Antithrombotic drugs, such as antiplatelet agents (APA) and anticoagulant therapies, are commonly prescribed for patients with cardiovascular disorders to prevent thrombosis, or blood clots. However, patients on antithrombotic medications are at increased risk of excessive blood loss during and after surgery with regional anesthesia.^1,2

Platelets, or thrombocytes, are small cellular components in blood whose function is the formation of blood clots to stop bleeding after injury. Internal signaling pathways in an activated platelet signal the release of molecules such as adenosine diphosphate (ADP), adrenaline, serotonin, thrombin, and thromboxane A2. Platelet glycoproteins then bind to fibrinogen, resulting in platelet aggregation and thrombus formation.¹ Acetylsalicylic acid, a commonly prescribed APA, inhibits thromboxane A2 production for the entire lifetime of a singular platelet (7–10 days). Ticagrelor is an APA that blocks critical G-protein activation and associated signaling pathways, while dipyridamole blocks the uptake of adenosine.¹ On the other hand, anticoagulant therapy prevents clot formation by disrupting the coagulation cascade. Most anticoagulants will either prevent the formation of coagulation factors such as factor IIa or inhibit the production of fibrin.^1,3

In late 2021, experts from the European Society of Anaethesiology and Intensive Care (ESAIC) and the European Society of Regional Anesthesia (ESRA) convened to discuss the extant literature on the prevention of excessive blood loss following regional anesthesia in patients on antithrombotic drugs.² After careful analysis, the committee recommended waiting at least 24 hours between the last intake of anticoagulant therapy and anesthesia administration. For antiplatelet drugs, such as aspirin, ticagrelor, clopidogrel, and prasugrel, the recommendation is a pre-operative waiting period of 3-7 days. ^2,4 Additionally, when combinations of antithrombotic drugs are used, the therapy-free time before anesthesia should be equivalent to that of the drug with the longest waiting period. Risk factors to consider include specific bleeding risks such as inherited bleeding disorders, acquired bleeding disorders, a history of significant bleeding, renal failure, hepatic failure, advanced age, female sex, and extreme body weight. An individual risk-benefit analysis must always be made, ideally in conjunction with the patient. Experts also found several reviews which suggest delaying the next antithrombotic drug dose for at least 48 to 72 hours after surgical intervention to prevent postoperative bleeding complications. Although the general recommendation is withdrawal of antithrombotic therapy some time before and after anesthetic administration, in situations where the risk of thromboembolism or ischemia is high, the anesthesiologist may decide to proceed without withdrawal.²

Healthcare teams must maintain their vigilance in the perioperative period to detect and manage excessive bleeding when the patient is undergoing anesthesia. During and after surgery, the team should look for persistent pain at the site of anesthesia, a drop in hemoglobin level, morphological skin changes, cardiovascular instabilities, or any neurologic deficits, as any of these symptoms should raise suspicion of a hemorrhagic complication due to regional anesthesia.²

In the future, more clinical trials may provide clearer and more standardized recommendations on the use of regional anesthesia in patients on antithrombotic therapy.

 

References

 

1. Mega, Jessica L., and Tabassome Simon. “Pharmacology of Antithrombotic Drugs: An Assessment of Oral Antiplatelet and Anticoagulant Treatments.” The Lancet, vol. 386, no. 9990, July 2015, pp. 281–91. https://doi.org/10.1016/S0140-6736(15)60243-4

1. Kietaibl, Sibylle, et al. “Regional Anaesthesia in Patients on Antithrombotic Drugs: Joint ESAIC/ESRA Guidelines.” European Journal of Anaesthesiology, vol. 39, no. 2, Feb. 2022, pp. 100–32. https://doi.org/10.1097/EJA.0000000000001600
2. Jiang, L., et al. “A Critical Role of Thrombin/PAR-1 in ADP-Induced Platelet Secretion and the Second Wave of Aggregation.” Journal of Thrombosis and Haemostasis, vol. 11, no. 5, May 2013, pp. 930–40. https://doi.org/10.1111/jth.12168
3. Douketis, James D., et al. “Perioperative Management of Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.” Chest, vol. 141, no. 2, Supplement, Feb. 2012, pp. e326S-e350S. https://doi.org/10.1378/chest.11-2298

Defined as the ability to perceive, understand, and project the elements of the environment, the concept of situational awareness is vital in the dynamic field of anesthesia. This capability allows anesthesiologists to make swift, accurate decisions in settings where conditions may change abruptly (1). Anesthesiologists must continuously monitor and interpret a broad spectrum of physiological data, anticipating potential complications. Recognizing subtle changes in blood pressure or heart rate and understanding their implications for immediate and future health outcomes are common applications of situational awareness in anesthesia care.

 

The three levels of situational awareness—perception, comprehension, and projection—offer a framework for practitioners to structure their interactions within the environment (2). Perception involves noticing critical signs and signals in the operating room, such as changes in the patient’s vital signs or medical alarms. At the comprehension level, anesthesiologists interpret these signals based on their medical knowledge and the specific context of the patient’s condition. Projection then involves anticipating future changes in the patient’s status based on current data and trends, enabling proactive management in anesthesia care (1).

 

Training in situational awareness has become a core component of education for anesthesia professionals. Simulation-based training strengthens anesthesiologists’ abilities to manage complex scenarios in a controlled environment. These simulations enhance their skills across all three levels, preparing them for real-life situations (3). Additionally, recent studies highlight the significant role of non-technical skills, such as teamwork and communication, in influencing situational awareness in clinical settings (4). Tools like the Situation Awareness Global Assessment Technique (SAGAT) enable objective evaluation of this skill by freezing simulations at various points and querying participants about their awareness of the scenario’s elements (2). While direct measures are informative, their complexity makes them challenging to implement in the high-pressure environment of the operating room. Thus, indirect measures, such as evaluating decision-making and outcomes, are commonly used to infer situational awareness levels during actual procedures (1).

 

Technological advancements have also led to the development of sophisticated monitoring systems designed to enhance awareness. These systems integrate multiple streams of physiological data and present them in more interpretable ways, reducing cognitive load during demanding surgical procedures (4). However, effective implementation of situational awareness concepts in anesthesia care still faces challenges due to individual capabilities, training variations, and the limitations of human attention under stress. Continued research and development are essential to address these challenges, optimize training methods, and improve technological supports (1).

 

Situational awareness is foundational for safe and effective anesthesia care. It encompasses the ability to perceive, understand, and anticipate developments in a dynamic clinical environment. Ensuring that anesthesiologists have the necessary training, tools, and support to maintain optimal levels of situational awareness is vital for patient safety and the overall effectiveness of medical care.

 

References

 

1. Schulz CM, Endsley MR, Kochs EF, Gelb AW, Wagner KJ. Situation awareness in anesthesia: concept and research. Anesthesiology. 2013;118(3):729-742. doi:10.1097/ALN.0b013e318280a40f
2. Endsley MR. Toward a theory of situation awareness in dynamic systems. Human Factors. 1995;37(1):32-64.
3. Gaba DM, Howard SK, Small SD. Situation awareness in anesthesiology. Hum Factors. 1995;37(1):20-31. doi:10.1518/001872095779049435
4. Fletcher GC, McGeorge P, Flin RH, Glavin RJ, Maran NJ. The role of non-technical skills in anaesthesia: a review of current literature. Br J Anaesth. 2002;88(3):418-429. doi:10.1093/bja/88.3.418

 

 

Monopolies in healthcare are a growing topic of discussion, especially within sectors like pharmaceutical companies or insurance providers. In the last year, the United States Justice Department has filed multiple antitrust lawsuits against healthcare entities (Wallace, 2024). Recently, concerns about monopolies anesthesia services have grown (Whoriskey, 2023).  

Anesthesia plays a crucial role in healthcare by ensuring patient comfort and safety during medical procedures and by managing substance use and pain. However, some have expressed concerns that the provision of anesthesia services has increasingly fallen under the control of large corporate entities such as U.S. Anesthesia Partners, Inc. (USAP) (Wallace, 2024). These entities typically emerge from a series of mergers and acquisitions. USAP, for instance, originated from a large private equity firm, initiating its operations by first acquiring the largest anesthesiology group in Denver (Whoriskey, 2023). It is also now the largest provider of anesthesia services in Texas (“FTC Challenges Private Equity Firm’s Scheme to Suppress Competition in Anesthesiology Practices across Texas”, 2023).   

A primary concern associated with monopolies in anesthesia—and in any industry—is the potential for diminished competition and increased pricing. When one entity dominates the market, it wields significant pricing power, which can result in increased healthcare costs for patients. For instance, USAP raised prices for some services by almost 30% during its inaugural year (Whoriskey, 2023). This escalation can further impede access to care, prompt physicians to depart from a practice, and exacerbate existing healthcare disparities. Moreover, physicians leaving monopolistic practices may face substantial financial penalties and geographic restrictions on practicing due to non-competes (Whoriskey, 2023). Notably, the Federal Trade Commission sued USAP and its founding firm in 2023, alleging a multi-year, multi-part plan to consolidate the anesthesiology market in Texas (“FTC Challenges Private Equity Firm’s Scheme to Suppress Competition in Anesthesiology Practices across Texas”, 2023). USAP rates with major insurance companies notably surpass industry averages (Whoriskey, 2023). 

Another concern revolves around potential compromises in patient care. Some argue that when a single entity monopolizes the anesthesia services of a region, it may prioritize profit over patient outcomes (La Forgia et al., 2022). It is imperative to have diverse and experienced anesthesia providers who are committed to innovation while prioritizing patient welfare to continue improving the quality of healthcare (Whoriskey, 2023). 

Concerns about monopolies in anesthesia, as illustrated by the USAP controversy, reflect broader concerns about healthcare costs and quality of care. Calls for enhanced transparency, oversight, and regulation within the anesthesia industry have amplified, with stakeholders advocating for measures to promote fair competition, safeguard patient interests, and ensure the delivery of quality care. Continued scrutiny of powerful healthcare systems and insurance companies is also necessary. By fostering competition, enhancing transparency, and prioritizing patient care, the healthcare industry can progress towards a more equitable and sustainable future.  

 

References  

1. “FTC Challenges Private Equity Firm’s Scheme to Suppress Competition in Anesthesiology Practices across Texas.” Federal Trade Commission, Federal Trade Commission, 21 Sept. 2023, www.ftc.gov/news-events/news/press-releases/2023/09/ftc-challenges-private-equity-firms-scheme-suppress-competition-anesthesiology-practices-across. 
2. La Forgia, Ambar et al. “Association of Physician Management Companies and Private Equity Investment With Commercial Health Care Prices Paid to Anesthesia Practitioners.” JAMA internal medicine vol. 182,4 (2022): 396-404. doi:10.1001/jamainternmed.2022.0004
3. Wallace, Claire. “Doubling down on Healthcare Monopolies: 4 Cases to Know.” Becker’s ASC Review, Becker’s Healthcare, 5 Mar. 2024, www.beckersasc.com/asc-news/doubling-down-on-healthcare-monopolies-4-cases-to-know.html. 
4. Whoriskey, Peter. “Financiers Bought up Anesthesia Practices, Then Raised Prices.” The Washington Post, 29 June 2023, www.washingtonpost.com/business/2023/06/29/private-equity-medical-practices-raise-prices/.  

The Current Procedural Terminology (CPT) codes provide medical practitioners with a uniform language to record medical services [1]. This system is praised for promoting accuracy and efficiency in medical reporting and has become the principal medical nomenclature system in US healthcare [1]. Although the system is quite comprehensive, some medical services, including emerging anesthesia procedures, are currently without CPT codes. As a result, medical providers struggle to figure out how to record those services when they are performed.

Generally, the lack of CPT coding for a given procedure can be attributed to the procedure’s relative novelty and, therefore, the need for more rigorous testing to ascertain its efficacy [2]. Unless the American Medical Association CPT Editorial Panel is certain of a procedure’s value and utility, they will not code the procedure [2, 3]. Therefore, it is often true that years must pass before a procedure receives a CPT code [2, 3]. Lacking a CPT code does not mean that practitioners cannot perform a procedure: many unlisted nerve blocks, for example, are commonly performed for anesthesia and pain management [2]. Nevertheless, the fact that a procedure is unlisted may jeopardize payment [2]. Some professionals work around this problem by using different codes that are not specific to the procedure in question but deemed close enough to record the service rendered [2]. Still, this practice can be imprecise [2].

Two examples of anesthesia procedures without CPT codes are the iPACK block, characterized by the infiltration of local anesthetic between the popliteal artery and posterior knee capsule, and the erector spinae plane (ESP) block [2].

Since 2014, medical professionals have used the iPACK block to achieve knee analgesia, primarily during total knee arthroplasty (TKA) [4, 5]. Compared to femoral blocks or obturator nerve blocks, research indicates that the iPACK block lowers patients’ probability of nerve or vascular injury, hence its widespread use [2, 4]. Furthermore, it appears to reduce the incidence of anesthesia-related side effects and improve physical therapy yield [5]. In some cases, however, iPACK block has been combined with femoral block or adductor canal block; research indicates that these hybrid techniques could be especially effective for pain management during TKA [3, 5]. Medical professionals who are wary of performing the iPACK block because it remains unlisted in the CPT code book may just opt for coded techniques, such as the femoral block and the obturator nerve block [5].

EPT block is another unlisted anesthesia procedure that appears to promote better analgesic results than many of its listed counterparts. First described in 2016, ESP has proven a versatile tool for addressing both chronic and acute pain arising from a variety of sources, including breast, valve, spine, abdominal wall, hip, and post-surgical [6, 7]. It is performed by either injecting anesthesia between the erector spinae muscle and the rhomboid major muscle if the practitioner opts for a superficial needle technique, or below the erector spinae muscle if the practitioner uses a deep needle [2]. Because of ESP’s adaptability, appropriate coded alternatives for the block depend on the context in question. Generally, though, medical professionals may consider paravertebral, neuraxial, or epidural blocks as alternatives, as well as general anesthesia, as appropriate [6, 7].

These two anesthesia procedures remain without CPT codes but are by no means rare in practice. Similar situations may be found in other specialties. As the medical field continues to evolve, CPT coding must continue to evolve as well to reflect modern medicine. Practitioners must weigh the benefits of performing novel and potentially more effective procedures against the logistical difficulties associated with using an unlisted technique.

 

References

[1] “CPT Overview and Code Approval,” American Medical Association. [Online]. Available: https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval.

[2] T. Mira, “Nerve Blocks for Acute Pain Management: The Main Coding Challenge,” Anesthesia Business Consultants, Updated November 23, 2020. [Online]. Available: https://www.anesthesiallc.com/publications/anesthesia-provider-news-ealerts/1377-nerve-blocks-for-acute-pain-management-the-main-coding-challenge.

[3] P. Dotson, “CPT^® Codes: What Are They, Why Are They Necessary, and How Are They Developed?,” Advances in Wound Care, vol. 2, no. 10, pp. 583-87, December 2013. [Online]. Available: https://doi.org/10.1089%2Fwound.2013.0483.

[4] T. Et et al., “Comparison of iPACK and periarticular block with adductor block alone after total knee arthroplasty: a randomized clinical trial,” Journal of Anesthesia, vol. 36, no. 2, pp. 276-86, February 2022. [Online]. Available: https://doi.org/10.1007%2Fs00540-022-03047-6.

[5] A. F. Caballero-Lozada et al., “IPACK block: emerging complementary analgesic technique for total knee arthroplasty,” Colombian Journal of Anesthesiology, vol. 48, no. 2, pp. 78-84, April-June 2020. [Online]. Available: https://doi.org/10.1097/CJ9.0000000000000153.

[6] B. C. H. Tsui et al., “The erector spinae plane (ESP) block: A pooled review of 242 cases,” Journal of Clinical Anesthesia, vol. 53, pp. 29-34, March 2019. [Online]. Available: https://doi.org/10.1016/j.jclinane.2018.09.036.

[7] P. Kot et al., “The erector spinae plane block: a narrative review,” Korean Journal of Anesthesiology, vol. 72, no. 3, pp. 209-20, March 2019. [Online]. Available: https://doi.org/10.1097/CJ9.0000000000000153.

Blood or cell salvage, also referred to as autologous blood transfusion or intraoperative blood salvage, is a medical procedure that consists in the harvesting red cells shed during surgery, processing and preparing them for safe return to the patient’s own circulation as an autologous red cell transfusion during or immediately after surgery ¹. The first publication of cell salvage in humans appeared in 1818, but it was then still associated with a high mortality rate. It was not until the 1960s that intraoperative blood salvage in its current recognisable form was first introduced and has become increasingly critical as a strategy for blood management during and after surgery. This technique, born out of the necessity to reduce reliance on donor blood and its associated risks, is now important to enhancing patient outcomes, minimizing transfusion-related complications, and optimizing resource utilization during surgical interventions.

 

Blood salvage involves the collection, filtration, and reinfusion of a patient’s own blood that is shed during surgery. This process begins with the meticulous collection of blood from the surgical field using a specialized device known as a cell saver. The collected blood is then processed through a series of filters to remove debris, contaminants, and unwanted substances, leaving behind a purified autologous blood product ready for reinfusion. The salvaged blood may remain outside the body during much of the surgery and be re-infused near the end of the surgical procedure. Hospitals with formal bloodless medicine programs have a significant amount of experience with these techniques ².

 

There are no good data to define the estimated blood loss at which blood salvage is appropriate. An estimated blood loss of approximately 1000 mL should justify a blood salvage procedure. However, it may be reasonable for some patients with estimated blood loss volumes ranging from 500 to 750 mL as well. However, different thresholds may apply to different patients, as the exact threshold is highly individual ³.

 

The versatility of blood salvage extends across a wide array of surgical specialties. This technique is implemented in the context various elective and emergency major surgical procedures, including cardiac, major vascular, major orthopedic, transplantation, trauma, and certain urologic, neurosurgical, gynecologic, and plastic surgical procedures ³. In cardiac surgery in particular, the ability to salvage and reinfuse the patient’s own blood aids in maintaining hemodynamic stability ⁴.

 

One of the primary advantages of blood salvage is its ability to minimize the risks linked to allogeneic blood transfusions. Allogeneic transfusions, while frequently necessary, carry risks such as infections, transfusion reactions, and immunological responses. By using a patient’s own blood, blood salvage significantly mitigates these risks, enabling a safer and more personalized approach to patient care ².

 

As the demand for donor blood decreases, so does the financial burden linked to the processes of blood procurement, testing, and storage. By recycling and reinfusing a patient’s own blood, the need for external blood donors is reduced, thereby minimizing the demand for donor blood products. Blood salvage thus allows for resource optimization and cost-effectiveness in surgery with benefits for patients and healthcare institutions. However, additional research and long-term data on the cost savings of blood salvage during surgery is warranted ⁵.

 

While blood salvage has revolutionized surgical practices, challenges remain. Not all surgical scenarios are conducive to effective blood salvage, and careful patient selection and surgeon expertise are critical. Ongoing research is focused on addressing these limitations and exploring innovations, such as improvements in cell saver technology and the development of novel blood substitutes.

 

References

 

1. Carroll, C. & Young, F. Intraoperative cell salvage. BJA Education (2021). doi:10.1016/j.bjae.2020.11.007
2. Intraoperative Blood Salvage | Allegheny Health Network. Available at: https://www.ahn.org/services/medicine/bloodless-medicine/faq/intraoperative-blood-salvage. (Accessed: 30th January 2024)
3. Surgical blood conservation: Intraoperative blood salvage – UpToDate. Available at: https://www.uptodate.com/contents/surgical-blood-conservation-intraoperative-blood-salvage. (Accessed: 30th January 2024)
4. Klein, A. et al. A survey of patient blood management for patients undergoing cardiac surgery in nine European countries. J. Clin. Anesth. (2021). doi:10.1016/j.jclinane.2021.110311
5. McLoughlin, C. et al. Cost-effectiveness of cell salvage and donor blood transfusion during caesarean section: Results from a randomised controlled trial. BMJ Open (2019). doi:10.1136/bmjopen-2018-022352