- Email: [email protected]
Meeting Notes From the 2011 ASA Annual Meeting
MEMBERSHIP
Meeting Notes From the 2011 ASA Annual Meeting Kim Kraft, BSN, RN, CPAN ASPAN HAS LONG benefited from a collegial relationship with the American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation (APSF). Each year, ASPAN leadership attends the ASA Annual Meeting at the invitation of the seated ASA President. ASPAN President Chris Price, 2011-2012, MSN, RN, CPAN, CAPA, and Vice President/President-elect Susan Carter, 2011-2012, BSN, RN, CPAN, CAPA, attended the ASA Annual Meeting held October 15-19, 2011, in Chicago, Illinois. The theme of the annual meeting was Transforming Patient Safety Through Science and Innovation. The keynote address was given by Harvard surgeon and best-selling author Atul Gawande, MD, a leader in patient safety. He spoke to the approximately 16,000 attendees on the topic ‘‘Target: Reducing Inpatient Surgical Mortality to Less than 1% Globally.’’ Dr. Gawande stressed the importance of presurgical checklists and teamwork in avoiding errors in the OR and the role anesthesiologists play in this process. Later that day, Chris Price, Dr. Scott Groudine (ASA’s liaison to ASPAN), and Linda Groah (Executive Director of the Association of PeriOperative Registered Nurses) presented a panel discussion on the patient care functions of perioperative and perianesthesia professionals and how the anesthesiologists can help them achieve their patient care goals and also increase the job satisfaction of all perioperative providers. As the incoming APSF liaison, I attended the opening session and represented ASPAN and the outgoing liaison, Susan Fossum, BSN, RN, CPAN, at the APSF Workshop and Board of Directors’ meeting after the opening session. The APSF’s vision is to ensure that no patient shall be harmed by anesthesia, Kim Kraft, BSN, RN, CPAN, Perianesthesia Nurse Clinician, Mercy Hospital, St. Louis, MO. Conflict of interest: None to report. Address correspondence to Kim Kraft, 615 South New Ballas, St. Louis, MO 63141; e-mail address: [email protected]. Ó 2012 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2012.06.003
Journal of PeriAnesthesia Nursing, Vol 27, No 4 (August), 2012: pp 295-299
and the foundation is guided by its mission statement ‘‘to improve continually the safety of patients during anesthesia care by encouraging and conducting: safety research and education; patient safety programs and campaigns and national and international exchange of information and ideas.’’1 This aligns closely with ASPAN’s strategic goal to ‘‘be the influential force for perianesthesia patient safety, public policy and practice standards.’’2 This can be achieved by partnering with such organizations as APSF to explore safety initiatives and represent the safety interests of perianesthesia practice. The annual APSF Board of Directors’ Workshop entitled Current Anesthesia Patient Safety Issues–Help Set the Priorities for Immediate Short-Term Resolution included more than 700 attendees. Six speakers each presented a patient safety concern and asked the attendees, via an audience response system, to respond to four questions: (1) ‘‘Do we have evidence/agreement for the etiology of the problem?’’ (2) ‘‘Do we have evidence/agreement for the solution to the problem?’’ (3) ‘‘Does anesthesia have control/influence over introducing the solution to the problem?’’ and (4) ‘‘Do we have a way to measure the incidence for baseline and postintervention data?’’ The safety issues were medication safety in the OR, hand-offs, cerebral ischemia and cerebral perfusion pressure, residual neuromuscular blockade, fire safety in the OR, and ischemic optic neuropathy. Looking at the problems in relation to the questions, the audience felt that fire safety in the OR, medication safety, and residual neuromuscular blockade had evidence for the etiology and solution of the problem and that they had control or influence in finding solutions. Detailed results can be found in the Winter 2012 issue of the APSF Newsletter, which is distributed electronically to all ASPAN members (http:// www.apsf.org/newsletters/pdf/winter_2012.pdf). The APSF will use this information to move forward with recommendations that can improve safety for perianesthesia patients. Following are abstracts from selected research findings presented at the 2011 Annual Meeting that are
295
296
of heightened interest to perianesthesia nurses. You may visit the ASA Web site at http://www. asahq.org to read more about the annual meeting, review abstracts of presentations and poster submissions, and obtain general information about the ASA. (The following information is compiled from news releases produced and copyrighted by the ASA for the 2011 ASA Annual Meeting.)
PtCO2 Monitoring in PACU, Predicting the Risk of Respiratory Depression Ravi Kumar Reddy Balireddy, MBBS, Marcel E. Durieux, MD, PhD, Franziska E. Blum, MD, Robert H. Thiele, MD University of Virginia, Charlottesville, VA Postoperative respiratory depression is a frequent and potentially fatal complication of surgery and anesthesia. Whereas patients are closely monitored in the PACU, they are less closely watched on the ward. Most fatal respiratory events happen after PACU discharge (DC). Predicting which patients are at risk for respiratory depression would allow the clinician to triage postoperative patients rationally and efficiently (as intense postoperative monitoring incurs significant costs) to monitored wards. Arterial desaturation is a late indicator of respiratory depression in patients receiving supplemental oxygen and therefore does not reliably detect respiratory depression in the PACU setting. The Sentec digital monitoring system provides continuous real-time monitoring of arterial hemoglobin oxygen saturation, transcutaneous carbon dioxide tension (PtCO2), and pulse rate via a sensor placed on the patient’s skin. The system has been validated in the intensive care unit and has been shown to correlate well with arterial blood gas values (PCO2 mean bias, 10.23 mm Hg). The purpose of this study was to investigate the ability of the Sentec monitor to evaluate postoperative respiratory function in PACU. Specifically, the authors wished to document the incidence of PtCO2 .45 mm Hg at DC from PACU and to determine if any other parameters predicted which patients would have PtCO2 .45 mm Hg at the time of meeting DC criteria. One hundred patients admitted to PACU after general anesthesia were included in this prospective, nonrandomized trial. PtCO2 data were recorded
KIM KRAFT
for the full PACU stay. They determined PtCO2 at PACU DC and then tested if this value was predicted by any of the following factors: PtCO2 when entering PACU, mean PtCO2, maximum PtCO2, and duration of time PtCO2 .50 mm Hg, .60 mm Hg, and .70 mm Hg. They tested the predictive value of age, gender, weight, height, body mass index, type of surgery, duration of surgery, and diagnosis of obstructive sleep apnea, as well as intraoperative and PACU opiate consumption. Modified STOP BANG scoring was performed to identify patients at risk for sleep apnea. Hypercapnia is common in patients meeting PACU DC criteria. No available perioperative metrics appear to be predictive of elevated PtCO2 at PACU DC. This suggests that directly measuring PtCO2 may enhance the ability of previously validated tools (eg, STOP BANG) to identify patients at risk for postoperative respiratory depression.
Time of Day of Surgery is Not a Risk Factor for Early PONV in Ambulatory Surgery: An Analysis of 27,113 Cases Michael R. Shaughnessy, MD, M. S. Melton, MD, Marcia A. Corvetto, MD, William D. White, MPH, Tong J. Gan, MB, Karen C. Nielsen, MD, Marcy S. Tucker, MD, PhD, Stephen M. Klein, MD Duke University Medical Center, Durham, NC Postoperative nausea and vomiting (PONV) is a significant ambulatory surgery complication that may lead to delayed discharge from the PACU and unanticipated hospital admission. Numerous risk factors for PONV have been well established including time-related factors such as duration of surgery and anesthesia; however, time of day of surgery (TODS) has not been investigated. The purpose of this study was to examine whether TODS is a risk factor for early PONV in ambulatory surgical patients. After institutional review board approval, four databases were searched for all surgical cases performed at the Duke Ambulatory Surgery Center between May 1, 2006, and April 30, 2010. All cases with electronically recorded surgical start and end time stamps were included. Patient demographics, risk factors, anesthetic technique and agents, surgical procedure and duration, antiemetics, opioids,
MEETING NOTES FROM THE 2011 ASA MEETING
intravenous fluids, and pain scores were collected for use as covariates along with surgical start time (SST). Worst nausea scores (11-point scale), episodes of emesis, and rescue antiemetics in the PACU were recorded. For the purpose of analysis, a primary outcome of early PONV was defined as the presence of any nausea in the PACU (worst nausea score .0), any episode of emesis, or any rescue antiemetic given. All others were considered ‘‘complete responders’’ for early PONV. To test for a nonlinear effect, SST was characterized and tested categorically, first in three groups, (, 9 a.m., 9 a.m.11:59 a.m., and $12 p.m.) and again using four groups (, 8:30 a.m., 8:30 a.m.-10:29 a.m., 10:30 a.m.-12:29 p.m., and $12:30 p.m.). There were 27,113 cases included for analysis. None of the models detected a significant effect of SST on PONV. Nearly all 25 adjustment variables were individually significant predictors of PONV. After forward selection, 15 variables remained significant in the regression model: (worst PACU pain score, prophylactic ondansetron, volatile anesthetic, gender, history of PONV, intraoperative opioid dose, smoking status, procedure category, postoperative opioid dose, prophylactic diphenhydramine, total intravenous fluids, age, race, nitrous oxide, and prophylactic promethazine). When added as a continuous variable to this model, retaining 23,679 cases, the effect of SST was not significant. When categorized into the three- and four-group models, SST was not significant. SST remained nonsignificant when the first and last groups of the three- and four-group categorization were compared. This study demonstrates that TODS is not a significant predictor of PONV in ambulatory surgical patients. This conclusion is strengthened by the sample size and observation that nearly all 25 covariables were individually significant predictors of PONV.
Emergency Reintubation During Postoperative Care in Patients Undergoing Neurosurgical Procedures Li Meng, MD, MPH University of Pittsburgh, Pittsburgh, PA In neurosurgical patients, the need for emergency tracheal intubations in the PACU has not been well
297
studied. The information regarding the overall incidence and contributory factors is incomplete. The aim of this retrospective study was to note the incidence and examine the associated patient, surgical, and anesthetic factors of emergency tracheal intubations in neurosurgical patients of our institute. After approval from the institutional review board, all reported emergency tracheal intubations in patients undergoing neurosurgical procedures from January 1, 2000, through December 31, 2009, were analyzed. Patients admitted directly to an intensive care unit were not included in the database. Medical records including PACU and anesthesia records of these patients were reviewed. An assessment form was used to document the following data: patient demographics, surgery type and length, American Society of Anesthesiologists (ASA) physical status classification, emergency or elective status, anesthetic technique, and outcome. Reintubation in PACU occurred in 0.56% of patients during the study period. Ninety-two patients were divided into intracranial procedures (group 1) or spinal procedures (group 2). Frequency of reintubation remained consistent till 2008 and decreased in 2009. The demographic data of the two surgical groups were comparable. The percentage of patients belonging to ASA I and II was significantly greater in group 1 compared with group 2. From multivariate analysis, patient’s factors that increased risk were ASA physical status .II, age .65 years, obesity, and male gender. Anesthetic risk factors included sedatives preoperatively (midazolam dose .1 mg) and total fentanyl dose of .2.0 mcg/kg/hour in patients who had undergone intracranial procedures. Patients in whom anesthesia was maintained with sevoflurane, compared with those who received isoflurane or desflurane, were at lower risk. Patients who underwent operations longer than 4 hours were at increased risk. Emergency tracheal intubations after neurosurgical procedures in the PACU are a rare event. Frequency decreased in 2009 likely because a dedicated neuroanesthesia team was formed. Multiple patient, surgical, and anesthetic factors are associated with emergency tracheal intubations in the PACU. The author suggests considering
298
forgoing preoperative sedation, using remifentanil instead of fentanyl, and favoring sevoflurane in patients undergoing neurosurgical procedures.
Total Intravenous Anesthesia With Propofol Decreases Postoperative Delirium in Elderly Patients Compared With Sevoflurane Anesthesia Koji Ishii, MD, Tetsuji Makita, MD, Hikoma Yamashita, MD, Syouji Matsunaga, MD, Daiji Akiyama, MD, Kouko Toba, MD, Katsumi Hara, MD, Koji Sumikawa, MD Sasebo City General Hospital, Sasebo, Japan Postoperative delirium is a common complication of anesthesia. The incidence of postoperative delirium in elderly patients has been reported as 1% to 61.3%. Postoperative delirium increases the morbidity and mortality in elderly patients. However, the effects of anesthetics on postoperative delirium are not well known. The present study was carried out to compare propofol with sevoflurane in terms of the incidence of postoperative delirium. After obtaining hospital ethics committee approval and written informed consent, 59 patients aged 70 years or older were enrolled in this prospective study. The subjects electively underwent gastrectomy, colectomy, or rectectomy under general anesthesia combined with epidural anesthesia from July 2009 to December 2010. The following patients were excluded: (1) those with history of psychosis, alcoholism, or liver cirrhosis; (2) those with history of using tranquilizers or steroids; and (3) those with no efficiency of epidural anesthesia. Fifty-nine patients were randomly divided into two groups. Group S received sevoflurane, and group P received propofol to maintain general anesthesia. Epidural anesthesia was continued until postoperative day 3 to control postoperative pain. Postoperative delirium was diagnosed with the confusion assessment method (CAM) by nurses in the intensive care unit. There were no significant differences in age, sex, operation time, anesthesia time, bleeding volume, transfusion volume, or total dose of fentanyl between the two patient groups. The incidence of postoperative delirium in group P (6.9%) was significantly less than that in group S (26.7%). Propofol an-
KIM KRAFT
esthesia decreases postoperative delirium in elderly patients compared with sevoflurane anesthesia.
Patterns of Multimodal Analgesia Utilization in the United States Jaime L. Baratta, MD, Kishor Gandhi, MD, Eugene Viscusi, MD Thomas Jefferson University Hospital, Philadelphia, PA Most surgical patients continue to experience moderate to severe pain during the perioperative period. Inadequate pain control has been shown to have significant postoperative morbidity. The American Society of Anesthesiologists (ASA) Task Force on acute pain management recommended an around-the-clock regimen of nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, and cyclooxygenase 2 inhibitors to treat surgical pain and minimize opioids. The aim of this survey was to assess current trends in behavioral practices regarding the use of multimodal analgesia at surgical facilities in the United States. A 15-question survey was sent to subscribers of a national magazine targeting inpatient and outpatient operating room personnel. Respondents were asked a series of questions based on their clinical setting and utilization of multimodal analgesia in the pre- and postoperative setting. Other questions inquired about the use of multimodal regimens in different surgical subspecialties. Eighty-three responders completed the survey. There were 47 respondents from ambulatory surgery centers, 35 from hospital settings, and one from a physician’s office. Most responders believed that the decision to use a perioperative multimodal regimen is determined by the anesthesiologist and the certified registered nurse anesthetist; however, only a minority (less than 25%) of the clinicians use more than two nonopioids for pain control. In comparing preoperative with postoperative use of multimodal analgesia, 47.6% of respondents stated that they used multimodal analgesia less than 25% of the time preoperatively; however, 25.9% of respondents stated that they used it 25% to 50% and greater than 75% of the time postoperatively. Specifically the majority reported preoperative use of NSAIDs, pregabalin or gabapentin, and acetaminophen less
MEETING NOTES FROM THE 2011 ASA MEETING
than 25% of the time. Orthopaedics was the most common subspecialty to incorporate multimodal analgesia with a response rate of 87.7%, and 42.5% stated they had a multimodal pain regimen protocol in place. In addition, most respondents (37.8%) believe that reduced opioid use is the most significant benefit derived from multimodal therapy. The findings of this survey indicate that multimodal analgesia is not yet standard practice despite the ASA Task Force recommendations. When used, a single nonopioid is likely to be used as an adjunct rather than a primary treatment and use of multimodal analgesia is uncommon. Surprisingly, acetaminophen is not widely used, given its safety profile. Pain management may be significantly improved by incorporating the recommendations of the ASA Task Force on multimodal analgesia. Despite the demonstration of positive outcomes with preemptive analgesia in animal models, clinical trials have failed to show benefit likely secondary to short duration and failure to include multimodal regimens. As most respondents do not use multimodal therapy preoperatively, there is opportunity to further study the potential benefit.
Parental Attitudes Regarding Analgesic Use for Children: Differences in Ethnicity and Language Michelle A. Fortier, PhD, Sarah R. Martin, MA, Danielle I. Kain, Student, Edwin T. Tan, PhD University of California, Irvine, CA
299
The purpose of this study was to identify the impact of ethnicity and language on parental attitudes regarding analgesic use to treat children’s pain. A total of 206 parents of children undergoing outpatient surgery were recruited to complete the Medication Attitudes Questionnaire, a measure of parental beliefs about using analgesic medications to treat children’s pain. Parents were grouped into one of three categories according to ethnicity and primary language spoken: English-speaking white, English-speaking Hispanic, and Spanish-speaking Hispanic. Group differences in pain medication attitudes were examined. After controlling for socioeconomic status, Englishspeaking Hispanic parents endorsed higher levels of misconceptions about pain medication use, including a tendency to avoid analgesic use for children, compared with English-speaking white and Spanish-speaking Hispanic parents. This study highlights parental characteristics, including ethnicity and language, which may place children at higher risk for undertreatment of acute pain based on misconceptions about analgesic use for children. Specifically, Englishspeaking Hispanic parents may be most likely to undertreat children’s pain at home. Future studies are needed to identify the most appropriate means of providing education to counter parental misconceptions and support optimal pain management of children’s pain in the home setting.
References 1. Anesthesia Patient Safety Foundation. About Us: MissionStatement. Available at: http://www.apsf.org/about.php. Accessed May 29, 2012. 2. American Society of Perianesthesia Nurses. Strategic Goals. Available at: http://www.aspan.org/ClinicalPractice/
SafetyinPractice/StrategicGoals/tabid/3260/Default.aspx. Accessed May 30, 2012.
Meeting Notes From the 2011 ASA Annual Meeting Kim Kraft, BSN, RN, CPAN ASPAN HAS LONG benefited from a collegial relationship with the American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation (APSF). Each year, ASPAN leadership attends the ASA Annual Meeting at the invitation of the seated ASA President. ASPAN President Chris Price, 2011-2012, MSN, RN, CPAN, CAPA, and Vice President/President-elect Susan Carter, 2011-2012, BSN, RN, CPAN, CAPA, attended the ASA Annual Meeting held October 15-19, 2011, in Chicago, Illinois. The theme of the annual meeting was Transforming Patient Safety Through Science and Innovation. The keynote address was given by Harvard surgeon and best-selling author Atul Gawande, MD, a leader in patient safety. He spoke to the approximately 16,000 attendees on the topic ‘‘Target: Reducing Inpatient Surgical Mortality to Less than 1% Globally.’’ Dr. Gawande stressed the importance of presurgical checklists and teamwork in avoiding errors in the OR and the role anesthesiologists play in this process. Later that day, Chris Price, Dr. Scott Groudine (ASA’s liaison to ASPAN), and Linda Groah (Executive Director of the Association of PeriOperative Registered Nurses) presented a panel discussion on the patient care functions of perioperative and perianesthesia professionals and how the anesthesiologists can help them achieve their patient care goals and also increase the job satisfaction of all perioperative providers. As the incoming APSF liaison, I attended the opening session and represented ASPAN and the outgoing liaison, Susan Fossum, BSN, RN, CPAN, at the APSF Workshop and Board of Directors’ meeting after the opening session. The APSF’s vision is to ensure that no patient shall be harmed by anesthesia, Kim Kraft, BSN, RN, CPAN, Perianesthesia Nurse Clinician, Mercy Hospital, St. Louis, MO. Conflict of interest: None to report. Address correspondence to Kim Kraft, 615 South New Ballas, St. Louis, MO 63141; e-mail address: [email protected]. Ó 2012 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2012.06.003
Journal of PeriAnesthesia Nursing, Vol 27, No 4 (August), 2012: pp 295-299
and the foundation is guided by its mission statement ‘‘to improve continually the safety of patients during anesthesia care by encouraging and conducting: safety research and education; patient safety programs and campaigns and national and international exchange of information and ideas.’’1 This aligns closely with ASPAN’s strategic goal to ‘‘be the influential force for perianesthesia patient safety, public policy and practice standards.’’2 This can be achieved by partnering with such organizations as APSF to explore safety initiatives and represent the safety interests of perianesthesia practice. The annual APSF Board of Directors’ Workshop entitled Current Anesthesia Patient Safety Issues–Help Set the Priorities for Immediate Short-Term Resolution included more than 700 attendees. Six speakers each presented a patient safety concern and asked the attendees, via an audience response system, to respond to four questions: (1) ‘‘Do we have evidence/agreement for the etiology of the problem?’’ (2) ‘‘Do we have evidence/agreement for the solution to the problem?’’ (3) ‘‘Does anesthesia have control/influence over introducing the solution to the problem?’’ and (4) ‘‘Do we have a way to measure the incidence for baseline and postintervention data?’’ The safety issues were medication safety in the OR, hand-offs, cerebral ischemia and cerebral perfusion pressure, residual neuromuscular blockade, fire safety in the OR, and ischemic optic neuropathy. Looking at the problems in relation to the questions, the audience felt that fire safety in the OR, medication safety, and residual neuromuscular blockade had evidence for the etiology and solution of the problem and that they had control or influence in finding solutions. Detailed results can be found in the Winter 2012 issue of the APSF Newsletter, which is distributed electronically to all ASPAN members (http:// www.apsf.org/newsletters/pdf/winter_2012.pdf). The APSF will use this information to move forward with recommendations that can improve safety for perianesthesia patients. Following are abstracts from selected research findings presented at the 2011 Annual Meeting that are
295
296
of heightened interest to perianesthesia nurses. You may visit the ASA Web site at http://www. asahq.org to read more about the annual meeting, review abstracts of presentations and poster submissions, and obtain general information about the ASA. (The following information is compiled from news releases produced and copyrighted by the ASA for the 2011 ASA Annual Meeting.)
PtCO2 Monitoring in PACU, Predicting the Risk of Respiratory Depression Ravi Kumar Reddy Balireddy, MBBS, Marcel E. Durieux, MD, PhD, Franziska E. Blum, MD, Robert H. Thiele, MD University of Virginia, Charlottesville, VA Postoperative respiratory depression is a frequent and potentially fatal complication of surgery and anesthesia. Whereas patients are closely monitored in the PACU, they are less closely watched on the ward. Most fatal respiratory events happen after PACU discharge (DC). Predicting which patients are at risk for respiratory depression would allow the clinician to triage postoperative patients rationally and efficiently (as intense postoperative monitoring incurs significant costs) to monitored wards. Arterial desaturation is a late indicator of respiratory depression in patients receiving supplemental oxygen and therefore does not reliably detect respiratory depression in the PACU setting. The Sentec digital monitoring system provides continuous real-time monitoring of arterial hemoglobin oxygen saturation, transcutaneous carbon dioxide tension (PtCO2), and pulse rate via a sensor placed on the patient’s skin. The system has been validated in the intensive care unit and has been shown to correlate well with arterial blood gas values (PCO2 mean bias, 10.23 mm Hg). The purpose of this study was to investigate the ability of the Sentec monitor to evaluate postoperative respiratory function in PACU. Specifically, the authors wished to document the incidence of PtCO2 .45 mm Hg at DC from PACU and to determine if any other parameters predicted which patients would have PtCO2 .45 mm Hg at the time of meeting DC criteria. One hundred patients admitted to PACU after general anesthesia were included in this prospective, nonrandomized trial. PtCO2 data were recorded
KIM KRAFT
for the full PACU stay. They determined PtCO2 at PACU DC and then tested if this value was predicted by any of the following factors: PtCO2 when entering PACU, mean PtCO2, maximum PtCO2, and duration of time PtCO2 .50 mm Hg, .60 mm Hg, and .70 mm Hg. They tested the predictive value of age, gender, weight, height, body mass index, type of surgery, duration of surgery, and diagnosis of obstructive sleep apnea, as well as intraoperative and PACU opiate consumption. Modified STOP BANG scoring was performed to identify patients at risk for sleep apnea. Hypercapnia is common in patients meeting PACU DC criteria. No available perioperative metrics appear to be predictive of elevated PtCO2 at PACU DC. This suggests that directly measuring PtCO2 may enhance the ability of previously validated tools (eg, STOP BANG) to identify patients at risk for postoperative respiratory depression.
Time of Day of Surgery is Not a Risk Factor for Early PONV in Ambulatory Surgery: An Analysis of 27,113 Cases Michael R. Shaughnessy, MD, M. S. Melton, MD, Marcia A. Corvetto, MD, William D. White, MPH, Tong J. Gan, MB, Karen C. Nielsen, MD, Marcy S. Tucker, MD, PhD, Stephen M. Klein, MD Duke University Medical Center, Durham, NC Postoperative nausea and vomiting (PONV) is a significant ambulatory surgery complication that may lead to delayed discharge from the PACU and unanticipated hospital admission. Numerous risk factors for PONV have been well established including time-related factors such as duration of surgery and anesthesia; however, time of day of surgery (TODS) has not been investigated. The purpose of this study was to examine whether TODS is a risk factor for early PONV in ambulatory surgical patients. After institutional review board approval, four databases were searched for all surgical cases performed at the Duke Ambulatory Surgery Center between May 1, 2006, and April 30, 2010. All cases with electronically recorded surgical start and end time stamps were included. Patient demographics, risk factors, anesthetic technique and agents, surgical procedure and duration, antiemetics, opioids,
MEETING NOTES FROM THE 2011 ASA MEETING
intravenous fluids, and pain scores were collected for use as covariates along with surgical start time (SST). Worst nausea scores (11-point scale), episodes of emesis, and rescue antiemetics in the PACU were recorded. For the purpose of analysis, a primary outcome of early PONV was defined as the presence of any nausea in the PACU (worst nausea score .0), any episode of emesis, or any rescue antiemetic given. All others were considered ‘‘complete responders’’ for early PONV. To test for a nonlinear effect, SST was characterized and tested categorically, first in three groups, (, 9 a.m., 9 a.m.11:59 a.m., and $12 p.m.) and again using four groups (, 8:30 a.m., 8:30 a.m.-10:29 a.m., 10:30 a.m.-12:29 p.m., and $12:30 p.m.). There were 27,113 cases included for analysis. None of the models detected a significant effect of SST on PONV. Nearly all 25 adjustment variables were individually significant predictors of PONV. After forward selection, 15 variables remained significant in the regression model: (worst PACU pain score, prophylactic ondansetron, volatile anesthetic, gender, history of PONV, intraoperative opioid dose, smoking status, procedure category, postoperative opioid dose, prophylactic diphenhydramine, total intravenous fluids, age, race, nitrous oxide, and prophylactic promethazine). When added as a continuous variable to this model, retaining 23,679 cases, the effect of SST was not significant. When categorized into the three- and four-group models, SST was not significant. SST remained nonsignificant when the first and last groups of the three- and four-group categorization were compared. This study demonstrates that TODS is not a significant predictor of PONV in ambulatory surgical patients. This conclusion is strengthened by the sample size and observation that nearly all 25 covariables were individually significant predictors of PONV.
Emergency Reintubation During Postoperative Care in Patients Undergoing Neurosurgical Procedures Li Meng, MD, MPH University of Pittsburgh, Pittsburgh, PA In neurosurgical patients, the need for emergency tracheal intubations in the PACU has not been well
297
studied. The information regarding the overall incidence and contributory factors is incomplete. The aim of this retrospective study was to note the incidence and examine the associated patient, surgical, and anesthetic factors of emergency tracheal intubations in neurosurgical patients of our institute. After approval from the institutional review board, all reported emergency tracheal intubations in patients undergoing neurosurgical procedures from January 1, 2000, through December 31, 2009, were analyzed. Patients admitted directly to an intensive care unit were not included in the database. Medical records including PACU and anesthesia records of these patients were reviewed. An assessment form was used to document the following data: patient demographics, surgery type and length, American Society of Anesthesiologists (ASA) physical status classification, emergency or elective status, anesthetic technique, and outcome. Reintubation in PACU occurred in 0.56% of patients during the study period. Ninety-two patients were divided into intracranial procedures (group 1) or spinal procedures (group 2). Frequency of reintubation remained consistent till 2008 and decreased in 2009. The demographic data of the two surgical groups were comparable. The percentage of patients belonging to ASA I and II was significantly greater in group 1 compared with group 2. From multivariate analysis, patient’s factors that increased risk were ASA physical status .II, age .65 years, obesity, and male gender. Anesthetic risk factors included sedatives preoperatively (midazolam dose .1 mg) and total fentanyl dose of .2.0 mcg/kg/hour in patients who had undergone intracranial procedures. Patients in whom anesthesia was maintained with sevoflurane, compared with those who received isoflurane or desflurane, were at lower risk. Patients who underwent operations longer than 4 hours were at increased risk. Emergency tracheal intubations after neurosurgical procedures in the PACU are a rare event. Frequency decreased in 2009 likely because a dedicated neuroanesthesia team was formed. Multiple patient, surgical, and anesthetic factors are associated with emergency tracheal intubations in the PACU. The author suggests considering
298
forgoing preoperative sedation, using remifentanil instead of fentanyl, and favoring sevoflurane in patients undergoing neurosurgical procedures.
Total Intravenous Anesthesia With Propofol Decreases Postoperative Delirium in Elderly Patients Compared With Sevoflurane Anesthesia Koji Ishii, MD, Tetsuji Makita, MD, Hikoma Yamashita, MD, Syouji Matsunaga, MD, Daiji Akiyama, MD, Kouko Toba, MD, Katsumi Hara, MD, Koji Sumikawa, MD Sasebo City General Hospital, Sasebo, Japan Postoperative delirium is a common complication of anesthesia. The incidence of postoperative delirium in elderly patients has been reported as 1% to 61.3%. Postoperative delirium increases the morbidity and mortality in elderly patients. However, the effects of anesthetics on postoperative delirium are not well known. The present study was carried out to compare propofol with sevoflurane in terms of the incidence of postoperative delirium. After obtaining hospital ethics committee approval and written informed consent, 59 patients aged 70 years or older were enrolled in this prospective study. The subjects electively underwent gastrectomy, colectomy, or rectectomy under general anesthesia combined with epidural anesthesia from July 2009 to December 2010. The following patients were excluded: (1) those with history of psychosis, alcoholism, or liver cirrhosis; (2) those with history of using tranquilizers or steroids; and (3) those with no efficiency of epidural anesthesia. Fifty-nine patients were randomly divided into two groups. Group S received sevoflurane, and group P received propofol to maintain general anesthesia. Epidural anesthesia was continued until postoperative day 3 to control postoperative pain. Postoperative delirium was diagnosed with the confusion assessment method (CAM) by nurses in the intensive care unit. There were no significant differences in age, sex, operation time, anesthesia time, bleeding volume, transfusion volume, or total dose of fentanyl between the two patient groups. The incidence of postoperative delirium in group P (6.9%) was significantly less than that in group S (26.7%). Propofol an-
KIM KRAFT
esthesia decreases postoperative delirium in elderly patients compared with sevoflurane anesthesia.
Patterns of Multimodal Analgesia Utilization in the United States Jaime L. Baratta, MD, Kishor Gandhi, MD, Eugene Viscusi, MD Thomas Jefferson University Hospital, Philadelphia, PA Most surgical patients continue to experience moderate to severe pain during the perioperative period. Inadequate pain control has been shown to have significant postoperative morbidity. The American Society of Anesthesiologists (ASA) Task Force on acute pain management recommended an around-the-clock regimen of nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, and cyclooxygenase 2 inhibitors to treat surgical pain and minimize opioids. The aim of this survey was to assess current trends in behavioral practices regarding the use of multimodal analgesia at surgical facilities in the United States. A 15-question survey was sent to subscribers of a national magazine targeting inpatient and outpatient operating room personnel. Respondents were asked a series of questions based on their clinical setting and utilization of multimodal analgesia in the pre- and postoperative setting. Other questions inquired about the use of multimodal regimens in different surgical subspecialties. Eighty-three responders completed the survey. There were 47 respondents from ambulatory surgery centers, 35 from hospital settings, and one from a physician’s office. Most responders believed that the decision to use a perioperative multimodal regimen is determined by the anesthesiologist and the certified registered nurse anesthetist; however, only a minority (less than 25%) of the clinicians use more than two nonopioids for pain control. In comparing preoperative with postoperative use of multimodal analgesia, 47.6% of respondents stated that they used multimodal analgesia less than 25% of the time preoperatively; however, 25.9% of respondents stated that they used it 25% to 50% and greater than 75% of the time postoperatively. Specifically the majority reported preoperative use of NSAIDs, pregabalin or gabapentin, and acetaminophen less
MEETING NOTES FROM THE 2011 ASA MEETING
than 25% of the time. Orthopaedics was the most common subspecialty to incorporate multimodal analgesia with a response rate of 87.7%, and 42.5% stated they had a multimodal pain regimen protocol in place. In addition, most respondents (37.8%) believe that reduced opioid use is the most significant benefit derived from multimodal therapy. The findings of this survey indicate that multimodal analgesia is not yet standard practice despite the ASA Task Force recommendations. When used, a single nonopioid is likely to be used as an adjunct rather than a primary treatment and use of multimodal analgesia is uncommon. Surprisingly, acetaminophen is not widely used, given its safety profile. Pain management may be significantly improved by incorporating the recommendations of the ASA Task Force on multimodal analgesia. Despite the demonstration of positive outcomes with preemptive analgesia in animal models, clinical trials have failed to show benefit likely secondary to short duration and failure to include multimodal regimens. As most respondents do not use multimodal therapy preoperatively, there is opportunity to further study the potential benefit.
Parental Attitudes Regarding Analgesic Use for Children: Differences in Ethnicity and Language Michelle A. Fortier, PhD, Sarah R. Martin, MA, Danielle I. Kain, Student, Edwin T. Tan, PhD University of California, Irvine, CA
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The purpose of this study was to identify the impact of ethnicity and language on parental attitudes regarding analgesic use to treat children’s pain. A total of 206 parents of children undergoing outpatient surgery were recruited to complete the Medication Attitudes Questionnaire, a measure of parental beliefs about using analgesic medications to treat children’s pain. Parents were grouped into one of three categories according to ethnicity and primary language spoken: English-speaking white, English-speaking Hispanic, and Spanish-speaking Hispanic. Group differences in pain medication attitudes were examined. After controlling for socioeconomic status, Englishspeaking Hispanic parents endorsed higher levels of misconceptions about pain medication use, including a tendency to avoid analgesic use for children, compared with English-speaking white and Spanish-speaking Hispanic parents. This study highlights parental characteristics, including ethnicity and language, which may place children at higher risk for undertreatment of acute pain based on misconceptions about analgesic use for children. Specifically, Englishspeaking Hispanic parents may be most likely to undertreat children’s pain at home. Future studies are needed to identify the most appropriate means of providing education to counter parental misconceptions and support optimal pain management of children’s pain in the home setting.
References 1. Anesthesia Patient Safety Foundation. About Us: MissionStatement. Available at: http://www.apsf.org/about.php. Accessed May 29, 2012. 2. American Society of Perianesthesia Nurses. Strategic Goals. Available at: http://www.aspan.org/ClinicalPractice/
SafetyinPractice/StrategicGoals/tabid/3260/Default.aspx. Accessed May 30, 2012.