Epidural Clonidine as the sole anesthetic for abdominal surgery

Dr. Waxer

A.A. Abd-Elsayed, S. Zaky

Epidural Clonidine as a sole analgesic agent during and after abdominal surgery

University of Cincinnati, Cincinnati, Anesthesiology, Cleveland Clinic, Cleveland, OH, USA

Clonidine is a well known agent that can provide analgesia with epidural anesthesia.  If this is so widely known, then why do people not use clonidine more regularly with epidural anesthesia?

In a study conducted by Dr. Abd-Elsayed and colleagues from the University of Cincinnati Academic Health Center, 40 ASA I-II patients aged 18-50 whom had elective lower abdominal surgery were studied.  Patients were randomized into receiving either epidural clonidine or epidural bupivacaine for supplemental anesthesia.  As it turns out, pain scores were found to be significantly lower in the patients who received clonidine.  With reduced postoperative nausea, vomiting and urinary retention in the clonidine group when compared with bupivacaine.  From Dr. Abd-Elsayed, “Clonidine was very effective at controlling pain and hemodynamic parameters in our patients.”

With such promising results, it certainly does beg a question; why do the majority of anesthesia providers no longer use clonidine on a regular basis for epidural anesthesia?

Perhaps this will be the beginning of a new resurgence in the use of clonidine for epidural analgesia.   

How to promote SCIP, Survey of anesthesia dept leaders

Dr. Waxer

Speck et al. Perioperative Medicine 2012, 1:5

Strategies to promote reporting of Surgical Care Improvement Project (SCIP) measures: a pilot survey of anesthesia department leaders

The SCIP (Surgical Care Improvement Project) is a CMS led initiative designed to improve care by maintaining certain core measures.  Hospitals are now reimbursed partly by how well they comply with both SCIP measures and HCAHPS data.  Most responded with voluntary reporting, mandated by service contract, or in preparation for pay for performance.  However a small number reported incentive from their hospital for participation.  This article ultimately was inconclusive in determining what particular strategies are effective in encouraging physician reporting of SCIP measures.  However this article does raise awareness to the fact the SCIP measures are now a reality, especially in current anesthesia practice and will need to be accounted for in the future in order to both maintain a high level of care for our patients and ensure appropriate reimbursement from CMS.  

Anesthetic Implications of Chemotherapy

May 2012

Nathan Waxer, DO

Anaesthetic Implications of Chemotherapy

Neil Allan MBChB FRCA EDIC; Catherine Siller MRCP PhD; Andrew Breen MBChB FRCA 05/14/2012; Cont Edu Anaesth Crit Care & Pain. 2012;12(2):52-56. © 2012 Oxford University Press

Many surgical patients that will go under the knife and require anesthesia have had prior chemotherapy.  The reason why this is important to consider is that chemotherapy can be very toxic to the natural cells of the body.  Common toxicities include cardiac, pulmonary, renal, hepatic, GI, bone marrow, and neurological damage and should all be considered within the anesthetic plan.

A few high yield examples from the article include: Vincristine can cause neuropathy and seizures.  Cisplatin, carboplatin, and oxaliplatin, are a common cause of renal tubular and glomerular damage.  Cyclophosphamide causes direct endothelial damage and haemorrhagic pericarditis or myocarditis.  In particular bleomycin toxicity can cause pulmonary fibrosis, and is important to avoid high inspired FiO2 on patients with bleomycin and if possible in those whom chemotherapy has been used but the agents are unknown.

CBC, blood biochemistry, ECG, are mandatory, and chest X-ray, an arterial blood gas, pulmonary function tests, and an echocardiogram, are tests that should be considered and may be required depending upon the treatment regimen used.

Overall this is an informative and valuable review for the anesthesia provider of the commonly used chemotherapy agents and the physiological effects that they can cause. 

Robot Anesthesiologist, Dr. Waxer

Nathan Waxer, DO

Can a machine perform anesthesia as well as a human?

This is a question that is not necessarily unique, however is certainly worth discussing.  A recent paper published in the February 2012 Journal, Anesthesiology by Liu et al. entitled "Feasibility of Closed-loop Titration of Propofol and Remifentail Guided by the Spectral M-Entropy Monitor" essentially compared humans and a machine in their ability to maintain patients sedated at a predetermined state entropy level.  The findings of their study suggest that a Dual closed-loop controller (a machine) outperformed manual control (a human).

Although this was a machine programmed to only control a few limited specific parameters and was not able to perform any other of the multitude of duties and responsibilities required of an anesthesiologist, it is fascinating to think of the possibilities that an "anesthesia machine" could provide.

We are already in full flight of the technological age with the majority of new anesthesia machines having electronic charting and vital sign monitoring.  If there was a machine able to safely titrate medications to maintain blood pressure and heart rate within a specific set of parameters, this could ultimately free up the hands of the Anesthesiologist to perform other important duties in the operating room.  Oftentimes when there is an unstable patient having an extra pair of hands is invaluable, but if a computer could essentially provide that pair of hands, it could perhaps make a challenging case more manageable and routine. 

Of course there are naysayers who will argue that a machine could never replace what an anesthesiologist does and is not able to multitask and provide the critical thinking and problem solving that a human can.  I for the most part am in agreement with this statement, at least for the recent foreseeable future.  However, we already have 'mechanical' ventilators, video laryngoscopes, echocardiography and a number of computerized devices that aid physicians already, and I only see that increasing as time goes on.  But at least for now, a human physician is able to see a patient, elicit a succinct but pertinent history and physical from a patient and determine an anesthetic plan in the matter of seconds.  At this time, there is no machine that could replace the airway management an anesthesiologist provides with induction of anesthesia.  And what if induction does not progress as planned, would a machine be able to quickly assess and skillfully utilize the difficult airway algorithm when necessary?   I feel that this is just the beginning of where we are headed.  And although one can look at these changes in a negative light, I feel that there is so much opportunity and potential that will prove to aid anesthesia providers in the future and improve the practice of anesthesia.   Let the future begin now.

News Update: CRNA's in California-editorial, Dr. Waxer

Nathan Waxer, DO

In California on March 15, 2012 in the suit California Society of Anesthesiologists v. Superior Court of City and County of San Francisco it was ruled by the appellate court that CRNAs are allowed to practice anesthesia in California without direct physician supervision.  The implications of this ruling are huge.  If this appeal holds, then CRNAs can now practice and bill for anesthesia services.  Current federal law denies Medicare reimbursements to hospitals that allow nurses to give anesthesia without supervision, unless, however, a state’s governor formally opts out of that requirement after consulting with the state’s medical board. In California, that is what Governor Schwarzenegger did while he was still in office.  On the surface this seems like a disastrous ruling for the CSA and Anesthesiologists.  Now physicians are being forced to "compete" head to head with lesser trained practitioners of Anesthesia for their share of the pie.  One could make the argument, why not hire a nurse anesthetist?  I can get more or less the "same" care for about a third of the cost of hiring an Anesthesiologist.  On the surface it seems like a simple economic decision.  More hospitals should hire CRNAs if that is the case.
However, it is not that simple.  Physician Anesthesiologists provide so much more than just direct anesthesia care in the operating room or OB.

First off, for the price of an anesthesiologist, one typically gets a physician who typically works 60-80 hour weeks, sometimes a lot more, day and night.  Physicians are not bound by any 6-2 working hours.  Their duty is to provide patient care from start to finish, not shift work.  Nurse anesthetists on the other hand, typically work 40 hour weeks, usually during the daytime hours.  When their time is done, they can usually just clock out.  An anesthesiologist on the other hand on a typical day may be supervising multiple rooms, taking care of a busy OB suite, monitoring patients in the PACU, fielding consults from the ICU, ED and dealing with hospital administrative duties.  Not to mention a physician is also often on call multiple times a week, available to provide care at any hour of the day.  Anesthesiologists can't just "clock out" after a certain number of hours.  Anesthesiologists breadth of duties are expansive and beyond just the anesthetic care of patients in the operating room or OB suite.  After rigorous training in medical school and even more demanding training while in residency, anesthesiologists become skilled problem solvers with a skill set that places them above and beyond being just a well trained anesthesia provider.  Anesthesiologists are first and foremost, physicians, and with that distinction also comes with it a wealth of knowledge and unique skills that cannot ever be replaced or supplanted by certified registered nurse anesthetists.  Perhaps one day we will look back on this ruling as a blessing, because it will serve to remind us that there is so much more to being an anesthesiologist than just providing "anesthesia".


http://www.scribd.com/doc/86012627/California-Society-of-Anesthesiologists-v-Superior-Court-of-City-and-County-of-San-Francisco

Technology: Cerebral Oximetry, Dr. Waxer

Nathan Waxer, DO

Cerebral Oximetry Emerging Applications For an Established Technology
Frost, Elizabeth A.M. M.D. Anesthesiology News April 2012

Summary:
Cerebral Oximetry has been studied for more than 30 years and been
commercially available for greater than 2 decades. Cerebral oximetry
is derived from both venous and arterial blood and thus values fall
between the two (60-80%).

Cerebral oximetry, however, has only been recently used to investigate
changes in oxygen delivery to the brain and may have use in "first
alert" monitoring of impending organ dysfunction.

The brain may be an index organ for how well the vital organs of the
body are perfused.  If we are able to monitor the oxygenation of the
brain, it could then be used to infer the perfusion of other vital
organs.  Cerebral oximetry may be a useful technique for predicting
mortality from cardiac arrest, demonstrating a correlation between
cardiac function and perfusion to the brain. Also cerebral oximetry a
documented decrease in rSO2 directly after a procedure that could
affect the perfusion to the brain could help prove that a neurologic
deficit was not related to anesthesia.