As anemia is an independent risk factor associated with significant morbidity and mortality, managing perioperative anemia is critical to reduce the associated risks of bleeding and transfusions.¹ Patient blood management is a multimodal approach that focuses on three goals: detecting and treating preexisting anemia, reducing the risk of intraoperative bleeding, and optimizing a patient’s physiological tolerance toward anemia.^1,2

Blood management begins preoperatively to identify risk factors while treating any pre-existing anemia. Reviewing medical records and interviewing the patient before surgery helps identify risk factors for transfusion or adjuvant therapy. Preadmission labs identify any preexisting anemia which can then be treated early. The American Society of Anesthesiologists (ASA) recommends iron supplementation in patients with iron deficiency anemia and to consider erythropoietin in select populations.³ This preoperative visit should also be used to inform patients of the potential risk associated with blood transfusions, educate when to discontinue anticoagulants and antiplatelets, and discuss the option for autologous blood collection if warranted.

Next, steps should be taken to reduce the risk of intraoperative bleeding. For the surgeon, this means utilizing laparoscopic or minimally invasive surgeries when possible. For the anesthesiologist, this means creating an appropriate anesthetic plan with specific pharmacologic interventions. For example, utilizing neuraxial techniques compared to general anesthesia has been shown to decrease blood loss likely secondary to lower pressures from sympathetic blockade.⁴ Additionally, the use of prophylactic antifibrinolytics (e.g., tranexamic acid) has shown to reduce bleeding and decrease transfusions.³ Other measures that can help reduce bleeding risk are to maintain normothermia and prevent acidosis or hypocalcemia to optimize hemostasis.¹

The final goal of patient blood management involves optimizing physiologic conditions to tolerate anemia. This practice involves assessing the individual’s physiology to ensure adequate oxygenation. For example, sepsis or pain can increase oxygen consumption. As such treating infections and ensuring adequate analgesia can help decrease metabolic oxygen demands.¹ Additionally, ensuring proper ventilation, oxygenation, and organ perfusion intraoperatively all help to optimize physiology for anemic conditions.

Lastly, if a patient requires transfusion, utilizing a restrictive strategy has been shown to be safe and even improves outcomes when compared to a liberal approach.^5,6 The National Institute for Health and Care Excellence (NICE) recommends using a hemoglobin concentration of 7 g/dl to justify transfusion for those without major hemorrhage or acute coronary syndrome (ACS). For those with ACS, this threshold is increased to 8 g/dl.⁶ ASA recommends a broader range of 6 to 10 g/dl but emphasizes analyzing factors such as rate and magnitude of bleeding, volume status, signs of organ ischemia, and cardiopulmonary reserve.³ Overall, the decision of when to transfuse is based on clinical judgment that is individualized to each patient and should take into account more than a single lab value. It is important that providers continue to stay updated on the growing body of literature regarding patient blood management in order to help reduce transfusion overuse while improving patient outcomes.

References: 

1. Desai N, Schofield N, Richards T. Perioperative Patient Blood Management to Improve Outcomes. Anesth Analg. 2018;127(5):1211-1220.

2. Muñoz M, Gómez-Ramírez S, Kozek-Langeneker Pre-operative Haematological Assessment in Patients Scheduled for Major Surgery. Anaesthesia. 2016;71 Suppl 1:19-28.

3. Practice Guidelines for Perioperative Blood Management. An updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*. Anesthes. 2015;122(2):241-275.

4. Richman JM, Rowlingson AJ, Maine DN, Courpas GE, Weller JF, Wu CL. Does Neuraxial Anesthesia Reduce Intraoperative Blood Loss? A Meta-analysis. J Clin Anesth. 2006;18(6):427-435.

5. Gupta PB, DeMario VM, Amin RM, et al. Patient Blood Management Program Improves Blood use and Clinical Outcomes in Orthopedic Surgery. Anesthesiology. 2018;129(6):1082-1091.

6. Padhi S, Kemmis-Betty S, Rajesh S, Hill J, Murphy MF. Blood Transfusion: Summary of NICE Guidance. BMJ. 2015;351:h5832.

In the age of rapidly shifting models regarding health and healthcare in the United States, Accountable Care Organizations are often cited as a practical example for how to solve the complex healthcare system and distill it down to the greatest care for the greatest number of patients.

To review, Accountable Care Organizations, or ACOs, are a healthcare model in which payers and providers collaborate to treat a specific patient population (1). ACOs may include value-based care initiatives, such as providing discounts or merits for reducing certain disease metrics, apply forward-thinking cost savings initiatives, and essentially aim to coordinate care across the patient population. While at first glance ACOs may seem geared towards primary care providers, in effect ACOs must include surgical and anesthesia providers in order to expand coordinated care to include tertiary and specialty care. Anesthesiologists and anesthesia providers may participate in an ACO by function of their dedicated health center, or they may also spearhead anesthesia specific models through what is known as Accountable Anesthesia Organizations, or AAOs. As the title suggests, these are anesthesia-specific ACO partnerships, led and managed by leaders in the field of anesthesia.

Given that ACOs have disseminated throughout the healthcare market for several years, it behooves healthcare leaders to analyze progress thus far, as well as areas for improvement moving forward. With this aim in mind, researchers from the University of Michigan’s Center for Healthcare Outcomes and Policy produced a longitudinal study that analyzed 10 years’ worth of data at the federal level (2). The aim of the study was to examine hospital and healthcare centers that are active participants in ACOs and elucidate whether these centers experienced a decrease in surgical spending. As surgical spending represents a significant portion of hospital global budgets, this metric was utilized as a proxy for evaluating trends on this topic. During analysis, variable such as hospital-specific patient segmentation, number of anesthesia and surgical staff, and other specificities were treated to control for potential skew.

In the end, the researchers found that participation in ACOs was not associated with a decrease in surgical spending. This effect extended to expenditures related to staffing, e.g. for anesthesia and surgical providers, post-acute care providers, etc., as well as to unit costs for patient length of stays and medications management. In an ancillary result, the study found an improvement in surgical outcomes for patients at ACO-partnered hospitals, although this effect was not strongly statistically significant. The results of this study have several applicable results for future practice. ACOs, or AAOs in the case of anesthesia providers, may not reduce costs in the initialization process of coordinated care implementation. Yet, importantly for anesthesia leaders, an increase in value-based care as measured by outcomes could result in viable savings later down the line, thus stimulating hospital development and patient population health in tandem.

Innovative healthcare delivery mechanisms will continue to encourage partnerships among healthcare providers. Anesthesiologists and other anesthesia providers, as healthcare practitioners active in multiple stages of perioperative care, will effectively serve as a bridge in this initiative to achieve the highest level of care possible for all patients.

References:

1. https://xenonhealth.com/accountable-care-organizations-acos/
2. https://journals.lww.com/annalsofsurgery/Abstract/2019/02000/Early_Impact_of_Medicare_Accountable_Care.1.aspx

The aging body is predisposed to developing pain. Osteoarthritis of the neck and lower back, chronic joint pain, and musculoskeletal pain are some of the most common complaints among the elderly. However, the complex links between chronic pain, opioid use, depression, dementia, and pseudodementia are decidedly difficult to study among advanced age patients. The following summary of recent literature outlines several interactions with which anesthesia providers should be familiar.

Nociception undergoes age-related changes. Notably, the thresholds for low and high intensity pain become dampened with age. That is to say, sub-threshold nociceptive stimuli may not illicit a pain response from the elderly. However, once perceived, the response to noxious stimuli may be exaggerated and complicate pain control.¹ This decay in pain tolerance may be due to alterations in the central inhibitory pathways and neuronal plasticity. Taken together, these altered mechanisms can work to increase an elderly person’s susceptibility to developing chronic pain after an injury.

Although the use of opioid medications may impart many risks to chronic users, deleterious cognitive effects associated with long-term use have not been observed in large studies. One prospective cohort study of patients over 65 years of age found little to no association between total opioid consumption and development of dementia or Alzheimer’s in a ten-year follow-up.² Moreover, a meta-analysis of studies on opioid prescriptions for cognitively-intact versus cognitively-demented patients found evidence for undertreatment of pain in the cognitively impaired.³ These data underscore the challenge of detecting and managing pain in patients who struggle to communicate and express their subjective experiences.

Age-related changes in the central nervous system, notably the development of amyloid plaques, neurofibrillatory tangles, and amyloid angiopathy, can be observed upon autopsy in patients with dementia.⁴ The extent to which neural injury from chronic pain contributes to these pathologic processes is uncertain. However, a past study found that patients with chronic pain demonstrate poor performance in several neuropsychological testing domains, suggesting that cognitive decline coincides with pain in the elderly.⁵ More recently, a longitudinal cohort study of over 10,000 patients aged over 62 years found that persistent pain hastens measurable impairments in everyday living.⁶ In fact, persistent pain accelerated memory decline, inability to manage personal finances, and the probability of developing dementia by roughly 10%.

Anesthesia providers should be aware of the associations between chronic pain and dementia. Elderly patients, especially those with dementia, may be more prone to inadequate treatment with analgesics as outpatients. Regional anesthesia and multimodal analgesia models should serve as the cornerstone for perioperative pain control. Diminishing the propensity for developing chronic pain after surgery continues to be a burgeoning area of research.

References:

1. Paladini et al. Chronic Pain in the Elderly: The Case for New Therapeutic Strategies. Pain Physician. 2015;18(5):E863-76.
2. Dublin et al. Prescription Opioids and Risk of Dementia or Cognitive Decline: A Prospective Cohort Study. J Am Geriatr Soc. 2015;63(8):1519-26.
3. Griffioen et al. Prevalence of the Use of Opioids for Treatment of Pain in Persons with a Cognitive Impairment Compared with Cognitively Intact Persons: A Systematic Review. Curr Alzheimer Res. 2017;14(5):512-522.
4. Love S. Neuropathological investigation of dementia: a guide for neurologists. J Neurol Neurosurg Psychiatry. 2005 Dec;76 Suppl 5:v8-14.
5. Landrø et al. The extent of neurocognitive dysfunction in a multidisciplinary pain centre population. Is there a relation between reported and tested neuropsychological functioning? Pain. 2013;154(7):972-7.
6. Whitlock et al. Association Between Persistent Pain and Memory Decline and Dementia in a Longitudinal Cohort of Elders. JAMA Intern Med. 2017;177(8):1146-1153.

In the realm of anesthesia and surgical services, patients who miss appointments create significant challenges for medical practice management. Colloquially known as “no-shows”, these patients contribute to a host of practitioner staffing and cost issues. No-shows can hinder an effective and cost-conscious practice when surgeons, anesthesiologists, and certified registered nurse anesthetists (CRNAs) need to be rescheduled to accommodate a missed appointment.  For surgical services and anesthesia management, it is essential to understand the etiology of the no-show, and to be knowledgeable about current interventions used to address the issue of missed appointments. Promising technological innovations are developing on the horizon that offer a possible avenue toward mitigating the impact of no-shows on medical practices nationwide.

From the patient perspective, there are several reasons why an individual may not show up to a scheduled surgery appointment. A recent article from BMC Health Services Research on the psychology of no-show patients explores these reasons in great detail.^[1] In an effort to understand no-shows, health economist researchers implemented a retrospective, cross-sectional study, which included variables such as patient demographics, time, healthcare provider, and type of operation in order to ascertain the most frequent reasons for cancellation. Researchers found that among approximately n=500 study subjects, “scheduling issues”, “patient reporting sickness on appointment date”, and “specialized clinical procedures” were the highest reported reasons for cancellation. This study has prompted future research into interventions for these high-frequency cancellation factors.

The cited factors for patient cancellation can be attributed to the patient or the provider. We have seen how the increasing prevalence of Anesthesia Information Management Systems (AIMS) combined with electronic health or medical records (EHR, EMR), has improved the capacity of practices, hospitals, and health centers to mitigate scheduling issues experienced by patients.^[2] But how can anesthesia management address cancellation issues involving a patient feeling unwell, or feelings of uncertainty surrounding specialized clinical procedures? One possible solution involves improved communication between patients and providers, facilitated by novel technology mechanisms such as patient engagement tools.^[3] These tools typically take the form of applications (apps), which are seamlessly integrated into mobile technologies. These apps can send basic communications to the patient, such as information pertaining to a patient’s pre-surgery regimen, as well as specific text reminders that include appointment dates, times, and locations. Moreover, these rapidly advancing patient engagement apps can help minimize no-shows by creating a portal for patients to instantly communicate with their healthcare provider, or their provider’s administrative representative. If a patient doesn’t feel they have enough information about a procedure the evening before, app portals can connect the patient to a knowledgeable representative or online source to acquire more information. If the patient feels unwell, there is a messaging function on the app that allows that patient to inform their provider prior to the day of the appointment. Many companies are taking advantage of these technologies to help decrease the communication gap between patient and provider, improving anesthesia and surgical management along the way. Most importantly, there is growing evidence to back the efficacy of these tools. A preliminary health system study reported that a text-based tool intervention reduced patient no-shows by over 66%, a notable and significant finding.^[4]

As patient engagement technologies develop, anesthesia and surgical services management should take note of interventions that have the potential to reduce patient no-shows and to improve the patient-provider relationship. Patient engagement technologies are just one example of how modernizing medicine can have a significant impact on the ways in which individuals experience healthcare, as well as the ways in which providers support patients on their surgical journeys.

References:

1. Da’Ar, Omar B., and Talal Al-Mutairi. “How Do Patient Demographics, Time-Related Variables, Reasons for Cancellation, and Clinical Procedures Affect Frequency of Same-Day Operating Room Surgery Cancelation? A Maximum Likelihood Method.” BMC Health Services Research, vol. 18, no. 1, 2018, pp. 1–9., doi:10.1186/s12913-018-3247-y
2. Roeder, Jacqueline A. “The Electronic Medical Record in the Surgical Setting.” AORN Journal, vol. 89, no. 4, 2009, pp. 677–686., doi:10.1016/j.aorn.2008.12.027.
3. Garvin, Lynn A and Steven R Simon. “Prioritizing Measures of Digital Patient Engagement: A Delphi Expert Panel Study” Journal of Medical Internet Research vol. 19,5 e182. 26 May. 2017., doi:10.2196/jmir.4778
4. Siwicki, Bill. “Text-Based Tool Reduces Patient No-Shows by More than Two-Thirds.” Healthcare IT News, HIMSS, 2018, www.healthcareitnews.com/news/text-based-tool-reduces-patient-more-two-thirds.

Atrial fibrillation (A Fib) is the most common sustained arrhythmia among adults. A Fib is characterized by disordered cardiac conduction within the atria, resulting in a classically irregularly irregular heart rhythm. The absence of P-waves represents disorganized atrial contraction and is a hallmark electrocardiographic (EKG) finding associated with A Fib. A Fib is concerning to perioperative providers because of its potentially fatal consequences, including cardiovascular collapse associated with tachyarrhythmias and thromboembolic events.

While chronic A Fib develops from several secondary causes, surgery is a common and discrete precipitant. One study found that 4% of adults develop A Fib after non-cardiac surgery.¹ A more recent database study revealed that, in descending order of risk, intrathoracic, vascular, and intra-abdominal surgeries were associated with clinically-important AFib.² In this study, age greater than 85 years was the strongest variable correlated with the development of A Fib.

Developing A Fib after cardiac surgery is more common than other surgeries, with the likelihood of developing A Fib ranging from 30-50% post-cardiac surgery.³ Among patients undergoing coronary artery bypass grafting (CABG), risk factors for postoperative A Fib include the following: age over 80 years, concurrent valvular surgery, off-pump procedures, withdrawal of beta blocker or angiotensin converting enzyme inhibitors, and prior history of A Fib or chronic obstructive pulmonary disease.⁴ Common prevention strategies include the use of perioperative beta blockers, amiodarone, and intracardiac atrial pacing.⁵ Despite having several models for risk stratification, no current standard exists for predicting whether a patient is at high or low risk for developing postoperative AFib.³ Thus, individualized assessments should be made by anesthesiologists, cardiothoracic surgeons, and cardiologists.

Initial assessment of new-onset (i.e., less than 48 hours since sinus rhythm) postoperative A Fib should focus on the stability of the patient. Patients with EKG findings of tachyarrhythmia (sustained heart rate >100 beats per minute) require immediate bedside attention. Patient complaints of newly developed lightheadedness, dizziness, chest pain, dyspnea, or diaphoresis should prompt providers to arrange for urgent direct current cardioversion (i.e., synchronized) at 100-200 joules. Administration of sedation or amnestic therapies (e.g., benzodiazepines) prior to cardioversion should be done at the anesthesiologist’s or cardiologist’s discretion. Stabilization of the arrhythmia may require multiple shocks and intravenous therapies.

Stable patients with new-onset A Fib and no associated symptoms should be medically managed prior to discharge from the recovery room. Standard laboratories should be obtained, with particular attention to values for hemoglobin, potassium, magnesium, and calcium levels. Intravenous beta-1 selective beta blockers (e.g., metoprolol, esmolol) are first-line therapies for A Fib. Second-line medications include intravenous non-dihydropyridine calcium channel blockers (e.g., diltiazem, verapamil). A Fib that is recalcitrant to the above therapies may respond to intravenous amiodarone. Caution should be exercised with the loading dose of amiodarone, as rapid administration may result in hypotension.

References:

1. Vaporciyan AA, et al. Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients. J Thorac Cardiovasc Surg. 2004;127(3):779
2. Alonso-Coello P, et al. Predictors, Prognosis, and Management of New Clinically Important Atrial Fibrillation After Noncardiac Surgery: A Prospective Cohort Study. Anesth Analg. 2017;125(1):162-169
3. O’Brien B, et al. Society of Cardiovascular Anesthesiologists/European Association of Cardiothoracic Anaesthetists Practice Advisory for the Management of Perioperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth. 2019 Jan;33(1):12-26.
4. Mathew JP, et al. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA. 2004;291(14):1720
5. Arsenault KA, et al. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev. 2013