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Do you know how you perform when it comes to quality? Regardless of where your performance falls on the quality spectrum, ASA has the tools, resources and expertise to help you determine where you are, identify where you need to be, close the gaps and benchmark your performance.

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ASA® Quality Meeting This two-day conference shares how to create, implement and evaluate quality management in your practice.

Anesthesia Quality Institute (AQI)AQI facilitates quality management through education and quality data feedback offering more than 9 registries to individuals, groups and hospitals. As the largest anesthesia registry organization in the country, AQI registries help anesthesiologists and their groups easily submit case information and receive reports that help identify existing gaps in knowledge or clinical application.

Educational ResourcesASA offers a variety of educational resources including: • The Manual for Anesthesia Department Organization and Management (MADOM) • Managing Clinical Risk through Communication and Teamwork • Patient Safety • Practice Performance Assessment and Improvement (PPAI)

Learn moreasahq.org/quality

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This activity has been approved for AMA PRA Category 1 Credit™.Directly Sponsored by the American Society of Anesthesiologists.

SPA: Society for Pediatric Anesthesia

28th Annual Meeting - Oct. 10 Sheraton New Orleans

SNACC: Society for Neuroscience in Anesthesiology and Critical Care

42nd Annual Meeting - Oct. 9-11Sheraton New Orleans

SAMBA: Society for Ambulatory Anesthesia

2014 Mid Year Meeting - Oct. 10 Renaissance New Orleans Arts Hotel

SEA: Society for Education in Anesthesia

2014 SEA Fall Meeting - Oct. 10JW Marriott New Orleans

SOAP: Society for Obstetric Anesthesia and Perinatology

Board of Directors Meeting - Oct. 10-11 Hotel Monteleone

AUA: Association of University Anesthesiologists

Committee Meeting - Oct.12 Hilton New Orleans Riverside

co

nte

nts

EditorN. Martin Giesecke, M.D., Chair

Assistant EditorsDoris K. Cope, M.D., M.A.Susan G. Curling, M.D.Kenneth Elmassian, D.O.Uday Jain, M.D., Ph.D.Girish P. Joshi, M.B. B.S., M.D.Sadeq A. Quraishi, M.D.Vernon H. Ross, M.D. Karen S. Sibert, M.D.Mary Ann Vann, M.D.Anna M. Weyand, M.D. (Senior Residents’ Review Co-Editor)Kristina L. Goff, M.D. (Junior Residents’ Review Co-Editor)

Editorial Staff Terri Navarrete Jamie Reid Roy A. Winkler

Send general NEWSLETTER questions to [email protected] or call Jamie Reid at (847) 268-9112

AdvertisingJulie O’HeirTel: (847) 268-9184Fax: (847) 825-5658 E-mail: [email protected]

The Subspecialty of Ambulatory Anesthesia ....................................... 10Thomas W. Cutter, M.D., M.A.Ed.

Safe Anesthesia in the Office-Based Surgical Setting................................. 14 Brian M. Osman, M.D. Fred E. Shapiro, D.O.

Adult Patient for Ambulatory Surgery: Are There Any Limits? .......................... 18 Alan Romero, M.D. Girish P. Joshi, M.B.B.S., M.D., FFARCSI

30 Anesthetics on the Same Child – Really! Pediatric Ambulatory Anesthesia for Proton Radiation .......................... 22 Hernando De Soto, M.D.

Outpatient Continuous Peripheral Nerve Blocks ................................... 24 Elie Joseph Chidiac, M.D.

Management of MH in the Ambulatory Environment ...................... 28 Andrew Herlich, D.M.D., M.D., FAAP

The ASA NEWSLETTER (USPS 033-200) is published monthly for ASA members by the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, IL 60173-4973. Editor: [email protected]: http://www.asahq.orgPeriodical postage paid at Schaumburg, ILand additional mailing offices.

POSTMASTER: Send address changes to the ASA NEWSLETTER, 1061 American Lane, Schaumburg, IL 60173-4973; (847) 825-5586. Copyright © 2014 American Society of Anesthesiologists. All rights reserved. Contents may not be reproduced without prior written permission of the publisher. The views expressed herein are those of the authors and do not necessarily represent or reflect the views, policies or actions of the American Society of Anesthesiologists.

SUBSTANCE ABUSE HOTLINE: Contact the ASA Office at (847) 825-5586 to obtain the addresses and telephone numbers for state medical society programs and services that assist impaired physicians.

features

Observations ...................................... 4 N. Martin Giesecke, M.D.

Administrative Update .......................... 6 James D. Grant, M.D.

CEO Report ........................................ 8 Paul Pomerantz

Committee News Committee on Economics ........................ 50

Quality and Regulatory Affairs .............. 52 Maureen Amos, M.S. Matthew T. Popovich, Ph.D.

State Beat ....................................... 54 Erin A. Sullivan, M.D.

What’s New In ... Committee on Trauma and Emergency Preparedness ........................ 56

Subspecialty News Society for Ambulatory Anesthesia ............... 62

Residents’ Review .............................. 64 Kristina L. Goff, M.D.

Anesthesiology in the News .................. 66

ASA News ........................................ 68

In Memoriam .................................... 68

Letters to the Editor ........................... 69

FAER Report ..................................... 70

Classified Ads ................................... 72

Euroanesthesia 2014: Part of ASA’s Growing International Focus .. 30

Scientific and Educational Exhibits at ANESTHESIOLOGYTM 2014 ..................... 31 Dean F. Connors, M.D., Ph.D.

John B. Neeld, Jr., M.D. 2013 Recipient of ASA Distinguished Service Award ......... 32 Mark A. Warner, M.D.

Rebecca A. Aslakson, M.D., Ph.D. to Receive 2014 Presidential Scholar Award ................................... 34 Daniel Nyhan, M.D. Peter J. Pronovost, M.D., Ph.D., FCCM

Henrik Kehlet, M.D., Ph.D. to Receive 2014 Excellence In Research Award ......... 38 Francesco Carli, M.D., M.Phil., FRCA, FRCPC

SEE Question .................................... 40

A Case Report From the Anesthesia Incident Reporting System..................... 42

ACE Question .................................... 45

Subspecialty Societies at ANESTHESIOLOGYTM 2014 ..................... 46 Amr E. Abouleish, M.D., M.B.A. Sarah L. Braun Beverly K. Philip, M.D.

articles

departments

Volume 78, Number 9September 2014

ASA Corporate Supporters help create opportunities for members to learn and connect with one another at the ANESTHESIOLOGY™ 2014 annual meeting in New Orleans.

Together with their support, we can continue to grow and advance the specialty.

Thank youasahq.org/corporatesupport

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THE PERFECT COMBINATION.

ASA® INDUSTRY SUPPORTERS

ASA® ANNUAL MEETING SUPPORTERS

ASA Corporate Supporters help create opportunities for members to learn and connect with one another at the ANESTHESIOLOGY™ 2014 annual meeting in New Orleans.

Together with their support, we can continue to grow and advance the specialty.

Thank youasahq.org/corporatesupport

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THE PERFECT COMBINATION.

ASA® INDUSTRY SUPPORTERS

ASA® ANNUAL MEETING SUPPORTERS

4 September 2014 n Volume 78 n Number 9

LLikely, you’ve read about my first job after residency – a solo private practice in Victoria, Texas. When Susan and I moved there in 1989, Victoria was a city of around 50,000 citizens. About eight other physician anesthesiologists shared call with me, and we covered a varied group of private practice surgeons, working at three hospitals and one independent outpatient surgery center. Twenty-five years ago, even that outpatient surgery center had a physician anesthesiologist as its medical director. I’ll come back to that. As mentioned above, the physician anesthesiologists provided care for the patients of many different surgeons. After I had been there a while, my practice took on a comfortable routine. On Mondays, I provided anesthesia for the patients of a general surgeon. Before completing his schedule, we might have worked at all four of the facilities mentioned above. Tuesdays saw me providing anesthesia for the cardiac surgeons. I was doing peribulbar blocks for an ophthalmologist and his patients on Wednesdays. On Thursdays, at least initially, I covered obstetrical anesthesia. Fridays, my patients were those of an oral surgeon. Since the oral surgeon usually only had one or two cases, the rest of my day was filled with caring for the patients of any other surgeon who wished to schedule with me. My first two weeks in Victoria, I picked up the schedule of two of the other solo physician anesthesiologists

who went on vacation. For a brief time after that, it took a while before the weekly rhythm of my collaboration with the surgeons was established. During this time, I was able to work with many different practitioners. One of those was actually an elderly family medicine physician who still did appendectomies, inguinal hernia repairs, etc. This doctor was reasonably skilled in the O.R. At work one day he told me he was a pilot. He had a single-engine prop plane that he enjoyed flying around the Texas coastal bend country. At the end of the conversation, he invited me to go flying with him one weekend. Being somewhat cautious about such an opportunity, it did not take me long to discuss this invitation with some of the other physician anesthesiologists. They told me this surgeon pilot was on his fourth plane. He had crashed three others on landing. And if I remember correctly, not all of those had been walk-away crashes. He had been injured in

one, though by the time I knew him, he was well recovered. My anesthesiologist buddies warned me away, and I never did go flying with the family practitioner. I’m not a pilot, but thinking about this accomplished physician, who was maybe not equally skilled at his avocation of flying, made me recall a computer game I played a couple years earlier, as an anesthesiology resident. I owned an early Macintosh computer, and I had a P-51 Mustang flying game. In this game, I played the part of a fighter pilot in the U.S. Army’s Eighth Air Force during World War II. I had the option of choosing from one of several English airfields, from which I took off and headed south or east, or both, to engage the enemy. The graphics and the control of the P-51 were rudimentary compared to today’s video games, but it was enjoyable to take off and fly over the English and French countryside. What is most memorable is that of all the times I flew this video game Mustang, I always crashed it on landing, doing a nose-over without fail. So despite continued simulation, and the ability to control the plane while in flight, it was still impossible for me to land safely. Let’s return now to that non-affiliated outpatient surgery center where I occasionally worked. You will recall that this facility had a physician anesthesiologist, Dr. Tony Jirka, as its medical director. This made excellent sense to me. As physician anesthesiologists, we have long been key promoters of patient safety. By that time, the ASA Closed Claims Project (www.asaclosedclaims.org) was already well under way, with its first report being

Pilots and Safe Outpatient Anesthesia Care

observations

N. Martin Giesecke, M.D.Editor, ASA NEWSLETTER

5September 2014 n Volume 78 n Number 9

published in 1988.1 And even prior to that, ASA’s initial Standards for Basic Anesthetic Monitoring were first approved by the House of Delegates in October 1986. It was already proven to me that physician anesthesiologists

had the education and training to manage the perioperative environment in a manner that would lead to improved patient outcomes. At this surgery center, that meant less postoperative nausea and vomiting, decreased length of time to discharge, etc. We remain at the forefront of patient safety, as is evidenced in the article in this NEWSLETTER by Maureen Amos, ASA Director of Quality and Regulatory Affairs, and Matthew T. Popovich, Ph.D., ASA Quality Specialist.2

One thing we did for staff development at this outpatient surgery center was play out rare scenarios. In this manner, we were using a tried-and-true method of commercial pilot simulation training – introducing uncommon settings and developing the cognitive ability to manage an otherwise stressful situation. In these training exercises, we enlisted all of the staff to play or

watch. In one situation, we played out an O.R. fire. An actual O.R. fire is rare, but like the rarely occurring malignant hyperthermia crisis, fires can occur in outpatient surgery centers. In fact, with the amount of plastic surgery and otolaryngology performed in outpatient centers, the risk of fire may actually be increased over a typical general O.R. suite at a hospital. Practicing these situations gave us, and the staff at the surgery center, the knowledge we needed to safeguard our patients, and ourselves.

References:1. Caplan RA, Ward RJ, Posner K, Cheney

FW. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology. 1988;68(1):5-11.

2. Amos M, Popovich M. Anesthesiologists among top performers in PQRS. ASA Newsl. 2014;78(9):52-53.

About to fly in the real thing – a P-51 Mustang.

P-51 Mustang


OOur world is becoming increasingly complex, but coming changes in health care give us the opportunity to mold our future. The challenges we face are increased bureaucratic hurdles, more regulation, pressure to reduce costs and increased demands by sophisticated patients. The future is as bright as we make it – we should be building our future and not be afraid of it. Physicians, and anesthesiologists in particular, need to be at the core of creating the agenda, not reacting to it. We have three options:1. We can resist change and yearn for the way things were;2. We can submit to change and let someone else make all the

decisions; or3. We can drive change and take the lead in shaping the

practice of medicine and the delivery of health care.

The world is surely changing before our eyes. Look at what has become part of our daily vocabulary: “patient value,” “patient experience,” “population management,” “shared risk,” “bundled payments.” Physicians have a great opportunity to mold a better health care system for patients. Maureen Bisognano, president and CEO of the Institute for Health Care Improvement, said it very well: “It’s a wonderful sign that physicians are expanding from clinical care to learning what it takes to be a good leader. When you can marry the clinical background and the leadership skills, you have an opportunity to lead in a very different and distinct way. When you get someone who knows what quality looks like and pair it with a curiosity about new ways to think about leading, you produce leaders who are providing dramatic innovations in the field.”

But from where will we lead this change? We will lead it from the exam room. We will lead it from the operating room. And, yes, we will lead it from the corner office. Physicians need to take greater roles in health care leadership. Health system reform needs to be led by physicians building common goals and leading teams that effectively move health care delivery in the right direction. Physician anesthesiologists are seen as leaders and visionaries who have a keen understanding of the complexities of health care systems. In 2009, of the 6,500 hospitals in the country, only 235 were led by physicians. That number doesn’t seem to have changed greatly; this translates to about 3.6 percent of the nation’s hospitals. But as the complexities of health care change, and as we develop a stronger focus on quality, outcomes and value-based care, the number of physician leaders is sure to rise. Just a few years ago, a study showed that hospitals with physician leaders had overall quality scores 25 percent higher than organizations not led by physicians. Actually, of the top 18 hospitals in the 2013 U.S. News and World Report, 10 were led by physicians. As health care becomes more complex, we are going to need leaders who understand more than balance sheets and buildings, but also a deep understanding of the clinical arena and the entire spectrum of patient care. Because of our backgrounds and focus on quality, safety and operational efficiencies, physician anesthesiologists are uniquely qualified to lead systems, and we are very proud of ASA members who have taken the lead throughout the country. ASA members Steven Allen, M.D., CEO of Nationwide Children’s Hospital in Columbus, Ohio, and Joanne Conroy, M.D., the newly appointed CEO of the Lahey Hospital and Medical Center in Boston, are examples of physician anesthesiologists who now lead major systems. “Health care organizations are increasingly complex systems of care whose problems require solutions that address the organizational and political environment as well as the institutional norms and standards. This is the world that anesthesiologists have ‘cut their teeth on’ in training and makes them well positioned for leadership,” said Dr. Conroy. ASA member, critical care specialist and now hospital CEO, Steve Allen shares this: “While leaders arise from a variety of backgrounds, I’ve found anesthesiology has provided experiences invaluable in my eight years of running a hospital. The remarkable breadth of

Health Care Will Follow Our LeadJames D. Grant, M.D.ASA Treasurer

James D. Grant, M.D. is Chair, Department of Anesthesiology, Beaumont Health System, Royal Oak, Michigan, and practices with American Anesthesiology of Michigan.

administrative update


contemporary anesthesiology is founded on the tenet that patients are best served when we function as a team. Listening to constructive information from every team member is as important to leading a health care institution as it is to the safe and efficient care of any aspect of our specialty.” Physician leaders of change are not only emerging in the corporate suites, but also joining the halls of Congress at an exponential rate. The New York Times recently reported on a Johns Hopkins study which found that from 1960 to 2004, only 24 physicians served in Congress. In our current Congress alone, there are 20 people with medical degrees on both sides of the aisle who come from diverse medical backgrounds. As this trend continues, the 2014 election cycle has 26 physician candidates for both the U.S. House of Representatives and Senate. ASA member Andy Harris, M.D. (R-MD) is one of those 20 and the first physician anesthesiologist to serve in Congress. It is truly refreshing to know there is a voice in the House of Representatives who not only has a first-hand understanding of the issues affecting the health care of all Americans, but also those concerns specific to anesthesiology.

On the state level, there are two physician anesthesiologists currently serving as legislators. ASA Immediate Past President John M. Zerwas, M.D. is currently in his fourth term as a member of the Texas House of Representatives. In addition, ASA member and 2012 president of the Tennessee Society of Anesthesiologists Steve Dickerson, M.D. serves in the Tennessee Senate. Leadership does not start in the corporate suite or in legislative chambers. It starts at the local level. You took the first step toward being a leader by joining ASA. Wherever you practice, get involved – whether in hospital affairs, community issues, or your state component or medical society. Be sure to show the vital role that physician anesthesiologists play in the fabric of the places you practice. Each day, as we talk to our patients, they see us as leaders. When you talk to legislators, policymakers and community leaders, they see you as a leader. Thank you for your leadership and for caring about our specialty, our patients and our profession. Together, we will all be leaders who continually work to build a patient-focused system based on quality, safety, outcomes and value.

Our metrics were good. We were operationally sound.

We had enormous value. We knew it was time to sell.

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Is it time to consider a sale or merger?Rich Berube 865.293.5638 or Janette Stephenson [email protected] [email protected]

TeamHealth Anesthesia is the premier partner for anesthesia groups. It is part of TeamHealth, one of the largest providers of outsourced physician services offering integrated clinical solutions to hospitals in the areas of emergency medicine, hospital medicine, specialty hospitalists, anesthesia, urgent care and pediatrics.

teamhealthanesthesia.com

September 2014 n Volume 78 n Number 98

CEO report

AAs I write this report, much of the ASA staff is busy preparing for the ANESTHESIOLOGY™ 2014 annual meeting, which takes place in New Orleans next month. Although the meeting certainly is an enormous undertaking and is the centerpiece of the society’s initiatives every year, I want to take this opportunity to update you on a few other important projects we’ve been working on in 2014. As CEO of your professional society, my overriding goal – and the force that drives all our society’s actions – is to provide you with the resources you need to help you do your job. Here are some of the ways we’re helping to do that:

Strategic Plan Because so much uncertainty exists regarding the future of health care in the U.S., it’s important that ASA move forward under the direction of a strong, carefully considered strategic plan. I believe our three-year strategic plan developed this year under the leadership of President-Elect John P. Abenstein, M.S.E.E., M.D. and the Administrative Council will help focus our priorities and leverage both our volunteer and staff talent and resources. Above all, the current plan makes the organization adaptable to a variety of external contingencies and to the changing nature of ASA members’ needs. Our overall mission is “advancing the practice and securing the future.” And our very top priority is to grow and more fully engage ASA membership. Details of the strategic plan will be shared publicly at our October House of Delegates meeting in New Orleans.

Perioperative Surgical Home (PSH) Learning Collaborative With each passing day, we’re seeing more real-world examples of PSH initiatives being instituted in practices across the United States. Specifically, the PSH Learning Collaborative has already surpassed our expectations, as a total of 44 provider organizations have joined the collaborative, the goal of which is to provide for shared learning of the PSH in real-world settings. Working groups have been formed around metrics, clinical guidelines and payment. You will recall that this initiative is an outgrowth of recommendations from the Committee on Future Models of Anesthesia Practice, under the leadership of Michael P. Schweitzer, M.D., which were approved at the October 2013 meeting of the House of Delegates. PSH Executive Celeste Kirschner said she is very pleased with the interchange of ideas between the collaborative members, who are fine-tuning the parameters of the PSH to meet the specific needs of individual participants. The Learning Collaborative concludes in June 2015 and we look forward to sharing its results with the entire membership at that time.

Building External Relationships This is the first year ASA has had a presence at the American Hospital Association’s (AHA’s) Leadership Forum. Held in San Diego in July, the 2014 forum was a highlight of ASA’s broad efforts to build relationships with important stakeholders from all areas of the health system. As a

Paul Pomerantz, CEO

An Update From ASA HQ

Paul Pomerantz is ASA Chief Executive Officer.

“ Specifically, the PSH Learning Collaborative has already surpassed our expectations, as a total of 44 provider organizations have joined the collaborative, the goal of which is to provide for shared learning of the PSH in real-world settings.”


co-sponsor of the event, ASA was recognized by AHA President Richard Umbdenstock in front of 1,800 attendees at the conference opening. Several physician anesthesiologists attended the meeting in their roles as hospital/medical executives. A PSH session held during the Physician Leadership Forum on innovative models of care was particularly well received by an interdisciplinary audience of physicians, health system executives, national and state association leaders, and AHA Fellows.

AQI Certified QCDR As you may have already heard, the Anesthesia Quality Institute’s (AQI’s) National Anesthesia Clinical Outcomes Registry (NACOR) was designated a Qualified Clinical Data Registry (QCDR) by CMS this year. One of just a handful of entities granted this designation, NACOR now allows participants to submit data to the Physician Quality Reporting System (PQRS) on up to 19 measures. This is a huge member benefit. CMS projects that use of registry-based or QCDR mechanisms in 2015 will jump from 47,000 eligible professionals to around 165,000. QCDR reporting is free to ASA members participating in NACOR. Expect to hear a lot more about the QCDR reporting mechanism in the coming months.

New Website During the ANESTHESIOLOGYTM 2014 annual meeting, you can get a preview of our redesigned website. Through collaboration between the Committee on Electronic Media and Information Technology, the Ad Hoc Committee on Web Oversight, Ad Hoc Committee on Information Resources,

member volunteer groups and feedback from the membership overall, we are building a state-of-the-art web experience with a responsive design that will work flawlessly with any platform, whether you’re using a phone, tablet or PC. I’ve personally previewed the site and can’t wait for you to use it. Stop by the ASA Resource Center at the annual meeting for a sneak peak. The official launch will take place in January 2015.

ANESTHESIOLOGY™ 2014 Annual Meeting We strive to make each annual meeting better than the one that came before it. And we can only do that with your input and feedback. So as you go about your activities during ANESTHESIOLOGY™ 2014 next month, make sure you let us know what you think we’ve done right, and what we could do better. That being said, I believe you’ll agree that Michael F. O’Connor, M.D., F.C.C.M. and the Committee on Annual Meeting Oversight have created a great program this year. We’ve leveraged technology so that participation in educational sessions and CME is more efficient than ever before, we’ve lined up talks with some of the best minds in medicine, and our international outreach initiatives continue to grow – nearly 25 percent of meeting attendees will come from outside the U.S. Don’t miss the Opening Session on Saturday morning, which focuses on the “disruptive innovations” altering the course of health care and the opportunities offered through the PSH model of care. I look forward to working with you at the annual meeting, and beyond.

We’re pleased to welcome Louisiana Governor Bobby Jindal to the ANESTHESIOLOGY™ 2014 annual meeting. A potential GOP presidential candidate in 2016, Governor Jindal helped transform Louisiana’s health care system and has been lauded for his efforts in education and ethics reform. Don’t miss his talk during the meeting’s Opening Session on Saturday, October 11.

I look forward to seeing you all in New Orleans!

BBecause of advances in technology (e.g., short-acting anesthetics and minimally invasive surgical techniques) and changes in remuneration,1 ambulatory anesthesia comprises greater than 70 percent of all anes-thetics administered in the United States (Figure 1). In 2006, 53 million surgical and non-surgical procedures were performed in an ambulatory setting, with 57 percent performed in a hospital as opposed to a freestanding center.1 This relationship has remained essentially constant through 2013 (Figure 2). Although ambulatory anesthesia is the most widely practiced subspecialty of anesthesia in the nation, relatively few physicians identify themselves as ambulatory anesthesiologists by membership in a professional society. The Society of Cardiovascular Anesthesiologists has 5,000 members2 and the American Society of Regional Anesthesia and Pain Medicine has 4,000 members,3 but the Society for Ambulatory Anesthesia (SAMBA) has only 1,600 members.4 There is a perception that anesthetics administered in outpatient centers simply draw from a common knowledge base to which nothing unique

is added because of the ambulatory setting. But ambulatory anesthesiologists and post-anesthesia care nurses will tell you that certain methods result in better outcomes and certain anesthesiologists achieve those outcomes more often than others. Optimal results in the ambulatory setting are a product of specialized knowledge and techniques. Preoperatively, most ambulatory anesthesiologists have encountered a patient who is deemed unsafe for an ambulatory procedure because of comorbidities, so one aspect of ambulatory practice is the painstaking selection of appropriate patients. Experienced ambulatory anesthesiologists are often asked for a list of criteria to determine suitable patients for the outpatient setting. Among the questions asked are: What is the maximum patient weight for an ambulatory procedure? Should I care for a patient with a known difficult airway? Is a spinal anesthetic acceptable? Are patients with an implantable cardiac defibrillator (ICD) appropriate? While there may be value in creating an ambulatory checklist, there are problems as well. To uniformly refuse care in an ambulatory center to all individuals

Thomas W. Cutter, M.D., M.A.Ed. is Professor, Associate Chairman, Anesthesia and Critical Care, Pritzker School of Medicine, University of Chicago, and Medical Director for Perioperative Services, University of Chicago Medical Center.

The Subspecialty of Ambulatory AnesthesiaThomas W. Cutter, M.D., M.A.Ed.


Figure 1

Percentage of cases identified as ambulatory anesthetics in the National Anesthesia Clinical Outcomes Registry, Anesthesia Quality Institute, 2010-14 (personal communication, Richard Dutton, M.D., Executive Director, Anesthesia Quality Institute, May 2014).

with a given condition may unduly limit patient access and reduce the facility’s value to providers. Rather than a checklist that is limited to patient characteristics, consideration also must be given to the providers, the procedure and the place. We have to integrate the comorbidities of the patient, the skill-sets of and access to the providers, the procedure itself, the availability of equipment and the location of the facility in terms of its proximity to advanced care. Facilities (place) in which ambulatory anesthesia is practiced may include hospitals with a designated suite of operating rooms or individual rooms throughout the general suite. Alternatively, a separate building may be dedicated to ambulatory procedures, referred to as an on-campus setting. Outpatient procedures also can be performed in a freestanding surgicenter located some distance from a hospital. The final location is the office, which is probably the ne plus ultra of ambulatory anesthesia. Each of these settings has its advantages and limitations in terms of the ability to care for a patient with a complex medical condition having a given procedure. Equipment and the proximity to other facilities for support or patient transfer are important factors to consider here. The number of providers and their level of training also impact the selection process. The skill-sets of the ancillary staff are important, especially for postanesthesia care. Having a receptionist with no medical training who also serves as the individual who monitors a patient after a procedure limits the complexity of the procedure and anesthetic technique. Utilizing

trained and capable post-anesthesia care nurses may mean that more complex procedures and anesthetics may be performed. Having an anesthesia technician provides for superior equipment support so that more sophisticated techniques (e.g., fiberoptic bronchoscopy) may be performed, as well as the benefit of having someone who can serve as a trained assistant familiar with anesthesia practices. Having an anesthesiologist participate in the anesthetic (i.e., perform, medically direct or supervise) is also advisable. Thus, the caliber and quantity of primary and support personnel should influence the selection process. The procedure is another important part of the equation. In the 1990s, criteria for an acceptable procedure included minimal blood loss or fluid shift, procedure time of less than 90 minutes with simple equipment, minimal postoperative care and postoperative pain that could be treated with oral medications.5 Today, the only requirement is that the patient goes home the same day or, in some settings, within 23 hours. There are no hard and fast rules to distinguish an ambulatory procedure from an inpatient procedure other than the patient’s ability to go home safely the same day. When an anesthesiologist administers an anesthetic from which the patient can recover within a few hours with minimal side effects, the limiting feature becomes the postoperative care associated with the procedure. The final factor in the equation is the patient. Some may believe that only ASA Physical Status (ASA-PS) 1 or 2 patients


Continued on page 12

Figure 2

Facility type for ambulatory cases reported to the National Anesthesia Clinical Outcomes Registry, Anesthesia Quality Institute, 2010-14 (personal communication, Richard Dutton, M.D., Executive Director, Anesthesia Quality Institute, May 2014).


should be cared for in an ambulatory setting, but others are more discerning. In one survey, more than 90 percent of Canadian anesthesiologists responded that they would administer an anesthetic to an ASA-PS 3 ambulatory patient,6 including those with stable congestive heart failure, asymptomatic valvular heart disease or a previous myocardial infarction older than six months. More than 90 percent of the anesthesiologists considered patients with unstable angina or morbid obesity with cardiovascular or respiratory complications unsuitable for ambulatory procedures. Yet such patients may be suitable if the place, the procedure and the personnel are also considered. For example, a patient with obstructive sleep apnea can safely receive a lower-extremity regional anesthetic with intravenous sedation and analgesia in many ambulatory facilities. There is little, if any, evidence that an otherwise healthy patient with a body mass index above a certain level is at increased risk for an ambulatory procedure, if the operative table is able to support the patient’s weight. Although some anesthesiologists may refuse to care for a patient with an ICD in an office-based practice or a surgicenter, performing a procedure for this patient in an on-campus or integrated facility may be entirely appropriate. Thus, one must assimilate a variety of factors into a meaningful whole before selecting a patient for admission to an ambulatory setting. Figures 3 and 4 illustrate this principle with overlapping circles indicating suitability. Guidelines may

follow when more data from the National Anesthesia Clinical Outcomes Registry (NACOR) and the SAMBA Clinical Outcomes Registry (SCOR) become available, but for now we must depend on our clinical acumen.

Since the defining aspect of an ambulatory anesthetic is the patient’s ability to safely and comfortably leave the facility the same day, the anesthesiologist must not only carefully select the patient, but also the intraoperative and postoperative techniques to avoid sequelae that would delay discharge to home. These “barriers” to discharge include pain, postoperative nausea and vomiting, excessive sedation and physiologic derangement. Pain has been regarded as the most common and most important adverse postoperative outcome after ambulatory surgery.7-9 Multimodal therapy using low-dose opioids, non-steroidal anti-inflammatory drugs and regional anesthesia can serve to mitigate pain. Postoperative nausea and vomiting is another impediment and can often be prevented or treated with a multimodal approach. Because excessive sedation also results in delayed discharge,10,11 preoperative and intraoperative sedative-hypnotics and intraoperative and

Continued from page 11

Figure 3

Patient, providers, procedure and place all overlap: proceed.

Figure 4

Patient, providers, procedure and place do not all overlap: do not proceed.

September 2014 n Volume 78 n Number 9 13

postoperative opioids should be used judiciously. Morbid events such as cardiac ischemia, hyperglycemia, a cerebral vascular accident or persistent hypotension also may delay discharge or result in admission to an inpatient facility. Preventing the sequelae of comorbidities, surgical and anesthetic side effects, and other complications is of paramount importance to ensuring a safe and timely discharge to home. Ambulatory anesthesia is a subspecialty, just as are cardiac, pediatric or obstetric anesthesia. Patients, procedures, facilities and providers are diverse, the combinations and permutations are many, and correct decisions are critical. The uniqueness of ambulatory anesthesia arises not just from the patient and the procedure, but also from the breadth and complexity of the problems and their solutions.

References:1. Cullen KA, Hall MJ. Golosinskiy A. Ambulatory surgery in

the United States, 2006. Natl Health Stat Report. 2009;(11):1-28. http://www.cdc.gov/nchs/data/nhsr/nhsr011.pdf. Published January 28, 2009. Revised September 4, 2009. Accessed July 16, 2014.

2. Society of Cardiovascular Anesthesiologists website. http://www.scahq.org/default.aspx. Accessed May 28, 2014.

3. American Society of Regional Anesthesia and Pain Medicine website. http://www.asra.com/membership.php. Accessed May 28, 2014.

4. Society for Ambulatory Anesthesia website. http://www.sambahq.org/p/cm/ld/fid=11. Accessed May 28, 2014.

5. White PF. Ambulatory anesthesia and surgery: past, present and future. In: White PF, ed. Ambulatory Anesthesia and Surgery. Philadelphia: WB Saunders; 1997.

6. Friedman Z, Chung F, Wong DT: Ambulatory surgery adult patient selection criteria - a survey of Canadian anesthesiologists. Can J Anaesth. 2004;51(5):437-443.

7. Macario A, Weinger M, Truong P, Lee M: Which clinical anesthesia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists. Anesth Analg. 1999;88(5):1085-1091.

8. Swan BA, Maislin G, Traber KB. Symptom distress and functional status changes during the first seven days after ambulatory surgery. Anesth Analg. 1998;86(4):739-745.

9. Chung F, Un V, Su J. Postoperative symptoms 24 hours after ambulatory anaesthesia. Can J Anaesth. 1995;43(11):1121-1171.

10. White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete’s scoring system. Anesth Analg. 1999;88(5):1069-1072.

11. Atiyeh L, Philip BK. Adverse outcomes after ambulatory anesthesia: surprising results [abstract A30]. Presented at: American Society of Anesthesiologists 2002 Annual Meeting; October 12-16, 2002; Orlando, Florida. http://www.asaabstrac ts .com/strands/asaabstrac ts/abstrac t .htm; jsess ionid=69F0DB1BD4957340DC7F28C84994D2AD?year=2002&index=1&absnum=796. Accessed July 17, 2014.

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Accreditation and Credit Designation StatementsThe American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

¥The American Society of Anesthesiologists designates this enduring material for a maximum of 5.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

*The American Society of Anesthesiologists designates this enduring material for a maximum of 100 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


TThe rapid growth in volume and complexity of office-based medical and surgical procedures over the last 25 years represents a profound change in how health care is delivered in the United States. Initially, cosmetic, gastrointestinal and ophthalmologic procedures made up the bulk of office-based surgeries, but this has expanded to many other medical specialties such as interventional radiology, cardiology, vascular surgery, gynecology and podiatry.1,2 In fact, nearly half as many outpatient hospital procedures are being performed; the caseload in offices and surgicenters has more than doubled.1,2

The advantages of this shift to the office-based setting include greater ease of scheduling, better overall patient satisfaction, and decreased costs to providers and the patients than if performed in a hospital.

How safe is anesthesia in the office-based setting? Despite the numerous advantages of performing procedures outside the hospital, the office environment can introduce significant concerns over patient safety and well-being. First, private offices may lack the necessary resources should an anesthetic or surgical emergency arise: difficult airway and/or rapid resuscitation equipment. Other issues could include personnel adequately trained to handle emergencies, having reliable transfer resources, plans and policies, and the proximity to a nearby hospital capable of handling serious complications. The capabilities and scope of practice of an office or surgicenter can be stretched, given the increased volume and complexity of cases and being faced with the chronic medical conditions of an aging population.

These potential issues have made “office-based safety” the focus of several publications and professional societies. The number of reported adverse events has garnered enough attention to warrant regulations at the federal and state level. Government regulations are attempting to heighten awareness and level “the playing field” across a variety of surgical sites to ensure a standard of care. Whereas the federal government is racing to keep up with the boom of office-based procedure expansion, the regulation of medical office suites is primarily done at a state level.3

Office-based safety: current literature Interest in patient outcomes regarding morbidity and mortality has prompted numerous retrospective studies that compare how patients fare in the office versus the hospital setting. To date, there is little evidence that measures how procedures in the office setting affect patient safety outcomes. The landmark retrospective studies, despite limitations, have offered an important foundation for the development of effective office-based safety strategies. One of the earliest studies performed by Vila et al. involved a collection of case reports from 2000-02 that opened the eyes of the medical community, focusing on the risk procedures performed outside of the hospital pose to patients.5,6 Coldiron et al. collected data from 2000-07 suggesting that generalizations made about location and type of anesthesia are not as important as the type of surgery performed in the office. From 2001-06, the American Association for Accreditation of Ambulatory Surgery Facilities collected data that suggest the mortality

Brian M. Osman, M.D. is Instructor in Anaesthesia, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston.

Fred E. Shapiro D.O. is Chair, ASA Committee on Patient Safety and Education; Assistant Professor of Anesthesia, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston.

Safe Anesthesia in the Office-Based Surgical SettingBrian M. Osman, M.D. Fred E. Shapiro, D.O.

Committee on Ambulatory Surgical CareCommittee on Patient Safety


rate in office-based procedures is extremely rare at a rate of 0.002 percent – the most common cause of morbidity and mortality being postoperative pulmonary embolus.7 Further studies attempted to pinpoint whether the type of anesthesia used makes any difference in injury during procedures performed in the office-based setting. Whereas the debate continues regarding the safety of MAC versus general anesthesia, facility accreditation, practitioner board certification and scope of practice have become important areas of scrutiny.

Does facility accreditation and board certification improve safety? The mantra behind this question is standardization of the quality of care provided by facilities and practitioners while also keeping providers and offices operating within their usual scope of practice. Similar processes are already in place at ambulatory surgery centers and hospital-based facilities, and new state mandates are requiring offices performing medical and surgical procedures to obtain accreditation.3 In fact, accreditation is being required for office-based surgery activities by nearly 30 states in the U.S., with more states to follow.3 Conversely, there is a lack of solid evidence suggesting that board certification and/or accreditation can make a difference in patient outcomes. A closer look at some of the adverse office surgical outcomes by Coldiron et al. in the state of Florida from 2000-07 showed that almost 40 percent of deaths and hospital transfers occurred from “accredited” sites where the majority of physicians were “board certified.”5,6 These findings

were corroborated by Starling et al. looking at six years of adverse event reporting in the state of Alabama.8 A movement to improve the uniformity and adverse event reporting in offices could shed light on the importance of certification and accreditation in office-based patient safety.

From ASA: appropriate patient and procedure selection Anesthesiology providers are expected to be gatekeepers for the appropriate selection of patients for office-based anesthesia. There are some patients who may have disease or comorbidities that will place them at a higher risk for morbidity and mortality within the office-based setting. ASA has addressed this issue by endorsing a general set of criteria for patient selection in order to standardize patient care irrespective of the procedure location.9

A detailed medical history, labs and preoperative testing should preferably be done ahead of the scheduled procedure date along with any optimization of chronic medical conditions.10

Selecting the proper procedure for patients involves assessing the capabilities of the facility and the type of surgery being performed, with attention given to duration and complexity. The physician should practice within his or her scope of practice and the procedure should allow for appropriate recovery and discharge times. Issues such as excessive blood loss, postoperative pain or the possibility of extreme nausea/vomiting need to be considered as well as the facility’s ability (i.e., equipment and staff) to handle surgical emergencies.



A recent review of the literature suggested that cosmetic and dental procedures are potentially high-risk interventions in the office setting. Keyes et al. suggested that abdominoplasty can be associated with a higher risk of deep venous thrombosis and death from pulmonary embolism.7,11 The American Society of Plastic Surgeons responded by setting certain limitations to the number of cosmetic procedures performed at one time as well as the duration of surgeries to help mitigate these risks.12

Dental procedures pose a unique set of challenges for the physician anesthesiologist, including the potential for ventilation and airway problems, smaller work areas compared to an operating room, and also the responsibility to ensure that all appropriate back-up and rescue equipment is readily available. Some state dental boards are now requiring additional licensing in order to administer anesthesia.1 Methods for quality improvement and monitoring outcomes Due to the lack of randomized controlled trials assessing the safety of office-based anesthesia, our best literature to date comes from the ASA Closed Claims Database. Despite the three- to five-year lag between an event and its appearance in the database, the claims represent a window to the distinct vulnerabilities within the office-based setting.11 Early studies reported that the severity of injury for office-based claims was worse than in other ambulatory anesthesia settings and,

consequently, the claims resulted in larger payment.13 Review of the closed claims data has shown that regardless of the type of anesthesia employed, general anesthesia and monitored anesthesia care (MAC) may carry a similar risk profile.14

However, given that MAC is frequently used for office-based procedures, commonly reported issues that have plagued anesthesia in both the inpatient and outpatient settings have warranted closer review for comparison of adverse events during office-based procedures. Studies examining claims involving respiratory and airway events, hypoxia from over-sedation and O.R. fires have suggested that the implementation of better monitoring equipment and better vigilance by the provider could have prevented injury.13 Bhananker et al. revealed that facial plastic surgery represented 26 percent of MAC liability incidents.14 Most of the evidence-based literature related to office-based safety comes from the plastic surgery field.11

Data collection from the Society for Ambulatory Anesthesia (SAMBA) from 2008-10 involved a large number of cases from a multitude of specialties.11 They reported very low overall complication rates and suggested that office-based anesthesia sites compared favorably with safety and outcome data from the ambulatory and hospital practices, in spite of a low number of self-selected voluntary reporting of outcomes.15 Implementation and expansion of clinical outcome registries have begun to address this issue and improve event reporting and accuracy of data guiding improvements in office-based anesthesia practices and patient safety.


“ Significant advancements in patient safety can be made with a national standard of care, safety checklists and enforcement of professional practice guidelines. As data emerges from effective, large administrative databases, we will be able to make more definitive conclusions about patient safety and outcomes.”


Future directions in office-based procedural and surgical safety Improvements to the quality of large-scale outcome reporting have become a focus of entities such as the SAMBA Clinical Outcomes Registry (www.scordata.org) and the ASA Anesthesia Quality Institute data registries (www.aqihq.org).11

Recently, an office-based anesthesia-specific checklist template has been developed based on the World Health Organization checklist as a means to further improve patient safety.16

Whereas several states are regulating office-based practices, some are already requiring accreditation by entities such as the Accreditation Association for Ambulatory Health Care (AAAHC), and it would seem logical that involvement of the government at the federal level is rapidly approaching.17 In 2012 and 2013, government agencies such as the Government Accountability Office (GAO) and Centers for Medicare & Medicaid Services (CMS) have initiated new regulation in ambulatory care centers, such as mandatory data collection and quality reporting, that could result in payment penalties for failure to properly report quality measures to CMS.18,19 One might speculate that these regulations will certainly find their way into office-based surgical facilities in the near future. Office-based anesthesia continues to expand rapidly, and the procedures are becoming more complex. The literature related to this topic is in its adolescence, but the similar risk profiles with other practice locations is drawing attention to the fact that office-based anesthesia should be held to the same standard of care as ambulatory surgicenters and hospitals. With patient safety and outcomes under increasing scrutiny, legislative mandates involving credentialing, qualifications, licensing and facility accreditation should be expected in the future. Significant advancements in patient safety can be made with a national standard of care, safety checklists and enforcement of professional practice guidelines. As data emerges from effective, large administrative databases, we will be able to make more definitive conclusions about patient safety and outcomes.11

References:1. Kurrek MM, Twersky RS. Office-based anesthesia: how to start an

office-based practice. Anesthesiol Clin. 2010;28(2):353-367.2. Koenig L, Doherty J, Dreyfus J, Xanthopoulos J; KNG Health

Consulting. An Analysis of Recent Growth of Ambulatory Surgery Centers. Rockville, MD: KNG Health Consulting; June 5, 2009.

3. Accreditation Handbook for Office-Based Surgery. Skokie, IL: Accreditation Association for Ambulatory Health Care (AAAHC); 2013.

4. Vila H Jr, Soto R, Cantor AB, Mackey D. Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers. Arch Surg. 2003;138(9):991-995.

5. Coldiron B, Shreve E, Balkrishnan R. Patient injuries from surgical procedures performed in medical offices: three years of Florida data. Dermatol Surg. 2004;30(12, pt 1):1435-1443.

6. Coldiron BM, Healy C, Bene NI. Office surgery incidents: what seven years of Florida data show us. Dermatol Surg. 2008;34(3):285-291.

7. Keyes GR, Singer R, Iverson RE, et al. Mortality in outpatient surgery. Plast Reconstr Surg. 2008;12(1)2:245-250.

8. Starling J 3rd, Thosani MK, Coldiron BM. Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal. Dermatol Surg. 2012;38(2):171-177.

9. Taghinia AH, Liao EC, May JW Jr. Randomized controlled trials in plastic surgery: a 20-year review of reporting standards, methodologic quality, and impact. Plast Reconstr Surg. 2008;122(4):1253-1263.

10. Ahmad S. Office based–is my anesthetic care any different? Assessment and management. Anesthesiol Clin. 2010;28(2):369-384.

11. Shapiro FE, Punwani N, Rosenberg NM, et al. Office-based anesthesia: safety and outcomes. Anesth Analg. 2014; 119:276-85.

12. Iverson RE; 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(5):1337-1342.

13. Domino KB. Office-based anesthesia: lessons learned from the closed claims project. ASA Newsl. 2001;65(6):9-11.

14. Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology. 2006;104(2):228-34.

15. Walsh MT, Kurrek MM, Desai M. Anesthesia outcomes in office-based anesthesia [abstract A798]. Presented at: American Society of Anesthesiologists 2010 Annual Meeting; October 18, 2010; San Diego, California. http://www.asaabstracts.com/strands/asaabstracts/search.htm;jsessionid=6CDD7A91159C9CAA33485BDCA991766A. Accessed July 18, 2014.

16. Rosenberg NM, Urman RD, Gallagher S, Stenglein J, Liu X, Shapiro FE. Effect of an office-based surgical safety system on patient outcomes. Eplasty. 2012;12:e59. http://www.eplasty.com/index.php?option=com_content&view=article&id=725&catid=173:volume-12-eplasty-2012&Itemid=121. Published December 25, 2012. Accessed July 18, 2014.

17. Florida Department of Health, Board of Medicine. Standard of Care for Office Surgery. Florida Administrative Code & Florida Administrative Register website. https://www.flrules.org/gateway/ruleno.asp?id=64B8-9.009. Accessed July 18, 2014.

18. Government Accountability Office. Patient safety: HHS has taken steps to address unsafe injection practices, but more action is needed. GAO-12-712. http://www.gao.gov/assets/600/592406.pdf. Published July 13, 2012. Accessed July 18, 2014.

19. Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical Center Payment; Hospital Value-Based Purchasing Program; Physician Self-Referral; and Patient Notification Requirements in Provider Agreements. Fed Regist. 2011;76(230):74122-74584. Codified at 42 CFR Parts 410, 411, 416, 419, 489, and 495. http://www.gpo.gov/fdsys/pkg/FR-2011-11-30/pdf/2011-28612.pdf. Published November 30, 2011. Accessed July 18, 2014.


IImprovements in surgical and anesthesia practice as well as economic pressures have increased the number of procedures being performed on an outpatient basis. Surgical procedures and patients once considered inappropriate for ambulatory surgery are now considered appropriate. For example, painful, invasive surgical procedures (e.g., major orthopedic surgery such as shoulder surgery and total knee arthroplasty) are increasingly being performed in an ambulatory setting1 due to improvements in surgical and local/regional analgesia techniques2 and modifications in postoperative/post-discharge care. As older and sicker patients undergo more complex surgical procedures in an ambulatory setting, patient selection has become the cornerstone of safe and efficient perioperative care. Clearly, identifying a patient suitable for an ambulatory procedure is a dynamic process that depends on the complex interplay between patient characteristics (e.g., coexisting medical conditions), invasiveness of the procedure (e.g., need for postoperative observation, blood loss requiring blood transfusion, need for parenteral therapy, including analgesics), anesthetic technique (e.g., local/regional versus general anesthesia) and post-discharge factors such as ability to manage pain and availability of a responsible caregiver. In addition, it is necessary to consider the ambulatory setting (i.e., office-based, free-standing ambulatory surgery center, hospital-based ambulatory surgery center or short-stay), as it

will influence the ability to manage complex patients based upon the availabilities of personnel and equipment. Although it may be difficult to quantify, appropriateness of patient selection may also depend upon the experience and skill of the surgeon and the physician anesthesiologist. Therefore, attempts to address individual factors without consideration of others is fraught with flaws. Overall, the literature on optimal patient selection for ambulatory surgery is sparse and of limited quality. However, there is a general agreement that patients with a high burden of comorbidities, particularly those with poorly stabilized medical conditions, are not suitable for ambulatory surgery. A recent study used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to assess the morbidity and mortality within 72 hours after ambulatory surgery in adults (n=244,397).3 The incidence of perioperative morbidity and mortality was 0.1 percent (1 in 1,053 cases). The independent risk factors for increased perioperative morbidity, after controlling for surgical complexity, included high body mass index (BMI), chronic obstructive pulmonary disease, history of transient ischemic attack/stroke, hypertension, previous cardiac surgical intervention and prolonged operative time. The most common morbidities included unplanned postoperative intubation, pneumonia and wound disruption. One of the limitations of this study is that the observed complication rate was low, resulting in inability to detect some

Alan Romero, M.D. is Assistant Professor at University of Texas Southwestern Medical Center, Dallas.

Girish P. Joshi, M.B.B.S., M.D., FFARCSI is Professor of Anesthesiology and Pain Management, and Director, Perioperative Medicine and Ambulatory Anesthesia, University of Texas Southwestern Medical Center, Dallas.

adult patient for ambulatory surgery: Are There Any Limits?Alan Romero, M.D.

Girish P. Joshi, M.B.B.S., M.D., FFARCSICommittee on Ambulatory Surgical Care


of the clinically meaningful risk factors.3 Furthermore, these retrospective analyses may not always be relevant in the current rapidly changing surgical and anesthetic practice environment. Another recent study reported that the predictors of unplanned hospital admission included length of surgery more than one hour, high ASA Physical Status classification (≥ASA 3), advanced age (>80 years) and increased BMI. The authors suggest that, despite its inter-rater variability, the ASA Physical Status classification could be used as a marker of perioperative risk rather than attributing risk to a specific disease process.4

Most studies have identified obesity as a risk factor for perioperative complications. However, a systematic review revealed that BMI alone does not influence perioperative complications or unplanned admission after ambulatory surgery.5 Morbidly obese patients (BMI>40 kg/m2) with

optimized comorbid conditions could safely undergo ambulatory surgery. On the other hand, super obese (i.e., BMI >50 kg/m2) may not be suitable for ambulatory surgery.5

Because 60-70 percent of morbidly obese patients have sleep-disordered breathing (i.e., obstructive sleep apnea [OSA] and obesity-related hypoventilation syndrome), it is necessary to consider the presence of OSA when determining suitability for ambulatory surgery, as it has also been associated with increased perioperative complications. A review of published literature assessing perioperative complications in patients with OSA undergoing ambulatory surgery revealed that OSA patients with inadequately treated co-morbid conditions are not suitable for ambulatory surgery.6

Patients with a known diagnosis of OSA (who are typically prescribed positive airway pressure [PAP] therapy) may be considered for ambulatory surgery if their comorbid medical conditions are optimized and they are able to use a PAP device in the postoperative period. It appears that postoperative PAP therapy may be protective against opioid-induced respiratory depression. Patients who are unable or unwilling to use a PAP device 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.6 ASA recently published updated guidelines regarding perioperative management of OSA patients, including selection for ambulatory surgery.7

Patients with diabetes mellitus often have several comorbidities; however, it is not a contraindication to ambulatory surgery. It is necessary that the surgical facilities

“ Overall, the literature on optimal patient selection for ambulatory surgery is sparse and of limited quality. However, there is a general agreement that patients with a high burden of comorbidities, particularly those with poorly stabilized medical conditions, are not suitable for ambulatory surgery.”



caring for this patient population have the necessary equipment to monitor blood glucose levels. The Society for Ambulatory Anesthesia (SAMBA) has published a consensus statement on perioperative blood glucose management, which provides some guidance on preoperative care of diabetic patients.8 Scheduling patients who are susceptible to malignant hyperthermia (MH) at a freestanding ambulatory surgery center remains controversial. There appears to be a higher rate of mortality for MH patients who are transferred from other health care facilities, including ambulatory surgery centers.9 Therefore, all anesthetizing facilities should prepare for the eventuality of an MH event if a triggering agent is being used. It is generally accepted that MH patients can undergo ambulatory surgery as long as the anesthesia machine is prepared properly and a trigger-free anesthetic can be provided.10 Increasing complexity of the newer anesthesia machines may increase the role for charcoal filters, which are able to filter inhaled anesthetics to lower than five parts per million.10 Of note, prophylactic dantrolene administration is not warranted, and postoperative discharge times do not need to be prolonged as long as a non-triggering anesthetic was given and the patient otherwise has no signs that can be attributed to an MH manifestation.

Summary Developing and implementing protocols also known as clinical pathways is the best way to improve perioperative outcome. Uniform practice improves safety and efficiency. This requires a multidisciplinary approach in which the physician anesthesiologist takes the lead in collaborating with surgeons and perioperative nurses. The first step in determining appropriate patient selection includes preoperative assessment and identification of any comorbid conditions, which should be optimized to minimize risks. The social situation should be evaluated to determine whether the patient has help at home for postoperative care. Also, it is necessary that we are involved with the post-discharge care, which includes education of patients and their caregivers regarding the need for increased vigilance after discharge home. Patients should receive written pre- and postoperative instructions and be discharged to the care of a responsible adult. In the near future, as more surgical procedures and patients are moved from inpatient facilities to outpatient facilities, it will be appropriate to develop exclusion criteria, rather than inclusion criteria, for patients who are not candidates for ambulatory surgery.

References:1. Lovald S, Ong K, Lau E, Joshi G, Kurtz S, Malkani A. Patient selection

in outpatient and short-stay total knee arthroplasty. J Surg Orthop Adv. 2014;23(1):2-8.

2. Joshi GP, Kehlet H. Procedure-specific pain management: the road to improve postsurgical pain management? Anesthesiology. 2013;118(4):780-782.

3. Mathis MR, Naughton NN, Shanks AM, et al. Patient selection for day case-eligible surgery: identifying those at high risk for major complications. Anesthesiology. 2013;119(6):1310-1321.

4. Whippey A, Kostandoff G, Paul J, Ma J, Thabane L, Ma HK. Predictors of unanticipated admission following ambulatory surgery: a retrospective case-control study. Can J Anaesth. 2013;60(7):675-683.

5. Joshi GP, Ahmad S, Riad W, Eckert S, Chung F. Selection of patients with obesity undergoing ambulatory surgery: a systematic review of the literature. Anesth Analg. 2013;117(5):1082-1091.

6. Joshi GP, Ankichetty S, Chung F, Gan TJ. Society for Ambulatory Anesthesia consensus statement on preoperative selection of patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115(5):1060-1068.

7. American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2014;120(2):268-286.

8. Joshi GP, Chung F, Vann MA, et al.; Society for Ambulatory Anesthesia. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg. 2010;111(6):1378-1387.

9. Rosero EB, Adesanya AO, Timaran CH, Joshi GP. Trends and outcomes of malignant hyperthermia in the United States, 2000 to 2005. Anesthesiology. 2009;110(1):89-94.

10. Litman R, Joshi GP. Malignant hyperthermia in the ambulatory surgery center: how should we prepare? Anesthesiology. 2014;120(6): 1306-1308.


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PProton therapy, a type of external-beam radiation therapy, was first proposed by Robert Wilson in a 1946 article that described the unique physical properties of protons and their potential application in oncology.1 The first proton centers were actually high-energy research facilities built in the 1950s. Clinically, patients first received proton radiation therapy in 1958. These early centers, although primitive in their design, demonstrated the potential for normal-tissue sparing with more accurate tumor targeting. Consequently, the technology mushroomed and in the past 10 years proton therapy has gained favor for pediatric malignancies. This is for two primary reasons: First, it is well-recognized that the developing organs of pediatric patients are especially sensitive to the damaging effects of ionizing radiation. Second, recent advances in pediatric oncology mean that more children are cured of their cancer, and survivors’ functional and quality-of-life endpoints are of highest importance. According to a recent patterns-of-care study,2 the total number of children treated at U.S. proton centers increased 33 percent between 2010 and 2012 (from 465 patients in 2010 to 694 patients in 2012). In 2012, the three most commonly treated pediatric tumors were brain tumors (ependymoma, 106 patients; medulloblastoma, 89 patients; and low-grade glioma [LGG], 78 patients).

Pediatric Ambulatory Anesthesia “Outside the O.R.” Recently, we have seen an increasing demand to perform anesthesia on children outside the O.R.3 This new development creates significant, exciting professional chal-lenges for the physician anesthesiologist. Patients having procedures performed in such distant locations as radiology suites, emergency rooms, burn units, GI labs, pulmonary labs, etc., will require sedation and/or anesthesia for diagnostic and therapeutic procedures. Children requiring such anesthesia outside the

O.R. need to have the same anesthesia requirements as those having surgery in the main O.R. Patient safety protocols need to be established, including a thorough preoperative evaluation, preparation for intraoperative course and a suitable location for postoperative care.4 Appropriate consultations and laboratory work-ups should be obtained as needed. A working system to admit the ambulatory patient or to transfer patients to the hospital (in a “freestanding” facility) need to be in place in the event of a complication or side-effect from the procedure. Most physician anesthesiologists in the U.S. do not have admitting privileges to hospitals, and this admitting dilemma needs to be sorted out before the commencement of the anesthesia service in that location. Pediatric patients scheduled for surgery in such locations often represent significant anesthesia challenges5 such as upper-respiratory infection, asthma, obstructive sleep apnea, heart murmur, prematurity, sickle-cell disease and cancer. Also, some children may be born with specific syndromes, especially craniofacial, that may complicate airway management and may include increased intracranial pressure. However, the children can be anesthetized safely as long as their medical condition is optimized.

The Child With Cancer The procedure being performed may contribute to the complexity of the situation.6 Often these procedures can be painful (i.e., bone marrow examinations and lumbar punctures). Procedure-related pain is a major source of distress to many children and their families, and it is often viewed as

Hernando De Soto, M.D. is an Associate Professor, Department of Anesthesiology, University of Florida, Jacksonville; Director of Pediatric Anesthesia, UF Health Jacksonville, Chief of Anesthesiology Services, UF Proton Therapy Institute, Jacksonville.

30 Anesthetics on the Same Child – Really! Pediatric Ambulatory Anesthesia for Proton RadiationHernando De Soto, M.D.


the worst aspect of the entire cancer experience. For years, physician anesthesiologists have been called upon to provide sedation or general anesthesia to alleviate the discomfort. Another challenging situation in the ambulatory center is that of children who must return daily for several weeks to receive radiation therapy. They must lie still for 15 to 45 minutes with the physician anesthesiologist outside the room. ASA standard monitoring guidelines should be used, including pulse oximetry, end-tidal CO2, EKG and non-invasive blood pressure measurements.7 Depending on the patient and the procedure, the physician anesthesiologist must decide what technique for sedation/anesthesia is best for the patient, e.g., spontaneous versus controlled ventilation, intubation versus laryngeal mask airway (LMA) versus non-invasive methods of airway management. Several techniques are commonly utilized for both proton and conventional radiation therapy. These techniques include general anesthesia (GA) with inhalation agents only, GA with a combination of an inhalation agent and a sedative drug (ketamine, propofol, dexmedetomidine, midazolam), or total intravenous anesthesia (TIVA), especially with propofol and/or dexmedetomidine.8-10

Florida Proton Therapy Institute (FPTI) Experience The FPTI in Jacksonville has been treating children since March 2007. As of April 2014, the institute has treated 303 children with anesthesia. The median age was 3.3 years old (range, 0.5-18.8 years old). Children from many parts of the world come for radiation treatment, including the United States, England, Scotland, Ireland, Holland, Norway, Finland, Bulgaria and Mexico, to name a few. The FPTI is involved in several treatment protocols from St. Jude Children’s Hospital, and many of their patients are treated here. The anesthesia team is directed by physician anesthesiologists specializing in the care of children.

Anesthesia Protocol Children are initially screened by a registered nurse and evaluated by a pediatric anesthesiologist to determine the best and safest anesthesia for the child. The parents are questioned extensively and an honest explanation is given to them about the risks and benefits of the anesthesia. The majority of the children receive approximately 30 radiation treatments, usually over a span of six weeks. They all have a port placed before starting treatments for I.V. medications. The same anesthesia technique is performed throughout the treatments, albeit with minor modifications in drug dosages based on patient needs. Approximately 10,000 anesthesia sessions, including CT simulations and PET scans, have been performed over the last seven years at the FPTI. The most frequent anesthesia technique in more than 95 percent of procedures in patients receiving treatment in the supine position has been a propofol induction

followed by LMA placement and inhalation maintenance with sevoflurane. With the LMA, intubation is not necessary; the airway is maintained with the child breathing spontaneously, and minimal experience is needed for successful mask placement. There has been no airway trauma secondary to the use of an LMA in any of the children treated at the institute. TIVA also has been used in the rest of the supine cases with success. These techniques have not prolonged the outpatient stay and have reduced the postoperative incidence of nausea and vomiting and emergence delirium to very low levels. For spine tumor patients required to be in a prone position for their treatment, the only change to the above protocol is that endotracheal intubation is performed every day for the duration of the treatments. Again, no airway trauma or complications have been seen in any of the children. Although most children are healthy and can safely undergo ambulatory surgery and anesthesia, occasionally the physician anesthesiologist is faced with management dilemmas. Children with cancer often undergo frequent outpatient procedures both diagnostic and therapeutic. The anesthetic approach should be aggressive toward pain management (if pain exists) and anesthetics and techniques that cause minimal side-effects in the context of repeated administration.

References:1. Wilson RR. Radiological use of fast protons. Radiology. 1946;47(5):

487-491.2. Indelicato DJ, Chang AL. Pediatric proton therapy: patterns of care

in 2012 across the United States. Presented at: Fall 2013 Children’s Oncology Group Meeting; October 8-12, 2014; Dallas, TX.

3. Cravero JP. Risk and safety of pediatric sedation/anesthesia for procedures outside the operating room. Curr Opin Anaesthesiol. 2009;22(4): 509-513.

4. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH; Pediatric Sedation Research Consortium. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric sedation Research Consortium. Anesth Analg. 2009;108(3):795-804.

5. Collins CE, Everett LL. Challenges in pediatric ambulatory anesthesia: kids are different. Anesthesiol Clin. 2010; 28(2): 315-328.

6. Latham GJ. Anesthesia for the child with cancer. Anesthesiol Clin. 2014;32(1):185-213.

7. Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006;118(6):2587-2602.

8. Buchsbaum JC, McMullen KP, Douglas JG, et al. Repetitive pediatric anesthesia in a non-hospital setting. Int J Radiat Oncol Biol Phys. 2013; 85(5):1296-1300.

9. Griffiths MA, Kamat PP, McCracken CE, Simon HK. Is procedural sedation with propofol acceptable for complex imaging? A comparison of short vs. prolonged sedations in children. Pediatr Radiol. 2013;43(10): 1273-1278.

10. Seiler G, De Vol E, Khafaga Y, et al. Evaluation of the safety and efficacy of repeated sedations for the radiotherapy of young children with cancer: a prospective study of 1033 consecutive sedations. Int J Radiat Oncol Biol Phys. 2001;49(3):771-783.

DDespite the focus on pain as “the fifth vital sign,” some outpatients are still going home with moderate to severe postoperative pain.1 This is especially true for outpatient orthopedic surgery.2 Single-shot peripheral nerve blocks (PNBs) can control pain, but they are time-limited by the duration of action of the local anesthetic and adjuvants. Continuous peripheral nerve blocks (CPNBs), however, can prolong pain relief well into the first postoperative day and beyond. This article will focus on the benefits of home CPNB following ambulatory surgery, what to tell naysayers who may be against a CPNB program at your institution and tips for a successful home CPNB service.

Benefits of Home CPNB The first CPNBs were reported in 1946 by Ansbro.3 This study involved a series of inpatients with a needle placed through a cork and into the supraclavicular area, with rubber tubings, a glass syringe, a metal stopcock and a beaker filled with procaine. Rather than a continuous infusion, patients received intermittent injections. In 1977, Selander reported the first CPNBs with a catheter,4 and in 1998 the first report was published on sending patients home with CPNBs and a disposable pump.5 Since then, anesthesia has become safer and the focus has shifted from the traditional outcomes of mortality and severe morbidity to patient-oriented outcomes,6 helping to highlight the benefits of CPNBs. They have been shown to improve the following: n Patient satisfaction: When comparing initial interscalene7

and popliteal8 blocks followed by a CPNB with ropivacaine versus placebo, patient satisfaction was greatly increased in the ropivacaine groups.

n Quality of sleep: Sending patients home with CPNB decreases insomnia and the number of awakenings at night.7,9,10

n Opioid use: In a meta-analysis of 19 randomized trials, CPNB provided better postoperative pain control compared to oral opioids at 24 hours, 48 hours and 72 hours postoperatively in all catheter locations.11 In those studies where patients were allowed to supplement the pain control from CPNB with oral opioids, there was a statistically significant decrease in the overall amounts needed, compared to those patients without CPNB. One recent study where CPNB was used for 48 hours showed that, for a full week, this group continued to have better pain relief than those with single-shot PNBs.10

n Hospital length of stay: Traditionally, joint replacement surgeries have necessitated postoperative admission for pain control and physical therapy. With a multimodal technique, including CPNB, there have been situations where patients were able to reach home-readiness one full day ahead of schedule12 or even go home on the day of surgery after more limited joint arthroplasties.13

n Other benefits: There are isolated case reports of at-home CPNB improving adhesive capsulitis of the shoulder, attenuating CRPS symptoms and abolishing phantom limb pain.

Elie Joseph Chidiac, M.D. is Chief, Regional Anesthesia Section and Residency Program Director, Detroit Medical Center/ Wayne State University, Detroit.

Outpatient Continuous Peripheral Nerve Blocks Elie Joseph Chidiac, M.D.

“ Compared to single-shot PNBs, the surgeons’ office staff have said they are receiving fewer phone complaints about severe postoperative pain at home and are seeing a drop in readmissions for pain control.”


Naysayers and What to Tell Them About CPNB Benefits in Outpatients Our program began in 2003 with one orthopedic surgeon, as others felt that a CPNB program would have a low success rate or delay the start of surgery. Very soon, everyone embraced it and started scheduling many major surgeries with home CPNB for their patients. Some procedures that once required postoperative admission for two to three days of pain control are now performed on an outpatient basis. Compared to single-shot PNBs, the surgeons’ office staff have said they are receiving fewer phone complaints about severe postoperative pain at home and are seeing a drop in readmissions for pain control. One of the last barriers to the home CPNB program had been the concern with sending patients home with a numb lower extremity, where there is a chance they might fall down. We tell surgeons it is better to go home with a numb non-weight-bearing leg than to go home groggy (from opioids) with an immobilized painful leg. Best is to give patients crutch training, place a knee immobilizer and instruct them about fall prevention. The newer adductor canal technique, which spares most of the nerve supply to the quadriceps muscles, can also decrease this complication.14

Another group of naysayers were ambulatory facility administrators, who complained about the cost of ultrasound and disposable equipment. First, we made sure the facility can charge for the use of ultrasound guidance, which then amortized the cost of the machines. We also pointed out to them the

cost savings of a shorter length of stay in the recovery room10

and the lower readmission rate for severe pain. And a meta-analysis showed cost savings when comparing the disposable equipment needed for CPNB to the cost of opioids and nausea management.11

Physician anesthesiologist naysayers tend to worry about infection risk at the catheter site, local anesthetic toxicity and phrenic nerve paralysis with interscalene catheters. However, true infections are extremely uncommon, despite a high incidence of catheter colonization. Risk factors include prolonged catheter placement, ICU admission, absence of antibiotic prophylaxis, frequent dressing changes, and femoral or axillary location.15 As to local anesthetic toxicity during home CPNB, unbound local anesthetic concentrations stay below toxic levels.16 Finally, compared to single-shot PNBs, the incidence of phrenic nerve paralysis with interscalene blocks is decreased with use of dilute infusions in home CPNB.17 Still, it is best to avoid interscalene catheter placement in patients with known respiratory compromise (severe emphysema or prior contralateral lung surgery) or those patients who cannot compensate for mild decreases in pulmonary function. At our institution, if the benefits are seen to outweigh this risk, we have placed catheters and given short-acting local anesthetics through the catheter. In the recovery room, if we suspect any compromise from phrenic nerve paralysis, we can choose to

Placement of interscalene catheter, May 2014. Left to right, Dr. Chidiac, Dr. R. Rahal (CA-3) and L. Kirk (medical student).



discontinue the catheter and monitor them until appropriate for discharge from the ambulatory center.

Tricks for Success Patients’ first encounter with the concept of home CPNB occurs in the surgeons’ offices. There, they receive a letter from the physician anesthesiologists telling them what to expect. In the preoperative holding room, in the presence of the “responsible adult” accompanying the patient, we explain catheter placement and the planned discharge with a home pump. When feasible, we invite this “responsible adult” into the block room, just after catheter placement but before taping, and have him/her watch us secure the catheter. We have found this helps them understand that the removal of the catheter at home (usually at 72 hours) is not harmful to their loved one. Prior to home discharge, we attach the disposable home infusion pump to the catheter and again discuss issues with the patient and “responsible adult.” We train both to recognize side-effects, tell them what to expect, instruct them regarding catheter removal, give them a way to reach us at all hours and confirm two contact numbers where we can reach them. We call the patients every day until one day after catheter removal, asking them specific questions regarding pain control, numbness, fluid leakage, signs of infection and pump malfunction. For patients who have programmable pumps or pumps with a patient-controlled bolus capability, we explain this feature to them prior to discharge and again reinforce it with our daily phone calls. If, prior to discharge from the ambulatory center, their extremity is still numb from the high-concentration local anesthetic, we point out to them that the difference in concentration will be noticeable later in the day, and they should expect less numbness (and possibly more pain) when the high-concentration initial bolus wears off. If the infusion may compromise the phrenic nerve (e.g., interscalene or supraclavicular placements), we inquire about any feeling of shortness of breath. If the infusion may affect the quadriceps muscle (e.g., femoral or adductor canal placements), we make sure to reinforce our previous instructions to avoid episodes of falling down. Some patients are so comfortable that they are anxious to remove the catheter and tape as soon as possible, assuming that the catheter is not needed on the second postoperative day. We tell them: “You are in control of your own pain control” and we suggest temporarily shutting off the infusion, rather than removing the catheter. If pain recurs, they can restart the pump on their own. In conclusion, a home CPNB program can offer numerous benefits for ambulatory surgical patients and allow certain cases to be performed in an outpatient center rather than an inpatient facility. For the physician anesthesiologist, it is a chance to

continue patient interactions well into the postoperative period, thus expanding his/her role as a true perioperative physician.

References:1. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain

experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-540.

2. Rawal N, Hylander J, Nydahl PA, Olofsson I, Gupta A. Survey of postoperative analgesia following ambulatory surgery. Acta Anaesthesiol Scand. 1997;41(8):1017-1022.

3. Ansbro FP. A method of continuous brachial plexus block. Am J Surg. 1946:71(6):716-722.

4. Selander D. Catheter technique in axillary plexus block. Acta Anaesth Scand. 1977;21(4):324-329.

5. Rawal N, Axelsson K, Hylander J, et al. Postoperative patient-controlled local anesthetic administration at home. Anesth Analg. 1998;86(1):86-89.

6. Wu CL, Fleisher LA. Outcomes research in regional anesthesia and analgesia. Anesth Analg. 2000;91(5):1232-1242.

7. Mariano ER, Afra R, Loland VJ, et al. Continuous interscalene brachial plexus block via an ultrasound-guided posterior approach: a randomized, triple-masked, placebo-controlled study. Anesth Analg. 2009;108(5):1688-1694.

8. White PF, Issioui T, Skrivanek GD, Early JS, Wakefield C. The use of a continuous popliteal sciatic nerve block after surgery involving the foot and ankle: does it improve the quality of recovery? Anesth Analg. 2003;97(5):1303-1309.

9. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Continuous interscalene brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesth Analg. 2003;96(4):1089-1095.

10. Salviz EA, Xu D, Frulla A, et al. Continuous interscalene block in patients having outpatient rotator cuff repair surgery: a prospective randomized trial. Anesth Analg. 2013;117(6):1485-1492.

11. Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg. 2006;102(1):248-257.

12. Ilfeld BM, Mariano ER, Girard PJ, et al. A multicenter, randomized, triple-masked, placebo-controlled trial of the effect of ambulatory continuous femoral nerve blocks on discharge-readiness following total knee arthroplasty in patients on general orthopaedic wards. Pain. 2010;150(3):477-484.

13. Dervin GF, Madden SM, Crawford-Newton BA, Lane AT, Evans HC. Outpatient unicompartment knee arthroplasty with indwelling femoral nerve catheter. J Arthroplasty. 2012;27(6):1159-1165.

14. Jæger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med. 2013;38(6):526–532.

15. Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology. 2009;110(1):182-188.

16. Bleckner L, Solla C, Fileta BB, Howard R, Morales CE, Buckenmaier CC. Serum free ropivacaine concentrations among patients receiving continuous peripheral nerve block catheters: is it safe for long-term infusions? Anesth Analg. 2014;118(1):225-229.

17. Renes SH, van Geffen GJ, Rettig HC, Gielen MJ, Scheffer GJ. Minimum effective volume of local anesthetic for shoulder analgesia by ultrasound-guided block at root C7 with assessment of pulmonary function. Reg Anesth Pain Med. 2010;35(6):529-534.



DISCOVER ANESTHESIOLOGY’S LATEST INNOVATIONS TODAY.

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EXCELLENCE IN ANESTHESIA PRACTICES

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FFrequently, questions arise as to the necessity of dantrolene availability in the office-based practice or the ambulatory surgery center that does not use volatile agents. Succinylcholine is only maintained in the same facility for airway rescue. In order to answer these important questions, we must turn to available data. Recent additions to the literature have pointed to a greater understanding of malignant hyperthermia (MH) events. Succinylcholine was once thought to be an exceedingly rare trigger of MH events in the absence of inhaled volatile agents. A recent article searched a Canadian database for MH triggers and characteristics.1 The investigators found that succinylcholine was identified as a sole agent trigger in greater than 15 percent of the 129 patients in the database. Additionally, the investigators found that 13 percent of patients had uneventful prior anesthetics. The authors of the Canadian study emphasized that despite the low likelihood of succinylcholine alone triggering MH, dantrolene needs to be stocked for that rare event. The first probability assessment of such an event and the need for dantrolene rescue was a full supply of dantrolene. A newer, 2014 cost-effectiveness assessment of maintaining an amount of dantrolene recommended by the Malignant Hyperthermia Association of the United States (MHAUS) was published, reaffirming the importance of a full supply.2 When compared to the likelihood of a fatal outcome from MH in an ambulatory surgical facility, the availability of dantrolene was deemed to be very cost effective. The authors acknowledged that the study had limitations due to the lack

of true long-term data, true incidence of MH and the rates of administration of dantrolene in cases of MH.3 However, the authors emphasized that the fatality of MH prior to the use of dantrolene was acknowledged to be about 80 percent. Since dantrolene therapy was introduced, the case fatality of MH decreased to 10 percent. Current estimates suggest that the case fatality may be even less than 5 percent due to improved patient monitoring and availability of dantrolene.4

Dantrolene should not be the only treatment for MH episodes irrespective of the location of the event. Active cooling, control of the dysrhythmias, hyperkalemia and metabolic acidosis are also requisite. If possible, the patient should be stabilized in preparation for transfer to a hospital. However, transfer should not be delayed in order to get the patient to the hospital. MHAUS has helped to develop transfer guidelines available for both ambulatory surgery centers as well as the office.5 These are easily found on its website.6 MHAUS Hotline consultants are frequently called during a suspected crisis by caregivers asking for assistance in diagnosis. Perioperative temperature elevation has many causes.7 If there is uncertainty, it is wiser to treat with dantrolene and other critical treatments. Then, as previously mentioned, proceed with transfer to a hospital setting. Although the complications of treatment with dantrolene are not common, it is associated with muscle weakness, phlebitis and abdominal pain. Respiratory failure is a less frequent complication of dantrolene treatment.8

Most of the data for MH incidence and specific demo-graphics in ambulatory settings are from ambulatory surgical centers. Data from office-based setting are scarce at best. Office-based MH episodes seem to be only known when a death or other severe outcome is publicized such as in the death of an 18-year-old female in Florida a number of years ago. Recent studies have analyzed more specifics with respect to agents, gender and rates/severity of complications. The investigators found that, overall, there were lower rates of complications and severity. However, the complication rates were increased when there was an increased interval from identification of an MH event to implementation of treatment. Males were found to be more affected than females.1 Pediatric

Andrew Herlich, D.M.D., M.D., FAAP is Professor and Vice-Chair for Faculty Development, Department of Anesthesiology, University of Pittsburgh School of Medicine.

Management of MH in the Ambulatory Environment: Recent Literature That Aids in Diagnosis, Treatment and OutcomesAndrew Herlich, D.M.D., M.D., FAAPCommittee on Ambulatory Surgical Care


MH from the North American Malignant Hyperthermia Registry shows no phenotypic variation with respect to age. MH is manifest differently in three age groups. Infants up to 24 months had the most mottling and metabolic acidosis. Patients from the middle pediatric range up to 12 years of age had a lower ETCO2 and PaCO2 than either the younger age group or the older age group. Patients older than 12 had the greatest incidence of hyperkalemia and diaphoresis. The oldest group was also the group with the longest onset time.9

Ambulatory and office-based anesthetic practices are likely to use a single volatile agent, if one is used at all, in order to reduce costs. Sevoflurane is the likely agent to be used due to a combination of lower costs, best tolerance for mask induction for children and low airway irritability. Although desflurane is quite useful for rapid emergence, its irritating airway properties as well as cost makes it a less desirable agent for these practices. Isoflurane is the least expensive of the volatile agents; however, its undesirable airway irritation also makes it a less desirable agent for use in the ambulatory and office-based practice. Despite the advantages of sevoflurane, it is the agent most commonly associated with an earlier onset of MH in contrast to desflurane and isoflurane.10

Concerns of scheduling patients who are known to be MH-susceptible or have suspicious family history persist. As summarized in the August 2013 ASA NEWSLETTER, MH-susceptible patients routinely undergo endoscopy, colonoscopy, and dental and ophthalmologic procedures without incident.11 Fear of triggering MH in patients who have not received triggering agents is unwarranted. The location of scheduling of MH-susceptible patients should be based upon medical co-morbidities and not the fear of triggering MH. If laryngospasm occurs, other methods of relieving laryngospasm besides the administration of succinylcholine exist. Deepening the anesthetic with propofol, positive pressure ventilation and the use of a transtracheal block with local anesthesia will also relieve laryngospasm. MH-susceptible patients should remain in the PACU or recovery area for 1.5 hours after the procedure. The exceedingly rare patient with a history of central core disease (CCD) has the potential for spontaneous triggering of MH. Patients with CCD are usually known to the surgical and anesthesia teams prior to scheduling. Patients with CCD also undergo procedures using local anesthesia or minimal to moderate sedation in ambulatory settings and office settings without problems. Interestingly, in one publication it was noted that children who have had episodes of MH seem to have more co-morbidities and hospital diagnoses.12 Nevertheless, the pediatric patient should be scheduled similarly as an adult patient. The child’s co-morbidities, aside from MH-susceptibility, should dictate the location of the care.

Finally, a new preparation of dantrolene has been approved by the FDA in July 2014.13 This preparation is concentrated as a lyophilized powder in 5 ml. When reconstituted, the preparation will have 10 ml. If approved, this preparation will add another possible approach to the administration of dantrolene during an MH episode. Storage of this preparation may be easier in a small pharmacy area of an ASC or office-based environment.

References:1. Riazi S, et al. Malignant hyperthermia in Canada: characteristics

of index anesthetics in 129 malignant hyperthermia susceptible probands. Anesth Analg. 2014;118(2):381-387.

2. Dexter F, Epstein RH, Wachtel RE, Rosenberg H. Estimate of the relative risk of succinylcholine for triggering malignant hyperthermia. Anesth Analg. 2013;116(1);118-122.

3. Aderibigbe T, Lang BH, Rosenberg H, Chen Q, Li G. Cost-effectiveness analysis of stocking dantrolene in ambulatory surgery centers for the treatment of malignant hyperthermia. Anesthesiology. 2014;120(6):1333-1338.

4. Kim DC. Malignant hyperthermia. Korean J Anesthesiol. 2012;63(5):391-401.

5. Larach MG, Dirksen SJ, Belani KG, et al; Society for Ambulatory Anesthesiology; Malignant Hyperthermia Association of the United States; Ambulatory Surgery Foundation; Society for Academic Emergency Medicine; National Association of Emergency Medical Technicians. Creation of a guide for the transfer of care of the malignant hyperthermia patient from ambulatory surgery centers to receiving hospital facilities. Anesth Analg. 2012;114(1);94-100.

6. Malignant Hyperthermia Association of the United State website. http://www.MHAUS.org. Accessed July 18, 2014.

7. Herlich A. Perioperative temperature elevation: not all hyperthermia is malignant hyperthermia. Pediatr Anesth. 2013;23(9):842-850.

8. Brandom BW, Larach MG, Chen MS, Young MC. Complications associated with the administration of dantrolene 1987 to 2006: a report from the North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States. Anesth Analg. 2011;112(5):1115-1123.

9. Nelson P, Litman RS. Malignant hyperthermia in children: an analysis of the North American Malignant Hyperthermia Registry. Anesth Analg. 2014;11(2)8:369-374.

10. Visoiu M, Young MC, Wieland K, Brandom BW. Anesthetic drugs and onset of malignant hyperthermia. Anesth Analg. 2014;118(2):388-396.

11. Li G, Brady JE, Rosenberg H, Sun LS. Excess co-morbidities associate with malignant hyperthermia diagnosis in pediatric hospital discharge records. Paediatr Anaesth. 2011;21(9):958-963.

12. Herlich A. Malignant hyperthermia in the ASC and office-based setting: recent developments in preparation and management. ASA Newsl. 2013;77(8):26-27.

13. Root C. Eagle Pharmaceuticals Announces FDA acceptance Of NDA for ryanodex in malignant hyperthermia. Clinical Leader website. http://www.clinicalleader.com/doc/eagle-pharmaceuticals-announces-fda-acceptance-of-nda-for-ryanodex-in-malignant-hyperthermia-0001. Published April 2, 2014. Accessed August 18, 2014.


Once again in 2014, ASA® had the honor of participating at Europe’s largest anesthesiology-related conference, Euroanaesthesia 2014, which took place in June in Stockholm, Sweden. The European Society of Anaesthesiology (ESA) shares an agreement with ASA in which the two societies present educational panels at each other’s annual meetings, an arrangement now celebrating its fourth year. ASA President Jane C.K. Fitch, M.D. introduced this year’s panel, which included Michael F. O’Connor, M.D., Audrée A. Bendo, M.D. and Karen B. Domino, M.D. After Dr. Bendo discussed the evidence that supports avoiding or using medications in specific clinical scenarios, Dr. Domino described ASA’s Closed Claims Database and outlined how it can be used for research to improve patient outcomes. Finally, Dr. O’Connor outlined the social construction of medical accidents using the perspective of human-factors research.

Euroanaesthesia 2014 was host to 7,000 attendees from 105 countries. Staff representing ASA this year included Paul Pomerantz, ASA chief executive officer, Chris Wehking, chief program officer, Sara Moser, director of marketing and corporate development, and Julie O’Heir, corporate development manager.

ASA Presence in Euroanaesthesia 2014 Exhibit Hall ASA was well represented in the exhibit hall at Euroanaestheia 2014, where staff promoted both the ANESTHESIOLOGYTM 2014 annual meeting and ASA membership. “I believe that the messaging at the booth was on point,” said Moser. “More than 1,500 attendees visited the booth to learn about the 2014 annual meeting as well as future years and to talk about opportunities with ASA for physician anesthesiologists from around the world.” As a recognized world leader in anesthesiology education, ASA continues to reach out to broaden its global membership base and is committed to supporting and adding value for its members by building on relationships with international societies with common issues. While attending Euroanaesthesia 2014, ASA leadership, including Dr. Fitch, president-elect John P. Abenstein, M.D., and First Vice President Daniel J. Cole, M.D., were able to meet with officers from ESA and other international societies, including the World Federation of Societies of Anaesthesiologists (WFSA), the Chinese Society of Anesthesiology (CSA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the International Anesthesia Research

Euroanesthesia 2014: Part of ASA’s Growing International Focus


September 2014 n Volume 78 n Number 9 31

The ANESTHESIOLOGY™ 2014 annual meeting this October in New Orleans will feature 24 scientific and edu-cational exhibits as well as more than 1,000 poster cases of the increasingly popular Medically Chal-lenging Cases. Many of the exhibits will focus on airway management, pain management and peripheral nerve blocks, including use of ultrasound techniques and exhibits that educate through the use of computer-based learning, advanced communication technology, handheld devices, videos and simulators. Exhibits portraying practical aspects of patient care such as vascular access, perioperative management issues and echocardiography will also be highlighted this year. Administrative exhibits will provide information on technology and anesthesia. The scientific exhibits will be evaluated by the committee for originality, clinical relevance, scientific merit and visual impact. Judging of the scientific exhibits will occur on Saturday, October 11. The Medically Challenging Cases continue to grow in popularity, with more than 1,100 submissions this year. The cases will be presented in Hall B1 at the Morial Convention Center, Saturday, October 11, through Tuesday, October 14, from 8 a.m. to 4 p.m. The Medically Challenging Cases will all be presented in an electronic format without the use of a poster board and with a facilitator/moderator to allow interaction and facilitate discussion. These sessions have allowed presentation of interesting and challenging cases that facilitate interaction from providers around the world. They have also served as a springboard for research clinical protocols that have emanated from the interaction of colleagues. The sessions continue to be received with great enthusiasm. Thanks go to the members of the Committee on Scientific and Educational Exhibits for all their hard work: Zvi Grunwald, M.D., vice chair, Wendy K. Bernstein, M.D., Sujatha P. Bhandary, M.D., Edward Deal, D.O., Stuart Forman, M.D., Ph.D., Michael Goldberg, M.D., Anthony T. Han, M.D., Ph.D., Vidya T. Raman, M.D., Andrew D. Rosenberg, M.D., Kristopher M. Schroeder, M.D., Shaheen F. Shaikh, M.D., David R. Sinclair, M.D. and John E. Tetzlaff, M.D.

Dean F. Connors, M.D., Ph.D. is Associate Professor of Clinical

Anesthesia, The Ohio State University Department of Anesthesia, Columbus.

scientific and educational exhibits at ANESTHESIOLOGY™ 2014Dean F. Connors, M.D., Ph.D., ChairCommittee on Scientific and Educational Exhibits

Medically Challenging Cases at ANESTHESIOLOGYTM 2013.

2013 First-Place Scientific Exhibit winners, University of Michigan: “High-Dose Opioid Taper Initiative.”


John B. Neeld, Jr., M.D. will receive the ASA Distinguished Service Award (DSA) at the ANESTHESIOLOGY™ 2014 annual meeting in New Orleans. The DSA is the highest award given by our society for meritorious service and achievement. First given in 1945, the DSA recognizes the unique contributions made by the recipient to the advancement of the specialty and to ASA which have helped transform how we practice, what we do and who we are. The DSA has been given annually nearly every year since 1945. A list of the specialty’s luminaries who have received this award may be found at http://www.asahq.org/for-members/about-asa/asa-governance/distinguished-service-award.aspx. Dr. Neeld received his undergraduate and medical degrees from Vanderbilt University, the latter being earned in 1966. He was a surgical intern at the same institution the following year. After his internship, he served as a general medical officer in the U.S. Army. During his military time, he had a remarkable tour of duty in Vietnam where he earned a Purple Heart, Bronze Star and Combat Medical Badge, among other awards. Upon completion of his military duty in 1970, he undertook an anesthesiology residency and research fellowship at Emory University in Atlanta, finishing these in 1973. He received his certification from the American Board of Anesthesiology the subsequent year.

Mark A. Warner, M.D. is Executive Dean, Mayo Clinic College of Medicine, Rochester, Minnesota.

John B. Neeld, Jr., M.D. 2013 Recipient of ASA Distinguished Service AwardMark A. Warner, M.D.2011 ASA President

John B. Neeld, Jr., M.D.

2013 DISTINGUISHED

SERVICE AWARD

presented at the

Emery A. Rovenstine Memorial Lecture

OCTOBER 13, 201410:15 - 11:20 a.m.

Ernest N. Morial Convention Center

New Orleans


Remaining in Atlanta, Dr. Neeld spent his professional career in private practice at Northside Hospital from 1973 through 2010. During his tenure, he served as department chair for 21 years from 1986 through 2007, building the largest anesthesiology department in Georgia. A proponent of developing mutually productive, positive relationships with institutions, he served on the Northside Hospital Board of Directors from 1991 through 2009, chairing that board from 1995-97.

Throughout his career Dr. Neeld has been a consistent advocate for the development of a strengthened, forward-looking ASA to better serve its members and our patients. During more than 30 years of service to ASA, he has served as President (1998-99), Treasurer (1993-96), Alternate Director for District 25 (1983-91) and member of the House of Delegates (1982-1991). He was honored as the 2013 Emery A. Rovenstine Memorial lecturer. He has been appointed to many positions of note, including service on six reference committees at our annual meeting. Additional appointments that recognized his commitment to ASA’s organizational development have included chair of the Administrative Council Task Force on the Structure and Function of ASA (1992), chair of the Task Force on Strategic Planning (1997-98), chair of the Ad Hoc Committee on Strategic Planning (1998-99), chair of the President’s Committee on Executive Office Oversight (2007), chair of the Ad Hoc Committee on Strategic Land Use (2010), which recommended the site on which our new headquarters was built, and membership on the Ad Hoc Committee on Headquarters Building Construction

(2012-14), which had oversight responsibility for the design and construction of ASA’s new headquarters. Additionally, Dr. Neeld served as a member of the board of directors of the Wood Library-Museum of Anesthesiology from 2004-12. Few ASA members have stepped outside the specialty to represent anesthesiology with the strength and passion Dr. Neeld has shown. He has represented anesthesiology to the American Medical Association as a member of the ASA delegation for nearly two decades and counting. A natural leader, he has chaired this delegation since 2003 and continues in this important role. His commitment to serving organized medicine was recognized by his appointment to the board of directors of the American Medical Association Political Action Committee (AMPAC) from 2004-12. Not surprisingly, he also chaired the AMPAC from 2006-08. At AMA, his efforts to create opportunities for young physicians to advance in specialty and state delegations within the House of Delegates was recognized by the Young Physicians Section with its “Young at Heart” award in 2014. A strong supporter of the physician anesthesiologist-led care team practice model, Dr. Neeld has been an advocate for anesthesiologist assistants (AAs), testifying successfully before legislative committees in Florida and North Carolina for their licensure. He served as president of the Association for Anesthesiologist Assistants Education (AAAE) from 2000-03 and has been a member of the board of directors of the National Commission for Certification of Anesthesiologist Assistants (NCCAA) since 2000. Given his long record of service to ASA and the AMA, it is not surprising that other organizations have also selected him for positions of responsibility. He served on the board of directors of the Medical Association of Georgia Mutual Insurance Co. (1998-2012), chaired the Vanderbilt Medical Center Advisory Board (1993-98) and served as president of the Vanderbilt Medical Alumni Association (2004-06). He has also received the DSA of the Medical Association of Atlanta in 2000. Dr. Neeld acknowledges that his long service to ASA and all of organized medicine would not have been possible without the support, advice, encouragement and limitless patience of his wife, Gail. The DSA will be presented to Dr. Neeld at the time of the Emery A. Rovenstine Memorial Lecture at 10:15-11:20 a.m. on October 13 in New Orleans. Please join me at that time as the society recognizes Dr. Neeld for his unparalleled service to our country, specialty and ASA.

“ Few ASA members have stepped outside the specialty to represent anesthesiology with the strength and passion Dr. Neeld has shown.”

In the current funding environment, success in academic research is difficult. While there are clear elements of luck and “right place, right time” to any success, Benjamin Franklin contended that “diligence is the mother of good luck.” Hard work and a clear focus are necessary yet not sufficient. A successful research career is a complex adaptive journey and a function of critical interrelated variables, including the identification of a recognized mentor, the acquisition of necessary formal training and the provision of adequate protected research time. All potentially successful researchers need advice on what to do (or not to do) from a skilled mentor who fosters mentee growth and development. Designing and completing high-quality research requires more than the knowledge acquired in medical school and in residency training. It also requires rigorous research-related coursework in areas such as study design, epidemiology, biostatistics and biomedical writing. Although some faculty do succeed without formal training, most high-impact research is conducted by faculty who have devoted the time to acquire the skills necessary to conduct high-impact research. These skills include asking important, impactful and answerable questions; designing and conducting studies to answer these questions; analyzing data; and preparing manuscripts. To produce successful researchers, academic department leaders need to work to secure resources to ensure that junior faculty can obtain formal training and protected time. Career development awards such as T or K awards are essential because they generally provide resources for a mentor, formal training and protected time for the mentee.

Daniel Nyhan, M.D. is Interim Chair of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore.

Peter J. Pronovost, M.D., Ph.D., FCCM is Senior Vice President, Patient Safety and Quality, Director, Armstrong Institute, Johns Hopkins Medicine, Baltimore.

REBECCA A. ASLAKSON, M.D., Ph.D. to Receive 2014 Presidential Scholar AwardDaniel Nyhan, M.D.

Peter J. Pronovost, M.D., Ph.D., FCCM

Rebecca A. Aslakson, M.D., Ph.D.


In the setting of effective mentorship and training and with the provision of protected time, a disciplined faculty member in a nurturing environment will usually develop into a competent academic researcher. In rare circumstances, you get an exceptional researcher, such as this year’s 2014 ASA Presidential Scholar Rebecca A. Aslakson, M.D., Ph.D. A passionate, innovative and skilled researcher, she spearheaded pioneering work into how best to deliver patient- and family-centered care and palliative care to severely ill patients and their families, particularly during the perioperative period.

Dr. Aslakson is a seminal example of an academic physician investigating and significantly advancing an important area in health care and doing so in a rigorous scientific manner. Moreover, both Dr. Aslakson and her environment recognize the skill-sets necessary to advance her important area of interest. The first female to receive this award since its inception in 2003, Dr. Aslakson’s work highlights the expanding breadth of anesthesia research and the impact physician anesthesiologists and intensivists can have on patient care. Dr. Aslakson obtained her undergraduate degree from Washington University in St. Louis and her M.D. from Harvard Medical School-Massachusetts Institute of Technology Health, Sciences and Technology Program in Boston. She completed her anesthesia residency at the Massachusetts General Hospital and her surgical critical care fellowship at The Johns Hopkins Hospital, Baltimore. After completing her fellowship in 2008, she was recruited to our faculty and concurrently pursued a Ph.D. in Clinical Research from the Johns Hopkins Bloomberg School of Public Health, Baltimore. Utilizing a T32 research fellowship award with its inherent requirements, she completed novel, foundational work exploring the influence of the quality of communication on prognosis in long-stay surgical intensive care unit (ICU) patients. This evolved into the core project

of her Ph.D. dissertation – a pilot of a communication-based intervention for long-stay surgical ICU patients and their families. Her interest in this patient cohort expanded to palliative care in other patient groups. Recognizing the importance of formal training and protected time for her research work, Dr. Aslakson completed clinical training with the Johns Hopkins Kimmel Cancer Center Pain and Palliative Care team and became board-certified in palliative care in 2010. She has published important work detailing more effective integration of palliative, critical and perioperative care.1 Moreover, she described barriers that impede this integration2-4 and quality improvement and interventions to improve patient outcomes.*5-8 As Dr. Aslakson’s research matured, she complemented her quantitative research skills with qualitative skills. She completed a two-year study funded by the Foundation for Anesthesia Education and Research exploring the palliative care-related experiences of patients and families in surgical critical care units. She showed that while patients and families prioritize humanistic and relationship-related aspects of care, surgical clinicians focus on technical aspects of care, e.g., following standards and providing “cutting-edge” technology. Based on this work, Dr. Aslakson was awarded a K08 grant from the Agency for Healthcare Research and Quality. The work focused on patient-centered metrics as a basis for providing quality palliative care in the ICU. She was concurrently awarded a three-year, $1.5 million contract from the Patient-Centered Outcomes Research Institute. The latter consists of leading physicians, nurses and public health investigators who work with families and patients preparing for high-risk surgeries. Dr. Aslakson is a core faculty member of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins. The Armstrong Institute grew from and is intimately connected to the department of anesthesiology and critical care medicine. The institute draws upon 18 different disciplines across Johns Hopkins University. Its goal is to partner with patients, their families and others to eliminate preventable harm, improve outcomes and experience, and eliminate waste. Dr. Aslakson’s work erases boundaries, aligns multiple disciplines around common goals and demonstrates how anesthesia researchers can impact patients, families and other providers both within and beyond the perioperative experience.

“ Dr. Aslakson’s work erases boundaries, aligns multiple disciplines around common goals and demonstrates how anesthesia researchers can impact patients, families and other providers both within and beyond the perioperative experience.”


* Dy SM, Aslakson R, Wilson RF, Fawole OA, Lau BD, Martinez KA, Vollenweider D, Apostol C, Bass EB. Interventions to Improve Health Care and Palliative Care for Advanced and Serious Illness. Closing the Quality Gap: Revisiting the State of the Science. Evidence Report No. 208. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract. No. 290-2007-10061-I.) AHRQ Publication No. 12-E014-EF. Rockville, MD: Agency for Healthcare Research and Quality. October 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.




For example, a systematic review9 found that proactive palliative care in the ICU shortens both ICU and hospital length of stay without changing mortality or family member satisfaction. This important finding was endorsed by the Society of Critical Care Medicine (SCCM), the American College of Surgeons, the American Academy of Hospice and Palliative Medicine, and the The Oncology Report. Dr. Aslakson is a founding and current member of the ASA Subcommittee on Palliative Medicine. Within the SCCM, she is part of a small international group of researchers revising SCCM guidelines for family-centered care within the ICU. Dr. Aslakson is also active in the American Academy of Hospice and Palliative Medicine (AAHPM) and the National Palliative Care Research Center, and serves on the national AAHPM research committee. She founded and co-chairs an ICU special interest group with AAHPM. Dr. Aslakson’s accomplishments and successes in the area of palliative care are to be honored, especially when viewed in the context of patient safety and preventable harm. Preventable harm is the third leading cause of death in the United States and is associated with large costs. Moreover, her focus on communication with patients and families is apt considering that 20 percent of patients feel disrespected and 50 percent feel they are not listened to. Dr. Aslakson’s success is a testament to her intrinsic qualities. Her work highlights the potential expanded role of physician anesthesiologists and anesthesiology departments. It also

illustrates the need for mentorship, appropriate formal training and protected time in order to develop successful academicians.

References:1. Aslakson R, Pronovost PJ. Health care quality in end-of-life care:

promoting palliative care in the intensive care unit. Anesthesiol Clin. 2011;29(1):111-122.

2. Shander A, Gandhi N, Aslakson RA. Anesthesiologists and the quality of death. Anesth Analg. 2014;118(4):695-697.

3. Aslakson RA, Wyskiel R, Shaeffer D, et al. Surgical intensive care unit clinician estimates of the adequacy of communication regarding patient prognosis. Crit Care. 2010;14(6):R218.

4. Aslakson RA, Wyskiel R, Thornton I, et al. Nurse-perceived barriers to effective communication regarding prognosis and optimal end-of-life care for surgical ICU patients: a qualitative exploration. J Palliat Med. 2012;15(8):910-915.

5. Fawole OA, Dy SM, Wilson RF, et al. A systematic review of communication quality improvement interventions for patients with advanced and serious illness. J Gen Intern Med. 2013;28(4):570-577.

6. Dy SM, Apostol C, Martinez KA, Aslakson RA. Continuity, coordination and transitions of care for patients with serious and advanced illness: a systematic review of interventions. J Palliat Med. 2013;16(4):436-445.

7. Martinez KA, Aslakson RA, Wilson RF, et al. A systematic review of healthcare interventions for pain in patients with advanced cancer. Am J Hosp Palliat Care. 2014;31(1):79-86.

8. Lau BD, Aslakson RA, Wilson RF, et al. Methods for improving the quality of palliative care delivery: a systematic review. Am J Hosp Palliat Care. 2014;31(2):202-210.

9. Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ, Pronovost PJ. Evidence-based palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med. 2014;17(2):219-235.

Huddle Up for Cesarean SafetyThe Society for Obstetric Anesthesia and Perinatology has initiated a campaign to promote a brief meeting among the obstetrician, nurse and physician anesthesiologist prior to a cesarean delivery. The purpose of this meeting is to improve communication and identify concerns from the various teams. This meeting is referred to as a “huddle.” Information and details on the huddle may be found at soap.org.

After all, every woman who delivers by cesarean deserves a huddle.

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Henrik Kehlet, M.D., Ph.D. is perhaps the most well-known surgeon among physician anesthesiologists around the world due to his substantial contributions toward the understanding of surgical pathophysiology. Dr. Kehlet completed his medical studies and surgical residency at the University of Copenhagen, Denmark. He then enrolled in a Ph.D. program within the same institution, authoring a thesis pertaining to the study of the hypothalamic-pituitary-adrenocortical function in glucocorticoid-treated surgical patients. Dr. Kehlet served as the Chief of Surgery and Professor of Surgery, Copenhagen University at Hvidovre University Hospital from 1989 to 2004. He was subsequently appointed as a Professor of Perioperative Therapy and Head of the Section for Surgical Pathophysiology at the Rigshospitalet in Copenhagen. Dr. Kehlet continues to be an extremely prolific writer, having authored more than 950 scientific articles covering topics of surgical pathophysiology, acute pain physiology and pharmacotherapy, surgical stress response, regional anesthesia and analgesia, perioperative immune function, fast-track surgery and the transition from acute to chronic pain. His work has been cited thousands of times, and he currently holds an H-index of 80. For his outstanding contributions to research, Dr. Kehlet has received numerous honorary awards from distinguished learned societies such as the Royal College of Anaesthetists of Great Britain, the American College of Surgeons and the American Surgical Association. He has also been invited worldwide to lecture and has given revered eponymous lectures such as the Bonica lecture, the Labat lecture, the Carl Koller lecture and the Simpson Memorial lecture.

From Surgical Stress Response to Multimodal Analgesia I had the personal fortune of meeting Dr. Kehlet for the first time in the late 1980s at the European Society of Regional Anaesthesia and Pain Therapy. At the time, he was investigating the effect of regional anesthesia on stress, pain and postoperative outcome. This original and ambitious research resulted in our current understanding of the effect of central neuraxial blockade on the endocrine and catabolic response to surgery. Dr. Kehlet demonstrated that a negative postoperative nitrogen balance could be attenuated by epidural blockade with local anesthetics. He then subsequently demonstrated the association between optimal perioperative pain relief in particular (the effects of regional anesthetic techniques) on surgical outcomes. Building on these results, Dr. Kehlet hypothesized that a multimodal analgesia approach, combining different analgesics with synergistic or additive effects, could provide better perioperative pain control and reduce side effects. Dr. Kehlet and others would go on to validate this groundbreaking hypothesis, effectively transforming the manner by which perioperative analgesia is administered.

Francesco Carli, M.D., M.Phil., FRCA, FRCPC is Professor and Staff Anesthesiologist, McGill University, Montreal, Quebec, Canada.

Henrik Kehlet, M.D., Ph.D. to Receive 2014 Excellence in Research AwardFrancesco Carli, M.D., M.Phil., FRCA, FRCPC

Henrik Kehlet, M.D., Ph.D.


Pre-emptive Analgesia and Transition From Acute to Chronic Pain Dr. Kehlet and co-workers are credited with proposing and evaluating the concept of pre-emptive analgesia, whereby analgesic administration commences prior to surgical injury, in order to decrease the intensity and duration of postoperative pain. His development of several randomized studies with subsequent reviews and editorials provided critical analysis of this pre-emptive concept, later resulting in the principle of “preventive analgesia.” The high-level evidence found in Dr. Kehlet’s studies also served as the introduction to our understanding of how acute postoperative pain could possibly persist into chronic pain, a finding later confirmed through large epidemiological studies in Denmark. Dr. Kehlet’s research in this area provided one of the first risk factor assessments for the development of persistent postsurgical pain. Dr. Kehlet also investigated how surgical treatments such as hernia mesh removal and neurectomy in the setting of neuropathic pain could assist in the treatment of chronic postoperative pain following hernia surgery.

Fast-track Surgery Following a natural evolution from his studies on surgical stress response, Dr. Kehlet launched in the mid-1990s the concept of “fast-track surgery:” a multimodal, evidence-based approach to surgical care. Through a series of prospective cohort studies and randomized controlled trials initially employing the model of colonic surgery, Dr. Kehlet demonstrated that modifying the perioperative surgical stress response and revising traditional surgical care could have a dramatic impact on postoperative recovery and shorten length of hospital

stay. The success of the “fast-track” methodology is based upon provision of effective, dynamic pain relief (non-opioid, multimodal analgesia allowing early mobilization and early feeding), thus reducing perioperative organ dysfunction and catabolic stress and accelerating postoperative recovery. From colonic surgery Dr. Kehlet has recently focused on fast-track hip and knee replacement surgery in multicenter collaboration with a focus on detailed assessment of early recovery aspects and minimizing morbidity. Since its introduction, Dr. Kehlet’s “fast track” concept has been met with universal acclaim, resulting in the implementation of “fast-track surgery” protocols throughout the Western hemisphere. Recognizing that success of fast-track protocols requires a stronger collaboration among surgeons and physician anesthesiologists, Dr. Kehlet established evidence-based, procedure-specific guidelines for perioperative pain management, also called PROSPECT. The aim of this collaboration has been to provide procedure-specific evidence for optimal analgesia, thus identifying appropriate and best analgesic techniques with minimal side effects.

Establishing Prospective Patient Databases In addition to his contributions to perioperative pain management, Dr. Kehlet is responsible for establishing the first nationwide hernia database in Denmark, with the purpose of optimizing outcome and documenting various approaches to improve care. The database has been widely recognized as an outstanding example of knowledge translation and has served as the model for other patient databases across Europe and North America. Dr. Kehlet’s record of insatiable intellectual curiosity and impeccable scientific merit serves as an excellent model for future leaders in surgery and anesthesia who are actively involved in investigating perioperative pathophysiology and surgical outcomes. Despite his astonishing contributions, Dr. Kehlet continues to be academically active and devotes his time to mentoring young physicians. When he is not challenging lingering surgical dogmas, Dr. Kehlet shares his passion for art and music with his wife, Susanne, and tries to find the time to leave Copenhagen and take refuge in their ocean cottage. Henrik is a great friend, an outstanding colleague and a passionate debater. I can think of few people more deserving of this fine award.

“ The high-level evidence found in Dr. Kehlet’s studies also served as the introduction to our understanding of how acute postoperative pain could possibly persist into chronic pain, a finding later confirmed through large epidemiological studies in Denmark.”



Interested in becoming a question writer for the SEE Program? Active ASA members are encouraged to submit their CVs for consideration to Regina Fragneto, M.D., SEE Editor-in-Chief, at [email protected].

Self-Education and Evaluation

SEE QuestionOne of your patients requires increasing doses of morphine for postoperative pain control. According to a recent study, what is the most likely outcome if this patient receives intravenous (I.V.) magnesium perioperatively?

q (A) The total dose of magnesium administered will correlate with this patient’s total morphine dose.

q (B) The total morphine dose will decrease.

q (C) The time to first analgesic request will be shorter.

q (D) This patient will be more sedated.

I.V. magnesium potentiates morphine analgesia and is thought to have other analgesic properties through its action on calcium regulation and N-methyl-d-aspartate antagonism. It may, however, increase sedation, prolong neuromuscular blockade, and contribute to cardiac arrhythmia. The authors of a recent systematic review and meta-analysis examined the published literature on perioperative magnesium usage to provide an evidence-based attestation of the use of magnesium for perioperative pain control. They only included articles that compared placebo to I.V. magnesium. The total dose of I.V. morphine or its equivalent at 24 hours postoperatively was the primary end point; secondary end points were magnesium-related side effects. The primary end point was further analyzed depending on the type of surgery and the mode of magnesium administration. A total of 43 trials were identified; 23 trials (1,461 patients) met the authors’ inclusion criteria. Of the patients included in the study, 48 percent underwent abdominal surgery, 24 percent underwent hysterectomy, and 24 percent underwent orthopedic surgery. A single I.V. bolus of magnesium (30–50 mg/kg) was administered in six trials; a bolus followed by an infusion was administered in 15 trials; and magnesium as an infusion only was administered in two trials. The total magnesium dose ranged from 1.03 g to 23.5 g.

The findings of this study were as follows:n Time to first analgesic request was not significantly different between

the placebo and magnesium groups.n Magnesium administration was associated with 24 percent less

morphine consumption.n The total dose of magnesium administered did not correlate with

postoperative morphine consumption.

n The mode of magnesium administration (bolus, infusion, or both) had no effect on postoperative morphine consumption.

n The reduction in morphine consumption occurred in all types of surgery investigated (abdominal, gynecological, orthopedic) with orthopedic surgery demonstrating the largest decrease.

n Mean pain scores at rest and with activity were reduced by 4.2 and 9.2 out of 100, respectively, in patients receiving magnesium compared to patients receiving placebo.

n More patients receiving magnesium experienced bradycardia compared to control. Bradycardia was always responsive to first-line therapy (e.g., atropine).

n Hypotension and sedation rates were similar between the groups. In conclusion, the findings of this review show that perioperative magnesium administration seems to decrease morphine consumption at 24 hours postoperatively, irrespective of method of administration (one-time I.V. bolus, infusion, or both). The optimal magnesium dose for this effect could not be established, but it was suggested that a bolus of between 40 and 50 mg/kg might be needed. Although the reported side effects were minor, this study was not sufficiently powered to address the safety issues of magnesium administration at the suggested doses.

Bibliography:• Albrecht E, Kirkham KR, Liu SS, Brull R. Perioperative intravenous

administration of magnesium sulphate and postoperative pain: a meta-analysis. Anaesthesia. 2013;68(1):79-90.

• Hurley RW, Wu CL. Acute postoperative pain. In: Miller RD, ed. Miller’s Anesthesia. 7th ed. Philadelphia, PA: Elsevier/Churchill Livingstone; 2010:2757-2781.

Answer: B

The Self-Education and Evaluation (SEE) Program is a self-study CME program that highlights “emerging knowledge” in the field of anesthesiology. The program presents relevant topics from more than 40 of today’s leading international medical journals in an engaging question-discussion format. SEE can be used to help fulfill the CME requirements of MOCA®. To learn more and to subscribe, visit see.asahq.org.

40

FRIDAY - TUESDAYDECEMBER 12 -16, 2014

MARRIOTT MARQUIS NEW YORK

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Anesthesiology

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ASA-Ad_825x105 7/7/14 2:45 PM Page 1


Case: “To Test or Not To Test, That is the Question” A woman of child-bearing age presented for dilatation and curettage of the uterus due to a history of chronic, heavy menstruation. A pre-op pregnancy test was reportedly negative. The D&C was performed, at which time it was identified that the patient was approximately eight weeks pregnant. It was later discovered that the patient’s pre-operative assessment was populated with a previous negative test result, rather than the later positive result.

Discussion: This is a very sad case, in which a pregnancy that was desired by the patient was lost due to inaccurate pre-op data. It highlights three separate but important patient safety concepts. Pre-operative pregnancy testing is the first and most obvious. The incident reporter indicated under “lessons learned” that all women of child-bearing age should have a current negative pregnancy test before entering the O.R. Despite decades of conversation within the anesthesia community, this remains a controversial issue. Unsuspected pregnancy occurs in 0.3-2.6 percent of women undergoing elective surgery,1-3 suggesting that testing might be indicated for all. The vast majority of cases in which an unsuspected pregnancy test is found have a subsequent change in care, usually cancellation or delay of surgery. In the case described above, the pregnancy test results would have altered the surgical plan. However, issues of cost and ethics must also be considered. In 2003, a task force of members from the ASA Committee on Ethics and the Committee on Standards and Practice Parameters indicated that the “state of pregnancy is very personal information that belongs to the patient, and it does not alter her right to proceed with anesthesia and surgery if she so desires,”4 and that a pregnancy test should be offered, but not required unless there is a medical need to know the results. Similarly, the 2006 results of an electronic mailing list poll of members of the ASA Committee on Practice Management demonstrated significant differences of opinion and practice.5 Most recently the ASA Practice Advisory

for Preanesthesia Evaluation stated that “pregnancy testing may (our emphasis) be offered to female patients of childbearing age and for whom the result would alter the patient’s management.”6 Further, only 7 percent of consultants and 17 percent of ASA members polled felt that pregnancy testing should be mandatory for all.

The corroboration of medical information, especially the information available in electronic health records (EHRs), is the second patient safety issue. The use of the phrase “previous test populated the patient’s pre-operative assessment” suggests that the data were either “copied and pasted,” or automatically filled into an electronic pre-op assessment. The proliferation of EHRs has greatly increased the ease (and likely frequency) of copying patient data from one note to another. With a simple “control C” and “control V,” one can complete an entirely “new” note, complete with all the errors present in the source.

Detailed review of unusual cases is a cornerstone of anesthesiology education. Each month, the AQI-AIRS Steering Committee will provide a detailed discussion based on a case submission to the Anesthesia

Incident Reporting System (AIRS). Feedback regarding this item can be sent by email to [email protected]. Report incidents in confidence or download the free AIRS mobile application (Apple or Android) at www.aqiairs.org.

“ Little information exists about the impact of electronic anesthesia records on misinformation due to copying. An estimated 75 percent of academic anesthesia practices will have an anesthesia information management system by the end of 2014, suggesting that a large number of patients are at risk for this type of error. ”


A study from the Veterans Administration system published seven years ago demonstrated that 25 percent of patients’ charts had evidence of copying.7 More recently, Thornton et al. found that 74 percent of ICU notes contained more than 20 percent copied information.8 Weir et al. found an average of more than one error per copied patient note, demonstrating the potential for dangerous proliferation of misinformation when using this technique.9 Health information technology, including corroboration of results, was the leading patient safety concern in 2013.10 Little information exists about the impact of electronic anesthesia records on misinformation due to copying. An estimated 75 percent of academic anesthesia practices will have an anesthesia information management system by the end of 2014,11 suggesting that a large number of patients are at risk for this type of error. Wilbanks12 and Driscoll13 each found high rates of missing information within anesthesia records, most commonly gas flow rates, medication administration times and neuromuscular function testing,12 and even potentially critical information such as depth of ETT placement, ease of mask ventilation and laryngoscopic view.13 These do not directly relate to patient history but do suggest concerns about accurate charting in general. Some copying or auto-populating of EHRs is likely helpful to improve efficiency and decrease transcription errors. However, much is still to be learned about the best ways to confirm the accuracy of this information and to prevent misinformation from moving forward in patients’ charts. The final patient safety issue highlighted in this case relates to how practitioners respond to adverse events. The discovery that the patient was pregnant was likely very stressful to the care providers. The strong emotional response to these events by providers has been coined the “second victim” effect.14

The emotional impact of these events tends to proceed along a relatively predictable path.15 The desire to prevent future episodes of the event, both for patient safety and to protect oneself from future emotional distress, is understandable. The reporter of the case above stated that all women should have a pregnancy test prior to any surgery and anesthesia. Clearly this is not the consensus view, but would likely prevent any future instances of this event. As humans, we are all victims of our anecdotes. Quality and safety experts are trained to look beyond emotional issues and identify the root cause(s) of adverse events, to look for system-based fixes and, hopefully, to care for the second victims involved in adverse events (see the AIRS Pro:Con article on “Root Cause Analysis” in the June 2014 ASA NEWSLETTER).

References:1. Kasliwal A, Farquharson RG. Pregnancy testing prior to

sterilisation. BJOG. 2000;107(11):1407-1409.2. Manley S, de Kelaita G, Joseph NJ, Salem MR, Heyman HJ.

Pre-operative pregnancy testing in ambulatory surgery. Incidence and impact of positive results. Anesthesiology. 1995;83(4):690-693.

3. Wheeler M, Cote CJ. Pre-operative pregnancy testing in a tertiary care children’s hospital: a medico-legal conundrum. J Clin Anesth. 1999;11(1):56-63.

4. Palmer SK, Jackson S. …Ethics: hot issues in legally sensitive times. ASA Newsl. 2003;67(10):30-31.

5. Bierstein K. Pre-operative pregnancy testing: mandatory or elective? ASA Newsl. 2006;70(7):37.

6. Apfelbaum JL, Connis RT, Nickinovich DG, et al.; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation. Anesthesiology. 2012;116(3):522-538.

7. Thielke S, Hammond K, Helbig S. Copying and pasting of examinations within the electronic medical record. Int J Med Inform. 2007;76(suppl 1):S122-S128.

8. Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med. 2013;41(2):382-388.

9. Weir CR, Hurdle JF, Felgar MA, Hoffman JM, Roth B, Nebeker JR. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med. 2003;42(1):61-67.

10. Denham CR, Classen DC, Swenson SJ, Henderson MJ, Zeltner T, Bates DW. Safe use of electronic health records and health information technology systems: trust but verify. J Patient Saf. 2013;9(4):177-189.

11. Stol IS, Ehrenfeld JM, Epstein RH. Technology diffusion of anesthesia information management systems into academic anesthesia departments in the United States. Anesth Analg. 2014;118(3):644-650.

12. Wilbanks BA, Moss JA, Berner ES. An observational study of the accuracy and completeness of an anesthesia information management system: recommendations for documentation system changes. Comput Inform Nurs. 2013;31(8):359-367.

13. Driscoll WD, Columbia MA, Peterfreund RA. An observational study of anesthesia record completeness using an anesthesia information management system. Anesth Analg. 2007;104(6):1454-1461.

14. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237): 726-727.

15. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18(5):325-330.

“The outcomes research that will be driven by massive aggregation of data accumulated by AQI will exponentially drive our ability to improve quality of care and patient safety.”

Jeff Apfelbaum, M.D., Chair, ASA Committee on Standards & Practice Parameters

“As of 2012, every day 2.5 exabytes (2.5×1018) of data were created. The question is how do we use these data to promote patient safety in the perioperative environment. Over the past 5 years, through the leadership and vision of Rick Dutton, AQI has made a signi� cant contribution for the advancement of perioperative patientsafety and by proxy the specialty of Anesthesiology.”

Zeev Kain, M.D., M.B.A., Chancellor’s Professor of Anesthesiology & Pediatrics & Psychiatry

“The Anesthesia Quality Institute has moved into the forefront with its development of a large clinical depository of case data, the National Anesthesia Clinical Outcomes Registry (NACOR). NACOR’s designation by CMS as a Quali� ed Clinical Data Registry (QCDR) recognizes anesthesiology’s importance and contribution towards quality of care for our patients.”

Stan Stead, M.D., M.B.A., ASA VP of Professional Affairs

“AQI � lls the information gap that most hospitals and clinically integrated networks have about the impact of anesthesia on perioperative care to ensure continued progress of their highly reliable organization’s journey to improve patient experience, health outcomes and decease costs.”

Mike Schweitzer, M.D., M.B.A., Chair on ASA Committee on Future Models of Anesthesia Practices

“In my view, the explosive growth and relevance of AQI in just 5 years is remarkable. We started with just an idea that gathering practice data would be useful to our profession. Because of the hard work and dedication of Dr. Dutton, the AQI staff, and many physician anesthesiologists throughout the United States, AQI has gathered almost 20 million cases. Recently, AQI has been recognized by CMS as a Quali� ed Clinical Data Repository allowing practices that are reporting to AQI to ful� ll their Physician Quality Reporting System (PQRS) requirements. I believe this will be the tipping point for participation in AQI. I expect, in just a few short years that few anesthesiology practice will choose not to report their data to AQI. Our patients and our profession will only bene� t from this success.”

JP Abenstein, MSEE, M.D.ASA President Elect

“I am honored to know Dr. Dutton and proud to have my company be a preferred vendor of the AQI. The potential of the AQI, when started � ve years ago, seemed straightforward. It would help anesthesiologists provide greater value to patients and hospitals.

Today, the AQI has become more vital and the platform is providing a way for our specialty to remain relevant in a time of uncertainty. The work done over the past � ve years has laid an incredible foundation and I look forward to contributing in the future any way I can.” Thanks Rick.

David Bergman, ePREOP, LLC CEO, DO

“Cerner Corporation would like to congratulate AQI on 5 years of providing an invaluable service to the anesthesia profession. As the largest data registry in the country, AQI continues to gather and synthesize volumes of perioperative, quality improvement data, enabling our clients to benchmark their performance against peers at the national, regional and facility level. This contribution to optimizing quality improvement in the perioperative environment is essential to the advancement of anesthesiology.”

Jason Boatright, Cerner Anesthesia Healthcare Executive

“AQI has done more over the � rst � ve years of its existence to advance the quality & safety of our practice than any other recent addition. Happy Birthday, AQI!”

Jane C.K. Fitch, M.D.President, ASA

“AQI exists to improve patient care. We make the measuring stick that anesthesiologists use to show their growth over time, and their improvement relative to others. We help our specialty understand itself: both what we do and how we do it. And we educate anesthesiologists every day on the science of quality improvement and on practical ways to improve patient safety.”

Richard P. Dutton, M.D., M.B.A.Executive Director, Chief Quality Of� cer, ASA

AQI HB.indd 1 8/14/14 11:12 AM

Anesthesiology Continuing Education

ACE QuestionA 4-year-old child has a history of difficult intravenous (I.V.) access and a fear of needles. A eutectic mixture of local anesthetic (EMLA) cream is applied to both hands and both feet and then covered with an occlusive dressing by the parents 90 minutes prior to arriving for a scheduled outpatient radiologic procedure under sedation. On arrival the child is noted to be lethargic and cyanotic. A pulse oximetry measurement reads 85 percent. Which of the following is the most likely explanation?

q (A) Methemoglobinemia

q (B) Lidocaine toxicity

q (C) Cyanide toxicity

q (D) An acute allergic reaction

Anesthesiology Continuing Education (ACE) is a self-study CME program that covers established medical knowledge in the field of anesthesiology. ACE can help fulfill the CME requirements of MOCA®. To learn more and to subscribe, visit ace.asahq.org.

A eutectic mixture of local anesthetic (EMLA) cream is a mixture of 2.5 percent lidocaine and 2.5 percent prilocaine that is applied to intact skin for local anesthetic effects. Topical application has been shown to significantly reduce pain and can be particularly useful in infants and children undergoing dermal procedures. The beneficial effects of EMLA cream require sufficient time between placement on the skin and the procedure. Typically it is applied under an occlusive dressing approximately one hour prior to a procedure, but slightly longer application times (one to three hours) can result in better analgesia. However, EMLA cream is often inappropriately applied too far in advance of a planned procedure, which can result in substantial systemic absorption and the potential for toxicity. Methemoglobin is normally produced within erythrocytes during the oxidation of hemoglobin and is then reduced back to regular hemoglobin by NADH-cytochrome b5 reductase. Young children, especially neonates, can be at risk for methemoglobinemia because of an increased amount of hemoglobin oxidation and decreased capacity for methemoglobin reduction. Prilocaine is metabolized mainly in the liver to ortho-toluidine. Accumulation of ortho-toluidine is responsible for oxidation of hemoglobin to methemoglobin. Very young patients, patients with glucose-6-phosphate dehydrogenase deficiency, and those taking oxidizing drugs (e.g., sulfonamides) are at increased risk of methemoglobinemia. The half-life of prilocaine can also be

increased in those with renal or hepatic dysfunction. Lidocaine toxicity will typically result in central nervous system (CNS) symptoms such as seizures. It may progress to CNS depression and cardiac dysrhythmias. Cyanide toxicity will result in a normal pulse oximetry reading in the absence of carbon monoxide toxicity. Cyanide toxicity can result in agitation, confusion, rapid loss of consciousness, cardiac depression, and coma. Allergic reactions to EMLA cream usually present as local reactions including rash, erythema, and/or edema. Because methemoglobin absorbs an equal amount of the two wavelengths of light used in conventional pulse oximetry, the reported value of Spo2 tends toward 85 percent.

Bibliography:• Shachor-Meyouhas Y, Galbraith R, Shavit I. Application of topical

analgesia in triage: a potential for harm. J Emerg Med. 2008;35(1): 39-41.

• Couper RT. Methaemoglobinaemia secondary to topical lignocaine/prilocaine in a circumcised neonate. J Paediatr Child Health. 2000; 36(4):406-407.

• Touma S, Jackson JB. Lidocaine and prilocaine toxicity in a patient receiving treatment for mollusca contagiosa. J Am Acad Dermatol. 2001; 44(2, pt 2):399-400.

• Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed. New York: Lange Medical Books/McGraw-Hill; 2006:141, 268-269, 563.

• Miller RD, ed. Miller’s Anesthesia. 6th ed. Philadelphia: Elsevier/Churchill Livingstone; 2005:589-590, 596.

45

Answer: A


Even with the broad variety of educational offerings that ASA provides, many ASA members also have specialized clinical, research or educational interests; hence, a variety of subspecialty societies exist. The perspective of ASA leaders is that there exists a natural synergy between ASA and many of these subspecialty societies – that ASA members find value in both a strong society and strong subspecialty societies. With this perspective in mind, ASA leadership has made it a priority in the past year to improve relations with existing affiliated subspecialty societies.

Existing affiliated societies are those with House of Delegate representation: n American Society of Regional Anesthesia and

Pain Medicine (ASRA)n Society for Ambulatory Anesthesia (SAMBA)n Society of Cardiovascular Anesthesiologists (SCA)n Society for Neuroscience in Anesthesiology and

Critical Care (SNACC)n Society for Obstetric Anesthesia and Perinatology (SOAP)n Society of Critical Care Anesthesiologists (SOCCA)n Society for Pediatric Anesthesia (SPA)

And also the educational societies: n Society for Education in Anesthesia (SEA)n Society of Academic Anesthesiology Associations (SAAA)n Association of University Anesthesiologists (AUA)

Further, ASA recognizes there are additional subspecialty societies, and ASA is developing pathways to recognize and enhance relationships with them. Some of the collaborations offered by ASA to the affiliated subspecialty societies include officer representation at affiliated subspecialty meetings and subsidized CME services for their society meetings through the ASA Joint Providership Program. This spring, executive leadership took part in the annual meetings of ASRA, AUA, SAMBA, SCA, SOCCA, SOAP and SPA, providing an “ASA Update” and answering

Sarah L. Braun is ASA Intersociety Relations Manager.

Amr E. Abouleish, M.D., M.B.A. is Professor, Department of Anesthesiology, University of Texas Medical Branch, Galveston.

Beverly K. Philip, M.D. is Professor of Anaesthesia, Harvard Medical School, and Founding Director, Day Surgery Unit, Brigham and Women’s Hospital, Boston.

Subspecialty Societies at ANESTHESIOLOGY™ 2014Amr E. Abouleish, M.D., M.B.A., ChairASA Committee on Specialty Societies

Sarah L. Braun ASA Intersociety Relations Manager

Beverly K. Philip, M.D. ASA Vice President for Scientific Affairs



Table 1

Affiliated Subspecialty Society Meeting/Location

AUA: Association of University Anesthesiologists

Committee Meeting – October 12, 2014 Hilton New Orleans Riverside and Convention Center

SAMBA: Society for Ambulatory Anesthesia

2014 Mid Year Meeting – October 10, 2014 Renaissance New Orleans Arts Hotel

SEA: Society for Education in Anesthesia

2014 SEA Fall Meeting – October 10, 2014 JW Marriott New Orleans

SNACC: Society for Neuroscience in Anesthesiology and Critical Care

42ND Annual Meeting – October 9-11, 2014 Sheraton New Orleans

SOAP: Society for Obstetric Anesthesia and Perinatology

Board of Directors Meeting – October 10-11, 2014 Hotel Monteleone

SPA: Society for Pediatric Anesthesia

28TH Annual Meeting - October 10, 2014 Sheraton New Orleans

Subspecialty Society Meeting/Location

ISPCOP: International Society of Perioperative Care of the Obese Patient

Annual Symposium – October 13, 2014 Loews Hotel

SAGA: Society for the Advancement of Geriatric Anesthesia Annual Meeting – October 13, 2014 Location TBD, please contact SAGA for information

SASM: Society of Anesthesia and Sleep Medicine 4TH Annual Meeting – October 9-10, 2014 Hotel Monteleone

STA: Society of Technology in Anesthesia Board of Directors Meeting – October 10, 2014 Hotel Monteleone

TAS: Trauma Anesthesiology SocietyAnnual Meeting – Friday, October 10, 2014 New Orleans Downtown Marriott at the Convention Center



questions about the ongoing relationship between ASA and the subspecialty societies. In addition to these formal activities, informal opportunities to work together often arise from specific issues. Such issues may include responding to governmental regulations, addressing payment policy and regulations of both government and private payers, providing information from member inquiries, and developing quality initiatives and educational activities.

The initial inquiry may come from ASA (staff or committee) or a subspecialty society. Finding the right person(s) to contact in either society can be daunting. For this reason, ASA leadership created a new position, the Intersociety Relations Manager, and hired Sarah Braun ([email protected]). Sarah is actively working on strengthening existing relations and developing new collaborations. Sarah’s primary focus is communicating,

advocating and working with anesthesiology subspecialty, academic and related organizations. She partners with the ASA staff in the Governance Support Unit, Member Services, Marketing, Education and Meetings departments to assist in all collaborative and support efforts in relation to subspecialty societies and anesthesia-related organizations. This synergy between ASA, subspecialty societies and anesthesia-related organizations can be seen at the ANESTHESIOLOGY™ 2014 annual meeting. ASA members will find educational offerings by subspecialty societies as well as attend meetings of some of these societies and other organizations before the start of the meeting (Tables 1, 2). A new initiative for the ANESTHESIOLOGY™ 2014 annual meeting is the “Affiliated Subspecialty Society Pavilion” in the exhibit area. Located in Booth #111, this will be a dedicated exhibit space for the affiliated subspecialty societies where they can promote their meetings and activities, meet with members and potential members, and answer questions. ASA recognizes the need for affiliated subspecialty society presence at the annual meeting and views this pavilion as a key opportunity to provide this service to our members. Look for it in the exhibit area this October! A listing of additional anesthesia-related meetings taking place at the ANESTHESIOLOGYTM 2014 annual meeting can be found at www.asahq.org/Annual%20Meeting/Network/Subspecialty%20Meetings.

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SUBSPECIALTY PANELSDate Time Track Fee Code Speaker Speaker Location

Saturday, Oct. 11

7-8:15 a.m. OB 601 (SOAP) Caring for Our Own: Focusing on the Care Provider to Optimize Safety for Our Patients

Robert Gaiser, M.D. Room 231-232

PN 602 (ASRA) Advancing Safety and Risk Management Strategies in Pain Medicine

David Provenzano, M.D. Room 238-239

Sunday, Oct. 12

7-8:15 a.m. FA 603 (STA) How Can Mobile Technology Help Me Help My Patients?

Maxime Cannesson, M.D., Ph.D.

Room 228-230

CC 604 (SOCCA) Trauma and Critical Care Pearls for the Non-Intensivists

Daniel Brown M.D., Ph.D. Room 231-232

AM 605 (SAMBA) TIVA in 2014 Steven Butz, M.D. Room 238-239

Monday, Oct. 13

7-8:15 a.m. NA 606 (SNACC) Anesthesia for Acute Stroke Management: Method, Timing and Hemodynamics

Rafi Avitsian, M.D. Room 231-232

PI 607 (SEA) Technology Today: Testing, Training and Learning

Ira Todd Cohen, M.D., M.Ed.

Room 238-239

Tuesday, Oct. 14

7-8:15 a.m. CA 609 (SCA) Cardiac Anesthesia Colleen Koch, M.D., M.S., M.B.A.

Room 231-232

PD 610 (SPA) The Child With Congenital Heart Disease Presenting for Non-Cardiac Surgery

Shobha Malviya, M.D. Room 238-239

RCL - REFRESHER COURSE LECTUREDate Time Track Fee Code Speaker Speaker Location

Saturday, Oct. 11

8-9 a.m. CC 101 Sepsis Current Concepts, Guidelines and Perioperative Management

Mark Nunnally M.D. F.C.C.M.

Rivergate

AM 102 Current Controversies in Adult Outpatient Anesthesia

Jeffrey Apfelbaum M.D. Room E-1

FA 103 Arterial Blood-Gas Analysis: Interpretation and Application

Steven Barker Ph.D. M.D. Room E-2

OB 104 Anesthesia for the Morbidly Obese Parturient Brenda Bucklin M.D. Room E-3

PN 105 Clinical Evaluation and Treatment of Neuropathic Pain

Timothy Lubenow M.D. Room 260-262

CA 106 New Developments in Cardiopulmonary Resuscitation

Matthias Riess M.D. Ph.D. La Nouvelle Ballroom AB

9:15-10:15 a.m. OB 107 Postpartum Hemorrhage Jill Mhyre M.D. Rivergate

CC 108 Pulmonary Hypertension and Right Ventricular Failure

Eric Jacobsohn M.B. Ch.B. Room E-1

NA 109 Adult Head Injury: Management Update and Controversies

Audree Bendo M.D. Martin Smith M.B. B.S.

Room E-2

RA 110 Upper Extremity Regional Anesthesia: Essentials for Your Practice

Joseph Neal M.D. Room E-3

Table 2

“ Further, ASA recognizes there are additional subspecialty societies, and ASA is developing pathways to recognize and enhance relationships with them.”

OUR MEMBERS ARE

LEADERS IN PATIENT SAFETY

www.asahq.org

mom teacher residency director ASA

Who is your guide?

coach mentorprofessor

At every stage in your development, you’ve had a guide: from family members

to teachers to coaches; from professors to residency directors to mentors. As you progress in your

professional career, the ASA is honored to help fill that role. On behalf of the Society and its 52,000

members, thank you for your commitment to the specialty and your colleagues.

The ASA Membership Department is always available to you. Anytime you have a question

or concern, wish to pay your dues, or have inquiries about products or services, please feel free to

contact Member Services by phone at 847.825.5586 or via email at [email protected].

asa_AD_SEP14_FNL.indd 1 7/29/14 7:10 AM


Among the many activities in which the Committee on Economics and its members participate is the American Medical Association/Specialty Society Relative Value Update Committee (RUC). In addition to recommending values for new and revised Current Procedural Terminology (CPT®) codes for Medicare, the RUC is frequently asked to provide updated recommendations of values for CPT codes that the Centers for Medicare & Medicaid Services (CMS) believes may be “misvalued.” Since many of the codes were valued some time ago, the valuation may or may not reflect current practice with respect to either physician work or associated practice expenses. Although misvalued codes may be valued either too high or too low, in most cases CMS believes the “correct” value of these services should be lower than the current Relative Value Units (RVUs) assigned to the codes describing those services. Since 2009, CMS has identified codes it believed were misvalued as part of its regulatory oversight of the Medicare program, identifying the codes in the Proposed Rule or Final Rule outlining changes to the Medicare Physician Fee Schedule (MPFS) each year. These are usually published around the beginning of July and November and become effective on January 1 of the following year. Once CMS publishes its list of potentially misvalued codes, the RUC usually requests that specialty societies representing the various groups of physicians who perform those procedures develop an action plan on how to

address CMS’ concerns. Action plans range from stating that the current value of the identified code is valid and requesting that CMS reaffirm that value, to agreeing to conduct a new survey of society members to develop current estimates of the appropriate RVU value for work and practice expenses (PEs) associated with providing the service. In the most recent Proposed Rule for the MPFS, CMS notes that it has identified and reviewed more than 1,250 potentially misvalued codes. Congress had previously required CMS to examine potentially misvalued services under seven different categories:n Codes and families of codes for which there has been the

fastest growth;n Codes and families of codes that have experienced substantial

changes in PEs;n Codes that are recently established for new technologies or

services;n Multiple codes that are frequently billed in conjunction with

furnishing a single service;n Codes with low relative value that are often billed multiple

times for a single service;n Codes that have not been reviewed since the inception

of the Resource-Based Relative Value System, commonly referred to as “Harvard-Valued Codes”; and

n Other codes determined to be appropriate by the secretary.

RUC Review of ‘Misvalued’ CodesMarc L. Leib, M.D., J.D.Chair, ASA Committee on Economics

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Marc L. Leib, M.D., J.D., is Chair, ASA Committee on Economics.


Section 220(c) of the Protecting Access to Medicare Act of 2014 (PAMA), the most recent temporary Sustainable Growth Rate formula fix, added nine additional statutorily required categories of codes the Agency must examine to identify potentially misvalued codes:n Codes that account for the majority of spending under the

MPFS;n Codes for services that have experienced a substantial change

in the hospital length of stay or procedure time;n Codes for which there may be a change in the typical site of

service since the code was last valued; n Codes for which there are significant differences in payment

for the same service between different sites of service;n Codes for which there may be anomalies in relative values

within a family of codes;n Codes for services where there may be efficiencies when a

service is furnished at the same time as other services;n Codes with high intra-service work per unit of time; n Codes with high PE RVUs; and n Codes with high cost supplies.

The ASA RUC team, including supporting ASA staff, devotes hundreds of hours collectively preparing responses to CMS regarding codes used by physician anesthesiologists that the agency believes are misvalued and providing the assessment at the RUC meetings. Over the last several years, most of these have involved codes describing pain medicine procedures rather than codes describing primary anesthesia care. The most common categories of codes ASA has been asked to review include:n Codes that have experienced the fastest growth: Examples

of codes in this category are those describing nerve blocks used to provide postoperative pain management, such as femoral nerve blocks following total knee arthroplasties. These services have increased during recent years as patients, surgeons, hospitals and even some payers have realized that patients recover more quickly, ambulate sooner, use less narcotics, go home sooner and are more satisfied with their care than those relying on IM or I.V. injections of pain medications. ASA maintains that the savings to the system from these advantages outweigh the costs of the block itself and that the codes are valued correctly.

n Codes billed in conjunction with providing a single service: This has been one reason CMS has bundled imaging guidance with spinal injection procedures in recent years, using a single code to describe the injection procedure and various imaging services used to guide and document needle placement and injection. One advantage for CMS bundling these services into a single code is to minimize the potential duplication of pre-service and post-service work when two or more codes are used to report the service.

n Codes that have experienced substantial changes in PE: Recent changes in CMS RVUs for intra-laminar epidural injections (CPT codes 62310, 62311, 62318 and 62319) reflect changes in PEs associated with those procedures. When those codes were originally valued, fluoroscopic guidance was commonly provided in a “fluoro room,” a lead-lined room with built-in fluoroscopic equipment. That type of facility was much more costly than today’s typical practice of using a mobile C-arm fluoroscope. The change in PE inputs significantly decreased the total unit value of intra-laminar injections. With respect to these codes, CMS also decreased the work RVUs for 2014 significantly below the values recommended by the RUC. However, due to the thousands of comments CMS received regarding the reductions in the values of these codes, it has decided to revert to the 2013 work RVUs and PE inputs for 2015 and reconsider how it values these four codes. Even though CMS will revert to the 2013 values for these four codes for 2015, it will prohibit billing for imaging guidance in conjunction with intra-laminar epidural injections. CMS will also identify these codes as potentially misvalued codes for reconsideration by the RUC in the future.

These are a few examples of the issues the RUC team and the Committee on Economics address on behalf of ASA members. We anticipate that with the new categories of potentially misvalued codes Congress identified this year, there will likely be more such issues arising in the future. Even though Medicare and other payers are trying to move away from a fee-for-service system of paying for each individual service, valuing these services correctly is necessary for the short term while fee-for-service still predominates. Changes in payment models make correct valuations important in the long term, as the values assigned to the codes will likely form the basis of determining payments for bundled services. Without accurate values for the individual services, calculating bundled payment fees becomes a difficult, if not meaningless, activity.

“ Without accurate values for the individual services, calculating bundled payment fees becomes a difficult, if not meaningless, activity.”


Each year, the Centers for Medicare & Medicaid Services (CMS) releases a summary of practitioner participation in the Physician Quality Reporting System (PQRS) and the eRx Incentive Program. The document contains significant data on these programs and illustrates participation variances among specialties. In its 2012 Reporting Experience Including Trends (2007-2013) report released earlier this year, physician anesthesiologists were among PQRS’s top participants, with 61.3 percent (some 28,318 practitioners) submitting quality data for the program. Physician anesthesiologists’ 2012 numbers were the latest in a steady increase in participation since 2009, when 41.3 percent of physician anesthesiologist eligible professionals (EPs) took part. Other top participating specialties included emergency medicine (68.0 percent), interventional radiologists (58.1 percent), ophthalmology (55 percent) and cardiology (53.5 percent). The PQRS reporting program combines incentive payments and payment adjustments to promote reporting of quality information by EPs. In 2012, the payment incentive for successfully reporting measures was 0.5 percent, with an average payment of $457 per individual EP and $5,736 per practice. Physician anesthesiologists received more than $4.9 million of these incentives, with an average payment excluding Maintenance of Certification Program (MOCP) of $212 and a maximum incentive payment of $8,153. Eighty-two percent of participating anesthesiologists, some 23,461 EPs, received the payment incentive in 2012. In addition to valuable information on physician anesthesiologists’ participation in PQRS, the report provides a variety of data segmented by various topics such as specialty, geographic region and reporting method. While such data can

be useful to identify performance trends and provide indicators of future performance, PQRS incentives, adjustments and available reporting measures have changed frequently over the past two years. The 2012 CMS incentive payments were based on successfully reporting three PQRS measures; in 2014, that requirement increased to nine across three National Quality Strategy (NQS) domains. In 2014, CMS retained the Measure-Applicability Validation (MAV) process for claims-based reporting but expanded it to apply to registry-based reporting as well. The methods available for PQRS participation have also changed. In 2012, physician anesthesiologists could report measures via claims, registry, Electronic Health Record (EHR) or the Group Reporting option (GPRO). Of note, more than 85 percent of anesthesiologists reported measures via the claims mechanism in 2012. This year, CMS added the Qualified Clinical Data Registry (QCDR) reporting option, allowing PQRS participants to report on measures already part of the program as well as specialty-based, registry-developed measures. The Anesthesia Quality Institute’s (AQI’s) National Anesthesia Clinical Outcomes Registry (NACOR) is a CMS-approved QCDR. In 2012, the five most reported measures by physician anesthesiologists in order of frequency were:n PQRS #30: Timing of Prophylactic Antibiotic –

Administering Physiciann PQRS #193: Perioperative Temperature Managementn PQRS #76: Prevention of Catheter-Related Bloodstream

Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol

Anesthesiologists Among Top Performers in PQRSMaureen Amos, M.S.

Matthew T. Popovich, Ph.D.

Maureen Amos, M.S. is ASA Director, Quality and Regulatory Affairs.

Matthew T. Popovich, Ph.D. is ASA Quality Specialist.

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n PQRS #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)

n PQRS #130: Documentation of Current Medications in the Medical Record.

PQRS measures are reviewed annually by CMS, with some being retired or removed. PQRS #124, for example, a top reported measure for EPs in 2012, has since been retired. Participation in PQRS also offers physician anesthesiologists the opportunity to review submitted quality data and identify problems in their submissions. Each year, CMS provides feedback reports for individual participants packaged at the TIN-level, with individual reporting (or NPI-level) and performance information for each EP who reported under that TIN during the reporting year. This information includes reporting rates, Quality-Data Coding errors, clinical performance, incentives and whether the participant went through the MAV process. Such reports also detail the potential impact of the MAV process on incentive eligibility. Although physician anesthesiologists are among the strongest participants in PQRS, nearly 40 percent still do not participate. The year 2014 marks the final reporting period where PQRS incentives will be available to satisfactory reporters and, as such, non-participating EPs risk losing up to 2 percent on their Medicare Part B Fee-For-Service payments (a payment adjustment) in 2016. Further, physician groups with 10 or more

EPs who do not avoid the payment adjustment in 2014 under PQRS or are non-PQRS participants may be subject to an additional 2 percent downward adjustment through the Value-Based Payment Modifier program. While PQRS participation is voluntary, payment adjustments for reporters and non-reporters may impact future anesthesiology practice payments. Physician anesthesiologists are encouraged to explore PQRS reporting options for the remainder of 2014, as well as for calendar year 2015. For information on reporting PQRS measures, please contact the ASA Department of Quality and Regulatory Affairs at (202) 289-2222 or via e-mail [email protected].

Additional resources:The 2012 Reporting Experience Including Trends (2007-2013) report may be downloaded here: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2012-PQRS-and-eRx-Experience-Report.zip.

Physician Quality Reporting Program http://www.cms.gov/pqrs

ASA Physician Quality Reporting System Online Tools: https://www.asahq.org/For-Members/Patient-Quality-and-Safety/Physician-Quality-Reporting-System.aspx

AQI NACOR Qualified Clinical Data Registry (QCDR): http://www.aqihq.org

SEDATION AND ANALGESIARESOURCES FOR NON-ANESTHESIOLOGISTS

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You will learn: • Guidelines from the authority in anesthesia • Industry standards for basic anesthetic monitoring to ensure patient safety • Quality assurance indicators to safely administer drugs • Plus much more

Assure patient safety with proper training in sedation and analgesia.

Order today education.asahq.org/sedation Call: 847-825-5586

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“I said ‘Somebody should do something about that.’ Then I realized I am somebody.” – Lily Tomlin

Each day is simply packed with things to do at work and at home, people to see and places to go. Family, work, extracurricular activities (if we have time to enjoy them) all vie for our attention. They are all positive aspects of our lives, but they can become overwhelming at times. When legislative or regulatory issues arise that might be injurious to our profession or – even worse, to patient safety – it is easy to say “shouldn’t somebody do something about that!?” Sometimes we’re angry when “someone” doesn’t “do anything about it” and the legislation or regulation passes or goes into effect. When it comes to protecting our patients and our profession, I have realized that “somebody” means “me.” If I don’t do something, who will? The answer is no one. Each of us could ask ourselves the same question and come to the same conclusion: we must each be that “somebody,” even if the actions we are able to take seem small. This year, there are countless opportunities to do something to protect our patients and further our calling as physicians. One of the easiest ways to make a difference is to get to know (and hopefully make friends with) your district’s candidate or incumbent running for state legislature. 2014 is a monumental mid-term election year. Every state other than Nebraska has two legislative chambers, meaning there are 99 legislative chambers altogether. A whopping 87 of the 99 chambers are holding state legislative elections on November 4, 2014. Here are those numbers in a different, possibly mind-blowing way: there are 6,055 state legislative seats up for election this November. Additionally, there are 36 gubernatorial races this year, and these races determine

who is in charge of “opt-outs” in your state as well as other crucial issues for our profession. Most of the state primaries have taken place by this point, so we can identify which candidates are moving forward to the general election. What if each one of us got to know our own district’s candidates or incumbent? Considering ASA’s membership, if all 52,000 of us forged relationships with state candidates, we would arguably cover most of the state legislators (and definitely all the governors) across the country. In turn for our efforts, hopefully these candidates (and soon-to-be legislators or governors) would be comfortable contacting us as experts on health care issues.

How do I become “somebody” to these candidates? Free time is hard to come by for all of us, but volunteering for a state legislative candidate can take as little or as much time as you want it to, depending on how you offer your services as a volunteer. Many candidates need volunteers to go door to door with literature or to make phone calls; if you offer to do this and don’t want to spend your entire weekend or day off doing this, call the campaign office (usually readily available through the candidate’s website) and say “I’m available on X date from 2-4 p.m. (or other finite time period). How can I help?” If the candidate’s campaign is worth two hoots, they will immediately give you a task to fill just that time period. Later on when you visit a new lawmaker, you can truthfully say, “Oh, I volunteered for your campaign doing ______. I’m so glad you won and please let me be a resource for you and your staff on health care issues!” Do you like to eat breakfast? What about brunch? Throwing a breakfast or brunch reception or fundraiser for your candidate of choice is probably the easiest (and least expensive!) fundraiser there is. To make things easy, breakfast fundraisers can be held just about anywhere – your home, your office (with permission of your office or hospital, of course), or even at a local restaurant. If you hold one at your home, don’t feel like you must provide

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Erin A. Sullivan, M.D. is Associate Professor of Anesthesiology, and Director, Division of Cardiothoracic Anesthesiology, University of Pittsburgh, Pennsylvania.

Erin A. Sullivan, M.D., Chair Committee on Governmental Affairs

“ Similarly, if you have interest in regulatory matters, you could frequently check your state’s board of medicine, board of nursing and department of health websites to find out what they’re up to.”


lavish food or drink. The candidate is mainly there to make contacts and pick up campaign contributions – muffins, bagels and coffee will suffice. Holding a morning fundraiser also keeps prices low since no one (well, almost no one) expects alcohol early in the morning! If you hold a fundraiser for a candidate, there is a chance you might need to report this to your state election authority; a candidate’s campaign staff can usually help you figure out what (if anything) you must report. Usually, such a fundraiser held by an individual (or group of individuals) is only reported by the candidate’s campaign, and not you. If you have any questions regarding this issue, though, please check with your state’s election authority, which is usually the state’s secretary of state. In addition to becoming friends with your state legislators and governors, you could also be “somebody” by becoming one of your state’s legislative or regulatory watchdogs. By checking out your state legislature’s website and doing a search for “anesthesia,” “anesthesiologist,” “anesthesiologist assistant,” “nurse anesthetist” or “pain management,” you can find the pieces of legislation that are going to be key for our profession in your state. Relay the bill numbers to your state component society and ask if they are taking any action; if they are taking action, how can you help?

Similarly, if you have interest in regulatory matters, you could frequently check your state’s board of medicine, board of nursing and department of health websites to find out what they’re up to. Sometimes these boards (especially the boards of nursing) prefer to circumvent the legislative process; we’ve seen this time and time again in many states. By consistently monitoring the board’s website, you could become a “Tim Howard” of the regulatory world and help block goals being made by opposition. Taking a “see something, say something” approach to monitoring your state legislatures and regulatory boards would definitely make you a “somebody!” We are all in this together, but each of us has a part to play in actively advocating for our patients. While we do this every day in our jobs, taking it to the next level and becoming that “somebody” who takes advocacy beyond the doors of the clinic or hospital becomes a hero to patients everywhere. You can be “somebody.” You can be a hero. For more ideas on how to be involved in your state, contact Jason Hansen at [email protected] or Erin Philp at [email protected].

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Accreditation and Credit Designation StatementsThe American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.


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Airway management presents a challenge for health care providers involved in the resuscitation of trauma victims. It requires vigilance, sound judgment and experience in performing various interventions for airway control throughout the spectrum of maneuvers from simple positioning to invasive techniques. Physician anesthesiologists involved in trauma care remain at the forefront of research and education, developing guidelines for establishing an airway in the trauma setting. In 2005, W. C. Wilson et al.1 modified the 2003 ASA Difficult Airway (DA) Algorithm2 and developed DA algorithms for various trauma settings. ASA originally developed practice guidelines for management of DA in 1993.3 Since then, these guidelines have been updated twice, in 2003 and 2013,2,4 following an extensive analysis of the scientific literature, thorough review of new evidence, and collected opinions of both experts and randomly selected ASA members. While the 2013 DA algorithm and guidelines for management of the DA proposed by the ASA DA task force continue to serve as an excellent starting point for trauma airway management, modifications in the trauma setting remain necessary. In recognition of such need, the ASA Committee on Trauma and Emergency Preparedness (COTEP) recommends various modifications of these guidelines. Over the past decade, airway management techniques in the trauma setting have expanded to encompass modalities such as video-assisted laryngoscopy (VAL), supraglottic airway devices (SGA), cricothyrotomy and others. Currently, there are insufficient outcome data that demonstrate an advantage of one technique over another, and it will not likely become available due to the need for the

very large sample size necessary to conduct such a trial. Consequently, the following recommendations were developed based on current scientific literature and expert opinion.

General Comments: The patient with trauma presents unique challenges for airway management, including:n Time pressure n Hemodynamic instabilityn Altered airway anatomyn Associated injuries, including face, neck and brain injuriesn Lack of patient cooperationn Risk of aspirationn Need for cervical spine protectionn Positioning concernsn Rapidly evolving, possibly competing, clinical prioritiesn Trauma team dynamicsn Pre-hospital scene safety n Triage, equipment, and mass casualty considerations.

Several strategies differ from the ASA DA algorithm, and the following issues should be considered when managing the airway in trauma patients:1. Waking up the patient or canceling the procedure is rarely

an option, as the need for emergent airway control will presumably remain.

2. A surgical airway may be the first/best choice in certain conditions (e.g., significant oromaxillofacial trauma).

3. The following conditions commonly occur when an unconscious or recently induced trauma patient must be intubated:

Difficult Airway Management Algorithm in Trauma Updated by COTEPCarin A. Hagberg, M.D., Chair Committee on Trauma and Emergency Preparedness

Olga Kaslow, M.D., Ph.D. Committee on Trauma and Emergency Preparedness

Carin A. Hagberg, M.D. is Joseph C. Gabel Professor and Chair, Department of Anesthesiology, UTHealth, University of Texas Health Science Center at Houston.

Olga Kaslow, M.D., Ph.D. isDirector, Trauma Anesthesia Service, and Associate Professor of Anesthesiology, Medical College of Wisconsin, Milwaukee.

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A. The clinician fails to recognize a DA in evaluation prior to the induction of anesthesia.

B. The patient has an obvious DA but is hemodynamically unstable (e.g., shock) or refuses to cooperate with an awake intubation (e.g., children, the intellectually disabled, intoxicated or head-injured adults).

4. If a tracheal intubation attempt fails and the patient is apneic or is rendered as such through anesthetic induction, O2-enriched bag-valve mask (BVM) ventilation should be initiated. If BVM ventilation is adequate, a variety of intubation techniques may be employed.

5. If BVM is inadequate, placement of an SGA should be attempted.

6. Cricoid pressure (CP) should be applied throughout induction and intubation attempts until the airway is secured. However, if necessary, CP should be altered or removed to ease BVM ventilation, insertion of an SGA or tracheal intubation, since maintaining patent airway takes precedence over the potential risk of aspiration.5

7. Gentle BVM ventilation performed at pressures <20 cm of H2O prior to intubation is beneficial in trauma patients in whom it may be difficult to achieve adequate preoxygenation due to clinical urgency, uncooperativeness or limited functional residual capacity (e.g., lung injury, obesity).5

Establishing BVM ventilation is especially important after a failed attempt at intubation.

8. Manual in-line stabilization (MILS) of the cervical spine during intubation is recommended in patients with suspected cervical injury. The aim of MILS is to prevent any flexion, extension or rotation of the cervical spine when laryngoscopy is performed. However, MILS may worsen laryngoscopic view, causing the person intubating to apply greater pressure (which may be transmitted to the cervical spine), or result in longer time or failure to secure the airway. One must balance the benefits of MILS against the risk for hypoxic damage if intubation and adequate ventilation cannot be accomplished. Therefore, as was noted for CP, MILS may be altered or discontinued if its use impedes tracheal intubation.6,7

9. VAL is now frequently used in patients with known or suspected cervical injury, as it appears to reduce cervical motion during intubation compared to direct laryngoscopy (DL), or in patients with predictors of a difficult airway.8-12 Some of the limitations of VAL are facial trauma leading to a jaw lock or limited mouth opening and difficulty in obtaining an adequate view in an oropharynx soiled with blood and secretions.13 Furthermore, the use of VAL in the trauma setting has been associated with longer intubation times and affecting neither intubation first-pass success rate nor survival to hospital discharge.14 Therefore, although the introduction of video laryngoscopes has expanded the airway armamentarium, these devices have not yet replaced DL in the trauma setting.

Difficult Airway Management Algorithm in Trauma1. Assess the likelihood and clinical impact of basic

management problems: • Difficulty with patient cooperation and consent • Difficult mask ventilation • Difficult supraglottic airway placement • Difficult direct laryngoscopy • Difficult intubation • Difficult surgical airway access.2. Adhere to Basic Anesthetic Monitoring standards.3. Actively pursue opportunities to deliver supplemental

oxygen throughout the process of DA management.4. Consider the relative merits and feasibility of basic

management choices: • Awake intubation vs. intubation after induction of

general anesthesia (GA) • Non-invasive techniques vs. invasive techniques

for the initial approach to intubation • VAL as an initial approach to intubation • Preservation vs. ablation of spontaneous ventilation.5. Develop primary and alternative strategies: (see Figure 1, page 59).



ASA DA Algorithm Applied to Specific Trauma ConditionsClosed Head Injury Algorithm:Key Points:A. In patient with a DA, perform awake intubation if the patient

is awake (Glasgow Coma Scale [GCS] ≥9), cooperative, hemodynamically stable and able to maintain adequate O2

saturation.B. Keep cerebral perfusion pressure at 50-70 mm Hg.C. Avoid hypoxia and hypercarbia.

Airway Disruption Algorithm:Key Points:A. Perform awake intubation if major laryngeal or tracheal/

bronchial tear, provided the patient is awake, cooperative, hemodynamically stable and able to maintain adequate O2 saturation.

B. If patient uncooperative and DA is not otherwise suspected, consider rapid sequence intubation (RSI) using VAL and FIS.

• Consider intubation and airway evaluation with VAL if a supralaryngeal defect is present. VAL has the added benefit of allowing multiple viewers, aiding in examination and surgical planning

• For infralaryngeal and tracheal injury, consider RSI followed by DL and insertion of a FIS (with appropriately sized endotracheal tube [ETT] already loaded over it) through the larynx to rapidly evaluate for possible airway injury. The ETT is then introduced over the FIS and the cuff positioned below the level of injury.6,15

C. Avoid positive pressure ventilation and transtracheal jet ventilation proximal to tear.

D. If bronchial disruption is suspected, consider lung separation via placement of a double lumen tube or bronchial blocker.

E. Consider cardiopulmonary bypass.

Oral and Maxillofacial Trauma Algorithm:Key Points:A. Radiological results are crucial to discern anatomic distortion

and airway integrity.B. Limited mouth opening and accumulated blood, secretions

and foreign bodies can all obscure visualization and compromise DL, VAL and FSI.13

C. Perform awake intubation if patient is cooperative, stable and able to clear airway; this will maintain both spontaneous ventilation and O2 saturation.

D. If awake, intubation fails, airway compromise occurs or the patient is agitated, an awake tracheostomy may be the best approach.

E. BVM ventilation may be difficult and result in displacement of facial fractures or even airway compromise.

F. Blind intubation (oral and nasal) is discouraged: it may

dislodge foreign bodies (teeth, bony fragments, blood clot) into the airway or create a false passage. Blind nasal attempts in the setting of midface fracture may lead to violation of the cranial vault.

G. Nasal intubation is not contraindicated in a patient with lateral or posterior skull base fractures; FSI could be safely performed even if the fracture occurred in the central anterior skull base.16 Risk vs. benefit discussion for choosing nasal route for intubation should be documented in a patient’s record.

H. If initial oral intubation interferes with the surgical approach, it can be converted later to submental or nasal intubation.

Cervical Spine Injury (CI) Algorithm: Key Points:A. High level of suspicion is required for patients with a CI in

the trauma bay and other acute care areas (particularly patients with blunt multi-system trauma, altered consciousness level/low GCS, injury above the clavicle, maxillofacial and head trauma).

B. If injury is at or above C5, intubation and ventilation are often required.7 In the post-traumatic period, progressive neck swelling due to edema and pre-vertebral hematoma expansion may further compromise the airway,17 even in the absence of changes to the surface anatomy examination.

C. Intubation should minimize cervical movement to prevent further neurological deterioration in a potential or actual spinal cord injury.

D. Perform RSI, MILS with the front of the cervical collar removed, CP and gentle DL/VAL.

• VAL may be a preferred tool in patients with known or suspected CI

• CP should be applied during induction and maintained through intubation until tube placement is confirmed; it may be applied through the anterior opening in cervical collar before the collar is temporarily removed

• Both MILS and CP should be altered or removed if they impede adequate ventilation or intubation.6,7

Airway Compression Algorithm: Key Points:A. Awake intubation is recommended if the patient is

cooperative, stable and can maintain spontaneous ventilation, airway patency and adequate O2 saturation.

B. Personnel able to perform a surgical airway should be prepared to immediately intervene should life-threatening airway obstruction occur.

C. Consider opening the wound if an expanding postoperative neck hematoma is suspected.




Recognized DACooperative patientHemodynamically stableMaintains adequate O2

AWAKE INTUBATIONwith FIS or VAL

Initial Intubationattempt successful*

UNSUCCESSFUL (a)

Invasive Airway Access (b)

BVM VENTILATION ADEQUATE BVM VENTILATION NOT ADEQUATE

CONSIDER/ATTEMPT SGA (e)

SGA ADEQUATE* SGA NOT ADEQUATE or NOT FEASIBLE

EMERGENCY PATHWAY Ventilation not adequate, intubation unsuccessful (d)

NON-EMERGENCY PATHWAY Ventilation adequate, intubation unsuccessful

Alternate approaches to intubation (c)

Success* FAIL (d)

Emergency Invasive Airway Access (f)

1. Call for help

2. BVM ventilation

3. Maintain delivery of supplemental O2

4. Maintain CP

Initial Intubation attempts UNSUCCESSFUL

Initial Intubationattempt successful*

Unrecognized DAUncooperative patientHemodynamically unstableLife-threatening emergency

INTUBATION AFTER INDUCTION OF GA:CP, MILS, RSI with DL or VAL

Figure 1


D. Maintain spontaneous ventilation with induction of GA.E. Position tracheal tube below level of obstruction.

Fiberoptic confirmation may be required.F. SGA is not recommended.G. VAL and FSI are good choices as long as they

allow visualizing airway.

Trauma algorithm footnotes (for Figure 1, page 59):*Confirm ventilation, tracheal intubation or SGA placement with standard confirmatory techniques (exhaled CO2, misting of tube, auscultation of breath sounds, improving SpO2). If perfusion (and exhaled CO2) absent, use additional confirmation methods (e.g., repeat laryngoscopy, bronchoscopy, esophageal detector device, chest X-ray).a. Other options in ASA algorithm: • Ventilation with a face mask or SGA might be difficult or

impossible in a patient with maxillofacial trauma • Local anesthesia infiltration or regional nerve blockade

are of limited value in extensive trauma surgery. b. Invasive airway access includes surgical or percutaneous

cricothyrotomy or tracheostomy, transtracheal jet ventilation and retrograde intubation.

c. Alternative difficult intubation approaches include (but are not limited to): VAL, SGA (e.g., laryngeal mask airway [LMA]as an intubation conduit with or without flexible scope guidance), flexible scope intubation (FSI), intubating stylet or tube changer, and light wand. Blind intubation (oral or nasal) is discouraged in patients with maxillofacial trauma and laryngeal or tracheal injury.

d. Aborting the case and awakening the patient to optimize and re-attempt intubation via a different airway technique (e.g., awake intubation) is impractical in most trauma cases due to the emergent condition of the patient.

e. Emergency non-invasive airway ventilation consists of SGA.f. Surgical airway kit should be immediately available.

Abbreviations:BVM .................................................................................................bag-valve mask CI ..............................................................................................cervical spine injury CP .....................................................................................................cricoid pressure DA .......................................................................................................difficult airway DL .............................................................................................direct laryngoscopy ETT ............................................................................................ endotracheal tube FIS ................................................................................. flexible intubation scope FSI ................................................................................. flexible scope intubation GA .............................................................................................. general anesthesia GCS .....................................................................................Glasgow Coma Scale LMA ...................................................................................laryngeal mask airway MILS ........................................................................manual in-line stabilization RSI ............................................................................. rapid sequence intubation SGA ........................................................................ supraglottic airway devices VAL .......................................................................video-assisted laryngoscopy

References:1. Wilson WC. Trauma: airway management. ASA Newsl. 2005;69

(11):9-16.2. American Society of Anesthesiologists Task Force on Management

of the Difficult Airway. Practice guidelines for management of the difficult airway. Anesthesiology. 2003;98(5):1269-1277.

3. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. Anesthesiology. 1993;78(3):597-602.

4. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. Anesthesiology. 2013;118(2):251-270.

5. Grissom TE, Varon AJ. Airway management controversies in trauma care. ASA Newsl. 2013;77(4):12-14.

6. Diez C, Varon AJ. Airway management. In: Varon AJ, Smith CE, eds. Essentials of Trauma Anesthesia. Cambridge: Cambridge University Press; 2012:28-42.

7. Dagal A. Acute care of traumatic spinal cord injury [abstract RCL-08] Presented at: IARS 2014; May 17-20, 2014; Montreal, Quebec.

8. Enomoto Y, Asai T, Arai T, Kamishima K, Okuda Y. Pentax-AWS, a new videolaryngoscope, is more effective than the Macintosh laryngoscope for tracheal intubation in patients with restricted neck movements: a randomized comparative study. Br J Anaesth. 2008;100(4):544-548.

9. Koh JC, Lee JS, Lee YW, Chang CH. Comparison of the laryngeal view during intubation using Airtraq and Macintosh laryngoscopes in patients with cervical spine immobilization and mouth opening limitation. Korean J Anesthesiol. 2010;59(5):314-318.

10. Lim Y, Yeo SW. A comparison of the GlideScope with the Macintosh laryngoscope for tracheal intubation in patients with simulated difficult airway. Anaesth Intensive Care. 2005;33(2):243-247.

11. Malik MA, Maharaj CH, Harte BH, Laffey JG. Comparison of Macintosh, Truview, EVO2, Glidescope, and Airwayscope laryngoscope use in patients with cervical spine immobilization. Br J Anaesth. 2008;101(5):723-730.

12. Robitaille A, Williams SR, Tremblay MH, Guilbert F, Thériault M, Drolet P. Cervical spine motion during tracheal intubation with manual in-line stabilization: direct laryngoscopy versus GlideScope videolaryngoscopy. Anesth Analg. 2008;106(3):935-941.

13. Kaslow OY, Gollapudy S. Anesthetic considerations for ocular and maxillofacial trauma. In: Varon AJ, Smith CE, eds. Essentials of Trauma Anesthesia. Cambridge: Cambridge University Press, 2012:198-208.

14. Yeatts DJ, Dutton RP, Hu PF, et al. Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. J Trauma Acute Care Surg. 2013;75(2):212-219.

15. Desjardins G, Varon AJ. Airway management for penetrating neck injuries. The Miami experience. Resuscitation. 2001;48(1):71-75.

16. Goodisson DW, Shaw GM, Snape L. Intracranial intubations in patients with maxillofacial injuries associated with base of skull fractures? J Trauma. 2001;50(2):363-366.

17. Lazott LW, Ponzo JA, Puana RB, Artz KS, Ciceri DP, Culp WC, Jr. Severe upper airway obstruction due to delayed retropharyngeal hematoma formation following blunt cervical trauma. BMC Anesthesiol. 2007;7:2.


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Learn from leading national experts on how to use quality management data to improve patient outcomes and measure performance.

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Accreditation and Credit Designation The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

This activity has been approved for AMA PRA Category 1 Credits™.

Learn moreeducation.asahq.org/AQM


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Thirty years ago, the idea of a society for ambulatory anesthesia was considered novel, as new anesthetic agents on the horizon promised faster recovery and fewer side effects after outpatient surgery. Fast forward to today, and the focus is now on patient outcomes and cost. With the development of the SAMBA Clinical Outcomes Registry (SCOR), SAMBA has positioned itself to allow clinical practices to evaluate their performance and patient outcomes. It seems that what the new frontier was then has become the expectation today from both our patients and payers. Over the years, the mainstay of SAMBA’s mission has always been education. The society has accomplished this predominantly through holding several CME meetings each year, including our annual meeting in the spring and our mid year meeting held the Friday immediately preceding the ASA annual meeting. Several years ago, we elected to also offer an annual meeting solely focused on office-based anesthesia (OBA) practice. Clinical practice guidelines, consensus statements and webinars targeted at residents have rounded out our educational offerings. So what changes are going on within SAMBA to provide value to its membership? First, we’re finalizing the creation of partnerships with specific companies through our new Corporate Affinity Program. The goal is to provide improved access to and discounts on various products and business solutions for SAMBA members in a streamlined and easy-to-navigate fashion. Second, we recently distributed a SAMBA Membership Needs Assessment Survey to better understand

what the society does well and what it can do better. Once those responses are in and tallied, we’ll use this information to drive improvements for our membership. Third, we’re revisiting our strategic plan that was initiated almost 2.5 years ago (under then-SAMBA President John Dilger, M.D.) to make sure we stay on target with our goals and ensure we continue to remain financially healthy.

SAMBA recognizes that ambulatory anesthesia as a practice encompasses much more than what occurs solely in an ambulatory surgery center. Office-based anesthesia also has its home within SAMBA and in many ways represents today what ASCs did decades ago; there is no doubt that OBA practices will continue to evolve in the coming years. Remote or non-O.R. anesthesia is also making its presence known within SAMBA as hospital-based practices realize ambulatory anesthetic techniques can greatly improve patient care and efficiency in these off-site locations. To remain relevant over the next 30 years, SAMBA will have to evolve to best serve its members. However, the focus on excellence in education and patient outcomes will remain at the forefront of SAMBA’s mission.

SAMBA 2014 UpdateBrian M. Parker, M.D., PresidentSociety for Ambulatory Anesthesia (SAMBA)

Brian M. Parker, M.D. is Medical Director, Hospital Operations, Cleveland Clinic; Associate Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

“ With the development of the SAMBA Clinical Outcomes Registry (SCOR), SAMBA has positioned itself to allow clinical practices to evaluate their performance and patient outcomes. It seems that what the new frontier was then has become the expectation today from both our patients and payers.”

MAKE STRIDESStudy at your own pace and test your knowledge with this go-anywhere, online program that allows you to pinpoint areas of pain medicine where you excel and areas where you may benefit from further study. Close the gaps in your knowledge while making progress toward meeting CME and MOCA® requirements at the same time.

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Learn moreeducation.asahq.org/12sampm

Accreditation and Credit Designation Statements

The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.


This self-assessment activity helps fulfill the self-assessment CME requirement for Part 2 of the Maintenance of Certification in Anesthesiology Program (MOCA) of The American Board of Anesthesiology (ABA). Please consult the ABA website, www.the ABA.org, for a list of all MOCA requirements.

MOCA®

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Shortly after I made the decision to specialize in anesthesia, my mother gave me a copy of a book she had just started reading, Oxygen by Carol Cassella, and suggested I might enjoy it as well. After all, the main character is a young anesthesiologist. At the risk of sounding a bit book-clubish, I absolutely loved it – tearing through its pages as only the refreshed mind of a fourth-year medical student can, picturing my own future career. But as the story developed, I became acutely conscious of an aspect of my profession to which I had paid little attention before, and as residency approached, I found the book seemed to haunt me. The plot revolves around an intraoperative error and its wide-reaching ramifications, both professionally and emotionally, for its main character. In those last few bright days of relative innocence as medical school drew to a close, it dawned on me that, in but a short time, I would be making choices unlike any I had made before, choices that would affect my patients’ lives much more than they would affect mine. These are choices that, if flawed, could well be irrevocably harmful to another human being. I was, of course, always aware that a physician carries great responsibility in this regard, but I was aware of it more in the way that a person is aware that an elephant is very heavy, having only ever seen one in the zoo. As I began writing my first orders as an intern and, as a matter of course, making my first mistakes, I began to actually feel the weight, as if that elephant had raised its massive foot and placed it squarely over my midsection.

As physicians, coping with our own mistakes is not an easy task. Mistakes, and the subsequent feelings of anxiety and inadequacy they cause, contribute significantly to physician burnout and dissatisfaction. They can be motivating factors behind major career changes and have been linked to post-traumatic stress disorder, depression and substance abuse among physicians as well. A classmate of mine recently asked one of our faculty members to share with us how he deals with mistakes. He is a much-admired anesthesiologist both in our department and across the country – someone I can only with difficulty imagine actually making a mistake. Hearing his honest reflections on some of the more challenging moments in his career was both eye-opening and reassuring. At least in my limited realm of experience, it has been rare that a discourse on this subject take place, and I found my classmate’s question extremely thoughtful and indicative of a need for more structured education and training in how to cope after making a mistake. Spurred on by a well-known 1999 report by the Institute of Medicine called To Err Is Human, numerous publications over the last decade have studied the best ways to address medical errors. My medical school, like many, offered a curriculum in

Learning to CopeKristina L. Goff, M.D.

Kristina L. Goff, M.D. is an Anesthesia Critical Care fellow, University of Washington, Seattle.


medical ethics, which addressed dealing with errors, the best ways to share information with patients and their families, and whether and how to apologize to them. While all of this information is valuable in guiding physicians in their interactions with patients and patients’ families, unfortunately, the focus has very infrequently turned inward.

We receive little coaching on how to process the emotional impact of our mistakes and move forward. Furthermore, it is often intimidating to seek help or advice after a misstep during residency, and even more so thereafter because of the implicit admission of guilt required in doing so. Aside from the embarrassment factor, many physicians are also concerned about the potential legal consequences of discussing such issues. We are essentially all in this same boat, struggling with the same issues rather blindly, resulting in a self-perpetuating culture of isolation that is harmful to both our patients and ourselves.

In recent years, some strides have been made toward educating physicians and opening forums for discussion with a focus more on the physician psyche. It would be prudent to incorporate this during residency training as well. The M&M conference is a familiar enough entity, in which we review cases with poor outcomes, hoping to find ways to improve our decision-making for the future. A newer concept, termed the Schwartz Center Rounds program, provides for an interdisciplinary discussion centered around an identified case, but focusing on the more human elements involved, including the frustrations and doubts a physician, nurse or other health care worker may feel in carrying out his or her job. In this way, physicians may find more support in their work environment. It is also important to identify mentors early in training, and it should be incumbent on both the faculty mentor and the residency program to help foster this relationship and encourage a non-judgmental, open dialogue between advisor and advisee. The subject of mistakes should be broached with each trainee in a non-threatening way so that residents feel more inclined to seek guidance in coping. Residents should be made aware of the resources available to them through employee health and graduate medical education should they feel the need to seek additional help. Many physicians dealing with anxiety can benefit from counseling and behavioral therapy, and this must be a readily available option. In Carol Cassella’s words, “to be an excellent physician you must accept the possibility of failure. A doctor who considers himself infallible is a most dangerous creature.” Knowing this is the case, should we not also invest time in educating ourselves so that we may better cope with our mistakes?

Anesthesia Business Consultants ..........................................................................................................................................................................p. 21

Merck & Co., Inc. ...............................................................................................................................................................................................back cover

New York State Society of Anesthesiologists, Inc. .......................................................................................................................................p. 41

Team Health® Anesthesia ............................................................................................................................................................................................p. 7

For more information about advertising, contact: Christine Kenney, National Sales Manager, The Walchli Tauber Group, Inc.

Cell: (443) 252-0571 • Phone: (443) 512-8899 – ext.115 • [email protected]

The advertisements in this publication shall not be construed as an endorsement or approval by ASA of any product, service or company.

ADVERTISER INDEX ASA NEWSLETTER

“ As physicians, coping with our own mistakes is not an easy task. Mistakes, and the subsequent feelings of anxiety and inadequacy they cause, contribute significantly to physician burnout and dissatisfaction.”

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Perioperative Surgical Home Model in Modern Healthcare ASA President Jane C.K. Fitch, M.D. authored a column in Modern Healthcare in July proposing the Perioperative Surgical Home (PSH) model of care. Dr. Fitch suggested the PSH as a solution to our country’s fragmented hospital surgery system. The article ran in the print and online editions of the magazine.

The PSH was also featured on KevinMD.com in a guest column authored by Dr. Fitch in June, where she discussed how the model leads to better outcomes and lower costs. Widespread Chronic Pain in Veterans In July, ASA member and pain specialist at Pittsburgh’s VA Medical Center, Michael Mangione, M.D., discussed widespread chronic pain among veterans with a local CBS Pittsburgh affiliate. Dr. Mangione stressed the prevalence and severity of chronic pain in those who have served and how comprehensive treatment is imperative to quality care for this patient population.

Epidural Myths Debunked in Chicago TribunePaloma Toledo, M.D., M.P.H. explained myths and realities about epidurals during labor in an article published by the Chicago Tribune. Dr. Toledo provided facts about epidurals to help readers make their decision regarding pain management during pregnancy. The article was published on more than 1,000 websites, including the San Francisco Chronicle and the Milwaukee Journal Sentinel.

Same-Day Surgery Advice in Reader’s Digest ASA member Steven Gayer, M.D. was quoted in a Reader’s Digest story about what patients should do before same-day surgery. Dr. Gayer advised patients to make sure their fingernails are polish-free, as the pulse oximeter must be able to send and receive light through the fingertip, and acrylics and other nail coatings interfere.

Scope-of-Practice Issue on NPR AffiliateMichigan Radio, part of the NPR digital network, featured the scope-of-practice issue in June. ASA member and Committee on Communications Chair Kenneth Elmassian, D.O. discussed how more authority for nurses will lead to slower care for Michiganders. Dr. Elmassian said that autonomy will end in nurses wanting to practice independently from physicians.

What Should You Ask Your Physician Anesthesiologist? On the local NBC Chicago affiliate station, ASA member David Rosen, M.D. gave advice to patients about to have surgery. Dr. Rosen recommended patients ask if there will be an attending physician anesthesiologist, and ask any questions they have before going in for the procedure. He emphasized that patients should be honest with their physician anesthesiologists, particularly when they forget to heed preoperative instructions.

Traveling with Chronic Pain ASA member John Dombrowski, M.D. gave advice to summer travelers with chronic pain on Healthline.com in June. Dr. Dombrowski told Healthline that many people who suffer from chronic pain do not know they can get long-lasting injections to ease their discomfort. He suggested that travelers plan ahead for their medical care just as they do with their airline tickets and travel insurance.

Anesthesiology Study Identifies New Compound to Treat Depression Researchers identified a compound, hydroxynorketamine, which treats symptoms of depression as effectively and rapidly as ketamine, without unwanted side effects. The study was featured in several outlets, including The Times (London), Medscape and Science World Report.

ANESTHESIOLOGY NEWSINTHE



GHO Heads Back to Rwanda ASA member Michael Heine, M.D. led a trip to Rwanda in July to provide education and training in anesthesia. The mission was featured on several websites, including KyForward, Becker’s ASC Review and News-Medical.net. Dr. Heine previously volunteered in Africa with ASA’s original outreach initiative Overseas Training Program, then run by founder Dr. Nicholas M. Greene.

PONV Prevention and Treatment ASA member Steven Gayer, M.D. authored an article in the July issue of Outpatient Surgery Magazine on the prevention of PONV. Dr. Gayer stressed the importance of planning ahead for surgical patients and potentially new and better treatments for the nausea and vomiting some patients endure after surgery.

Avoiding Intubation Trauma Among Patients In the July issue of Outpatient Surgery Magazine, ASA member Robin Elwood, M.D. discussed intubation trauma. Dr. Elwood covers a number of topics in the article, including occurrence rates of intubation trauma, recognizing vulnerable patients and alternative options, such as video laryngoscope.

One Member’s Story of Challenge, Success and Heartbreak in Kenya Donna-Ann Thomas, M.D. authored a guest column on KevinMD.com in May about her mission trip to Kenya. Dr. Thomas discussed her experience in the East African country, including a number of challenges she encountered, such as the physician strike over wages and equipment. Due to the strike, Dr. Thomas’ was the only health care team available in the area aside from private hospitals.

Choosing Wisely® List of Tests and Procedures to Avoid The list released in 2013 as part of the ABIM Foundation’s Choosing Wisely® campaign continues to garner coverage. The list featured five common tests and procedures patients should avoid and was published in JAMA Internal Medicine in June. ASA member and senior author of the article Lee Fleisher, M.D. was interviewed on Tampa Bay WHNZ radio’s “Health, Wealth and Wisdom,” where he discussed the campaign and its relevance to patients.

Surgical Patients More Likely to Comply with an Instruction Sheet A study in the July issue of Anesthesiology revealed that patients who receive a simple, multicolor, standardized medication instruction sheet before surgery are more likely to comply with their physician’s instructions and experience a significantly shorter post-op stay in recovery. The study was picked up in Medscape, OutpatientSurgery.net and DailyRx.

ASA Applauded for Malpractice Lawsuit Assessment ASA was applauded for conducting a comprehensive assessment in 1982 and ultimately revamping procedures, training, machines and safety devices on KevinMD.com in June. The article mentioned the mortality rate from anesthesia dropped from 1 in 6,000 administrations to 1 in 200,000 during a 10-year period, and physician anesthesiologists’ malpractice insurance rates fell to among the lowest of any specialty.


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Since an announcement was made in the April NEWSLETTER, 10 ASA members have declared their candidacies for elected offices. In August, the Candidates for Office page will be available on the ASA website at www.asahq.org/candidates/approve. A member’s announcement of candidacy does not constitute a formal nomination to an office, nor is it a prerequisite for being nominated. Formal nominations are made from the floor of the House of Delegates at the first session, as prescribed by the ASA Bylaws (section 1.6.1.1). Those who have declared they are seeking office are:

President-Elect Daniel J. Cole, M.D.

First Vice President Jeffrey Plagenhoef, M.D.

Vice President for Professional Affairs Stanley W. Stead, M.D., M.B.A.

Vice President for Scientific Affairs Beverly K. Philip, M.D.

Secretary Linda J. Mason, M.D.

Treasurer James D. Grant, M.D.

Assistant Secretary John F. Dombrowski, M.D.

Assistant Treasurer Mary Dale Peterson, M.D.

Speaker, House of Delegates Steven L. Sween, M.D.

Vice Speaker, House of Delegates Ronald L. Harter, M.D.

Candidates Announced for Elected Office

IN MEMORIAM

Lafe W. Bauer, M.D.Prairie Village, KansasMarch 14, 2014

James J. Berny, M.D. Boardman, OhioNovember 19, 2013

Brad N. Brian, M.D.St. George, UtahMay 7, 2014

Chad Cripe, M.D.Philadelphia, PennsylvaniaFebruary 1, 2014

Gifford V. Eckhout, Jr., M.D.Tyler, TexasJune 22, 2014

Eduardo M. Figallo, M.D.Pittsburgh, PennsylvaniaApril 15, 2014

Glen C. Hutchison, M.D.Hays, KansasMay 9, 2014

Jordan Katz, M.D.Solana Beach, CaliforniaJune 28, 2014

Jay W. Lang, MD. Carmel, IndianaJuly 8, 2014

Hugh S. Mathewson, M.D.Overland Park, KansasNovember 26, 2012

Thomas McCaughey, M.D.Montreal, Quebec, CanadaDecember 23, 2013

Robert D. McKay , M.D.Bristol, TennesseeMay 19, 2014

S. R. Sellaro, D.O.Erie, PennsylvaniaJune 20, 2014

Byron G. Sherman, Jr., M.D.Manchester Center, VermontJuly 29, 2013

David H. Skinner, M.D. Laguna Hills, California July 30, 2014

Raymond D. Sphire, M.D.Grosse Pointe Farms, MichiganNovember 5, 2013

Kenneth Sugioka, M.D.Chapel Hill, North CarolinaJune 19, 2014

Hildegard Wessel-Manitsas, M.D.McLean, VirginiaApril 24, 2014


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Reader Wants Beliefs Weeded Out of Facts on Marijuana In their otherwise valuable article “Substance Use Disorder in Anesthesiology Residents: Still a Serious Problem” in the July ASA NEWSLETTER, Drs. Warner and Berge assert that “intravenous opioid use is [not] any more dangerous than any other substance, including alcohol and illicit drugs such as cocaine and marijuana.” Since there are few, if any, deaths attributable to marijuana, this statement seems prejudicial and belief-based, not factual.

Lucille Mostello, M.D.Silver Spring, Maryland

Response From Drs. Warner and Berge: Thank you for your comment, which prompted us to re-examine our data, originally analyzed by grouping those who used either cocaine or marijuana. Although most marijuana use was associated with the use of other drugs, of the eight individuals whose records indicated only marijuana use for their initial episode of substance use disorder, two (25 percent) achieved board certification, and two (25 percent) relapsed, proportions similar to that observed for the entire group of 384 residents. We also note that of the 56 individuals with a history of substance use prior to use in residency, 24 (43 percent) had used marijuana. Fortunately, none of these individuals died. Although it is difficult to make comparisons with such low numbers (which is why we originally grouped the categories for analysis), these data suggest that the consequences of marijuana use can be serious.

David O. Warner, M.D.Rochester, Minnesota

Keith Berge, M.D.Rochester, Minnesota

The views and opinions expressed in the “Letters to the Editor” are those of the authors and do not necessarily reflect the views of ASA or the NEWSLETTER Editorial Board. Letters submitted for consideration should not exceed 300 words in length. The Editor has the authority to accept or reject any letter submitted for publication. Personal correspondence to the Editor by letter or e-mail must be clearly indicated as “Not for Publication” by the sender. Letters must be signed (although name may be withheld on request) and are subject to editing and abridgement. Send letters to [email protected].


Coming off of the heels of its commitment to fund $2.5 million in new research grants in 2014 and awarding the first-ever year-long medical student research fellowships, the board of directors of the Foundation for Anesthesia Education and Research (FAER) is pleased to announce FAER’s 2015 research grant funding and medical student fellowship opportunities. FAER provides research grant funding for physician anesthesiologists, anesthesiology trainees and medical students to gain additional training in basic science, clinical and translational, health services and education research. For early-career anesthesiologists interested in pursuing careers as physician-scientists, FAER grants can be an important starting point. These grants aim to help physician anesthesiologists develop the skills and preliminary data they need to become independent investigators.

RESEARCH GRANT FUNDING – 2015 OPPORTUNITIES The following research grant funding opportunities are available to physician anesthesiologists and anesthesiology trainees. The application website for the 2015 grant funding cycle will open November 1, 2014. The deadline for applications is February 15, 2015. For more information regarding FAER grants and eligibility requirements, visit FAER.org/research-grants or call the FAER office at (507) 266-6866.

Mentored Research Training GrantsResearch Areas: Basic Science (MRTG-BS) Clinical and Translational (MRTG-CT) Health Services Research (MRTG-HSR)Purpose: To help physician anesthesiologists develop

the skills and preliminary data to become independent investigators

For Whom: Faculty members who completed core anesthesiology residency within the past 10 years

Funding: $175,000Duration: Two yearsPercent Research: 75%

Research Fellowship GrantResearch Areas: Basic Science, Clinical and Translational,

Health Services or EducationPurpose: To provide significant training in research

techniques and scientific methodsFor Whom: Anesthesiology trainee after the CA-1 yearFunding: $75,000Duration: One yearPercent Research: 80%

Research in Education GrantResearch Areas: Education ResearchPurpose: To improve the quality and impact of

anesthesiology education researchFor Whom: Faculty member of any rank

(junior or senior faculty)Funding: $100,000Duration: Two yearsPercent Research: 40%

RESEARCH GRANT APPLICATION KEY DATESOnline application opens November 1, 2014Applications due February 15, 2015Award notifications made by May 15, 2015Project start date July 1, 2015 or January 1, 2016

2015 Research Grant Funding and Medical Student Fellowship Opportunities Announced – Applications Open This Fall

Denham S. Ward, M.D., Ph.D.

Denham S. Ward is President and CEO, Foundation for Anesthesia Education and Research, and Emeritus Professor of Anesthesiology and Biomedical Engineering, University of Rochester Medical Center, Rochester, New York.

FAER Report


RESEARCH GRANT ELIGIBILITY CRITERIA – UPDATED FOR 2015 The FAER Grant Management Committee has made a few changes and clarifications to the eligibility criteria and rules for research grant funding.n Applicants may submit only one grant application per award

cycle.n Tuition is not allowed in the budget for any grant.n The applicant and the primary mentor for the grant must be

at the same institution.

To view the complete eligibility requirements and application guide, visit FAER.org/research-grants.

MEDICAL STUDENT FELLOWSHIPS – 2015 OPPORTUNITIES FAER’s Medical Student Anesthesia Research Fellowships provide funding to support medical students over a summer or a year in focusing on anesthesiology research, training in scientific methods and techniques, and learning how to incorporate research into a medical career. Medical student anesthesia research fellowships are awarded through an annual application cycle. For more information about the MSARF program and eligibility requirements, visit FAER.org/MSARF.

Medical Student Anesthesia Research Fellowship (MSARF) Summer Program The summer fellowship provides medical students with an eight-week research experience within an academic anesthesiology department. During the fellowship, students participate in research and training activities, as well as clinical anesthesia activities. In addition, medical student summer fellows have the opportunity to make a scientific presentation at the ASA annual meeting. Students receive a stipend during the fellowship.

Student Application Key Dates (Summer Program)Online application opens November 15, 2014Applications due December 15, 2014Award notifications made by January 31, 2015Fellowships take place throughout late spring / summer 2015

Host Department Application Key Dates (Summer Program)Online application opens September 1, 2014Applications due October 1, 2014Match results announced by January 31, 2015Fellowships take place throughout late spring/summer 2015

Medical Student Anesthesia Research Fellowship (MSARF) Year-Long Program FAER’s year-long medical student fellowship is for those who would like to spend a year focusing on anesthesiology research and receive additional training, and who have completed their core clinical rotations but have not yet graduated. Students who participate in the 2015-16 program will present their research at the 2016 ASA annual meeting. Through the program, medical student fellows can expect:n One year of full-time research in anesthesiology.n A formal mentor-protégé relationship with an experienced

investigator.n Training in scientific methods and research techniques.n A $32,000 stipend, plus additional funding to cover

relocation, housing, health insurance, travel to a national meeting and other related expenses.

Student Application Key Dates (Year-Long Program)Online application opens November 15, 2014Applications due December 31, 2014Award notifications made by February 15, 2015Fellowships take place starting late spring/summer 2015

Donate to Support Research in Anesthesiology

You can create a better future for anesthesiology by making a donation to FAER. When you give, you enable the careers and education of anesthesiologists who will bring about new knowledge, scientific discoveries and progress in patient care.

Here are ways you can make your gift today:Online: Visit FAER.org/donate to make a gift

using our secure gift form.

By Mail: Mail your donation to FAER at P.O. Box 157, Rochester, MN 55903-9941

By Phone: Call FAER’s office at (507) 266-6866 to make your gift. Our business hours are Monday through Friday, 8 a.m. to 5 p.m. CT.

Thank you for your generosity!

PROFESSIONAL SERVICES

Anesthesia Business Consultants is the most comprehensive practice management company specializing in the practice of anesthesia & pain management. See our ad on page 21 or visit us @ www.anesthesiallc.com.

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2014 Classified Advertising

POSITIONS AVAILABLE • PROFESSIONAL SERVICES • FELLOWSHIPS • SEMINARS MEETINGS • TUTORING • VACATION RENTALS

LINE RATES $30 per line or fractional line, 42 characters per line, including spaces. 5 line minimum charge.$100 additional charge for border around ad.

BLACK & WHITE DISPLAY AD RATESFrequency 1/12 page 1/6 page 1/3 page 1 x $1,033 $1,840 $3,230 3 x $1,000 $1,780 $3,120

COLOR DISPLAY ADS Please contact Julie O’Heir, Corporate Development Manager for details.

ASA MEMBER BENEFIT 30% discount off Line Rate. Display Ad rate discount available. Please contact Julie O’Heir, Corporate Development Manager for details.

MECHANICAL REQUIREMENTSSubmission of Ads: We prefer and strongly recommend the submission of display ads via Acrobat PDF files: Save with basic Distiller settings; No OPI; No ICC profiles; embed all fonts; effective resolution minimum 300 DPI; include bleed. Microsoft Word documents are accepted (for text only). For any other media, call for information.Ads must be complete and sized at 100%. Ads must be saved as high resolution for print publication (minimum 300 DPI). Laser proof must accompany all digital file submissions. Electronic Transfer: E-mail (for file sizes 5 MB or less). Please contact Corporate Development Manager prior to submitting file via e-mail.

DISPLAY SIZES:1/12 page 1/6 page 1/3 page2¼” x 2¼” 2¼” x 4½” 4 3/4” x 4½”

CLOSING DATES: Issue DeadlineJANUARY November 21FEBRUARY December 20MARCH January 30APRIL February 26MAY March 25JUNE April 25JULY May 24AUGUST June 24SEPTEMBER July 26 OCTOBER August 26 NOVEMBER September 24 DECEMBER October 29

SALES: Christine Kenney, National Sales Manager The Walchli Tauber Group, Inc. Mobile: 443-252-0571 Phone: 443-512-8899, ext. 115 Email: [email protected]

REACH MORE QUALIFIED ANESTHESIA CANDIDATES. Advertise online at careers.asahq.org.

NEWSLETTER

Society (IARS). These societies will be exhibiting and conducting educational sessions at the ANESTHESIOLOGY™ 2014 annual meeting in New Orleans.

Extending ASA’s Global Reach With a growing international presence at its annual meeting (25 percent of attendees in 2013), ASA acknowledges its role as a world leader in anesthesia education and plans to offer multiple sessions with a global perspective at this year’s meeting, themed “Global Leaders in Outcomes, Education, Safety and Discovery.” ASA will also participate in influential anesthesia meetings around the globe. ESA’s panel at the ANESTHESIOLOGYTM 2014 annual meeting in New Orleans, titled “Challenges in Anesthesiology: A European Perspective,” will take place on Saturday morning, October 11. Four additional international panels will be featured at the ANESTHESIOLOGYTM 2014 annual meeting, including the WFSA panel “Government Funded Healthcare and Anesthesia: An International Perspective on Successes and Failures” on Sunday morning, “Professionalism – An International Perspective,” and “Perioperative Management of Patients with Endocrine Disease: A Global Perspective,” also on Sunday, and “International Forum on Patient Safety and Quality Outcomes” on Monday morning. Correspondingly, ASA plans to participate in the 2014 CSA Academic Annual Meeting in Chengdu, China, Euroanaesthesia 2015 in Berlin, IARS 2015, and the WFSA WCA 2016 meeting in Hong Kong.


Euroanesthesia 2014

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Mark your calendars for the premier educational event for physician anesthesiologists and practice administrators:

• Learn from leading experts about critical topics such as Group Governance, Risk Management, and Bundled Payments

• Gain insight into current healthcare regulations, legislation and how changes may affect your anesthesiology practice

• Obtain strategies to improve practice performance and your bottom line

This activity has been approved for AMA PRA Category 1 Credit™. Directly Sponsored by the American Society of Anesthesiologists.

Join useducation.asahq.org/pm

Interested in conducting your own research?

Copyright © 2014 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. Printed in USA ANES-1124773-0000 07/14

How to get started:To learn more about the areas of interest for anesthesia and requirements for submission visit http://engagezone.merck.com/anesthesia.html.

There are two review cycles for anesthesia submissions:

• First cycle deadline is in early February 2015.

• Second cycle deadline is in early April 2015.

The mission statement of the Merck Investigator Studies Program (MISP) is to advance science and improve patient care by supporting, through the provision of drug/vaccine and total/partial funding, high-quality research that is initiated, designed, implemented and sponsored by external investigators.

The Merck Investigator Studies Program is open to all academic and community-based physicians, anesthesiologists, surgeons, and researchers worldwide who are interested in conducting their own research.

This program consists of committees of medical and scientific staff from different therapeutic areas who meet regularly to review Merck investigator study proposals. Support and funding are provided based on the scientific merit of the proposal as well as whether it is in alignment with the published areas of interest.

Who Can Participate?

How Does the Program Work?

What is MISP?

Consider the Merck Investigator Studies Program.

ANES-1124773-0000.indd 1 8/4/14 8:38 AM

09 Sep 2014

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