Tumescent anaesthesia: its applications and well tolerated use in the out-of-operating room setting.

PURPOSE OF REVIEW: Tumescent anaesthesia is a method of administering dilute local anaesthetic into the subcutaneous tissue. Many anaesthesiologists are unfamiliar with the technique, its applications and potential risks. RECENT FINDINGS: The maximum safe dose of lidocaine with epinephrine in tumescent anaesthesia for liposuction is probably between 35 and 55 mg/kg. Without liposuction, the maximum dose of lidocaine with epinephrine should be no more than 28 mg/kg. After tumescent infiltration for liposuction, serum lidocaine concentrations peak between 12 and 16 h after injection. When tumescent lidocaine without epinephrine is used for endovenous laser therapy, peak serum lidocaine concentrations are observed much earlier, between 1 and 2 h after injection. Slow administration of more dilute concentrations of local anaesthetic decreases the risk of local anaesthetic systemic toxicity. SUMMARY: Although appealing because of its ability to provide prolonged analgesia, high doses of local anaesthetic are frequently administered using the tumescent technique, and absorption of local anaesthetic from the subcutaneous tissue is variable. When caring for patients having procedures in which tumescent anaesthesia is used, the risk of local anaesthetic toxicity should be acknowledged and lipid emulsion should be available for prompt treatment if needed.

Trends in healthcare and the role of the anesthesiologist in the perioperative surgical home - the US perspective.

PURPOSE OF REVIEW: Although advances in science are important, changes in population structure and developments in health policy have equally critical roles in shaping the future of anesthesia practice. Therefore, it is important for anesthesiologists to be aware of these trends and their implications. RECENT FINDINGS: As in other industrialized nations, population aging implies that patients presenting for elective surgery in future decades will be older and sicker. Nevertheless, in part for economic reasons, the fraction of surgeries performed in the ambulatory environment will continue to increase. Furthermore, the gradual elimination of fee-for-service care in favor of bundled payments will place additional risk on providers to prevent costly complications. In the USA, the American Society of Anesthesiologists has offered the 'surgical home' as a new model for perioperative care delivery in which the anesthesiologist serves as the coordinator of care from the preoperative through the postoperative phase. The purpose is not only to increase patient-centeredness but also to find opportunities for cost savings and increased efficiencies. SUMMARY: Global demographic and health policy trends are calling for new models of healthcare delivery. Anesthesiologists have much experience in the fields of risk assessment and quality improvement. They are well positioned to become leaders in the perioperative care environment of the future.

Perioperative cardiac risk reduction.

Cardiovascular complications are the most common cause of perioperative morbidity and mortality. Noninvasive stress testing is rarely helpful in assessing risk, and for most patients there is no evidence that coronary revascularization provides more protection against perioperative cardiovascular events than optimal medical management. Patients likely to benefit from perioperative beta blockade include those with stable coronary artery disease and multiple cardiac risk factors. Perioperative beta blockers should be initiated weeks before surgery and titrated to heart rate and blood pressure targets. The balance of benefits and harms of perioperative beta-blocker therapy is much less favorable in patients with limited cardiac risk factors and when initiated in the acute preoperative period. Perioperative statin therapy is recommended for all patients undergoing vascular surgery. When prescribed for the secondary prevention of cardiovascular disease, aspirin should be continued in the perioperative period.

Successful implementation of a perioperative glycemic control protocol in cardiac surgery: barrier analysis and intervention using lean six sigma.

Although the evidence strongly supports perioperative glycemic control among cardiac surgical patients, there is scant literature to describe the practical application of such a protocol in the complex ICU environment. This paper describes the use of the Lean Six Sigma methodology to implement a perioperative insulin protocol in a cardiac surgical intensive care unit (CSICU) in a large academic hospital. A preintervention chart audit revealed that fewer than 10% of patients were admitted to the CSICU with glucose <200 mg/dL, prompting the initiation of the quality improvement project. Following protocol implementation, more than 90% of patients were admitted with a glucose <200 mg/dL. Key elements to success include barrier analysis and intervention, provider education, and broadening the project scope to address the intraoperative period.

Preoperative beta-blocker use: impact of national guidelines on clinical practice.

STUDY OBJECTIVE: To determine if recommendations regarding perioperative beta-blocker therapy were followed by an increase in the number of eligible presurgical patients receiving beta-blockers and the number achieving the recommended heart rate (HR <60 beats per minute [bpm]). DESIGN: Retrospective, observational study. SETTING: Tertiary-care teaching hospital. MEASUREMENTS: The records of all 718 patients who underwent elective vascular surgery or coronary artery bypass grafting between January 2001 and March 2002 (pre-guideline) and those who did so between April 2002 and September 2003 (post-guideline) were reviewed. Percentage of eligible patients who received beta-blockers preoperatively and the target HR achieved in pre-guideline versus post-guideline patients were recorded. Differences were assessed using the unpaired t test and chi2 analysis. A P value of less than 0.05 is reported. MAIN RESULTS: Fifty percent of the post-guideline patients in the vascular surgery group were receiving beta-blockers at the time of preanesthetic evaluation versus 48% of pre-guideline patients (P = nonsignificant [NS]). Mean HR in the vascular surgery post-guideline beta-blocker group (70 +/- 14 bpm) was higher than in the pre-guideline beta-blocker group (65 +/- 11 bpm) (P < 0.01). Only 22% of those vascular surgery patients in the post-guideline group who were taking beta-blockers achieved the target HR of less than 60 bpm versus 29% of the vascular surgery patients taking beta-blockers in the pre-guideline group (P = NS). In the coronary artery bypass grafting group, 80% of post-guideline patients received beta-blocker before anesthesia assessment versus 75% of pre-guideline patients (P = NS). Mean HR in the post-guideline beta-blocker group (67 +/- 15 bpm) was similar to the pre-guideline beta-blocker group (64 +/- 13 bpm) (P = NS). Only 28% of the post-guideline patients who were receiving beta-blockers achieved the target HR of less than 60 bpm, which was not significantly different from the 17% achieved in the pre-guideline group (P = NS). CONCLUSION: At our institution, preoperative beta-blocker use was not significantly changed by publication of the recommendations.

Quadricuspid aortic valve with aortic insufficiency: case report and review of the literature.

We report the case of a 42-year-old woman with aortic regurgitation discovered to be caused by a quadricuspid aortic valve (QAV) diagnosed by intraoperative transesophageal echocardiogram. With improvements in echocardiographic imaging, the diagnosis of QAV is likely to be made more reliably in the future and should prompt close clinical follow-up given the frequent association of this lesion with valvular insufficiency.

Preanesthesia clinics, information management, and operating room delays: results of a survey of practicing anesthesiologists.

BACKGROUND: One purpose of preanesthesia evaluation clinics (PECs) is to decrease the incidence of day-of-surgery delays and cancellations by ensuring that patients are medically ready for surgery. In several single-center studies, PECs have been shown to have a positive impact. However, limited information is available regarding their overall use and perceived effectiveness. METHODS: A survey was distributed to attendees of the 2005 Annual Meeting of the American Society of Anesthesiologists. The survey addressed the national prevalence of PECs and the most common methods for referral to them. Respondents were also asked to address the impact of PEC visits on perceived prevalence of day-of-surgery delays caused by missing patient information. RESULTS: One thousand eight hundred fifty-seven surveys were returned. Sixty- nine percent of respondents worked at institutions with a PEC. Fifty-seven percent of respondents indicated that delays occur in at least 1 in 10 patients not seen for preanesthesia evaluation prior to the day of surgery. For patients who had a PEC visit prior to surgery, the same frequency of delays was reported by 23% of respondents. CONCLUSIONS: Day-of-surgery delays caused by missing information remain relatively common despite preanesthesia evaluation. Possible causes for these delays include failures of information transfer, lack of consensus on criteria for surgical readiness, or other institutional factors.

Modeling perioperative risk: can numbers speak louder than words?

Perioperative care is one of the most complex segments of medicine, because it imposes unique and unprecedented stress on the patient and requires the participation of multiple medical specialists. For this reason, the concept of risk management is ideally suited for application in the perioperative period. The authors believe that risk stratification systems applied to perioperative management should address the three dimensions of patient condition, surgical risk and invasiveness, and anesthetic complexity. They have proposed a system that integrates these factors to document and communicate the relevant elements affecting the "shape" of preoperative patients. Admittedly far short of the ideal formula, we hope this nonetheless prompts efforts to establish more uniform means of assessment and communication and provides a foundation for this endeavor. The old adage can be modified: "if your patient rates more than two ASPIRIN, call me before the morning (of surgery)."