General Articles of Interest

Last Updated: 09/15/2021

Pulmonary Aspiration of Gastric Contents: A Closed Claims Analysis

Mark A Warner, MD; Karen L Meyerhoff, MD, MPH; Mary E Warner, MD; Karen L Posner, PhD; Linda Stephens, PhD; Karen B Domino, MD, MPH

Anesthesiology; August 2021; 135(2):284–291.

PMID: 34019629 DOI: 10.1097/ALN.0000000000003831

  • Perioperative pulmonary aspiration of gastric contents has been, and continues to be, associated with severe morbidity and death in spite of recent advances in relevant guidelines and airway management
What This Article Tells Us
  • In a closed claims analysis of 115 cases of pulmonary aspiration, death occurred in 57% of the claims and severe permanent injury in another 14%
  • Sixty-one percent of the patients in the claims had either gastrointestinal obstruction or another intraabdominal process
  • Anesthetic practice was judged to be substandard in 59% of the 115 claims

Levels of Evidence Supporting the North American and European Perioperative Care Guidelines for Anesthesiologists between 2010 and 2020: A Systematic Review 

Andres Laserna, MD; Daniel A Rubinger, MD; Julian E. Barahona-Correa, MD; Noah Wright, DO; Mark R. Williams, MD; Julie A Wyrobek, MD; Linda Hasman, MSLS; Stewart J Lustik, MD, MBA; Michael P Eaton, MD; Laurent G Glance, MD

Anesthesiology; July 2021; 135(1):31–56.

PMID: 34046679 DOI: 10.1097/ALN.0000000000003808

  • Anesthesia clinical practice guidelines make evidence-based recommendations intended to optimize patient outcomes. The extent to which these recommendations are supported by high-quality evidence is not known.
What This Article Tells Us
  • In a systematic review of 2,280 recommendations in 60 guidelines published by major North American and European societies, half of the recommendations were supported by a low level of evidence.
  • The proportion of recommendations supported by a high level of evidence did not increase between 2010 and 2020.

Postoperative Pulmonary Complications’ Association with Sugammadex versus Neostigmine: A Retrospective Registry Analysis 

Gen Li, M Stat., M Chem; Robert E Freundlich, MD, MS, MSCI; Rajnish K Gupta, MD;  Christina J Hayhurst, MD; Chi H Le, BS; Barbara J Martin, RN, MBA; Matthew S Shotwell, PhD; Jonathan P Wanderer, MD, M Phil, FASA, FAMIA

Anesthesiology; June 2021; 134(6):862-873

PMID: 33730169 DOI: 10.1097/aln.0000000000003735

  • Compared with neostigmine, sugammadex demonstrates improved rates of residual neuromuscular blockade
  • There are limited data using validated surgical registry outcome data to evaluate the association between use of sugammadex and reduced pulmonary complications
What This Article Tells Us
  • At a medical center that implemented a complete switch from neostigmine to sugammadex, a statistically significant difference in pulmonary complication rates was not observed between 7,800 general surgery patients receiving neostigmine versus 2,691 general surgery patients receiving sugammadex
  • Although rates of pulmonary complication after general surgery are decreasing, some of this change may be attributable to temporal trends in practice unrelated to the use of neostigmine versus sugammadex

Intraoperative Blood Pressure Monitoring in Obese Patients: Arterial Catheter, Finger Cuff, and Oscillometry

Roman Schumann, MD; Agnes S Meidert, MD; Iwona Bonney, PhD; Christos Koutentis, MB, ChB, MS; Wilbert Wesselink, PhD.; Karim Kouz, MD; Bernd Saugel, MD

Anesthesiology; February 2021: 134(2):179–188

PMID: 33326001 DOI: 10.1097/aln.0000000000003636

  • Optimal blood pressure monitoring in obese surgical patients remains unknown because multiple invasive and noninvasive monitoring methods are available with little understanding of agreement between different methods.
 What This Article Tells Us
  • In a study of 90 obese patients having bariatric surgery, the agreement between finger cuff and intraarterial measurements was better than the agreement between oscillometric and intraarterial measurements for mean arterial and diastolic blood pressure, but not systolic blood pressure. Forearm oscillometry demonstrated better measurement performance than upper arm or lower leg oscillometry.

Management of Difficult Tracheal Intubation: A Closed Claims Analysis 

Aaron M Joffe, DO; Michael F Aziz, MD; Karen L Posner, PhD; Laura V Duggan, MD, FRCPC; Shawn L Mincer, MSW; Karen B. Domino, MD, MPH

Anesthesiology; October 2019; 131(4):818–829

PMID: 31584884 DOI: 10.1097/aln.0000000000002815

  • Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists.
  • Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes.
What This Article Tells Us
  • This article compared recent malpractice claims related to difficult tracheal intubation to historic claims using the Anesthesia Closed Claims Project database.
  • Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. The number of claims during the induction phase of anesthesia in this report is comparable with the previous report of 1993 to 1999, but outcomes are poorer.
  • Inadequate airway planning and judgment errors were contributors to patient harm. Almost three fourths exhibited judgment failures, which were more common in elective and urgent intubation procedures than emergency tracheal intubations.
  • Delay in surgical airway initiation during “can’t intubate, can’t oxygenate” emergencies remains an issue in airway management.

ENT Anesthesia

Last Updated: 09/15/2021

Perioperative Care of Patients with Obstructive Sleep Apnea Undergoing Upper Airway Surgery: A Review and Consensus Recommendations

Madeline JL Ravesloot, MD, PhD, MSc; Christel A L de Raaff, MD; Megan J van de Beek; Linda B L Benoist, MD; Jolien Beyers, MBS; Ruggero M Corso, MD; Gunther Edenharter, MD; Chantal den Haan; Jacqueline Heydari Azad; Jean-Pierre T F Ho, DDS, MD; Benedkt Hofauer, MD; Eric J Kezirian, MD, MPH; J Peter van Maanen, MD, PhD; Sabine Maes, MD; Jan P Mulier, MD, PhD; Winfired Randerath, MD; Olivier M Vanderveken, MD, PhD; Johan Verbraecken, MD, PhD; Patty E Vonk, MD; Edward M Weaver, MD, MPH; Nico de Vries, MD, PhD

JAMA Otolaryngol Head Neck Surg; August 1 2019; 145(8):751-760

PMID: 31246252 DOI: 10.1001/jamaoto.2019.1448

What this article tells us?
  • Recommendations for perioperative management of patients undergoing surgical management of OSA are based largely on expert opinion, with very low to low quality of evidence to support consensus statements.

Nonopioid, Multimodal Analgesia as First-line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

John D Cramer, MD; Michael L Barnett, MD; Samantha Anne, MD; Brian T Bateman, MD; Richard M Rosenfeld, MD, MPH, MBA; David E Tunkel, MD; Michael J Brenner, MD

Otolaryngol Head Neck Surg; April 2021; 164(4):712-719

PMID: 32806991 DOI: 10.1177/0194599820947013

What this article tells us?

This synthesis of systematic reviews of randomized controlled trials across all surgical fields, prioritizing otolaryngology, concludes that a combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens.

The Safety and Efficacy of the Use of the Flexible Laryngeal Mask Airway with Positive Pressure Ventilation in Elective ENT Surgery: A 15-year Retrospective Single-center Study.

Vladimir Nekhednzy; Vijay K Ramaiah; Jeremy Collins; Hendrikus J Lemmens; Sam P Most

Minerva Anestesiol; September 2017; 83(9):947-955

PMID: 28358175 DOI: 10.23736/s0375-9393.17.11403-3

What this article tells us?
  • This study of 705 patients undergoing mostly sinus and facial plastics surgery with general anesthesia utilizing a flexible laryngeal mask airway found an overall success rate of 92.6%. The remainder did not seat well or were dislodged.
  • There were no complications.

Gynecological Anesthesia

Prepared by: Connie Tran, MD, FASA
Last Updated: 09/15/2021

Addition of Lidocaine to the Distension Medium in Hysteroscopy Decreases Pain During the Procedure-A Randomized Double-blind, Placebo-controlled Trial

Oshri Barel, MD, MHA, FRANZCOG; Elad Preuss, MD; Natan Stolovitch, MD; Shiri Weinberg, MD; Eran Barzilay, MD, PhD; Moty Pansky, MD

J Minim Invasive Gynecol; April 2021;28(4):865-871

PMID: 32798723 DOI: 10.1016/j.jmig.2020.08.003 

  • Pain is the main cause of office hysteroscopy. Adding a local anesthetic to distension medium in the office diagnostic hysteroscopy using the vaginoscopic “no touch” approach (avoiding speculum and tenaculum) may reduce pain.
  • Oher modalities such as injection of intrauterine, cervical local anesthetic is painful and adds time to the procedure.
What This Article Tells Us
  • Randomized double blind placebo-controlled study of 100 patients. 10 ml of lidocaine 2% added to 1000ml of saline solution used as distension medium for hysteroscopy in the control group of 50 patients and 1000ml saline solution for the control
  • The lidocaine group has a lower VAS pain score (an average rise of 1.9 vs. 2.9 in the control group) without the added time to procedure or side effects.

Pain Management for Medical and Surgical Termination of Pregnancy Between 13 and 24 Weeks of Gestation: A Systematic Review

E Jackson; N Kapp

BJOG; October 2020; 127(11):1348-1357

PMID: 32162427 DOI: 10.1111/1471-0528.16212

  • Pain control for termination of pregnancy is dependent on practitioners and the available guidelines do not specify optimal strategies.
  • This study looked at articles from PubMed, Cochrane and Embase databases, and US National Library of Medicine clinical trials registry from inception to end of June 2019. A total of 11 studies comparing pain management strategies for induced medical (7 studies) or surgical (4 studies) termination of pregnancy between 13 and 24 weeks of gestation were included.
What This Article Tells Us 
  • 10% of women who need termination of pregnancy globally have gestation of > 13 weeks. Termination of pregnancy at later gestational age increases the pain intensity and length of time.
  • Regional analgesia and NSAIDs decrease second trimester medical termination of pregnancy pain
  • General anesthesia and deep IV sedation alleviated surgical termination of pregnancy pain. Nitrous oxide was ineffective when compared to moderate sedation using IV fentanyl and midazolam

Vaginal and Laparoscopic Hysterectomy as an Outpatient Procedure: A Systematic Review

Suzanne J Dedden; Peggy MAJ Geomini; Judith AF Huirne; Marlies Y Bongers

Eur J Obstet Gynecol Reprod Biol; July 2017; 216:212-223

PMID: 28810192 DOI: 10.1016/j.ejogrb.2017.07.015

  • Vaginal and laparoscopic hysterectomy patients are usually admitted overnight unlike other gynecological procedures such as laparoscopic sterilization and oophorectomies which are same day discharge.
  • Review of literature to identify complications, risk factors for admission, financial consequences, and patient satisfaction for same day discharge after a vaginal or laparoscopic hysterectomy.
What This Article Tells Us
  • 27 articles from PubMed, UptoDate, Embase, Cochrane and CINAHL database from inception until July 16, 2016
  • Overall re-admission rate varies from 0.73-4%. Main reasons for admission were pain, nausea, urinary retention, infection, and anemia. Preoperative factors that negatively influence same day discharge are increased age, medical co-morbidities, concomitant procedures, and surgeon’s preference.
  • Same day discharge after laparoscopic and vaginal hysterectomy can be feasible in pre-selected, and healthy patients.It is associated with low admission rate, low complication rate, reduced hospital costs, and high patient satisfaction.

Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper

Rebecca Stone, MD, MS; Erin Carey, MD; Amanda N Fader, MD; Rick Rosenfield, MD; Stacey Scheib, MD; Erica Weston, MD

J Minim Invasive Gynecol; February 2021; 28(2):179-203

PMID: 32827721 DOI: 10.1016/j.jmig.2020.08.006

  • The first Enhanced Recovery After Surgery (ERAS) guideline for women undergoing minimally invasive gynecologic surgery (MIGS) created by the American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons based on the 2016 ERAS Society.
What This Article Tells Us
  • Only one third of participants attending the inaugural Enhanced Recovery after Minimally Invasive Surgery panel session at the 2018 Annual American Association of Gynecologic Laparoscopists have a formal ERAS pathway for patients undergoing minimally invasive gynecologic surgery.
  • ERAS pathways are a compilation of evidence-based, best practice guidelines applied across the perioperative period to mitigate the physiologic stress response to surgery and promote recovery.
  • The ERAS protocol addressed the key components
    • Preoperative patient education and optimization
    • Multimodal and narcotic sparing analgesia
    • Nausea, SSI and VTE prophylaxis
    • Maintenance of euvolemia
    • Liberalization of activity

Pediatric Anesthesia

Last Updated: 09/15/2021

Ultrasound Evaluation of Gastric Emptying Time in Healthy Term Neonates after Formula Feeding

Jennifer J Lee, MD; Jerri C Price, MD, PhD; Andrew Duren, MD; Alon Shertzer, MD; Robert Hannum III, MD; Francis A Akita, MD; Shuang Wang, PhD; Judy H Squires, MD; Oliver Panzer, MD; Jacquelin Herrera, BS

Anesthesiology; June 2021; 134(6):845–851

PMID: 33861856 DOI: 10.1097/aln.0000000000003773

  • The temporal kinetics of gastric emptying in formula-fed neonates are incompletely understood • Currently, American Society of Anesthesiologists guidelines recommend 6 h of fasting in formula-fed neonates and infants before anesthesia
What This Article Tells Us
  • Serial ultrasound imaging of the gastric antrum in healthy term neonates after formula feeding reveals gastric emptying times ranging from 45 to 150 min
  • These observations suggest that preanesthesia fasting of healthy term neonates could be substantially shorter than is currently recommended.

Availability of Inpatient Pediatric Surgery in the United States

Michael L McManus, MD, MPH; Urbano L França, PhD

Anesthesiology; 2021; 134(6):852–861

PMID: 33831167 DOI: 10.1097/aln.0000000000003766

Pediatric hospital care in the United States has been naturally consolidating. • In 2015, the American College of Surgeons launched its Children’s Surgery Verification Quality Improvement Program to promote regionalization and improve the quality of pediatric surgical care.

 What This Article Tells Us
  • Before the start of the American College of Surgeons Children’s Surgery Verification Quality Improvement Program, pediatric surgical care was highly concentrated, with less than 7% of hospitals responsible for more than 80% of procedures. Nearly half of all pediatric procedures undertaken outside of these centers involved teenagers.

Effects of Premedication With Midazolam on Recovery and Discharge Times After Tonsillectomy and Adenoidectomy

Andrew Garcia, Elizabeth A Clark, Sohel Rana, Diego Preciado, George M Jeha, Omar Viswanath, Ivan Urits, Alan D Kaye, Claude Abdallah

Cureus; Febraury 3 2021; 13(2):e13101

PMID: 33728122 DOI: 10.7759/cureus.13101 

What This Article Tells Us
  • Premedication with midazolam was not associated with prolonged emergence or discharge time or higher incidence of complications after anesthesia for T&A in patients with OSA.

Patient Selection

Last Updated: 09/15/2021
Prepared by: Catherine Tobin, MD, FASA and Kara Barnett MD, FASA

Safety of Same-day Discharge in High-risk Patients Undergoing Ambulatory General Surgery

George Pang, MD; Michelle Kwong, BHSc; Christopher M. Schlachta, MDCM; Nawar A. Alkhamesi, MD, PhD; Jeffrey D. Hawel, MD; and Ahmad I. Elnahas, MD, MSc

J Surg Res; July 2021; 263:71-77

PMID: 33639372 DOI: 10.1016/j.jss.2021.01.024

Retrospective study using data from National Surgical Quality Improvement Program (NSQIP) comparing overnight stay versus same day discharge in “high risk” patients undergoing ambulatory surgery.

What this article Tells Us?
  • Overall mortality and morbidity is low in both groups. It is acceptable to discharge sicker patients on the same day when indicated.
  • Overnight stay did not appear to lower the complication risks.
  • Risk factors for complications are renal failure, disseminated cancer, ascites, older patients, diabetes, CHF, and nondependent functional status, and bleeding disorder.

Patient Selection in Outpatient Surgery

Tripti Kataria, MD; Thomas W. Cutter, MD, MEd; Jeffrey L. Apfelbaum

Clin Plastic Surg; July 2013; 40(3):371–382

PMID: 23830745 DOI: 10.1016/j.cps.2013.04.004

What this article Tells Us?
  • There are no set recommendations on patient selection for outpatient surgery.
  • One must follow general guidelines. More work in this area is needed.
  • Patient selection is a complex issue that requires algorithms to be developed that include patient comorbidities, location of procedure, who is doing the procedure, who is doing the anaesthesia, and type of anesthesia.

Patient Selection for Day Case-eligible Surgery Identifying Those at High Risk for Major Complications

Michael R. Mathis, MD; Norah N. Naughton, MD, MBA; Amy M. Shanks, MS; Robert E. Freundlich, MD, MS; Christopher J. Pannucci, MD, MS; YiJia Chu, MD; Jason Haus, MD; Michelle Morris, MS; Sachin Kheterpal, MD, MBA

Anesthesiology; December 2013; 119(6):1310-1321

PMID: 24108100 DOI: 10.1097/ALN.0000000000000005

Data from American College of Surgeons’ National Surgical Quality Improvement Program was used to see if risk factors for morbidity and mortality in ambulatory surgery could be found since clear outcomes are lacking.

What this article Tells Us?
  • When the surgical complexity was controlled, risk factors for increased morbidity and mortality were: COPD, HTN, Previous stent or cardiac surgery, history of CVA or TIA, and longer surgeries were identified.

Predictors of unanticipated admission following ambulatory surgery: a retrospective case-control study

Amanda Whippey, MD; Greg Kostandoff, BMBS; James Paul, MD; Jinhui Ma, MSc; Lehana Thabane, PhD; P Heung Kan Ma, MD

Can J Anesth; April 19 2013; 60(7):675–683

PMID: 23606232 DOI: 10.1007/s12630-013-9935-5

Retrospective study of 3 Canadian hospitals ambulatory surgeries in adult patients looking at unanticipated admissions and did not include emergency surgeries.

What this article Tells Us?
  • MAC cases as compared to general were less likely to have an unexpected admission.
  • Smokers had a decreased risk of admission.
  • Cases longer (1- 3 hours), patient age over 40, BMI over 30, higher ASA scores had higher unplanned admissions.

Preoperative Evaluation for Ambulatory Anesthesia What, When, and How?

Obianuju Okocha, MD; Rebecca M. Gerlach, MD; BobbieJean Sweitzer, MD

Anesthesiol Clin; March 22 2019; 37(2):195–213

PMID: 31047124 DOI: 10.1016/j.anclin.2019.01.014

What this article Tells Us?
  • Routine testing does not improve outcomes.
  • “Same day anesthesia pre- op” workups are common.
  • Cataract surgery is super low risk despite patients being elderly with health problems.
  • Patients with cardiac pacemakers, and ICDS, on dialysis, and complex pain syndromes benefit from perioperative planning on coordination ahead of time.
  • American College of Cardiology/American Heart Association (ACC/AHA) guidelines for cardiac evaluation in non cardiac surgery from 2014 are still an excellent resource.

The High Risk Patient for Ambulatory Surgery

Niraja Rajan

Curr Opin Anesthesiol; December 2020; 33(6):724–731

PMID: 33093300 DOI: 10.1097/ACO.0000000000000919

What this article Tells Us?
  • Article has guidelines, risk stratification, optimization, and tips to help anesthesiologist with high risk patients in ambulatory. Role of anesthesiologist is important in perioperative workup.
  • Prehabilitation, Pre op phone call about NPO guidelines, medications to take etc. when possible is helpful for cases.
  • Pre op testing in ASA 1,2s and cataracts is not needed and does not decrease complications.
  • Pre op testing only indicated if medical optimization could be done or it would change perioperative management.

High-risk Surgical Procedures and Semi-emergent Surgical Procedures for Ambulatory Surgery

Mark A Skues

Curr Opin Anesthesiol; December 2020; 33(6):718–723

PMID: 33002955 DOI:10.1097/ACO.0000000000000918

Review of hysterectomy, joint replacement, thyroidectomy, and spinal procedures, and semi-urgent and non-elective surgeries in ambulatory surgery. 

What this article Tells Us?
  • Multimodal analgesia, PONV guidelines, and post-operative follow-up are important parts of ambulatory management in complex cases.
  • More complex cases can be considered for ambulatory operating rooms.

Improving outcomes in ambulatory anesthesia by identifying high risk patients

Mike T Walsh

Curr Opin Anesthesiol; December 2018; 31(6):659–666

PMID: 30325340 DOI: 10.1097/ACO.0000000000000653

What this article tells us?
  • Screening high risk patients for ambulatory can help optimize their conditions prior to surgery and aid in post-operative care.
  • Age, obesity, frailty, higher ASA status, OSA are risk factors for complications.

Non-Operating Room Anesthesia: Patient Selection and Special Considerations

Timothy Wong, Paige L Georgiadis, Richard D Urman, Mitchell H Tsai

Local Reg Anesth; January 8 2020; 13:1–9

PMID: 32021414 DOI: 10.2147/LRA.S181458

What this article tells us?
  • Endoscopy, interventional pulmonology, interventional radiology, interventional cardiology, MRI, Pediatrics, IVF Retrieval are specifically covered in this review.
  • NORA locations have sicker patients, higher radiation exposure to anesthesia providers, and higher complications. Anesthesia providers should become more familiar with the unique environment to lower risks.
  • Pre-op, intra-op, post-op/ discharge have special considerations in NORA locations.

Preoperative Assessment and Optimization of Cognitive Dysfunction and Frailty in the Ambulatory Surgery Patient

Karina Charipova; Ivan Urtis; Omar Viswanath; Richard D Urman

Curr Opin Anaesthesiol; December 2020; 33(6):732-739

PMID: 32769745 DOI: 10.1097/ACO.0000000000000901

What this article tells us?
  • Screen elderly patients (>65 years old) for preoperative neurocognitive decline and frailty to guide treatment decision making.

Older Adults and Unanticipated Hospital Admission within 30 Days of Ambulatory Surgery: An Analysis of 53,667 Ambulatory Surgical Procedures.

Gildasio S De Oliveira Jr., MD; Jane L Holl, MD, MPH; Lee Ann Lindquist,MD, MBA; Nicholas J Hackett, BA; John Y S Kim, MD; Robert J McCarthy, PharmD  

J Am Geriatr Soc; August 2015; 63(8):1679-1685

PMID: 26200608 DOI: 10.1111/jgs.13537

What this article tells us?
  • There were rates of 2.5% of unplanned hospital admission and 2% morbidity within 30 days of ambulatory surgery.
  • The following characteristics were associated with an increased risk of unplanned admission: age (≥ 70 years), renal failure, chronic obstructive pulmonary disease, current cancer treatment, diabetes mellitus, and history of amputation or revascularization.
  • Most common reasons for admission include wound problems, infections, bleeding, and pain.

A Novel Index of Elevated Risk of Inpatient Hospital Admission Immediately Following Outpatient Surgery.

Lee A Fleisher, MD; L Reuven Pasternak, MD, MBA, MPH; Alan Lyles, ScD, MPH

Arch Surg; March 1 2007; 142(3):263-268

PMID: 17372051 DOI: 10.1001/archsurg.142.3.263

What this article tells us?
  • Immediate outpatient surgery admission rate of 0.6% with an index developed and included the following point values: (1) ≥ 65 years, (1) operating time > 120 minutes, (1) cardiac diagnoses, (1) peripheral vascular disease, (1) cerebrovascular disease, (1) malignancy, (1) seropositive for human immunodeficiency virus, (1) regional anesthesia and (2) general anesthesia.
  • Odds ratio of hospitalization relative to those with 0-1 points included: score =2: 9.5, Score 3: 20.6 and score ≥4: 32.

Ambulatory Surgery Adult Patient Selection Criteria – A Survey of Canadian Anesthesiologists

Zeev Friedman; Frances Chung; David T Wong; Canadian Anesthesiologists’ Society

Can J Anaesth; May 2004; 51(5):437-443

PMID: 15128628 DOI: 10.1007/BF03018305

What this article tells us?
  • 75% of the anesthesiologists surveyed found the follow comorbidities would still allow the patient to proceed with ambulatory surgery: ASA III, low grade angina pectoris, prior myocardial infarction > 60 months ago, low grade congestive heart failure, asymptomatic valvular disease, sleep apnea and monitored anesthesia care or regional anesthesia without narcotics, morbid obesity (BMI=35-44) without cardiovascular or respiratory comorbidities, insulin dependent diabetes mellites, and malignant hyperthermia susceptible.
  • 75% felt the following comorbidities were not appropriate for ambulatory anesthesia locations: ASA IV patients, high grade angina pectoris (symptoms with daily activities or present at rest), prior myocardial infarction within 6 months, high grade congestive heart failure (symptoms at rest), sleep apnea with general anesthesia and postoperative narcotics, morbid obesity (BMI ≥ 45) with cardiovascular or respiratory comorbidities, and no patient escort.

Patient Selection in Outpatient Surgery.

Tripti Kataria, MD; Thomas W Cutter, MD, MEd; Jeffrey L Apfelbaum, MD

Clin Plast Surg; July 2013; 40(3):371-382

PMID: 23830745 DOI: 10.1016/j.cps.2013.04.004

What this article tells us?
  • To determine if a patient is appropriate for the surgery in the outpatient setting, assess patient comorbidities, surgical procedure, who the surgeon/proceduralist is, anesthetic need, anesthetic provider available and the type of surgical setting.

Unplanned Hospital Admission After Ambulatory Surgery: A Retrospective, Single Cohort Study

M Stephen Melton, MD; Yi-Ju Li, PhD; Richard Pollard; MD; Zhengxi Chen; John Hunting; Thomas Hopkins, MD; William Buhrman, MD; Brad Taicher, DO; Solomon Aronson, MD; Mark Stafford-Smith, MD; Karthik Raghunathan, MBBS, MPH

Can J Anaesth; January 2021; 68(1):30-41

PMID: 33058058 DOI: 10.1007/s12630-020-01822-1

What this article tells us?
  • The rate of unplanned hospital admission after ambulatory surgery was 0.7% with the following factors increasing this risk: > 50 years, ASA III or IV vs II, chronic obstructive pulmonary disease, diabetes mellitus, transient ischemic attack, specific procedures (respiratory, digestive, or musculoskeletal), general anesthesia with peripheral nerve block vs general anesthesia, and ambulatory surgery center facility.
  • ICU admission rate was 0.4% with the following factors increasing this risk: ASA III or IV vs. II, musculoskeletal procedure and ambulatory surgery center.
  • Reduced risk of unplanned hospital and/or ICU admission with monitored anesthesia care vs general anesthesia.

Factors Associated with Hospital Admission after Outpatient Surgery in the Veterans Health Administration.

Hillary J Mull, PhD, MPP; Amy K Rosen, PhD; William J O’Brien, MS; Nathalie McIntosh, PhD; Aaron Legler, MPH; Mary T Hawn, MD, MPH; Kamal M F Itani, MD; Steven D Pizer, PhD

Health Serv Res; October 2018; 53(5):3855-3880

PMID: 29363106 DOI: 10.1111/1475-6773.12826

What this article tells us?
  • Rate of hospital admission within 7 days after VA outpatient surgery was 16% but varied by procedure surgical specialty as listed: general surgery 14%, urology 28%, orthopedics 6%, ear nose and throat 26%, and podiatry 5%.

Incidence, Predictions, and Causes of Unplanned 30-Day Hospital Admission After Ambulatory Procedures.

Bijan Teja, MD; Dana Raub, Cand Med; Sabine Friedrich, MD; Paul Rostin, Cand Med; Maria D Patrocínio, MD; Jeffrey C. Schneider, MD; Changyu Shen, PhD; Gabriel A. Brat, MD; Timothy T Houle, PhD; Robert W Yeh, MD, MSc; Matthias Eikermann, MD, PhD

Anesth Analg; August 2020; 131(2):497-507

PMID: 32427660 DOI: 10.1213/ANE.0000000000004852

What this article tells us?
  • Instrument developed to predict unplanned 30-day hospital admission after ambulatory anesthesia procedures included the following point values: (2) chronic pulmonary disease, (2) diabetes mellitus), (2) peripheral vascular disease, (3) liver disease, (4) congestive heart failure, (4) depression, (4) anemia, (5) moderate or severe renal failure, (6) drug abuse, (8) malignancy, or the following types of surgeries: (14) emergency procedure, (1) male genital system, (2) eye and ocular adnexa, (4) female genital, (5) integumentary system, (5) maternity care or delivery, (7) musculoskeletal system, (10) endocrine system, (10) hemic and lymphatic system, (14) digestive system, (14) nervous system, (14) urinary system, (16) respiratory system, (18) mediastinal and diaphragm, (18) vascular system.
  • Overall readmission rate of 2% with lowest readmission rate of 0.5% if ≤ 4 points to rate of 8.7% if ≥ 24 points.
  • Most common reasons for admission include issues related to malignancy, nonsurgical site infection and surgical complications.

Complex Cancer Surgery in the Outpatient Setting: The Josie Robertson Surgery Center.

Hanae Tokita, MD; Rebecca Twersky, MD, MPH; Vincent Laudone, MD; Marcia Levine, MSN, RN, NE-BC; Daniel Stein, MD, PhD; Peter Scardino, MD; Brett Simon, MD, PhD

Anesth Analg; September 2020; 131(3):699-707

PMID: 32224721 DOI: 10.1213/ANE.0000000000004754

What this article tells us?
  • Facility patient selection criteria (eg. BMI > 45, presence of AICD, end stage renal disease on hemodialysis) adjusted to serve as red flags rather than rigid exclusion criteria. 

Last Updated: 01/04/2022
Prepared by: Niraja Rajan, MD, SAMBA-F

Patient Selection for Adult Ambulatory Surgery: A Narrative Review

Niraja Rajan, MD, SAMBA-F, Eric B Rosero, MD, Girish Joshi, MB, BS, MD, FFARCSI, SAMBA-F

Anesth Analg. 2021;133(6):1415-1430.

PMID: 34784328     DOI: 10.1213/ANE.0000000000005605

What this article tells us?
  • Anesthesiologists who practice at ambulatory surgery centers need to have clearly defined patient selection criteria allowing for safe and efficient care of medically complex patients undergoing extensive surgical procedures with the expectation of discharge to home on the day of surgery.
  • Patient selection is not a “one size fit all.” Determining suitability of a patient for surgery as an outpatient is a dynamic process, involving the complex interplay of several factors such as surgical procedure, patient characteristics, expected anesthetic technique (eg, sedation/analgesia, local/ regional anesthesia, or general anesthesia), type of ambulatory setting (ie, short-stay [23-hour stay] facilities, hospital-based ambulatory center, freestanding ambulatory surgery center [ASC], and office-based surgery) and social factors, such as availability of transportation and a responsible individual to take care of the patient at home.
  • The majority of comorbid conditions do not preclude ambulatory surgery, provided they are optimized and stable. Severe comorbid conditions with the potential for perioperative instability should not be cared for in the outpatient setting. These include conditions listed in the ASA PS 4 classification.
  • It is advisable to develop procedure-specific exclusion criteria for patients that are not candidates for ambulatory surgery. Developing and implementing protocols (or clinical pathways) for patient selection and prehabilitation would further enhance patient safety and efficiency. A pragmatic question to ask is: Will postoperative hospitalization influence patient care or perioperative outcome? If no improvement would be achieved, then the patient should undergo the procedure on an ambulatory basis.

Ophthalmologic Surgery

Prepared by: Janette Covington, MD
Last Updated: 10/20/2021

The Value of Routine Preoperative Medical Testing Before Cataract Surgery

Oliver D Schein, MD, MPH; Joanne Katz, ScD; Eric B Bass, MD, MPH; James M Thielsch, PhD; Lisa H Lubomski, PhD; Marc A Feldman, MD, MPH; Brent G Petty, MD; and Earl P Steinberg, MD, MPP for the Study of Medical Testing for Cataract Surgery

New England Journal of Medicine; January 20, 2000; 342(3):168-175

PMID: 10639542 DOI: 10.1056/NEJM200001203420304

Why this study was performed

  • Cataract surgery is the most common operation performed in the elderly population, and the morbidity and mortality of this procedure is extremely low.
  • The utility of preoperative testing in cataract surgery is uncertain and many physicians feel that preoperative testing and examination is required.
  • The cost of preoperative testing to Medicare is quite high.

What this article tells us:

  • Adverse medical events during and immediately after cataract surgery as well as cancellations and postponements are independent of preoperative routine testing.
  • This is irrespective of severity of risk class or coexisting illnesses.
  • Routine medical testing before cataract surgery doesn’t measurably increase the safety of the surgery. 

Preoperative Medical Testing in Medicare Patients Undergoing Cataract Surgery

Catherine L Chen, MD, MPH; Grace A Lin, MD, MAS; Naomi S Bardach, MD, MAS; Theodore H Clay, MS; W. John Boscardin, PhD; Adrian W Gelb, MB, ChB; Mervyn Maze, MB, ChB; Michael A Gropper, MD, PhD and R Adams Dudley, MD, MBA

New England Journal of Medicine; April 16, 2015; 372(16): 1530-8

PMID: 25875258 DOI: 10.1056/NEJMsa1410846

Why this study was performed:

  • Cataract surgery has been shown to be a very safe procedure and routine preoperative testing has been shown to be unnecessary.
  • This study was performed to assess provider adherence to the previously-published guidelines recommending that no preoperative testing is required for routine cataract surgery.

What this article tells us:

  • Over 50% of patients undergoing cataract surgery underwent at least one preoperative test despite evidence against its benefit, resulting in likely unnecessary Medicare expenses.
  • There is no difference in the amount of testing performed compared to 20 years prior to the study.
  • Publishing evidence-based guidelines alone does not alter behavior and the physician care team is the primary determinant of whether testing is performed. 

Does Intraoperative Ketorolac Increase Bleeding in Oculoplastic Surgery?

Minwook Chang, MD. PhD; Adam Gould, MD; Zvi Gur, MD; Ortal Buhbut, MD; Hetal Hosalkar, MD; Catherine Y. Liu, MD, PhD; Bobby S Korn, MD, PhD, FACS and Don O Kikkawa, MD, FACS

Ophthalmic Plast Reconstr Surg; Jul/Aug 2020; 36(4): 355-358

PMID: 31809483 DOI: 10.1097/IOP.0000000000001549

Why this study was performed:

  • To report adverse hemorrhagic outcomes in patients who received intravenous ketorolac during oculoplastic surgery.

What this article tells us:

  • Interoperative ketorolac administration does not increase the risk of postoperative bleeding in oculoplastic surgical procedures.
  • This may be a useful adjunct to multimodal analgesia and thus decrease the use of narcotics. 

Anesthesia Recovery After Ophthalmologic Surgery at an Ambulatory Surgery Center

Kyle M Russell, RN; Mary E Warner, MD; Jay C Erie, MD; Chandralekha S Kruthiventi, MD; Juraj Sprung, MD, PhD and Toby N Weingarten, MD

Journal of Cataract & Refractive Surgery; June 2019; 45(6): 823-829

PMID: 31146933 DOI: 10.1016/j.jcrs.2019.01.017

Why this study was performed:

  • To examine anesthesia recovery duration after ophthalmologic procedures performed at an ambulatory surgery center.

What this study tells us:

  • Duration of recovery after ophthalmologic surgery in an ambulatory surgery center is associated primarily with procedure type with longest recoveries for orbitotomy and strabismus procedures; shortest for cataract surgery.
  • Intraoperative fentanyl use, severe postoperative pain and postoperative opioid requirements are associated with longer recoveries. 

Non-Operating Room Anesthesia

Prepared by: Catherine Tobin, MD, FASA
Last Updated: 12/13/2021

Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review

Abigail D Herman, Candace B Jaruzel, Sam Lawton, Catherine D Tobin, Joseph G Reves, Kenneth R Catchpole, Myrtede C Alfred

Br J Anaesth. 2021 Nov;127(5):729-744.

PMID: 34452733 DOI: 10.1016/j.bja.2021.07.007

This a narrative review of morbidity and mortality in NORA settings. 30 articles qualified for inclusion published from 1994 to 2021. Higher rates of morbidity and mortality were seen in NORA compared to the operating room.

What This Article Tells Us?
  • There is diverse list of system factors contributing to NORA morbidity and mortality. Identification of risk and then recommendations on how to improve are important.
  • SEIPS (Systems Engineering Initiative for Patient Safety) model was used. Modifiable areas to improve patient safety can divided into categories including environment, tools and technology, tasks, organization, person.
  • Table 2 in article has recommendations for each category for example, in environment: provide necessary electrical outlets, organize workspace as standard and same in all sites, more lighting or plans for illumination, and more input from anesthesia team, remote cameras for monitoring.

Prepared by: Anthony Bonavia, MD, FCCP
Last Updated: 02/17/2022

Non-operating room anesthesia in the intensive care unit

Anthony Bonavia, MD, FCCP; Basem Abdelmalak, MD, FASA, SAMBA-F; Kunal Karamchandani, MD, FCCP, FCCM

J Clin Anesth; Feb 2022; Online ahead of print.

PMID: 35131557, DOI: 10.1016/j.jclinane.2022.110668

Non-operating room anesthesia (NORA) constitutes up to 40% of anesthetic services delivered, yet encompasses a wide range of practice settings and patient populations. NORA delivered in the intensive care unit involves the highest risk and most medically complex patients.

What This Article Tells Us?
  • Weighing the risks and benefits of proceeding with NORA in the ICU is a critical part of the anesthesiologist’s role
  • Anesthesiologists should consider adopting an “airway, breathing and circulation” structure to their preoperative evaluation, which is both more time-efficient and more pertinent to highly complex patients
  • Ergonomic challenges should be anticipated and should form an integral part of pre-procedural planning

Regional Anesthesia

Prepared By: Karlyn Powell, MD
Last Updated: 02/03/2022

American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity checklist: 2020 version

Joseph M Neal; Erin J Neal; Guy L Weinberg

Regional Anesthesia and Pain Medicine; 2021; 46: 81- 82.

PMID: 33148630 DOI:10.1136/rapm-2020-101986

  • ASRA regularly updates its practice advisories and cognitive aids including the LAST checklist based on user feedback, simulation studies and medical knowledge advancements.
What this article tells us?
  • The updated 2020 LAST checklist is in an easy-to-read process-flow format with simplified lipid emulsion dosing instructions.

Effect of peripheral nerve blocks on postanesthesia care unit length of stay in patients undergoing ambulatory surgery: a retrospective cohort study

Victor Polshin, Julie Petro, Luca J Wachtendorf, Maximilian Hammer, Thomas Simopoulus, Mathias Eickermann, Peter Santer

Regional Anesthesia and Pain Medicine; 2021; 46: 233- 239.

PMID: 33452202 DOI:10.1136/rapm-2020-102231

  • Retrospective cohort study of 57,040 adult ambulatory surgery cases in which PACU length of stay (LOS) and intraoperative opioid doses were compared between patients who received a PNB and a MAC or GA and those who did not receive a PNB.
What this article tells us?
  • Patients who received a PNB had a LOS decrease of 7.3min
    • Longer surgeries with a PNB had a LOS decrease of 11.2 min
    • Lower extremity surgery with a PNB had a LOS decrease of 15.1min.
  • Patients receiving a PNB had a decrease in intraoperative opioid administration of 9.40mg oral morphine equivalents.
  • Lower doses of intraoperative opioids may be responsible for decreased PACU LOS.

Intermittent bolus versus continuous infusion techniques for local anesthetic delivery in peripheral and truncal nerve analgesia: the current state of evidence

Ram Jagannathan, Adam D Niesen, Ryan S D’Souza, Rebecca L Johnson

Regional Anesthesia and Pain Medicine; 2019; 44: 447- 451.

PMID: 30914472 DOI:10.1136/rapm-2018-100082

  • There is unclear evidence of the benefits of intermittent bolus (IB) over continuous infusions for PNB and fascial plane blocks.
  • This article is a review 13 randomized controlled trials of intermittent bolus in truncal and peripheral nerve blockade between 2008 and 2018 including: 6 trials on lower extremity blockade (2 popliteal, 1 femoral, 2 adductor canal, 1 fascia iliaca), 3 trials on upper extremity blockade (2 interscalene, 1 axillary), 2 trials on paravertebral blockade, and 2 trials on transversus abdominus plane blocks.
  • Reviewers examined pain assessments, opioid and local anesthetic consumption, patient satisfaction, adverse events, and PT metrics.
What this article tells us?
  • Authors concluded that there is limited data at this time to endorse intermittent bolus over continuous infusion.
  • Of studies that noted a difference:
    • Popliteal IB for hallux valgus surgery showed reduction in pain scores at 6,8, and 12h and decreased local PCA usage but no difference in quality of block or use of rescue medications at 24h.
    • Femoral IB for TKA revealed decreased IV PCA and lower pain scores POD1 but no differences thereafter.
    • Adductor canal IB for ACLR noted decreased VAS scores and morphine consumption up to 24h.
    • Fascia iliaca IB for THA noted lower pain scores up to 36h.
    • Adductor canal IB for TKA revealed improved quadricep strength on POD2 but no other differences.

Efficacy of perineural versus intravenous dexmedetomidine as a peripheral nerve block adjunct: a systematic review

Nasir Hussain, Chad M Brummett, Richard Brull, Yousef Algothani, Kenneth Moran, Tamara Sawyer, Faraj W Abdallah

Regional Anesthesia and Pain Medicine; 2021; 46: 704- 712.

PMID: 33975918 DOI:10.1136/rapm-2020-102353

  • As there is concern in off label use of perineural dexmedetomidine, there has been interest in a systemic route which may provide similar analgesic effects.
  • This article involves a meta-analysis of 10 randomized trials comprising of 717 patients in 7 upper extremity block trials, 2 lower extremity block trials, and one truncal block trial comparing perineural to IV dexmedetomidine.
  • Primary endpoints included durations of sensory and motor blockades.
  • Dexmedetomidine dose varied with predetermined 50 mcg and a weight-based dose of 0.5-1.0 mcg/kg given perineural or IV.
What this article tells us?
  • Most studies showed that perineural dexmedetomidine had a faster onset and longer duration of sensory and motor blockade.
  • IV dexmedetomidine appears to be an inferior PNB adjunct compared to perineural dexmedetomidine.

Randomized comparison between perineural dexamethasone and dexmedetomidine for ultrasound-guided infraclavicular block

Julian Aliste, Sebastian Layera, Daniela Bravo, Diego Fernandez, Alvaro Jara, Armando Garcia, Roderick J Finlayson, De Q Tran

Regional Anesthesia and Pain Medicine: 2019; 44: 911- 916.

PMID: 31300595 DOI:10.1136/rapm-2019-100680

  • Both dexamethasone and dexmedetomidine have been shown to increase the duration of brachial plexus blocks as adjucts to local anesthetics.
  • This randomised trial compared perineural preservative free dexamethasone 5mg to dexmedetomidine 100mcg in 120 patients receiving an infraclavicular block with 35ml lidocaine 1%/ bupivacaine 0.25% and epinephrine 5 mcg/ml.
What this article tells us?
  • Dexamethasone had a longer duration of motor block, sensory block, and analgesia than dexmedetomidine:
    • Longer duration of motor block of 17.4 vs 14.3h
    • Longer duration of sensory block 19.0 vs 15.0h
    • Longer duration of postop analgesia 22.2 vs 16.9h.
    • Dexmedetomidine had a shorter block onset time with a 2.2-2.6min difference, lower HRs and BPs, and increased level of postop sedation.