Anesthesia management Archives - Page 2 of 20 - Xenon Health

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.

The Enhanced Recovery After Surgery (ERAS) protocol was initiated in the 1990s and describes a multimodal, interdisciplinary, and evidence-based approach to perioperative management for major surgeries. The protocol aims to reduce post-operative complications and hospital stay duration, earlier return of bowel function, earlier return of normal activities, and improvement in cardiopulmonary function.

The body undergoes profound stress during and after surgery, and ERAS attempts to disrupt medical stressors by addressing preoperative counseling, optimizing nutrition, standardizing analgesic and anesthetic regimens, and early mobilization. Many of these goals are achieved through management by the anesthesiologist or CRNA. Preoperatively, the patient remains hydrated with minimized fasting periods and carbohydrate loading to maintain euglycemia. Intraoperatively, the anesthesiologist maintains normothermia with warmed fluids and warming blanket, utilizes goal-directed fluid therapy, closely controls blood glucose levels within a specific range, and utilizes lung protective ventilation. Opioids are minimized or avoided completely. Postoperatively, nausea is avoided with prophylactic medications like dexamethasone and ondansetron. Oral intake and nutrition is encouraged, and ambulation and gut motility are supported by adhering to an opioid free pain regimen.

Multimodal analgesia is an important component of ERAS, as recovery can be delayed by inadequate analgesia. First-line analgesia often relies on large doses of opioids, which can contribute to sedation, nausea, constipation, and delaying return to normal activity and resumption of bowel function. By using two or more analgesic agents or techniques simultaneously, better pain relief can be achieved. Minimizing opioids can be accomplished with regional anesthesia such as peripheral nerve blocks or epidurals, non-opioid analgesics like COX-2 inhibitors or NSAIDs, intravenous or oral acetaminophen, anticonvulsants, and infusions of ketamine or lidocaine.

There are many benefits of the ERAS protocol. There are a multitude of reports in literature describing improvement in surgical outcomes including reduction in postoperative complication rates and opioid prescribing rates. There has been a decrease in hospital mortality among colorectal surgery patients as well as reduction in delirium, blood clots, muscle atrophy, infection, and nausea. In addition, patient satisfaction is increased, and cost effectiveness has been demonstrated in numerous studies around the world. The considerable costs of implementing an ERAS program is easily offset by the potential savings of thousands of dollars per surgery. As the benefits of ERAS become better known and accepted, healthcare providers should expect ERAS and multimodal analgesia to become more prevalent in the perioperative setting.

On September 5th, 2017, Dr. Jerome Adams was sworn in as the 20th Surgeon General of the United States, marking an important moment in the movement for anesthesia clinicians as emerging prominent leaders in the U.S.^[1]

Dr. Adams’ career trajectory is an essential combination of academic prestige, private and public sector experience, and emerging leadership roles.[2] Dr. Adams received his medical degree from the Indiana University School of Medicine and Master’s in Public Health from the University of California, Berkeley. Although he began in private practice, Dr. Adams swiftly moved into academia and public service, working as an Assistant Professor at his alma mater while writing frequently on topics pertinent to the pain management field. Dr. Adams then received his first major leadership role when he was nominated as the Indiana State Health Commissioner, setting the stage for his future nomination to the national stage. In his role as Surgeon General, Dr. Adams represents the first anesthesiologist to hold the position, which in the past has taken candidates from a pool of pediatricians, internists, and registered nurses (RNs). Dr. Adams has publicly stated that with this new leadership position, he aims to focus on issues that sit at the center of his specialty and U.S. healthcare needs, e.g. the national opioid crisis. As a leading national expert on substance abuse, and a practicing physician, Dr. Adams holds an impressive wealth of knowledge that will serve him well as the new acting Surgeon General.

Surgeon General is merely one of the leadership roles that physicians, and increasingly anesthesiologists, are aiming to occupy. CEOs of hospital networks, heads of anesthesia management companies, medical leads at insurance companies…The possibilities are nearly endless when it comes to clinician executive leadership, and anesthesiology-related professionals have a high chance of capturing these opportunities.

To begin, anesthesia professionals, such as anesthesiologists and CRNAs, have extensive experience in participating and managing complex teams. As Thomas H. Lee, M.D., writes in the Harvard Business Review, “More often, institutional leaders must move groups …to bring physicians from different disciplines but the same patient population closer to one another.” ^[3] In this regard, anesthesiologists and CRNAs have a built-in advantage towards leading effective team alignment strategies: As anesthesiology-based clinicians must routinely work with an array of physicians and nurses from other departments to provide holistic care, they understand the process and purpose of non-siloed management. This enhances the capability for strong leadership in a complex healthcare setting, both on the clinical and business side of organizational management.

Moreover, the need for physicians in healthcare-centered executive roles is rising, paving the way for anesthesiologists and CRNAs to acquire new opportunities in leadership. In 2011, a study was released in Social Science and Medicine citing that quality scores were approximately 25 percent higher in hospitals with physician CEOs as compared to hospitals led by non-clinical managers.^[4] Therefore, the literature supports the hypothesis that physician executive leaders can produce better outcomes for the facility and for patients themselves.

While Dr. Adams is but one of many physician executive leaders, his distinct skill set as an anesthesiologist and public health leader have distinguished him as a unique leader in the field. Armed with a background in team management, anesthesiology clinicians are well-poised to follow his example and begin the ascent to leadership — at the local, hospital-wide, and even national level.

[1] https://www.asahq.org/about-asa/newsroom/news-releases/2017/08/jerome-adams-confirmation

[2] https://www.uschamberfoundation.org/bio/jerome-adams

[3] https://hbr.org/2010/04/turning-doctors-into-leaders

[4][4] https://www.ncbi.nlm.nih.gov/pubmed/21802184

“When physicians are active on social media sites, it affords them with an additional opportunity to reach patients and impact the daily choices that patients make…social media is a simple way to reach hundreds of thousands of patients —and it only takes minutes.” In a recent interview in Forbes Magazine , Dr. Kevin Campbell details the ways in which physicians can connect with patients via social media. Dr. Campbell, as a clinician, physician executive leader, and spokesperson, is an avid advocate of social media use in the healthcare space. He is not the only one beginning to shift the landscape on the diverse applications of social media. Hospitals, third-party applications, and medical research institutions are beginning to integrate social media into their patient engagement frameworks, demonstrating a larger systematic change in the way providers are able to connect with patients.

In recent years, hospitals have begun to implement social media use in an effort to extend care beyond the confines of the facility walls. For example, the Mayo Clinic, a nationally renowned hospital and research institution, currently has 1.7 M followers on Twitter. The content the account produces varies from the scientific to the humanistic, with pieces on the essential nature of blood tests, new research in behavioral therapy, and signs and symptoms of strokes to touch on the former, and personal stories to address the latter. In addition to these posts, the account also serves as a forum to celebrate health-related national events, such as Ovarian Cancer Awareness Month. It is perhaps these posts that generate the most feedback from consumers on the Internet, as patients recognize and respond to the hospital’s personal tone. With each post, the Mayo Clinic engages more with current and potential patients in a forum that is both comfortable and familiar. Massachusetts General Hospital (MassGen) in Boston, MA has built upon existing social media foundations to create their own platform via application. Bringing together clinicians, software developers, and communications specialists alike, MassGen worked to produce a phone application that allows users to locate the closest emergency room to them — regardless of whether it was affiliated with MassGen Hospital. In creating this application, MassGen reaffirmed its commitment to patients first, while also lowering the bar to accessing care. Whether it is aligning with current social media platforms to spread medical information, or producing new platforms to assist patients, it is evident that hospitals are joining the ranks of social media in healthcare — and it is clear the managed care organizations, such as anesthesia management companies, will likely be the next to follow.

Third-party applications (apps) also have a role in the integration of social media into medicine. Independent, secure apps can work at either the provider or patient level to ensure a smooth journey as the patient moves through the system. These apps have the advantage of independence from both parties, meaning they have an objective approach to securing care. Potential actions the app may initiate include scheduling appointments; pharmacy updates; quick messaging functionality between clinicians and patients; medication administration reminders; and health condition calendar tracking. Because apps are typically used from patients’ own devices, which often require both a passcode and a personal identification, the question of patient confidentiality piece is deftly addressed.

Furthermore, the barrier to communication is lifted because patients can communicate with their providers or generate actionable items online, from the comfort of their own home. In effect, the patient is urged to engage with his or her health provider in a low investment way, requiring few in-person meetings or telephone calls. These apps can also improve the standards of care received at home, ensuring that a patient does not miss a pharmacy delivery or dosages of medications. Therefore, the rise of hospitals and providers utilizing third-party apps to ameliorate medical care is an exemplification of increased patient engagement via social media.

From a slightly different perspective, medical research institutions are beginning to increase social media use for research purposes. Institutions like these primarily use social media for study subject recruitment and enrollment, which are often the most time-intensive stages of the clinical study processes. This recruitment strategy is most effective when investigators are targeting adults or adolescents, as those are the highest users of social media by demographic. Moreover, the strategy can also be used to address potential study participants of all age and condition, simply by spreading the message about the study.

In all cases, strict adherence to patient confidentiality and the needs of the patient are of course the highest priority when utilizing any form of social media in a healthcare space. However, when utilized effectively, social media can streamline systems of care, increase patient engagement, and ensure an optimal experience for both patients and providers on the journey of care.

In the U.S., trauma is the leading cause of death for patients younger than 40 years old, and up to a third of all hospital admissions are related to trauma.  Management of trauma patients can be especially challenging due to the intensive resource requirements and multiple injuries to various body systems.  In a trauma center, the anesthesiologist often becomes involved as soon as the patient arrives to the ED trauma bay, beginning with airway and resuscitation management and possibly proceeding through the operating room, then postoperatively to the intensive care unit.

The anesthesiologist must have an understanding of the design of the trauma system and what the surgical priorities are.  Trauma patients are unique in that their history is limited, they are frequently have full stomachs and cervical spine instability, and are often intoxicated. The advanced trauma life support (ATLS) course from the American College of Surgeons is a widely recognized framework for caring for injured patients, with emphasis on the ABCDE mnemonic: airway, breathing, circulation, disability, and exposure.  

The anesthesiologist is especially qualified in airway management, and ensuring an open airway and adequate respiration is of utmost importance to avoid cerebral hypoxia and death.  Rapid sequence induction should be performed and an endotracheal intubation must be confirmed by capnometry.  Intubation should be performed using in-line cervical stabilization, and a surgeon who is proficient at cricothyroidotomy  should be readily available.  A bougie, Glidescope, or LMA may be necessary to manage a difficult airway.

Managing bleeding is a priority, and shock is presumed to be from hemorrhage until proven otherwise.  Administration of fluids including blood products via large bore intravenous catheters is critical in increasing cardiac output and blood pressure in a hypovolemic trauma patient.  Emergency surgery may be necessary to diagnose or control active bleeding.  The anesthesiologist can ensure the patient receives warming fluids rapidly, and assist in increasing the room temperature and covering the patient with warm blankets.  Maintaining cerebral perfusion may be critical in patients with severe traumatic brain injury and intracranial hemorrhage.  Invasive monitors such as arterial lines, central lines, and pulmonary artery catheters may be necessary but should not delay the aforementioned resuscitation priorities.

Patients of all ages and backgrounds can suffer trauma, and because of its prevalence, many anesthesiologists will have to care for trauma patients.  Because of their appropriate and specific type of training, anesthesiologists are ideally suited to care for these patients.