the june 2012 digital edition of anesthesiology news

New App Predicts Chronic Pain After Inguinal Hernia SurgeryNew York—Surgeons and patients considering hernia sur-gery can now use a free app that predicts a person’s chance of expe-riencing chronic pain after ingui-nal hernia repair, based on the outcomes of nearly 1,700 patients treated over the last five years.

The app, the Carolinas Equa-tion of Quality of Life (CeQOL), was officially launched at the 5th International Hernia Congress and is available for free download on smartphones, tablets and desktop computers.

The app will help educate

patients about the risks for chronic pain, an issue sometimes glossed over in preoperative discussions between physicians and patients, said B. Todd Heniford, MD, the senior researcher of the team that designed the app and chair of gas-trointestinal and minimally inva-sive surgery at Carolinas Medical Center, in Charlotte, N.C.

“This app opens up the discus-sion about the chance of chronic discomfort following ingui-nal hernia surgery and gives patients a very specific idea of risk,” Dr. Heniford said. “It’s a tool that

sets the stage for what we should strive for with every operation: an objective plan to obtain personal quality-of-life outcomes for post-operation and therapy.”

Anesthesia Training Shorts Practice Issues

M ost anesthesiologists believe residency pro-grams do a poor job of training young doc-tors in practice management, according to

results of a recent survey of the specialty.The results, presented at this year’s American Soci-

ety of Anesthesiologists (ASA) Conference on Prac-tice Management, showed that most respondents felt

Femoral Blocks a Boon For Hip, Knee Surgery

F emoral blocks offer wide-ranging ben-efits after knee and hip replacement, from reducing pain during early recov-

ery to lowering health care costs, new research has found.

Three new studies presented at the 2012 annual meeting of the American Academy of Orthopaedic Surgeons highlighted the advantages of femoral blocks over other anesthetic approaches in these patients. They showed that femoral blockade can spare patients from opioid-related adverse effects, reduce the need for joint manipulation after surgery and hasten discharge from the postanesthe-sia care unit (PACU).

The IndependenT MonThly newspaper for anesThesIologIsTsAnesthesiologyNews.com • J u n e 2 0 1 2 • Volume 38 Number 6

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40th Anniversary

see app page 14

see femoral page 26

see practice page 29

INsIde08 | COMMENTARYAvoid the wrong bet on P4P.

12 | PAiN MEdiCiNEResearchers explore combat-related pain.

24 | CLiNiCAL ANEsThEsiOLOgYOverweight patients may receive excessive neuromuscular blockade.

30 | POLiCY & MANAgEMENTTransfusions a wild card for hip replacement.

‘Current anesthesiology

trainees who believe

they are going to make

a comfortable living just

providing OR anesthesia,

I think are going to be

sorely disappointed

with their careers.’

—David Mackey, MD

Educational REviEwUltrasound-Guided Central Vein Cannulation: Current Recommendations and Guidelines, see insert at page 16.

cME: PREanEsthEtic assEssMEntLesson 297, Part 2: PreAnesthetic Assessment of the Patient Undergoing Thoracic Endovascular Aneurysm Repair, see page 18.

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June 2012

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The five most-viewed articles last month on anesthesiologynews.com1. Cancelled surgeries Costing hospitals millions2. Current Concepts in the management of the difficult

Airway (educational review)3. Calif. ruling on CrNA practice promises Nationwide

Tremors4. Anesthesiologists Take on Central role in stroke Care5. Neuromuscular Blockers linked to post-op Breathing

problems

register for free @ anesthesiologynews.com to read these and other articles.

Heard Here First:

See article on page 8.

The long commitment of anesthesiologists to

protecting patients and advancing the specialty

through research, guidelines and education is worthy of support.

payment experiments that distract from clinical care are not. Anesthesiologists should

double down on meaningful quality improvements and double

back on care distractions.

PONV prevent ion:

Gets to work early.

Stays late.

PONV prevention that covers the entire at-risk period from post-op to PACU discharge

Priming dose starts early

Unique transdermal delivery system provides a priming dose of scopolamine upon application

Statistically significant reduction in nausea, vomiting, and retching 2 to 4 hours post-op1

Continuous release keeps working

Extended release delivers a near constant dose over 24 hours2

66% of Transderm Scop® patch patients vs. 46% for placebo reported no retching/vomiting within the 24-hour period postadministration

®

Indications and Important Risk Information for the Transderm Scop® patch (scopolamine 1.5 mg) Transdermal Therapeutic System

IndicationsThe Transderm Scop® patch is indicated in adults for prevention of nausea and vomiting associated with recovery from anesthesia and surgery. The patch should be applied only to skin in the postauricular area.

Important Risk Information The Transderm Scop® patch is contraindicated in:

Persons who are hypersensitive to the drug scopolamine or to other belladonna alkaloids or to any ingredient or component in the formulation or delivery system.

Patients with angle-closure (narrow-angle) glaucoma.

The Transderm Scop® patch should not be used in children.

The Transderm Scop® patch should be used with caution in the elderly or in individuals with impaired liver or kidney function; patients with pyloric obstruction, urinary bladder neck obstruction, or in patients suspected of having intestinal obstruction. Also use with caution in patients with a history of seizures or psychosis.

Monitor glaucoma therapy in patients with chronic open-angle (wide-angle) glaucoma.

Since drowsiness, disorientation and confusion may occur, patients should not drive, operate dangerous machinery, or participate in activities that require alertness. Patients should not use alcohol. Use with caution in patients taking other drugs that can cause CNS effects, such as sedatives or tranquilizers.

Rarely, idiosyncratic reactions have occurred. The most serious that have been reported include acute toxic psychosis, confusion, agitation, rambling speech, hallucinations, paranoid behavior and delusions.

Since scopolamine can cause dilation of pupils and blurred vision upon direct eye contact, patients should be strongly advised to wash hands thoroughly with soap and water immediately after handling the patch.

Because of an aluminized layer in the delivery system, it is recommended to remove The Transderm Scop® patch prior to undergoing an MRI. Skin burns have been reported at the patch site during an MRI.

In five postoperative nausea and vomiting clinical studies, the most commonly reported adverse events were dry mouth (29%) and dizziness (12%).

Baxter is a registered trademark of Baxter International Inc.Transderm Scop is a registered trademark of Novartis AG.

1. Kotelko DM, Rottman RL, Wright WC, et al. Transdermal scopolamine decreases nausea and vomiting following cesarean section in patients receiving epidural morphine. Anesthesiology. 1989;71:675-678. 2. Transderm Scop® [package insert]. New Providence, NJ: Baxter Healthcare Corporation; 2006.

01/12 720254Please see full prescribing information on the following page.

MCAN2078.indd 1 2/15/12 3:59 PM

U.S. Survey Shows Decline in Postsurgical Deaths

T he number of inpatient deaths within 30 days of surgery

in the United States declined by just over 15% between 1996 and 2006, according to a nation-wide report published in Surgery (2012;151:171-182). Before this analysis, national rates and pat-terns of death after surgery were unknown.

Investigators from the Har-vard School of Public Health and the Center for Surgery and Pub-lic Health at Brigham and Wom-en’s Hospital, in Boston, compared deaths that occurred within 30 days of admission among patients undergoing surgery in 1996 and 2006. Using the Nationwide Inpa-tient Sample, which covers

approximately 20% of hospitals in the United States, the research-ers examined the inpatient 30-day death rate for all surgical proce-dures, procedures with the most deaths, and high-risk cardiovascu-lar and cancer procedures, and for patients who suffered a recorded complication.

The researchers found that

hospital admissions involving surgical procedures increased by 14.4% (from just over 12.5 million in 1996 to more than 14.3 million in 2006), while deaths within 30 days of admis-sion dropped by 15.4% (from 224,111 in 1996 to 189,690 in 2006). The adjusted 30-day inpa-tient mortality rate decreased from 1.68% to 1.32% during that period (P<0.001).

“The decline in the number of deaths may have occurred through reduced mortality of individual procedures, reduc-tions in the volume of high-risk procedures and the rescue of patients who had a complica-tion,” the authors wrote.

The investigators identified 21 procedures associated with the most deaths in 1996 (account-ing for 3,160,643 admissions and 101,146 deaths) and found that, in 2006, the same pro-cedures accounted for 26.5% fewer deaths (3,339,722 admis-sions and 74,254 deaths). The inpatient 30-day mortality rate for patients who had a complica-tion decreased from 12.10% to 9.84% (P<0.001).

Mortality decreased for nine of 14 high-risk cardiovascular and cancer procedures. The inci-dence of sepsis and pneumonia increased from 1996 to 2006, but the failure-to-rescue rate declined during the study period for both groups (sepsis, from 18.69% to 14.03%; pneumonia, from 8.54% to 7.34%).

Overall, the investigators esti-mated that 51,000 fewer people died in 2006 than would have if the postsurgical mortality rate from 1996 had continued.

The authors noted that “addi-tional research to determine the underlying causes for decreased mortality is warranted.”

—Victoria Stern


iN BRiEF

Baxter Healthcare Corporation | 95 Spring Street | New Providence, NJ 07974 1-800-ANA-DRUG (1-800-262-3784) | 01/12 720254| www.baxter.com

J u N e 2 0 1 2 A n e s t h e s i o l o g y N e w s . c o m I 7

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Time To Double Back—not Down—on P4PSpate of new studies expose flaws in performance-based payments

P ay for performance, at least the government version, does not work well. That is the con-clusion of several studies published recently

in the New England Journal of Medicine and Health Affairs.

Pay for performance, also known as P4P, seeks to improve the quality of health care by paying bonuses to physicians and hospitals that meet various per-formance measures. Health care is continuing to improve despite the ineffectiveness of P4P, or its renaming as value-based purchasing. We should dou-ble back on this payment confusion and bureaucracy before reformists and regulators double down on it again.

The reality is that P4P has never worked well, especially in anesthesiology, where every patient is seen preoperatively, each anesthetic is delivered per-sonally and safety defines the choices.

History of Anesthesia InstructiveAnesthesiologists have a history of improving

patient safety and clinical care that long predates the P4P fad. Clinicians can find a hundred standards, guidelines, advisories and other practice parameters on the Web site of the American Society of Anesthe-siologists (ASA) under “Patient Quality and Safety.” None was developed for extra pay.

Trying to jerry-rig guideline steps into bonus pay-ment formulas to improve quality is an errand for fools. Early studies of P4P showed little gain in quality for the money spent, as well as evidence that suggested unintended consequences, such as the avoidance of high-risk patients when payment depends on outcome improvements.

The latest data are more bad news for advocates of value-based purchasing in health care. Among the recently published studies, researchers at the Harvard School of Public Health compared outcomes among 252 hospitals participating in the Medicare Premier Hospital Quality Incentive Demonstration and 3,363 others outside the project. They found no evidence that hospital-based P4P programs decrease 30-day mortality, and concluded that any expectations for programs modeled after these programs should remain modest.

Meanwhile, researchers at the University of Penn-sylvania studied 260 hospitals in Medicare P4P,

comparing them with 780 hospitals not participat-ing in the demonstration project. After five years, the quality scores of the two groups had increased—but to the same degree.

These two studies corroborated the results of a third analysis by a team from the Rand Corpora-tion, who looked at performance reports of physi-cian groups contracting with a large network health maintenance organization to compare clinical qual-ity before and after the implementation of P4P. Yet again, they failed to find evidence that this P4P ini-tiative resulted in any major improvements in quality of care.

Of course, lack of evidence has not slowed down reformers committed to implementing P4P. Several sections of the Patient Protection and Affordable Care Act establish new payment plans that hinge on performance measurements. Accountable care organizations, for instance—a current reform rage—demand the inclusion of 33 measures of care coordi-nation, patient safety, preventive health services, care for at-risk populations and patient experience to earn any shared savings. There is now a P4P industry, with national meetings, newsletters, software, specialists and agendas for growth.

Patient Expectations, Not Bonus Pay, Driving Care

Extra pay for physicians and hospitals that do good work makes sense, in theory. But it is too far removed from clinical decision-making to affect care, and good care is expected anyway.

Anesthesiologists who report that they adminis-tered the correct prophylactic antibiotic to a surgical patient during the hour before incision, or two hours for a fluoroquinolone antibiotic, can qualify for an extra 0.5% of the allowed Medicare payment. Yet anesthesiologists administer the antibiotic whether they file for, or receive, the extra payment. Surveys that predate P4P payments show an intensive level of involvement by anesthesiologists in the adminis-tration of perioperative antibiotics. Infection prophy-laxis is just part of good anesthesia and surgery.

Filing for bonuses primarily measures whether the extra payment in any system is worth the extra has-sle. Only about 20% of eligible physicians and health professionals now participate in Medicare quality

bonus payment programs and only about 12% receive bonuses.

Keeping patients warm also qualifies for a P4P payment. Numerous studies established the value of normothermia during surgery, and clinical guidelines promoted its use, before the Centers for Medicare & Medicaid Services adopted it into its bonus program. Most anesthesiologists keep their patients normothermic because it makes anesthesia safer and smoother, and most do not know how to code and report it for P4P funds. Anesthesiologists perform anesthetics as best they can, and hope their administrator knows when and where to add codes 4255F and 4250F, and how to report them.

The major problem with P4P for anesthesiolo-gists is that the bonus payment program does not improve patient care or reduce health care costs, any more than does simply paying for the care. Continu-ing research on anesthesia techniques and outcomes, education on what techniques work best, and feed-back to practitioners on how they are doing are all that is needed. Checklists and facilitated communi-cations, two recent quality innovations, will improve care more than bonus payments.

P4P is at best irrelevant, and at worst distract-ing, to the provision of quality care. The model also creates an expensive bureaucracy. Eliminating P4P might even reduce the overall cost of health care.

The long commitment of anesthesiologists to pro-tecting patients and advancing the specialty through research, guidelines and education is worthy of sup-port. Payment experiments that distract from clinical care are not. Anesthesiologists should double down on meaningful quality improvements and double back on care distractions.

—Robert E. Johnstone, MD

Dr. Johnstone is professor of anesthesiology at West Virginia University, in Morgantown. He comments frequently on health care politics. This commentary represents his personal views.

Suggested Reading1. Jha AK, Joynt KE, Orav EJ, Epstein AM. The long-term effect of

premier pay for performance on patient outcomes. N Engl J Med. 2012;366:1606-1615.

2. Mullen KJ, Frank RG, Rosenthal MB. Can you get what you pay for? Pay-for-performance and the quality of healthcare providers. Rand J Econ. 2010;41:64-91.

3. Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA. 2005:294:1788-1793.

4. Ryan AM, Blustein J, Casalino LP. Medicare’s flagship test of pay-for-performance did not spur more rapid quality improvement among low-performing hospitals. Health Aff. 2012;31:797-805.

5. Warters RD, Szmuk P, Pivalizza EG, et al. The role of anesthesiologists in the selection and administration of perioperative antibiotics: A survey of the American Association of Clinical Directors. Anesth Analg. 2006;102:1177-1182.

6. Werner RM, Kolstad JT, Stuart EA, Polsky D. The effect of pay-for- performance in hospitals: lessons for quality improvement. Health Aff. 2011;30:690-698.


COMMENTARY

Robert E. Johnstone, MD

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anesthesianews

Unreported clinical Trial Data rampant, lead to research Bias

C linical drug trials often are hailed as the standard for rel-evant and reliable information

on potential new products.But a recent editorial in the British

Medical Journal suggests that research-ers often fail to report relevant trial data (BMJ 2012;344:d8158).

“We are not dealing here with trial design, hidden bias or problems of data analysis—we are talking simply about the absence of the data,” the authors wrote. This behavior, in turn, biases research, wastes health care resources and may harm patients, the editorial-ists argued.

“Moreover, researchers or others who deliberately conceal trial results have breached their ethical duty to trial par-ticipants,” they wrote. In fact, a slew of studies accompanying the editorial in the journal “confirm the fact that a large proportion of evidence from human trials is unreported, and much of what is reported is done so inad-equately,” the editorial argued. The studies explore the extent and conse-quences of leaving out data from clini-cal trials.

In one study, investigators showed that the addition of unpublished data to published meta-analyses of drug tri-als often changed the results (BMJ 2012;344:d7202). The researchers integrated previously unpublished data into existing meta-analyses of nine FDA-approved drugs and showed that the recalibrated trial data produced identical estimates of drug efficacy in three of 41 cases (7%), but 46% greater and 46% lower drug efficacy in the remaining 38 cases (19 for each).

The editorialists acknowledged that “it is sometimes assumed that incorpo-ration of missing data will reduce esti-mates of drug benefits, but this study shows that ‘publication bias’ can cut both ways. Each increment of data can change the overall picture, but in most cases with no certainty that the picture is complete.”

Not only is evidence frequently missing from trials, but the require-ments for mandatory trial registra-tion and appropriately timed sharing of results often are not followed prop-erly. Another study found that fewer than half of trials funded by the National Institutes of Health (NIH) are published in a peer-reviewed jour-nal within 30 months of trial comple-tion, and even at 51 months, one-third of results remained unpublished (BMJ 2012;344:d7292). Furthermore, in the

United States, in 2009, only 22% of drug trials sub-ject to mandatory

reporting require-ments disclosed their results within the required one year after the trial ended (BMJ 2012; 344: d7373).

“So it seems that most trials haven’t reported results, which we think is seri-ous,” said lead author Andrew P. Prayle, BMedSci, clinical research fellow at the University of Nottingham, in the United Kingdom.

A recent Cochrane review provided an example of allegedly unreported data (Cochrane Database Syst Rev 2012;1:CD008965). Attempting to study the anti-influenza antiviral drugs zanamivir (Relenza, GlaxoSmithKline) and oseltamivir (Tamiflu, Genen-tech USA, Inc., member of the Roche Group), the researchers received coop-eration from GlaxoSmithKline, but reported that they were “unable to obtain the full set of clinical study reports or obtain verification of data” from Roche despite five requests between June 2010 and February 2011.

Tom Jefferson, MD, an independent epidemiologist in Rome, leader of the study, said his group had reached “ten-tative conclusions which are at odds with the manufacturers’ statements,” but “full testing of all these findings, which may have a profound public health impact, cannot be done in the absence of the complete data set.”

Roche maintained that it does make “detailed clinical trial reports” available and that it “stands behind the robust-ness and integrity of our data support-ing the efficacy and safety of Tamiflu.”

The lack of reporting appears to vio-late the FDA Amendments Act of 2007. That prompted Rep. Henry A. Waxman (D-Calif.) and congressio-nal colleagues to write to the heads of the NIH and the FDA, for an explana-tion, and an answer to why the penalty of $10,000 per day for violating the law had apparently not been enforced.

The NIH declined to comment and said it would respond to the representatives.

Pat El-Hinnawy, an FDA spokes-woman, said a delay in publishing data

may result if the sponsor of a clinical trial is seek-ing approval of a new use of a drug or device.

“FDA has identified a number of factors that

skew the data and impact the percentage of results

Prayle [et al] reported,” Ms. El-Hinnawy said.

As for enforcement, Ms. El-Hinnawy said that the

agency has focused on providing infor-mation and assistance “to encourage compliance and to ensure an under-standing of the responsibilities.”

Frederick Stearns, JD, partner at Keller and Heckman LLP, in Wash-ington, D.C., said he suspected that policing the clinical trial reporting requirements “is a lower-priority issue, given all of the other matters the agency is responsible for.” In addition, he said, the $10,000 per day monetary pen-alty may seem “unduly harsh for a data

submission requirement.”Elizabeth Loder, MD, MPH, a BMJ

editor and co-author of the editorial, noted that most clinical interventions in use today are based on trials carried out before the era of mandatory registration.

“And here the task of data retrieval by systematic reviewers and national advi-sory bodies becomes impossible,” the editorialists wrote. “Our patients will have to live with the consequences of these failures for many years to come.”

Potential solutions to the prob-lem of underreporting of data have been proposed. Dr. Prayle suggested that “a greater awareness of the report-ing requirement will go a long way.” Dr. Jefferson added, “Reform and trans-parency are needed across the board.”

Dr. Loder proposed a harsher solu-tion: “Penalties for not reporting trial data need to be enforced,” adding that academic institutions and professional organizations need to be involved, and researchers doing meta-analyses need to look beyond published trials.

—George Ochoa

J u N e 2 0 1 2 A n e s t h e s i o l o g y N e w s . c o m I 1 1

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continuing medical and pharmacy education

Pain care in war Zones Mostly not Battle-relatedNew Orleans—Traumatic inju-ries among service members in Iraq and Afghanistan have received con-siderable attention, but the major cause of unit attrition in modern warfare involves painful injuries sus-tained beyond the field of battle. And managing those injuries represents a major challenge for military clinicians, experts said.

“Non–battle-related injuries are the No. 1 cause [of attrition],” said Col. Steven P. Cohen, MD, professor at the Uniformed Services University of the Health Sciences in Bethesda, Md., and associate professor of anesthesiol-ogy and critical care at Johns Hopkins School of Medicine, in Baltimore. “As military medicine evolves, pain man-agement capabilities will take on an increasingly vital role.”

Noninterventional strategies used to prevent chronic pain—resump-tion of normal activities, immediacy,

expectancy, avoidance of sick role and secondary gain—should be empha-sized, with early, aggressive treatment administered, Dr. Cohen said at a ses-sion on pain medicine and combat-related injuries at the spring meeting of the American Society of Regional Anesthesia and Pain Medicine.

Musculoskeletal Complaints Common

In one study, Dr. Cohen and his colleagues found that musculoskeletal and connective tissue disorders were the most common reasons for medical evaluation, documented among 24% of the 34,006 personnel who were medically evacuated during Opera-tion Iraqi Freedom and Operation Enduring Freedom (Lancet 2010; 375: 301-309). Spinal pain was reported by another 7%.

A five-year prospective study, which included 285 special operation

reservists, about half of whom had no history of low back problems, showed that back pain became fre-quent over 18 months of duty. Among the 154 patients who never reported an episode of back pain either by his-tory or over a three-year run-up to the monthly surveillance, pain scores of 2 or greater on the Oswestry Dis-ability Index (with 0 being the low-est possible score) were reported by 84%, scores of 4 to 9 were reported by 64% and scores of 10 or greater were reported by 14%; at least 25% scored 10 or greater (Spine 2009; 34: 978-983). Among deployed solders, Dr. Cohen said, “back pain is the rule.” Joining the military, he added, is asso-ciated with a 200% increase in the risk for back problems.

Risk factors for back pain in deployed soldiers include increased activity level, carrying heavy gear, psychosocial stress, post-traumatic

stress disorder and combat stress, reduced coping mechanisms and sec-ondary gain or poor job satisfaction. Only 13% of soldiers with back pain

illness and injury in combat Zones: return-to-Duty rates can Be improvedKnowledge of the risk factors that prevent return to duty, and aggressive interventions, can help motivated soldiers stay in theaterNew Orleans—For service members who become ill or are injured, return-to-duty rates historically have been low. But recognition of risk factors imped-ing their return, and aggressive inter-ventions for pain, can result in the majority of these individuals resuming active duty, according to one expert.

Col. Steven Cohen, MD, said that pain treatment in the U.S. armed forces focuses on two key goals: returning battle-wounded soldiers to their pre-morbid state and treating and pre-venting injuries unrelated to battle. Knowledge of the risk factors that pre-vent return to duty and aggressive interventions can help motivated sol-diers stay in theater, he said.

Dr. Cohen is professor at the Uni-formed Services University of the Health Sciences in Bethesda, Md., and associate professor of anesthesiology and critical care medicine at the Johns Hopkins School of Medicine, in Bal-timore. Dr. Cohen spoke at a ses-sion on combat-related injuries at the spring meeting of the American Soci-ety of Regional Anesthesia and Pain

Medicine.He described a study he co-authored

on medical diagnoses among 162 sol-diers serving in Operation Iraqi Free-dom who were referred to two large pain treatment centers outside the theaters of combat (Anesth Analg 2005;101:1098-1103). Fifty-three per-cent presented with either radicular or axial low back pain, with lumbar her-niated disk being the most frequently diagnosed condition (24%).

The two most implicated etiologies were exacerbation of a previous pain condition treated with surgery (15%) and motor vehicle accidents (12%). Only 17% of patients were injured in combat.

“With the exception of battle-related injuries, the pain conditions suffered during modern warfare reflect what we see in the typical civilian pain clinics,” Dr. Cohen said.

Treatment primarily consisted of nonsteroidal anti-inflammatory drugs (NSAIDs; 56%), short-acting opioids (43%), physical therapy (34%) and anticonvulsants (31%).

Aggressive Management Makes a Difference

“Among the 49 patients in whom data were available, only 2% returned to combat duty in Iraq,” Dr. Cohen said. “What matters most in the mil-itary is whether you can do your job. And this is an abysmal outcome.”

But according to Dr. Cohen, when aggressive pain management strat-egies are used in forward-deployed areas (where troops must be ready for action), high return-to-duty rates can be achieved.

This was shown in another pro-spective observational study that Dr. Cohen co-authored with Ron White, MD (Anesthesiology 2007;107:1003-1008), involving 113 coalition forces. Most had lum-bar radiculopathy (56%); the rest had thoracic pain (12%), cervical radicu-lopathy (7%), groin pain (7%), non-radicular leg pain (7%) and axial low back pain (6%). Epidural steroid injec-tions were by far the most frequently performed treatment, followed by trigger point injections, lumbar facet

blocks and groin blocks. Most patients also received NSAIDs; 25% were referred to physical therapy.

The return-to-duty rate for these ser-vice members reached 94.7%, “a dra-matic difference from our previous study,” Dr. Cohen noted. “These were motivated patients who wanted to stay in theater.”

In a recent prospective cohort study, Dr. Cohen further determined factors that predicted which service members are most likely to be returned to duty, based on 34,006 personnel medically

1 2 I A n e s t h e s i o l o g y N e w s . c o m J u N e 2 0 1 2

PAiN MEdiCiNE

evacuated out of theaters of opera-tion returned to duty in a 2009 study he conducted (Arch Intern Med 2009; 169: 1916-1923). Factors associated with negative outcomes were being in the Navy or Marines, having a psychi-atric diagnosis and not being treated

in a pain clinic.Among multiple risk factors for

back pain–associated disability, hav-ing high job stress, a physically demanding job, poor coping skills, high anxiety levels and, importantly, lacking the opportunity for a reduced

workload after returning to duty, par-ticularly stand out, Dr. Cohen said.

Post-Amputation Pain Growing Problem

Injury resulting from improvised explosive devices is common in the Iraq and Afghanistan wars and is the main cause of wartime amputations. Post-amputation pain (e.g., phantom limb pain [PLP] and residual limb pain), which occurs in between 60% and 80% of major limb amputees, is a treatment challenge. Treatment of pain in the residual limb should address the underlying cause and may include revi-sion surgery, neuroma injections, sym-pathetic blocks, pharmacotherapy, different prosthetics and complemen-tary and alternative medicine.

As a means of preventing PLP after amputation, results have been equiv-ocal for epidural injections and pre-emptive nerve blocks “but they weakly favor preemptive analgesia,” Dr. Cohen said. Some studies have shown that good preoperative and postoperative pain control may decrease PLP and that the benefits may be greater if epi-dural analgesia is started early. Studies were more likely to detect differences when the “control” group was not opti-mally managed, he said. “The effect may be small, and limited to select patients, but there are other advantages to epidurals, such as a reduced need for opioids and anesthesia during the pro-cedure,” he added.

PLP is treated similarly to other forms of neuropathic pain; evidence is strongest for the use of opioids, although the long-term use of opioids can have significant adverse effects in

young people with concomitant psy-chological conditions. The incidence of PLP diminishes over time, and about 17% of service members return to duty post-amputation, Dr. Cohen said. “This is far higher than was seen 15 years ago, when just 2.3% returned to duty.”

Other therapies for post-amputation pain include transcutaneous electrical stimulation, massage and physiother-apy, sensory discrimination training, acupuncture, biofeedback and self-hypnosis, visual feedback with mirrors, spinal cord and motor cortex stimula-tion and electroconvulsive therapy.

There is no firm evidence that chronic pain can be prevented through preemptive analgesic agents, although there are some positive data for gabapentinoids and the anti-depressant venlafaxine (Effexor, Eli Lilly), he added.

Rick Fisher, DO, a physician fellow in interventional pain management at Walter Reed, agreed that manag-ing post-amputation patients with PLP requires the pain specialist to be espe-cially attentive to special needs.

“We have large numbers of patients who do fairly well after amputation, but others have very real problems and take a lot of your time. I see these patients almost every day in my clinic,” Dr. Fisher said. “We use all the modal-ities we can and try to strike a balance between doing enough and doing too much. A lot of what we do is talk to them about the process, and encour-age them to give the treatments time to work. It’s ‘expectations management.’”

—Caroline Helwick

evacuated during Operation Iraqi Free-dom and Operation Enduring Free-dom (Lancet 2010;375:301-309).

Musculoskeletal complaints and con-nective tissue disorders were the main reasons for medical evaluation (24%), followed by combat injuries (14%), neurologic disorders (10%), psychiatric diagnoses (9%) and spinal pain (7%), the study found.

Factors most strongly associated with return to duty were being a senior offi-cer, having a disease and non-battle injury (DNBI), and presenting with

chest or abdominal pain, a gastrointes-tinal disorder or genitourinary disor-der. Factors associated with a decreased probability of return were serving in the Navy, Coast Guard or Marines, and pre-senting with a combat injury, psychiatric disorder, musculoskeletal or connective tissue disorder, spinal pain or other wound.

Efforts ApplaudedU.S. Army Lt. Col. Philip J. Belmont

Jr., MD, director of the Orthopaedic Surgery Residency Program at William

Beaumont Army Medical Center/Texas Tech University Health Sciences Center in El Paso, also has observed that within combat zones, the contri-butions of DNBI are frequently over-looked and significantly underreported.

“These have historically accounted for a far greater proportion of casual-ties than all other categories combined,” said Dr. Belmont, who also is associate professor of surgery at the Uniformed Services University of the Health Sciences.

In a study he led, musculoskeletal non–battle-related injuries accounted for more than 50% of the total DNBI casualties and more than 25% of the DNBI casualties requiring subsequent

medical evacuation (Mil Med 2010; 175: 469-476).

“Dr. Cohen’s report [in Anesthesiol-ogy] detailing the aggressive treatment of mainly spinal conditions with a combination of epidural steroid injec-tions, trigger point injections, facet blocks, NSAIDs and physical ther-apy holds great promise in the treat-ment of those musculoskeletal DNBI casualties because they were able to achieve a return-to-duty rate of greater than 90%,” and the effort allowed deployed units to ‘conserve their fight-ing strength,’” Dr. Belmont said.

—Caroline Helwick


PAiN MEdiCiNE

Between 8% and 40% of patients who undergo inguinal hernia repair have chronic pain after sur-gery, according to previous stud-ies. And that pain often triggers legal action against physicians and hospi-tal systems. In the United Kingdom, chronic pain following hernia repair is the No. 1 cause of malpractice suits. In the United States, 35% of all mal-practice case law that relates to hernia

repair is related to chronic pain or discomfort.

Bruce Ramshaw, MD, a hernia sur-geon and chief medical officer for the Transformative Care Institute, in Day-tona Beach, Fla., said the app marks a change in the way outcomes after med-ical and surgical care are measured.

“This app is great because it’s focused on patient quality of life and outcomes from the patient perspective. That’s the direction we are going as a hernia society.”

The app is based on an algorithm developed by Igor Belyansky, MD, a fel-low in laparoscopic surgery at Carolinas Medical Center. Dr. Belyansky and col-leagues studied data collected between September 2007 and September 2011 by the International Hernia Mesh Reg-istry, a prospectively collected multi-center database that includes data on patients from 30 sites in Canada, the United States, Europe and Australia.

Patients submit data to the registry, by mail or email, and answer questions

regarding quality of life, Carolinas Comfort Scale scores and postopera-tive complications.

Researchers studied 2,146 inguinal hernia patients, after excluding cases where more than 10 tacks were used in the repair. (An earlier study, from the same group, showed that the use of more than 10 tacks increases long-term pain [Ann Surg 2011;254:709-714]).

The average age of the patients was 56.4±14.6 years; 94% were male and 38% underwent laparoscopic repair. Overall, 20% of patients had bilat-eral repair and 12% were treated for a recurrent hernia. Almost 58% of patients reported preoperative pain.

Patients were queried at regular intervals for a year after their hernia repair (77.7% follow-up rate). One month after surgery, just over one-fourth of patients (26.1%) reported postoperative pain. That figure dropped by more than half over the next year, with 12.5% reporting post-operative pain one year after surgery.

The investigators found that younger age, female sex, bilateral repair, recur-rent inguinal hernia repair, preoper-ative pain, postoperative hematoma, postoperative recurrence and postop-erative urinary tract problems all were predictive of chronic pain.

Based on these results, the research-ers developed an algorithm to pre-dict chronic pain. They used a random sample of 80% of patients in the data-base to develop the algorithm and con-firmed the results in the remaining 20% of patients. A Harvard statistician independently tested the equation, and confirmed its sensitivity and specificity.

The app was developed to make the algorithm more practical for use by physicians and patients. It is the first app for medical and surgical outcomes, Dr. Heniford said.

According to CeQOL, a young asymptomatic patient with no preoper-ative pain has about a 10% risk for dis-comfort one year after surgery. Patients with preoperative pain, bilateral ingui-nal hernias and recurrent hernias have an increased risk for developing chronic pain after surgery. Interest-ingly, older patients are less likely to have symptoms of chronic pain than younger patients.

Dr. Belyansky said the app will help identify high-risk individuals who may benefit from a multidisciplinary treat-ment approach. “Furthermore, in a pre-operative or pretreatment setting, full disclosure of postoperative quality-of-life expectations should become a standard part of the counseling and consent process for surgery and major


TEChNOLOgY

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medical treatments,” he said.Surgeons at Carolinas currently use

the app for all inguinal hernia patients who come into the clinic. Surgeons fill in the app as they speak to patients, or patients do it themselves on an iPad.

New products come into the hernia field at rapid speed but data on out-comes follow much more slowly, said Shirin Towfigh, MD, associate profes-sor of surgery at Cedars-Sinai Medical Center, in Los Angeles, and assistant professor of surgery at the University of Southern California.

The new app keeps the focus on patients, she said. “What this app helps quantify in very real terms, and for the first time ever, is how much chronic pain a typical patient may suffer based on simple preoperative symptoms,” Dr. Towfigh said. “Surgeons can help use this app to educate their patients about the risks and benefits of hernia repair.”

Dr. Heniford, who is the outgo-ing president of the American Her-nia Society, encouraged clinicians and their patients to use the app. Currently, the app applies only to men, because of a shortage of outcomes data fol-lowing hernia repair in women. He said CeQOL represents a paradigm shift in which the success of a proce-dure is judged not only by recurrence rates, which are quite low, but also by patients’ quality of life.

“The team should be congratulated for pioneering an app that bridges evolving technology and patient care outcomes. As CeQOL gets used by multiple surgeons and patients, its validity and usefulness will be tested,” said Brian Jacob, MD, attending sur-geon at Mount Sinai Medical Center, in New York City.

“Pain complaints after hernia surgery, in general, are very subjective, and often factor in many variables that are depen-dent on any given surgeon’s technique,

patient population and follow-up reg-imen,” he said. “Such variables make it tough for an app to reliably account for things like the type of hernia repair being performed, the surgeon’s experi-ence with the technique and the loca-tion or type of pain complaint being reported. Therefore, the risks that CeQOL produces might have a chance to overestimate or generalize.”

Dr. Jacob said he does plan to use the app in his own practice and see

“how reliable it is with my patients.”

The research team plans to recheck the algorithm and update it as needed as more information on quality of life is collected. They also are designing trials for patients with a high risk for chronic discomfort after inguinal hernia repair to perform patient-directed care instead of hernia-directed care.

Dr. Belyansky won the World Her-nia Congress Resident/Fellow Research Award for 2012 for this project.

—Christina Frangou


TEChNOLOgY

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MCAN2077.indd 1 2/13/12 5:08 PM

obese Patients experience Fewer Post-op complications

O bese adults have fewer compli-cations following non-bariatric surgery than their leaner peers,

according to a review of more than 230,000 patients.

“These findings are the opposite of what we would expect to see,” said Thomas Beer, MD, an anesthesiologist in Scottsdale, Ariz., who specializes in bariatric medicine but was not involved in the study.

Olubukola Nafiu, MD, assistant pro-fessor of anesthesiology at the Univer-sity of Michigan, in Ann Arbor, and several colleagues, analyzed data from 235,076 general and vascular inpatient surgeries conducted between 2005 and 2008.

Dr. Nafiu’s team compared the inci-dence of postoperative complications among older and younger normal-weight, obese and morbidly obese patients. The researchers excluded underweight patients from their analysis, as this pop-ulation often has comorbidities—such as cancer—that increase their risk for mor-tality. They also excluded patients under-going outpatient surgeries, who typically are healthier than hospitalized patients.

The researchers found that 16% of all patients suffered a major postopera-tive complication and 2% of all patients died within 30 days of surgery (Table). Normal-weight adults younger than age 65 years had significantly higher odds of death and major postoperative complica-tions than did obese and morbidly obese adults.

Although the mortality rate for the elderly population was still signifi-cantly lower in obese patients compared with normal-weight patients, morbidly obese patients enjoyed no such protec-tion, the researchers found (4.7% for normal weight, 3% for obese and 3.7% for morbidly obese; P<0.001 for all). Major postoperative complications in the elderly followed a similar J-curve, according to the researchers, occurring in 25.3%, 23.8% and 25.6% of normal-weight, obese and severely obese older patients, respectively (P<0.001).

The study is not the first to describe an “obesity paradox.” Obese patients with heart failure and stroke, as well as those in the surgical intensive care unit, seem to have better outcomes than their normal-weight peers, Dr. Nafiu said.

“The reasons for the obesity paradox are still largely unresolved,” Dr. Nafiu said. “Some of the reasons may be physiologic, such as having higher nutri-tional buffers of inflammation or earlier manifestations of symptoms.”

However, Dr. Beer said obese patients may be observed more closely in the

perioperative period, which may reduce complications and deaths.

“At my clinic, perioperative nurses fol-low a protocol specifically designed to look for complications such as hypoxia, hypercarbia, early signs of bleeding or infection, which our morbidly obese patients are at highest risk for,” Dr. Beer said. “I suspect clinicians across the country are equally as vigilant and these results likely reflect that.”

—David Wild

Table. Complications and Mortality After non-Bariatric Surgery

Normal-Weight Adults

Obese Adults

Severely Obese Adults

30-day all-cause mortality 1.10% 0.80% 0.70%a

Major postoperative complications 15.60% 15.80% 12.70%b

a P<0.001 for obese and severely (morbidly) obese versus normal; b P<0.001 for severely (morbidly) obese versus normal


CLiNiCAL ANEsThEsiOLOgY




Each installment contains articles from the current month’s issue ahead of print, as well as links to podcasts and other Web-exclusive content


Lesson 297: PreAnesthetic Assessment of the Patient Undergoing Thoracic Endovascular Aneurysm Repair: Part 2WRITTEN BY: Jayanta Mukherji, MBBS Associate Professor, Department of Anesthesiology, Loyola University Medical Center, Maywood, Illinois

Michael Trembowicz, DOFellow in Cardiothoracic Anesthesia, Department of Anesthesiology, Loyola University Medical Center, Maywood, Illinois

REVIEWED BY: Pierre Levan, MDProfessor, Department of Anesthesiology, Loyola University Medical Center, Maywood, Illinois(In Part 1 of this 2-part series, the causes of thoracic aneurysms and the noninvasive treat-ment by stent placement are described. In Part 2, the complications of this therapy and monitoring requirements will be outlined.)

DISCLOSURES The authors, editor, and reviewer have declared no conflict of interest related to financial disclosures, research, and written presentation of this manuscript.

PROFESSIONAL GAPSThoracic endovascular aneurysm repair represents a technique with special considerations that may not be known by many practicing anesthesiologists. This lesson aims to explain these changes and developments.

CALL FOR WRITERSIf you would like to write a CME lesson for An esthesiology News, please send an email to Eliz a beth A.M. Frost, MD, at [email protected].

TARGET AUDIENCEAnesthesiologists

LEARNING OBJECTIVESAt the end of this activity, the participant should be able to:1. Outline the causes of aortic dissection and natural history of descending thoracic

aneurysm.2. Describe the criteria and technique used for performing thoracic endovascular aneurysm

repair (TEVAR).3. Prescribe the preanesthetic assessment of the patient undergoing TEVAR.4. Evaluate the anesthetic implications for the patient undergoing endovascular graft

deployment.5. Tabulate the criteria for TEVAR.6. List common comorbidities in vascular patients.7. Recognize the off-label status of endovascular stents when used in the treatment of

aortic dissection.8. List the indications for stent graft placement.9. Identify perioperative goals.10. Describe the intraoperative use of adenosine.

CASE HISTORYA 67-year-old woman presented to the emergency room with severe back pain and diaphore-sis. She had a history of hypertension and coronary artery disease (CAD). Computed tomog-raphy (CT) angiogram revealed an aortic dissection involving the descending thoracic aorta distal to the left subclavian artery origin extending to the aortic bifurcation. There was a 6-cm dilatation of the proximal region of the descending thoracic aorta with evidence of extra-vasation. There was no disruption of blood flow to the celiac axis, superior mesenteric, and renal vessels on angiogram. Cardiac catheterization revealed nonobstructive CAD and an ejection fraction of 40%. Transthoracic echo revealed left ventricular hypertrophy with normal aortic root and ascending aorta.On physical examination, the patient had no neurologic deficits; blood pressure (BP) was 170/110 mm Hg; heart rate was 110 beats per minute; and all peripheral pulses were palpa-ble. She was scheduled to undergo thoracic endovascular stent placement to create a seal at the area of extravasation.

PREANESTHETIC ASSESSMENTDr. Elizabeth A.M. Frost, who is the editor of this continuing

medical education series, is clinical professor of an esthes iology at the Mount Sinai School of Medicine in New York City. She is the author of Clinical Anesthesia in Neu rosur gery (Butterworth-Heinemann, Boston) and numerous articles. Dr. Frost is past president of the Anesthesia History Association and former editor of the journal of the New York State Society of Anesthe siologists, Sphere. She is also editor of the book series based on this CME program, Preanesthetic Asses s ment, Volumes 1 through 3 (Birkhäuser, Bos ton) and 4 through 6 (McMahon Publishing, New York City).

A COURSE OF STUDY FOR AMA PRA CATEGORY 1 CREDIT(S)™

Read this article, reflect on the information presented, then go online (www.mssm.procampus.net) and complete the lesson

post-test and course evaluation before June 30, 2013. (CME credit is not valid past this date.) You must achieve a score of 80% or better to earn CME credit.TIME TO COMPLETE ACTIVITY: 2 hoursRELEASE DATE: June 1, 2012TERMINATION DATE: June 30, 2013

ACCREDITATION STATEMENT

The Mount Sinai School of Medicine is accredited by the Accred-itation Council for Con tinuing Medical Education to provide con-tinuing medical education for phy sicians.

CREDIT DESIGNATION STATEMENT The Mount Sinai School of Medicine designates this enduring

material for a maximum of 2.0 AMA PRA Category 1 Credit(s).™

Physicians should only claim credit commensurate with the extent of their participation in the activity.

DISCLOSURE STATEMENT

It is the policy of Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.

All antihypertensive and antianginal medications should be continued until the time of surgery. Systemic hypertension contributes to expansion and rupture of TAA. Strict control of hypertension is initially a top priority and is immediately implemented. The first-line manage-ment of hypertension includes a short-acting β-blocker such as esmolol. By lowering the heart rate and slowing the force of contraction, β-blockade reduces the shear force exerted on the dissection. The likelihood of propa-gation of the dissection is decreased. Second-line agents include vasodilators such as nitroprusside, which lower systolic blood pressure (BP), aortic wall stress, and the possibility of rupture.

Preoperative sedation should be based on the patient’s clinical condition and concurrent medical diseases.

Anxiolysis helps reduce hypertension and tachycardia, thus lowering the risk for myocardial ischemia and aneu-rysm rupture.

Preanesthetic Considerations for TEVAR

The goal of preoperative evaluation is to optimize the patient’s medical status and plan an anesthetic technique that minimizes complications. Aortic sur-

gery and emergency operations are independent risk fac-tors for major complications.

The anesthetic approach to the patient with a thoracic aortic aneurysm (TAA) is selected based on the urgency of repair. An unstable hemodynamic presentation sug-gests ongoing hemorrhage from a leaking aneurysm, car-diac tamponade, myocardial ischemia, or heart failure. Prior to surgery, it is important to discuss with the sur-geon the operative procedure, cannulation strategy (if applicable), and whether evoked potential monitoring is planned. Symptomatic patients with leaking aneurysms require urgent intervention, and there generally is little time to perform more than the most basic preoperative assessment.

CONTINUINGMEDICAL EDUCATION JUNE 201218 This lesson is available online at www.mssm.procampus.net

Patients undergoing an elective TEVAR need a detailed workup encompassing every organ system.

Cardiovascular SystemPatients undergoing TEVAR are subjected to less hemo-

dynamic stress, as the aorta is not cross-clamped and the anesthesiologist does not have to contend with major fluid shifts and blood loss. Clinicians should assess for the presence of comorbidities, such as coexisting hyperten-sion, atherosclerotic disease, coronary artery disease, and congestive heart failure. The chart is reviewed for pre-vious hospitalizations and procedures, including pace-makers, coronary artery bypass, and percutaneous stent placements.

Specific preoperative studies should include the following: • Electrocardiography (ECG), which may reveal evidence

of ischemia or prior myocardial infarction, left ventricu-lar hypertrophy, and conduction blocks

• Echocardiography, which is used to determine the size, location, and extent of the aneurysm, assess the func-tional status of the valves, and evaluate biventricular function

• Computed tomography angiography or magnetic res-onance angiogram (MRA), which determines the size, location, and extent of the aneurysm.

Pulmonary SystemPreoperative pulmonary evaluation includes ascer-

taining the presence and severity of chronic obstructive pulmonary disease (COPD), smoking history, and func-tional status. There is less concern for respiratory failure in patients undergoing TEVAR than in those undergo-ing open descending thoracic aneurysm repairs, because there is less pulmonary insult from massive fluid shifts, transfusion of blood products, and one-lung ventila-tion. Respiratory failure is a likely sequela of TEVAR if the patient has baseline pulmonary insufficiency.

If feasible, active smokers should refrain from smoking for at least 4 weeks before surgery. Patients with poor dif-fusing capacity or severe COPD may require preoperative optimization, despite not being subjected to prolonged ventilation.

Dyspnea or stridor may be signs of tracheal or bron-chial compression on physical examination. Hemopty-sis may be a sign of aneurysmal leakage into the airway. Patients should be evaluated for a history of recurrent laryngeal nerve damage because there is potential for damage to the left recurrent laryngeal nerve if the proce-dure is converted to open repair.

Central Nervous SystemPreexisting neurologic deficits in the central nervous

system must be determined. A history of transient isch-emic attacks, stroke, and seizures should be specifically sought preoperatively because of the potential for neu-rologic complications after surgery. Carotid angiography or duplex studies may be appropriate in selected patients with a history of stroke or severe atherosclerosis.

Renal SystemBaseline renal insufficiency is related to hypertension,

diabetes, and atherosclerotic disease and is an indepen-dent predictor of postoperative renal failure. The angi-ographic contrast dye used preoperatively during CT imaging and during the intraoperative evaluation of the aneurysm often causes transient abnormalities of renal function. Elective repairs should be delayed until these values have normalized.

Hematologic SystemPreoperatively, it is routine to discontinue antiplatelet

medications and warfarin. Point-of-care testing is used to guide transfusion of blood products. Coagulopathy fol-lowing TEVAR is uncommon but is likely to occur in the setting of hypothermia, and in the use of heparin.

Gastrointestinal and Hepatic SystemsAneurysmal involvement of the celiac and mesenteric

arteries can predispose to bowel ischemia. Abnormal liver function tests should be noted.

Radiologic EvaluationThe extent and location of the aneurysm is determined

by reviewing the CT or MRA. It may be beneficial to locate the origin of the artery of Adamkiewicz (ARM) preopera-tively by angiography if TEVAR is converted to open repair, as identification and reimplantation of ARM reduces the risk for paraplegia by 5%. However, the significance of identifying the origin of ARM for endovascular aneurysm repairs is not known.

Anesthetic Considerations in Endovascular Graft Deployment

Although endovascular repair is a less-invasive proce-dure, patients should be anesthetized with the possibil-ity that open surgical repair may be necessary. The risk has decreased with improvements in endovascular devices and with greater surgical experience.

Endovascular aortic repair should be classified, similar to aortic and peripheral vascular surgery, as a higher-risk procedure. Vascular patients are likely to have significant comorbid conditions such as hypertension, hyperlipid-emia, stroke, ischemic heart disease, COPD, and diabe-tes. Preoperative assessment needs to address the typical issues associated with a general anesthetic in a vascular patient.8

Perioperative goals during TEVAR are to provide hemo-dynamic stability while preserving cardiac, spinal, and splanchnic flow and maintaining intravascular volume, adequate oxygenation, and body temperature. Both gen-eral and regional techniques have been used successfully. However, with the increasing use of neurologic moni-toring and transesophageal echocardiogram (TEE) dur-ing TEVAR, general anesthesia is an appropriate choice.

Although epidural anesthesia can be used, it may be diffi-cult to distinguish the effects of central neuroaxial block-ade by local anesthetics from spinal cord ischemia (SCI). The use of epidural anesthesia is disadvantageous if lower extremity weakness ensues following operations involv-ing the thoracic aorta. Neurologic examination is per-formed immediately upon emergence from general anesthesia. Any neurologic deficit detected should be considered to be SCI until ruled out.

In early cases of TEVAR, surgeons preferred a “still” field during stent graft deployment, accomplished by the use of adenosine to achieve transient bradycardia or ventricu-lar asystole. With the availability of newer self-deploying stents, this technique is no longer necessary. Various imaging modalities such as angiography, fluoroscopy, and TEE may be used to confirm the position of the stent. The proximal and distal ends of the endograft are then sealed to the aortic wall by endoluminal balloon inflation. The transient balloon inflation may cause a short-lived hemo-dynamic change that usually will not require any interven-tion. However, even this ephemeral increase in afterload may be poorly tolerated in patients with severe ventricu-lar dysfunction.

Blood loss may be difficult to quantify, as it often is lost around the sheaths and catheters and can be retroperito-neal in the case of injury to femoral or iliac vessels. A ret-roperitoneal approach is an alternative technique used in cases with failed femoral access. However, this approach results in higher chances of retroperitoneal bleeding and a longer procedure time. Large-bore IV access is useful in resuscitating unstable patients with rapid, ongoing blood loss. Because of the difficulty associated with accurate prediction of substantial blood loss and the possible need for allogeneic blood transfusion, it is appropriate to set up a cell salvage device in a backup mode. Intraoperative cell salvage and reinfusion can obviate allogeneic blood transfusion and its attendant risks. After graft deployment, vasopressors and inotropes are needed to manage hemo-dynamic emergencies and maintain higher mean arterial pressures (MAPs).9

Spinal Cord IschemiaThe risk for SCI is lower after TEVAR than after open pro-

cedures but the complication still occurs, with an inci-dence of approximately 4% to 7%.10 A Crawford type II thoracoabdominal aortic aneurysm involves most of the descending thoracic aorta and the entire abdomi-nal aorta; this type of aneurysm has the highest incidence of neurologic complications following endovascular repair (19%). There are other risk factors for SCI related to patients’ underlying conditions and the nature of the sur-gery (Table 1).

The anatomic peculiarity of spinal blood supply explains the susceptibility of the spinal cord to ischemia. A single anterior spinal artery supplies the anterior two-thirds of the spinal cord, which represents the motor region. In the cervical region, the vertebral arteries mainly supply the anterior spinal artery. In general, very few radicular arteries bolster the anterior spinal blood flow. It is critical to maintain the patency of the largest supplier, known as the ARM, as major SCI is likely with its occlusion. Other noteworthy collaterals improving anterior spinal flow arise from intercostal and lumbar segmental arter-ies that are branches off the descending thoracic aorta. In severe atherosclerosis, in which these collaterals are occluded, the anterior spinal blood supply may be derived from lumbar and perivertebral vessels and the pelvic cir-culation. Thus, the collateral network is dynamic and can supply blood to the spinal cord from another source when one is reduced. The posterior third of the spinal cord is

Table 1. Risk Factors for Spinal Cord Ischemia After TEVAR

Emergency surgery

Previous abdominal aortic aneurysm repair

Intraoperative hypotension

More extensive coverage of the thoracic aorta by graft

Coverage and occlusion of the left subclavian artery or hypogastric arteries by graft

Severe peripheral vascular disease

Severe atherosclerosis of the thoracic aorta

Aortic dissections

Anemia

TEVAR, thoracic endovascular aneurysm repair

CONTINUING MEDICAL EDUCATIONJUNE 2012 19

predominantly a sensory region supplied by 2 posterior spinal arteries.

Although the incidence of paraplegia is definitively lower with endovascular procedures, it remains one of the most dreaded complications. The cause differs from that encountered in open surgery, as no aortic cross-clamping is employed, and is most likely because of permanent cov-erage of important collateral arteries and intercostals sup-plying the spinal cord. With the recognition of this risk, cerebrospinal fluid (CSF) drainage during the periopera-tive period is an important consideration when extensive lengths of descending thoracic aorta are to be covered and in patients who had previous aortic repair.

Monitoring Considerations in TEVAR

In patients at high risk for SCI, additional intraoperative neurologic monitoring with transcranial motor evoked potentials (MEPs) and/or somatosensory evoked poten-tials (SSEP) is useful.

Patients are prepared for evoked potential monitor-ing with baseline measurements following induction of general anesthesia. Both inhalational and IV anesthetic agents have effects on neural synaptic and axonal func-tional activities. Intraoperative neurophysiologic moni-toring can be challenging, because recording SSEP and MEP signals requires critical anesthetic choices and atten-tion to temperature changes. The anesthetic effect on any given response depends on the pathway affected and the mechanism of action of the anesthetic agent. Inhaled anesthetics decrease the waveform amplitude and increase latency to a greater extent than IV anesthet-ics. Halogenated agents and nitrous oxide also depress MEP signals more than total IV anesthesia. An IV propofol–based anesthetic is preferred because it causes less sup-pression of cortical SSEPs with better preservation of SSEP amplitude at an equivalent depth of anesthesia compared with isoflurane.11 The management of pharmacologic neu-romuscular blockade is crucial to myogenic MEP record-ing, as some blockade may be desirable for surgery, but excessive blockade may eliminate responses.

Monitoring helps in the early detection of SCI and per-mits intervention before ischemia evolves to infarction.12 Decreased SSEP and MEP amplitudes have been shown to correlate with SCI, but the sensitivity and specificity of

these techniques remain to be determined.Intraoperative loss of SSEP or MEP signals is not nec-

essarily caused by SCI. SSEP latency is increased and the magnitude is reduced by benzodiazepines and normal clinical concentrations of volatile anesthetic agents. SSEP detects lateral and posterior column ischemia but is a poor monitor for anterior motor column. A potential limi-tation of SSEP monitoring is that SCI confined to the ante-rior spinal cord may cause a selective motor deficit with intact sensation.

Impaired peripheral nerve functioning from ischemia may affect the associated SSEPs or MEPs. Intraopera-tive strokes and lower limb ischemia from vascular insuf-ficiency are known to cause loss of peripheral SSEPs or MEPs in the absence of SCI.

Techniques To Improve Spinal Cord Perfusion

Because spinal cord perfusion pressure (SCPP) is equal to the MAP minus the lumbar CSF pressure, close atten-tion is given to CSF drainage if lumbar CSF pressure is increased. Spinal cord perfusion is improved by augment-ing the arterial pressure alone or in combination with lumbar CSF drainage. Vasopressor agents such as norepi-nephrine have been used to maintain a MAP of 80 mm Hg or greater to assure an SCPP of at least 70 mm Hg. Patients at risk for SCI may even need a higher MAP to improve SCPP. Attention needs to be given to optimizing oxygen delivery by improving cardiac output, correcting anemia, and maintaining a normal central venous pressure.

CSF is drained by the percutaneous insertion of a silas-tic catheter into the subarachnoid space. It is performed on an awake patient in the lumbar position. CSF is drained passively to reduce lumbar CSF pressure to approximately 10 to 12 mm Hg during the operation. The catheter is usu-ally left in place for 48 to 72 hours postoperatively. Emer-gent CSF drainage has been performed postoperatively to reverse delayed-onset paraplegia in combination with augmentation of MAP up to 100 mm Hg.13

Hypotension should be assiduously avoided, as it worsens SCI. It results from bleeding, anesthetics, and an underlying cardiac condition. SCI, which may itself

contribute to hypotension, is a neurogenic shock associ-ated with autonomic dysfunction. Immediate treatment of hypotension is a priority, as prolonged ischemia may progress to spinal cord infarction.

The various options for spinal cord revascularization that exist in open repairs are not available in TEVAR. Here, the preservation of spinal artery blood flow by segmental vessels is not feasible if the aneurysm is excluded by the stent graft. In some situations, the left subclavian artery may need to be covered by the endovascular stent graft in order to exclude the aneurysm. Because subclavian arte-rial flow contributes substantially to anterior spinal artery supply, a prior transposition of the subclavian artery onto the left carotid artery is required. Another method used to preserve left subclavian artery flow in TEVAR is to per-form a left carotid to subclavian bypass graft with subse-quent coil embolization of the proximal left subclavian artery stump during TEVAR.14 Because coverage of the left subclavian artery without bypass has been independently associated with paraplegia, many centers now perform elective left subclavian revascularization before TEVAR if the preoperative plan involves coverage of this artery in order to obtain an adequate proximal seal zone.

Lumbar CSF drainage is performed in patients who will subsequently require anticoagulation with boluses of heparin for endovascular stent placement. It is gener-ally deemed safe, although complications related to intra-spinal or epidural hematoma may exist with a traumatic drain placement. Rapid drainage of CSF is another cause of serious complications such as subdural hematoma, intracranial hemorrhage, and remote cerebellar hemor-rhage. Precautions such as continuous measurement of CSF pressure, controlled intermittent drainage of CSF, and assessment of coagulation function may decrease the risks associated with lumbar CSF drainage (Table 2).15

Renal Concerns With TEVAR

TEVAR patients encounter exposure to large volumes of radiographic contrast to assist in suitable deployment of the graft and to ensure that the aneurysmal sac is com-pletely excluded. Prevention is emphasized, as there is no specific treatment for contrast-induced acute renal failure

Table 2. Avoiding Complications With Lumbar Drains

Verify adequate coagulation, including platelet function, before catheter insertion.

Monitor and maintain CSF pressure of 10 to 12 mm Hg to maintain spinal cord perfusion.

Use intermittent CSF drainage rather than contin-uous drainage to avoid intracranial hypotension or subdural hematoma.

Prevent infection by maintaining a closed CSFcollection system.

Occlude lumbar catheter for 24 hours before removal.

Supervise catheter removal; place patients in lateral decubitus position for removal to avoid catheter fracture.

Adapted from Pokhrel B, et al. Neurosurgery 2002;51:1414-1421.

Table 3. Use of Intraoperative TEE for TEVAR Procedures

Confirming aortic pathology Define the extent and size of aneurysm, check presence of coexisting aortic aneurysms.

Detect the presence of widespread atherosclerotic plaques

Severe plaques in landing zone make graft deployment difficult.Detached plaques can embolize to brain.

Endograft imaging Guide precise placement to ensure exclusion of the aneurysmal sac.

Differentiate true from false lumen in dissections

Confirm position of guide wire in true lumen.

TEE probe used as a marker during fluoroscopy

Serves as a marker of aortic level on fluoroscopy without contrast.

Monitoring cardiac performance Monitor during a brief period of aortic occlusion because of inflation of the endovascular balloon; enables fixation of the endograft to the aortic wall.

Regional wall motion abnormality

Seen with CAD, severe ventricular dysfunction.

Check for endoleaks after graft deployment

Define type and severity of endoleaks.

CAD, coronary artery disease; TEE, transesophageal echocardiography; TEVAR, thoracic endovascular aneurysm repair


(ARF). Preexisting renal failure and diabetes place patients at highest risk for contrast-induced ARF.

Measures include hydration with isotonic sodium bicar-bonate along with the administration of the antioxidant acetylcysteine to reduce the risk for contrast-induced ARF. Diuretics and/or mannitol have no role in the prevention of contrast-induced ARF.

Role of TEE in TEVAR

The proximity of the esophagus to the aorta in the intrathoracic space makes TEE an appealing imaging modality for detection of aortic pathology. During TEVAR, intraoperative TEE provides valuable feedback regarding the extent and severity of the aortic pathology, guiding placement of the endograft, monitoring cardiac perfor-mance during and following aortic occlusion caused by transient balloon, and detecting endoleaks after endo-graft deployment. Cardiac performance may be moni-tored by TEE during the acute hemodynamic disturbances of stent deployment. Diastolic dysfunction is the end result of perioperative myocardial injury that remains undetected by any other monitoring modality (Table 3).16

An endoleak is a unique complication of TEVAR and occurs when blood flows outside the lumen of the endo-graft but within an aneurysm sac. The causes of endoleak are described in Table 4. Endoleaks have been classified into types I to IV based on the underlying cause and anatomic

site of origin. Accurate detection and classification are essential for proper management because the method of endoleak treatment is determined by its source.17

In general, high-pressure leaks (types I and III) require urgent management because of the relatively high short-term risk for sac rupture. Observational management of type II endoleaks may be associated with continued sac expansion, requiring close monitoring (Table 5). Low-pressure lesions (type II) are considered less urgent but may require continued endovascular evaluation if there is impending growth of the aneurysm sac. Endoleaks requir-ing correction include all type I and III lesions as well as type II lesions associated with aneurysm enlargement. Techniques used incorporate extension endografts or cuff, balloon angioplasty, and bare stents. Type II endoleak con-tinues to be the most common but also the most con-troversial in terms of evaluation, need for treatment, and methods of treatment. Postoperative lifelong follow-up with CT imaging is needed.18

Management of the Case Presented

This patient has a type B aortic dissection complicated by periaortic leakage but with no evidence of organ mal-perfusion or limb ischemia. Surgical or endovascular repair was indicated for the periaortic leak with poten-tial for aortic rupture. Maintaining BP control and hemo-dynamic stability is of critical importance, with the goal of

keeping systolic BP below 120 mm Hg while maintaining sufficient organ perfusion to the brain, heart, and kidneys.

The patient was given esmolol and sodium nitroprus-side infusions preoperatively for strict BP control and to minimize the shear forces on the aorta. She was not receiving anticoagulants or clopidogrel, so after discus-sion with the surgeon, a decision was made to place a lumbar drain, as the surgeon was planning to cover a large area of the thoracic aorta. The risk for SCI was antic-ipated for this procedure, and a plan was made to moni-tor her neurologic status intraoperatively using SSEPs and MEPs.

Prior to the patient’s arrival in the operating room, a right radial arterial cannula was placed for close BP mon-itoring and frequent blood gas sampling, along with a large-bore peripheral IV. The right radial artery was cho-sen for arterial line placement due to the possibility of the proximal landing zone covering the left subclavian artery, thereby inhibiting flow to the left radial artery.

The patient received premedication with IV midazolam and was brought to the operating room, where standard monitors were placed. A lumbar drain was placed atrau-matically in sitting position. Opening CSF pressures were normal. CSF pressures were transduced and fluid intermit-tently drained if CSF pressure exceeded 10 mm Hg.

Anesthesia was induced with sufentanil, propofol, and succinylcholine, and she was maintained with pro-pofol and sufentanil infusions along with 0.5% inspired isoflurane. After induction, central venous access was obtained by a right internal jugular vein 9 Fr introducer for potential central venous pressure monitoring and for rapid infusion. A central line is recommended for rapid fluid administration from acute blood loss secondary to procedure-related complications or aortic pathology. It provides portals for pharmacologic therapy with pressors or inotropes, and for insertion of invasive monitors, such as a pulmonary artery catheter if necessary, to optimize hemodynamic status in hypotensive states. Although there are concerns about central line–related complica-tions leading to pneumothorax, hematoma, infection, and thrombosis, we routinely place a central line for this pro-cedure using ultrasound guidance and remove the cath-eter early if it is not required. Pulse pressure variations are dynamic preload indicators and also can be used to assess volume responsiveness in ventilated patients.

TEE probe was placed atraumatically to provide rapid real-time assessment of cardiac structures, with a view to assessing functional status and treating hemodynamic instability. Pericardial effusion and aortic valve abnor-malities were excluded, and aortic pathology comprising aneurysm and intimal flap in descending thoracic aorta was identified. True and false lumens were confirmed, and the location of guide wire in the true lumen was checked. The aortogram demonstrated a descending thoracic aor-tic aneurysm with a portion of the posterior aorta show-ing extravasation. Both proximal and distal landing zones were observed, and it was determined that the left sub-clavian artery would not be covered by the endograft. A 34 mm ×10 cm TAG device was chosen based on the aortogram, and was advanced over the guide wire and brought into position and deployed. This was followed by ballooning of the proximal and distal portions of the graft. A proximal type I endoleak was noted distally by TEE, so the balloon was reinserted and inflated along the length of the graft. The balloon inflation resolved the endoleak on TEE. A final aortogram revealed adequate seal of the proximal and distal landing zones.

TEE helped to guide administration of fluids and pres-sors. Patient had decreased end-diastolic volume on trans-gastric short axis view, with increased contractility and no

Table 4. Causes of Endoleak

Causes of Endoleak Endoleaks Related to

Misplacement of endograft Technical error consequential to techniques used for endograft placement

Poor sizing of endograft

Material fatigue Device failure

Displacement or distortion of endograft

Reactions to the endograft within the aneurysmal sac environment

Patient factors

Table 5. Types of Endoleak and Treatment

Type Description of Endoleak Treatment

I • Persistent flow around the attachment site (proxi-mal and distal) of the endograft due to inadequate seal

• Most frequent complication after stent graft place-ment for aneurysm (24%)

• Technical error leading to failure of stenting• Additional stent graft deployment needed for

sealing

II • Retrograde flow into the aneurysmal sac from a patent collateral branch vessel

• Not a major concern, as it does not impede remodeling and thrombosis in the false lumen

• Resolves spontaneously after 5 to 6 months

III • Flow into the aneurysmal sac because of tear or defect in the endograft fabric or because of leakage between modular segments of an endograft

• Early or late graft material fatigue is caused by greater hemodynamic stress

• More common in the thoracic region

• Endovascular placement of a covered stent to reline the failing endograft

IV • Flow detected in the aneurysmal sac after comple-tion of angiography

• Occurs due to highly porous graft material rather than device failure

• Difficult to distinguish from other types of graft leakage

• Diagnosis is made after exclusion of any identi-fiable source of endoleak

CONTINUING MEDICAL EDUCATIONJUNE 2012 21

Visit www.mssm.procampus.net today for instant online processing of your CME post-test and evalua-tion form. There is a registration fee of $15 for this non–industry-supported activity. For assistance with technical problems, including questions about navigating the Web site, call toll-free customer service at (888) 345-6788 or send an email to [email protected].

For inquiries about course content only, send an email to [email protected]. Ram Roth, MD, is director of PreAnesthetic Assessment Online and assistant professor of anesthesiology at The Mount Sinai School of Medicine, New York, NY.

Post-Test

1. The indications for surgical intervention in Stanford type B aortic dissection include _____a. extravasation of blood from the aortab. rapidly expanding false aneurysm c. hypertension d. obstruction of renal vessels

2. Using the technique of thoracic endovascular aneurysm repair (TEVAR) to manage descending thoracic aneurysm entails the following anesthetic plan: a. Use of one-lung ventilation to visualize

the descending aorta.b. Radial line can be placed in either upper

extremity.c. Mean arterial pressures (MAPs) need to

be maintained higher than 80 mm Hg before stent graft is deployed.

d. Monitoring blood loss, as significant loss can occur from groin and retroperitoneal hematomas.

3. The surgical considerations for endovascular repair of thoracic aortic aneurysm include all of the following EXCEPT:a. adequate proximal and distal landing

zonesb. access to femoral or iliac vessels

c. endograft coverage may span coverage between left common carotid artery and celiac axis

d. the celiac axis must never be covered to achieve an adequate distal landing zone

4. Anesthetic considerations for endovascular graft deployment include all of the following EXCEPT:a. consideration should always be given

to the idea of an open procedure being needed.

b. the procedure is performed on vascular patients with significant comorbidities.

c. regional techniques are preferred, as they facilitate neurologic examination.

d. vasopressors and inotropes should be immediately available for management of hemodynamic emergencies.

5. A lumbar drain a. should be routinely used in all patients

undergoing TEVAR.b. may be placed postoperatively if there is

delayed-onset paraparesis.c. should not be used if heparin is given

intraoperatively during TEVAR.d. should be continuously drained to

prevent spinal cord ischemia.

6. Cerebrospinal fluid (CSF) pressures during TEVAR should be maintained at _____a. <12 mm Hgb. 12-15 mm Hgc. 15-17 mm Hgd. 17-20 mm Hg

7. Each of the following is a method of treatment or prevention of spinal cord ischemia during TEVAR EXCEPT:a. early detection of ischemia by

intraoperative monitoring with somatosensory evoked potential and motor evoked potential (MEP).

b. augmentation of spinal cord perfusion by elevated blood pressure and CSF drainage.

c. performing an elective subclavian revascularization if the subclavian artery needs to be covered by endovascular stent graft.

d. MAP may be kept lower and lumbar drain is not needed in treating type II Crawford thoracoabdominal aortic aneurysm.

8. _____ can be used to maintain adequate MEP signals intraoperatively.a. Nondepolarizing muscle relaxants

b. High-dose volatile anestheticsc. Propofol infusiond. Succinylcholine

9. All of the following are true regarding aortic aneurysms EXCEPT:a. they are classified according to location,

morphology, and etiology.b. location is NOT used to determine

surgical approach.c. aortic dissection may be associated with

an aneurysm.d. true aneurysms involve all layers of the

aortic wall.

10. Which of the statements regarding endoleaks is true?a. A type I endoleak is a diagnosis of

exclusion, and a contrast angiography is not needed for its diagnosis.

b. Most type II leaks should only be observed if they are associated with continued sac expansion.

c. A type I leak occurs due to reactions of the endograft within the aneurysmal sac environment.

d. Transesophageal echocardiography is not helpful in the detection of type I endoleaks.

regional wall motion abnormality. Fluid boluses and nor-epinephrine infusion helped achieve a MAP between 80 and 90 mm Hg for adequate spinal cord perfusion after the stent deployment.

The patient was successfully extubated in the oper-ating room, and her neurologic exam was normal. She was monitored in the intensive care unit, and MAPs were maintained between 80 and 90 mm Hg. The spinal drain was removed after 48 hours. A follow-up CT angiogram was performed and confirmed adequate placement of the endograft with no evidence of extravasation or displace-ment. She was transferred to floor, in stable condition.

Conclusions

TEVAR is emerging as the treatment of choice for acute surgical emergencies involving the descending tho-racic aorta. The data support the safety and efficacy of TEVAR for aortic pathologies with a low mortality rate. We described a case of successful anesthetic management of a patient who presented with acute aortic dissection Stan-ford type B associated with periaortic hematoma and aor-tic dilatation necessitating surgical intervention. Her BP was initially controlled while further workup and imaging studies were performed.

The patient met the surgical criteria for endovascu-lar stent placement and had no complications related to organ malperfusion. She was considered at high risk for SCI, and a lumbar drain with CSF pressure and intraopera-tive neurologic monitoring were done. Invasive hemody-namic monitoring and TEE were additionally employed. We conclude that perioperative workup and anesthetic

technique need to be tailored to the patient’s underly-ing comorbidities and aortic pathology. Current endograft technology has evolved sufficiently to allow for successful treatment for emergent conditions involving the descend-ing thoracic aorta.

References1. Ramanath VS, Oh JK, Sundt TM 3rd, Eagle KA. Acute aor-

tic syndromes and thoracic aortic aneurysm. Mayo Clin Proc. 2009;84(5):465-481.

2. Davies RR, Goldstein LJ, Coady MA, et al. Yearly rupture or dis-section rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg. 2002;73(1):17-27.

3. Mitchell ME, Rushton FW Jr, Boland AB, Byrd TC, Baldwin ZK. Emergency procedures on the descending thoracic aorta in the endovascular era. J Vasc Surg. 2011;54(5):1298-1302.

4. Sachs T, Pomposelli F, Hagberg R, et al. Open and endovascu-lar repair of type B aortic dissection in the Nationwide Inpa-tient Sample. J Vasc Surg. 2010;52(4):860-866.

5. Hughes GC, Sulzer CF, McCann RL, Swaminathan M. Endovas-cular approaches to complex thoracic aortic disease. Semin Cardiothorac Vasc Anesth. 2008;12(4):298-319.

6. Falkenberg M, Lönn L, Schroeder T, Delle M. TEVAR and cov-ering the celiac artery. Is it safe or not? J Cardiovasc Surg (Torino). 2010;51(2):177-182.

7. Fanelli F, Dake MD. Standard of practice for the endovascu-lar treatment of thoracic aortic aneurysms and type B dissec-tions. Cardiovasc Intervent Radiol. 2009;32(5):849-860.

8. Gutsche JT, Szeto W, Cheung AT. Endovascular stent-ing of thoracic aortic aneurysm. Anesthesiol Clin. 2008;26(3):481-499.

9. Vaughn SB, Lemaire SA, Collard CD. Case scenario: anesthetic

considerations for thoracoabdominal aortic aneurysm repair. Anesthesiology. 2011;115(5):1093-1102.

10. Conrad MF, Cambria RP. Contemporary management of descending thoracic and thoracoabdominal aor-tic aneurysms: endovascular versus open. Circulation. 2008;117(6):841-852.

11. Liu EH, Wong HK, Chia CP, Lim HJ, Chen ZY, Lee TL. Effects of isoflurane and propofol on cortical somatosensory evoked potentials during comparable depth of anaesthesia as guided by bispectral index. Br J Anaesth. 2005;94(2):193-197.

12. Cheung AT, Pochettino A, McGarvey ML, et al. Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms. Ann Thorac Surg. 2005;80(4):1280-1288.

13. Sinha AC, Cheung AT. Spinal cord protection and thoracic aortic surgery. Curr Opin Anaesthesiol. 2010;23(1):95-102.

14. Wynn MM, Mell MW, Tefera G, Hoch JR, Acher CW. Compli-cations of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008. J Vasc Surg. 2009;49(1):29-34.

15. Dardik A, Perler BA, Roseborough GS, Williams GM. Subdural hematoma after thoracoabdominal aortic aneurysm repair: an underreported complication of spinal fluid drainage? J Vasc Surg. 2002;36(1):47-50.

16. Rocchi G, Lofiego C, Biagini E, et al. Transesophageal echocar-diography-guided algorithm for stent-graft implantation in aortic dissection. J Vasc Surg. 2004;40(5):880-885.

17. Parmer SS, Carpenter JP, Stavropoulos SW, et al. Endoleaks after endovascular repair of thoracic aortic aneurysms. J Vasc Surg. 2006;44(3):447-452.

18. Cao P, De Rango P, Verzini F, Parlani G. Endoleak after endo-vascular aortic repair: classification, diagnosis and manage-ment following endovascular thoracic and abdominal aortic repair. J Cardiovasc Surg (Torino). 2010;51(1):53-69.


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overweight Patients often receive excessive nMBAsChicago—A significant propor-tion of overweight patients receiv-ing vecuronium are being overdosed, a practice that may increase rates of reintubation, Florida researchers have found. The investigators concluded that because the use of total body weight results in excessive dosing, ideal body weight may be a more desirable guide to administering the drug.

“Here in Florida, we have one of the highest reintubation rates in the country,” said Lalitha V. Sundarara-man, MD, an anesthesiology resident at the University of Miami’s Jack-son Memorial Hospital. “To help get to the root of this issue at our insti-tution, Drs. Michael Vigoda, Luis Rodriguez and I started looking at iat-rogenic factors that may contribute to

reintubation.”Previous research showed that using

total body weight to determine dose in obese patients may increase the duration of action of neuromuscu-lar blockers. Dr. Sundararaman and her colleagues analyzed the electronic medical records of 3,004 elective cases performed by senior anesthesiology providers in all subspecialties. Patients

were aged between 3 and 80 years, and their body surface area ranged from 25 to 32 kg/m2. Calculations of ideal body weight were adjusted for age and sex. Intubation doses of vecuronium and rocuronium were compared with the traditional maximum accepted doses of 0.1 and 1.2 mg/kg, respectively.

“We found that we are sadly overdosing our patients,” said Dr. Sundararaman, who reported the results at the 2011 annual meeting of the American Society of Anesthesi-ologists (abstract 440). In the 1,921 patients who received rocuronium, the maximum acceptable dose was exceeded in 3.59% of cases when total body weight was used to calculate appropriate doses.

Vecuronium was used in 1,071 cases. In those patients, the maximum accept-able dose was exceeded in 23% of patients when total body weight was used. The difference was found to be statistically significant (P<0.01) in both the rocuronium and vecuronium groups. The investigators also tracked dosing based on sex, and found that 70% of the patients who received higher-than-maximum doses were women.

“I think the reason we overdose vecuronium so much is that it is so short-acting, and we tend to be more



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Bw, body weight; iBw, ideal body weight

liberal with it,” Dr. Sundararaman told Anesthesiology News. “We think our patients will come out quickly and it won’t be a problem. But that’s not really a good strategy, because there are always some patients in whom the surgery finishes early and we’re caught red-handed. So it’s always better to give the right dose.”

Making estimates of ideal body weight is a tricky undertaking at the best of times, so Dr. Sundararaman rec-ommended several free smartphone applications that help do the job.

“Then you can note the patient’s ideal body weight in the preoperative chart, so it’s readily available when you need it,” she said.

Although the researchers have yet to report if their efforts have affected reintubation rates, Dr. Sundararaman said these and other changes can serve only to improve patient care at the institution.

“We also made it mandatory that anesthesiologists have to check the 100-Hz fade to tetanus before they extubate,” she said. “There is a signif-icant iatrogenic component to all of this, and one we think can actually be corrected easily.”

Michael Higgins, MD, MPH, pro-fessor of anesthesiology, surgery and biomedical informatics at Vander-bilt University School of Medicine, in Nashville, Tenn., said anesthesiologists could take a few lessons from the pedi-atric subspecialty.

“Not to insult anyone, but in pediat-rics—because of the variable weights of our patients—we keep dosing sheets for the typical medications in every operating room,” Dr. Higgins said.

“Well, we’re sort of entering into that realm with adult patients now, with high variability and extremes of weight. And maybe it’s not too inconceivable to think of doing the same thing with adults.”

—Michael Vlessides



@Contact the editor of Anesthesiology News

[email protected]

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Less pain. Less opioids.From the start.

OFIRMEV® provides signifi cant pain relief*1

• OFIRMEV 1 g (Q6h) + patient-controlled analgesia (PCA) morphine demonstrated signifi cant pain relief vs placebo + PCA morphine (P<0.05 over 6 h)1

• OFIRMEV 1 g (Q6h) + PCA morphine showed greater reduction in pain intensity over 24 h (SPID24)† compared to placebo + PCA morphine (P<0.001)2

OFIRMEV reduces opioid consumption*1

• OFIRMEV 1 g (Q6h) + PCA morphine signifi cantly reduced morphine consumption vs placebo + PCA morphine (–46% over 6 h, P<0.01; –33% over 24 h, P<0.01)1

• The clinical benefi t of reduced opioid consumption was not demonstrated

OFIRMEV from the start• Consider administering the fi rst dose

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Important Safety InformationOFIRMEV is contraindicated in patients with severe hepatic impairment, severe active liver disease or with known hypersensitivity to acetaminophen or to any of the excipients in the formulation. Acetaminophen should be used with caution in patients with the following conditions: hepatic impairment or active hepatic disease, alcoholism, chronic malnutrition, severe hypovolemia, or severe renal impairment.

Do not exceed the maximum recommended daily dose of acetaminophen. Administration of acetaminophen by any route in doses higher than recommended may result in hepatic injury, including the risk of severe hepatotoxicity and death.

OFIRMEV should be administered only as a 15-minute intravenous infusion.

Discontinue OFIRMEV immediately if symptoms associated with allergy or hypersensitivity occur. Do not use in patients with acetaminophen allergy.

The most common adverse reactions in patients treated with OFIRMEV were nausea, vomiting, headache, and insomnia in adult patients and nausea, vomiting, constipation, pruritus, agitation, and atelectasis in pediatric patients.

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* Randomized, double-blind, placebo-controlled, single- and repeated-dose 24-h study (n=101). Patients received OFIRMEV 1 g + PCA morphine or placebo + PCA morphine the morning following total hip or knee replacement surgery. Primary endpoint: pain relief measured on a 5-point verbal scale over 6 h. Morphine rescue was administered as needed.

† SPID24=sum of pain intensity differences, based on VAS score, from baseline, at 0 to 24 h.

References: 1. Sinatra RS, Jahr JS, Reynolds LW, Viscusi ER, Groudine SB, Payen-Champenois C. Effi cacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. Anesthesiology. 2005;102:822-831. 2. Data on fi le. Cadence Pharmaceuticals, Inc.

©2012 Cadence Pharmaceuticals, Inc. All rights reserved. OFIRMEV and the OFIRMEV dot design are trademarks of Cadence Pharmaceuticals, Inc. OFV11330112 OFIRMEV.com

“I applaud the efforts of these inves-tigators, because we need more data on the benefits and risks of femo-ral nerve blocks,” said Brian M. Ilfeld, MD, MS, associate professor of anes-thesiology at the University of Cal-ifornia, San Diego, who was not involved in the studies. “We recognize there are sometimes complications with any invasive procedure, including regional anesthetics, so the more data

we have, the more information we can provide patients.”

Femoral Blockade Versus Periarticular Injection

One of the studies (abstract P201) compared two widely used protocols for perioperative pain management after total knee arthroplasty (TKA). The prospective, randomized con-trolled trial enrolled 90 patients. Half received epidural analgesia plus femo-ral nerve block (PCEA/FNB); the rest

received periarticular injections plus oral opioids (PAI).

Patients in both protocols had similar lengths of stay in the hospi-tal and similar postoperative pain scores. However, patients who received PCEA/FNB reported significantly less pain with ambulation on postopera-tive day 1, and less pain with regard to quality of recovery. Patients in both groups reported similar pain levels on the second and third days after surgery. The researchers also found no signif-icant differences between the groups in global quality of recovery scores, patient satisfaction or opioid intake.

“We were surprised that PAI worked almost as well as PCEA/FNB,” said Geoffrey H. Westrich, MD, orthope-dic surgeon at the Hospital for Special Surgery in New York City, who led the research. “We can now tell smaller hos-pitals that don’t have our level of exper-tise that PAI works extremely well; much better than just giving pain pills after surgery.”

The PAI approach also is less expensive than PCEA/FNB, and Dr. Westrich noted that he would con-sider trying the protocol in his surgical practice. However, he added, a multi-modal approach to pain management works best.

“One of the most common concerns patients have is how much pain they’ll experience and how we’ll treat it. They like the control they have with a pain pump,” he said.

Dr. Ilfield said the study was an important addition to the data set on FNB. “It has become a trend for



FemorAl continued from page 1

orthopedic surgeons to try high-dose local anesthetics,” Dr. Ilfeld said. “But we don’t have adequate data. This study sheds more light on what’s opti-mal for patients after TKA for pain control.”

Easier RecoveryIn a second, unrelated study (abstract

P195), researchers at New England Baptist Hospital, in Boston, found that regional anesthesia, including con-tinuous FNB, significantly improved patients’ postoperative range of motion and reduced their need for manipula-tion following TKA.

The retrospective review looked at 1,091 TKA procedures performed by two surgeons using identical prostheses, postoperative rehabilitation protocols and surgical techniques. The surger-ies occurred both before and after the hospital’s anesthesiologists began using continuous femoral nerve catheters.

Before the catheters became routine, 12% of TKA patients required manip-ulation after surgery. That figure fell to 6% once the catheters became widely used. The decrease was independent of the surgeon.

“Because manipulation is expen-sive—if you avoid it, you easily more than make up the cost of the infu-sion,” Dr. Ilfeld said. “The results dem-onstrate a need for a large, prospective randomized trial.”

Femoral Block or Morphine?In a third, unrelated study (abstract

666), researchers at the Hospital for Joint Diseases at NYU Langone Med-ical Center, in New York City, found that single-injection FNBs are an excel-lent alternative to routine narcotic pain medication after hip arthroscopy.

In the study, 40 patients were ran-domized into two groups once they reached the PACU. Half received rou-tine IV opioids if their pain scores were 7 or greater; the rest received a femoral block for pain of the same severity.

Patients who received opioids stayed in the PACU longer, were more likely to report postoperative nausea and reported being less satisfied with their postoperative pain control than patients in the FNB group.

“An hour decrease of PACU time is enormous, and provides a huge cost savings,” Dr. Ilfeld said. “These are important results because we don’t have a lot of data looking at post-op outcomes other than pain, and how they benefit patients and the entire health care system.”

—Dana Hawkins-Simons



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Ponv Steroids Seen Safe for wound Healing After cancer SurgeryChicago—Dexamethasone for the prevention of postoperative nausea and vomiting does not increase the risk for wound complications after laparotomy for endometrial cancer, a recent study has found.

“Corticosteroids such as dexametha-sone have been associated with delayed wound healing and increased risk for wound infection when high and

moderate doses were given immedi-ately after cellular injury,” said Corey S. Bolac, MD, anesthesia resident at Duke University Medical Center, in Durham, N.C., who led the study.

“Nevertheless, the current literature is inconclusive on whether the use of single-dose dexamethasone increases the risk for postoperative wound complications.”

Dr. Bolac’s group analyzed medical records from 431 women who under-went laparotomy for endometrial can-cer at Duke between 2002 and 2007 (median age, 60 years; median body mass index [BMI], 34 kg/m2; median surgical time, 160 minutes).

The investigators looked for reports of cellulitis, surgical site infection, superficial wound separation or fascial

dehiscence. They also analyzed base-line characteristics and perioperative details that have been found to be independently associated with wound infections after surgery.

Baseline characteristics included BMI, age, diabetes, immunosuppres-sion and smoking status; perioperative details included use of preoperative antibiotics, duration of surgery, lymph node dissection, surgical closure, esti-mated blood loss, intraoperative tem-perature and other variables.

Roughly 30% (134) of patients developed a wound complication after their procedure. Yet the research-ers found no link between dexa-methasone and poor wound healing: 27.6% of patients who received dexa-methasone (53 of 192) developed an infection, compared with 33.9% of patients who did not receive dexa-methasone (81 of 239; P=0.16). Nor did escalating dose appear to have an effect.

“Our study was performed in a high-risk patient population for sur-gical site infections,” Dr. Bolac said.

“These patients all had cancer with its associated immunocompromised state, tended to be obese, primarily underwent large midline laparotomy and had longer operative durations. These characteristics would seem to make them more susceptible to the immunosuppressive effects of corti-costeroids, but we could find no such association.”

Not particularly surprising, the researchers said, was the finding that BMI and smoking were the most sig-nificant predictors of wound infection in this patient population—and the only ones to remain after multivariate analysis.

Narinder Rawal, MD, profes-sor of anesthesiology and intensive care at Örebro University Hospital in Örebro, Sweden, said the research-ers’ definitions of wound infection as

“anything requiring extra care,” might have confounded their findings. That happens to be what the Centers for Disease Control and Prevention rec-ommends for defining such compli-cations, Dr. Bolac noted, although it leaves a substantial amount of discre-tion to clinicians.

The researchers reported their find-ings at the 2011 annual meeting of the American Society of Anesthesiol-ogists (abstract 785).

—Michael Vlessides



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residents receive inadequate exposure to key issues in billing, reimbursement, liability, contracts and other aspects of running their practice. At the same time, most respondents agreed that these issues are “important” in their workday.

“Physicians are trained well in clin-ical sciences, but we don’t get a lot of training in some of the business and practice management areas that are also an important part of being a phy-sician,” said study author Philip Kalar-ickal, MD, MPH, clinical assistant professor of anesthesiology at Tulane University School of Medicine, in New Orleans.

Dr. Kalarickal and his colleagues convened a working group of practic-ing anesthesiologists, including some on the ASA committee on practice management, to compile a list of topics that they believe should be an impor-tant part of any curriculum in practice management (abstract PM19). The researchers then mailed a survey to the entire ASA membership, asking them if they had received adequate training in these areas, and collected responses from May through October 2011.

More than 3,600 clinicians responded, for a response rate of 12%. The majority said they did not believe

residency programs included enough training in practice management.

“Our working hypothesis was it would indeed be the case that there were deficiencies,” Dr. Kalarickal told Anesthesiology News. “But I was sur-prised at how strong they were.”

For instance, between 68% and 88% of respondents said they thought res-idents were inadequately exposed to billing issues; 71% said there was not enough training in insurance reimbursement.

However, the majority of all partic-ipants—at least 84% in every bracket of experience—agreed that training in practice management could help improve patient care and outcomes, quality, safety and containment of health care costs.

More than half of respondents said they believed residents got enough exposure to the topics of quality assurance/improvement and

scheduling in the operating room (OR). And residency program direc-tors were least likely to say that train-ing failed to address issues in practice management.

That makes sense, Dr. Kalarickal said, for obvious reasons. “Their per-ception is that they may be doing a bet-ter job than they actually are.”

Dr. Kalarickal said he hoped the findings will encourage program direc-tors to look more critically at their curricula, and add more time and expertise to program management.

“We hope that residency programs, based on this, recognize that there is a need for more training in these areas.”

David Mackey, MD, professor in the Department of Anesthesiology and Perioperative Medicine at the Uni-versity of Texas MD Anderson Can-cer Center, in Houston, said he agreed with the gist of the survey findings. Anesthesia trainees are not getting

enough exposure to practice manage-ment, said Dr. Mackey, who was not involved in the study. “I think trainees understand this better than program directors do.”

Health care has changed dramati-cally in recent years, Dr. Mackey added. Programs need to help anesthesiology residents transition from simply work-ing in the OR to taking on a broader role in health care by leading and man-aging the delivery of procedural ser-vices in integrated systems. “Current anesthesiology trainees who believe they are going to make a comfortable living just providing OR anesthesia, I think are going to be sorely disap-pointed with their careers.”

Private practices, especially at places like Mayo Clinic and the Cleve-land Clinic, are transitioning to inte-grated health care delivery more easily than traditional academic centers, Dr. Mackey noted. He recommended that leaders of private practices form a standing group to create a practice management curriculum that would give trainees exposure and hands-on experience in business and interper-sonal skills. “OR skills are as important as ever,” Dr. Mackey said, “but business management and leadership skills are becoming equally important.”

—Alison McCook


CLAssiF iEds

‘Current anesthesiology trainees who believe

they are going to make a comfortable living just

providing OR anesthesia, I think are going to

be sorely disappointed with their careers.’

—David Mackey, MD

POLiCY & MANAgEMENT

prActice continued from page 1

For classifiedadvertising:contact Alina Dasgupta

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AN-0212-002.pdf

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Transfusions a wild card For Hip replacementStudy highlights need for standards

W hich patients will receive blood transfusion during hip replacement surgery is

a significant area of uncertainty in the operating room—leading to unneces-sary costs and potential risks for harm, according to a new abstract presented at this year’s American Society of Anesthe-siologists Conference on Practice Man-agement (abstract PM20).

After reviewing more than 2,000 hip replacements for osteoarthritis that took place over 15 months in 2009 and 2010, Pittsburgh anesthesiologist Jonathan Waters, MD, and his co-author found that roughly 40% of patients received blood products during the procedure. Some surgeons were much more likely to administer transfusions than others—one surgeon had a 4% transfusion rate, whereas another transfused nearly 90% of patients.

“We found hugely varying blood use among surgeons for the exact same pro-cedure,” Dr. Waters, chief of anesthesia at Magee-Women’s Hospital, told Anes-thesiology News.

And those transfusions carry conse-quences. The average cost of hip replace-ment reached $82,480 when patients received blood transfusions (range, $36,732 to $213,740), but only $64,766 without transfusion (range, $35,703 to $121,190), according to the researchers.

Patients who received blood prod-ucts also had longer hospital length of stay (LOS) following surgery—3.5 days with transfusion, 3.2 without. The dif-ferences in both cost and LOS were sta-tistically significant (P<0.05).

The ultimate goal of the study is to help standardize transfusion practices, explained Dr. Waters. In most cases, patients undergoing hip replacement do not need a blood product.

“Probably in the vast majority of cir-cumstances, blood is used outside of an indication. So we’ve been trying to cut back on overuse,” he said.

Every year, the University of Pitts-burgh Medical Center (UPMC)—of which Magee-Women’s Hospital is a part—spends $52 million purchasing blood products, Dr. Waters said. When the cost of administering the blood and all the other expenses involved with obtaining and storing the fluid are con-sidered, transfusions likely cost the entire hospital system $250 million per

year, he said.That’s a lot of money to spend on

something that often is unnecessary, Dr. Waters noted, adding that the Joint Commission recently deemed transfu-sion of red blood cells one of the most overused procedures in medicine.

To evaluate how often transfu-sions occur during one procedure in the UPMC health system, Dr. Waters and his co-author Trent Emerick, MD, reviewed how often red blood cell trans-fusions were included in hip replace-ments procedures. They selected this procedure, Dr. Waters explained, because “it should be a really similar sur-gical procedure.”

Even if patients are anemic, he explained, that problem should be managed before surgery so it does not become an issue. Alternatively, surgeons can avoid transfusions during surgery by administering drugs that minimize the loss of blood, or perform blood-salvaging procedures that let doctors return lost blood back to patients.

Aryeh Shander, MD, chief of the Department of Anesthesiology and Critical Care at Englewood Hospi-tal Medical Center in Englewood, N.J., agreed that the ultimate aim of this research should be to reduce transfu-sion rates—particularly because they are associated with infections and other potential risks to patients. “There are not only financial implications for unnecessary transfusions, there may be many other clinical implications,” Dr. Shander said.

Dr. Shander, who is also the chair of the Committee of Blood Management for the American Society of Anesthesi-ologists, said the substantial variability in the use of transfusion among UPMC doctors was unsurprising. “There’s enor-mous variability in transfusion practice across the United States and across mul-tiple surgical procedures,” he said.

Dr. Shander noted, however, that the authors did not state if there was any stratification of patients, suggest-ing that some of those who received transfusions required additional care that might have been unrelated to the transfusion, which indepen-dently added to cost and prolonged hospitalization.

—Alison McCook

Jim, put this link before the byline:http://www.jointcommission.org/assets/1/6/

HAP_NPSG_Overuse_Rpt_2011-11-14.pdf.

Table. The Added Cost of Blood Transfusions

2009 Q 3 2009 Q 4 2010 Q 1 2010 Q 2 2010 Q 3

Discharges 376 442 432 411 409

Total Receiving Blood 153 179 138 175 151

% Total that Receive 40.7% 40.5% 31.9% 42.6% 36.9%

Average Units per Case 1.97 1.93 1.87 2.22 1.87

ALOS w Blood 3.8 3.4 3.3 3.4 3.6

ALOS w/o Blood 3.5 3.3 3.1 3.1 3.1

Ave Charges w Blood $90,965 $81,021 $82,873 $78,380 $79,704

Ave Charges wo Blood $65,493 $63,276 $62,018 $65,165 $68,276

% Autologous 12.4% 10.1% 8.0% 9.1% 12.6%

Home Discharge % 71.5% 70.4% 83.1% 73.5% 69.9%

Facilty Discharge % 28.5% 29.6% 16.9% 26.5% 30.1%

Deceased Discharge %

Other Discharge %


‘Probably in the vast

majority of circumstances,

blood is used outside

of an indication.’

—Jonathan Waters, MD

POLiCY & MANAgEMENT The following advertorial has been provided by Preferred Physicians Medical and is designed to support the advertisement presented on the adjacent page.

Preferred Physicians Medical Q. who is Preferred Physicians Medical?A. Preferred Physicians Medical (PPM) is an anesthesiologist-only professional liability insurance company.

Q. How many years has PPM been in business?A. 2012 marks PPM’s 25th year in business.

Q. who owns the company?A. PPM is a stock company owned exclu-sively by the anesthesiologists it insures.

Q. will PPM settle a claim with-out the insured physician’s consent?A. No. PPM’s policy states that the company will not settle a claim without the insured physician’s consent.

Q. How is PPM different from its multispecialty competitors?A. Most notably, we are anesthesia-specific and do not have multiple agendas or try to be all-encompassing to all physicians. The nature and practice of anesthesia are vastly different from the nature and practice of obstetrics, neurosurgery, radiology, cardi-ology and other specialties, and represent unique and different exposures from a lia-bility standpoint. We spend our entire day, every day, servicing anesthesia practices exclusively. No other company in America does this.

Q. How much anesthesia loss experience data does the company have?A. We believe PPM possesses the most extensive anesthesia claims database in existence. Collectively, our policyholders have generated a database comprising well over 65,000 doctor-years of anesthesia prac-tice, including more than 44,000 since joining the company. This includes prior-acts cover-age back to 1980.

Since 1987, we have reviewed the claims history of more than 16,000 practicing anes-thesiologists. In addition, PPM’s claims department has investigated more than 11,000 adverse incident outcomes, and more than 3,000 claim or litigation files. With this information, PPM has an unparalleled abil-ity to identify and address loss trends. PPM uses this data to establish fair and appropri-ate premium levels, manage claim files and provide anesthesia-specific risk manage-ment advice to its policyholders in the form of seminars, publications such as Anesthesia & the Law and through a policyholder-only resource area on our Web site.

Q. what makes PPM unique?A. PPM is the only company of its kind in Amer-ica—the only company founded by and for anes-thesiologists exclusively. As well, PPM has historically turned down more than 25% of its applicants. A condition of insurance is that all physicians meet or exceed the American Soci-ety of Anesthesiologists (ASA) Standards of Care when practicing, thereby creating what we believe to be the safest risk pool in the country. No other company requires this of their insureds. Although only 4% of the total physician popu-lation is anesthesiologists, 100% of PPM’s cli-ents are anesthesiologists, so 100% of our time is spent developing products and services specific to the professional liability needs of anesthesia practices. This is especially important in risk man-agement efforts.

Q. can you comment on your risk management efforts?A. Risk management is one of PPM’s strong areas, and, again, is unique insofar as it is entirely anesthesia-specific. PPM’s five in-house attor-neys spend all day, every day overseeing, manag-ing and defending anesthesia claims exclusively. These same attorneys conduct our site-specific risk management seminars every year for our insured owners.

Some examples of topics at the seminars include but are not limited to causes and preven-tion of intraoperative fires, implementation of the new ASA Standard for Basic Anesthesia Mon-itoring, postoperative drug-induced respiratory depression, securing narcotics and medication in the operating room, top 10 anesthesia claims and how to avoid them, and more.

PPM’s risk management is proactive, designed for each insured group’s specific practice and provides practical, thoughtful advice. With a claims database in excess of 64 million adminis-tered anesthetics, more than 11,000 adverse inci-dent reports and more than 3,000 claim reports, PPM’s policyholders are assured they are receiv-ing insightful, valuable and important information they can use to mitigate their exposures mov-ing forward and apply immediately in their prac-tice setting.

Q. what else should i know?A. You should know that it costs nothing to eval-uate your options. If you are not currently sharing risk with other ASA Standard of Care clinicians, isn’t it worth five minutes of your time to learn what PPM can offer that your existing carrier may be unable to provide? Don’t settle—Own!

Call us at (800) 562-5589 and let us show you who we are and what we can do for you!

Add your good name to our growing list of ASA “standard of care” clinicians. Call us toll free today at 800.562.5589 and join other select anesthesiologists who have already secured ownership in their professional reputations.

Preferred Physicians Medical (PPM) formed in 1987 to exclusively insure anesthesiologists and their practices. From day one, each new policyholder also became an owner of PPM, so it’s no surprise that protecting our physicians’ professional reputation is at the core of everything we do.

Our substantial database of more than 11,000 adverse anesthesia events collected over the last quarter of a century arms our physician owners with practical, anesthesia-specifi c strategies to effectively identify and manage risk, including:

On-site, anesthesia-specifi c risk management seminars

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Don’t wait another year. Take ownership of your own reputation by calling PPM today.

POWERFLOWINSIDE

MCAN2093.indd 1 3/14/12 6:39 PM

PRINTER-FRIENDLY VERSION AT ANESTHESIOLOGYNEWS.COM

1INDEPENDENTLY D EVELOP ED BY M C M AH ON P U BL ISHIN G A N E STHE SIOLOGY N E WS • JUN E 2012

Ultrasound-Guided Central Vein Cannulation: Current Recommendations and Guidelines

JULIE A. GAYLE, MDAssistant Professor of Clinical AnesthesiologyLouisiana State University School of MedicineNew Orleans, Louisiana

ALAN DAVID KAYE, MD, PHD Professor and ChairmanDepartment of AnesthesiologyLouisiana State University School of MedicineNew Orleans, Louisiana

The authors report no relevant financial conflicts.

Ultrasound technology has

become an essential tool

for the everyday practice of anesthesiology. Some of the many uses include

the placement of central, arterial, and peripheral lines, as well as peripheral nerve

blocks. Until recently, neither a national standard for ultrasound use nor a well-

accepted standard in training for ultrasound-guided central venous cannulation

(CVC) existed. In the past few years, several specialty societies and national

organizations—including the American Society of Anesthesiologists, the American

Society of Echocardiography, the Society of Cardiovascular Anesthesiologists, and

the Centers for Disease Control and Prevention (CDC)—have published guidelines

and recommendations regarding ultrasound-guided vascular cannulation.

INDEPENDENT LY DEVELOP ED BY M C M AH ON P UBL ISHIN G2

Catheterization of venous vessels allows access for hemodynamic monitoring; administration of drugs, flu-ids, and parenteral nutrition; placement of a difficult peripheral IV; and hemodialysis. The internal jugular vein (IJV) and subclavian and femoral veins are the ves-sels of choice when acquiring central access. For many anesthesiologists, the IJV is a first choice. Historically, entry into the IJV has been facilitated by the visual-ization and palpation of certain anatomic landmarks. Additional techniques include the use of a smaller bore “finder needle” to first locate the IJV prior to cannula-tion with a larger bore needle; an indirect ultrasound method, in which the practitioner marks the path of the vein prior to cannulation; and a direct ultrasound tech-nique, in which the vein is visualized using sonography during cannulation.1

The risk for complications during CVC is reported to be between 2% and 15%.2 This rate varies significantly depending on several factors, including the experi-ence of the practitioner and the overall status of the patient.3,4 Among the more frequently encountered complications of CVC, and their respective incidences, are pneumothorax (0-6.6%), carotid artery puncture (6%), subclavian artery puncture (0.5%-4%), and hemo-thorax (1%).1 In addition, the overall rate of unsuccessful central venous cannulation of the IJV is approximately 12%.5

Earlier studies showed that the use of ultrasound may increase the rate of success of central venous catheter placement and may reduce the incidence of traumatic complications.6 More recent literature has confirmed that ultrasound guidance during insertion of a central venous catheter in the IJV improves the likelihood of first-pass cannulation and decreases the incidence of injury to adjacent arterial vessels.7

HistoryIn 1978, Ullman and Stoelting described the first use

of ultrasonography for accessing central veins. They used Doppler localization to mark the skin overlying the IJV. They reported that using an ultrasound Dop-pler blood-flow detector took the “guesswork” out of finding the vein and allowed them to locate the IJV as it traversed the neck. According to the authors, this new technique would increase the success rate of IJV catheterization and decrease accidental puncture of the carotid artery compared with the traditional tech-nique using only anatomic landmarks.8 In 1986, Yonei et al reported on the use of real-time ultrasonographic guidance for IJV cannulation.9 In 2001, the Agency for Healthcare Research and Quality (AHRQ) reported that use of ultrasonography during central venous access deserved widespread implementation based on the strength of evidence in the literature.10 The AHRQ rec-ommended the use of ultrasound guidance for the placement of central lines as one of 11 evidence-based

practices most likely to improve patient safety. In 2002, the National Institute for Clinical Excellence stated that ultrasound guidance was the preferred method for insertion of central venous catheters into the IJV, and recommended that all clinicians involved in placing these catheters receive appropriate training.11

In 2011, the CDC recommended use of ultrasound guidance to place central venous catheters to reduce the number of cannulation attempts and mechanical complications. Furthermore, in its publication, Guide-lines for the Prevention of Intravascular Catheter-Related Infections, the CDC stated that ultrasound guidance should only be used by those clinicians fully trained in the technique.12

Static Versus Dynamic ImagingStatic, or indirect, ultrasound imaging during central

venous access allows the operator to identify an entry point on the skin over the vessel prior to sterile prepara-tion of the site. Anatomic variations and vital structures may be noted. Compared with the traditional anatomic landmark approach, use of static ultrasound for mark-ing the skin site before cannulation of the IJV is more likely to result in a successful insertion into the vessel.13 Dynamic, or direct, imaging during CVC allows for nee-dle observation as the needle approaches the target vessel. In addition to being more likely to result in a suc-cessful insertion on the first attempt, real-time imaging during cannulation of the IJV also reduces access time and the rate of arterial puncture and has a higher over-all success rate.14-16

TrainingThe evidence clearly indicates that the use of ultra-

sound imaging during central venous catheterization, particularly of the IJV, improves success and safety during cannulation. However, the technique also has a well-recognized learning curve. Knowledge of the anat-omy of the vessels and surrounding structures is imper-ative. Interpreting 2-dimensional images of vessels and the surrounding structures takes practice. It takes more practice to perform the 3-dimensional task of placing a needle into the target vessel and developing the eye-hand coordination required to direct the probe to opti-mize visualization of the needle.

Although individuals acquire the necessary knowl-edge and skills at different rates, it has been suggested that a minimum of 10 ultrasound-guided vascular access procedures be supervised to demonstrate competency in the technique.7 Kaye et al identified a “critical” num-ber of central line insertions to differentiate the “expe-rienced” ultrasound user from the novice. They found that anesthesiologists who had performed at least 20 central line insertions under ultrasound guidance had significantly fewer complications than inexperienced clinicians (Figure 1).1

A N E STHE SIOLOGY N E WS • JUN E 2012 3

Simulation has proven to be a beneficial training tool for developing proficiency in the use of ultrasound guidance for placing a CVC. Simulation-based ultra-sound training results in improved identification of the target vessel with ultrasound compared with landmark techniques and helps inexperienced operators achieve higher rates of successful central line placement with an improved safety profile.17,18 Studies looking specifically at simulation-based training and various outcomes of CVC support its use as a teaching method. These out-comes include successful first cannulation, fewer nee-dle passes, successful catheter insertion, and fewer pneumothoraces.19,20

Site SelectionRecommendations regarding selection of a site for

placing a line for central venous access involve consid-erations such as risk for infection, thrombosis, hema-toma, pneumothorax, and arrhythmias. To minimize the risks for infection and thrombosis, insertion sites in the upper body, IJV, and subclavian vein are preferred to the femoral vein. The insertion site should be free of contamination or potential contamination. Sites in close proximity to wounds, burns, saliva, excrement, and infections should be avoided.

The subclavian vein is the preferred site for longer-dwelling catheters because it has the lowest rate of infection and thrombosis. Although ultrasound guid-ance for insertion of a catheter in the IJV has over-whelming support in the literature, the use of ultrasound for cannulation of the subclavian vein is more compli-cated. The clavicle obscures visualization of the vessel, making dynamic imaging during cannulation difficult. However, patients in whom external landmarks are hard to identify, such as the morbidly obese or those who have local scarring from surgery or radiation in the neck, static ultrasound imaging prior to cannulation may help to visualize the vessel and rule out thrombosis.7

The femoral vein is a frequent site of catheterization during cardiac procedures, emergent central access, and other therapies that require short-term access to a vessel. Reliable anatomic landmarks and relatively quick and safe access are advantages of femoral vein can-nulation. Ultrasound examination of the anatomy prior to cannulation reveals the location of the vessels and surrounding structures. However, real-time ultrasound imaging during femoral vein catheterization has not been shown to improve outcomes, and evidence cur-rently does not support routine use of ultrasound imag-ing during this procedure.7

Confirmation of Location Unintentional dilation of an artery during CVC is best

avoided by confirming location of the guide wire prior to dilating the vessel. Real-time ultrasound guidance is a reliable way to determine if the wire sits in a vein.22 The technology is particularly helpful for avoiding dila-tion of the carotid artery while attempting catheter-ization of the IJV (Figure 2). Ultrasound visualization of the guide wire in the longitudinal view, or long axis, of the vein is less ambiguous than the cross-sectional, or short axis, view by itself (Figures 3 and 4). Aligning the ultrasound probe to view the long axis of a cen-tral vein and the wire within takes less than a minute for most users and provides another safety measure to avoid arterial injury.7 Manometry, transesophageal echocardiography, direct pressure transduction, anal-ysis of blood gases, fluoroscopy, and electrocardiog-raphy also can help confirm the location of a wire in a vein.23

When available, these techniques provide a more definitive, although time-consuming, confirmation that the wire is in a central blood vessel. Confirmation of the correct location of the catheter tip following CVC requires chest radiography or fluoroscopy.

Removal of a catheter following inadvertent arte-rial cannulation carries risks for serious complications including stroke, hemothorax, and arteriovenous fistula. In this situation, the catheter should be left in place and a general or vascular surgeon should be consulted immediately for optimal removal.24

7

6

5

4

3

2

1

0

Non-experienced Experienced National average

Co

mp

licati

on

Rate

s, %

Carotid Puncture Pneumothorax

4.6

6.0

1.0

0.0

6.6

0.9

Figure 1. Complication rates of experienced versus non-experienced ultrasound practitioners. National average represents blind technique. Expe-rienced ultrasound practitioners had significantly reduced complication rates. Experienced practitio-ners were defined as those clinicians taught with ultrasound for central line insertion on a minimum of 20 different patients.1


Infection ControlEvidence-based recommendations for the preven-

tion of bloodstream infections associated with central lines emphasize education and training of the health care providers inserting and maintaining the catheters, aseptic technique, maximum sterile barrier precautions during insertion, and use of an alcoholic formulation of chlorhexidine for skin disinfection and manipulation of the vascular line.12 To prevent infection, routine place-ment of central venous catheters should be avoided. If such a catheter is necessary, an insertion site in the upper body should be considered first.

To minimize the risk for infection, insertion into the subclavian vein is preferable. Use of a bio-occlusive dressing is recommended, and only qualified person-nel should be involved in the changing and care of the

catheter.12 Central venous catheters should be removed promptly when no longer necessary. In the event of a catheter-related infection, a new catheter should be placed at a new site rather than changing the cathe-ter over a guide wire.24 Use of ultrasound guidance for CVC has not been shown to increase the rate of cathe-ter-related infections; no published study has noted this complication. Sterile needle guides and probe sleeves are widely available and should be used to maintain sterile technique during insertion of the catheter.

Cost and ImplementationDespite overwhelming evidence that the use

of ultrasound guidance for CVC improves patient safety and clinical outcomes, the technology must be available to the practitioner. The typical cost of

Figure 2. Cervical ultrasound anatomy relevant to internal jugular venipuncture. Left. Operator’s view of the 4 right-sided ultrasound probe positions; inset shows a magnified view of the region of the sternocleidomastoid triangle and the locations of the 6 right-sided cutaneous vantage points (Vs). Right. Composite diagram of overlapping transverse ultrasonic images obtained from the 3 right-sided cricoid-level ultrasound probe positions of one subject (head rotated 45° to the left). Key to color coding of rectangles indicating standard ultrasound probe positionings: blue=high anterior; yellow=high middle; orange=high posterior; gray=low middle.

45, head rotated 45° away from the side of measurement; a, overlying the anterior (medial) portion of SCMM; aa, medial to SCMM; ant, anterior; b, base of neck; c, cricoid level; CCA, common carotid artery; IJV, internal jugular vein; LN, lymph node; m, overlying the mid portion of the SCMM (transverse plane) or between its sternal and clavicular heads; OmHM, omohyoid muscle; p, overlying the posterior (lateral) portion of the SCMM; post, posterior; pp, posterior to the SCMM; R, right side of neck; rt, right; SCMM, sternocleidomastoid muscle; StHM, sternohyoid muscle; StTM, sternothyroid muscle; Thy, thyroid gland; Trach, trachea.21 Reprinted with permission.

A N E STHE SIOLOGY N E WS • JUN E 2012 5

an ultrasound machine, including probes, is $20,000 to $30,000. Therefore, it is important to consider the potential cost savings associated with use of ultra-sound for CVC. Ultrasound guidance for catheteriza-tion of the IJV consistently results in higher rates of successful cannulation, a lower incidence of compli-cations and cannulation attempts, and a reduction in time spent trying to successfully place a catheter.25 The estimated cost of a pneumothorax resulting from landmark-guided insertion of a central line is approxi-mately $134 per patient. Based on a conservative esti-mate of 1.5 pneumothoraces per 100 patients using the landmark technique, this complication translates into $5 million to $10 million per year nationally in avoid-able expenditures.26

Reductions in failure rates and number of attempts improve efficiency and help demonstrate the eco-nomic benefits of ultrasound. Furthermore, ultrasound guidance plays a role in other procedures. The tech-nology has a clearly established role in the placement of peripheral nerve blocks and arterial lines.27,28 Over-all cost savings can be realized through a reduction in complications, improved efficiency of health care pro-viders, and increased patient safety.

Future Directions The possibility that ultrasound could create an

unhealthy dependence on technology for future gen-erations of anesthesiologists has been the subject of recent debate. It has been suggested that if ultrasound guidance becomes the standard of care for CVC, the anatomic landmark technique might be abandoned. As a consequence, practitioners would lose their skills and trainees would never acquire the ability to place a central line by anatomic landmarks alone. In the event that an ultrasound device is unavailable or not working properly, complications and decreased success rates might result. Advocates of the anatomic landmark tech-nique argue that every anesthesiologist should be able to place a central venous catheter without ultrasound and still achieve a low incidence of complications and a high rate of success.29

Some authors have tried to reconcile the 2 seemingly opposing techniques, suggesting that training pro-grams should teach the landmark technique alongside ultrasound guidance. But, is it realistic to require train-ees to learn the landmark technique when it is unlikely they will use it enough to become skillful or even remain competent in the method?30 Real-time ultrasound guid-ance has become standard practice for cannulation of the IJV and has an expanding role in securing other sites for vascular access. The importance of training in ultrasound guidance for CVC to achieve improved clini-cal outcomes has been demonstrated repeatedly. Train-ing, therefore, would perhaps be better spent mastering the ultrasound guidance of CVC.31

ConclusionCurrent literature supports the use of real-time ultra-

sound guidance for cannulation of the IJV whenever possible to improve success rates and reduce complica-tions. Evidence also clearly indicates that proper train-ing is necessary to achieve better clinical outcomes and improve patient safety.

Figure 3. Long-axis view of internal jugular vein and carotid artery.

Figure 4. Short-axis view of internal jugular vein in close proximity to carotid artery.


16. Mallory DL, McGee WT, Shawker TH, et al. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. Chest. 1990;98(1):157-160.

17. Hirvela E, Parsa C, Aalmi O, Kelly E, Goldstein L. Skills and risk assessment of central line placement using bedside simulation with 3-dimensional ultrasound guidance system. Crit Care Med. 2000;28:A78.

18. Sekiguchi H, Tokita JE, Minami T, Eisen LA, Mayo PH, Narasimhan M. A prerotational, simulation-based workshop improves the safety of central venous catheter insertion: results of a successful internal medicine house staff-training program. Chest. 2011;140(3):652-658.

19. Evans LV, Dodge KL, Shah TD, et al. Simulation training in central venous catheter insertion: improved performance in clinical prac-tice. Acad Med. 2010;85(9):1462-1469.

20. Ma IW, Brindle ME, Ronksley PE, Lorenzetti DL, Sauve RS, Ghali WA. Use of simulation-based education to improve outcomes of central venous catheterization: a systematic review and meta-analysis. Acad Med. 2011;86(9):1137-1147.

21. Riopelle JM, Ruiz DP, Hunt JP, et al. Circumferential adjustment of ultrasound probe position to determine the optimal approach to the internal jugular vein: a noninvasive geometric study in adults. Anesth Analg. 2005;100(2):514.

22. Stone MB, Nagdev A, Murphy MC, Sisson CA. Ultrasound detection of guidewire position during central venous catheterization. Am J Emerg Med. 2010;28(1):82-84.

23. Ezaru CS, Mangione MP, Oravitz TM, Ibinson JW, Bjerke RJ. Elim-inating arterial injury during central venous catheterization using manometry. Anesth Analg. 2009;109(1):130-134.

24. Rupp SM, Apfelbaum JL, Blitt C, et al. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access.Anesthesiology. 2012;116(3):539-573.

25. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ. 2003;327(7411):361.

26. Kinsella S, Young N. Ultrasound-guided central line placement as compared with standard landmark technique: some unpleasant arithmetic for the economics of medical innovation. Value Health. 2009;12(1):98-100.

27. Domingo-Triadó V, Selfa S, Martínez F, et al. Ultrasound guidance for lateral midfemoral sciatic nerve block: a prospective compara-tive, randomized study. Anesth Analg. 2007;104(5):1270-1274.

28. Shiver S, Blaivas M, Lyon M. A prospective comparison of ultra-sound-guided and blindly placed radial arterial catheters. Acad Emerg Med. 2006;13(12):1275-1279.

29. Hessel EA 2nd. Con: we should not enforce the use of ultrasound as a standard of care for obtaining central venous access. J Cardiothorac Vasc Anesth. 2009;23(5):725-728.

30. O’Leary R, Bodenham A. Future directions in ultrasound-guided central venous access. Eur J Anaesthesiol. 2011;28(5):327-328.

31. Ridley S. Farewell to history (editorial). Anaesthesia. 2010;65(9):877-879.

References 1. Kaye AD, Fox CJ, Hymel BJ, et al. The importance of training for

ultrasound guidance in central vein catheterization. MEJ Anesthe-siol. 2011;21(1):61-66.

2. Domino KB, Bowdle TA, Posner KI, Spitellie PH, Lee LA, Cheney FW. Injuries and liability related to central vascular catheters: a closed claims analysis. Anesthesiology. 2004;100(6):1411-1418.

3. Bo-Linn GW, Anderson DJ, Anderson KC, McGoon MD. Percu-taneous central venous catheterization performed by medical house officers: a prospective study. Cathet Cardiovasc Diagn. 1982;8(1):23-29.

4. Eisenhauer ED, Derveloy RJ, Hastings PR. Prospective evaluation of central venous pressure (CVP) catheters in a large city/county hospital. Ann Surg. 1982;196(5):560-564.

5. Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the exter-nal landmark-guided technique. Circulation. 1993;87(5):1557-1562.

6. Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus subclavian access—a systematic review. Crit Care Med. 2002;30(2):454-460.

7. Troianos CA, Hartman GS, Glas KE, et al. Guidelines for perform-ing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Soci-ety of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2011;24(12):1291-1318.

8. Ullman JI, Stoelting RK. Internal jugular vein location with the ultra-sound Doppler blood flow detector. Anesth Analg. 1978;57(1):118.

9. Yonei A, Nonoue T, Sari A. Real-time ultrasonic guidance for per-cutaneous puncture of the internal jugular vein. Anesthesiology. 1986;64(6):830-831.

10. Rothschild JM. Ultrasound guidance of central vein catheterization. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. AHRQ Publication No 01-EO58. Rockville, MD: Agency for Healthcare Research and Quality; 2001:245-253.

11. National Institute for Health and Clinical Excellence. NICE Technol-ogy Appraisal No 49: Guidance on the use of ultrasound locating devices for placing central venous catheters. http://www.nice.org.uk/nicemedia/live/11474/32461/32461.pdf. Accessed March 2012.

12. O’Grady NP, Alexander M, Burns LA, et al. Healthcare Infection Control Practices Advisory Committee. Guidelines for the pre-vention of intravascular catheter related infections. Am J Infect Control. 2011;39(4 Suppl 1):S1-S34.

13. Milling TJ Jr, Rose J, Briggs WM et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assis-tance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Crit Care Med. 2005;33(8):1764-1769.

14. Bansal R, Agarwal SK, Tiwari SC, Dash SC. A prospective random-ized study to compare ultrasound-guided with non-ultrasound guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. Ren Fail. 2005;27(5):561-564.

15. Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultra-sound-guided catheterization of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10(6):R162.




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