiography
education training program, and resolved that ASA uniquely or collaboratively explore a pathway for
anesthesiologists to obtain experience and privileges in echocardiography as a basic perioperative monitor. Through
a collaborative effort between the ASA and the SCA, a strategic plan was developed to make available to ASA
members, a CME course on basic perioperative echocardiography. These courses are designed to introduce

practitioners to the fundamental principles and applications of a focused perioperative echocardiographic
examination, and are geared to those who are intent upon gaining sufficient knowledge and experience to integrate
this modality into their clinical practice outside of the cardiac surgical environment. The ASA finalized an
agreement with the National Board of Echocardiography (NBE) in 2010 to (1) develop a Basic Perioperative TEE
examination and (2) to develop criteria for a certification pathway to achieve diplomate status in Basic Perioperative
Echocardiography under the scope of practice which includes non-diagnostic monitoring within the customary
practice of anesthesiology; a focus on intraoperative monitoring rather than specific diagnosis; and with the
understanding that except in emergent situations, diagnoses requiring intraoperative cardiac surgical intervention
or post-operative medical/surgical management must be confirmed by an individual with advanced skills in TEE or
by an independent diagnostic technique. A Basic PTEE Exam and Certification process has been available from the

Refresher Course Lectures Anesthesiology 2013 American Society of Anesthesiologists. All rights reserved. Note: This publication contains
material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
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NBE since 2010. The next Basic PTEE Examination will also be given in July 2014. Current criteria for Basic
Perioperative TEE Certification proposed by the NBE include:

Requirement 1. Applicants must have passed the Basic PTE Exam or the PTEeXAM
Requirement 2. Applicants must hold a current and unrestricted license to practice medicine at the time of
application
Requirement 3. Applicants must be board certified in anesthesiology
Requirement 4. Specific Training in PTEE: performance/review of 150 basic PTEE examinations with
variations in +/- supervision, +/- CME, time frame for completion (2 - 4 yrs), depending upon the pathway:

1) Supervised Training Pathway
2) Practice Experience Pathway (availability through 6/2016)
3) Extended CME Pathway

Conclusions

Perioperative echocardiography for non-cardiac surgical patients is useful for diagnosing cardiovascular
pathology and assessing hemodynamics. A recent consensus statement of the ASE and SCA entitled Basic
Perioperative Transesophageal Echocardiography Examination highlights the multidisciplinary recognition of this
important utility of perioperative TEE.
29
Echocardiographic evaluation of cardiac performance compares favorably
to other gold standards, and expands on the ability to obtain a comprehensive cardiovascular exam. In recognition
of the utility of intraoperative TEE for non-cardiac surgery, the ASA, SCA and National Board of Echocardiography
have collaborated to develop a pathway for certification in basic perioperative TEE (www.echoboards.org). In
addition, the ECHO-in-ICU group and the American College of Emergency Physicians (ACEP) and a joint effort
by boith the ASE and ACEP have all proposed limited scope training guidelines for the focused use of
echocardiography in the initial management of critically ill patients
30
in the ICU and emergency room respectively
31-34
. As the popularity of echocardiography increases and the indications for its perioperative utility evolves,
appreciation for its value in the non-cardiac surgical population will continue to develop.


References

1. Eagle KA, Brundage BH, Chaitman BR, et al for the committee on perioperative cardiovascular evaluation for
non-cardiac surgery. Guidelines for perioperative cardiovascular evaluation for non-cardiac surgery: Report of the
American College of Cardiology/American Heart Association task force on practice guidelines.
Circulation 1996;93:1278-1317.
2. Cheitlin MD, Alpert JS, Armstrong WF, et al for American College of Cardiology and the American Heart
Association Task Force on Practice Guidelines. ACC/AHA guidelines for the clinical application of
echocardiography. Circulation 1997;95:1686-1744.
3. Thys DM, Abel M, Bollen BA, et al. Practice guidelines for perioperative transesophageal echocardiography: A
report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task
Force on Transesophageal Echocardiography. Anesthesiology 1996;84:986-1006.
4. Suriani RJ, Neustein S, Shore-Lesserson L, Konstadt S. Intraoperative transesophageal echocardiography during
non-cardiac surgery. J CardioThorac Vasc Anesth 1998;12:274-280.

5. Denault AY, Couture P, McKenty S, et al. Perioperative use of transesophageal echocardiography by
anesthesiologists: impact in non-cardiac surgery and in the intensive care unit. Can J Anesth 2002;40:287-293.

6. Brandt RR, Oh JK, Abel MD, et al. Role of emergency intraoperative transesophageal echocardiography.
J Am Soc Echocardiogr 1998;11:972-977.
7. American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on
Transesophageal echocardiography. Practice guidelines of perioperative transesophageal echocardiography.
Anesthesiology 1996;84:9861006.


Refresher Course Lectures Anesthesiology 2013 American Society of Anesthesiologists. All rights reserved. Note: This publication contains
material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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Page 5
8. Shillcutt S, Markin N, Montzingo C, Brakke T. Use of rapid rescue perioperative echocardiography to improve
outcomes after hemodynamic instability in noncardiac surgical patients. JCTVA 2012; 26: 362-370

9. Memtsoudis S, Rosenberger P, Noveva M, et al. Usefulness of transesophageal echocardiography during
intraoperative cardiac arrest Anesth Analg 2006;102:1653-1657.

10. Schmidlin D, Bettex D, Bernard E, et al. Transesophageal echocardiography in cardiac and vascular surgery:
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11. Lambert AS, Mazer CD, Duke PC. Survey of the members of the cardiovascular section of the Canadian
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12. Eisenberg MJ, London MJ, Leung JM, et al. for the study of Perioperative Ischemia Research Group. Monitoring
of myocardial ischemia during non-cardiac surgery: a technology assessment of transesophageal echocardiography
and 12-lead electrocardiography. JAMA 1992;268:21016.

13. Comunale ME, Body SC, Ley C, et al. for the Multicenter Study of Perioperative Ischemia (McSPI) Research
Group. The concordance of intraoperative left ventricular wall-motion abnormalities and electrocardiographic S-T
segment changes. Association with outcome after coronary revascularization. Anesthesiology 1998;88:945-54.

14. Benson MJ, Cahalan MK. Cost-benefit analysis of transesophageal echocardiography in cardiac surgery.
Echocardiography 1995;12:171-183.

15. Roizen MF, Beaupre PN, Alpert RA, et al. Monitoring with two-dimensional transesophageal echocardiography:
Comparison of myocardial function in patients undergoing supraceliac, suprarenal-infraceliac, or infrarenal aortic
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16. Prah GN, Lisman SR, Maslow AD, et al. Transesophageal echocardiography reveals an unusual cause of
hemodynamic collapse during orthotopic liver transplantation: Two case reports. Transplantation 1995;59:921-925.
17. Michel-Cherqui M, Brusset A, Liu N, et al. Intraoperative transesophageal echocardiographic assessment of
vascular anastamoses in lung transplantation: A report on 11 cases. Chest 1997;111:1229-1235.
18. Koessler MJ, Fabiani R, Hamer H, Pitto RP. The clinical relevance of embolic events detected by
transesophageal echocardiography during cemented total hip arthroplasty: A randomized clinical trial. Anesth Analg
2001;92:49-55.

19. Permet JL, Horrow JC, Singer R, et al. Echogenic emboli upon tourniquet release during total knee arthroplasty:
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20. Porter JM, Pidgeon C, Cunningham AJ. The sitting position in neurosurgery: a critical appraisal.
Br J Anaesth 1999;82:117-128.

21. Belfort MA, Rokey R, Saade GR, Moise KJ Jr. Rapid echocardiographic assessment of left and right heart
hemodynamics in critically ill obstetric patients. Am J Obstet Gynecol 1994;171:884-892.
22. Brooks SW, Young JC, Cmolik B, et al. The use of transesophageal echocardiography in the evaluation of chest
trauma. J Trauma-Injury Infect & Crit Care 1992;32:761-768.

23. Karalis DG, Victor MF, Davis GA, et al. The role of echocardiography in blunt chest trauma: a transthoracic and
transesophageal echocardiographic study. J Trauma-Injury Infect & Crit Care 1994;36:53-58.

24. Khoury AF, Afridi I, Quinones MA, Zoghbi WA. Transesophageal echocardiography in critically ill patients:
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material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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25. Heidenreich PA, Stainback RF, Redberg RF, et al. Transesophageal echocardiography predicts mortality in
critically ill patients with unexplained hypotension. J Am Coll Cardiol 1995;26:152-158.
26. Kaul S, Stratiendko AA, Pollock SG,et al. Value of two-dimensional echocardiography for determining the basis
of hemodynamic compromise in critically ill patients: A prospective study.J Am Soc Echocardiogr 1994;7:598-606.
27. Fontes ML, Bellow W, Ngo L, Mangano DT. Assessment of ventricular function in critically ill patients:
limitations of pulmonary artery catheterization. Institution of the McSPI research group.
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28. Tousignant CP, Walsh F, Mazer CD. The use of transesophageal echocardiography for preload assessment in
critically ill patients. Anesth Analg 2000;90:351-355.
29. !""#"$ &' ()*+", -' &./01$ 2' "3 1+4 Basic Perioperative transesophageal echocardiography examination: A
consensus statement of the American Society of Echocardiography and the Society of Cardiovascular
Anesthesiologists. .J Am Soc Echocardiogr 2013;26:443-56

30.Vieillard-Baron A, Slama M, Cholley B, et al.. Echocardiography in the intensive care unit: from evolution to
revolution? Intensive Care Med 2008; 34:243-9.
31. American College of Emergency Physicians. ACEP emergency ultrasound guidelines-2001.
Ann Emerg Med 2001;38:470-81.
32. Beaulieu Y. Bedside echocardiography in the assessment of the critically ill.Crit Care Med. 2007;35:S235-S249.
33. Beaulieu Y, Marik PE. Bedside ultrasonography in the ICU: part 1. Chest. 2005;128:881-895.
34. Labovitz A, Noble V, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: A consensus statement
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Echocardiogr 2010;23:1225-30.

Disclosure
Philips Healthcare, Inc, Self, Other Material Support

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214
Page 1
Anesthesia for Cardiac Patients Outside of the Operating Room
Douglas C. Shook, M.D. Boston, Massachusetts
Over the past ten years the scope and complexity of procedures performed in the cardiac catheterization lab (CCL)
and electrophysiology lab (EPL) has changed dramatically. Interventional procedures have moved from diagnostic
to therapeutic treatment of patients with a wider range of pathology and acuity of disease. Simple sedation for this
new and changing patient population needs to be re-evaluated with greater involvement of the anesthesiologist as a
periprocedural physician to guide safe and optimal outcomes. This requires collaboration with the cardiologist,
interventionalist, and cardiac surgeon to develop safe and effective patient management strategies for existing
procedures and new ones being developed in the future. As in the operating room, the anesthesiologist is best suited
to help guide the development of these strategies across multiple specialties.
A thorough understanding of the procedure to be performed is required in order for anesthesiologists to define and
delineate the extent of their involvement and is a clear prerequisite for the formulation of a safe and effective
anesthetic plan. Common CCL and EPL procedures are listed below.
Patient care in these off-site locations requires an understanding of the types of patients that will undergo the
procedure and their need for anesthesia consultation, knowledge about the lab environment to deliver a safe
anesthetic, and details of the procedure including potential complications.
Consultation
Many emergencies can be avoided with appropriate pre-procedure planning. The trigger for anesthesia consultation
usually revolves around presenting patient factors and/or the complexity of the procedure.
Non-anesthesia personnel in the CCL and EPL should be taught how to perform basic airway histories and exams in
order to establish the need for consultation. Patient airway characteristics that should trigger an anesthesia
consultation include:
Morbid obesity
Obstructive sleep apnea
Inability to lie flat
Known or suspected difficult airways (Mallampati Class III or IV)
It can be very challenging to manage an airway in an oversedated or unstable patient in the CCL/EPL. The head of
the patient is often surrounded by fluoroscopy equipment. The fluoroscopy table doesnt have the same
functionality as an operating room table. In addition, control of the table is at the foot of the bed away from the
anesthesiologist. Personnel in the CCL and EPL typically do not have training in advanced airway management and
Cath Lab:
Diagnostic cardiac catheterizations
Percutaneous coronary interventions
Peripheral vascular procedures
Percutaneous ventricular assist devices
Placement of septal occlusion devices
Percutaneous valve repair and replacement
EP Lab:
Diagnostic EP studies
Atrial and ventricular ablation procedures
Electrical cardioversion
Implantation and removal of rhythm
management devices

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are often not helpful or even unintentionally obstructive in an emergency. Therefore, airway assessment is critical in
this environment.

Other patient factors that may trigger an anesthesia consultation include:
Chronic obstructive pulmonary disease
Low oxygen saturation
Current congestive heart failure
Hemodynamic instability
Psychiatric disorders
Medications that could complicate the administration of sedative agents

Procedure factors that may prompt a provider to seek an anesthesia consultation include the potential for an outcome
that requires immediate surgical back up such as unprotected left-main coronary artery stenting or investigational
percutaneous valve procedures. If the case is likely to precipitate instability i.e., valvuloplasties in very elderly and
frail patients or implantation of ventricular assist devices, a consultation is also warranted. These types of
procedures can be long and complicated requiring the full attention of the interventionalist. There is benefit in
having an anesthesiologist in the room whose attention is focused solely on airway and hemodynamic control. In the
EPL, complex arrhythmia ablation procedures (atrial fibrillation and ventricular tachycardia or fibrillation) and
complicated lead extractions (laser lead extraction) should also have anesthesia consults. Obviously, any procedure
that requires general anesthesia needs pre-procedure anesthesia evaluation and planning.

Establishing criteria for anesthesia consultation will eventually lead to more efficient and safe patient care. An
interdisciplinary approach to determine the best route for catheterization (radial versus femoral), optimal patient
positioning to reduce sedation induced airway obstruction, and type and amount of sedative medications can reduce
intra-procedural complications. Non-anesthesia personnel delivering sedation will be more comfortable caring for
the patient, cardiologists can focus on the task at hand, and anesthesiologists are alerted to the possible
complications they maybe called to manage.

The Patient
Many patients arrive in the pre-procedure area after failed interventions, recent myocardial infarctions, acute
exacerbations of heart failure, or with uncontrolled arrhythmias. This is not the typical patient population seen in
the operating room. In addition to the typical pre-anesthetic work-up a comprehensive review of all previous cardiac
interventions must be obtained:
Diagnostic catheterizations
Coronary stent placement (type, location and age)
Known left and right sided cardiac pressures
Previous surgical interventions
Arrhythmia interventions and ablations
Echocardiograms (ventricular function and dimensions, valve disease)
Chest x-rays
A comprehensive medication list along with any recent changes to the medication regimen

Frequently the patient has just arrived from an outside hospital. The interventionalist may be focused on the
technical aspects of the procedure at hand. Therefore the anesthesiologist may be the only provider aware of recent
changes to the health status of the patient due to the urgency of the procedure. What may seem essential to an
anesthesiologist may seem of secondary importance to a cardiologist, and vice versa. Patient optimization prior to
the procedure is essential to a successful outcome. Collaboration and communication with the patient care team is
necessary to determine a sedation plan or need for general anesthesia. Radial artery catheterization instead of a
femoral approach may be a better option in some patients, since this allows the patient to sit up more during the
procedure. Some patients need the procedure emergently which limits options and necessitates direct involvement
of an anesthesiologist for sedation or general anesthesia.

As stated previously, airway assessment is critical in this patient population. Not only should ease of endotracheal
intubation be assessed, but also the ability to mask ventilate should be evaluated as this can bridge a moment of
oversedation during a procedure. A history of difficult intubation or possible difficult intubation does not preclude

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sedation, but should be a warning that oversedation can be dangerous. Early communication of and prompt response
to sedation problems during the procedure is imperative.

The Lab
All labs include a separate control station and procedure room. The control station is shielded from radiation and
usually has a technician recording the progress of the procedure. The technician communicates with the cardiologist
frequently and controls many aspects of the case including patient monitoring, video recording and editing, and
digital record keeping.

The procedure room is where the cardiologist, anesthesiologist, nurses, and other technicians care for the patient
during the procedure. The anesthesiologist should become familiar with the contents of each procedure room, which
vary from institution to institution. Gas outlets and suction, monitors for vital signs, cardioverter/defibrillator,
emergency medications and airway equipment are critical and may not be optimally or even obviously placed.
Locations for a ventilator, anesthesia cart, and possible difficult airway cart should also be planned if needed. Other
equipment regularly used during cases includes ventricular assist devices, intra-aortic balloon pumps, and
echocardiography.

CCLs and EPLs are designed for the cardiologist and not for the needs of the anesthesiologist. Space is always an
issue in complex cases. The fluoroscopy table and fluoroscopy equipment are controlled by the cardiologist and can
move unexpectedly during the procedure. Long intravenous lines, extra oxygen tubing, and long breathing circuits
must be utilized to allow for both movement of the table and fluoroscopy equipment.

Basic anesthesia monitoring equipment may not be present in the CCL and EPL. It is essential that all sedation in
the CCL and EPL be performed with capnography. It is much harder to assist when called to the cath lab if
capnography isnt being utilized. Since an anesthesia workroom is not typically located near the CCL or EPL,
stocking labs with airway equipment and an emergency airway cart is essential. Having an anesthesia cart stocked
with extra IVs, medications, and other items located in the CCL and EPL helps during emergent consultations. All
personnel in the lab should know the location and names of emergency equipment since the anesthesiologist will be
occupied with the patient if called emergently to a procedure area.

Sedation
Non-anesthesia personnel administering mild to moderate sedation should be trained in the pharmacology of
commonly used agents and in the use of monitoring equipment. Early recognition and management of abnormal
respiratory patterns and hemodynamic problems, which evolve during mild, moderate, and deep sedation, is also
important. Caregivers must understand the potentially synergistic drug interactions of benzodiazepines, opioids, and
other commonly administered sedatives such as diphenhydramine (given to patients who have IV contrast reactions),
especially in patients with complicated airways or diminished respiratory capacity. Anesthesiologists should take an
active role in developing and maintaining sedation standards for non-anesthesia personnel throughout the hospital.

Management of sedation needs must be based on a firm understanding of the procedure and a thorough grasp of the
patients co-morbidities. It is critical to know when the patient is likely to be stimulated so that deeper sedation can
be administered. Tachypnea and tachycardia resulting from inadequate sedation can be just as dangerous as airway
obstruction and/or snoring from over sedation. Both situations can make interventions more difficult for the
cardiologist and less safe for patients. In circumstances where brief unconsciousness is necessary during a
procedure, the assistance of an anesthesiologist should be sought (i.e., ICD testing after implantation or
cardioversion during ablation). In some patients given the complexity of the procedure and/or respiratory and airway
compromise of the patient, sedation isnt appropriate and general anesthesia is administered. In most instances, it is
safer to start a procedure with general anesthesia then convert during the procedure.

Monitoring the Patient
Patient Monitoring in the CCL and EPL is often designed with the cardiologist in mind. The fluoroscopy screen and
patient vital signs are easy for the cardiologist to see, but maybe difficult to see if the anesthesiologist is at the head
of the bed. Monitoring the fluoroscopy screen helps determine the flow of the procedure and anticipate changes in
patient comfort and hemodynamics.


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Certain simple functions such as blood pressure cuff cycling and pulse oximetry volume are typically controlled
outside of the actual procedure room so the anesthesiologist may want to add their own equipment in this case.
During prolonged cases or with compromised patients (or both), invasive arterial monitoring with a display visible
to the anesthesiologist may be preferable. It is worth remembering that blood pressure cuffs may not function during
fast or erratic heart rhythms.

Many cases employ transesophageal echocardiography (TEE) to guide and monitor the patient during the procedure.
Familiarity with standard views and assessment of cardiac function assists the anesthesiologist in determining the
progress of the case including success and complications of the procedure. If hemodynamic instability occurs, TEE
provides instant assessment of contractility, volume status, and valve function.

Medications
In addition to the standard medications used for sedation and general anesthesia, the anesthesiologist must be
familiar with the medications commonly used in the CCL and EPL:
Heparin
Glycoprotein IIb/IIIa platelet receptor inhibitors
Clopidogrel
Direct thrombin inhibitors such as bivalirudin
Vasoactive and intropic medications
Sodium channel blockers (class 1: quinidine, lidocaine, flecainide)
Beta-blockers (class 2: metoprolol, sotalol)
Potassium channels blockers (class 3: amiodarone, sotalol, ibutilide, dofetilide)
Calcium channel blockers (class 4: verapamil, diltiazem)

Prior to the procedure, it must be clear how medications will be delivered to the patient, and who will do it. In
addition, the cardiologist may directly bolus medications such as nitroglycerine or calcium channel blockers directly
into cardiac catheters, which can have a profound effect on the patients hemodynamics. Communication must be
clear so that cardiologists and anesthesiologists are both aware of when drugs are administered so that subsequent
hemodynamic effects can be anticipated and double dosing can be avoided.

Percutaneous Ventricular Assist Devices
Percutaneous ventricular assist devices are placed in patients who are having high-risk PCI, high-risk ablation
procedures, or who are hemodynamically compromised. The TandemHeart (Cardiac Assist, Inc., Pittsburg, Pa,
USA) and the Impella Recover LP 2.5 and 5.0 (Abiomed Inc., Danvers, MA, USA) are two commercially available
percutaneous ventricular assist devices. The TandemHeart and Impella LP 5.0 can produce cardiac outputs that can
completely replace left ventricular function. During this time pulse oximetry and non-invasive blood pressure cuffs
may not work properly because blood flow may not be pulsatile. The Impella LP 2.5 uses a smaller cannula that
achieves a maximum cardiac output of 2.5 liter/min. Therefore the patient must have some intrinsic cardiac function
to maintain hemodynamic stability.

Large bore IV access is desirable since a large amount of blood loss is possible during the procedure. Blood loss is
more likely with the TandemHeart or Impella LP 5.0 since the cannulas used are larger. Surgical back up may be
necessary during these procedures. The anesthesiologist may be consulted for these procedures because the patient is
usually already unstable or the procedure can have both airway and hemodynamic complications. Depending on the
procedure and state of the patient, either sedation or general anesthesia can be used to safely care for the patient.
Communication with the cardiologist helps determine the type of anesthetic most appropriate for the case and the
patient.

Percutaneous Closure of Septal Defects
These procedures are used to close patent foramen ovale (PFO), atrial septal defects (ASD) and ventricular septal
defects (VSD). There are a number of percutaneous closure devices available to close septal defects. The
complications of device placement are similar across the platforms available. Complications of percutaneous
closure devices include but are not limited to: intra-procedure air embolism; device embolization; device
malpositioning; device thrombosis and embolization (cerebral embolization may occur from either air, a piece of the

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device itself or thrombus) during or following the procedure; device related arrhythmias (usually atrial but include
sudden death); and cardiac perforation with or without cardiac tamponade.

The placement of intra-cardiac septal occluder devices requires an anesthesiologist if TEE is used to guide
placement of the device, the alternative is for the cardiologist to use intra-cardiac or intra-vascular echo. Patient
history is important to determine the reason to close the defect. Closure of PFOs tends to be simpler than closure of
ASDs. In patients with ASDs, it is important to determine if right ventricular function and pulmonary arterial
pressures are normal since the right side of the heart has been volume overloaded due to the typical left to right
shunt through the ASD. In patients with VSDs, the anesthesiologist needs to determine if the VSD is congenital or
acquired (post myocardial infraction) and the direction of flow through the defect. Typically VSDs have left to right
flow. Patients with post myocardial infarction VSDs can be hemodynamically unstable and more likely to have
complications (hypotension, arrhythmias) during closure of the defect.

Echocardiography is used during the procedure to help guide placement and confirm a successful result. If TEE is
used, then general anesthesia will be necessary for the procedure. Intra-cardiac echocardiography (ICE) can also be
used to guide the procedure. If ICE is used, the procedure can be performed under sedation. An arterial line usually
isnt need for either an ASD or PFO closure but recommended for most VSD closures. Two IVs should be available
so that one can be used for boluses and the other for infusions. The cardiologist can place a femoral venous line for
infusions if necessary. The determination of sedation versus general anesthesia should be based on the complexity
of the closure and patient medical history.

Percutaneous Valve Repair and Replacement
Percutaneous valve repair and replacement represent the changing paradigm of interventional cardiology procedures.
The procedures are more complex with increased patient acuity. At the present time cardiac surgical mitral valve
repair is the procedure of choice for the treatment of symptomatic mitral regurgitation or mitral regurgitation with
impaired left ventricular function (EF < 60%). Current techniques under investigation for percutaneous mitral
valve repair include coronary sinus annuloplasty, direct annuplasty, leaflet repair and chamber + annular
remodeling.

The MitraClip (Abbott Vascular) is the most extensively studied in US patients. The current COAPT Trial is
randomizing patients with functional mitral regurgitation who are not surgical candidates. The femoral vein is
accessed and the clip is delivered via an atrial trans-septal puncture and passed into the left ventricular cavity. The
clip is then opened and pulled back to contact both the anterior and posterior mitral leaflets. Positioning is performed
with both fluoroscopy and TEE. The clip is then closed to create a double-orifice mitral valve with improvement of
mitral regurgitation. The results of the current study are still 12-24 months away.

Percutaneous mitral valve repairs are performed under general anesthesia with fluoroscopic and TEE guidance. The
type of device and approach should be communicated prior to the procedure. During these cases, the procedure
room is very crowed and establishing space to care for the patient can be difficult. Two peripheral IVs should be
placed for infusions and boluses. Endotracheal intubation is preferred and arterial invasive monitoring should be
considered depending on the patients ventricular function. Communication during the procedure is vital to
successful placement of the device as the case can be long and multiple attempts maybe needed to ensure proper
device placement with an acceptable result.

Percutaneous aortic valve replacement or transcatheter aortic valve replacement (TAVR) is a relatively new
treatment for aortic stenosis. Currently there are two devices in patient clinical trials in the United States. The
CoreValve (Medtronic) is a porcine self-expanding prosthesis sutured into a Nitinol stent. The Sapien valve
(Edwards Lifesciences) is a bovine pericardial prosthesis sutured into a balloon-expandable metal stent. In the
United States, the Sapien valve received FDA approval in November 2011 for placement in patients with severe
aortic stenosis who are deemed inoperable. Current trials are comparing TAVR to surgical AVR. The most recent
study published in the New England Journal of Medicine (June 9. 2011) showed that TAVR survival was non-
inferior to surgical AVR at one and two years. Unfortunately TAVR patients have a higher stroke rate and more
paravalve leaks. On the other hand they had fewer bleeding complications and shorter hospital lengths of stay.
Despite this study commercial use of TAVR is limited to non-operative patients only.


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Access to the aortic valve is via either a transfemoral, trans-apical (via the left ventrical), or trans-aortic (ascending
aorta) approach. Transfemoral arterial access is the preferred route to place the valve if the femoral and iliac arteries
are big enough to allow the larger cannulas and sheaths to pass.

Patients receive general endotracheal anesthesia and invasive monitoring (arterial line and pulmonary artery
catheters). Like percutaneous mitral valve repairs, fluoroscopy and TEE are used to guide device placement.
Patients frequently become hemodynamically unstable during the case and can develop myocardial ischemia and
significant arrhythmias both before and after device placement. Rapid ventricular pacing is needed to place the
device and can result in prolonged hypotension and ischemia. The cannulas used to place these devices are large
and can result in large blood loss and damage to the femoral and iliac vessels if done via the trans-femoral access.
Other complications include: AV nodal block, abnormal valve deployment (paravalve leaks, aortic insufficiency,
embolization), coronary occlusion, cardiovascular collapse (needing cardiopulmonary bypass), and stroke.

Catheter Ablation
Radiofrequency is used to treat arrhythmias that are refractory to pharmacologic therapy as well as a first-line
treatment for other arrhythmias. Catheter ablation is used to treat supraventricular tachyarrhythmias such as atrio-
ventricular nodal re-entry tachycardia; Wolf-Parkinson-White syndrome related tachycardias, atrial tachycardia,
atrial flutter, atrial fibrillation, and ventricular tachyarrhythmias (both structural and idiopathic).

Both venous and arterial access to the heart may be needed to place the mapping and ablation catheters. Complex
mapping techniques are utilized to identify the source of the arrhythmia so as to specify the exact intra-cardiac
location to which the radiofrequency energy must be applied. Different types of mapping techniques include pace
mapping, activation mapping, entrainment mapping, and anatomic mapping. The patients must remain still during
the mapping and ablation portions of the procedure. The decision to use sedation versus general anesthesia is
determined both by the patients co-morbidities and the type of arrhythmia. A patient with severe sleep apnea who
cannot lay flat will likely do better with general anesthesia for a 4-6 hour procedure. On the other hand, right-sided
idiopathic VT is commonly suppressed by general anesthesia so sedation is preferred. Pulmonary vein isolation
ablation performed for paroxysmal atrial fibrillation is primarily anatomically mapped so general anesthesia has less
effect on the outcome. It is important to discuss the patients co-morbidities and arrhythmia prior to designing the
anesthetic technique to optimize patient outcomes and minimize procedural risk.

Radiofrequency ablation procedures are becoming more tedious and more time consuming. Patients with atrial
fibrillation often require a procedure time of at least 4-6 hours, followed by a prolonged observation time post
ablation with repeat electrophysiology testing to ensure success of the procedure. Patients can be young and
essentially healthy or have extensive co-morbidities. Coughing, snoring, and partial airway obstruction can be
problematic during intra-cardiac mapping since they precipitate a swinging motion of the intra-atrial septum and
make trans-septal catheter placement difficult as well as mapping the arrhythmia. Drugs that affect the sympathetic
nervous system should be avoided during mapping of ectopic foci and tracts. In patients with ventricular
dysfunction, intropic and vasoactive agents maybe necessary in order to both anesthetize and maintain
hemodynamic stability during arrhythmia induction and ablation. Communication with the cardiologist is necessary
in these situations to maintain patient safety and still allow the mapping process to proceed.

Complications from ablations procedures include:
Hemorrhage, hematoma, AV fistula most common
Hypotension
Heart failure/fluid overload
Pulmonary vein stenosis (4-10% for afib ablations)
Left atrial-esophageal fistula (rare but high fatality rate in afib ablations)
Steam pops ! the radiofrequency current used for ablations causes steam formation that can explode
through the tissue (tamponade can occur).
The risk of tamponade is greater with ablations involving the right ventricle (thin walled).
Risk of thrombus formation with ablation catheters.
Damage to the aortic or mitral valve gaining access to the LV.
Vascular access complications.
Cerebral or systemic embolism (up to 2.7%)

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Atrioventricular nodal block (especially with VT that originates from the septum)
With epicardial ablation risk of coronary artery injury is a major concern
Damage to the left phrenic nerve as it courses down the lateral aspect of the LA and LV

Device Placement and Testing
Many of these patients have multiple co-morbidities including a history of ventricular tachycardia/fibrillation,
ejection fraction < 30%, and coronary artery disease as these are indications for implantable cardioverter-
defibrillator (ICD) placement. Other indications include arrhythmogenic right ventricular dysplasia, long QT
syndrome, and hypertrophic cardiomyopathy.

Most of these devices are placed with mild to moderate sedation and standard monitors. Testing the device requires
deep sedation. ICD placement and testing can be accomplished without an arterial line. External
cardioverter/defibrillator pads are placed on the patient at the beginning of the procedure. When testing ICDs, they
are used induce ventricular fibrillation and to serve as back-up if the implanted device fails.

Implanted ICD may be tested at the end of the procedure. Repeated testing is usually well tolerated without
deterioration of ventricular function even in patients with ejection fractions < 35%. In patients with evidence of
untreated coronary disease, recent stent placement or evidence of atrial or ventricular thrombus, testing is sometimes
omitted. Significant coronary artery disease is a concern when testing with prolonged hypotension as a possible
complication. It is important to remember that ICD testing is always an elective procedure should the patient
demonstrate deterioration during implantation.

Some patients needing ICDs are also having biventricular pacemakers placed for cardiac resynchronization therapy.
These patients have low ejection fractions and associated co-morbidities including valvular heart disease, pulmonary
hypertension, and right ventricular dysfunction. Patients may not be able to lie flat comfortably and can easily
become hemodynamically unstable with sedation. Oversedation can lead to hypercapnia that may not be tolerated in
patients with pulmonary hypertension and/or right ventricular dysfunction. The anesthesiologist must be ready to
convert to general anesthesia at anytime during the case. Complications from these procedures include possible
cardiac injury (perforation/tamponade), myocardial infarction, stroke, and pneumothorax from the subclavian
venous access.

Conclusion
Anesthesiologists, in collaboration with cardiologists, must establish guidelines for their involvement in patient care
and procedure planning in the CCL and EPL. The goal is to improve patient safety and procedural efficiency while
advancing the frontiers of medical care in an expanding and exciting new venue.

Reviews and Articles to Read:
1. Shook DC, Gross W: Offsite anesthesiology in the cardiac catheterization lab. Curr Opin Anaesthesiol 20:352,
2007
2. Shook DC, Savage RM. Anesthesia in the cardiac catheterization laboratory and electrophysiology laboratory.
Anesthesiol Clin 2009; 27(1):47-56
3. Patel K, Crowley R, Mahajan A. Cardiac electrophysiology procedures in clinical practice. Int Anesthesiol Clin
2012;50(2):90-110
4. Hayman M, Forrest P, Kam P. Anesthesia for Interventional Cardiology. J Cardiothorac Vasc Anes;26(1):134-
147.
5. Elkassabany NM, Mandel JE. Con: A general anesthesiologist with a certain skill set is qualified to provide
services in the interventional cardiology and electrophysiology laboratory. J Cardiothorac Vasc Anes
2011;25(3):557-58
6. Mahajan A, Chua J. Pro: A cardiovascular anesthesiologist should provide services in the catheterization and
electrophysiology laboratory. J Cardiothorac Vasc Anes 2011;25(3):553-556
7. Gaitan BD, Trentman TL, Fassett SL. Sedation and analgesia in the cardiac electrophysiology laboratory: a
national survey of electrophysiologists investigating the who, how, and why? J Cardiothorac Vasc Anes
2011;25(4):647-659
8. Wazni O, Wilkoff B, Saliba W. Catheter ablation for atrial fibrillation. N Engl J Med 2011;365:2296-304
9. Stevenson WG, Soejima K. Catheter Ablation for Ventricular Tachycardia. Circulation 2007;115:2750-2760

Refresher Course Lectures Anesthesiology 2013 American Society of Anesthesiologists. All rights reserved. Note: This publication contains
material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
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10. Cesario DA, Mahajan A, Shivkumar K. Lesion-forming technologies for catheter ablation of atrial fibrillation.
Heart Rhythm 2007;4(3):s44-s50
11. Holmes D, Mack M, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter
aortic valve replacement. J Thorac Cardiovasc Surg 2012;144(3):e29-e84
12. Fassl J, Augoustides J. Transcatheter aortic valve implantation-part 2: anesthesia management. J Cardiothorac
Vasc Anes 2010;24(4):691-699

References:
1. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 96:1004, 2002
2. Kushner, FG, Hand, M, Smth, SC, et.al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of
Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and
ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007
Focused Update).Journal of the American College of Cardiology Vol. 54, No. 23, 2009, December 1,
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3. Smith Jr. SC, Feldman TE, Hirshfeld Jr. JW, et al: ACC/AHA/SCAI 2005 Guideline update for percutaneous
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on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous
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5. Siegenthaler MP, Brehm K, Strecher T, et al. The Impella Recover microaxial left ventricular assist device
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7. Henriques JP, Remmelink M, Baan J, Jr., et al: Safety and feasibility of elective high-risk percutaneous
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8. Pretorius M, Hughes AK, Stahlman MB, et al: Placement of the TandemHeart percutaneous left ventricular
assist device. Anesth Analg 103:1412, 2006
9. Delaney JW, Li JS, and Rhodes JF. Major complications associated with trans-catheter atrial septal occluder
implantation: a review of the medical literature and the manufacturer and user facility device experience
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10. Chessa M, Carminati M, Walsh K, et. al. Early and Late Complications associated with transcatheter occlusion
of secundum atrial septal defect. J Am Coll Cardiol 2002, 39:1061.
11. LaRosee K, Krause D, Becker M, et.al. Transcatheter Closure of atrial septal defects in adults. Practicality and
safety of four different closure systems used in 102 patients. Dtsch Med Wochenschr. 2001 Sep
21;126(38):1030-6.
12. Carroll JD, Dodge S, and Groves BM Percutaneous patent forman ovale closure. Cardiol Clin 23 (2005) 13-33.
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septal ruptures. Catheter Cardiovasc Interv 69:403, 2007
14. Garay F, Cao QL, Hjazi ZM: Percutaneous closure of post-myocardial infarction ventricular septal defect. J
Interv Cardiol 19:S67, 2006
15. Creager MA and Libby P. Libby: Braunwalds Heart Disease: A Textbook of Cardiovascular Medicine, 8th
Edition. Copyright2007 Saunders, an Imprint of Elsevier. Chapter 57 Peripheral Arterial Diseases.
16. Norgen L, Hiatt WR, Dormandy JA, et al. Inter-Society consensus for the management of peripheral arterial
disease (TASC II). J Vasc Surg 2007; 45: Suppl S: S5.
17. Feldman T. Percutaneous mitral valve repair. J of Int cardio vol 20, no. 6, pp. 488-494, 2007.
18. Block PC: Percutaneous transcatheter repair for mitral regurgitation. J Interv Cardiol 19:547, 2006
19. Rajagopal V, Kapadia SR and Tuzcu EM. Advances in the percutaneous treatment of aortic and mitral valve
disease. Minerva Cardioangiol 2007; 55:83-94.
20. Webb JG. New treatment options in aortic stenosis. ACCEL April 2008, vol. 40, No. 4, disc 1.
21. ACC/AHA/HRS Writing Committee Circulation: Dec 5, 2006: ACC/AHA/HRS 2006 Key Data Elements and
Definitions for Electrophysiological Studies and Procedures: A Report of the American College of
Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing

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Committee to Develop Data Standards on Electrophysiology Circulation 2006; 114; 2534-2570; originally
published online Nov 27, 2006
22. Moss AJ, Zareba W, Hall WJ, et al: Prophylactic implantation of a defibrillator in patients with myocardial
infarction and reduced ejection fraction. N Engl J Med 346:877, 2002
23. Epstein AE, DiMarco JP, Ellenbogen KA, et al: ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline
Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with
the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol 51:e1,
2008

Disclosure
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221
Page 1
Cerebral Protection During Cardiac Surgery
Charles W. Hogue, M.D. Baltimore, Maryland
Clinical stroke occurs in 13% of patients after cardiac surgery, predisposing affected patients to high mortality,
excessive medical cost, and impaired quality of life.
1-3
Cerebral injury may have manifestations other than focal
neurologic deficits. Postoperative cognitive dysfunction (POCD) is reported in 3040% of patients early after
cardiac surgery and in 2030% of patients 4 to 6 weeks postoperatively.
4-8
Psychometric testing is associated with
many methodological limitations (e.g., timing of testing, definitions of decline, interpretation alongside preexisting
cognitive dysfunction, test-retest improvement, etc.) that confound its ability to serve as an accurate marker of brain
injury after cardiac surgery.
9
Whether POCD is relevant to long-term cognition is still controversial. Although early
investigations suggested a link between POCD and long-term cognitive decline, those studies did not include a
control group. Selnes et al
10
, however, reported the results of a longitudinal study that compared cognition of
patients undergoing CABG surgery to a control group with known coronary artery disease undergoing medical
management. In patients who underwent cardiac surgery, cognitive performance recovered by 6 months after
surgery and the rate of further decline over 6 years of follow-up was no different than that observed in controls.
Further, Van Dijk et al
11
reported no differences between cognition in patients 5 years after CABG surgery
(performed with or without cardiopulmonary bypass, CPB) and that in a group of subjects without cardiac disease.
More recently, Evered et al
12
reported that the incidence of POCD was similar for patients 3 months after coronary
angiography (21%), total hip joint replacement surgery (16%), and CABG surgery (16%; p=0.13). Data from a
meta-analysis of 28 studies involving 2043 patients who underwent CABG surgery suggested improvement in
cognitive function during the first year after surgery.
13
Taken together, the current data suggest that any impact of
CABG surgery on cognition is short-lived, and further decrements are explained by natural progression of cerebral
vascular disease. Delirium is an acute form of cerebral dysfunction that affects as many as 3040% of patients after
cardiac surgery. This condition is characterized by an acute fluctuation in level of consciousness associated with
changes in cognition, attention, and perception.
14
Delirium is associated with prolonged hospitalization, reduced
functional status, mortality, and future cognitive decline.
15
The mechanism of delirium after cardiac surgery is
likely multifactorial and is dependent on the interaction of preexisting patient factors and perioperative
perturbations.
Investigations involving sensitive diffusion-weighted brain MRI (DWI) scanning of patients after cardiac surgery
have provided important insight into the frequency of clinically silent brain injury after cardiac surgery.
4;

16;

17;

18;

19

DWI is an MR sequence that detects acute brain ischemic injury within minutes to 2 weeks after its occurrence. In a
systematic review of studies involving 446 patients undergoing cardiac surgery, 29% of patients exhibited new
ischemic lesions on DWI after surgery.
20
The lesions are usually multiple and small (1 to 10 mm) and located in all
vascular territories, but usually in frontal and watershed regions. Because these lesions are usually not accompanied
by evidence of stroke, some controversy exists as to the clinical significance of their presence in an otherwise
asymptomatic patient. Longitudinal studies in the general population, though, have shown that brain infarctions that
are initially clinically silent subsequently progress in volume, causing patients to have a greater eventual risk for
cognitive decline and dementia than patients without MRI evidence of brain infarction.
20
;
21
Thus, cerebral injury
after cardiac surgery may have multiple manifestations that are both clinically obvious (stroke, delirium) and
clinically silent (POCD, DWI lesions). The aim of neuroprotection should be to prevent all forms of cerebral injury,
even those that may not necessarily be accompanied by clinical signs and symptoms.
Proposed Mechanisms
Two mechanisms have been proposed for cerebral injury from cardiac surgery: cerebral macro/microembolism and
cerebral hypoperfusion.
3,4
It is hypothesized that the clinical manifestations depend on the size and location of the
injury (e.g., motor areas vs. areas involved with cognition). Importantly, embolism and hypoperfusion do not
necessarily occur in isolation; they can co-exist in the same or different areas in a given patient.
22
Although, primary
221
Page 2
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cerebral hemorrhage is believed to be a rare cause of cerebral injury, MRI imaging for micro-bleeding suggests that
punctuate hemorrhages can occur after surgery in some patients, such as those with endocarditis.
23
Inflammatory
processes resulting from CPB, organ ischemia/reperfusion, and genetic susceptibility may further contribute to
injury.
3,24-26

Atherosclerosis of the ascending aorta is a potential source of cerebral macro- and micro- (<200 m)
emboli, based on prospective ultrasound investigations, intraoperative transcranial Doppler (TCD) monitoring, and
autopsy studies.
4,27
Fat arising from the cardiotomy suction aspirate has been suggested as another source of
microemboli.
28
Although early studies implicated cerebral microemboli as a cause of POCD by correlating the
number of TCD-detected cerebral embolic signals with cognitive decline after CABG surgery, these findings were
not confirmed.
29,30,31,32
It is likely that the composition and not the number of microemboli is more important for the
manifestations of cerebral injury. Cerebral injury from hypoperfusion may be more common in contemporary
practice because of a growing number of patients with preexisting, and typically clinically asymptomatic,
cerebrovascular disease.
4
This concern is reinforced by data showing that as many as 2743% of patients experience
regional or global cerebral O
2
desaturations during CPB, indicating cerebral O
2
demand/delivery mismatch.
33

Further, one study found that 68% of strokes that occurred after cardiac surgery were hypoperfusion-type watershed
strokes based on diffusion-weighted MRI.
34
Cerebral hypoperfusion might be of particular concern during off-
pump surgery, when displacement of the heart results in systemic hypotension and cerebral venous hypertension.
One study showed that 15% of patients undergoing off-pump CABG surgery exhibited EEG evidence of cerebral
hypoxemia and near-infrared spectroscopy (NIRS) desaturations.
35


Approaches to Cerebral Protection
Cerebral ischemic injury is broadly classified as global or regional. Brain energy stores are rapidly depleted during
ischemia, leading to depolarization and release of excitatory neurotransmitters. Cerebral ischemia triggers activation
of multiple pathways (ischemic cascade) over a period of hours to days that determine the ultimate extent of injury
and functional outcome.
36
Other injury pathways that are activated lead to altered calcium homeostasis, free radical
production, activation of proteases, and initiation of apoptosis. Vulnerability to injury varies between cell subtypes,
with neurons located in the hippocampus, cortex, cerebellum, corpus striatum, and thalamus having particular
susceptibility.
37
The central area of ischemic injury is surrounded by viable tissue that is vulnerable to infarction
(the ischemic penumbra) from the secondary events that follow the initial injury. Prevention of cerebral injury
from cardiac surgery is distinguished from rescue therapies for patients who present with a stroke in progress,
such as those in non-surgical settings. Cerebral protective measures can be categorized into several basic strategies:
1) prevention of injury from cerebral emboli; 2) ensuring cerebral O
2
delivery/demand balance; and 3) prevention of
secondary brain injury to the ischemic penumbra.

Reducing Cerebral Emboli
Performing CABG surgery off pump has been proposed as a means for reducing the injurious consequences of CPB,
including the introduction of microemboli into the systemic circulation.
38
Nonetheless, several prospectively
randomized trials comparing off- and on-pump CABG surgery have failed to demonstrate that avoiding CPB
provides a clear reduction in stroke rate or risk for POCD.
39,40
;
41-43
.
40
The decision to carry out CABG surgery off
pump must be individualized, but the current data do not indicate that this surgical approach substantially improves
neurologic outcomes.
Atherosclerosis of the ascending aorta is a known source of cerebral emboli that may cause stroke and possibly
POCD.
4
In patients presenting with stroke, aortic atherosclerosis is associated with blood hypercoagulability, which
increases the risk for recurrent stroke and death.
44
Detection and surgical management of atherosclerosis of the aorta
are distinct clinical issues. Epiaortic ultrasound is more sensitive than direct palpation or transesophageal
echocardiography for detecting atherosclerosis of the ascending aorta.
45,46
This method allows the surgeon to
identify and avoid atheroma during aortic cannulation and cross-clamping. Approaches to surgical management of
patients who have been found to have an atherosclerotic aorta include: 1) converting to off-pump surgery; 2) using
alternative sites for CPB cannulation; 3) using the single cross-clamp technique to avoid partial aortic occlusion
clamping for proximal bypass graft anastamosis; 4) using fibrillatory arrest rather than cardioplegic arrest to avoid
cross-clamping; 5) avoiding proximal anastomosis by using arterial grafts; and 6) replacing the ascending aorta
under circulatory arrest.
4
Improved neurologic outcomes have been reported with epiaortic ultrasound-guided
surgery and with practices that minimize the risk for embolization.
47-49
A meta-analysis of 7 studies found that the
rate of stroke was 0.31% for patients undergoing off-pump CABG with minimal aortic manipulations but 1.35% for
patients undergoing off-pump CABG with a side-clamp or proximal graft anastomosis device (p=0.003).
50

Insufflation of CO
2
into the mediastinum may increase the rate of absorption of intravascular emboli by
221
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refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
substituting the more soluble CO
2
for air in the surgical wound.
4
The effectiveness of this strategy for reducing
neurologic complications is not clear, but its use has few associated risks. Cardiotomy suction aspirate is high in
lipid content and is a source of cerebral lipid microemboli in experimental canine CPB.
4,51
Based on animal data and
inferential data from humans, many centers have adopted a practice of either discarding cardiotomy suction aspirate
or processing it with a cell-salvage device before returning it to the CPB circuit. As platelets and coagulation factors
are lost with either approach, these practices might increase the frequency of blood transfusions when the suction
volume is high. This possibility is an important consideration, as transfusion of allogeneic packed red blood cells
(PRBC) and platelets is associated with increased risk for stroke after cardiac surgery.
52
Rubens et al
53
reported no
difference in the frequency of POCD 1 week or 3 months after CABG and/or aortic valve surgery between patients
whose cardiotomy blood was processed with a cell saver and those who had direct return to the CPB circuit.
However, Djaiani et al
54
found that processing cardiotomy blood with a continuous-flow cell saver led to a
significantly lower rate of POCD 6 weeks after CABG surgery. Neither study showed a difference in the number of
TCD embolic signals between cell-saver and control groups. In both studies, patients in the cell-saver group had
higher rates of transfusion than did controls. Thus, the data are conflicting on whether routine processing of
cardiotomy suction aspirate with a cell saver improves neurologic outcomes. Any benefits might depend on the
volume of aspirated blood and/or the type of device used.

Improving Cerebral Oxygen Balance
Blood Pressure Management: Cerebral blood flow (CBF) autoregulation remains functional when alpha-stat pH
management is used during CPB. Thus, low mean arterial pressure (MAP) is believed to be tolerated because CBF is
ensured to blood pressures of 50 mmHg or even lower.
7
Whether this practice is appropriate for the rising proportion
of patients with cerebrovascular disease is not clear. Gottesman et al,
34
for example, found a relationship between a
decrease in MAP by !10 mmHg from baseline during CPB and a risk for watershed stroke detected by MRI. Other
data suggest that maintaining MAP between 80 and 90 mmHg during CPB is associated with less delirium and less
early cognitive dysfunction.
55
Our group has reported in animal and clinical studies that real-time continuous
monitoring of CBF autoregulation with TCD or NIRS may provide a novel approach for individualizing MAP
targets during CPB.
56,57
This method allows for MAP to be optimized within an individuals autoregulatory range,
thus reducing the potential for cerebral hypoperfusion. We have found that the average MAP at the lower limit of
CBF autoregulation in adults during CPB is 66 mmHg (95% CI, 6558 mmHg). The range of pressures, though, at
the autoregulation threshold was 40 to 90 mmHg. Importantly, patients with stroke had a higher MAP at the
autoregulatory threshold than did patients without stroke (CVA, 7415 mmHg; no CVA, 6612 mmHg, p=0.054).
We have also found a link between the product of the magnitude and duration that the MAP is below the lower limit
of CBF autoregulation and acute postoperative kidney injury.
58
Our growing experience suggests that monitoring
CBF autoregulation in real-time might be necessary to identify the optimal MAP for CPB. Further, individualizing
MAP with this approach may lead to better organ perfusion and possibly better patient outcomes.

Red Cell Transfusion: In retrospective analyses, anemia has been linked to adverse outcomes, including stroke,
particularly when Hct is <21% during CPB.
59,60
The TRACS study examined whether treatment of anemia with
transfusion of PRBC improves patient outcome in a clinical trial of 502 patients undergoing cardiac surgery with
CPB.
61
Patients were randomly assigned to a liberal or restrictive transfusion group (Hct !30% or ! 24%,
respectively). The hemoglobin level in the liberal transfusion group (10.5 g/dL) was higher than that in the
restrictive group (9.1 g/dL, p<0.001). The frequency of the primary composite endpoint of 30-day all-cause
mortality or severe morbidity (cardiogenic shock, ARDS, or acute renal injury requiring dialysis or hemofiltration)
was similar between groups (10% liberal vs. 11% restrictive, p=0.85]. Non-leukocyte-depleted blood was used in
this study, but the PRBC units were stored for a median of 3 days before transfusion. These variables have been
associated with reduced risk from PRBC transfusion.
62,63
Further, cell salvage was not used in the study patients.
The number of transfused PRBC units was an independent risk factor for clinical complications or death at 30 days
(hazard ratio per unit transfused, 1.2; 95% CI, 1.11.4; p=0.002). The Society of Thoracic Surgeons and Society of
Cardiovascular Anesthesiologists clinical practice guidelines opine that For patients on CPB with risk for critical
end-organ ischemia/injury, it is not unreasonable to keep hemoglobin level at 7 g/dL or more.
64


Temperature Management: Extensive laboratory data have demonstrated that hypothermia provides neuronal
protection from ischemic injury via multiple mechanisms.
4
Clinically, hypothermia has been shown to improve
neurologic recovery in comatose survivors of cardiac arrest.
37
Hypothermia may extend the time that circulatory
arrest is tolerated during complex aortic surgery, but there is little clinical evidence that it provides robust
neuroprotection during routine cardiac surgery.
65
The ineffectiveness of hypothermia might be explained by the
221
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absence of hypothermia during all periods of cerebral risk or inadvertent hyperthermia with rewarming.
4
The latter
might result from the proximity of the aortic cannula (returning warm blood) to cerebral vessels and/or inaccurate
patient temperature monitoring that underestimates brain temperature. Rewarming to 34
o
C rather than to 37
o
C
resulted in improved neurocognitive outcome after CABG surgery.
66
However, at 3 months after CABG surgery, the
rates of POCD did not differ among patients who were maintained at 37
o
C (with a circulating warming blanket)
during CPB and those who were maintained at 34
o
C without rewarming.
67
Our group has shown that CPB re-
warming is associated with impaired CBF autoregulation in a high proportion of patients.
68
These results indicate
that CBF is pressure-passive in some patients during rewarming at a time when systemic vascular resistance is
typically low and cerebral metabolic rate is elevated. These conditions might lead to a CBF that is inadequate for
metabolic demand. In that study, there was an association between impaired CBF autoregulation and stroke.

Neuromonitoring: NIRS is used to monitor regional cerebral O
2
saturation (rScO
2
) during cardiac surgery. We have
recently performed a systematic review to evaluate evidence regarding the relationship between rScO
2
desaturations
and POCD and stroke.
69
Several case reports and many observational studies offered anecdotal evidence that rScO
2

monitoring has value for identifying CPB cannula malposition. Nine observational studies evaluated the potential
association between acute rScO
2
desaturation and POCD based on the Mini-Mental Status Examination (n=3
studies) or more detailed cognitive testing (n=6 studies). Six of the studies found an association, but three did not.
Two retrospective studies reported a relationship between rScO
2
desaturation and stroke or type I and II neurologic
deficits after surgery compared with historical controls. The observational studies have many limitations, including
small sample size, assessments only during the immediate postoperative period, and failure to perform risk-
adjustments. Moreover, these studies have failed to determine whether the relationship between rScO
2
desaturation
represents a modifiable risk factor for poor neurologic outcome or whether it is an epiphenomenon that identifies
patients generally of higher risk for poor outcome.
70
Two randomized studies attempted to answer the question of
whether interventions for rScO
2
desaturation improve patient outcomes. The results of one are difficult to interpret
owing to poor adherence with the protocol for treating rScO
2
desaturations. In the other study of 200 CABG surgical
patients, NIRS-guided interventions were associated with less major organ injury (death, MI, stroke) and shorter
ICU length of stay compared to standard care.
71
Algorithms have been proposed for treating cerebral O
2

desaturation.
72
Interventions include ensuring adequate CPB flow, increasing MAP, avoiding hypocarbia
(decreasing gas-inflow), deepening anesthesia, increasing the FiO
2
, instituting pulsatile CPB flow, considering
transfusion if indicated, administering anticonvulsant drugs when indicated, and considering hypothermia.

Protecting the Ischemic Penumbra
Areas of brain infarction are surrounded by viable but vulnerable tissue termed the ischemic penumbra. The viability
of the ischemic penumbra is threatened by the multiple injury pathways that comprise the ischemic cascade
referenced earlier. Microcirculatory changes resulting from brain injury, particularly inflammatory and hemostatic
activation, can contribute to cerebral hypoperfusion due to the no reflow phenomenon. Thus, measures aimed at
neuroprotective hemodynamic management may be critical to protection from secondary brain injury. Other
measures for protecting the ischemic penumbra are mostly pharmacologic, including avoidance of hyperglycemia.

Blood Glucose Control: Hyperglycemia worsens experimental cerebral injury and is associated with poor neurologic
outcome after stroke in humans via multiple mechanisms.
73
The relationship between serum glucose and stroke
severity appears to be J shaped. Experimentally, the nadir glucose level associated with best neurologic outcome
appears to be around 120 mg/dL.
74
Initial results showing that intensive insulin treatment improves outcomes of
critically ill patients were rapidly extrapolated to patients undergoing cardiac surgery.
75
Data from the NICE-
SUGAR study, though, demonstrated in a multicenter, randomized trial that a glucose target of 81 to 108 mg/dL was
associated with higher mortality than a target of "180 mg/dL in adult critically ill patients. Importantly, these trials
were conducted in the ICU.
76
Data in cardiac surgery patients have not supported intensive insulin therapy for
improving neurologic outcomes. In a randomized trial of 400 patients undergoing cardiac surgery, the frequency of
the composite outcome of death, cardiac morbidity, stroke, or renal failure was higher for patients given an insulin
infusion to maintain intraoperative glucose between 80 and 100 mg/dL than for patients who received conventional
treatment [insulin given when glucose was >200 mg/dL (p=0.02)].
77
A prospectively randomized trial found no
difference in the frequency of neurologic complications 6 weeks or 6 months after CABG surgery between patients
who received intraoperative insulin when glucose was >100 mg/dL and those who received insulin when glucose
was >200 mg/dL.
78
A recent meta-analysis identified 7 randomized studies of intravenous insulin administration for
acute stroke.
79
Administration of insulin when glucose is >140 mg/dL is recommended for nonsurgical patients with
stroke.
80

221
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Drugs for Cerebral Protection: Little progress has been made in the clinical translation of pharmacologic agents that
target key pathways of the ischemic cascade as a clinically relevant approach for cerebral protection. Multiple
agents that showed promising effects in vitro via multiple mechanisms have failed to provide clinical protection
against ischemic cerebral injury, including barbiturates, propofol, Ca
2+
channel blockers, NMDA receptor
antagonists, anti-inflammatory agents, antioxidants, GABA receptor blockers, 17!-estradiol, piracetam, and
others.
4,81-84
Volatile anesthetics and xenon have laboratory-proven cerebroprotective effects. However, based on a
systematic literature review, Schifilliti et al
85
concluded that evidence was insufficient to choose one anesthetic over
another for the purposes of cerebral protection. Magnesium was investigated as a cerebral protectant in a
randomized, blinded, placebo-controlled trial of 350 patients undergoing cardiac surgery.
86
At a dose that increased
serum levels to 1# to 2 times normal, Mg
2+
use was associated with improved cognitive performance compared with
placebo use 24 to 96 hours after surgery, but these benefits were not present 3 months after cardiac surgery.
Experimentally, ketamine protects against ischemic neuronal injury by blocking NMDA receptors and by
attenuating inflammation.
87
In a small randomized pilot study (n=52), the frequency of POCD 1 week after cardiac
surgery was lower in patients who received ketamine than in those who received placebo (33% vs. 81%, p<0.001).
83

Likewise, the frequency of delirium was lower for patients given ketamine during surgery than for those given
placebo.
88
A recent retrospective study involving 1134 patients reported better outcomes among patients who
received dexmedetomidine than among those who received other types of sedation after CABG plus/minus valve
surgery.
89
In hospital (1.23% vs. 4.59%; odds ratio, 0.34; 95% CI, 0.1920.614; p<0.0001), 30-day (1.76% vs.
5.12%; adjusted OR, 0.39; 95% CI, 0.2260.655; p<0.0001), and 1-year (3.17% vs. 7.95%; adjusted OR, 0.47; 95%
CI, 0.3120.701; p=0.0002) mortalities were lower for patients who received dexemedetomidine than for patients
who did not receive it. Dexmedetomidine therapy reduced the risk of overall complications (OR, 0.80; 95% CI,
0.680.96; p=0.0136) and delirium (5.46% vs. 7.42%; adjusted OR, 0.53; 95% CI, 0.370.75; p=0.003). These
findings are consistent with a meta-analysis of strategies to reduce postoperative delirium in which
dexmedetomidine sedation was found to be associated with less delirium than were other drugs (2 randomized trials
with 415 patients, pooled risk ratio, 0.39; 95% CI, 0.160.95).
90


Conclusions
A comprehensive approach to cerebral protection that includes interventions to reduce cerebral embolism and ensure
cerebral O
2
supply/demand balance may result in improved neurologic outcomes.
4
Strategies for improving
neurologic outcomes from cardiac surgery are summarized in the Table.

Table. Evidence-based recommendations for cerebral protection during cardiac surgery.




Strategies Supported by Clinical Investigations
Epiaortic ultrasound for detection of atherosclerosis of the ascending aorta
Avoidance of hyperthermia during CPB rewarming
Strategies With Reasonable Level of Clinical Evidence
The use of a membrane oxygenator and an arterial line filter ("40 $m) during CPB
"-stat pH management during CPB
Single cross-clamp technique for proximal CABG anastamosis patients at risk for atheroembolism
Arterial blood pressure kept >70 mmHg during CPB in high-risk patients
Strategies That Are Acceptable and Considered Reasonable Treatment by Most Experts
NIRS monitoring, especially in high-risk patients
Insulin infusion should be considered for serum glucose > 140 mg/dL
Consider processing cardiotomy suction aspirate with a cell-saver device
Transfusion of packed red blood cells should be considered in high-risk patients when hemoglobin is "7 g/dL or
higher depending on other patient-specific considerations.
221
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77. Ann Intern Med 146 233-43, 2007.
78. J Thorac Cardiovasc Surg 130 1319, 2005.
79. Cochrane Database Syst Rev:CD005346, 2011.
80. Stroke 38:1655-711, 2007.
81. Stroke 38 2048-54, 2007.
82. Stroke 40:880-7, 2009.
83. Med Sci Monit 14:PI53-7, 2008.
84. Ann Thorac Surg 87:820-5, 2009.
85. CNS Drugs 24:893-907, 2010.
86. J Thorac Cardiovasc Surg 131:853-61, 2006.
87. J Cardiothorac Vasc Anesth 24:131-42, 2010.
88. Acta Anaesthesiol Scand 53:864-72, 2009.
89. Circulation, 2013.
90. Crit Care 17:R47, 2013.


Disclosure
Covidien Self Funded Research Honoraria; Ornim Self Other Material




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223
Page 1
Introducing Blood Conservation Into Clinical Practice:
Can the New Guidelines Lead Us?
Colleen G. Koch, M.D., MS, MBA Cleveland, Ohio
Objectives
Understand the role practice guidelines in the clinical practice setting.
Become aware of the issues and controversies involved with adoption and implementation of practice
guidelines.
Recognize that guidelines represent one component to comprehensive blood conservation and blood
management programs.
Become aware of components to effective blood conservation and blood management through examples of
an institutional blood management program whose outcomes involve more effective use of blood and
product management.
Practice guidelines serve to aide physicians in making patient care decisions and in particular, in the setting of
considerable practice variation, serve as useful tools to more effectively manage and guide patient care. Guidelines
are meant to provide the best evidence for decision-making from currently available research with the ultimate
goal of providing a more methodological approach to evidence-based patient care along with the most efficient use
of healthcare resources. Whether practice guidelines in general, and more specifically the current: Perioperative
blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons (STS) and the
Society of Cardiovascular Anesthesiologists (SCA) clinical practice guidelines have been widely accepted and
implemented into clinical practice by caregivers is under debate. While development of practice guidelines follows
formal well-described procedures, the actual adoption and implementation is reportedly variable in a number of
practice settings. A recent investigation reported on the effect of the perioperative blood transfusion and blood
conservation in cardiac surgery clinical practice guidelines by the STS and SCA on clinical practice. Among the
groups surveyed were members of the SCA, the American Academy of Cardiovascular Perfusion, Canadian Society
of Clinical Perfusion and the American Society of Extracorporeal Technology. The authors used a standardized
survey instrument to evaluate the change to clinical practice based on the available STS/SCA guidelines. Responses
were received from 891 institutions; 78% of anesthesiologists and 67% of perfusionists who responded reported
reading the all/ part of the guideline document however overall little change to clinical practices was attributed to
the guidelines. Of note, among reasons put forth for poor adoption of the clinical practice guidelines were that the
number of recommendations were based on limited/very limited scientific evidence. It is the lack of evidence on
when and who to transfuse RBC that limits adoption of guidelines that are based on expert opinion rather than
results of randomized controlled trials.
Blood and component therapy are limited and costly resources and have been associated with an increased morbidity
risk following surgical and interventional procedures and in the intensive care unit settings. A recent investigation
reported considerable variation on a national level with red blood cell (RBC) use from a large national surgical
database. Despite similar surgical procedures and patient population comorbidity, there was wide variability in RBC
and component product use-- despite the availability of the STS/SCA updated guidelines. This investigation and
other investigations on RBC transfusion and patient outcomes highlight a number of issues: 1). We continue to be

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challenged in our ability to identify specific patients who will and will not benefit from RBC transfusion, 2). There
is continued lack of sufficient high-level evidence to form the foundation for evidence-based guidelines on

transfusion thresholds and 3). Insufficient availability of bedside technology to determine tissue oxygenation to
access need for RBC transfusion.

Blood management programs serve as multidisciplinary programs with the aim of appropriately allocating blood
products, ensuring safety and providing value to the patient and institution. Guidelines may be a component to blood
management however only in so much as they provide sound evidence for evidence-based practice decisions. Local
educational initiatives, physician and nursing engagement and accountability, culture change and process
improvements are all important components to a successful blood management program. Blood management
performance outcome measures may soon be part of formal measurement tools to gauge success of blood
management programs.

References

1. Ferraris V et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of
Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists clinical practice guidelines. Ann Thorac
Surg 2007;83:S27-86.
2. Woolf S et al. Clinical guidelines: potential benefits, limitations and harms of clinical guidelines. BMJ
1999;318:527-30.
3. Grol R et al. Attributes of clinical guidelines that influence use of guidelines in general practice: observational
study. BMJ 1998:317:858-61.
4. Grilli R et al. Evaluating the message: the relationship between compliance rate and the subject of a practice
guideline. Med Care 1994;32:202-213.
4. Timmermans S. From autonomy to accountability: the role of clinical practice guidelines in professional power.
Perspect Biol Med 2005;48:490-501.
5. Likosky D et al. Effect of perioperative blood transfusion and blood conservation in cardiac surgery clinical
practice guidelines of the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists upon
clinical practice. Anesth Analg 2010;111:316-23.
6. Koch CG, et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in
isolated coronary artery bypass grafting. Critical Care Medicine 2006;34:1608-1616.
7. Koch CG, et al. Persistent effect of red cell transfusion on health-related quality of life after cardiac surgery.
Annals of Thoracic Surgery 2006;82:13-20.
8. Murphy G, et al. Increased mortality, postoperative morbidity and cost after red blood cell transfusion in patients
having cardiac surgery. Circulation 2007;116:2544-2552.
9. Koch CG, et al. Duration of red-cell storage and complications after cardiac surgery. New England Journal of
Medicine. 2008;358:15-25.
10. Koch C, Li L, Figueroa P, Mihaljevic T, Svensson L, Blackstone EH. Role of Transfusion in Lung Injury and
Pulmonary Morbidity after Cardiac Surgery, Annals of Thoracic Surgery 2009;88:1410-8.
11. Koch CG, Li L, Duncan A, Mihalijvec T, Starr N, Blackstone E. Perioperative red blood cell transfusion is
associated with reduced long-term survival in isolated coronary artery bypass grafting, Annals of Thoracic Surgery
2006;81:1650-7.
12. Vivacqua A, Koch CG, Nowicki E, Houghtaling P, Blackstone EH, Sabik J. Morbidity of Bleeding after Cardiac
Surgery: Is It Blood Transfusion, Reoperation for Bleeding or Both? Annals of Thoracic Surgery 2011;91:1780-
1790.
13. Kumar A, Figueroa P, Gowans LK, Parker B, Proctor A, Benitez Santana SM, Koch CG. An Evolution in Blood
Management: Past, Present and Future. Quality Management in Healthcare 2011;20(4):311-321.
14. Bennett-Guerrero E, et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA
2010;304:1568-1575.


Disclosure
This speaker has indicated that he or she has no significant financial relationship with the manufacturer of a
commercial product or provider of a commercial service that may be discussed in this presentation.

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Perioperative Pacemaker and Defibrillator Management: What You Need to Know
Marc A Rozner, Ph.D, M.D. Houston, Texas
Introduction Battery operated pacemakers (PM) were developed in 1958, and implantable cardioverter-
defibrillators (ICDs) followed in 1980. The complexity of these cardiac implantable electrical devices (CIED) limits
generalizations that can be made about the perioperative care of these patients. Population aging, continued
enhancements, and new indications for implantation of CIED will lead to increased implantations. Initially, ICDs
treated only sudden cardiac arrest (SCA), whether from ventricular tachycardia (VT) or ventricular fibrillation (VF).
Now, any patient with an ejection fraction < 35%, regardless of the etiology and without induction testing for VT or
VF, is considered a likely ICD recipient.
Many technical issues conspire to create confusion in this field. All ICDs have the ability to provide brady
pacing, but ICDs never provide asynchronous pacing without reprogramming, even with magnet placement.
Second, ICDs respond to, and process, electromagnetic interference (EMI) differently than a PM. Third, case
Preoperative Key Points (HRS-ASA; ASA)
Identify the manufacturer and model of the cardiac
implantable electrical device (CIED).
Establish preoperative contact with the patients
CIED physician / clinic to obtain appropriate
records and perioperative prescription (HRS).
Have the CIED interrogated (ASA) by a
competent authority shortly before the anesthetic.
Obtain a copy of this interrogation. Obtain
perioperative prescription from the CIED
physician (HRS). Ensure that any ICD treatment
settings are appropriate and that the CIED will
pace the heart.
Consider replacing any CIED near its elective
replacement period in a patient scheduled to
undergo either a major surgery or surgery within
25 cm of the generator.
Determine the patients underlying rhythm / rate to
determine the need for backup pacing support.
Ensure that all magnet behavior (pacing, suspend
shock therapy) is appropriate if magnet use is
planned.
Program minute ventilation rate responsiveness off,
if present.
Program all rate enhancements off.
Consider increasing the pacing rate to optimize
oxygen delivery to tissues for major cases.
Disable antitachycardia therapy if a defibrillator.
Although a magnet might work, magnet use has
been associated with inappropriate ICD discharge.
Intraoperative Key Points
Monitor cardiac rhythm / peripheral pulse with pulse
oximeter (plethysmography) or arterial waveform.
Consider disabling the artifact filter on the ECG
monitor.
Avoid use of monopolar electrosurgery (ESU).
Use bipolar ESU only; if not possible, then pure cut
(monopolar ESU) is better than blend or coag.
Place the ESU dispersive electrode to prevent
electricity from crossing the generator-heart
circuit, even if it must be placed on the distal
forearm and the wire covered with sterile drape.
If the ESU causes ventricular oversensing and pacer
quiescence, limit the period(s) of asystole.
Consider avoiding sevoflurane, isoflurane or
desflurane in the patient with long QT syndrome.
Postoperative Key Points
Consider postoperative interrogation if monopolar
ESU has been used, blood transfused, or
preoperative reprogramming took place.
Optimum heart rate and pacing parameters should
be determined and programmed if needed.
ICD patients must be monitored until the
antitachycardia therapy is restored.


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reports, often with misidentified issues, and very small case series are used to justify policy. Fourth, asymptomatic
patients can have nonfunctioning devices.
1,2

These issues led the American Society of Anesthesiologists (ASA) to publish a Practice Advisory for these
patients,
3
and the Heart Rhythm Society has now published an Expert Consensus Statement.
4
Other guidelines
have been published as well,
5-7
although not all authors recommend ICD disablement in the perioperative period.
8,9

ALL ICDs perform cardiac pacing, so ICD issues related primarily to brady pacing should be reviewed in the Pacing
section.
Notices regarding potential failures for PMs,
10-13
ICD leads,
14
and ICDs
15-17
get published often.
18
Retrospective
analysis suggests that outright failure occurs in 4.6 (PM) and 20.7 (ICD) per 1,000 implants,
19
and outright lead
failure is not rare.
20
Also, for about 46,000 ICDs, Guidant has found that the device improperly enters the magnet
mode, which prevents any detection (and, therefore, treatment) of tachyarrhythmias. As a work-around, Guidant
has recommended the permanent disabling of the magnet mode through programming.
16
Finally, devices
resembling cardiac pulse generators are being implanted at increasing rates for pain control, thalamic stimulation to
control Parkinsons disease, phrenic nerve stimulation to stimulate the diaphragm in paralyzed patients, and vagus
nerve stimulation to control epilepsy and possibly obesity.
21

The subcutaneous ICD introduced to the US by Boston Scientific late last year (present in EU since 2009 by
Cameron Health) behaves differently from the transvenous ICDs, since it has no antitachycardia pacing and no
permanent brady pacing support.
Disagreement between the ASA Perioperative Advisory
3
and the HRS-ASA Consensus document
22
center
primarily over: 1) the recommendation for a de-novo preoperative interrogation (ASA) versus contact with the
patients CIED physician (HRS); 2) the use of programming (ASA) rather than magnet application (HRS) to
mitigate the effects of EMI; and 3) the timing of a postoperative evaluation, should one be needed. Regardless,
important information must be conveyed to the CIED physician by the perioperative team (Table 1) and a
perioperative prescription must be communicated by the CIED physician to the perioperative team (Table 2).
Nevertheless, application of a magnet in the place of a preoperative evaluation has led to harm in several patients.
23


Pacemaker Overview More than 2,500 PM models have been produced by 26 companies, and more than 300,000
adults and children in the US undergo new PM placement yearly. Nearly 3 million US patients have PMs. Outdated
literature, limited or inadequate training, and conventional wisdom lead to confusion in this field.
Pacing systems consist of an impulse generator and lead(s). Leads can have one (unipolar), two (bipolar), or
multiple (multipolar) electrodes with connections in multiple chambers. In unipolar pacing, the generator case serves
as an electrode, and tissue contact can be disrupted by pocket gas.
24
PMs with unipolar leads produce larger
spikes on an analogue-recorded ECG, and they are more sensitive to EMI. Most PM systems use bipolar pacing /
sensing configuration, since bipolar pacing usually requires less energy and bipolar sensing is more resistant to
interference from muscle artifacts or stray electromagnetic fields. Often, bipolar electrodes can be identified on the
chest film since they will have a ring electrode 1 to 3 cm proximal to the lead tip. But generators with bipolar leads
can be independently programmed to the unipolar mode for pacing, sensing, or both.
The Pacemaking Code of the North American Society of Pacing and Electrophysiology (NASPE) and the
British Pacing and Electrophysiology Group (BPEG) describes basic pacing behavior (Table 3).
25
Most PMs in the
US are programmed either to the DDD (dual chamber) or VVI mode (single chamber). DDI is used for atrial
dysrhythmias, and VDD pacing (single wire device providing AV synchrony) can be found in patients with AV
nodal disease but normal sinus node function. Atrial-only pacing (AAI) is uncommon in the US. Biatrial pacing is
Table 1: Information Provided to CIED Service by
Perioperative Team
Type of procedure
Anatomic location of procedure
Patient position for procedure
Need and site for monopolar electrosurgery or other EMI
Planned cardioversion or defibrillation
Surgical venue (OR, office, surgicenter)
Postprocedural plan (hospital admission, outpatient)
Unusual circumstances (surgery encroaching leads or
generator
Table2: Information Provided by CIED Service to
Perioperative Team
Device type, manufacturer, model
Date of last interrogation; remaining battery longevity
Indication for placement, lead revisions if within 3
months
Current settings
Pacing dependence
Magnet behavior
Individualized prescription and follow-up plans
Unusual circumstances such as alert status


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301
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being investigated as a means to prevent atrial fibrillation,
26
and biventricular (BiV) pacing (also called Cardiac
Resynchronization Therapy [CRT]) is used to treat dilated cardiomyopathy (D-CMP).
27-29


Indications Permanent pacing indications (Table 4) are reviewed in detail elsewhere.
30
In order to be effective,
BiV, HOCM, and D-CMP pacing must provide the stimulus for ventricular activation, and A-V synchrony must be
preserved.
31
PM inhibition, loss of pacing (from native conduction, junctional rhythm, EMI), or AV dys-synchrony
can lead to deteriorating hemodynamics. BiV pacing can lengthen the Q-T interval in some patients, producing
torsade-de-pointes.
32
Thus access to rapid defibrillation is required for the patient with BiV pacing.


Pacemaker Magnets Despite oft-repeated folklore,
magnets were never intended to treat PM
emergencies or prevent EMI effects. Rather, magnet-
activated switches were incorporated to produce
pacing behavior that demonstrates remaining battery
life and, sometimes, pacing threshold safety factors.
Placement of a magnet over a generator might
produce no change in pacing since NOT ALL PACEMAKERS SWITCH TO A CONTINUOUS
ASYNCHRONOUS MODE WHEN A MAGNET IS PLACED. Also, not all models from a given company behave
the same way. Common effect(s) of magnet placement on conventional PMs are shown in Table 5. Magnet
behavior can be altered or disabled via programming in many devices. For generators with programmable magnet
behavior [Biotronik, BOS, CPI, Guidant Medical, Pacesetter, St Jude Medical], only a magnet test or interrogation
with a programmer can reveal current settings. HRS recommends magnet placement to create asynchronous pacing
when needed where the magnet behavior is known, appropriate for the patient, the patient is supine, the magnet can
be observed, and access to the magnet is possible.
22

Table 3: NASPE / BPEG Generic Pacemaker Code (NBG) [Revised 2002]
Position I Position II Position III Position IV Position V
Chambers
Paced
Chambers
Sensed
Response to
Sensing
Programmability Multisite Pacing
O = None O = None O = None O = None O = None
A = Atrium A = Atrium I = Inhibited R = Rate Modulation A = Atrium
V = Ventricle V = Ventricle T = Triggered V = Ventricle
D = Dual (A+V) D = Dual (A+V) D = Dual (T+I) D = Dual (A+V)
Table 4: Permanent Pacemaker Indications
Sinus Node Disease
Atrioventricular (AV) Node Disease
Long Q-T Syndrome
Hypertrophic Obstructive Cardiomyopathy (HOCM)
33,34

Dilated Cardiomyopathy (D-CMP)
34



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Preanesthetic Evaluation and Pacemaker
Reprogramming Preoperative management of
the patient with a PM includes evaluation and
optimization of coexisting disease(s). No
special laboratory tests or x-rays are needed for
the patient with a conventional PM. A patient
with a BiV PM or ICD might need a chest film
to document the position of the coronary sinus
(CS) lead, especially if central line placement is
planned, since spontaneous CS lead
dislodgement can occur.
35,36

Important features of the preanesthetic
device evaluation are shown in Preoperative
Key Points. Current HRS and Medicare
guidelines include frequent telephonic (q3-12
months, depending upon device type and age)
and a comprehensive device interrogation with
a programmer at least once per year.
37,38

Direct interrogation with a programmer
remains the only reliable method for evaluating
battery status, lead performance, and adequacy
of current settings. Some devices retain pacing
histograms and information about
tachydysrhythmia(s). Appropriate
reprogramming (Table 6) is the safest way to
avoid intraoperative problems, especially if
monopolar "Bovie" electrosurgery will be used.
Some PM manufacturers stand ready to assist with this task (see Appendix for company telephone numbers);
however, any industry-employed allied professional (i.e., the rep) should be supervised by an appropriately trained
physician.
39

Reprogramming the pacing mode to
asynchronous, at a rate greater than the
patients underlying rate, usually ensures that
no over- or undersensing from EMI will take
place. However, setting a device to
asynchronous mode has the potential to create a
malignant rhythm in the patient with
structurally compromised myocardium.
42

Reprogramming a device will not protect it
from internal damage or reset caused by EMI.
In general, rate responsiveness and
"enhancements" (dynamic atrial overdrive,
hysteresis, sleep rate, A-V search, etc.) should
be disabled by programming.
43-45
Note that for
many older Guidant and/or CPI devices,
Guidant Medical recommended increasing the
pacing voltage to "5 volts or higher" when
monopolar electrosurgery will be used. Few
cardiologists know or follow this recommendation, but there are reports of threshold changed during both
intrathoracic
46
and non-chest surgery.
47,48
Some disease states might increase pacing threshold.
49
Special attention
must be given to any device with a minute ventilation (bioimpedance) sensor (Table 7), since inappropriate
tachycardia has been observed secondary to mechanical ventilation,
50,51
monopolar (Bovie) electrosurgery,
50,52,53

Table 5: Pacemaker Magnet Behavior
Most common responses - Asynchronous high rate pacing (85-
100 bpm), not always in the best interest of the patient.
Biotronik (ONLY when programmed to asynchronous mode,
[not the default state]) 90 bpm, 80 if battery depleted (BUT
can be programmed OFF)
BOS/Guidant Medical / CPI (current models since 1990)
generally 100 bpm (but can be 90), 85 if battery depleted
(BUT can be programmed OFF)
Medtronic (most models) 85 bpm, 65 if battery depleted
Sorin (was ELA Medical (current models since 1989) > 80
bpm (max 96 bpm), 80 if battery depleted. ELA devices
take 8 additional asynchronous cycles (six at magnet rate,
then two at programmed rate) upon magnet removal.
Magnet placement increases the pacing voltage to 5v
St Jude Medical (current models since 1990) > 87 bpm (max
100 bpm), 86.3 if battery depleted (BUT can be
programmed OFF)
Brief (10-100 beats) asynchronous pacing, then return to program
values (all Intermedics; most Biotronik models when
programmed to their default state)
Continuous or transient loss of pacing
Pacing threshold problems
Discharged battery (some pre-1990 devices)
Diagnostic "Threshold Test Mode" (Siemens)
Table 6: Pacemaker Reprogramming Likely Needed
Any rate responsive device see text (problems are well known,
and have been misinterpreted with potential for patient injury,
and the FDA has issued an alert regarding devices with minute
ventilation sensors (Table 5)
Special pacing indication (HOCM, D-CMP, pediatrics)
Pacing-dependent patient
Major procedure in the chest or abdomen
Rate enhancements are present that should be disabled
Special Procedures
Lithotripsy
Transurethral or Hysteroscopic Resection
Electroconvulsive Therapy
Succinylcholine use (although no convincing evidence)
MRI (usually contraindicated by device manufacturers),
possible in some patients
40,41



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301
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and connection to an ECG monitor with respiratory
rate monitoring.
54-59
Sometimes, inappropriate
<anesthetic> therapy has been delivered in these
settings with bad results.
51,60


Intraoperative (or Procedure) Management of
Pacemakers No special technique or monitoring is
needed for the PM patient, but attention must be given
to a number of concerns (Table 8). Monopolar
"Bovie" electrosurgery (ESU) use remains the
principal intraoperative issue for the patient with a
PM. Between 1984 and 1997, the US FDA was
notified of 456 adverse events with pulse generators,
255 from electrosurgery, and a significant number
of device failures.
61
Monopolar ESU is more likely
to cause problems than bipolar ESU.
62
Magnet
placement during electrosurgery might prevent
aberrant PM behavior. Spurious reprogramming with
magnet placement is unlikely. If monopolar
electrosurgery is to be used, then the ESU current-
return pad must be placed to ensure that ESU current
path does not cross the pacemaking system. Some
authors recommend placement of this pad on the
shoulder for head and neck procedures or the distal
arm (with sterile draping of the wire) for breast and axillary procedures.
62,63

Choice of anesthetic agents should be dictated by the patients underlying physiology as well as the procedure.
However, the use of drugs that suppress the AV or SA node (such as potent opiates or dexmedetomidine) can
abolish any underlying rhythm that might be present and render the patient truly PM dependent. Also, some potent
inhalational agents (isoflurane, sevoflurane, and desflurane) might exacerbate the long Q-T syndrome.
64-67


Pacemaker Failure PM failure has three etiologies: 1) failure to capture; 2) lead failure; or 3) generator failure.
Failure to capture can result from myocardial ischemia / infarction, acid-base disturbance, electrolyte abnormalities,
or abnormal antiarrhythmic drug level(s). External pacing might further inhibit PM output at pacing energies that
will not produce myocardial capture.
68,69
Sympathomimetic drugs generally lower pacing threshold. Outright
generator and/or lead failure is rare.

Post Anesthesia Pacemaker Evaluation Any PM that was reprogrammed for the operating room should be reset
appropriately. For non-reprogrammed devices, most manufacturers recommend interrogation to ensure proper
functioning and remaining battery life if any electrosurgery was used.

Implantable Cardioverter-Defibrillator (ICD) Overview For the patient with VT or VF, ICDs clearly reduce
deaths,
70,71
and they remain superior to antiarrhythmic drug therapy.
72
Initially approved by the US FDA in 1985,
more than 100,000 devices will be placed this year, and more than 250,000 patients have these devices today.
Further, data showing ICD placement in patients without evidence of tachyarrhythmias (Multicenter Automatic
Defibrillator Implantation Trial II [MADIT-II] - ischemic cardiomyopathy, ejection fraction less than 0.30
73
and
Sudden Cardiac Death Heart Failure Trial [SCD-HeFT] any cardiomyopathy, ejection fraction less than 0.35
74
)
has significantly increased the number of patients for whom ICD therapy is indicated. ICD placement reduces
mortality from arrhythmia even in patients on optimal heart failure therapy.
75
Like PMs, ICDs have a four-place
code (Table 9).
76
The Pacemaker Code can be used instead of Position IV.
ICDs measure each cardiac R-R interval and categorize the rate as normal, too fast (short R-R interval), or too
slow (long R-R interval). When enough short R-R intervals are detected, an antitachycardia event is begun. The
internal computer chooses antitachycardia pacing (ATP - less energy use, better tolerated by patient) or shock,
depending upon the presentation and device programming. Newer Medtronic ICDs begin a run of ATP while
charging for shock. Most ICDs are programmed to reconfirm VT or VF after charging to prevent inappropriate
therapy. Typically, ICDs deliver 6 18 shocks per event. Once a shock is delivered, no further ATP can take place.
Table 7: Devices with Minute Ventilation Sensors
BOS, Guidant Medical and/or CPI Advantio, Altrua
(S401-404, S601-606), Ingenio, Insignia Plus (1194,
1297, 1298), Pulsar (1172, 1272), Pulsar Max (1170,
1171, 1270), Pulsar Max II (1180, 1181, 1280)
Medtronic Kappa 400 series (401, 403)
Sorin (was ELA) Medical Brio (212, 220, 222), Chorus
RM (7034, 7134), Opus RM (4534), Reply DR,
Rhapsody, Symphony, Talent (113, 133, 213, 223, 233)
Telectronics / St Jude Meta (1202, 1204, 1206, 1230,
1250, 1254, 1256), Tempo (1102, 1902, 2102, 2902)
Table 8: Essentials of Device Monitoring
ECG monitoring of the patient must include the ability to
detect PM discharges (artifact filter disabled)
Perfused (peripheral) pulse must be monitored with a
waveform display
The pacing rate might need to be increased due to an
increased oxygen demand
BiV and HOCM patients probably need beat-to-beat cardiac
output monitoring
Appropriate equipment must be on hand to provide backup
pacing and/or defibrillation


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Despite improvements in detection of ventricular dysrhythmias (Table 10),
77
more than 10% of shocks are for
rhythm other than VT or VF.
78
Recent data suggests that any high energy therapy (either ATP or shock) injure the
myocardium,
79
these myocardial injuries shorten life,
80
and that in-hospital EMI leading to shock is an unrecognized
source of harm for patients.
81


ICDs measure each cardiac R-R interval and categorize
the rate as normal, too fast (short R-R interval), or too
slow (long R-R interval). When enough short R-R
intervals are detected, an antitachycardia event is begun.
The internal computer chooses antitachycardia pacing
(ATP - less energy use, better tolerated by patient) or
shock, depending upon the presentation and device
programming. Newer Medtronic ICDs begin a run of
ATP while charging for shock. Most ICDs are
programmed to reconfirm VT or VF after charging to
prevent inappropriate therapy. Typically, ICDs deliver
6 18 shocks per event. Once a shock is delivered, no
further ATP can take place. Despite improvements in
detection of ventricular dysrhythmias (Table 8),
77
more
than 10% of shocks are for rhythm other than VT or VF.
78

Supraventricular tachycardia remains the most common etiology of inappropriate shock therapy,
82,83
and causes
of inappropriate shock have been reviewed elsewhere.
84
Lead degradation also has led to unexpected and
inappropriate shock.
14,85
Most ICDs will begin <brady> pacing when the R-R interval is too long. ICDs with
sophisticated, dual and three chamber pacing modes (including rate responsiveness) are approved for patients who
need permanent pacing (about 20% of ICD patients). Note that the use of dual chamber (DDD) pacing in an ICD
patient might decrease survival when compared to single chamber (VVI) pacing.
86


ICD Indications Initially, ICDs were placed for VT or
VF. Currently, any patient with significant
cardiomyopathy (EF ! 35%) will likely be a candidate for
ICD placement. Table 11 shows current ICD indications.
Note that CMS requires 40 days from an ischemic event
or mechanical intervention to ICD implant.

ICD Magnets Like PMs, magnet behavior in many ICDs
can be altered by programming. Most ICDs will suspend
tachydysrhythmia detection (and therefore therapy) when
a magnet is appropriately placed. ICDs from BOS and St
Jude Medical can be programmed to ignore magnet
placement. Guidant now recommends permanently
disabling the magnet mode on 45,000 ICDs under alert for magnet switch failure.
16
In general, magnets will not
affect the brady pacing mode or rate. Sorin (was ELA) devices change pacing rate (VVI mode) to reflect battery
voltage. Interrogating the device and calling the manufacturer remain the most reliable method for determining
magnet response.

Table 9: NASPE / BPG Generic Defibrillator Code (NBD)
Position I Position II Position III
Position IV
(or use Pacemaker Code)
Shock Chambers
Antitachycardia Pacing
Chambers
Tachycardia Detection
Antibradycardia Pacing
Chambers
O = None O = None E = Electrogram O = None
A = Atrium A = Atrium H = Hemodynamic A = Atrium
V = Ventricle V = Ventricle V = Ventricle
D = Dual (A+V) D = Dual (A+V) D = Dual (A+V)
Table 10: ICD Features to Reduce Undesired Shock
Onset criteria - usually, VT onset is abrupt, whereas
SVT onset has sequentially shortening R-R intervals
Stability criteria - R-R intervals of VT is relatively
constant, whereas R-R intervals of a-fib with rapid
ventricular response is quite variable
QRS width criteria - usually, QRS width in SVT is
narrow (<110 msec), whereas QRS width in VT is
wide (>120 msec)
"Intelligence" in dual chamber devices attempting to
associate atrial activity to ventricular activity
Morphology waveform analysis with comparison to
stored historical templates
Table 11: ICD Indications
Ventricular tachycardia
Ventricular fibrillation
Post-MI patients with EF ! 30% (MADIT II)
Cardiomyopathy from any cause with EF ! 35%
(SCD-HeFT)
Hypertrophic cardiomyopathy
Awaiting heart transplant
Long Q-T syndrome
Arrhythmogenic right ventricular dysplasia

Brugada syndrome (right bundle branch block, S-T
segment elevation in leads V1-V3)


Refresher Course Lectures Anesthesiology 2013 American Society of Anesthesiologists. All rights reserved. Note: This publication contains
material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
301
Page 7
Preanesthetic Evaluation and ICD Reprogramming The patient with an ICD likely has a significant
cardiomyopathy (CMP). Guidelines from the ACC / AHA recommend beta blockade and afterload reduction for al
most every CMP patient.
87,88
Since benefits of this can therapy accrue quickly,
89
consideration might be given to
delaying a case for 1-2 weeks after initiation of therapy.
Prior to any surgery, every ICD patient should undergo preoperative ICD interrogation (ASA). ALL ICDs
should have antitachycardia therapy disabled if monopolar Bovie use is planned
43,90
or there are lead problems
predisposing to inappropriate shock.
14,85
HRS suggests that magnet placement is appropriate provided that magnet
function is enabled, the patient is supine, the magnet can be observed, and access to the magnet is unimpeded by the
surgical field.
22
The comments in the Pacing Section apply here for antibradycardia pacing.

Intraoperative (or Procedure) ICD Management No special monitoring or anesthetic technique (due to the ICD)
is required for the ICD patient. ECG monitoring and the ability to deliver external cardioversion or defibrillation
must be present during the time of ICD disablement. Note that an inappropriate shock can be delivered without
prior ECG changes if a lead is damaged or defective.
85
If emergency cardioversion or defibrillation is needed, the
defibrillator pads should be placed to avoid the pulse generator to the extent possible. Nevertheless, one should
remember that the patient, not the ICD, is being treated. The recommendations in the section Intraoperative (or
Procedure) Management of Pacemakers apply here as well. ICDs should be disabled prior to insertion of a central
line to prevent inappropriate shock, possible ICD failure, or patient injury.
91


Post Anesthesia ICD Evaluation The ICD must be reinterrogated and re-enabled, and pacing parameters should
be checked and reset as necessary. Postop interrogation might be unnecessary if no monopolar ESU was used, no
blood transfused, limited fluid administered, and no untoward issues were identified. For a disabled ICD, the
patients ECG should be continuously monitored with immediate access to defibrillation equipment until
reactivation takes place.
92,93
All ICD events should be reviewed and counters should be cleared.

Summary Electronic miniaturization has permitted the design and use of sophisticated electronics in patients who
have need for artificial pacing and/or automated cardioversion / defibrillation of their heart. These devices are no
longer confined to keeping the heart beating between a minimum rate (pacing function) and a maximum rate (ICD
functions), as they are being used as therapy to improve the failing heart. The aging of the population and our
ability to care for a patient with increasingly complex disease suggest that we will be caring for many more patients
with these devices, and we must be prepared for this situation. Safe and efficient clinical management of these
patients depends upon our understanding of implantable systems, indications for their use, and the perioperative
needs that they create.


Reference List

1. Rozner MA. J Cardiothorac Vasc Anesth 2008;
22:341
2. Boriani G et al. J Cardiothorac Vasc Anesth 2008;
22:423
3. Practice advisory for the perioperative
management of patients with cardiac implantable
electronic devices: pacemakers and implantable
cardioverter-defibrillators: an updated report by the
American Society of Anesthesiologists task force on
perioperative management of patients with cardiac
implantable electronic devices. Anesthesiology 2011;
114:247
4. Crossley G.H. et al. Heart Rhythm. 2011.
URL=www.hrsonline.org/content/download/1432/20
Appendix: Company Phone Numbers
Angeion (discontinued products) 651-484-4874 Medtronic 800-505-4636
Biotronik 800-547-0394 Pacesetter (SJM) 800-722-3774
Biotronik 800-227-3422 St Jude Medical (SJM) 800-722-3774
Cardiac Pacemakers, Inc - CPI
(BOS)
800-227-3422 Telectronics (SJM) 800-722-3774
ELA Medical 800-352-6466 Ventritex (SJM) 800-722-3774
Guidant Medical 800-227-3422 Vitatron (Medtronic) 800-505-4636
Intermedics (BOS) 800-227-3422


Refresher Course Lectures Anesthesiology 2013 American Society of Anesthesiologists. All rights reserved. Note: This publication contains
material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission. Reprinting or using individual
refresher course lectures contained herein is strictly prohibited without permission from the authors/copyright holders.
301
Page 8
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