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Frances Chung - One of the best experts on this subject based on the ideXlab platform.
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fourth consensus guidelines for the management of postoperative nausea and vomiting
Anesthesia & Analgesia, 2020Co-Authors: Tong J Gan, Pierre Diemunsch, Kumar G. Belani, Frances Chung, Sergio D Bergese, Ashraf S Habib, Zhaosheng Jin, Anthony L Kovac, Tricia A MeyerAbstract:This consensus statement presents a comprehensive and evidence-based set of guidelines for the care of postoperative nausea and vomiting (PONV) in both adult and pediatric populations. The guidelines are established by an international panel of experts under the auspices of the American Society of Enhanced Recovery and Society for Ambulatory Anesthesia based on a comprehensive search and review of literature up to September 2019. The guidelines provide recommendation on identifying high-risk patients, managing baseline PONV risks, choices for prophylaxis, and rescue treatment of PONV as well as recommendations for the institutional implementation of a PONV protocol. In addition, the current guidelines focus on the evidence for newer drugs (eg, second-generation 5-hydroxytryptamine 3 [5-HT3] receptor antagonists, neurokinin 1 (NK1) receptor antagonists, and dopamine antagonists), discussion regarding the use of general multimodal PONV prophylaxis, and PONV management as part of enhanced recovery pathways. This set of guidelines have been endorsed by 23 professional societies and organizations from different disciplines (Appendix 1).Guidelines currently available include the 3 iterations of the consensus guideline we previously published, which was last updated 6 years ago; a guideline published by American Society of Health System Pharmacists in 1999; a brief discussion on PONV management as part of a comprehensive postoperative care guidelines; focused guidelines published by the Society of Obstetricians and Gynecologists of Canada, the Association of Paediatric Anaesthetists of Great Britain & Ireland and the Association of PeriAnesthesia Nursing; and several guidelines published in other languages.The current guideline was developed to provide perioperative practitioners with a comprehensive and up-to-date, evidence-based guidance on the risk stratification, prevention, and treatment of PONV in both adults and children. The guideline also provides guidance on the management of PONV within enhanced recovery pathways.The previous consensus guideline was published 6 years ago with a literature search updated to October 2011. Several guidelines, which have been published since, are either limited to a specific populations or do not address all aspects of PONV management. The current guideline was developed based on a systematic review of the literature published up through September 2019. This includes recent studies of newer pharmacological agents such as the second-generation 5-hydroxytryptamine 3 (5-HT3) receptor antagonists, a dopamine antagonist, neurokinin 1 (NK1) receptor antagonists as well as several novel combination therapies. In addition, it also contains an evidence-based discussion on the management of PONV in enhanced recovery pathways. We have also discussed the implementation of a general multimodal PONV prophylaxis in all at-risk surgical patients based on the consensus of the expert panel.
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Patient selection in Ambulatory Anesthesia - An evidence-based review: part II
2020Co-Authors: Md Gregory L Bryson, Frances Chung, Robin G Cox, M B Frcpc, Frca Frcpc, Md Marie-josée Crowe, Md John Fuller, Md Cynthia Henderson, Frcpc Barry A FineganAbstract:P Pu ur rp po os se e: : This is the second of two reviews evaluating the management of patients with selected medical conditions undergoing Ambulatory Anesthesia and surgery. Conditions highlighted in this review include: diabetes mellitus; morbid obesity; the ex-premature infant; the child with an upper respiratory infection; malignant hyperthermia; and the use of monoamine oxidase inhibitors. S So ou ur rc ce e: : Medline search strategies and the framework for the evaluation of clinical evidence are presented in Part I. P Pr ri in nc ci ip pa al l f fi in nd di in ng gs s: : Diabetes mellitus has not been linked with adverse events following Ambulatory surgery. The morbidly obese patient is at an increased risk for minor respiratory complications in the perioperative period but these events do not increase unanticipated admissions. The ex-premature infant may be considered for Ambulatory surgery if post-conceptual age is > 60 weeks and hematocrit is > 30%. The child with a recent upper respiratory tract infection is at an increased risk for perioperative respiratory complications, particularly if endotracheal intubation is required. Patients with malignant hyperthermia may undergo outpatient surgery but require four hours of postoperative temperature monitoring. Sporadic cases of drug interactions have been reported when meperidine and indirectacting catecholamines are administered in the presence of monamine oxidase inhibitors. Ambulatory Anesthesia and surgery is safe if these combinations of drugs are avoided. C Co on nc cl lu us si io on n: : Ambulatory Anesthesia can be performed in, and is being offered to, a variety of patients with significant coexistent disease. In many cases there is little evidence documenting the outcomes expected in such patients. Prospective observational and interventional trials are required to better define perioperative management. Objectif : C'est la seconde revue qui évalue la prise en charge de patients, dont les pathologies médicales ont été ciblées, qui doivent subir une anesthésie en chirurgie ambulatoire. Les situations choisies comprennent : le diabète, l'obésité morbide, l'enfant né prématurément, l'enfant atteint d'infection des voies respiratoires supérieures, l'hyperthermie maligne et l'usage d'inhibiteurs de la monoamine-oxydase. Source : Les stratégies de recherche dans Medline et le cadre de l'é-valuation de la preuve clinique sont présentés dans la partie I. Constatations principales : Le diabète n'a pas été relié à des événements indésirables à la suite d'une opération ambulatoire. Le patient très obèse est plus à risque de complications respiratoires péri-opératoires mineures, ce qui n'augmente pas les admissions hospitalières imprévues. L'enfant prématuré est admis en chirurgie ambulatoire si l'âge post-conception est > 60 semaines et si l'hématocrite est > 30 %. L'enfant qui a une infection récente des voies respiratoires supérieure
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consensus guidelines for the management of postoperative nausea and vomiting
Anesthesia & Analgesia, 2014Co-Authors: Tong J Gan, Pierre Diemunsch, Frances Chung, Mehernoor F Watcha, Ashraf S Habib, Anthony L Kovac, Tricia A Meyer, Peter Kranke, Shane Angus, Christian C ApfelAbstract:The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.
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society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for Ambulatory surgery
Anesthesia & Analgesia, 2012Co-Authors: Girish P Joshi, Tong J Gan, Saravanan P Ankichetty, Frances ChungAbstract:The suitability of Ambulatory surgery for a patient with obstructive sleep apnea (OSA) remains controversial because of concerns of increased perioperative complications including postdischarge death. Therefore, a Society for Ambulatory Anesthesia task force on practice guidelines developed a consensus statement for the selection of patients with OSA scheduled for Ambulatory surgery. A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Although the studies evaluating perioperative outcome in OSA patients undergoing Ambulatory surgery are sparse and of limited quality, they do provide useful information that can guide clinical practice. Patients with a known diagnosis of OSA and optimized comorbid medical conditions can be considered for Ambulatory surgery, if they are able to use a continuous positive airway pressure device in the postoperative period. Patients with a presumed diagnosis of OSA, based on screening tools such as the STOP-Bang questionnaire, and with optimized comorbid conditions, can be considered for Ambulatory surgery, if postoperative pain can be managed predominantly with nonopioid analgesic techniques. On the other hand, OSA patients with nonoptimized comorbid medical conditions may not be good candidates for Ambulatory surgery. What other guidelines are available on this topic? The American Society of Anesthesiologists (ASA) practice guidelines for management of surgical patients with OSA published in 2006. Why was this guideline developed? The ASA guidelines are outdated because several recent studies provide new information such as validated screening tools for clinical diagnosis of OSA and safety of Ambulatory laparoscopic bariatric surgery in OSA patients. Therefore, an update on the selection of patients with OSA undergoing Ambulatory surgery is warranted. How does this guideline differ from existing guidelines? Unlike the ASA guidelines, this consensus statement recommends the use of the STOP-Bang criteria for preoperative OSA screening and considers patients' comorbid conditions in the patient selection process. Also, current literature does not support the ASA recommendations that upper abdominal procedures are not appropriate for Ambulatory surgery. Why does this guideline differ from existing guidelines? This consensus statement differs from existing ASA guidelines because of the availability of new evidence.
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society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing Ambulatory surgery
Anesthesia & Analgesia, 2010Co-Authors: Girish P Joshi, Frances Chung, Tong J Gan, Mary Ann Vann, Shireen Ahmad, Daniel T Goulson, Douglas G Merrill, Rebecca S TwerskyAbstract:Optimal evidence-based perioperative blood glucose control in patients undergoing Ambulatory surgical procedures remains controversial. Therefore, the Society for Ambulatory Anesthesia has developed a consensus statement on perioperative glycemic management in patients undergoing Ambulatory surgery. A systematic review of the literature was conducted according the protocol recommended by the Cochrane Collaboration. The consensus panel used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for providing suggestions. It was revealed that there is insufficient evidence to provide strong recommendations for the posed clinical questions. In the absence of high-quality evidence, recommendations were based on general principles of blood glucose control in diabetics, drug pharmacology, and data from inpatient surgical population, as well as clinical experience and judgment. In addition, areas of further research were also identified.
Girish P Joshi - One of the best experts on this subject based on the ideXlab platform.
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malignant hyperthermia susceptible adult patient and Ambulatory surgery center society for Ambulatory Anesthesia and Ambulatory surgical care committee of the american society of anesthesiologists position statement
Anesthesia & Analgesia, 2019Co-Authors: Richard D Urman, Kumar G. Belani, Niraja Rajan, Steven Gayer, Girish P JoshiAbstract:This document represents a joint effort of the Society for Ambulatory Anesthesia (SAMBA) and the Ambulatory Surgical Care Committee of the American Society of Anesthesiologists (ASA) concerning the safe anesthetic care of adult malignant hyperthermia (MH)-susceptible patients in a free-standing Ambulatory surgery center (ASC). Adult MH-susceptible patients can safely undergo a procedure in a free-standing ASC assuming that proper precautions for preventing, identifying, and managing MH are taken. The administration of preoperative prophylaxis with dantrolene is not indicated in MH-susceptible patients scheduled for elective surgery. There is no evidence to recommend an extended stay in the ASC, and the patient may be discharged when the usual discharge criteria for outpatient surgery are met. Survival from an MH crisis in an ASC setting requires early recognition, prompt treatment, and timely transfer to a center with critical care capabilities.
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pain management for Ambulatory arthroscopic anterior cruciate ligament reconstruction evidence based recommendations from the society for Ambulatory Anesthesia
Anesthesia & Analgesia, 2019Co-Authors: Faraj W Abdallah, Richard Brull, Girish P JoshiAbstract:Ambulatory arthroscopic anterior cruciate ligament reconstruction is associated with moderate pain, even when nonopioid oral analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs are used. Regional analgesia can supplement nonopioid oral analgesics and reduce postoperative opioid requirements, but the choice of regional analgesia technique for anterior cruciate ligament reconstruction remains controversial. Femoral nerve block, adductor canal block, and local instillation analgesia have all been proposed and are supported by some evidence from randomized controlled trials. Consequently, regional analgesia practice in patients undergoing anterior cruciate ligament reconstruction remains mixed. Published systematic reviews were used to identify the regional analgesia modality that would provide a balance between analgesic efficacy and associated potential risks in the setting of nonopioid multimodal analgesic strategies. Based on the evidence available, local instillation analgesia provides the best balance of analgesic efficacy and associated risks (strong recommendation, moderate level of evidence) when used as a component of multimodal analgesic technique in the first 24 hours after outpatient arthroscopic anterior cruciate ligament reconstruction. In the absence of local instillation analgesia, clinicians might use adductor canal block or femoral nerve block (weak recommendation, weak level of evidence). These recommendations have been endorsed by the Society of Ambulatory Anesthesia and approved by its board of directors.
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succinylcholine for emergency airway rescue in class b Ambulatory facilities the society for Ambulatory Anesthesia position statement
Anesthesia & Analgesia, 2017Co-Authors: Girish P Joshi, Steven Gayer, Meena S Desai, Hector VilaAbstract:Procedures in class B Ambulatory facilities are performed exclusively with oral or IV sedative-hypnotics and/or analgesics. These facilities typically do not stock dantrolene because no known triggers of malignant hyperthermia (ie, inhaled anesthetics and succinylcholine) are available. This article
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society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for Ambulatory surgery
Anesthesia & Analgesia, 2012Co-Authors: Girish P Joshi, Tong J Gan, Saravanan P Ankichetty, Frances ChungAbstract:The suitability of Ambulatory surgery for a patient with obstructive sleep apnea (OSA) remains controversial because of concerns of increased perioperative complications including postdischarge death. Therefore, a Society for Ambulatory Anesthesia task force on practice guidelines developed a consensus statement for the selection of patients with OSA scheduled for Ambulatory surgery. A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Although the studies evaluating perioperative outcome in OSA patients undergoing Ambulatory surgery are sparse and of limited quality, they do provide useful information that can guide clinical practice. Patients with a known diagnosis of OSA and optimized comorbid medical conditions can be considered for Ambulatory surgery, if they are able to use a continuous positive airway pressure device in the postoperative period. Patients with a presumed diagnosis of OSA, based on screening tools such as the STOP-Bang questionnaire, and with optimized comorbid conditions, can be considered for Ambulatory surgery, if postoperative pain can be managed predominantly with nonopioid analgesic techniques. On the other hand, OSA patients with nonoptimized comorbid medical conditions may not be good candidates for Ambulatory surgery. What other guidelines are available on this topic? The American Society of Anesthesiologists (ASA) practice guidelines for management of surgical patients with OSA published in 2006. Why was this guideline developed? The ASA guidelines are outdated because several recent studies provide new information such as validated screening tools for clinical diagnosis of OSA and safety of Ambulatory laparoscopic bariatric surgery in OSA patients. Therefore, an update on the selection of patients with OSA undergoing Ambulatory surgery is warranted. How does this guideline differ from existing guidelines? Unlike the ASA guidelines, this consensus statement recommends the use of the STOP-Bang criteria for preoperative OSA screening and considers patients' comorbid conditions in the patient selection process. Also, current literature does not support the ASA recommendations that upper abdominal procedures are not appropriate for Ambulatory surgery. Why does this guideline differ from existing guidelines? This consensus statement differs from existing ASA guidelines because of the availability of new evidence.
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society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing Ambulatory surgery
Anesthesia & Analgesia, 2010Co-Authors: Girish P Joshi, Frances Chung, Tong J Gan, Mary Ann Vann, Shireen Ahmad, Daniel T Goulson, Douglas G Merrill, Rebecca S TwerskyAbstract:Optimal evidence-based perioperative blood glucose control in patients undergoing Ambulatory surgical procedures remains controversial. Therefore, the Society for Ambulatory Anesthesia has developed a consensus statement on perioperative glycemic management in patients undergoing Ambulatory surgery. A systematic review of the literature was conducted according the protocol recommended by the Cochrane Collaboration. The consensus panel used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for providing suggestions. It was revealed that there is insufficient evidence to provide strong recommendations for the posed clinical questions. In the absence of high-quality evidence, recommendations were based on general principles of blood glucose control in diabetics, drug pharmacology, and data from inpatient surgical population, as well as clinical experience and judgment. In addition, areas of further research were also identified.
Richard D Urman - One of the best experts on this subject based on the ideXlab platform.
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malignant hyperthermia susceptible adult patient and Ambulatory surgery center society for Ambulatory Anesthesia and Ambulatory surgical care committee of the american society of anesthesiologists position statement
Anesthesia & Analgesia, 2019Co-Authors: Richard D Urman, Kumar G. Belani, Niraja Rajan, Steven Gayer, Girish P JoshiAbstract:This document represents a joint effort of the Society for Ambulatory Anesthesia (SAMBA) and the Ambulatory Surgical Care Committee of the American Society of Anesthesiologists (ASA) concerning the safe anesthetic care of adult malignant hyperthermia (MH)-susceptible patients in a free-standing Ambulatory surgery center (ASC). Adult MH-susceptible patients can safely undergo a procedure in a free-standing ASC assuming that proper precautions for preventing, identifying, and managing MH are taken. The administration of preoperative prophylaxis with dantrolene is not indicated in MH-susceptible patients scheduled for elective surgery. There is no evidence to recommend an extended stay in the ASC, and the patient may be discharged when the usual discharge criteria for outpatient surgery are met. Survival from an MH crisis in an ASC setting requires early recognition, prompt treatment, and timely transfer to a center with critical care capabilities.
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comparison of Anesthesia for dental oral surgery by office based dentist anesthesiologists versus operating room based physician anesthesiologists
Anesthesia Progress, 2017Co-Authors: Mark A Saxen, Richard D Urman, Juan F Yepes, Rodney A Gabriel, James E JonesAbstract:Few studies have examined the practice characteristics of dentist anesthesiologists and compared them to other Anesthesia providers. Using outcomes from the National Anesthesia Clinical Outcomes Registry and the Society for Ambulatory Anesthesia Clinical Outcomes Registry for dental/oral surgery procedures, we compared 7133 predominantly office-based anesthetics by dentist anesthesiologists to 106,420 predominantly operating room anesthetics performed by physician Anesthesia providers. These encounters were contrasted with 34,191 previously published encounters from the practices of oral and maxillofacial surgeons. Children younger than 6 years received the greatest proportion of general anesthetic services rendered by both dentist anesthesiologists and hospital-based Anesthesia providers. These general Anesthesia services were primarily provided for complete dental rehabilitation for early childhood caries. Overall treatment time for complete dental rehabilitation in the office-based setting by dentist a...
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comparison of Anesthesia for dental oral surgery by office based dentist anesthesiologists versus operating room based physician anesthesiologists
Anesthesia Progress, 2017Co-Authors: Mark A Saxen, Richard D Urman, Juan F Yepes, Rodney A Gabriel, James E JonesAbstract:Few studies have examined the practice characteristics of dentist anesthesiologists and compared them to other Anesthesia providers. Using outcomes from the National Anesthesia Clinical Outcomes Registry and the Society for Ambulatory Anesthesia Clinical Outcomes Registry for dental/oral surgery procedures, we compared 7133 predominantly office-based anesthetics by dentist anesthesiologists to 106,420 predominantly operating room anesthetics performed by physician Anesthesia providers. These encounters were contrasted with 34,191 previously published encounters from the practices of oral and maxillofacial surgeons. Children younger than 6 years received the greatest proportion of general anesthetic services rendered by both dentist anesthesiologists and hospital-based Anesthesia providers. These general Anesthesia services were primarily provided for complete dental rehabilitation for early childhood caries. Overall treatment time for complete dental rehabilitation in the office-based setting by dentist anesthesiologists was significantly shorter than comparable care provided in the hospital operating room and surgery centers. The Anesthesia care provided by dentist anesthesiologists was found to be separate and distinct from Anesthesia care provided by oral and maxillofacial surgeons, which was primarily administered to adults for very brief surgical procedures. Cases performed by dentist anesthesiologists and hospital-based Anesthesia providers were for much younger patients and of significantly longer duration when compared with Anesthesia administered by oral and maxillofacial surgeons. Despite the limited descriptive power of the current registries, office-based Anesthesia rendered by dentist anesthesiologists is clearly a unique and efficient mode of Anesthesia care for dentistry.
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history of Anesthesia for Ambulatory surgery
Current Opinion in Anesthesiology, 2012Co-Authors: Richard D Urman, Sukumar P DesaiAbstract:Purpose of review Anesthesia for Ambulatory surgery has come a long way since 1842 when James Venable underwent surgery for removal of a neck mass with Crawford W. Long administering ether and also being the surgeon. We examine major advances over the past century and a half. Recent findings The development of Anesthesia as a medical specialty is perhaps the single most important improvement that has enabled advances in the surgical specialties. Moreover, improved equipment, monitoring, training, evaluation of patients, discovery of better anesthetic agents, pain control, and the evolution of perioperative care are the main reasons why Ambulatory Anesthesia remains so safe in modern times. The development of less invasive surgical techniques, economic factors, and patient preferences provided addition impetus to the popularity of Ambulatory surgery. Summary Beyond the discovery in the mid-19th century that ether and nitrous oxide could be used to render patients unconscious during surgical procedures, subsequent developments in our specialty have added modestly, in a stepwise manner, to reduce mortality and morbidity associated with its use. These improvements have allowed us to safely meet the steadily increasing demand for Ambulatory surgery.
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specialized Ambulatory Anesthesia teams contribute to decreased Ambulatory surgery recovery room length of stay
The Ochsner journal, 2012Co-Authors: Pankaj Sarin, Beverly K Philip, Aya A Mitani, Sunil Eappen, Richard D UrmanAbstract:Background: Many institutions have organized specialized groups of Ambulatory surgery anesthesiologists with the aim of improving Ambulatory surgery patient care and efficiency. We hypothesized that specialized Ambulatory Anesthesia teams produce better patient outcomes such as lower postoperative nausea and vomiting (PONV) rates, lower postoperative pain scores, and shorter postAnesthesia care unit (PACU) lengths of stay (LOS). Methods: In this prospective observational study, we collected outcomes data on 1,299 patients including incidence of PONV, PACU LOS, maximum and average pain scores, amount of postoperative opioid use, and rescue antiemetic use. Results: Ambulatory anesthesiologists had statistically shorter phase 2 PACU LOS times (P < .05) and overall recovery times (P < .01). The PONV incidence odds ratio for Ambulatory versus nonAmbulatory anesthesiologists was 1.31 (95% CI 1.01-1.72). We found no significant difference in the amount of postoperative opioid use, maximum postoperative pain scores, or PACU phase 1 LOS time. Conclusions: The decreased PACU LOS for the study group’s patients occurred despite the increased incidence of PONV. Ambulatory anesthesiologists contributed to decreased PACU LOS while practicing evidence-based Anesthesia with regard to PONV and pain control. Ambulatory subspecialization may benefit institutions as a way to increase perioperative efficiency and improve surgeon and patient satisfaction.
Paul F White - One of the best experts on this subject based on the ideXlab platform.
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Ambulatory Anesthesia advances into the new millennium
Anesthesia & Analgesia, 2000Co-Authors: Paul F WhiteAbstract:Recent advances in anesthetic and surgical practices have facilitated the rapid growth in Ambulatory surgery throughout the world. With the availability of rapid, short-acting anesthetic, analgesic, sympatholytic, and muscle relaxant drugs, as well as improved monitoring devices, it has been possible to minimize the adverse effects of Anesthesia on the recovery process. Improvements in the perioperative care of outpatients has allowed surgeons to perform an increasing array of more invasive surgical procedures on an Ambulatory (day-case) basis. Major Ambulatory surgery procedures (e.g., extensive knee and shoulder reconstructions, laparoscopicassisted vaginal hysterectomies, gastric fundoplications, splenectomies, and adrenalectomies) are being performed at many centers around the world. Even patients undergoing carotid endarterectomy, pulmonary lobectomy, prostatectomy, and minor craniectomy procedures are being discharged on a same-day (or 23-hour admit) basis. Although it is commonly assumed that the primary reason for the continued expansion in Ambulatory surgery is related to pressure from third-party payors and governmental agencies to reduce health care costs, there may be other, less obvious, benefits for patients and their families (1). More aggressive rehabilitation leads to faster recovery of organ function, fewer surgical and anesthetic complications, reduced mental and physical disability, and, most importantly, earlier resumption of normal activities. For patients “at risk” of hospital-acquired infections (e.g., immunosuppressed patients), Ambulatory surgery may also reduce postoperative infectious complications.
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a cost comparison of methohexital and propofol for Ambulatory Anesthesia
Anesthesia & Analgesia, 1999Co-Authors: Rui Sun, Mehernoor F Watcha, Paul F White, Gary D Skrivanek, James D Griffin, Louis A Stool, Mark T MurphyAbstract:Methohexital is eliminated more rapidly than thiopental, and early recovery compares favorably with propofol. We designed this study to evaluate the recovery profile when methohexital was used as an alternative to propofol for the induction of Anesthesia before either sevoflurane or desflurane in combination with nitrous oxide. One hundred twenty patients were assigned randomly to one of four anesthetic groups: (I) methohexitaldesflurane, (II) methohexital-sevoflurane, (III) propofoldesflurane, or (IV) propofol-sevoflurane. Recovery times after the anesthetic drugs, as well as the perioperative side effect profiles, were similar in all four groups. A costminimization analysis revealed that methohexital was less costly for the induction of Anesthesia. At the fresh gas flow rates used during this study, the costs of the volatile anesthetics for maintenance of Anesthesia did not differ among the four groups. However, at low flow rates (#1 L/min), the methohexital-desflurane group would have been the least expensive anesthetic technique. In conclusion, methohexital is a cost-effective alternative to propofol for the induction of Anesthesia in the Ambulatory setting. At low fresh gas flow rates, the methohexitaldesflurane combination was the most cost-effective for the induction and maintenance of general Anesthesia. Implications: Using methohexital as an alternative to propofol for the induction of Anesthesia for Ambulatory surgery seems to reduce drug costs. When fresh gas flow rates #1 L/min are used, the combination of methohexital for the induction and desflurane for maintenance may be the most cost-effective general anesthetic technique for Ambulatory surgery. (Anesth Analg 1999;89:311‐6)
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Is the Bispectral Index Useful in Predicting Fast- Track Eligibility After Ambulatory Anesthesia with Propofol and Desflurane?
Anesthesia & Analgesia, 1998Co-Authors: Dajun Song, Janet Van Vlymen, Paul F WhiteAbstract:UNLABELLED This study was designed to test the hypothesis that outpatients with higher electroencephalographic (EEG) Bispectral Index (BIS) values at the end of Anesthesia achieve a modified Aldrete score of 10 and satisfy fast-track eligibility criteria more rapidly after Ambulatory surgery. Sixty consenting women undergoing laparoscopic tubal ligation procedures were studied. After premedication with midazolam 2 mg IV, Anesthesia was induced with propofol 2 mg/kg IV, fentanyl 1.5 microg/kg IV, and succinylcholine 1 mg/kg IV and was initially maintained with either desflurane 4% (n = 31) or a propofol infusion 100 microg kg(-1) min(-1) (n = 29), in combination with nitrous oxide 65% in oxygen. Subsequently, the inspired desflurane concentrations (2%-6%) and propofol infusion rates (50-150 microg.kg(-1) min(-1) were varied to maintain a clinically acceptable depth of Anesthesia. The average BIS value during the 3-min interval immediately before the discontinuation of the maintenance anesthetics was recorded. Emergence times and modified Aldrete scores were assessed from the end of Anesthesia until patients were considered fast-track-eligible. The BIS values at the end of Anesthesia were significantly correlated with the time to reach fast-track eligibility in both the desflurane (r = -0.68) and propofol (r = -0.76) groups. We concluded that the EEG-BIS value at the end of Anesthesia is useful in predicting fast-track eligibility after laparoscopic tubal ligation procedures with either a desflurane- or propofol-based anesthetic technique. IMPLICATIONS In outpatients receiving either desflurane and propofol Anesthesia for laparoscopic tubal ligation surgery, the times to achieve criteria for bypassing the recovery room (i.e., fast-tracking) correlated with the electroencephalographic-Bispectral Index values at the end of Anesthesia.
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use of the laryngeal mask airway as an alternative to the tracheal tube during Ambulatory Anesthesia
Anesthesia & Analgesia, 1998Co-Authors: Girish P Joshi, Paul F White, Yoshimi Inagaki, Lisa Taylorkennedy, Clifford Gevirtz, John M Mccraney, Dori Ann MccullochAbstract:UNLABELLED: We designed a prospective, randomized, multicenter study to compare anesthetic requirements, recovery times, and postoperative side effects when a laryngeal mask airway (LMA) was used as an alternative to the tracheal tube (TT) during Ambulatory Anesthesia. After induction of Anesthesia with midazolam 2 mg, fentanyl 1 microg/kg, and propofol 2 mg/kg, 381 patients were randomly assigned to receive either an LMA (n = 207) or TT (n = 174) for airway management. In patients assigned to the TT group, succinylcholine 1 mg/kg or a nondepolarizing muscle relaxant was administered to facilitate tracheal intubation. Anesthesia was maintained with volatile anesthetics in combination with nitrous oxide 60% and oxygen. The average time to placement of the two airway devices (5 min) and the failure rates (1%) were similar in the two groups. Although there was a significant decrease in the intraoperative fentanyl requirement in the LMA group, the difference was of little clinical significance. Furthermore, there were no differences in the volatile anesthetic requirements. The time from end of surgery to removal of the airway device (5 min) was also similar in the two study groups. Although duration of the postAnesthesia care unit stay and time to ambulation were significantly shorter in the LMA group, there were no differences in the times to "home readiness." The incidence of nausea and vomiting and the need for rescue antiemetic treatments in the postoperative period were similar in the two airway management groups. However, the incidence of postoperative sore throat was significantly greater in patients receiving the TT (versus the LMA). In conclusion, this study suggests that the LMA is a useful alternative to the TT for airway management during Ambulatory Anesthesia. IMPLICATIONS: Use of the laryngeal mask airway can obviate the need for insertion of a tracheal tube for many Ambulatory surgery procedures, and thereby decrease the incidence of postoperative sore throats.
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use of the laryngeal mask airway as an alternative to the tracheal tube during Ambulatory Anesthesia
Anesthesia & Analgesia, 1998Co-Authors: Girish P Joshi, Paul F White, Yoshimi Inagaki, Lisa Taylorkennedy, Clifford Gevirtz, John M Mccraney, Linda I Wat, Dori Ann MccullochAbstract:We designed a prospective, randomized, multicenter study to compare anesthetic requirements, recovery times, and postoperative side effects when a laryngeal mask airway (LMA) was used as an alternative to the tracheal tube (TT) during Ambulatory Anesthesia.After induction of Anesthesia with midazola
Kumar G. Belani - One of the best experts on this subject based on the ideXlab platform.
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fourth consensus guidelines for the management of postoperative nausea and vomiting
Anesthesia & Analgesia, 2020Co-Authors: Tong J Gan, Pierre Diemunsch, Kumar G. Belani, Frances Chung, Sergio D Bergese, Ashraf S Habib, Zhaosheng Jin, Anthony L Kovac, Tricia A MeyerAbstract:This consensus statement presents a comprehensive and evidence-based set of guidelines for the care of postoperative nausea and vomiting (PONV) in both adult and pediatric populations. The guidelines are established by an international panel of experts under the auspices of the American Society of Enhanced Recovery and Society for Ambulatory Anesthesia based on a comprehensive search and review of literature up to September 2019. The guidelines provide recommendation on identifying high-risk patients, managing baseline PONV risks, choices for prophylaxis, and rescue treatment of PONV as well as recommendations for the institutional implementation of a PONV protocol. In addition, the current guidelines focus on the evidence for newer drugs (eg, second-generation 5-hydroxytryptamine 3 [5-HT3] receptor antagonists, neurokinin 1 (NK1) receptor antagonists, and dopamine antagonists), discussion regarding the use of general multimodal PONV prophylaxis, and PONV management as part of enhanced recovery pathways. This set of guidelines have been endorsed by 23 professional societies and organizations from different disciplines (Appendix 1).Guidelines currently available include the 3 iterations of the consensus guideline we previously published, which was last updated 6 years ago; a guideline published by American Society of Health System Pharmacists in 1999; a brief discussion on PONV management as part of a comprehensive postoperative care guidelines; focused guidelines published by the Society of Obstetricians and Gynecologists of Canada, the Association of Paediatric Anaesthetists of Great Britain & Ireland and the Association of PeriAnesthesia Nursing; and several guidelines published in other languages.The current guideline was developed to provide perioperative practitioners with a comprehensive and up-to-date, evidence-based guidance on the risk stratification, prevention, and treatment of PONV in both adults and children. The guideline also provides guidance on the management of PONV within enhanced recovery pathways.The previous consensus guideline was published 6 years ago with a literature search updated to October 2011. Several guidelines, which have been published since, are either limited to a specific populations or do not address all aspects of PONV management. The current guideline was developed based on a systematic review of the literature published up through September 2019. This includes recent studies of newer pharmacological agents such as the second-generation 5-hydroxytryptamine 3 (5-HT3) receptor antagonists, a dopamine antagonist, neurokinin 1 (NK1) receptor antagonists as well as several novel combination therapies. In addition, it also contains an evidence-based discussion on the management of PONV in enhanced recovery pathways. We have also discussed the implementation of a general multimodal PONV prophylaxis in all at-risk surgical patients based on the consensus of the expert panel.
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Nuts and Bolts of Ambulatory Anesthesia Billing
Manual of Practice Management for Ambulatory Surgery Centers, 2019Co-Authors: Jason Habeck, Kumar G. BelaniAbstract:Understanding billing and compliance is important to avoid errors. The rules of billing and processes change and update regularly and require ongoing tracking. The Centers for Medicare and Medicaid Services has a list of procedures that are appropriate in an Ambulatory setting. All patients require ASA physical status and Healthcare Common Procedure Coding System modifier for billing. Anesthesiologists need to comply with the Tax, Equity and Fiscal Responsibility Act for billing. Using a certified electronic health recording technology and participation in the Medicare Access and CHIP Reauthorization Act of 2015 will optimize reimbursement.
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malignant hyperthermia susceptible adult patient and Ambulatory surgery center society for Ambulatory Anesthesia and Ambulatory surgical care committee of the american society of anesthesiologists position statement
Anesthesia & Analgesia, 2019Co-Authors: Richard D Urman, Kumar G. Belani, Niraja Rajan, Steven Gayer, Girish P JoshiAbstract:This document represents a joint effort of the Society for Ambulatory Anesthesia (SAMBA) and the Ambulatory Surgical Care Committee of the American Society of Anesthesiologists (ASA) concerning the safe anesthetic care of adult malignant hyperthermia (MH)-susceptible patients in a free-standing Ambulatory surgery center (ASC). Adult MH-susceptible patients can safely undergo a procedure in a free-standing ASC assuming that proper precautions for preventing, identifying, and managing MH are taken. The administration of preoperative prophylaxis with dantrolene is not indicated in MH-susceptible patients scheduled for elective surgery. There is no evidence to recommend an extended stay in the ASC, and the patient may be discharged when the usual discharge criteria for outpatient surgery are met. Survival from an MH crisis in an ASC setting requires early recognition, prompt treatment, and timely transfer to a center with critical care capabilities.
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succinylcholine use and dantrolene availability for malignant hyperthermia treatment database analyses and systematic review
Anesthesiology, 2019Co-Authors: Marilyn Green Larach, Thomas T Klumpner, Michelle T Vaughn, Andrew Herlich, Janine Limoncelli, Sheila Riazi, Erica L Sivak, Barbara W. Brandom, Kumar G. Belani, John F CapacchioneAbstract:Editor's Perspective What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B Ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.
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succinylcholine use and dantrolene availability for malignant hyperthermia treatment database analyses and systematic review
Anesthesiology, 2019Co-Authors: Marilyn Green Larach, Thomas T Klumpner, Michelle T Vaughn, Andrew Herlich, Janine Limoncelli, Sheila Riazi, Erica L Sivak, Barbara W. Brandom, Kumar G. Belani, John F CapacchioneAbstract:Editor's Perspective What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B Ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.