Anesthesia management company Archives - Xenon Health

Delirium, a fluctuating state of inattention and disorganized thinking, is often seen in elderly hospitalized patients and the critically ill. It is distinct from emergence delirium, a separate phenomenon seen in young children emerging from anesthesia, which will not be discussed here. Postoperative delirium in the adult population carries a significant burden of morbidity, and its prevention and treatment should be familiar to anesthesia providers.

Identifying patient risk factors is important to stratify who may be at risk for postoperative delirium. Preoperative factors include advanced age, disease severity, previous neurological disease (e.g. Alzheimer’s), preexisting psychiatric disease, and substance abuse. Intraoperative factors include surgical complexity, anesthetic medications and dosages, and large variations in blood pressure, temperature, and hematocrit. Postoperative causes include certain medications (benzodiazepines are notorious for causing delirium), sleep deprivation, immobility, and prolonged ICU and/or mechanical ventilation duration.

Several standardized scoring methods have been validated in both intubated and non-intubated patients, primarily in the ICU, however they are seldom used by practitioners. Among these scoring systems, the confusion assessment method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) have been deemed the most valid when compared to the gold standard (DSM-IV criteria).

Anesthesia providers can help prevent postoperative delirium by avoiding benzodiazepines in patients at risk, and using opiates judiciously (though they can cause confusion in elderly or neurologically compromised patients, they can also treat pain, a known trigger of delirium). Dexmedetomidine is a promising agent in delirium prevention, having decreased the incidence of ICU delirium when compared to sedation with propofol or midazolam infusions. A single 0.5mg/kg dose of ketamine has been shown to decrease the incidence of postoperative delirium. Titrating anesthetic dosages according to Bispectral Index (BIS) has also been shown to decrease postoperative delirium.

Prophylactic use of antipsychotic drugs has not been shown to be helpful in delirium prevention. Also lacking evidence of efficacy is the use of cholinesterase inhibitors, arising from the theory that the etiology of delirium lies in acetylcholine deficiency in the brain. Using antipsychotic agents such as haloperidol and seroquel for the treatment of delirium is currently standard of care, but there is little evidence these medications reduce either the duration or severity of symptoms. The atypical antipsychotic olanzapine, on the other hand, has shown some efficacy in decreasing the incidence of delirium. As always, QT monitoring should be observed while administering these medications.

Ultimately, nonpharmacologic measures such as patient reorientation, sleep protocols, and early mobilization are the most inexpensive and lowest risk ways to combat postoperative delirium. Implementing these measures as standard of care for at-risk patients can be an important step to decreasing the incidence and duration of postoperative delirium.

References:

Evans AS, Weiner MM, Arora RC, et al. Current approach to diagnosis and treatment of delirium after cardiac surgery. Annals of Cardiac Anaesthesia. 2016;19(2):328-337. doi:10.4103/0971-9784.179634.

Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD005563. DOI: 10.1002/14651858.CD005563.pub3.

While many specialty providers will face a medical malpractice suit at one time in their careers, anesthesiologists are higher on the risk spectrum to be subject to a claim. Anesthesiologists continue to be subject to among the highest of medical malpractice claims, with an average paid indemnity of about $100,000.^[1] There are a variety of reasons that a patient may submit a claim against an anesthesiologist, and these reasons are heightened with a dramatic event during an unsuccessful surgery: for example, an airway collapse or a drug overdose. While the most likely reason for a patient to submit a claim against an anesthesiologist is due to injury, patients may also submit claims based on actions of medical error, lack of medical information on the part of the patient, or failure to treat.^[2] When considering medical malpractice in the anesthesia field, it is also necessary to consider the role and responsibilities of Certified Registered Nurse Anesthetists (CRNAs).  CRNAs are often under the supervision of anesthesiologists or surgeons, such that in an event of potential medical malpractice the supervising physician is held responsible.^[3] However, national regulations do exist to address claims against CRNAs.  In most states, the typical liability limit for CRNAs are $1,000,000 per claim and $3,000,000 total.^[4] CRNAs may also participate in a medical malpractice insurance plan offered by his or her associated hospital network. Overall, the medical malpractice space is more highly dependent on individual claims, as little precedent has been set for the CRNA case.

In cases of medical malpractice, including for anesthesia services, the government may step in to resolve medical malpractice claims between the patient and the physician. On a state basis, Patient Compensation Funds (PCFs) are utilized in cases of medical malpractice. Essentially, these funds grant compensation to patients and/or patient’s families that have fallen subject to a medical error or omission by a physician that is in the associated state PCF system. The state then agrees to allocate and manage the PCF by collecting insurer surcharges and enrolling physicians in the fund. The state also designs specific methods to decide how and to whom the PCF can be granted.^[5] For example, New Mexico, Nebraska, Wisconsin, and Indiana have specific caps in place to restrict the individual or total award amounts granted by the Fund. More qualitative regulations may also be in place, such as in South Carolina, which requires the patient to receive specific medical information about the course of the case before formally pursuing the claim. Ideally, PCFs act as an important middleman, providing for the effective release of compensation to the patient while also minimizing social and financial impact on the provider. PCFs are therefore an effective tool to continue improving the paradigm of care in the healthcare system, thus ensuring that patients are provided for, and that physicians are encouraged to continue to raise the standard of care.

^[1] https://www.insurance.wa.gov/sites/default/files/documents/2016-med-mal-annual-report.pdf

^[2]  http://www.medscape.com/features/slideshow/malpractice-report-2015/

^[3] https://biotech.law.lsu.edu/books/lbb/x943.htm

^[4] http://www.aana.com/insurance/Documents/understanding-crna-malpractice-insurance101-practice.pdf

^[5] http://via.library.depaul.edu/cgi/viewcontent.cgi?article=1396&context=law-review

Cesarean delivery, the most commonly performed major surgery in the United States, is often conducted under neuraxial anesthesia, however epidurals are routinely removed immediately after operation and spinals wear off within hours. Effective perioperative pain management relies on a multimodal approach to avoid complications such as delayed functional recovery, impaired maternal-fetal bonding, increased postpartum depression, and persistent chronic pain – all associated with poor perioperative pain control. Incisional and pelvic pain may persist beyond 6 months after surgery in up to 18% of patients, at incidences higher than associated with vaginal deliveries but lower than non-obstetric surgeries.

Neuraxial anesthesia is preferable to general anesthesia in regards to prevention of persistent pain after cesarean birth, unsurprising as severe acute postoperative pain is one of the strongest predictors of the development of chronic pain. Single shot spinal anesthetics are the most common method, with epidural and combined spinal-epidural anesthetics as alternatives.  While continuing epidural analgesia after the immediate postoperative period may be a viable option for high-risk patients (i.e. those with preexisting chronic pain), routine use risks increased thromboembolic events due to decreased mobility, increases costs, and burdens nursing staff.

Neuraxial (intrathecal or epidural) morphine has a longer half-life than more lipophilic opiates such as fentanyl, with a duration of action from 14 to 36 hours. The optimal dose is unclear, with escalating doses (>100mcg) leading to increased side effects such as nausea, vomiting and pruritus. Respiratory depression can occur, but was not observed in studies reviewed in a 2016 meta-analysis. Even in women with risk factors for respiratory depression (e.g. obstructive sleep apnea), neuraxial opiates are still recommended over IV opiate administration.

Scheduled non-steroidal anti-inflammatory medications and acetaminophen is recommended in all patients undergoing cesarean delivery unless contraindicated (e.g. postpartum hemorrhage would preclude the use of NSAIDs). NSAIDs decrease opiate use by 30-50%, and acetaminophen by 20%.

Wound infiltration of local anesthetics can reduce pain scores and opiate use for up to 48 hours postoperatively, with continuous infusion via subfascial catheters placed intraoperatively being more effective than single dose techniques. These catheters offer more mobility than epidural catheters, but only treat somatic and not visceral pain.

Transversus abdominis plane blocks are another option for somatic pain, significantly improving postoperative pain and reducing opiate consumption in patients under general anesthesia or when neuraxial morphine was not used. It is also a viable rescue technique in severe acute postoperative pain. The duration of effect of single shot TAP blocks is 6-12 hours.

Postoperative pain control after cesarean delivery should be a priority, with a multimodal approach being recommended to reduce maternal and fetal exposure to opiate medications and prevent the development of persistent postoperative pain.

References:

Carvalho B, Butwick AJ. Postcesarean Delivery Analgesia. Best Pract Res Clin Anaesthesiol. 2017 Mar;31(1):69-79. doi: 10.1016/j.bpa.2017.01.003.

Tonsillectomy and adenoidectomy is one of the most common surgical procedures in children, and is sometimes performed in adults. Its unique constellation of patient population, surgical considerations, and anesthetic complications leads to an increased risk of morbidity and mortality that can be significantly influenced by anesthetic technique. Debate over many aspects of anesthetic management of these cases still continues.

Many indications exist for removing the tonsils and adenoids, including upper airway obstruction, dysphagia, sleep disorders such as obstructive sleep apnea (OSA), peritonsillar abscess unresponsive to medical management, febrile seizures due to tonsillitis and tonsillar biopsy.

OSA is increasingly becoming a common indication for tonsillectomy in children. Children with OSA may present with insidious symptoms such as failure to thrive, behavior problems, and poor school performance. Symptomatology often does not correlate with disease severity. This patient population is at risk for postoperative apnea and hypoxia, which in children could quickly deteriorate to cardiac arrest if not corrected. Some anesthesiologists choose to avoid long acting narcotics in these patients, however adequate postoperative pain control must be ensured to prevent other complications common in this surgical procedure such as postoperative nausea and vomiting (PONV) and emergence delirium. Multimodal analgesia is recommended with a combination of opiates, acetaminophen, and NSAIDs. Toradol is associated with increased postoperative bleeding according to a Cochrane analysis and is thus avoided, but there is insufficient data that other NSAIDs carry this same association. Surgeon-administered local anesthesia to the lesser palatine and glossopharyngeal nerves is an excellent adjunct for pain control in addition to general anesthesia, and also has the benefit of a smoother extubation.

Postoperative nausea and vomiting is a significant concern in this population, as retching can cause rebleeding of the surgical site. Dexamethasone and ondansetron are routinely administered for prophylaxis. Liberal IV hydration has also showed promise in preventing PONV, with a bolus of 10-30ml/kg/hr in older children resulting in significantly decreased symptoms.

Airway management warrants special consideration, as the airway must be shared between the anesthesiologist and surgeon. An endotracheal tube (ETT) is the gold standard, typically an oral RAE or reinforced ETT taped down the midline. However reinforced laryngeal mask airways (LMA) have been described in the literature. The use of LMAs should be limited to practitioners who are experienced in their use for tonsillectomies, as they carry an increased risk of laryngospasm and aspiration. Advocates argue that they allow for a smoother emergence and avoidance of neuromuscular blockade.

Extubation may be carried out deep or awake. The conservative approach is to remove the ETT when the patient is awake, to decrease the risk of laryngospasm, aspiration, and post-extubation apnea. However deep extubations afford smoother emerge and decreased emergence delirium. There have not been significant differences in complications between the two methods that have been borne out in the literature. Dexmedetomidine is a useful adjunct for decreasing emergence delirium in the pediatric population.

Post-tonsillectomy bleeding is a major complication of this procedure, and must be promptly recognized and managed. Establishment of large bore IV access, ready availability of suctioning, rapid sequence induction and resuscitation with blood products are crucial to avoiding mortality and morbidity.