The Heart of the Matter: Increasing Quality and Charge Capture from Intraoperative Transesophageal Echocardiography.
A & A case reports
2016; 6 (8): 249-252
TITRATION OF SEVOFLURANE IN ELDERLY PATIENTS: BLINDED, RANDOMIZED CLINICAL TRIAL, IN NON-CARDIAC SURGERY AFTER BETA-ADRENERGIC BLOCKADE
JOURNAL OF CLINICAL MONITORING AND COMPUTING
2011; 25 (3): 175-181
Although transesophageal echocardiography is routinely performed at our institution, there is no easy way to document the procedure in the electronic medical record and generate a bill compliant with reimbursement requirements. We present the results of a quality improvement project that used agile development methodology to incorporate intraoperative transesophageal echocardiography into the electronic medical record. We discuss improvements in the quality of clinical documentation, technical workflow challenges overcome, and cost and time to return on investment. Billing was increased from an average of 36% to 84.6% when compared with the same time period in the previous year. The expected recoupment of investment for this project is just 18 weeks.
View details for DOI 10.1213/XAA.0000000000000169
View details for PubMedID 27082233
Laparoscopic diaphragmatic pacer placement - a potential new treatment for ALS patients: a brief description of the device and anesthetic issues
JOURNAL OF CLINICAL ANESTHESIA
2010; 22 (7): 549-552
Monitoring depth of anesthesia via the processed electroencephalogram (EEG) has been found useful in reducing the amount of anesthetic drugs, optimizing wake-up times, and, in some studies, reducing awareness. Our goal was to determine if titrating sevoflurane as the maintenance anesthetic to a depth of anesthesia monitor (SEDLine™, Masimo, CA) would shorten time to extubation in elderly patients undergoing non-cardiac surgery while on beta-adrenergic blockade. This patient population was selected because the usual cardiovascular signs of inadequate general anesthesia may be masked by beta-blocker therapy.Surgical patients older than 65 years of age receiving beta-adrenergic blockers for a minimum of 24 h preoperatively were randomized to two groups: a group whose titration of sevoflurane was based on SEDLine™ data (SEDLine™ group) and a group whose titration was based on usual clinical criteria (control group) where SEDLine™ data were concealed. The primary endpoint was time from skin closure to time to extubation. Aldrete score, White Fast Track score and QoR-40 were also assessed.There was no significant difference in time to extubation [12.5 (SD 7.4) min in the control group versus 13.0 (SD 5.9) min for the treatment group]. The control group used more fentanyl [339 mcg (SD 205)] than did the treatment group [238 mcg (SD 123)] (P<0.02). There was no difference in sevoflurane utilization, Aldrete, White Fast Track scores, time to PACU discharge, or QoR-40 assessments between the groups.Use of the SEDLine™ monitor's data to titrate sevoflurane did not improve the time to extubation or change short-term outcome of geriatric surgical patients receiving beta-adrenergic blockers. (ClinicalTrials.gov number, NCT00938782).
View details for DOI 10.1007/s10877-011-9293-1
View details for Web of Science ID 000298814400004
View details for PubMedID 21830049
Accidental intrathecal sufentanil overdose during combined spinal-epidural analgesia for labor
INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA
2009; 18 (1): 78-80
The Diaphragm Pacing Stimulator (DPS) has been used to treat ventilatory insufficiency in quadriplegic patients. The FDA approved a trial using the DPS in patients with amyotrophic lateral sclerosis (ALS). Three patients with advanced ALS, who underwent laparoscopic diaphragmatic pacer placement, and their general anesthetic management, are presented.
View details for DOI 10.1016/j.jclinane.2009.09.010
View details for Web of Science ID 000284791000011
View details for PubMedID 21056813
General anesthesia and chronic amphetamine use: Should the drug be stopped preoperatively?
ANESTHESIA AND ANALGESIA
2006; 103 (1): 203-206
A laboring woman was accidentally given 45 microg of sufentanil intrathecally in the course of combined spinal-epidural analgesia. She experienced intense pruritus and transient swallowing difficulty without respiratory depression, but still had incomplete pain relief, with delivery and episiotomy repair requiring additional analgesia. This case highlights the importance of adding local anesthetic to intrathecal opioids to facilitate effective analgesia during the second stage of labor. The contributory systems issues and multiple factors that allowed this error to occur are examined.
View details for DOI 10.1016/j.ijoa.2008.10.001
View details for Web of Science ID 000262736700017
View details for PubMedID 19111229
Anesthesia for older patients with hypertrophic cardiomyopathy: is there cause for concern?
JOURNAL OF CLINICAL ANESTHESIA
2005; 17 (6): 478-481
Prescription amphetamines are being used more often for several medical conditions. Anesthesia concerns focus on the cardiovascular stability of patients who may be catecholamine-depleted and thus have a blunted response to intraoperative hypotension. Previously we reported one case of a patient receiving chronic amphetamine therapy who had a stable intraoperative course. We now report eight additional patients taking chronic prescription amphetamines who underwent a safe general anesthesia and outcome. Predominantly prescribed for narcolepsy and attention deficit hyperactivity disorder, amphetamine drugs had been given to these 8 patients for 2 to 10 yr. Ages ranged from 22 to 77 yr and genders were equally divided. All required general anesthesia for their surgical procedures and 6 of the 8 patients were tracheally intubated. Anesthesia operating room times ranged from 30 min to 4.25 h. The authors conclude that amphetamine use need not be stopped before surgery and anesthesia.
View details for DOI 10.1213/01.ane.0000221451.24482.11
View details for Web of Science ID 000238661900040
View details for PubMedID 16790654
The preoperative anesthesia evaluation.
Thoracic surgery clinics
2005; 15 (2): 305-315
Hypertrophic cardiomyopathy (HCM) may remain clinically silent and undiagnosed until patients reach advanced age. We describe 2 older patients with previously undetected and probable late-onset HCM whose preoperative cardiac examination revealed only the presence of a systolic murmur. Both patients were diagnosed with HCM by perioperative echocardiography. We provide an algorithm for the evaluation of murmurs detected during the preoperative anesthesia evaluation, with emphasis on the clinical characteristics of HCM, and we discuss the perioperative management of these patients. In addition, recent findings concerning the natural progression of HCM are discussed, revealing differences between HCM in younger patient populations and that in older patient populations and its implications for anesthetic management.
View details for DOI 10.1016/j.jclinane.2004.09.009
View details for Web of Science ID 000232551100013
View details for PubMedID 16171671
Concealed mothball abuse prior to anesthesia: mothballs, inhalants, and their management
ACTA ANAESTHESIOLOGICA SCANDINAVICA
2005; 49 (1): 113-116
Thorough and timely anesthesia preoperative evaluation is essential for good patient outcomes. Perioperative care is becoming more complex and comprehensive, while older and sicker patients are being considered for major thoracic surgery. In addition to pulmonary and wound care, prevention of cardiac complications with beta-blocker therapy, multimodal pain control, tighter glycemic control, nutritional support, and prevention of thromboembolism are important perioperative goals. Early identification of significant medical and nonmedical issues allows for complete evaluation and planning and decreases the likelihood of delays, cancellations, and complications. Good communication and preparation benefit everyone. The implementation of an anesthesia preoperative assessment program or clinic can help achieve these important goals.
View details for PubMedID 15999528
What is quality improvement in the preoperative period?
International anesthesiology clinics
2002; 40 (2): 1-16
The preoperative assessment of the cancer patient.
Current opinion in anaesthesiology
2001; 14 (6): 721-729
Mothballs are one of a number of volatile compounds including model airplane glue, spray paint, nail polish remover, room fresheners, and gasoline that are intentionally inhaled for the purpose of recreational self-intoxication. Their inhalation produces a rapid 'high' characterized by euphoria and generalized intoxication. Chronic abuse can be associated with significant organ impairment, and, in rare cases, cardiac dysrhythmias and deranged end-tidal gas monitoring. Mothballs contain the aromatic compound naphthalene and/or paradichlorobenzene. Prolonged exposure can cause hepatic failure and severe hemolytic anemia. We present a case of a young adult who initially concealed her chronic mothball inhalation. The literature regarding mothball abuse as well as inhalant abuse relevant to anesthesia is reviewed, and suggestions for the diagnosis and peri-operative management are offered.
View details for DOI 10.1111/j.1399-6576.2004.00510.x
View details for Web of Science ID 000226638800024
View details for PubMedID 15675996
An airway management device: The laryngeal mask airway - A review
JOURNAL OF INTENSIVE CARE MEDICINE
1998; 13 (1): 32-43
The cancer patient presents special challenges to the anesthesiologist. Cancer may have multiple effects including those due to the primary tumor, metastases, the effects and toxicity of cancer therapy, associated paraneoplastic and physiologic responses to the tumor and the strong psychological responses elicited by cancer. The preoperative evaluation of the cancer patient provides opportunities to understand the patient's medical condition and to plan management. Specific goals of the preoperative assessment include a relevant and complete patient history with emphasis on the cancer, thorough examination of the patient, appropriate diagnostic testing and formation of an anesthetic and perioperative plan. Patient education and reassurance regarding issues of safety, pain control and respect for patient preferences are important goals as well. This review provides the anesthesiologist with both general and specific information important to the systematic and complete preoperative evaluation of the patient with cancer.
View details for PubMedID 17019171