08 Aug 2015

Dont miss the largest educational event in anesthesiology.
Opening Session: Michael Abrashoff

Former Navy Commander and author of
Its Your Ship.
Saturday, October 24 | 9-10:30 a.m.
In an inspiring story of innovative leadership
and organizational transformation, Mike
Abrashoff took command of the worstperforming ship in the fleet and made it #1
by changing his leadership style and the
culture not the crew.
Charitable Networking Event:

An International Tasting Reception
Central Library at Joan Irwin Jacobs Common
Sunday, October 25 | 6-8 p.m.
Catch up with peers, meet new colleagues
and enjoy an amazing array of food and
beverages while supporting the work
of ASAs Charitable Foundation.
Space is limited; register early.
Welcome Reception
Saturday, October 24 | 5:30-6:45 p.m.
Kick off the ANESTHESIOLOGY 2015
annual meeting by mixing and mingling
with your fellow attendees during the
Welcome Reception at the San Diego
Convention Center in the Connection
Center.
Self-Study Program
Watch for the new Self Study
Stations at ANESTHESIOLOGY 2015!
Self-directed, case-based modules
will offer CME credit and the flexibility
to learn and participate when its
convenient for you.
Register today and save

goanesthesiology.org
Dont miss out!
Be sure to register early to save your seat for PBLDs and

workshops at ANESTHESIOLOGY 2015.
Abstract presentations
Latest in science and technology
Hands-on
workshops
Cadaver workshops
Simulation seminars
Ultrasound workshops
This activity has been approved for AMA PRA Category 1 Credit. Directly sponsored by
the American Society of Anesthesiologists.
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practice of anesthesiology safer for all
With the help of ASA Industry Supporters, the
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advancing the practice of anesthesiology and providing
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deliver the best and safest medical care.
Learn more
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14-398
contents
Volume 79, Number 8

August 2015
features
Total Intravenous Anesthesia:

Present and Future.............................. 10
Eric Rosero, M.D., M.Sc.
Girish P. Joshi, M.B.B.S., M.D., FFARCSI
Establishing and Reinforcing a

Culture of Safety in Anesthesia
Outside of the O.R............................... 12
Keira P. Mason, M.D.
Mohamed Mahmoud, M.D.
Editor
N. Martin Giesecke, M.D., Chair
Assistant Editors
Uday Jain, M.D., Ph.D.
Girish Joshi, M.B., B.S., M.D.
Sadeq Quraishi, M.D.
Kristin Richards, M.D.
Vernon Ross, M.D.
Stephen Rublaitus, D.O.
Karen Sibert, M.D.
Mary Ann Vann, M.D.
Anita Vinjirayer, M.B., B.S., FRCA
Kristina Goff, M.D.

(Senior Residents Review Co-Editor)
Mark Jensen, M.D.
(Junior Residents Review Co-Editor)
Ex Officios
Kenneth Elmassian, D.O.
Editorial Staff
George Kendall
Director, Publications and Digital Content
Terri Navarrete
Graphic Design Manager
Jamie Reid
Publications Assistant
Roy A. Winkler
Postanesthesia Discharge Scoring System

for Pediatric Patients Undergoing
Ambulatory Surgery............................. 16
Pain Management in the

Ambulatory Setting.............................. 20
David M. Dickerson, M.D.
Dexmedetomidine and
Amublatory Surgery.............................. 24
Preoperative Evaluation for

Ambulatory Procedures......................... 28
BobbiJean Sweitzer, M.D., FACP
Aditee Ambardekar, M.D., M.S.Ed.

Girish P. Joshi, M.B.B.S., M.D., FFARCSI
articles
The Latest Science in Anesthesiology......... 30

Joy L. Hawkins, M.D.
William R. Furman, M.D.
Subspecialty Panels: Rise and Shine With

Cutting-Edge Sessions.......................... 34
House of Delegates Sessions at
ANESTHESIOLOGY 2015....................... 38
Steven L. Sween, M.D.
Ronald L. Harter, M.D.
Charitable Networking Event:

An International Tasting Reception............ 40
Brenda A. Gentz, M.D.
Alexander A. Hannenberg, M.D.
Six Years Strong: Run For The Warriors 5K

Coming to San Diego Again This October..... 42
A Case Report From the

Anesthesia Incident Reporting System....... 44
ACE Question..................................... 48
Providing Anesthesia Services Outside
of the Hospital: How Compliant Are You?..... 50
Julie Marhalik-Helms, RN, BSN
SEE Question..................................... 54
Anethesia History Association (AHA) Seeks
Nominations for David M. Little Prize......... 57
Call for Nominations for
ASA Resident Component ...................... 66
AHA Announces 2015 C. Ronald
Stephen, M.D. History Essay Contest ......... 69
Residents Research Essay

Winners Honored................................. 43
Managing Editor, ASA Publications
Send general NEWSLETTER questions

to j.reid@asahq.org or call Jamie Reid
at (847) 268-9112
The ASA NEWSLETTER (USPS 033-200)
is published monthly for ASA members by
the American Society of Anesthesiologists,
1061 American Lane, Schaumburg, IL
60173-4973.
Editor: Newsletter_Editor@asahq.org
website: http://www.asahq.org
Periodical postage paid at Schaumburg, IL
and additional mailing offices.
POSTMASTER: Send address changes to the
ASA NEWSLETTER, 1061 American Lane,
Schaumburg, IL 60173-4973;
(847) 825-5586.
Copyright 2015 American Society of
Anesthesiologists. All rights reserved.
Contents may not be reproduced without prior
written permission of the publisher. The views
expressed herein are those of the authors and
do not necessarily represent or reflect
the views, policies or actions of the
American Society of Anesthesiologists.
departments
Observations....................................... 4
N. Martin Giesecke, M.D.
Administrative Update........................... 6
CEO Report......................................... 8
Paul Pomerantz
Committee News
Committee on Communications................... 56
Payment and Practice Management........ 58

Samia Ayoobi, CCA
Subspecialty News
Society for Neuroscience in Anesthesiology

and Critical Care................................... 62
ASA News......................................... 63
Anesthesiology in the News................... 64
Letter to the Editor............................. 67
Residents Review............................... 68
Daniel A. Hansen, M.D.
Matthew C. Gertsch, M.D.
FAER Report...................................... 70
Classified Ads.................................... 72
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observations
Operating Outside the Operating Room
As Drs. Mason and Mahmoud

discuss in this edition of the ASA
NEWSLETTER, providing anesthesia
care outside of the O.R. has become
much more common over the last two
decades.1 This is certainly true in my
academic practice of anesthesiology. As
a service line, anesthesia departments
are being requested more and more often
to step further away from the O.R. to
provide care for procedures ranging from
plastic surgery to dental restoration,
from interventional pulmonary work to
hysteroscopy. One major difference about
these non-operating room anesthetics
(NORAs) is that compared to the early
days of outpatient surgery, where patient
selection was prospectively controlled
to promote the best outcomes, it seems
as though these NORAs are often
on patients whose condition poses a
significantly greater risk to their own
good outcome.
We are suffering from the benefits
of our own success. Modern anesthetic
agents allow us to provide safe,
controlled-duration anesthesia to
practically every patient presenting to
us. It is only natural that the surgeons
and interventionalists with whom we
work have seen us in action and have
taken comfort from the fact that we are
there. We have freed them from having
to concern themselves with a particular
patients physiologic condition; thus,
they are able to devote their full
concentration to the task at hand. Our
dilemma is that by being successful with
N. Martin Giesecke, M.D.

Editor, ASA NEWSLETTER
our care, our surgeons are presenting us

with ever more difficult patients to care
for. And they are asking us to stop giving
general anesthesia (because it takes too
long for the patient to emerge from the
anesthetic). Besides, they argue, isnt
sedation safer than general anesthesia?
Drs. Mason and Mahmoud also discuss
this issue in their article.1
It is interesting to watch the evolution
of care for these new procedures with
which we are becoming involved. I recall
the early days of doing endovascular
aortic aneurysm repairs. Many of
those patients were enrolled to receive
endostent repair because they were
considered inoperable, most often due
to severe pulmonary disease or extensive
cardiac disease. There were even patients
who were believed to be poor candidates
for endotracheal anesthesia, also due
to their pulmonary disease. It was fun,
even back then, to show everyone that
these patients could indeed tolerate an
anesthetic and be extubated at the end of

the surgical procedure with no apparent
ill effects. It was ironic when one of
those stent procedures took a turn for the
worse, and these patients who were not
surgical candidates just moments before
had to undergo emergent open repairs
of now seriously leaking abdominal
aortic aneurysms. My experience was
that the interventionalists preferred
general anesthesia while they themselves
were in the learning phase of doing
the endostent repairs. After they were
comfortable and proficient with the
procedure, they would begin to say that
general anesthesia was no longer needed.
And at other institutions, I.V. sedation
for these procedures was the norm.
The same progression seems to be
the case for the transcatheter aortic
valve replacements (TAVRs). When the
procedure and the surgical team are in
their infancy at an institution, everyone
wants general anesthesia; everyone
benefits from this arrangement, including
the patient. Then, as the surgical team
becomes more and more proficient with
their skills, they begin to argue that the
current state of the art is to do these
without general anesthesia. I certainly
would not want that for myself or any
of my family members. But maybe Im
an iconoclast.
So here we are, being asked to provide
anesthesia care, whether it be general
anesthesia with potent inhalational
agents or total intravenous anesthesia,
in scenarios further and further from the
comfort of the O.R. And we are being
asked to do this with patients who just
a few years ago would not be considered
August 2015
Volume 79
Number 8
a candidate for a procedure outside the O.R. It will be

interesting to see how far the evolution of medical care takes
us. But let us not forget that first we do no harm. Let us always
remember that we are the standard bearers for patient safety.
water at the lakefront. After that, my duties in the House of

Delegates (HOD) precluded my taking part in the run in
Washington, D.C. the event was held quite a distance from the
HOD meeting, so a quick morning run, followed by a shower
and an on-time arrival at the HOD was no longer possible.
This year, the run is back along the San Diego waterfront.
The start time is advertised as 6:45 a.m. That might just give
me time to enjoy a nice run before the first session of the
HOD convenes. Hope to see you there!
Run For The Warriors

At this years ANESTHESIOLOGY annual meeting, we
will see, and be able to participate in, the sixth consecutive
annual ASA-hosted 5K run/walk to support wounded warriors.
I counted myself as fortunate to be able to participate in
that first Run For The Warriors, also held in San Diego
back in 2010. The course was a pleasant one, winding
through the waterfront park, among the marinas and the
other sights. As luck would have it, I also ran in the second
event, held the following year in Chicago, also along the
References:
1. Mason KP, Mahmoud M. Establishing and reinforcing a culture of

safety in snesthesia outside the Operating Room. ASA News. 2015;
79 (8):12.
Dr. Giesecke (eighth from left) participated with Team Texas in the first Run For The Warriors at ANESTHESIOLOGY 2010 in San Diego.
August 2015
Volume 79
Number 8
administrative update
To Secure the Future

Speaker, House of Delegates
Last May, my wife Barbara and I shared the unique and

joyful experience of witnessing medical school commencement ceremonies at two separate, distinguished institutions of
higher learning. We were there specifically to celebrate the
graduations of our son-in-law at the Tulane University School
of Medicine, who will be pursuing a career in emergency
medicine, and our daughter at the University of Pittsburgh
School of Medicine, who will begin her residency training in
anesthesiology. The experience for me was far more than the
great personal satisfaction and reward inherent in seeing your
children succeed. I was continually drawn, almost compelled, to
reflect upon my own medical school graduation more than three
decades earlier, and the extraordinary opportunity, privilege
and responsibility that a career in medicine brings to those
individuals fortunate and determined enough to achieve that
goal. I am certainly mindful and reasonably concerned about
the tremendous cost, both opportunity and real, of a medical
education, and the long and somewhat uncertain pathway to an
established career in medicine. In spite of those concerns, I am
absolutely heartened by the quality, intellect and character of the
class of 2015 and those that follow. The competencies of future
physicians, future physician anesthesiologists and perioperative
specialists have never been greater, but the challenges and
responsibilities they will assume are certainly daunting and will
require great teamwork, leadership and mentoring.
How can we as a physician community, a medical specialty

society and a dominant nation in health care development and
delivery ensure the success of these physicians? The future of our
medical profession and the lifeblood of our specialty are directly
related to the success and activities of our young professionals.
It is our duty, our responsibility, to guide them and support them
in their pursuit of excellence and success.
Commencement speakers and their messages come in many
different flavors. Our recent experience was unified by one
certain theme: the health care delivery system is currently
Steven L. Sween, M.D., is Chair and

Medical Director, Physician Specialists
in Anesthesia, PC, Atlanta.
August 2015
Volume 79
Number 8
marked by significant change and uncertainty. In fact, Dean

Arthur S. Levine, M.D., at the University of Pittsburgh,
characterized the sweeping changes we are experiencing as the
early years of the Second Revolution in Medicine. He believes
the first revolution in medicine began with the publication of
the Flexner Report in 1910. I think that lends perspective to
the significance and potential magnitude of our changing health
care delivery landscape and the uncertainty of our immediate
future. In spite of this mandate and imperative to substantive
change, I am extremely inspired and reassured by the optimism,
determination and academic/clinical potential of our medical
school graduates. I am hopeful that our greater physician and
medical specialty communities can also move more willingly
and gracefully toward accepting, adopting and managing
change while advocating in the strongest possible terms for
physician-led teams.
Perri Klass, M.D., Professor of Journalism and Pediatrics at

NYU, was the invited guest speaker to the graduating class at
the University of Pittsburgh. She delivered a powerful message,
emphasizing the extremely important and influential role that
physicians play in their respective communities. She gave
detailed accounts, highlighting and contrasting her personal
experiences as physician, mother of a sick patient, daughter of a
sick and dying patient, and renowned author. She reminded the
graduates that the most influential and meaningful physician/
patient relationships are those that extend well beyond the
abnormal biopsy or lab test or imaging study. To maximize your
potential and provide your greatest impact, she encouraged truly
engaging with patients and getting to know them as unique
individuals with widely varying social, economic, ethical and
family considerations. Finally, Dr. Klass reminded the class of
2015 that it is easy to become all-consumed with their chosen
profession. Too often, the intense focus on vocation overwhelms
the avocation, and balance is lost. Never forget that there are
friends and loved ones who seek your attention and need your
influence, just as your patients need you. She reminded that
extending ones reach to nonclinical community activities will
most often enhance your potential as an informed, engaged
clinician.
Both ceremonies included the recitation of a physicians
oath by the graduates. Physician members in the audience were
kindly invited to stand and participate in the oath. A very
powerful moment for me, I was reminded of the extraordinary
privilege, opportunity, trust and responsibility that are vested in
every medical school graduate. It reinforced in a very thoughtful
and moving way my great personal pride in welcoming our firstborn daughter and her husband to my chosen profession, still
the most noble profession: physician. Let our lives and careers
be measured not merely by success, but by significance. Let us
not be defined solely by what we produce, but by the wisdom
and informed, compassionate action that we express toward
those who need us, those who depend upon us. What we do
every day really matters to those we serve.
As we contemplate the future of this great medical specialty
and develop our strategies for growth and continued strength
and significance, let our legacy reflect support for abundant
representation and a strong voice from our young physician
colleagues, who, with our guidance and leadership, will carry
our banner high into the next era.
The competencies of future physicians,

future physician anesthesiologists and
perioperative specialists have never
been greater, but the challenges and
responsibilities they will assume are
certainly daunting and will require great
teamwork, leadership and mentoring.
In the face of certain and possibly transformative change to

our delivery system models, we must not be constrained by that
to which we have become accustomed. Rather, we must dream
and extend our boundaries beyond our comfort zone. We must
encourage our young physician colleagues to pursue their dreams,
to reach out beyond current limits, to broaden their horizon
and to never forget the extraordinary importance of scientific
discovery. It is the depth of scientific study and knowledge
that principally differentiates physician from non-physician
providers. The importance of continued emphasis on scientific
discovery, innovation and academic achievement cannot be
under-emphasized in the Second Revolution of Medicine, and
we, as the entire physician community, must continue to engage
and tirelessly advocate for the essential funding and support of
scientific and clinical discovery.
August 2015
Volume 79
Number 8
CEO report
The Way Up
Paul Pomerantz
Id like to share with you some of what we learned. First,

the survey reflected some interesting demographic shifts.
Practice is moving toward larger groups, multidisciplinary
groups and health systems:
n The percentage of ASA members who work at a community
hospital has declined since 2012 by 6 percent (39 percent in
2012 to 33 percent in 2015), while the percentage working at
a multi-location health system has increased (18 percent in
2012 to 23 percent in 2015).
n
34 percent of members in 2015 reported working at a
single-specialty practice, compared to 44 percent in 2012.
Those who reported working in an academic setting increased
from 29 percent in 2012 to 34 percent in 2015, making the
two groups equal in size.
Up is not an easy direction. It defies gravity, both cultural and

magnetic.

U
.S. Navy Captain D. Michael Abrashoff,
best-selling author and ANESTHESIOLOGY 2015
Opening Session speaker
Id like to thank Chief Quality Officer Richard Dutton,

M.D. for his June report on our progress in data collection
through the Anesthesia Quality Institute, and also Chief
Advocacy Officer Manuel Bonilla for his July update on the
accomplishments of our advocacy and legislative teams. ASA is
busy on many fronts, and I feel its important for our members to
hear from the executive team members who work to serve your
interests and to help improve the value of your membership and
the standing of the society. In reference to Captain Abrashoffs
quote above, were constantly striving to take ASA in only one
direction: up.
Part of our key responsibilities as leaders is to undertake
what Captain Abrashoff calls, listen aggressively. In a large
organization like ASA, we do this in a number of ways, and one
crucial way is through our biannual member survey.
The results also reflect a trend toward younger members

and women:
n
The percentage of members with three years or less of
experience has nearly doubled since 2012 (6 percent to
11 percent), reflecting a strong pipeline and recognition of
value among our young physician members.
n There has been a 5 percent increase in female members since
2012 (23 percent to 28 percent), highlighting increasing
gender diversity within the profession.
Membership Survey
This spring, ASA worked with Avenue M Group, a
company specializing in member needs assessment, to create a
comprehensive survey of the ASA membership. The response
rate was well above industry standards, which indicates ASA
members strong level of engagement. The results were fascinating,
almost unanimously helpful and will be critical in guiding the
course of the society now and in the future.
We were very pleased not only with high level of participation,

but with the positive and valuable commentary we received:
n
66 percent of members say ASA membership is equal to or
greater than the cost of membership.
n 71 percent say that ASA is relevant to their professional lives.
According to the survey, the two areas most frequently listed
that drive the decision to be an ASA member are:
n Continuing Professional Development
(55 percent of respondents).
n Stay informed on the latest clinical information
(51 percent of respondents).
Professional development and clinical resources are major
areas of focus for ASA. This month, we are launching a new
learning management system (LMS) that will greatly improve
the way you interact with our growing catalog of educational
and other ASA resources. The mobile-friendly, responsive design
Paul Pomerantz is
ASA Chief Executive Officer.
August 2015
Volume 79
Number 8
of the newLMS will have features incorporated in the coming

weeks that follow the initial launch to facilitate an easy-touse dashboard, allowing you to track your CME progress,
ABA/MOCA progress, AQI data elements, state licensing
progress in meeting requirements and, in the future, offer screenbased simulation opportunities, among other great features.
There has been a recent increase in the amount of
clinical information in the journal Anesthesiology.As a
result, it has led to improved satisfaction rates seen in the
current survey. When asked What ASA resources did you
use or access in the past year? the journal was cited by
82 percent of survey participants. Almost half of respondents
listed the journal as extremely important and 23 percent were
extremely satisfied with it. We are also in the early stages of
exploring a new peer-reviewed journal devoted solely to clinical
content applicable to your day-to-day practice. Although such
a journal could still be a couple years away, please stay tuned
for more information on this publications progress.
This diversity in membership motivation in ASA is a

challenge and an opportunity. Its a challenge to meet the unique
needs of more than 52,000 individual members, but it is also an
opportunity to capitalize on what we do well, revise what we
can, and strive for continuous improvement and re-invention.
This diversity challenges us and ensures we remain relevant and
valuable to current and future members.
Thanks to each and every member who responded to the
survey. There really were a lot of valuable insights and rich
data generated.
Annual Meeting
We hope many of you have finalized your plans to attend
the ANESTHESIOLOGY 2015 annual meeting in San Diego
this October. Id like to mention one more interesting group
of responses from our survey concerning the way members feel
about ASA overall. The final survey question asked participants
to choose key words and terms that best describe the society.
The top five were: 1) physicians, 2) patient safety leaders, 3)
knowledge experts, 4) perioperative leaders and 5) patient safety
advocates. The word leaders appeared five times in the top 10.
Appropriately, Leadership will be perhaps the most notable
theme running through this years annual meeting, which is
titled Leaders in Perioperative Medicine.
We are particularly excited
about our opening session speaker,
Captain D. Michael Abrashoff,
author of Its Your Ship, who turned
one of the worst-performing ships
in the U.S. Navy into the bestperforming ship of the Pacific
fleet in less than two years.
Captain Abrashoffs methods of
optimizing performance, changing
organizational culture and leading
by example are as applicable in
medicine as they are on a Navy
ship. Im confident youll find his
keynote address both inspirational
U.S. Navy Captain
and valuable.
Member Personas
Segmentation of member attitudes and behaviors identified
five member personas that provide a deeper understanding of
ASA members and their motivations for membership.
n Enthusiasts (20 percent of members) are the most loyal
members. They belong to support the profession, professional
development and to participate in a wide range of ASA
activities and resources. They are primarily mid- and latecareer physicians across all practice settings.
n
Distant Learners (22 percent of members) belong primarily
for professional development and to keep up to date on the
latest clinical information. They prefer self-study education
and are mostly mid- and late-career physicians in small
practice settings.
n
Social Learners (18 percent of members) attend in-person
conferences for the social and networking opportunities as
well as the education. They are more likely to be actively
engaged in their component society as well. These members
are primarily late-career physicians.
n
MOCA Members (26 percent of members) tend to be young
physicians who belong to ASA because they see it as a means
toward meeting MOCA requirements.
n
Passives (14 percent of members) are young and mid-career
physicians who are not very engaged with their profession or
with ASA. They belong to ASA because it is expected, and
usually their employer pays their dues.
August 2015
Volume 79
Number 8
D. Michael Abrashoff
total intravenous anesthesia: Present and Future

Eric Rosero, M.D., M.Sc.
Girish P. Joshi, M.B.B.S., M.D., FFARCSI, Chair

Educational Track Subcommittee on Ambulatory Anesthesia
The availability of short-acting sedative-hypnotics

(i.e., propofol) and opioids (i.e., remifentanil) and smart
delivery systems (e.g., target-controlled infusion [TCI] systems)
have increased the popularity of total intravenous anesthesia
(TIVA). TIVA techniques are increasingly being used in an
ambulatory setting, particularly the office-based anesthesia
(OBA) practice in which the office operating room may
have limited space and minimal equipment,1 as administration
of TIVA does not require an anesthesia machine and
scavenging equipment. In addition, TIVA is associated
with lower incidence of postoperative nausea and vomiting
(PONV) and avoids the risk of malignant hyperthermia
(MH). Although TIVA techniques are generally considered
to be more expensive, the differences in costs between inhaled
anesthetic and TIVA techniques are difficult to measure
because of the many factors that may influence costs.2 Despite
its advantages, TIVA has some limitations. TIVA lacks the
muscle relaxant effects of inhaled anesthesia. Also, in contrast
to inhaled anesthesia where the end-tidal concentrations can be
used for prevention of recall, bispectral index (BIS) monitoring
is recommended during TIVA.3
A typical TIVA technique consists of administration
of propofol with or without remifentanil. When used in
combination, both medications demonstrate synergism,
requiring less dose of each drug to achieve a desired effect, better
hemodynamic stability and earlier recovery from anesthesia.
The infusion rates of one or both drugs are adjusted according
to the degree of surgical stimulation and the interpretation
of a set of clinical responses, as subjectively assessed by the
anesthesia provider. Furthermore, because of the complexity

of drug pharmacokinetics, rapid and accurate achievement of a
constant drug concentration at the effect-site, i.e., the central
nervous system, is not feasible when TIVA is performed using
manually controlled infusion devices.4 Thus, TIVA techniques
using conventional infusion pumps can be challenging and
may be considered empirical.
The development of smart infusion pumps (i.e., TCI
devices) that administer sedative-hypnotics and opioids
according to their pharmacokinetic profiles in order to maintain
desired plasma or effect-site concentrations of the drugs
improves upon the manual TIVA technique.5 These devices
Girish P. Joshi, M.B.B.S., M.D., FFARCSI,

is Professor of Anesthesiology and
Pain Management, and Director,
Perioperative Medicine and Ambulatory
Anesthesia, University of Texas
Southwestern Medical Center, Dallas.
Eric Rosero, M.D., M.Sc., is Assistant

Professor of Anesthesiology and Pain
Management, University of Texas
10
August 2015
Volume 79
Number 8
are equipped with software (i.e., pharmacokinetic models)

that continuously controls the infusion rates of the drugs.
Most current TCI algorithms for anesthesia use threecompartment pharmacokinetic models and include age,
gender, height, weight and lean body mass as covariates.6
The TCI system calculates the dose regimen for each drug,
which usually consists of a bolus dose delivered to fill the central
compartment (i.e., plasma), a constant infusion rate equivalent
to the elimination rate and two exponentially decreasing
secondary infusions to equilibrate the amount of drug transferred
to the peripheral compartments of distribution. The program,
therefore, calculates the expected drug concentration at the
target site and delivers the drugs, adjusting the infusion rates
at preset intervals.
There is evidence that hemodynamic stability, recovery time

and discharge time are improved by the use of TCI systems
compared with manual administration of TIVA. However,
TCI techniques have several limitations, mainly related
to inter-individual variability in pharmacokinetics, which
may lead to poor performance of the models in prediction of
target concentrations. Target concentrations predicted from
pharmacokinetic models are based on an average healthy
patient. However, dosing errors can occur when the model is
applied to patients who deviate from the average population,
such as the morbidly obese or patients at the extremes of age.
Models that use total body weight for the calculations may
overdose morbidly obese patients. Similarly, the elderly have
a smaller central volume of distribution, decreased clearance,
increased receptor sensitivity to drugs and increased time to peak
effect. Therefore, caution should be exerted when using TCI in
this population, especially in sick, elderly patients. Furthermore,
the TCI model does not take into consideration that there is
broad interpatient pharmacodynamic variability (differences
in an individuals sensitivity to the drugs) and that the depth
of hypnosis and antinociception required during a surgical
procedure varies significantly, which requires manual changes in
effect-site concentrations to achieve a required effect.
A step forward in the use of TCI technology is the
implementation of closed-loop controlled anesthesia. This
technique uses concepts of control theory in engineering, where
the aim is to control a system, often called the plant, so its
output follows a desired control signal, called the reference.8,9
An example of a control system is a cars cruise control, a
device designed to maintain vehicle speed at a reference value.
In this case, the controller is the cruise control, the plant is
the car, the system output is the cars speed, and the control
itself is the engines throttle position. A speed monitor sends
data to a controller, which continuously compares it with the
reference speed. The controller calculates the difference (error)
and adjusts the throttle position (the control) to match the
cars speed to the reference speed. In closed-loop controlled
anesthesia, feedback from a measure of the clinical effect is
used to continuously adjust drug infusion rates. The aim is to
provide greater hemodynamic and respiratory stability, more
stable depth of hypnosis and the ability to predict recovery.
An example of closed-loop controlled anesthesia is one
where the plant is the patient; the output can be a measure of
hypnosis (e.g., a BIS value); the controller is a device composed
of a BIS monitor in interface with a TCI system; and the
control is the effect-site target concentration of the anesthetic.
The controller compares the observed BIS value with a
reference value (e.g., BIS of 40 to 60) and adjusts the target
Furthermore, because of the complexity

of drug pharmacokinetics, rapid and
accurate achievement of a constant drug
concentration at the effect-site, i.e., the
central nervous system, is not feasible
when TIVA is performed using manually
controlled infusion devices.
In practice, during TCI, instead of selecting bolus doses and

infusion rates, the anesthesia provider only needs to program
the effect-site target concentrations for the drugs on the TCI
device. The clinician can then change the programed effectsite target concentrations according to patient needs. If the
target concentration needs to be increased, the system will
administer a bolus to rapidly fill the central compartment. The
bolus dose is calculated using data on the central compartment
volume and the difference between the current and the new
target concentration. After the bolus, the infusion restarts at
a new rate to replace the drug that is lost by distribution and
elimination. If the target concentration needs to be decreased,
the anesthesia provider enters the desired target concentration
on the device. The system, then, stops the infusion and waits
until it calculates that the blood concentration has reached
the target concentration and then restarts the infusion at a
lower rate, appropriate to keep the blood concentration at the
target level. Several TCI systems are commercially available
in Europe, Asia, the South Pacific, South America and Africa.
However, TCI devices are not approved for clinical use in the
United States.7
August 2015
Volume 79
Number 8
Continued on page 57
11
Establishing and Reinforcing a Culture of

Chair, Abstract Review Subcommittee on Ambulatory Anesthesia
Ex-Officio, Educational Track Subcommittee on Ambulatory Anesthesia
Over the past two decades, the volume of anesthesia,

sedation and monitored anesthesia care (MAC) demands
in areas outside the O.R. has increased. Frequently, the
patients are medically complex and undergoing high-risk
procedures. The deliveries of anesthesia and sedation in these
non-operating room anesthesia (NORA) areas have been
associated with a comparatively higher risk of mortality than
those anesthetics in the O.R. A closed claims analysis of claims
after 1990 demonstrated that there was a higher proportion
of deaths in remote locations.1 Pediatric dental anesthesia
and sedation has recently garnered attention because of a
perception of higher incidences of untoward events in this area.
A review of closed claims for a leading malpractice insurance
carrier revealed that between 1993 and 2007, there were 13
sedation-related pediatric dental deaths. It is estimated that
there are between 100,000-250,000 pediatric dental sedations
and anesthetics annually,2 In fact, a higher percentage of death
was associated with pediatric dental sedation and anesthesia of
children in the office-based setting between the age of 2-5 years
who received moderate sedation via oral or I.V. route.3
Frequently, the procedures in the NORA environment
are sedation or monitored anesthesia care, and the anesthesia
provider is lulled into believing that sparing a general
anesthetic (GA) will minimize risk. That sedation or MAC is
safer than GA is a myth: The ASA Closed Claims Database
of cases between 1990-2002 showed no difference in the risk
of death and permanent brain damage between MAC and

GA.s Understanding the risks, outcomes, culture and unique
considerations of each particular NORA environment will
guide the physician anesthesiologist in the creation and
implementation of a NORA culture of safety. There is a
growing national and international imperative to improve
quality, safety, efficiency and effectiveness of anesthesia
delivery in NORA. Currently, many institutions are adopting
process improvement initiatives, which are creative and
dynamic ways of changing institutional culture in which all
members within the organization have input. To establish and
maintain a safety culture, change-making must be an integral
part of everyones job, every day, in all parts of the system.
This review will incorporate the pertinent literature and
authors extensive clinical NORA experience in highlighting
methods to improve safety.
Building and Maintaining a Culture of Safety
Leape asserted in 1994 that errors in medicine are inevitable,
even among the most conscientious professionals operating with
and under high standards. He reflected that these errors reflect
system and not character flaws,5 and Leapes vision parallels
those of the airline and nuclear power industry. In fact, the
original term safety culture emerged from the analysis of the
1986 Chernobyl nuclear power plant accident. An inadequate
culture of safety may have contributed to this accident.
Keira P. Mason, M.D., is Associate

Professor of Anesthesia, Department of
Anesthesiology, Perioperative and Pain
Medicine, Boston Childrens Hospital
and Harvard Medical School, Boston.
She is also Chair, ASA Abstract
Review Subcommittee on
Ambulatory Anesthesia.
Mohamed Mahmoud, M.D. is

Associate Professor of Clinical
Anesthesia and Pediatrics, Department
of Anesthesiology, Cincinnati Childrens
Hospital Medical Center, Cincinnati.
12
August 2015
Volume 79
Number 8
Safety in Anesthesia Outside of the O.R.
Defenses in Depth
Figure 1: The role of multiple defenses in preventing system failure; despite inevitable defects, multiple layers of system defenses effectively shield
the patient (adapted from Reasons Swiss cheese model, Reason J. Human Error. New York, Cambridge University Press, 1990).
The root cause of this disaster was multifactorial, not attributed

to just human performance or flaws in the engineering design
or equipment. Similarly, in medicine, there is a growing body
of literature to support that the majority (at least 80 percent) of
medical errors are multifactorial and system-derived, attributed
to system flaws, processes and conditions that lead people to make
mistakes or fail to prevent them.6 Adverse drug events, improper
transfusions, wrong-site surgery, miscommunications during
hand off and transitions in care, and inadequate preoperative
assessment (failure to identify a documented difficult airway),
preparation and postoperative care, are just a few examples of
potentially preventable errors.
A culture of safety in health care can be thought of as one
in which staff has positive perceptions of psychological safety,
teamwork and leadership and feel comfortable discussing
errors.7 The workforce and processes in this culture should focus
on improving the reliability and safety of care for patients by
August 2015
Volume 79
Number 8
encouraging open discussion of mistakes, open reporting of

near-misses and incidents without fear of reprisal, transparency
and creating systems-based thinking as opposed to blaming
individuals. Rarely is a significant adverse outcome the fault of
one person, device or system alone. The Swiss cheese model of
accident causation adopted from Reason (Figure 1) identifies
accidents as the result of successive layers of defenses, barriers
and safeguards being breached.8,9 This causation theory is
recognized not only in medicine but also in the airline industry.
One of the best-studied laboratories of this science has been the
aviation industry.
Research in commercial aviation has demonstrated
important ties between teamwork and performance. Frequently,
an analogy between the pilot and the anesthesiologist is made
the anesthesiologist being the pilot of his or her patient.10,11
13
Continued from page 13
As early as the 1920s, the aviation industry began to take a

careful look at improving safety via systematic approaches.
An important association between teamwork and safety was
most obvious after plane crash investigations exposed cockpit
crew members reluctance to question a captains performance
as a root cause of aviation accidents. Up to 30 percent of all
aircraft accidents are the result of human error. Similarly, in the
health care environment, there are now multiple professionals
and caregivers of different qualifications (registered nurses,
nurse anesthetists, physician assistants, nurse practitioners,
medical residents, anesthesia and surgical residents and fellows,
staff surgeons and anesthesiologists) who play a role in the
care of the patient. Multiple caregivers have been shown to
hamper communication and teamwork.12-14 Teamwork and
communication is critical, and an applicable model to establish
teamwork cites five critical components: team orientation, team
leadership, mutual performance monitoring, back-up behavior
and adaptability.15
Table 1: Eight Steps Required to Achieve

Patient Safety and High Reliability
The workforce and processes in this

culture should focus on improving the
reliability and safety of care for patients
by encouraging open discussion of mistakes,
open reporting of near-misses and incidents
without fear of reprisal, transparency
and creating systems-based thinking as
opposed to blaming individuals.
Step One:
Address Strategic Priorities,

Culture and Infrastructure
Step Two:
Engage Key Stakeholders
Step Three:
Communicate and Build Awareness
Step Four:
stablish, Oversee and

E
Communicate System-Level Aims
Step Five:
Track/Measure Performance
Over Time, Strengthen Analysis
Step Six:
upport Staff and Patients/Families

S
Impacted by Medical Errors
Step Seven:
Align System-Wide Activities

and Incentives
Step Eight:
Redesign Systems and Improve

Reliability
an example of the proposed eight steps required to achieve

patient safety and high reliability at any institution.18
Identifying role models is critical in order to champion a
culture of safety. Not all role models need be at the top of the
hierarchy. The term positive deviants has been applied to those
who are unique role models and able to make positive changes.
Specifically, positive deviance is the observation that in most
settings a few at-risk individuals follow uncommon beneficial
practices and consequently experience better outcomes than
their neighbors who share similar risks.19 Identifying positive
deviants and allowing them to be role models for change can
shift the culture of a community and produce a positive change.
In health care, we should seek out such deviants to improve our
culture of safety.
Root cause analysis in medicine is important not only to
debrief after an untoward event but also to review existing
practice for the possibility of making improvements. A rootcause analysis is an attempt to problem-solve, define the
problem, analyze how it happened and then, finally, consider
how to prevent this occurrence in the future. In medicine, a root
cause analysis frequently leads to a review and amendment of
existing policies, procedures and guidelines. Guidelines, policies
and procedures do not ensure safety. Rather, they must be
followed and amended if necessary. For example, a review at one
institution demonstrated that after the implementation of Joint
Commission Procedural Sedation and Analgesia Guidelines
in 2001, the adverse event rate in the hospital decreased.20 In
contrast, a review of sedation practice in the Netherlands and
The willingness of personnel to speak up about a patientsafety concern is a critical component of safety in NORA
locations. Individual organizations should work on creating a
culture where any care provider, at any level, can speak up and
provide feedback on potential system inefficiencies and safety
concerns and can feel that their input is desired and respected
instead of using shame-and-blame methodology. Similarly, in
the aviation industry, the Crew Resource Management system
began in the 1980s and focused on non-technical skills such as
open communication without barriers in an effort to improve
teamwork. The airline industry identified the importance of
this approach soon after it implemented checklists.16,17 In health
care, such a culture requires transparency, professionalism and
collegiality initiating from the leadership of the institution
(clinicians, executives and governing bodies). Table 1 provides
14
August 2015
Volume 79
Number 8
among different medical specialists in the U.S. revealed that

they do not follow their own guidelines and recommendations
for competency, emergency preparedness and physiologic
monitoring.21,22 Hypoxia and respiratory depression have been
identified as the most significant risk factors for morbidity
and mortality in NORA. Pulse oximetry and capnography
should be implemented as standard of care during GA, MAC
and sedation.1,4,23
Establishing a culture of safety in NORA requires a

multisystem approach. Simple interventions such as the
implementation of checklists that are tailored to the particular
NORA environment should have positive effects. The
outcomes of these NORA-implemented checklists should be
evaluated and modified on a regular basis and re-evaluated after
critical events. All critical events require a root cause analysis
with subsequent implementation of change, if needed. A culture
of safety requires that all hierarchical barriers between health
care providers be removed and that there be a culture of nofault and open communication. Different NORA environments
(radiology, gastroenterology, ambulatory locations) may have
unique procedural nuances and may pose different challenges
(the magnetic environment of the MRI suite, for example).
A core group of individuals who comprise a team is the best
approach to optimizing care and creating the safest environment
possible. A critical review of even the near miss events can lead
to the implementation of pre-emptive processes that can reduce
or mitigate unfavorable outcomes. Hospital staff in partnership
with leadership and positive deviants as role models should
champion a broader view of all components and potential risk
factors of the NORA microcosm.
Role of Checklists and Simulation in Safety Culture

Checklists to establish a routine and, in the case of an
emergency as a reminder list of critical steps, were introduced
by the airline industry as early as 1935, after the crash of the
newly introduced and more complex Boeing Model 299. The
skilled and experienced pilot omitted a critical step, attributed
to the complexity and inexperience with this newly introduced
model.17,24 In medicine, almost 70 years after the introduction of
checklists in the aviation industry, checklists were championed
in the medical realm.24 Applying and modifying the Gawande
checklist and adopting a World Health Organization
Safety Checklist in the O.R. have reduced adverse events
intraoperatively and postoperatively.24-28 The implementation
of checklists, tailored to each NORA environment, should be
implemented to promote patient safety by ensuring the patient,
team, equipment and systems are optimally configured at every
key transition.29 Emerging studies in simulation have shown
that these checklists reduce the amount of crucial steps that are
missed in rare intraoperative emergencies.30
One of the most exciting training innovations in medicine
has been the development of high-fidelity simulation to prepare
providers for error-prone, high-risk or unusual situations.31
Emerging studies showed that safety was enhanced when
simulation was incorporated into physician and resident
(trainee) training.32,33
References:
1. Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia
at remote locations: the US closed claims analysis. Curr Opin
Anaesthesiol. 2009;22(4):502-508.
2.
Chicka MC, Dembo JB, Mathu-Muju KR, Nash DA, Bush HM.
Adverse events during pediatric dental anesthesia and sedation:
a review of closed malpractice insurance claims. Pediatr Dent.
2012;34(3):231-238.
3. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated
with pediatric dental sedation and general anesthesia. Paediatr
Anaesth. 2013;23(8):741-746.
4. Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino
KB. Injury and liability associated with monitored anesthesia care: a
closed claims analysis. Anesthesiology. 2006;104(2):228-234.
5. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857.
6. Leonard MS, Frankel A, Simmonds T, Vega KB. Achieving Safe
and Reliable Healthcare: Strategies and Solutions. Chicago: Health
Administration Press; 2004:5.
7. Leonard M, Frankel A. How can leaders influence a safety culture?
Thought paper. The Health Foundation website. http://www.health.
org.uk/publications/how-can-leaders-influence-a-safety-culture/.
Published May, 2012. Accessed June 12, 2015.
8. Reason JT. Human Error. Cambridge, England: Cambridge University
Press; 1990.
9. Reason JT. Managing the Risks of Organizational Accidents. Aldershot,
Hants, England: Ashgate; 1997.
10. Helmreich RL, Merritt AC. Culture at Work in Aviation and Medicine:
National, Organizational, and Professional Influences. Aldershot,
Hants, England: Ashgate; 1998.
Concluding Thoughts for the Future of Safety in NORA

Although all improvement involves change, not all changes
result in improvement. We need measurements to help
monitor safety culture. In 2004, the Agency for Healthcare
Research and Quality (AHRQ) released a hospital staff survey
on patient safety culture to help hospitals assess the culture
of safety in their institutions (www.ahrq.gov/professionals/
quality-patient-safety/patientsafetyculture/hospital/index.
html). Statements of this survey are assessed on a scale of 1 to 5.
Examples of statements include, Staff feels like their mistakes
are held against them and Please give your work area/unit in
this hospital an overall grade on patient safety. It is important
to have an active patient safety committee that meets regularly
to identify, review and analyze these adverse safety events data.
August 2015
Volume 79
Number 8
For a complete list of references, please refer to the back of the

online version of the ASA NEWSLETTER at asahq.org or email
Jamie Reid at j.reid@asahq.org.
15
Postanesthesia Discharge Scoring System for

Pediatric Patients Undergoing Ambulatory Surgery
Aditee Ambardekar, M.D., M.S.Ed.
Girish P. Joshi, M.B.B.S., M.D., FFARCSI, Chair

Educational Track Subcommittee on Ambulatory Anesthesia
Advances in surgical techniques and anesthetic delivery

coupled with paradigm shifts related to health care
delivery and finance have dramatically increased the throughput
of pediatric surgical patients in the ambulatory care setting.
In just a 10-year span, we have seen an almost 50 percent
increase in the number of anesthetics delivered to children
in ambulatory surgery centers (ASC), totaling 2.3 million in
2006.1 With the increase in surgical procedures performed on an
outpatient basis, ASCs are forced to be more efficient with
respect to rapid discharge home. Therefore, strategies for
efficiently assessing postoperative home readiness will be
imperative to keep up with the throughput demands of pediatric
patients in ASCs.
It is well accepted that discharge from an ambulatory setting
should not be time-based, as it may prolong the recovery
process unnecessarily. The updated practice guidelines for postanesthetic care by ASA suggest that a mandatory stay should
not be required and discharge criteria should be designed to
minimize post-discharge risk of central nervous system and
cardiorespiratory depression.2 Thus, there is a move away from
time-based discharge to clinical-based discharge.
The postanaesthesia discharge scoring system (PADSS) is
the most commonly used tool to determine home readiness.3,4
This scoring system requires that patients have stable vital
signs, can ambulate at preoperative level, and have minimal
postoperative nausea and vomiting (PONV), pain and
bleeding. In the updated PADSS, the need for mandatory

oral intake and voiding before discharge has been eliminated
(Table 1). In fact, the PADSS has now become the gold standard
in home readiness after ambulatory surgery in adults. However,
criteria developed and validated for the adult population are
not always applicable to the pediatric outpatient population.
The evolution of discharge criteria for pediatric patients and
validation is necessary to ensure clinical applicability.
Aditee Ambardekar, M.D., M.S.Ed. is

Assistant Professor of Anesthesiology
and Pain Management, University
of Texas Southwestern Medical
Center, Dallas, and is a member of
the pediatric anesthesiology faculty,
Childrens Medical Center, Dallas.
Girish P. Joshi, M.B.B.S., M.D., FFARCSI,

is Professor of Anesthesiology and
Pain Management, and Director,
Perioperative Medicine and Ambulatory
Anesthesia, University of Texas
16
August 2015
Volume 79
Number 8
Table 2: Postanesthesia Discharge Scoring System

for Determining Home-readiness in
Pediatric Outpatients
Table 1: Modified Postanesthesia Discharge

Scoring System for Determining Home-Readiness
Vital Signs
Vital Signs1
Blood pressure and pulse within

20% of preoperative value
Blood pressure and pulse

20-40% of preoperative value
Blood pressure and pulse within 20% of

preoperative value
Blood pressure and pulse > 40%

of preoperative value
Blood pressure and pulse 20-40% of

preoperative value
Blood pressure and pulse > 40%

of preoperative value
Activity Level
Activity Level
Steady gait, no dizziness,

or meets preoperative level
Requires assistance
Unable to ambulate
Nausea and/or Vomiting

Minimal: successfully treated with oral medication
Moderate: successfully treated with intramuscular

medication
Severe: continues after repeated treatment
Not acceptable
Moderate: up to two dressing changes required
Severe: more than three dressing changes

required
Number 8
Minimal: no anti-emetic needed
Moderate: vomiting controlled by one dose of

anti-emetic drug
Severe: continues despite one dose of

anti-emetic drug
Yes (VAS2 < 3 or OPS3 < 3)
No (VAS > 3 or OPS >3)
Minimal: does not require dressing change
Moderate: up to two dressing changes required
Severe: more than three dressing changes

required
In the event that a preoperative blood pressure was not

obtainable due to patient anxiety, heart rate alone can be
used as a reference point.
2
Visual Analog Scale.
3
Objective Pain Scale.
Score 9 and absence of 1) breathing difficulty or hoarseness,
2) request from parents to see anesthesiologist before
discharge, and 3) requirement of anesthesiologist to see
parents or child before discharge are required for discharge;
Adapted from Moncel JB, et al. Ped Anes. 2015.6
Volume 79
Unable to ambulate or hypotonic
Recent publications describe the development and

evaluation of a pediatric-specific discharge tool for ambulatory
surgery that may enable pediatric ASCs to efficiently yet
safely handle exceptionally high throughput.5,6 Biedermann et
al.5 adapted the PADSS to reflect the physical and emotional
developmental variations in the pediatric population. Where
steadiness of gait and ability to ambulate are scored in
PADSS, axial and peripheral tone are instead evaluated in
Ped-PADSS. The ability to obtain an accurate preoperative
blood pressure can be challenging in a child who is upset or
Surgical Bleeding
Score 9 required for discharge;

Marshall and Chung: Anesth Analg. 1999; 88:508-17.4
August 2015
Requires assistance to walk or reduced level of

activity (if developmentally unable to walk)
Pain
Surgical Bleeding
Minimal: does not require dressing change
Nausea and/or Vomiting
Pain
Acceptable
Steady gait, no dizziness, or meets preoperative

level (if developmentally unable to walk)
17
fighting, thus only heart rate is considered when evaluating

proximity to baseline hemodynamics. Severity of PONV
was assessed based on the need for antiemetic therapy. In absence
of antiemetic therapy, PONV was graded minimal. If only
one dose of antiemetic was administered, PONV was graded as
moderate. The need for more than one antiemetic dose graded
PONV as severe. Finally, age-appropriate pain scales are used
in assessing the level of pain as acceptable or not acceptable.
Moncel et al.6 added three additional caveats to the use of
the assessment tool described by Biedermann et al.5 Absence
of 1) postoperative respiratory compromise, 2) request by the
patient or patients family to consult with the anesthesiologist
and 3) an order from the anesthesiologist to see the patient
before discharge were three conditions necessary to authorize
discharge using the score alone. This ensures not only the safety
of the patient but also the value-add to efficiency of the system
for not requiring an anesthesiologists input regarding readiness
for discharge. Ped-PADSS scores above 9 are considered
necessary for readiness for discharge home so long as the above
three caveats were not present (Table 2, previous page).
for delayed vomiting and dehydration, as children typically

have a greater incidence of vomiting after discharge from the
hospital.7,8 None of the 1,041 children who were discharged
home on the basis of the scoring system required readmission
within two days of surgery. Furthermore, investigators noted a
decrease in postoperative stay by 69 minutes when comparing
the median postoperative length of stay before and after
institution of the Ped-PADSS.
In summary, unnecessary delay in discharge reduces the
effectiveness and efficiency of an outpatient setting. On the
other hand, premature discharge from the hospital may increase
the incidence of readmission and postoperative complications
and may have legal repercussions. The use of criteria that are
simple, clear, objective and reproducible provides a reliable
guide for safe discharge of outpatients. The recently reported
Ped-PADSS is the latest in the evolution of the discharge
assessment tools, specifically for use in pediatric ambulatory
patients. It includes parameters necessary to prove not only
emergence from anesthesia and return of physiologic parameters
but also home-readiness while under the supervision, at home,
of a responsible adult. It is important to recognize that homereadiness is not synonymous with complete recovery from
anesthesia and surgery. Therefore, parents should be given
clear instructions and cautioned against patients performing
functions that require complete recovery. This proposed
Ped-PADSS tool is easy to apply, allows safe and expeditious
discharge home, and decreases postoperative length of stay. The
impact on resource utilization, personnel needs and thus facility
costs still remains to be seen.
The use of criteria that are simple,

clear, objective and reproducible
provides a reliable guide for safe
discharge of outpatients.
References:
1. Rabbitts JA, Groenewald CB, Moriarty JP, Flick R. Epidemiology of

ambulatory anesthesia for children in the United States: 2006 and
1996. Anesth Analg. 2010;111(4):1011-1015.
2. American Society of Anesthesiologists Task Force on Postanesthetic
Care. Practice guidelines for postanesthetic care: an updated report.
Anesthesiology. 2013;118(2):291-307.
3. Chung F, Chan VW, Ong D. A post-anesthetic discharge scoring
system for home readiness after ambulatory surgery. J Clin Anesth.
1995;7(6):500-506.
4. Marshall SI, Chung F. Discharge criteria and complications after
ambulatory surgery. Anesth Analg. 1999;88(3):508-517.
5. Biedermann S, Wodey E, De La Briere F, Pouvreau A, Ecoffey
C. Paediatric discharge score in ambulatory surgery [in French].
Ann Fr Anesth Reanim. 2014;33(5):330-334.
6. Moncel JB, Nardi N, Wodey E, Pouvreau A, Ecoffey C. Evaluation
of the pediatric post anesthesia discharge scoring system in an
ambulatory surgery unit [published online ahead of print January 8,
2015]. Paediatr Anaesth. 2015;25(6):636-641. doi: 10.1111/pan.12612.
7. Schreiner MS, Nicolson SC, Martin T, Whitney L. Should
children drink before discharge from day surgery? Anesthesiology.
1992;76(4):528-533.
8.
Schreiner MS, Nicolson SC. Pediatric ambulatory anesthesia:
NPO-before or after surgery? J Clin Anesth. 1995;7(7):589-596.
The feasibility and safety of the Ped-PADSS scoring system

was assessed in a prospective, observational cohort study of
1,060 pediatric ambulatory surgical patients.6 Healthy children,
ASA Physical Status 1 and 2, between the ages of 6 months
and 16 years undergoing ambulatory surgery, were evaluated by
nurses at one-hour intervals after arriving in the postanesthesia
care unit (PACU). Ped-PADSS scores at one hour and two
hours exceeded 9 in 97.2 percent and 99.8 percent of the
patients, respectively. Nineteen children were excluded from
the study due to unanticipated postoperative hospitalization or
incomplete scoring by nursing staff. While PONV was a reason
that two of the 1,041 children had prolonged PACU stay and was
reported as a persistent symptom at home (3.5 percent) the day
after surgery, the authors discuss the value in risk stratification
in the guidance of appropriate antiemetic therapies rather than
oral challenge. Oral challenge as a requisite to discharge, in fact,
increases the incidence of vomiting by more than 50 percent in
children, prolongs hospital stay, and is not necessarily a surrogate
18
August 2015
Volume 79
Number 8
Industry Supporters
Congratulations on the success of the Annual

Perioperative Surgical Home Summit held in
Huntington Beach this summer. ASA is grateful for the
generosity of the ASA Industry Supporters and Summit
Supporters. With their help, ASA continues to work on
improving the delivery of healthcare for all patients.
The Summit was sponsored by the American Society
of Anesthesiologists and University of California, Irvine
Department of Anesthesiology and Perioperative Care.
Thank you
PSH Summit Supporters
14-414
asahq.org/corporatesupport
pain management in the
David M. Dickerson, M.D.
Because pain and nausea have been identified as the

two primary causes of unexpected hospital admission or
delayed discharge after ambulatory anesthesia, an intense
focus on effective, opioid-sparing analgesia has developed.1-3
Despite myriad new techniques in regional anesthesia and novel
non-opioid therapies, rates of moderate and severe uncontrolled
pain persist.4 Despite developments in therapeutics, several
questions can be raised: Are patients becoming more challenging
to treat? Are surgeries becoming more painful? Are physician
anesthesiologists undertreating pain? Do the current methods of
pain management recognize pain as a complex, individualized
experience? Through a better understanding of the experience
of pain and a system for treating postsurgical pain, surgical
outcomes and patient experience can be improved.
All Pain is in the Brain
The pain experience depends on the patient, injury or
pain management characteristics. Pain is grossly subjective
and highly individualized. It has been described as what the
patient says it is. More formally, the International Association
for the Study of Pain (IASP) defines pain as an unpleasant
sensory and emotional experience related to actual or potential
tissue damage.5 As a nociceptive afferent impulse relays
from the periphery to the somatosensory cortex, the patient
feels the sensation of pain; yet this same impulse relays to
limbic structures resulting in an emotional response.6 Loesers
biopsychosocial model of pain incorporates a separation
between nociception, pain and suffering.7 Some patients with
a high degree of nociception, which results in an unpleasant

sensory and emotional experience (pain), may not suffer as
much as others because endogenous protective mechanisms
produce analgesia or modulate the quantum of nociceptive
afference. Pain may result from nociceptive afference or even
in its absence. It has been suggested that pain education
should emphasize a sociopsychobiological perspective of pain.8
Without a common delineation of pain from suffering and other
unpleasant phenomenon, its effective amelioration remains a
conundrum for outcomes research and clinical care.
A Systematic Approach to a
Highly Subjective Phenomenon
My residents and fellows manage perisurgical pain with
the three Is: identify, implement and intervene. By identifying
patients at increased risk, implementing broad, costeffective multimodal analgesia and intervening when the
implemented plan falls short, the ambulatory anesthesiologist
can reduce the number of potential delayed discharges and
unanticipated admissions.
David M. Dickerson, M.D., is

Assistant Professor, Anesthesiology
and Pain Management,
University of Chicago. He is Chair
of the Society for Ambulatory
Anesthesia Website Committee.
20
August 2015
Volume 79
Number 8
ambulatory setting
Risk Stratification
In a perfect world, a patient would complete a simple
questionnaire in the surgeons office that gathers key data
on pain history. Questions are straightforward: Do you have
frequent or daily pain? Have you taken pain medicine for
longer than the past month? Have you had issues with pain
control after surgery? Do you have nausea with pain medication?
Do you have obstructive sleep apnea? Do you have a history
of anxiety? Do you take buprenorphine (Butrans, Subutex,
Suboxone), Oxycontin, Opana, or methadone or wear a
fentanyl patch? Do you expect to go home after your surgery?
Do you believe your pain will keep you from being able to go
home? If you have a pain physician, have you discussed your
upcoming surgery and discussed a plan for the management of
any chronic pain issues postoperatively? The responses, the
patients body mass index, problem list and specific location of
surgery are given to the anesthesiology group before the day of
surgery for treatment planning. While more work preoperatively,
such risk-stratification and preparation could optimize a patients
experience after surgery. Concerned patients may find such
questions comforting because they affirm the physicians focus
on pain control.
If screening cannot be performed preoperatively within
days or weeks, on the day of surgery, a detailed history and
physical examination will identify patient characteristics that
reflect difficult pain control or aberrant pain processing. These
include opioid tolerance or intolerance, opioid antagonist
or partial agonist therapy, history of chronic pain, anxiety
disorders, comorbidities that may alter the therapeutic
window for analgesics, and previous uncontrolled severe
postoperative pain. A questionnaire may be used to streamline
information gathering.
Once a patient is identified as having a high risk for
uncontrolled postsurgical pain, the additional steps required by
the anesthesia team and surgical team should be discussed with
the surgeon and the patient. This meeting should be patientcentered and multidisciplinary and include the surgical team.
At first, patients and surgeons may not recognize the complexity
of the situation and the inherent challenges in achieving safe,
effective analgesia. Every challenging patient offers a chance to
advance the education of the clinical group as long as someone
is willing to illustrate the nuances and lead the discussion.
Implementing Valuable Multimodal Analgesia

Based on the patients risk for uncontrolled postoperative
pain or chronic postsurgical pain, the anesthetist can implement
meaningful, cost-effective multimodal analgesia. Much like
developing a plan for airway management, goals are identified
(e.g., reduce opioid exposure, prevent hyperalgesia from
unattenuated nociceptive afference, minimize side effects
and risks from non-opioids) and contingencies are defined
(e.g., rescue blockade, additional analgesics in recovery).
Preoperatively, when appropriate, the anesthesiologist discusses
the risks and benefits of postoperative regional anesthesia (rescue
blocks) if regional anesthesia is not administered preoperatively.
Following ASAs guidelines for acute postoperative pain, a
non-opioid with or without an opioid analgesic is administered
and, when appropriate, combined with a regional anesthetic
technique. The guidelines, however, do not delineate the
number of non-opioids. After reading Dr. Atul Gawandes
most recent piece in The New Yorker, Overkill, I considered
the many potential low-value interventions in acute pain
management.9 Such agents cost more with equivocal efficacy or
risk reduction compared to their less expensive counterparts. In
some surgical centers and in the name of preemptive analgesia,
on the day of surgery patients are given a medication with a
narrow margin of comparative benefit for the additional cost.
Such costs contribute to the high costs of health care and create
an ethical dilemma for the anesthetist.
For effective non-opioid therapy, ambulatory patients may
benefit from an oral dose of diclofenac, celecoxib, acetaminophen
or gabapentin before surgery with a sip of water to replace
intravenous formulations of these agents intraoperatively.10
Intravenous formulation may be reserved as rescue agents when
conventional care falls short or for patients at a high risk for
uncontrolled postoperative pain.
Pain care for specific ambulatory surgical procedures
may optimize outcomes via enhanced recovery after surgery
protocols.11 The pathway for patients at higher-than-baseline
risk for postoperative pain may incorporate additional
preoperative and postoperative contingencies. Intravenous
acetaminophen, increased potency opioids (e.g., oxycodone
rather than hydrocodone) or a supplemental regional technique
are adjuncts for an opioid-tolerant patient or for patients with
uncontrolled pain while on the standard pathway.
August 2015
Volume 79
Number 8
21
exposure. Chronic pain patients are reminded that flare-ups are

possible postoperatively. The chronic pain physician and surgeon
initiate the plan in place for such an event while the anesthetist
minimizes causes of hyperalgesia and optimizes control of the
surgical pain. Ultimately, if preoperatively a patient feels he or
she will not be able to go home after surgery, the reason should
be explored and, if valid, a non-ambulatory setting considered.
When Multimodal Analgesia Falls Short:

Timely, Cost-Effective Intervention
Blanketing intervention preoperatively or intraoperatively
may overexpose a patient to unnecessary procedures and cost.
Regional anesthesia is low-risk, but never risk-free. Cost can
depend on the supplies, agents and personnel involved.12 In
accepting the challenge to implement effective multimodal
analgesia without increased risk or cost, however, some patients
may be undertreated, resulting in secondary hyperalgesia and
potential increased cost downstream through unanticipated
admission or delayed discharge. Conversely, overtreatment may
result in unnecessary spending. Selecting high-risk patients
for additional analgesics and exposing them to the additional
interventions preemptively may achieve the highest value.
Regardless, a system for response to uncontrolled pain in the
recovery room should be in place for timely intervention.
Contingency plans for additional analgesia should be discussed
with recovery room nursing personnel at the time of handoff.
Adequate staffing and equipment for a supplemental or primary
regional anesthetic should be available.
Investing in a Modern Approach

Effective pain care is a highly complex effort achieved
through multidisciplinary communication, risk stratification,
implementation of multimodal analgesia, including regional
anesthesia, and timely intervention in the operating room or
recovery room when these strategies fall short. While only one
aspect of anesthesia care, expertise in pain management defines
an anesthesia consultant.
References:
1. Coley KC, Williams BA, DaPos SV, Chen C, Smith RB. Retrospective
evaluation of unanticipated admissions and readmissions after same
day surgery and associated costs. J Clin Anesth. 2002;14(5):349-53.
2. Pavlin DJ. Pain as a factor complicating recovery and discharge after
ambulatory surgery. Anesth Analg. 2002;95(3):627-634.
3. Pavlin DJ, Chen C, Penaloza DA, Buckley FP. A survey of pain and
other symptoms that affect recovery process after discharge from
an ambulatory surgical unit. J Clin Anesth. 2004;16(3):200-206.
4. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence,
patient satisfaction, and perceptions of post-surgical pain: results
from a US national survey. Curr Med Res Opin. 2014;30(1):149-160.
5. Merskey H, Lindblom U, Mumford JM, Nathan PW, Sunderland S.
Pain terms: a current list with definitions and notes on usage. In:
Merskey H, Bogduk N, eds. Classification of Chronic Pain. 2nd ed.
Seattle: IASP Press; 1994.
6.
Basbaum AI, Bautista DM, Scherrer G, Julius D. Cellular and
molecular mechanisms of pain. Cell. 2009;139(2):267-284.
7.
Loeser JD. Perspectives on pain. In: Turner P, ed. Clinical
Pharmacology & Therapeutics: Proceedings of Plenary Lectures
Symposia and Therapeutic Sessions of the First World Conference on
Clinical Pharmacology & Therapeutics. London: MacMillan; 1980.
8. Carr DB, Bradshaw YS. Time to flip the pain curriculum.
Anesthesiology. 2014;120(1):12-14.
9. Gawande A. Overkill. The New Yorker. May 11, 2015:42-53.
10. American Society of Anesthesiologists Task Force on Acute Pain
Management. Practice guidelines for acute pain management
in the perioperative setting: an updated report. Anesthesiology.
2012;116(2):248-273.
11. Miller TE, Thacker JK, White WD, et al.; Enhanced Recovery Study
Group. Reduced length of hospital stay in colorectal surgery after
implementation of an enhanced recovery protocol. Anesth Analg.
2014;118(5):1052-1061
12.
Mariano ER. Making it work: setting up a regional anesthesia
program that provides value. Anesthesiol Clin. 2008;26(4): 681-692.
13.
Clarke H, Kirkham KR, Orser BA, et al. Gabapentin reduces
preoperative anxiety and pain catastrophizing in highly anxious
patients prior to major surgery: a blinded randomized placebocontrolled trial. Can J Anesth. 2013;60(5):432-443.
At first, patients and surgeons may not

recognize the complexity of the situation
and the inherent challenges in achieving
safe, effective analgesia. Every challenging
patient offers a chance to advance the
education of the clinical group as long as
someone is willing to illustrate the
nuances and lead the discussion.
Patients are assessed to discriminate between nociception
and suffering and to localize the specific dermatome or
peripheral nerve field. In hopes of preventing hyperalgesia,
timely intervention with parenteral or oral agents or with
neural blockade is critical. Uncontrolled anxiety, a preoperative
predictor of postoperative pain, is treated with anxiolytics
such as benzodiazepenes, or potentially gabapentinoids, which
may also modulate spinal nociception resulting in analgesia.13
Patients who take opioids at home should continue with their
usual medications. There is a two- to three-fold increase in opioid
requirement in opioid-dependent patients. Multidimensional
assessment is important in patients already experiencing
preoperative pain. In these patients, chronic pain may flare
up after surgery from immobilization or polypharmaceutical
22
August 2015
Volume 79
Number 8
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for your practice and how to use data to improve patient care.
Join us and learn how to:
Find, collect and report quality data.

Achieve regulatory mandates for quality.
Identify registries that can help drive quality care.
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Distinguish the relation between quality and value.
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The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing
Medical Education to provide continuing medical education for physicians.
The American Society of Anesthesiologists designates this live activity for a maximum of 12.25 AMA
PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of
their participation in the activity.
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Dexmedetomidine and Ambulatory Surgery

Chair, Abstract Review Subcommittee on Ambulatory Anesthesia
Ex-Officio, Educational Track Subcommittee on Ambulatory Anesthesia
Advances in surgical technique, technology and

improvements in perioperative care have allowed more
complex patients and surgical procedures to be scheduled on
an ambulatory basis. Recently, health care providers are being
faced with a tremendous demand and growth in the number of
these patients. Choosing the appropriate anesthetic technique
in this setting is an integral part of providing safe, fast, efficient,
and cost-effective anesthesia and analgesia.
As an -2 adrenergic agonist, dexmedetomidine (DEX)
possesses properties that may be advantageous for the ambulatory
setting: sedation that has similarities to non-REM sleep,
anxiolysis, analgesia, sympatholysis, an anesthetic (volatile
agent and narcotic) sparing effect, a decreased incidence of
emergence delirium after volatile anesthetics and the ability to
preserve respiration. These physiologic effects lend themselves
to incorporating -2 agonists into an ambulatory anesthetic.
Anesthesia providers must have a comprehensive understanding
of the pharmacologic, pharmacokinetic and pharmacodynamic
effects and limitations of these agents in order to maximize
their safe, efficacious and efficient applications for robust
ambulatory schedules.
Dexmedetomidine1,2 and clonidine are both of the
imidazole subclass, but DEX is eight times more selective
for the -2 receptor than clonidine, with an -2: -1
selectivity ratio of 1620:1 (200:1 for clonidine).3 DEX,
now off patent in the United States but still on-patent in
Europe, is approved worldwide only for adult usage via the
I.V. route. In Europe, DEX labelling restricts it to the ICU
Mohamed Mahmoud, M.D. is

Associate Professor of Clinical
Anesthesia and Pediatrics,
Department of Anesthesiology,
Cincinnati Childrens Hospital
Medical Center, Cincinnati, Ohio.
setting, administered by continuous infusion and without a

bolus. In the U.S., it may be administered in areas outside of
the O.R. and ICU via bolus and continuous infusion. Off-label
DEX use via the non-I.V. route and for the pediatric population
has been widely described.
Photo courtesy of Hospira, Inc.
Keira P. Mason, M.D., is Associate

Professor of Anesthesia, Department of
Anesthesiology, Perioperative and Pain
Medicine, Boston Childrens Hospital
and Harvard Medical School, Boston.
24
August 2015
Volume 79
Number 8
Preoperative Applications
DEX has been described as an anxiolytic and sedative
prior to anesthesia. As a premedication, particularly in
children, it can sedate and offer advantages to midazolam
in enabling the child to tolerate a mask for an inhalation
induction.4,5 Preserving the respiratory drive with negligible
effects on respiration, DEX offers benefits especially to those
prone to obstructive sleep apnea (pediatric and adult) from
enlarged tonsils and morbid obesity.6-10 With a bioavailability
of approximately 65 percent via the intranasal (IN) route,
DEX does not burn or cause discomfort when administered
IN.11,12 Doses of 1 mcg/kg IN DEX reported a median sedation
onset of 25 minutes and median duration of 85 minutes in
healthy children undergoing elective surgery.13 Doses of up to
2.5 mcg/kg IN DEX have been described for successful sedation
with hemodynamic stability for computerized tomography
in children without I.V. access.14 Similar doses have been
described for the I.V. route for MRI sedation in children6,15-21
as well as for use as a pre-medication prior to anesthesia
induction. Two mcg/kg IN DEX has produced faster onset and
more favorable conditions at all stages of anesthesia (induction,
emergence and recovery) than has 0.5 mg oral midazolam.22
More prospective, randomized, blinded controlled trials are still
required to identify the optimal doses, routes and indications for
the use of perioperative DEX in ambulatory anesthesia.
pressure equalizing myringotomy tubes, DEX does not offer

an advantage over IN fentanyl or acetaminophen.36 Similar
results were shown when used for upper-gastrointestinal
endoscopy in children; DEX was not found to offer any
advantages either alone or in combination with propofol.37
For oral and maxillofacial ambulatory procedures in adults,
DEX as a sole sedative (1 mcg/kg infused over 10 minutes
followed by a maintenance dose of 0.2 to 0.8 mcg/kg/hour)
resulted in recoveries that were considered too long for the
busy office setting.38 Similar conclusions have been made when
evaluating DEX for colonoscopy39 and cataract surgeries in the
adult population.
Postoperative Applications
DEX has been shown in adults to alter the pain perception,
specifically to decrease the perception of pain induced by cold
and ischemia.40 A meta-analysis in adults demonstrated that
intraoperative DEX could decrease the pain intensity and
morphine requirement for up to 24 hours without affecting
recovery time.41 Compared to placebo or opiates, a metaanalysis of 28 trials in adults demonstrated that DEX decreased
postoperative pain and opiate-related adverse events.23 Similar
results have been shown in meta-analysis evaluating the effect
of DEX in children: A review of 27 randomized, controlled
trials demonstrated that 0.15-1 mcg/kg I.V. DEX decreased
pain, agitation and postoperative nausea and vomiting after
sevoflurane anesthesia. Although there was no effect on time
to extubation, there was an increase in recovery and discharge
time.42 Another meta-analysis supported that DEX decreased
the postoperative opiate requirement in children.43
Emergence delirium and agitation (ED and EA), described as
early as 1961, are relatively common, particularly after volatile
anesthetics in the pediatric population.44,45 It is associated with
prolonged recovery time and the potential for maladaptive
behavior for up to two weeks.45-47 DEX has been shown in
meta-analysis to decrease the incidence of emergence delirium
and agitation after sevoflurane anesthetics in children.42,48
DEX may offer benefits over propofol in decreasing EA
and ED.49-51,52 Compared to placebo, DEX (0.5 mcg/kg and
1 mcg/kg) reduces the incidence of EA from 47.6 to
4.8 percent, albeit a slightly prolonged emergence and time
to extubation.53,54 In comparison with fentanyl (1 mcg/kg),
intraoperative DEX (2 mcg/kg bolus followed by 0.7 mcg/kg/hour)
decreased the incidence of severe EA, postoperative opioid
requirements and episodes of desaturation in children with
OSA following tonsillectomy and adenoidectomy.55
DEX decreases vasoconstriction and may have a role
in altering thermoregulatory shivering. Studies in adults
Intraoperative Applications and Limitations

Intraoperative DEX has been shown to decrease
postoperative pain scores, volatile anesthetic requirement
and intraoperative narcotic consumption.23-28 Although not
approved for administration as a regional anesthetic (spinal,
caudal, epidural), DEX has been described via these routes in the
adult and pediatric population. Intranasal DEX has been shown
to decrease the intubation response and facilitate fiberoptic
intubations in both adults and children.29-31
In children, combining caudal DEX with bupivacaine
or levobupivicaine has been shown to reduce sevoflurane
requirements, incidence of emergence agitation, dosage of local
anesthesia, adjuvant postoperative analgesics and duration of
postoperative pain relief.32,33 A meta-analysis has shown that
as a neuraxial adjuvant, DEX decreases pain and prolongs the
analgesia from bupivacaine and ropivicaine with maintained
blood pressure despite some bradycardia.34
A limitation of DEX may be the half-life, which approaches
two hours, potentially delaying achievement of discharge
criteria. Although the majority of studies demonstrate that
DEX does not delay discharge from the recovery room, there
are a few studies which suggest that at high doses there may
be a short delay compared to other alternative agents such
as propofol.15-21,35 For short procedures in children, such as
August 2015
Volume 79
Number 8
25
have demonstrated the efficacy of DEX in the setting of

postoperative shivering.56-59 Similar results have been shown
in a prospective, nonrandomized open-label study of 24
shivering children (7 to 16 years) after general anesthesia.
DEX 0.5 mcg/kg I.V. over three to five minutes stopped the
shivering in all the children within five minutes, without
recurrence. No adverse effects were noticed with the rapid
bolus.60 Studies in healthy children have demonstrated that
rapid boluses of up to .49 mcg/kg DEX over five seconds maintain
heart rate and mean arterial blood pressure within 30 percent
of baseline in half of the children. The maximum decrease in
median heart rate and mean arterial blood pressure occurred in
50 seconds and 100 seconds, respectively.61
In conclusion, data regarding the perioperative use of DEX

in the ambulatory surgery setting are promising, albeit with
some limitations related mostly to its half-life. Despite the
synergistic properties of DEX with respect to narcotics and
volatile anesthetics, the lingering sedation may prolong
discharge from the recovery room. To date, animal, rodent
and some human (adult) studies suggest that at clinical
doses, DEX may be neuroprotective and improve cognitive
outcome.64-67 In the neonatal rat model, DEX has been
shown to protect from hyperoxia-induced changes in some
areas of the brain.68 Future studies are warranted to support
the neuroprotective potential for DEX. An in-depth
understanding of the pharmacologic, pharmacokinetic and
pharmacodynamic effects of DEX are critical to not only
maximize its safe and effective delivery in the ambulatory
anesthesia setting, but also to broaden the scope of its usage.
A meta-analysis has shown that as a

neuraxial adjuvant, DEX decreases
pain and prolongs the analgesia from
bupivacaine and ropivicaine with
maintained blood pressure despite
some bradycardia.
References:
1. Precedex (dexmedetomidine) [package insert]. Lake Forest, IL:

Hospira, Inc.; 2008.
2. Dexdor (dexmedetomidine) [package insert]. Espoo, Finland: Orion
Corporation; 2014.
3. Virtanen R, Savola JM, Saano V, Nyman L. Characterization of the
selectivity, specificity and potency of medetomidine as an alpha
2-adrenoceptor agonist. Eur J Pharmacol. 1988;150(1-2):9-14.
4. Yuen VM, Hui TW, Irwin MG, et al. A randomised comparison
of two intranasal dexmedetomidine doses for premedication in
children. Anaesthesia. 2012;67(11):1210-1216.
5. Sun Y, Lu Y, Huang Y, Jiang H. Is dexmedetomidine superior to
midazolam as a premedication in children? A meta-analysis of
randomized controlled trials. Paediatr Anaesth. 2014;24(8):863-874.
6. Mahmoud M, Gunter J, Donnelly LF, Wang Y, Nick TG, Sadhasivam
S. A comparison of dexmedetomidine with propofol for magnetic
resonance imaging sleep studies in children. Anesth Analg.
2009;109(3):745-753.
7.
Ziemann-Gimmel P, Goldfarb AA, Koppman J, Marema RT.
Opioid-free total intravenous anaesthesia reduces postoperative
nausea and vomiting in bariatric surgery beyond triple prophylaxis.
Br J Anaesth. 2014;112(5): 906-911.
8. Tufanogullari B, White PF, Peixoto MP, et al. Dexmedetomidine
infusion during laparoscopic bariatric surgery: the effect on recovery
outcome variables. Anesth Analg. 2008;106(6):1741-1748.
9. Mahmoud M, Jung D, Salisbury S, et al. Effect of increasing depth
of dexmedetomidine and propofol anesthesia on upper airway
morphology in children and adolescents with obstructive sleep
apnea. J Clin Anesth. 2013;25(7):529-541.
10. Abu-Halaweh S, Absalom AR, Aloweidi A, et al. Dexmedetomidine
versus morphine infusion following laparoscopic bariatric surgery:
effect on supplemental narcotic requirement during the first
24 hours. Surg Endosc. In press.
Precautions of Using -2 Agonist Agents

Clinicians should be familiar with the relative
contraindications and the expected hemodynamic variability
associated with using DEX. -2 agonists mediate their effects
through a complex mechanism that involves both presynaptic
and postsynaptic receptor activation. The activation of the
presynaptic -2 adrenoreceptors on the sympathetic nerves and
the central nervous system induces sympatholysis, which seems
to be responsible for hypotension and bradycardia. Although
decreases in heart rate and the biphasic effect on blood pressure
associated with loading dose are observed with increasing doses
of DEX, the literature supports that concurrent hemodynamic
collapse or need for pharmacologic resuscitation does not occur.62
Importantly, however, clinicians should recognize that the
incidences of cardiac arrest or severe bradycardia associated with
DEX have occurred in patients being treated with digoxin.1,63

26
August 2015
Volume 79
Number 8
Did you know

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in August?
To continue delivering a highly-valued member
experience and meet the future needs of ASA
members, were upgrading several of our systems.
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14-409
Preoperative Evaluation for Ambulatory Procedures
BobbiJean Sweitzer, M.D., FACP
Considerable attention has recently been focused on

patients undergoing cataract surgery. The procedure is
common in the elderly, who often have extensive comorbid
diseases, and is thought to be safe. It is performed with local
anesthesia and mild sedation. Worldwide, an estimated more
than 150 million eyes are blind because of cataracts. More than
22 million Americans have cataracts, and that number will
continue to rise. Each year, 3 million Americans have cataract
surgery (estimated to be 4.4 million by 2020) at a current cost
of $3.5 billion. Of these 3 million, 99.5 percent will have no
serious perioperative complications.1,2
Preoperative testing before cataract surgery has not been
shown to improve safety or alter outcomes, and it is a poor
utilization of limited health care resources. In a Cochrane review
of preoperative testing before cataract surgery, routine testing
did not increase safety.3 Preoperative tests in this population did
not prevent adverse events, was not associated with cancellation
of procedures (approximately 2 percent rate, with no difference
with presurgical testing) and was not cost-effective. Costs are
2.55 times higher for patients having routine preoperative tests
than for patients having selective testing.3
Despite decades of work showing the lack of benefit of
testing before cataract surgery, there has been no change
in the amount of testing and an increase in the number of
consultations before this procedure.4,5 Testing is costly,
but preoperative office visits likely cost more. Of 440,000
patients in a cohort of Medicare beneficiaries who had
cataract surgery in 2011, 53 percent had a preoperative
evaluation.5 The costs of tests during the month before
surgery were $4.8 million higher, and of office visits,
$12.4 million more than in the preceding 11 months. In

one study, practitioners billed 40 percent of visits as level 3,
35 percent as level 4, and 11 percent as level 5.4 Level 5
assessments reflect comprehensive history-taking and physical
examination and high-complexity medical decision-making
for conditions of moderate to high complexity. The
typical payment for level 5 service is more than $200.
It is surprising that more than one in 10 patients
having cataract surgery requires this level of care.
A study in Australia found that persons who had cataract
surgery had a 40 percent lower long-term risk of death than
those who did not have the surgery.6 Given the shortage
of primary care services in the United States, why are
resources being wasted?
Preoperative testing and evaluations vary widely among
physicians, geographic areas and surgical facilities.4,5,7 The
strongest predictor of preoperative consultation before cataract
surgery appears to be the ophthalmologist. More than a third
of ophthalmologists in one study referred 75 percent of their
patients, and 8 percent of ophthalmologists referred all of their
patients for preoperative consultation.5 Are patients referred
to satisfy a perceived requirement for a preoperative history
BobbieJean Sweitzer, M.D., FACP, is

Professor of Anesthesia and Critical
Care, Professor of Medicine and
Director, Anesthesia Perioperative
Medicine Clinic, University of Chicago.
28
August 2015
Volume 79
Number 8
and physical examination because of medico-legal concerns or

the need for basic health care? Or is the fee-for-service model
motivating the referrals? Understanding the rationale may
help reverse the trend.
Some have defended this practice because abnormalities
are discovered during medical visits. A retrospective chart
review of more than 500 patients evaluated before cataract
surgery found that a new medical issue was identified in
22 percent of patients; an unstable condition was identified in
23 percent of patients.8 Despite these findings, surgery was
delayed only 4 percent of the time. The significance of such
findings is not clear. Newly identified problems included
first-degree atrioventricular block, premature ventricular
contractions, and new or worsening chronic gastroenterologic
or dermatologic symptoms. The authors acknowledged that
the findings of the preoperative visit did not alter perioperative
care or outcomes but that the discoveries may have long-term
consequences. This acknowledgement is especially troubling
given that the annual physical examination, ubiquitous in
health care, has been shown to result in excessive testing and
iatrogenic harm. Advocates have called for abandonment of this
practice. Relying on preoperative encounters to address basic
health care screening and needs demonstrates a lack of adequate
primary care. The goal of the preoperative visit should be to
minimize perioperative risk and improve outcomes. Patients
undergoing cataract surgery have a 0.014 percent chance of
dying,3 and it is likely not possible to lower the risk any more.
With no blood loss or fluid shifts and no need to interrupt
routine medications, there is minimal associated physiological
stress. Stopping oral diabetic medications, long-acting insulin,
antiplatelet agents or anticoagulants is harmful or worsens
chronic conditions. There is a low incidence of bleeding with
continuation of aspirin, clopidogrel or warfarin for cataract
surgery, even in patients receiving blocks.9 The American
College of Chest Physicians designates continuation of
warfarin for patients having cataract surgery as a grade 1
recommendation.10 Society for Ambulatory Anesthesia
guidelines state: There are insufficient data to specifically
recommend the level of preoperative fasting blood glucose or
HbA1c levels above which elective ambulatory surgery should
be postponed.11 Likewise, neither hyper- nor hypokalemia is
associated with adverse outcomes in minor procedures.12,13
Cataract surgery is likely on par with dental care, colonoscopies
or even activities of daily living, which do not require testing or
a visit to the doctor.
Cataract surgery has enormous benefits. With eyesight
restored, daily activities can be resumed, social interactions
increase and the risk of falls decreases. In a cohort of U.S.
Medicare beneficiaries aged 65 years or older with a diagnosis
of cataract, patients who had cataract surgery had lower odds
August 2015
Volume 79
Number 8
of hip fracture within one year after surgery than patients who
had not undergone cataract surgery.14 The highest risk of falls
appears between the first and second cataract surgeries.15
Providers who care for patients having cataract surgery
must accept that there is a small risk of unfavorable outcomes
given the population of elderly individuals who often have
advanced diseases. As long as a patient arrives to the facility and
can lie flat for the procedure, there are very few conditions and
no test abnormalities, other than acute ST-segment elevations
or unstable arrhythmias, that preclude proceeding with
cataract surgery.16
References:
1. Schein OD, Cassard SD, Tielsch JM, Gower EW. Cataract

surgery among Medicare beneficiaries. Ophthalmic Epidemiol.
2012;19(5):257-264.
2. Foster A. Vision 2020: the cataract challenge. Community Eye
Health. 2000;13(34):17-19.
3. Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative
medical testing for cataract surgery. Cochrane Database Syst Rev.
2012;3:CD007293. doi: 10.1002/14651858.CD007293.pub3.
4. Thilen SR, Treggiari MM, Lange JM, Lowy E, Weaver EM,
Wijeysundera DN. Preoperative consultations for Medicare
patients undergoing cataract surgery. JAMA Intern Med. 2014;174(3):
380-388.
5. Chen CL, Lin GA, Bardach NS, et al. Preoperative medical testing
in Medicare patients undergoing cataract surgery. N Engl J Med.
2015;372(16):1530-1538.
6. Fong CS, Mitchell P, Rochtchina E, et al. Correction of visual
impairment by cataract surgery and improved survival in older
persons: The Blue Mountains Eye Study cohort. Ophthalmology.
2013;120(9):1720-1727.
7. Thilen SR, Bryson CL, Reid RJ, Wijeysundera DN, Weaver EM,
Treggiari MM. Patterns of preoperative consultation and surgical
specialty in an integrated healthcare system. Anesthesiology.
2013;118(5):1028-1037.
8.
Phillips MB, Bendel RE, Crook JE, Diehl NN. Global health
implications of preanesthesia medical examination for ophthalmic
surgery. Anesthesiology. 2013;118(5):1038-1045.
9. Katz J, Felman MA, Bass EB, et al.; Study of Medical Testing for
Cataract Surgery Team. Risks and benefits of anticoagulant and
antiplatelet medication use before cataract surgery. Ophthalmology.
2003;110(9):1784-1788.
10. Douketis JD, Spyropoulos AC, Spencer FC, et al. Perioperative
management of antithrombotic therapy: antithrombotic therapy
and prevention of thrombosis, 9th ed: American College of
Chest Physicians evidence-based clinical practice guidelines. Chest.
2012;141(2 suppl):e326S-e350S. doi: 10.1378/chest.11-2298.
29
The Latest Science in Anesthesiology: Join Us

Joy L. Hawkins, M.D., Chair
Committee on Scientific Advisory
William R. Furman, M.D., Vice Chair

Committee on Scientific Advisory
Are you looking for cutting-edge science from leaders

representing every area of the specialty? The highly
anticipated scientific abstract sessions are offered throughout
the entire ANESTHESIOLOGY 2015 annual meeting
(Saturday through Wednesday) and consist of three session
formats: oral/slide-assisted presentation sessions, moderated
poster-discussion sessions, and poster grand round sessions.
Presentations are organized by topic/category (e.g., Clinical
Circulation, Experimental Neurosciences, Outcomes and
Database Research). Experts in the field facilitate or moderate
all scientific abstract sessions. If you can only attend over the
weekend, check out which sessions occur throughout the day
on Saturday and Sunday for the latest science on complex issues
that challenge our practices.
Scientific Sessions
The ANESTHESIOLOGY 2015 annual meeting will
again offer a wide variety of scientific sessions presented in
different formats and spanning across each area of the specialty.
Oral/slide-assisted presentation sessions are 90 minutes and
consist of up to six abstracts with 10 minutes for presentation
followed by five minutes of moderated audience questions.
Moderated poster-discussion sessions include up to eight
abstracts presented over 90 minutes. During the first 30 minutes,
attendees may walk between the poster display monitors to
view and discuss each poster one-on-one with the authors. This
walk-around is followed by a 60-minute period in which the
entire group convenes for a brief, formal presentation of each
abstract and a moderated question-and-answer period.
The remaining category of abstract sessions is the e-poster
grand rounds that are offered Saturday through Tuesday.
Expert discussants visit each poster to review the findings
with the presenting author and attendees. Presenting authors
will be at their poster and available for discussion and one-onone interaction with moderators and attendees during their
30-minute scheduled presentation period. Each two-hour poster
session consists of four 30-minute, timed poster presentations
grouped categorically. Allowing a more in-depth discussion
of each poster, the sessions are limited to a maximum of
16 abstracts. All electronic posters will be available for attendees
to view at their leisure during the conference via the e-poster
on-demand kiosks placed strategically throughout the
convention center and poster area.
NEW! Young Investigator Poster Discussion Sessions

ASA is proud to debut a new mentoring opportunity for
early investigators within the specialty. Sixteen high-quality
scientific abstracts were selected for this new program that
brings young investigators and established academicians
together to engage in scholarly dialog related to their work.
Through these interactive sessions, ASA hopes to expand
its mentoring opportunities at the meeting and continue to
promote the education, scientific work and involvement of
junior investigators. Two Young Investigator sessions covering
basic science and clinical science, with eight presentations each,
will be held in a poster discussion format during the conference.
Watch for these new sessions and join the discussion!
William R. Furman, M.D., is Professor

and Vice Chair for Clinical Affairs,
Department of Anesthesiology/
Executive Medical Director for
Perioperative Services, Vanderbilt
University, Nashville.
Joy L. Hawkins, M.D., is Professor

of Anesthesiology, Vice Chair for
Education and Director of Obstetric
Anesthesia, University of Colorado
School of Medicine, Aurora.
30
August 2015
Volume 79
Number 8
in San Diego for ASAs Scientific Abstract Sessions

The Committee on Scientific Advisory will again offer
electronic viewing for all poster-discussions and poster
sessions, featuring 60-inch LCD monitors without the aid of
physical posters.
New and Enhanced

Scientific ePoster Features
Special Scientific Symposia

The 2015 Journal Symposium titled The Anesthesiologist
and Health Care Redesign will be organized by the editors
of Anesthesiology and held on Sunday, October 25 from
9 a.m.-noon. The symposium will include three lectures and
discussion of 12 abstracts in room Upper 4 of the San Diego
Convention Center. In addition, this will be the eighth year
of the very popular Best of Abstracts: Basic Science and
Best of Abstracts: Clinical Science sessions, with abstracts
hand-selected by the editors of Anesthesiology. Authors will
be given the opportunity to submit an enhanced and more
detailed abstract in advance of the meeting, and two prizes will
be given for the best clinical science and the best basic science
work. The sessions will be divided into Basic Science with
12 abstracts on Sunday, October 25, from 1-3 p.m. in room
Upper 4, and Clinical Science with eight abstracts on
Saturday from 1:10-3:10 p.m. in room Upper 4.
Another popular event is the Foundation for Anesthesia
Education and Research (FAER) Medical Student Anesthesiology Research Symposium held on Sunday, October 25, from
2-5 p.m. to accommodate the resident and medical student
schedules. The medical student symposium highlights research
done by medical students who have participated in FAER
research fellowship programs. These residents and medical
students are our future colleagues advancing the specialty
of anesthesiology and will become our scientific leaders in
the years ahead.
n All
ePosters will be displayed on high-resolution

60-inch monitors.
n The
ePoster On-Demand system will again be

available to attendees during the conference to
view all poster presentations at their leisure,
even if they cannot attend the scheduled,
formal presentation.
n
NEW!
ePoster Charts will track real-time data

statistics of the poster program, showing
attendees the most popular posters, authors,
topics and sessions.
Meeting Subcommittees and Abstract Selection

All submitted abstracts were graded, and selected
abstracts were grouped into sessions by the scientific abstract
subcommittees under the oversight of the Committee on
Scientific Advisory using a Web-based process. ASA sincerely
appreciates the dedicated efforts of all subcommittee members
who volunteered substantial time and expertise toward
August 2015
Volume 79
Number 8
Scientific poster sessions will be grouped

thematically and clearly denoted by color for
attendees who wish to follow the program by track.
31
EW! The ePoster live mobile app will allow

N
attendees to create a personal itinerary, customize
push notifications with schedule reminders,
changes, last-minute announcements and
messages. The app will offer interaction with
other attendees and the authors.
the selection and presentation of the latest science at the

ANESTHESIOLOGY 2015 annual meeting. All abstracts
to be presented at the 2015 meeting, and those from past
meetings will be available via the ASA annual meeting website
(www.goanesthesiology.org).
represented at our scientific program that has distinguished

anesthesiology as a leading specialty in medicine. The
Committee on Scientific Advisory has developed a researchbased educational program that is sure to be valuable to your
professional career and to patient care. The scientific program
at the ANESTHESIOLOGY 2015 annual meeting has been
designed to cover the breadth of basic science and clinical topics
in anesthesiology and to address your research and practice
interests. Please be sure to take advantage of these outstanding
educational and networking opportunities!
See You In San Diego!

Research and new knowledge are what drive innovation in
medicine. We must continually seek new knowledge to improve
upon the care of our patients. It is this science such as that
Photo courtesy of Joanne DiBona
MOCA
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Reach peak performance with the Anesthesiology Continuing Education (ACE) program, the
specialtys highly-revered, self-assessment review of demonstrated knowledge.
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with one annual subscription.
ACE | Patient Safety | PPAI Modules | SAM-CC | SAM-PEDS | SAM-PM | SEE
Learn more
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Accreditation and Credit Designation Statements

The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The American Society of Anesthesiologists designates this CME activity for a maximum of 60 AMA PRA Category 1 Credits. Physicians should claim only the credit
commensurate with the extent of their participation in the activity.
Mobile
This self-assessment activity helps fulfill the self-assessment CME requirement for Part 2 of the Maintenance of Certification in Anesthesiology Program (MOCA) of The
American Board of Anesthesiology (ABA). Please consult the ABA website, www.theABA.org, for a list of all MOCArequirements.
14-404
32
August 2015
Volume 79
Number 8
Are you interested in reporting PQRS through the

ASA QCDR in 2016?
Take the ASA QCDR Readiness Assessment to receive an ASA QCDR Tool Kit specific to
your practice. The tool kit includes information about PQRS and the ASA QCDR, as well as a
checklist to guide your practice through set-up.
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14-410
Subspecialty Panels: Rise and Shine

NEW THIS YEAR:
The Subspecialty Panels will be

presented this year at various times during the
ANESTHESIOLOGY 2015 annual meeting at the San Diego
Convention Center. The panels have been selected by
subspecialty experts to help you gain the latest insights
into your field.
Speaker: Richard Rosenquist, M.D., Understanding the

Importance of the Value Equation for the Effective Delivery
of Perioperative Pain Medicine.
Saturday, October 24
The Society for Pediatric Anesthesia (SPA) and American

Academy of Pediatrics will address American College of
Surgeons Optimal Resources in Childrens Surgical Care:
What It Means for Anesthesiologists Who Care for Children.
The panel will provide evidence for the need for specialized
childrens surgical centers, describe guidelines that have
been developed by the American Academy of Pediatrics and
the American College of Surgeons (ACS) to optimize the
pediatric perioperative environment, and present the primary
components of the ACS verification program of childrens
surgical centers and the experience gleaned from the initial
site visits. Pediatric surgeon Keith Oldham, M.D., the leader of
this initiative, will describe its history and plans for the future.
Speaker: Colin McCartney, M.B.Ch.B., FRCA, FCARCSI,

FRCPC, Defining the Outcomes That Matter for Perioperative
Pain Medicine.
The Society of Cardiovascular Anesthesiologists

(SCA) will present Research Update in Cardiothoracic
Anesthesiology, providing extensive knowledge of literature
in their area. This panel will address a literature review of key
publications and their impact on the practice.
Lead Speaker: Kathryn Glas, M.D.
Speaker: Roman Sniecinski, M.D., Update on Cardiac
Anesthesiology Research.
Speaker: Wanda Popescu, M.D., Update on Thoracic
Anesthesiology Research.
Speaker: Nathaen Weitzel, M.D., Update on Quality and
PI Research in Cardiac Surgical Care.
Lead Speaker: Lynn Martin, M.D.
The American Society of Regional Anesthesia and

Pain Medicine (ASRA) will look at How to Define and
Demonstrate Value of Regional Anesthesia and Pain Medicine
Services. Health care delivery is undergoing dramatic
change with value-based care driving decision-making
and reimbursement.
This panel will help the learner understand how regional
anesthesia and pain management services can offer value to
the health care system. Since value is defined as outcomes/
costs, the learner will get exposure to the importance of using
the correct outcomes metrics (numerator) and how costs are
determined (denominator). Finally, the panel will approach
the important topic of how to gather and share performance
data with colleagues and patients. This panel is meant to educate
the community on how regional anesthesia and pain medicine
can produce meaningful value to the health care system. Such
value is critical for obtaining institutional/governmental
support going forward with health care reform.
Speaker: Jayant Deshpande, M.D., M.P.H., Evidence the Need

for Specialized Pediatric Surgery Centers.
Lead Speaker: Brian Sites, M.D.
Lead Speaker: Daniel Brown, M.D., Ph.D.
Speaker: Douglas Merrill, M.D., M.B.A., How Does the Busy

Anesthesiologist Share Performance and Quality Data Associated
With Perioperative Pain Medicine?
Speakers: David Barbara, M.D., Vanessa Moll, M.D.,

and John Turnbull, M.D.
Speaker: Constance Houck M.D., The Pediatric Perioperative

Environment: AAP and ACS.
Standards Speaker: Keith Oldham, M.D., The American
College of Surgeons Verification Program: Putting the Idea
Into Practice.
Sunday, October 25
Critical Care Year in Review will be addressed at the
Society of Critical Care Anesthesiologists (SOCCA) panel,
which will identify and review key studies published within
the past year in the critical care literature that have potential
implications for physician anesthesiologists. The focus of the
review will be journals not considered core anesthesia sources.
A large number of reports will be covered and a hard copy of
references made available to attendees for further study.
34
August 2015
Volume 79
Number 8
with Cutting-Edge Sessions
Lead Speaker: Manuel Vallejo, Jr., M.D., D.M.D., High-risk

Preoperative Consultation.
Monday, October 26
How Can Mobile Technology Help Me Help My
Patients? is the subject of the panel by the Society of
Technology in Anesthesia (STA), focusing on new techniques
and technologies in anesthesia.
Speaker: Lawrence Tsen, M.D., Prophylactic Early Epidural

Catheter Placement.
Speaker: May Suresh, M.D., Airway Devices in Obstetric
Anesthesia.
Lead Speaker: Thomas Hemmerling, M.D.

Speaker: Orlando Hung, M.D., The Challenges of Videolaryngoscopes.
The Society for Education in Anesthesia (SEA) will

examine efforts in technological advancements and their effect
on medical education and physician evaluation. Education in
the Context of Healthcare Reform Preserving the Academic
Mission will review the risks to the academic mission as
systems seek to evolve and meet the challenge of health care
reform; and will explore the role of education and research in
preserving anesthesiologists relevance and value in the face of
health care reform.
Speaker: Nathan Delson, Ph.D., Latest Airway Mannequin

Technologies.
Speaker: M. Dylan Bould, M.B., Ch.B., MRCP, FRCA, M.Ed.,
Technical Realization of Anesthesia-related Simulation in the
Third World.
The Society for Obstetric Anesthesia and Perinatology
(SOAP) will present Preventing Maternal Mortality: Practical,
Cost-Effective Steps for the Practicing Clinician. This panel
will stress the actual costs, use and impact of the high-risk
preoperative consultation, prophylactic early labor epidural
placement, and airway devices used in the obstetrical patient.
Lead Speaker: Stephen Kimatian, M.D., FAAP

Speaker: Jeffrey Berger, M.D., M.B.A., Financing Graduate
Medical Education The DIOs Perspective.
August 2015
Volume 79
Number 8
35
Speaker: John Mitchell, Leveraging Technology to Combat

Diminishing Educational Resources.
Speaker: Marek Brzezinski, M.D., Ph.D., Research in the Age of
Healthcare Reform: The Feasibility of Funding.
The Society for Ambulatory Anesthesia (SAMBA) will
present What the Joan Rivers Tragedy Has Taught Ambulatory
Surgery. Attendees will learn why the ambulatory center
where Joan Rivers passed has a plan of correction that includes
improvements to credentialing for physicians and observers,
completing medical history and physical prior to procedures,
having oxygen available during propofol sedation, checking
vital signs every five minutes during sedation, and running
resuscitation drills quarterly. These oversights by the clinic
can be avoided by following current accreditation and CMS
guidelines for ambulatory centers. This panel will describe how
to do effective peer review and credentialing, cover required
policies to run a safe center and reinforce common errors found
by CMS during surveys.
Lead Speaker: Steven Butz, M.D., Performing Effective Peer
Review and Credentialing.
Speaker: Arnaldo Valedon, M.D., CMS Hot Topics.
The Society for Neuroscience in Anesthesiology and

Critical Care (SNACC) panel Is There Enough Evidence
to Implement Protocols for Enhanced Recovery After
Neurosurgery? will review the process by which enhanced
recovery after surgery (ERAS) protocols are developed and
updated. Two specific topics the choice of intravenous fluid
type for spine surgery and the choice of anesthetic technique
for intracranial surgery will be used as examples of specific
choices that must be made for intraoperative care to establish
ERAS protocols, the data supporting superiority or equivalency
of different fluid therapies or anesthetic techniques, and
methods beyond the randomized controlled trial that can be
used to efficiently fill critical gaps in knowledge.
Speaker: Mary Ann Van, M.D., Policies Needed for Safe Care
and Accreditation.
Tuesday, October 27
New ASRA Anticoagulation Guidelines for Interventional
Pain Procedures will be the focus of ASRA on Tuesday. In
this symposium, as pain medicine has evolved into its own
specialty and pain procedures have become more invasive,
regional anesthesia guidelines have become less applicable.
This panel will highlight the main areas of new multispecialty
anticoagulation guidelines. These guidelines were developed
with the support of various pain medicine organizations,
including ASRA, the European Society of Regional
Anaesthesia, International Neuromodulation Society, American Academy of Pain Medicine, World Institute of Pain and
North American Neuromodulation Society. The authors will
present their data on the impact of NSAIDS, anti-platelets,
anticoagulants and herbal remedies in the coagulation system.
Lead Speaker: Adrian Gelb, M.B., B.Ch., FRCPC

Speaker: Timothy Miller, M.B., Ch.B., Navigating the Surging
Waves: Pitfalls in Designing and Implementing an Enhanced
Recovery Protocol.
Speaker: Louanne Carabini, M.D., Finding the Heavy Waves
and Avoiding the Riptides: Do We Have Evidence to Choose
Which Fluids to Administer During Spine Surgery?
Lead Speaker: Carlos Pino, M.D., Why Do Pain Procedures

Need Different Anticoagulation Guidelines?
Speaker: Samer Narouze, M.D., Risk Classification Based on
Anatomical Considerations and Pain Procedure.
Speaker: Dhanesh Gupta, M.D., Avoiding the Ankle Slop and

Finding the Epic Wave Is There More to Choosing Anesthetic
Techniques for Intracranial Surgery Than Pharmacokinetics?
Speaker: David Provenzano, M.D., Anticoagulation Guidelines

in Patients Taking NSAIDs and COX-2 Inhibitors.
Speaker: Honorio Benzon, M.D., Anticoagulation Guidelines
in Patients on Antiplatelets and New Anticoagulants.
36
August 2015
Volume 79
Number 8
MOCA
The next generation of pain

medicine education is here
Self-Assessment Module Pain Medicine (SAM-PM) has the most up-to-date clinical
content in the subspecialty of pain medicine.
Popular features include:
120 questions with answers and detailed rationale

Helps meet ABA MOCA Part 2 requirements
30 AMA PRA Category 1 Credits
SAM-PM was developed

through partnership with the
American Society of Regional
Anesthesia and Pain Medicine
and the American Society of
Anesthesiologists, the leaders
in anesthesiology education for
pain specialists.
Learn more
asahq.org/14sampm

The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians.
The American Society of Anesthesiologists designates this enduring material for a maximum of 30 AMA PRA Category 1 Credits.
Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This self-assessment activity helps fulfill the self-assessment CME requirement for Part 2 of the Maintenance of Certification in
Anesthesiology Program (MOCA) of The American Board of Anesthesiology (ABA). Please consult the ABA website, www.the ABA.
org, for a list of all MOCA requirements.
14-403
Mobile
HOUSE OF DELEGATES SESSIONS

AT ANESTHESIOLOGY 2015
Speaker of House of Delegates

Vice Speaker of House of Delegates
The Speakers office hours will be held Tuesday (although

the Speakers will be in the Speakers office most of Monday
and Tuesday) to discuss any procedural issues or questions with
regard to reference committee reports to be presented at the
Wednesday session of the House. Specific times and locations
will be posted on the Governance Resources page of the ASA
website at the time of the annual meeting. The Speakers
will be available to assist members in crafting motions they
might wish to make on the floor of the HOD. When possible,
members are asked to submit their amendments to ASA
governance staff in writing (preferably in Word format on a
flash drive) prior to the House meeting on Wednesday in order
to project the amendments during the session. Any member
who plans to introduce substantial or potentially controversial
amendments is strongly encouraged to discuss these with the
Speakers in advance so that all business may be conducted in an
expeditious manner.
Our Meetings
The first session of the House of Delegates (HOD) will
convene at 8 a.m. on Sunday, October 25, 2015. ASA
President J.P. Abenstein, M.S.E.E., M.D., and President-Elect
Daniel J. Cole, M.D., will present their remarks at this session.
This opening session will also include the presentation of
awards, an ASA Political Action Committee update, and the
nomination of officers and candidate speeches to the HOD.
The second session of the HOD will convene promptly at
8 a.m. on Wednesday, October 28, 2015. Election of officers
will be one of the first agenda items. The House will then
consider the reports of the four reference committees using
formal parliamentary procedure to dispose of the recommendations and any motions, amendments, referrals or other
such actions of the House. The time of adjournment cannot
be anticipated. Members are strongly urged to consider the
volume, nature and potential amount of debate that may occur
on Wednesday when making their departure reservations.
The ASA Board of Directors will meet immediately after the
adjournment of the House.

New Delegates Briefing, Chair Orientation
and Speakers Office
New delegates, alternate delegates or any ASA member
with questions regarding procedure should attend the new
delegates briefing, which will be conducted by the Speaker and
Vice Speaker from 7:30-8:30 a.m. on Saturday, October 24,
and is open to all ASA members. A New Committee,
Section and Division Chair Orientation session is planned for
Friday afternoon.
Caucus Meetings
It is highly recommended that all members attend
their caucus meetings (e.g., New England, Mid-Atlantic,
Southern, Western, Midwest and various states) on Saturday
and Tuesday afternoons. At these caucuses, issues before the
House and candidates for election will be discussed. Meeting
locations and times will appear in the Handbook for
Delegates and will be posted on the governance page of the
ANESTHESIOLOGY 2015 annual meeting website.
We look forward to working with you to make the
ANESTHESIOLOGY 2015 annual meeting a great success.
See you in San Diego.
Ronald L . Harter, M.D., is Professor

and Jay J. Jacoby, M.D., Ph.D. Chair,
Department of Anesthesiology,
The Ohio State University Wexner
Medical Center, Columbus, Ohio.
Steven L. Sween, M.D., is Chair and

Medical Director, Physician Specialists
in Anesthesia, PC, Atlanta.
38
August 2015
Volume 79
Number 8
Avoid denied claims

keep your coding
library current
Each year CPT codes and reporting guidelines
are updated, get the most up-to-date resources
to avoid coding errors and denied claims.
2016 CROSSWALK
Purchase the authoritative coding resource for surgery and anesthesia CPT codes. The 2016
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Other essential coding resources:

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14-411
charitable networking event:

Networking Event Icon

Brenda A. Gentz, M.D., First Vice Chair
Committee on Annual Meeting Oversight
Alexander A. Hannenberg, M.D., President
ASA Charitable Foundation
This years inaugural Charitable Networking Event at

the ANESTHESIOLOGY 2015 annual meeting might be
the most fun youll have during your stay in San Diego.
But the events cause also has much more far-reaching
intentions improvement of the health and medical care of
underserved communities throughout the world.
The event was organized in collaboration between the
Committee on Annual Meeting Oversight and the ASA
Charitable Foundation. The first event of its kind at an
ASA annual meeting, the Charitable Networking Event
will introduce the very first class of Global Scholars from
Honduras, Mongolia and Zambia, who will be attending
through newly created grants from the Charitable Foundation.
Youll find no better opportunity to socialize and network
than here. Our individual lives and our specialty are enriched
immeasurably by the connections we make in the international
community. And our hope is that the Charitable Networking
Event will increase the awareness of ASAs philanthropic
endeavors as well as foster an interest in volunteerism all in a
relaxing, casual environment in one of the most beloved cities
in the United States.
The diversity of the connections youll make here will
certainly be matched by the menu and entertainment
options. A truly international assortment of ethnic dishes will
be paired with specialty drinks and offered throughout the
course of the evening. The fabulously talented Mark Langford,
San Diego-area musician, will treat attendees to flamenco
Photo Courtesy of Natalia Robert
CHARITABLE NETWORKING EVENT:

CENTRAL LIBRARY at
JOAN IRWIN JACOBS COMMON
Shiley Special Event Suite and Terraces
Sunday, October 25 | 6-8 p.m.
Alexander A. Hannenberg, M.D., is

Associate Chair, Department of
Anesthesiology, Newton Wellesley
Hospital, Newton, Massachusetts.
He was ASA President in 2010.
Brenda A. Gentz, M.D., is

Associate Professor of Anesthesiology,
Banner University Medical CenterTucson, Tucson, Arizona.
40
August 2015
Volume 79
Number 8
guitar. Finally, you couldnt ask for a better setting,

as the San Diego Library Shiley Special Events
Suite has beautiful night views from the Woods
Family Sunset View Terrace. The Central Library
is just a short walk from the convention center.
ASA recognizes that the specialty of
anesthesiology is a global community, said
ASA President J.P. Abenstein, M.S.E.E., M.D.
With the first-ever Charitable Networking
Event, we hope weve created a valuable and
enjoyable activity that allows members from all
over the world to mingle, network and contribute
to ASAs long history of successful philanthropic
initiatives.
Space is limited, but you can still purchase
tickets. Visit goanesthesiology.org, click
Network, then Charitable Networking Event.

Ticket Pricing:
n Envoy level donor $150
n Ambassador level donor $250
About ASAs Charitable Foundation

The Foundation improves health and
medical care in underserved communities
and provides a platform for the philanthropic
contributions of physician anesthesiologists.
ASA Charitable Foundation programs include
Hope for the Warriors, Lifebox and the ASA
Global Scholars. ASA members contribute their
skills around the world and have donated generously to provide essential
patient monitoring equipment in resource-poor settings, protecting patient
lives during surgery. Foundation programs serve to advance the quality
of and access to anesthesia care, support the anesthesiology professions
response to disasters and health crisis, and promote educational
opportunities for future global leaders in the field of anesthesiology.
ASA estimates $75 of the ticket price is not deductible as

a charitable contribution. The greater your donation, the
more benefit to the ASA Charitable Foundation. Donors
will be recognized with ribbons and scrolling displays
during ANESTHESIOLOGY 2015.
C0 M94 Y100 K0 web #EE3524
80% Tint
C100 M0 Y19 K23 web #008DA8
20% Tint
C100 M0 Y85 K24 web #008752
30% Tint
Saving lives through safer surgery
Photo Courtesy of Joanne DiBona
August 2015
Volume 79
Number 8
41
Six Years Strong H H H H H H H H H H H H H H H H H
Run For The Warriors 5K
Coming to San Diego Again This October

Hope For The Warriors
Run For The Warriors 5K Run/Walk
Sunday, October 25 | 6:45 a.m.
San Diego was the site of the very first ASA Run For The
Warriors 5K Run/Walk at the ANESTHESIOLOGY 2010
annual meeting. That year, more than 320 athlete-philanthropists
raised almost $70,000 to support wounded service members and
their families through partnership with the charity organization
Hope For The Warriors.
42
The event has now become a successful tradition, and ASA

welcomes the 5K run/walk back for its sixth consecutive year to
the city where it all began.
So be sure to pack your running shoes and join hundreds of
fellow meeting attendees, exhibitors, local residents and military
personnel who will unite to support a great cause. The mission
of Hope For The Warriors is to enhance the quality of life for
post-9/11 service members, their families, and the families of the
fallen who have sustained physical and psychological wounds in
the line of duty. Hope For The Warriors is dedicated to restoring
a sense of self, restoring the family unit, and restoring hope for our
service members and our their families.
The race route will be published at goanesthesiology.org
when it is made available. If youd like to participate, please
visit www.asacharity.org and click Hope For The Warriors.
For more information on Hope For The Warriors, please visit
www.hopeforthewarriors.org.
August 2015
Volume 79
Number 8
Residents Research Essay Winners Honored
Evan D. Kharasch, M.D., Ph.D., Chair, ASA Committee on Research, has announced that the committee
will award prizes for the following two entries in the 2015 ASA Residents Research Essay Contest:
First Prize
Gene T. Yocum, M.D., Columbia University, New York, New York, for
Selective Pharmacologic Targeting of the GABA-A Receptor 4 Subunit
in Airway Smooth Muscle to Alleviate Bronchoconstriction.
Second Prize
Seyed A. Safavynia, M.D., Ph.D., Emory University, Atlanta, for
The Effects of GABAA Receptor Modulation by Flumazenil
on Emergence From General Anesthesia.
Winners receive a plaque and cash award to acknowledge
their achievements. The first-place winner will present a
five-minute presentation during the Celebration of Research
on Monday, October 26, at the San Diego Convention
Center, as well as each individual presentation scheduled
during the ANESTHESIOLOGY 2015 annual meeting.
MOCA
Improve practice performance with Practice Performance

Assessment and Improvement (PPAI) modules
The PPAI program helps you evaluate your practice and implement a plan to improve
outcomes and patient care. Choose from a variety of specialized courses related to your
practice. Available for both single and group participation.
PPAI helps you meet ABA MOCA Part 4

requirements and offers up to 20 AMA PRA
Category 1 Credits.
Learn more
asahq.org/ppai

The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The American Society of Anesthesiologists designates this CME activity for a maximum of 20 AMA PRA Category 1 Credits. Physicians should claim only the credit
commensurate with the extent of their participation in the activity.
This PPAI activity fulfills the Case Evaluation requirement of Part 4 of the Maintenance of Certification in Anesthesiology Program (MOCA) of The American Board of
Anesthesiology (ABA). Please consult the ABA website, www.theABA.org, for a list of all MOCArequirements.
14-413
August 2015
Volume 79
Number 8
43
Mobile
Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering
Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion
of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be
discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback
regarding this article can be sent by email to r.dutton@asahq.org. Report incidents or download the AIRS mobile app at www.aqiairs.org.
Case 2015-8: Mission Creep
Discussion
A 37-year-old woman presented for dilation and curettage,

hysteroscopy and endometrial ablation. The planned anesthetic was
deep sedation using propofol, midazolam, fentanyl and ketamine
with a natural airway and spontaneous ventilation. An unexpected
uterine myoma was discovered, and a hysteroscopic myomectomy was
added to the planned procedure. At the end of the myomectomy, as
the endometrial ablation was about to begin, the patient developed
fulminant pulmonary edema. Oxygen saturation declined to <80
percent. Intubation was attempted, but proved difficult due to copious
edema fluid. High mask ventilation pressures were necessary, and
subcutaneous emphysema resulted. An endotracheal tube was
eventually placed and the patient was transferred to the intensive care
unit. Hyperchloremic metabolic acidosis was noted along with clinical
evidence of aspiration pneumonia. The patient required 10 days to
recover sufficiently for discharge home.
This patient experienced significant morbidity. Multiple

complications resulted from a common and simple procedure.
Or was it? The actual surgical procedure performed was more
involved than originally intended and might have led to a different
anesthetic plan if scheduled that way from the beginning. Any
intraoperative change in the surgical procedure represents an
elevated safety risk, which can be mitigated by planning for the
unexpected. But that sounds like an impossible mission itself.
How would you plan for what you cannot expect?
Mission creep is often unavoidable and should not be treated
as the surgeons latest effort to ruin our day. Some instances of
radical change in a surgical procedure may indeed result from
poor planning or technical errors which we should object to
but even these anecdotes may be colored by hindsight bias.
Which of us has not planned poorly or made technical errors?
More often than not, a surprise change in the surgical plan
represents the surgeons expert adaptation to imperfections
in the original diagnostic data. In fact, the failure to change the
surgical plan when indicated would be a cognitive fixation error
on the surgeons part. This variety of fixation error is called
plan continuation. Such a surgical error can be as costly to
our patient as any mistake we can make. When the right thing
is to increase the complexity of the surgical procedure, we have
a great opportunity to showcase our own adaptive expertise and
professionalism.
The terms surprise, fixation and adaptive expertise have
specific meanings in the field of human factors engineering. Each
is critical to safety.
The multiple definitions of surprise include an unexpected
event or piece of information and the feeling caused by
something that is unexpected or unusual. Being surprised is a
personal experience not directly related to the patient. Surprise
is a human factors construct more than a medical one. In
general, we should not be surprised by something routine. Lanir1
introduced a useful nomenclature: Situational surprise versus
Fundamental surprise.
Disclaimer
Frequent readers of this column will note a change to our
introduction header this month. The case presented, like many
received by AIRS, raises many questions. How well was the patient
tolerating sedation prior to the unexpected surgical finding?
How much irrigating fluid was infused (and potentially absorbed)
during the myotomy? Did airway obstruction or pulmonary
edema develop first? How quickly did the patient become
distressed? Was a neuromuscular blocking drug administered
to facilitate intubation? What airway management techniques
were attempted, and what approach finally worked? While these
are all worthy points for discussion, we cannot address all of
them in the space available and will therefore choose to focus
on just one: the potential hazard resulting from an intraoperative
change in surgical plan. This will allow us to dig deeper on one
important feature of the case, while saving discussion of other
aspects for future columns.
44
August 2015
Volume 79
Number 8

Situational surprise is a surgeon who has never had to take
back a bleeding cardiac patient suddenly having to do so. We did
not expect it, maybe because of complacency, but we knew it
could happen. Fundamental surprise, on the other hand, would
be the first occurrence of something we did not know could
happen, such as a device failure never previously reported in
the literature. Fundamental surprise is experienced far more
intensely than situational surprise. The safety implication is that
immediately after a fundamental surprise, we are not ourselves
and, in fact, may question ourselves. To successfully lead a team
in this situation we should make increased used of cognitive aids
and the input of colleagues and repeat a mantra such as, Yes,
I was caught by surprise, but I can still fall back on my training.
A second difference is that for fundamental surprise, we
could not have defined in advance the issues for which we
must be alert, no matter how hard we tried. The process of
learning from a fundamental surprise is far more complex and
personal than learning from a situational surprise. It requires
deep examination of the whole system, including our cognition.
If we handle surprise well, we can return to our roots. As
physician anesthesiologists, we pride ourselves on our ability to
accomplish most goals in more than one way and to adapt our
actions to changing circumstances. We should be comfortable
with the idea of surprise as a cognitive phenomenon.
Fixation is a psychological term indicating obsession with one
idea while excluding others. Cognitive fixation, or fixation error,
is the most clinical of the phenomena we are touching on. In the
clinical sense, fixation is the tendency to cling to a provisional
diagnosis or treatment plan in the face of evidence that other
possibilities must be considered. When analyzing incident
reports, fixation can be seen, for example, in perseverating
with attempts at direct laryngoscopy to accomplish a difficult
intubation rather than shifting to a supraglottic airway, calling
for the fiberoptic bronchoscope or allowing the patient to
awaken and performing a regional anesthetic. Surgical mission
creep presents the threat of fixating on the existing anesthetic
plan. In the case under discussion, blindly continuing to maintain
moderate sedation rather than pausing to initiate general
anesthesia would be a fixation error. Mindful anesthesiologists
can avoid this trap by remembering the first law of holes: when
youre in one, stop digging!
accounted for in any book or any standard operating procedure.

Adaptive expertise is mission critical to safety.
All three of these threats surprise, fixation and failure to
adapt can be defeated. The antidotes are:
n Metacognition, thinking about our own thinking.
n
Asking others for input into what our working diagnosis is,
what we may be missing and how we are managing it.
n
Stepping back and looking at the big picture. Ask yourself
what would be seen by a colleague just entering the room?
Application
We started off by asking: How would you plan for what you
cannot expect? ASA has recently championed the development
of checklists for crisis management. It is possible to develop
a checklist for surgical mission creep. Mission creep can be
expected or novel, situational or fundamental. Examples of
the first are converting a minimally invasive surgery to an open
operation. We should be prepared for this eventuality, and its
management should be routine.
Examples of fundamental surprise are more concerning, such
as a complete change in the surgical procedure. Episodes of mission
creep can be characterized by consideration of multiple factors,
many with dichotomous approaches. The extra complexity may
or may not require an upgrade of the airway management. This
may be easy, challenging or impossible without repositioning the
patient (or contaminating the surgical wound) or deepening the
anesthetic. It may or may not require addition of neuromuscular
block (NMB), increasing administered analgesics or addition of
new monitors. Higher-capacity I.V. access, upgrading the blood
bank order, repositioning or placement of an arterial catheter
may or may not be indicated. Recruitment of additional nursing
or surgical personnel may be warranted. Ditto for augmenting
the anesthesia team.
In most cases, the family waiting for the patient will not be
empowered to modify the informed consent process, but both
anesthesia and surgical providers must consider communicating
with the family. Finally, the appropriate location for recovery and
postoperative care should be re-evaluated in light of the new
operative and anesthetic plan. This collection of issues can serve
as a case-creep safety checklist (Table 1, page 46).
There are two actions that must be automatic when
plans change. One is to have a discussion with the surgeons,
acknowledging that plans have changed. This discussion may be
thought of as pre-briefing version two, a necessary revision of
the discussion we should have had prior to the surgery. The
surgeons, while not the final authority, may be able to shed light
on what the patient would wish. More importantly, they can
decide with us, as a team, if the proposed modified or additional
procedure is best done now or scheduled for another day. Our
surgical colleagues can also consider, with us, the status of the
informed consent vis a vis the new procedure. In many cases,
the surgeons will already have presented contingency plans to
Adaptive expertise was originally defined as

the development of flexible knowledge and dispositions that
facilitate effective navigation across varied settings and tasks,2
or
a depth of understanding that allows [response] to unusual
clinical problems with original rather than habitual approaches3
New ways to endanger patient care (by omission or
commission) will continue to arise, considering the infinite
variations of human physiology and the complexities of modern
health care. It is a rare case that proceeds without any deviation
in the plan from scheduling through discharge. We manage
by adapting to new challenges, small and large, which are not
August 2015
Volume 79
Number 8
45

Table 1: Checklist for Intraoperative Mission Creep
the patient and family; it behooves us to do the same

during our preoperative discussion. This is especially
true for cases (such as cancer resection) with a high
potential for mission creep.
The other critical action is discussion of the new
plan with all providers involved. This includes nurse
anesthetists, anesthesiologist assistants or residents
working with us, the circulating and scrub nurses in
the room, and our colleague running the O.R. for
the day.
Following these discussions, the next question
is: Can the anesthetic be safely changed? Converting
from deep sedation to general anesthesia with a
protected airway is often a wise decision, especially
when the ongoing intensity or duration of the
procedure is unknown. In the case presented,
hindsight suggests that this was not done soon
enough and was not done in a deliberate fashion
based on discussion with the surgeon. Once the
anesthesia teams hand was forced, events cascaded
downhill quickly, with development of pulmonary
edema, airway trauma and a protracted and difficult
intubation. But these are issues for another day.
Safety is the absence of something (causes of
unwanted outcomes). It is also the presence of
something that we create on a minute-to-minute
basis by reflecting on our thinking, modeling adaptive
expertise and managing surprise. Lou Pangaro,
a physician educator, has said that if we had to
differentiate what makes a physician unique among
todays confusing assortment of providers, we
should aspire to the following: a physician can follow
a protocol, write a protocol, and know when to alter or
ignore a protocol.
Like all checklists, this should be modified for

local circumstances.
References:
4. Notify O.R. management (nursing and anesthesia)

of the change in plans.
1. Lanir Z. Fundamental Surprises. Tel Aviv: Center

for Strategic Studies; 1983. http://reut-institute.
org/en/Publication.aspx?PublicationId=2245.
Accessed June 16, 2015.
2. Scardamalia M, Bereiter C. Knowledge building:
theory, pedagogy, and technology. In: Sawyer
RK, ed. The Cambridge Handbook of the Learning
Sciences. New York: Cambridge University Press;
2006:97-115.
3.
Cooke M, Irby DM, OBrien BC. Educating
Physicians: A Call for Reform of Medical School and
Residency [Kindle]. San Francisco, Calif.: JosseyBass; 2010:277.
1. Discuss with the surgeon the changes needed,

with the following questions:
a. Will the operation take longer?
b. Will repositioning be required?
c. Will the new procedure cause new or different pain?
d. Will blood loss increase?
e. Is the addition within the boundaries of the
preoperative consent? Or
f. Is the addition necessary on an emergency basis?
2. Formulate an adaptive anesthesia plan:
a. H
ow would you have done the case if it was scheduled
this way from the start?
b. How do we get from here to there?
i. Do I change the anesthetic?
ii. Do I change the airway management?
iii. Do I add additional lines or monitors?
3. Discuss with the O.R. team the implications
of the new plan:
a. Will a pause to reset the anesthetic be required?
b. Will new O.R. equipment be needed?
c. Should blood products be ordered?
d. Will postoperative plans change?
a. Reschedule to follow cases as needed.

b. Arrange for staffing if the case will run late.
5. Request assistance if needed:
a. A
nesthesia help to add monitoring or assist
with induction.
b. Nursing assistance to find equipment or
facilitate repositioning.
6. Notify the patients family of the change in plans.
a. When will the case be likely to finish?
b. Where can they see the patient postoperatively?
46
August 2015
Volume 79
Number 8
SEE anesthesiology from

a different angle
Interested in the scientific literature, but have little time to research new drugs and techniques
that will shape your practice in the future? Using the American Society of Anesthesiologists
Self-Education and Evaluation (SEE) program makes learning easier! Our practicinganesthesiologist editors review hundreds of articles about clinical anesthesia, critical care and
pain management from more than 40 professional journals, saving you time and effort.
SEE helps you meet the ABA MOCA Part 2 requirements and offers up to 60 CME credits.
SEE is available as an annual subscription of two issues, each of which consists of 100
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asahq.org/MOCA

The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to
provide continuing medical education for physicians.
This activity has been approved for AMA PRA Category 1 Credit.
This self-assessment activity helps fulfill the self-assessment CME requirement for Part 2 of the Maintenance of Certification in
Anesthesiology Program (MOCA) of The American Board of Anesthesiology (ABA). Please consult the ABA website, www.theABA.
org, for a list of all MOCA requirements.
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Anesthesiology Continuing Education

ACE Question
A 52-year-old man is intubated and ventilated in the intensive care unit after repair of a thoracoabdominal aortic
aneurysm. Which of the following will most effectively decrease his risk of ventilator-associated pneumonia?
q (A) Elevation of the head of the bed more than 30 degrees.
q (C) Nasal intubation.
q (B) Administration of prophylactic antibiotics.
q (D) Changing of the ventilator circuit daily.
Ventilator-associated pneumonia (VAP) is a parenchymal

lung infection manifesting more than 48 hours after initiation
of mechanical ventilation. It occurs in 10-25 percent of patients
intubated for longer than 48 hours and is one of the most
commonly acquired infections in intensive care unit (ICU)
patients. Prevention of VAP has been a focus of quality initiatives
in the ICU. Mechanisms of VAP include:
n
Colonization of oropharynx and stomach with pathogenic
organisms (facilitated by use of antibiotic and antacid therapy)
n
Aspiration of subglottic secretions which pool above the
tracheal tube cuff
n
Aerosolization of aspirated secretions into the lung during
positive pressure breath
A specialized tracheal tube has been developed in an effort

to reduce the volume of oropharyngeal secretions pooling above
and leaking around the tracheal tube cuff. Use of this tube,
which has an additional lumen for intermittent drainage of
subglottic secretions, has been shown to decrease the risk of
VAP in the ICU. However, there was no beneficial effect on
the duration of mechanical ventilation, ICU length of stay,
or mortality.
Prophylactic antibiotics have not been demonstrated to
reduce the risk of ventilator-associated pneumonia and may
increase the risk of developing resistant organisms.
Bibliography:
1. Leong JR, Huang DT. Ventilator-associated pneumonia. Surg Clin

North Am. 2006; 86:14091429.
2.
Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of
continuous aspiration of subglottic secretions in cardiac surgery
patients. Chest. 1999; 116:13391346.
3. Smulders K, van der Hoeven H, Weers-Pothoff I, et al. A randomized
clinical trial of intermittent subglottic secretion drainage in patients
receiving mechanical ventilation. Chest. 2002; 121:858862.
4. Lorente L, Blot S, Rello J. Evidence on measures for the prevention of
ventilator-associated pneumonia. Eur Respir J. 2007; 30:11931207.
5. Chastre J, Fagon JY. Ventilator associated pneumonia. Am J Respir Crit
Care Med. 2002; 165:867903.
6.
Murray MJ, Coursin DB, Pearl RG, et al. Critical Care Medicine:
Perioperative Management. 2nd ed. Philadelphia: Lippincott Williams
& Wilkins; 2002:389392.
Methods to decrease the risk of VAP include:

n
Use of the semirecumbent position (elevation of the head of
the bed greater than 30 degrees) to decrease the chance of
aspiration associated with the supine position.
n
Use of noninvasive ventilation, thus avoiding tracheal
intubation, which is associated with bypassing the usual
oropharyngeal protective mechanisms.
n
Less frequent change of ventilator circuitry. Changing
the ventilator circuit more often than every seven days is
associated with a higher risk of VAP.
n Staff hand washing.
n Regular patient oral hygiene and teeth cleaning.
n Decrease in the length of mechanical ventilation
(e.g., by means of sedation holidays).
n Oral (versus nasal) intubation. Nasal intubation increases the
risk of sinusitis and ventilator-associated pneumonia.
Answer: A
Anesthesiology Continuing Education (ACE) is a self-study CME program that covers established medical knowledge in the
field of anesthesiology. ACE can help fulfill the CME requirements of MOCA. To learn more and to subscribe, visit ace.asahq.org.
48
Are you prepared to make first response

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response to circulatory crisis in the OR online course. Identify rare
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The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to
provide continuing medical education for physicians.
The American Society of Anesthesiologists designates this enduring material for a maximum of 5.75 AMA PRA Category 1 Credits.
14-381
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ASA offers a variety of coding resources, online courses and live
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August 2015
Volume 79
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49
Providing Anesthesia Services Outside of the Hospital:

How Compliant Are You?
AQI Practice Quality Improvement Committee
Clinical care provisions in our health care delivery system

are keenly focused on efficiency and quality. Surgery in the
ambulatory care setting has been shown to deliver high-quality
care in a more efficient and lower-cost setting, thus the number
of cases performed in these settings continues to rise. This trend
is also evident in the National Anesthesia Clinical Outcomes
Registry (NACOR). The absolute number of ambulatory
anesthesia cases continues to increase steadily (Figure 1), as
does the percentage of ambulatory cases as a percentage of
overall caseload (Figure 2). Anesthesia providers are actively
participating in this transition of care to locations outside of the
hospital and need to be aware of the many different regulatory
standards, guidelines and requirements for reporting adverse
events and outcomes in the ambulatory setting.

Figure 2: Percentage of ambulatory anesthetics as identified by
NACOR, Anesthesia Quality Institute, 2010-15 (to date).

As the senior director of quality improvement for a large and
busy anesthesia practice, I regularly see staffing of anesthesia
providers across state lines to provide services in various
settings. From a clinical perspective, physicians with solid
clinical skills practicing within the scope of their specialty are
on solid ground. However, these clinicians may not be aware
of and compliant with the differences in regulations found in
different states.
Its logical to assume that regulatory compliance in an ASC
or office-based setting is simpler, as the patient population is
healthier and the procedures generally less complex. This is not
the case.
As you cross state lines, office-based surgery and anesthesia
regulations change. While not intended as a complete or current
list, and not a substitute for reading the original regulations, here
are some noteworthy points from a quick review of documents
to illustrate potential issues:
n In some states, it is the anesthesia provider who is responsible
for reporting adverse events and outcomes to the state, not
the surgeon or proceduralist.
n
Some states regulate office-based anesthesia but not
specifically office-based surgery.
n
There are some states with separate boards for medicine
and osteopathy; thus, M.D.s may have office-based surgery/
anesthesia guidelines to follow but D.O.s may not, or each
may have different guidelines set by their respective board.
n Osteopathic boards may be less likely to have regulations for
office-based practice than medical boards.1,2
Figure 1: Case volumes by quarter for reported ambulatory anesthesia

cases in the NACOR, Anesthesia Quality Institute, 2010-14.

is Senior Director of Quality
Improvement, North American
Partners in Anesthesia (NAPA).
50
August 2015
Volume 79
Number 8

Some states require accreditation of the facility in
conjunction with state guidelines; other states impose state
guidelines in the absence of accreditation status.
n
A state (e.g., Texas) may waive state standards/guidelines
if the office-based location is accredited by an organization
recognized by that state, such as The Joint Commission (TJC)
or the Accreditation Association for Ambulatory Health
Care (AAAHC), American Association for Accreditation
of Ambulatory Surgery Facilities (AAAASF), etc., and has
an agreement with the accrediting body to provide event
reporting to the state.
n
According to the Texas Medical Board,3 if you provide
services in an office-based location in Texas, the anesthesia
provider must register with the state and pay a fee to provide
anesthesia services in that setting. If you provide anesthesia
services to more than one office location, your fee is based on
the highest level of anesthesia/sedation that you provide in
this setting, regardless of the number of locations.
n A state requiring notification for untoward events may have
a standard formatted event report that must be completed
and submitted, or the state may require notification of the
event in a written letter format.
n
Reportable events differ by state as does the notification
period. For example, Kentucky requires notification of
the medical board within three days on a specific form of
any anesthetic or surgical mishap requiring resuscitation,
emergency transfer or death,2 whereas Virginia requires
notification in writing (no standardized form) of similar
events within 30 days.4
n
The period of tracking reportable events will vary by state.
For example, up to 72 hours or up to 30 days.
n
Some states designate guidelines or regulations by the level
of surgery, other states by the level of anesthesia, and some
use both methods.
n
A minimum patient age for the office-based setting is
established by some states.
n
According to the Federation of State Medical Boards,
25 states, including Washington, D.C. and Hawaii, have no
state guidelines for office-based surgery and/or anesthesia.
Additionally, Arizona, California and Oklahoma have
guidelines for M.D.s via the state medical board but do not
have guidelines for D.O.s.2
n Many states require transfer agreements with local hospitals
or EMS services, and these agreements may be the
responsibility of the anesthesia provider/group.
n
Massachusetts has a 60-page document outlining the state
guidelines for office-based surgery, last updated in 2011.5
n
The definition of office-based can vary between states.
Some definitions extend regulations or guidelines into
ambulatory surgery centers. Examples:
August 2015
Volume 79
Number 8

Alabama:
Office-based surgery is surgery performed

outside a hospital or outpatient facility licensed by the
Alabama Department of Public Health.6

Kentucky: Office-Based Surgery means the performance
of any surgical or other invasive procedure requiring
anesthesia, analgesia or sedation, including cryosurgery
and laser surgery, which results in patient stay of less than
24 consecutive hours and is performed by a practitioner in
a location other than a hospital or a diagnostic treatment
center, including freestanding ambulatory surgery centers.1
New Jersey: Office means a location at which medical,
surgical or podiatric services are rendered and which
contains only one operating room and which is not
subject to the jurisdiction and licensure requirements
of the New Jersey State Department of Health and
Senior Services.2
New York: Office-based surgery means any surgical or
other invasive procedure, requiring general anesthesia,
moderate sedation or deep sedation, and any liposuction
procedure, where such surgical or other invasive
procedure or liposuction is performed by a licensee in a
location other than a hospital, as such term is defined in
article 28 of this chapter, excluding minor procedures and
procedures requiring minimal sedation.2

Oregon: Office-based surgery means the performance
of any surgical or other invasive procedure requiring
anesthesia, analgesia or sedation, which results in patient
stay of less than 24 consecutive hours and is performed
by a practitioner in a location other than a hospital,
diagnostic treatment center or freestanding ambulatory
surgery center.2

Tennessee: Medicine (Osteopathic definition almost
identical) (2) Level II office-based surgery means
Level II surgery, as defined by the board of medical
examiners in its rules and regulations, that is performed
outside of a hospital, an ambulatory surgical treatment
center or other medical facility licensed by the
department of health; (3) Office-based surgery or
Level III office-based surgery means Level III surgery
requiring a level of sedation beyond the level of sedation
defined by the board of medical examiners as Level II
surgery that is performed outside a hospital, an ambulatory
surgical treatment center or other medical facility
licensed by the department of health.2

Virginia: Office-based means any setting other than
(i) a licensed hospital as defined in 32.1-123 of the
Code of Virginia or state-operated hospitals or (ii) a
facility directly maintained or operated by the federal
government.4
51

n

If searching various state board websites does not yield
guidelines, statues or regulations for office-based anesthesia
or surgery, review the state department of health website.
Some states, such as Florida, set forth guidelines established
and monitored through the department of health.7
50 percent of all cases. Your denominator for this

includes cases performed in office-based locations/ASCs.
Participation in an approved method of PQRS
reporting to CMS is required, and penalties for
noncompliance include a negative payment adjustment
from CMS (2017 reduction for reporting of 2015
quality data).8
This article summarizes some of the complexities of

compliance for anesthesia providers practicing outside of the
hospital. Other important considerations include:
n
Did you help create the policies for anesthesia care in the
office setting in which you provide care, or are you aware that
such policies exist?
n If you provide services to an accredited (versus unaccredited)
office-based location, there is a higher likelihood but no
guarantee of state compliance.
n
Regulations imposed by the DEA and board of pharmacy
also vary by state. Anyone administering or discarding
medications in an office-based location should be aware of
compliance measures with these agencies as well.
n
If you are reporting quality measures via a QCDR (AQI
is a registered QCDR), every individual provider in
your practice must provide quality outcomes for at least
Female
Learning From the Data

According to NACOR, a query of data submitted between
2010 and early 2015 identifies 191,199 cases in which anesthesia
care was provided in the office-based setting. This is likely
a small fraction of the anesthetic care being provided in the
office-based setting, but large enough to suggest some patterns.
The data reveal quality and compliance demographics that can
be useful when considering state compliance. For example,
many state guidelines include patient eligibility criteria for the
office/ASC setting, such as ASA Physical Status classification
and age. When pediatric patients are permitted for officebased surgery/anesthesia, there are additional requirements to
consider, such as PALS certification (Figures 3 and 4).
Male
Not Reported
Total
ASA Physical
Status
Percent
Percent
Percent
Percent
I - II
49,928
26.11
26,908
14.07
67
0.04
76,903
40.22
III
12,881
6.74
11,168
5.84
24,049
12.58
IV
926
0.48
1,204
0.63
2,130
1.11
35
0.02
37
0.02
Not Reported
49,529
25.90
37,139
19.42
Total
113,299
59.26
76,456
39.99
1,377
0.72
1,444
0.76
72
0.04
88,045
46.05
191,199
100.00
Figure 3: ASA Physical Status data for patients receiving ambulatory anesthesia in an office-based setting as identified by NACOR, Anesthesia
Quality Institute, 2010-15 (to date).
Female
Male
Not Reported
Total
Patient Age
Group
Percent
Percent
Percent
Percent
<1
269
0.14
380
0.20
0.00
653
0.34
1 - 18
5,115
2.68
6,331
3.31
0.00
11,449
5.99
19 - 49
45,706
23.91
22,843
11.9 5
51
0.03
68,600
35.88
50 - 64
40,532
21.20
30,615
16.01
0.00
65 - 79
17,829
9.33
13,859
80+
3,541
1.85
2,390
Not Reported
Total
307
113,299
0.16
59.26
38
76,456
71,152
37.21
7.25
31,688
16.57
1.25
5,931
3.10
0.02
39.99
1,381
1,444
0.72
0.76
1,726
0.90
191,199
100.00
Figure 4: Age-related demographics for patients receiving ambulatory anesthesia in an office-based setting as identified by NACOR, Anesthesia
Quality Institute, 2010-15.
52
August 2015
Volume 79
Number 8
As anesthesia providers become more involved in expanding

office-based and ambulatory surgery center care delivery systems,
its essential to research, understand and comply with state
regulations, statutes and guidelines applicable in these settings.
Nothing relieves the anesthesia provider from compliance.
Reporting quality and case demographics for office-based and
ASC cases to AQI, to build the NACOR database, will help
establish meaningful benchmarks for our specialty and establish
physician anesthesiologists as leaders in driving value-based care
in non-hospital-based ambulatory settings.
What Are We Doing in the Office?

Among the types of procedures performed in the office-based
setting, GI endoscopy procedures are most common, followed
by orthopedic, dental, cosmetic and gynecologic procedures
(Figure 5).
References:
1. Federation of State Medical Boards, State by State Statutes,

Regulations and Guidelines A-M, 04 April 2014. [Online]. Available:
ht tp: //w w w.fsmb.or g /Media /Default /PDF/FSMB/Advocacy/
GRPOL_Office_Based_Surgery_A-M.pdf. [Accessed 28 May 2015].
2. Federation of State Medical Boards, State by State Statutes,
Regulations and Guidelines N-Z, 04 April 2014. [Online]. Available:
ht tp: //w w w.fsmb.or g /Media /Default /PDF/FSMB/Advocacy/
GRPOL_Office_Based_Surgery_N-Z.pdf. [Accessed 28 May 2015].
3. Texas Medical Board Office Based Anesthesia, Renewals, 31 May
2015. [Online]. Available: http://www.tmb.state.tx.us/page/renewaloffice-based-anesthesia. [Accessed 29 May 2015].
4. Virginia Board of Medicine Office Based Anesthesia, 25 September
2013. [Online]. Available: https://www.dhp.virginia.gov/medicine/
medicine_laws_regs.htm#Reg. [Accessed 29 May 2015].
Figure 5: Data identified by NACOR, Anesthesia Quality Institute,

2010-15 (to date).
Quality Events Reported (Figure 6)

Its quite interesting to review reported quality events for
office-based anesthesia. The number of reported quality events
is low. We know that this is in part due to the great medical
care provided, but also likely due to the lack of standardized,
mandatory reporting.
Quality Indicators

N of Events
N of Cases
Percent
Pain
Inadequate pain control
300
4,830
6.21
PONV
Nausea / Vomiting
198
5,299
3.74
Medication
Adverse drug reaction
110
0.91
Administration
Extended PACU Stay
392
0.51
Upgrade of care
ICU admission
3,633
0.17
Administration
Case cancelled
5,217
0.15
Respiratory
Reintubation
3,630
0.14
Upgrade of care
Unplanned admission
5,295
0.13
Airway management
Difficult airway
3,613
0.08
Respiratory
Respiratory Arrest
3,623
0.06
Cardiovascular
Hypotension
3,647
0.05
Other patient injury
Patient Injury
3,647
0.05
Cardiovascular
Cardiac arrest
3,673
0.05
Eye injury
Eye injury
3,631
0.03
Respiratory
Aspiration
3,649
0.03
Death
Death
3,651
0.03
Figure 6: Reported Quality Data identified by NACOR, Anesthesia Quality Institute, 2010-15.
August 2015
Volume 79
Number 8
53
Self-Education and Evaluation
SEE Question
According to a recent study, the risk of major adverse cardiovascular events (MACE) after cessation of dual antiplatelet
therapy (DAPT) following percutaneous coronary intervention (PCI) was highest in which of the following scenarios?
q (A) Physician-recommended discontinuation
q (B) Brief interruption for surgery one month after PCI
q (C) Disruption due to noncompliance two months after PCI
q (D) Disruption due to bleeding one week after PCI.
A prospective observational study, PARIS (patterns of

nonadherence to antiplatelet regimens in stented patients), was
conducted in 15 centers in the United States and Europe from
2009 to 2010. The purpose of this study was to examine risk of
MACE in relation to the context and duration of cessation of
DAPT after PCI.
Patients were followed one, six, 12 and 24 months after PCI
with stent implantation and discharge on DAPT. This study
included more than 5,018 patients, with follow-up maintained for
4,678 patients after two years.
The investigators categorized the context for cessation of
DAPT as follows:
n Discontinuation: physician-directed withdrawal of DAPT when
the patient no longer needs it.
n
Interruption: temporarily stopping DAPT (14 days) when
required for surgery.
n
Disruption: withdrawal of DAPT because of bleeding or
noncompliance.
These categories were not mutually exclusive.
Over two years, the cumulative incidence of DAPT cessation
from all three categories was 57.3 percent. The most common cause
for cessation of DAPT was discontinuation (40.8 percent), followed
by disruption (14.4 percent) and interruption (10.5 percent).
For patients whose DAPT was not stopped, the mean duration
of therapy during the study period was 686 202 days. Patients
whose DAPT was stopped had a mean duration of therapy of
382 169 days in the discontinuation group, 230 201 days in the
disruption group, and 357 202 days in the interruption group.
In the interruption group, the mean duration of DAPT
interruption was 6.2 5.7 days.
Over two years, the overall MACE rate was 11.5 percent;
most of these events (74 percent) occurred while patients were
taking DAPT. The discontinuation category was associated
with a decreased risk of MACE (hazard ratio [HR], 0.63), the
interruption category with a nonsignificant increase (HR, 1.41)
and the disruption category with increased risk (HR, 1.5), with
the highest risk in the latter group occurring within seven days
of disruption. These results were not affected when patients with
bare metal stents or undergoing target-lesion revascularization
were excluded, or when analysis was limited to patients with
drug-eluting stents (DES).
The observed count of MACE in both the interruption and
disruption groups was 93 events, compared with an expected
count of 63.1 events had the patient remained on DAPT. Thus,
in the sample size of 558 events, a calculated MACE rate of
5.4 percent can be attributed to either interruption or disruption
of DAPT. For specific events, the calculated risk due to
Interested in becoming a question writer for the SEE Program? Active ASA members are encouraged to submit
their CVs for consideration to Regina Fragneto, M.D., SEE Editor-in-Chief, at fragnet@email.uky.edu.
The Self-Education and Evaluation (SEE) Program is a self-study CME program that highlights emerging knowledge in the field of anesthesiology.
The program presents relevant topics from more than 40 of todays leading international medical journals in an engaging question-discussion format.
SEE can be used to help fulfill the CME requirements of MOCA. To learn more and to subscribe, visit see.asahq.org.
54
August 2015
Volume 79
Number 8
ducation and Evaluation
interruption or disruption was 15 percent for spontaneous MI,

7.7 percent for definite or probable stent thrombosis, 4.1 percent
for target lesion revascularization, and 7.4 percent for cardiac
death. The authors noted that these calculated attributable risks
represent statistical association and not necessarily causal relation.

Over two years, the overall MACE rate

was
11.5
percent;
most
of
these
events

(74 percent) occurred while patients were

taking DAPT. The discontinuation category
was associated with a decreased risk of

MACE (hazard ratio [HR], 0.63), the

interruption category with a nonsignificant
increase (HR, 1.41) and the disruption

category with increased risk (HR, 1.5),

with the highest risk in the latter group

occurring within seven days of disruption.

The risk for MACE was highest when DAPT cessation occurred
due to disruption within seven days of PCI. Increased MACE risk
after disruption attenuated within 30 days, supporting a causal
association, as the prothrombotic effects of antiplatelet therapy
withdrawal usually appear within three weeks. No association was
found between interruption and subsequent thrombotic events.
The finding that 74 percent of MACE occurred in patients taking

DAPT calls into question the necessity of extended DAPT after
PCI in otherwise stable patients. The authors speculated that the
use of safer, second-generation DES might have mitigated the risk
of MACE associated with DAPT cessation after PCI. Randomized
studies have suggested that a DAPT duration of three to six months
could be safe with second generation DES. The authors concluded
that, because risk varies according to context and duration of DAPT
cessation, individualized management is preferable to a uniform
approach that deals with DAPT as an on-versus-off phenomenon.
The authors noted several limitations to their study, including its
observational design and a lack of demographic data such as mental
health status, income, and ethnic origin. Cerebrovascular events
were not included as an end point; therefore, this study could not
examine the association between cessation of DAPT and stroke.
Although the results indicated an association between early DAPT
disruption and MACE, the small number of events in the category
(n=7) limits the reliability of this finding. Finally, the findings
might not apply to patients treated with P2Y12 inhibitors such as
prasugrel or ticagrelor, as these were rarely used in this study.
Bibliography:

Mehran R, Baber U, Steg PG, et al. Cessation of dual antiplatelet
treatment and cardiac events after percutaneous coronary intervention
(PARIS): 2 year results from a prospective observational study. Lancet.
2013;382(9906):1714-1722.
Answer: D
August 2015
Volume 79
Number 8
55
committee news
Educate and Prepare Your Patients

With ASAs New and Updated Brochures
Jeffrey S. Jacobs, M.D.
Committee on Communications
Finding out how to prepare for outpatient surgery and

anesthesia is just one of the topics patients can learn
about in ASAs new and improved public education
brochures. They are designed to provide patients with
important information regarding anesthesia and the role
physician anesthesiologists play before, during and after surgery
and as anesthesia, pain and critical care specialists.
Herbal and
Dietary
Supplements
and Anesthesia
If youre having surgery or a medical procedure, your

doctors will ask you for a list of the medications you are
taking, such as those that lower your cholesterol, relieve
your headache or ease your upset stomach. But dont stop
there. Be sure to mention the ginkgo youre taking to
improve your memory, the echinacea to boost your immune
system, the multivitamin for your general health or any
other herbal or dietary supplements you are taking.
If you take herbal or dietary supplements, youre not alone.
Its a $27-billion-a-year business, with half of all Americans
taking them.
Specific brochure topics include:

n Awareness and Anesthesia
n Childbirth and Anesthesia
n Children and Anesthesia
n Herbal and Dietary Supplements and Anesthesia
n Obesity, Sleep Apnea and Anesthesia
n Outpatient Surgery and Anesthesia
n Pain Management
n Seniors and Anesthesia
n Physician Anesthesiologists: The Anesthesia, Pain and
Critical Care Specialists
n Sedation, Analgesia and Anesthesia
n Stop Smoking for Surgery
n Help Your Patients Stop Smoking for Surgery (for physicians)
n Surgery and Anesthesia Checklist
Seniors and
Anesthesia
But just like some prescription and over-the-counter

medications, herbal supplements can cause problems
during surgery, such as reacting with the anesthesia used
to control your pain.
Age may bring wisdom but it also brings a greater chance

of developing health problems, some of which might
require surgery. Being older also affects the way your body
reacts to surgery and anesthesia. Half of all people 65 and
older will have at least one surgical procedure in their
lifetime. If youre one of them, you should know about the
anesthesia options available to safely and effectively
control your surgery-related pain.
Awareness
and Anesthesia
If youre having a major surgey, such as a knee replacement or

back surgery, you most likely will receive general anesthesia and
be unconscious during the procedure. Very rarely, patients who
have general anesthesia become aware or conscious during the
procedure when the intention was for the patient to be
unconscious. This is called anesthesia awareness, and it happens
in only one or two out of every 1,000 medical cases involving
general anesthesia in adults. Although it can be very unsettling,
patients who experience awareness generally do not feel pain.
Anesthesia awareness is not the same thing as remembering
some activities surrounding your procedure, such as just before
the anesthesia starts working, or when its effects begin wearing
off after the surgery. These are expected and normal. You might
even dream during surgery, and only think you have experienced
awareness.
The term physician anesthesiologist also was integrated

into all brochures to help increase public awareness of our
specialty. Because nearly six in 10 Americans do not know
that an anesthesiologist is a physician, these brochures
serve to not only inform but advocate for patient-centered,
anesthesiologist-led care. Our research found that the term
physician anesthesiologist was preferred by key audiences
and resonated more when asked who plays a large and essential
role in providing safe and quality health care services. ASA
has been continuously promoting the use of this phrase in its
public education outreach.
The refreshed brochures also include an updated design
that incorporates a consistent and cohesive look, with each
featuring a photo and highlighted information. Instead of
selling the brochures, ASA members can download brochure
PDFs for free from www.asahq.org and print the two-sided,
8.5 x 11 patient brochure sheets in whatever quantities needed.
If you have questions about the brochures or how to download
the information, contact Public Relations Associate Ashley
Romano at a.romano@asahq.org.
The copy for each brochure was reviewed by ASA committee

members to ensure the information was current, accurate, and
that the language was consumer-friendly and did not contain
too much technical information or medical jargon. Readability
also was enhanced with the use of headings and bullets to break
up long text blocks and highlight specific topics.
Jeffrey S. Jacobs, M.D. is

ASA Alternate Director from
Florida and the Immediate Past
President of the Florida Society of
Anesthesiologists and a staff
anesthesiologist, Cleveland
Clinic Florida.
56
August 2015
Volume 79
Number 8
Anesthesia History Association (aha)

Seeks Nominations for David M. Little Prize
Each year, the AHA awards the David M. Little
Prize for the best work of anesthesia history published
the previous year in English in each of three
categories: book, journal article and audiovisual
medium. The prize is named after Dr. David M. Little,
Jr. (1920-1981), longtime Chair of Anesthesia at
Hartford Hospital in Connecticut. For many years,
Dr. Little wrote the Classical File series of history
columns for the Survey of Anesthesiology. Awards are
announced each October at the Annual Dinner
Meeting of the AHA during the ASAs annual meeting.
david m. little, jr., m.d.
AHA
The 2015 awards are for works published in 2014. The deadline for this years
award is September 1, 2015 and should be sent electronically to George S.
Bause, M.D. at ujyc@aol.com.
Total Intravenous Anesthesia: Present and Future

3.
Avidan MS, Mashour GA. Prevention of intraoperative
awareness with explicit recall: making sense of the evidence.
Anesthesiology. 2013;118(2):449-456.
4. Sahinovic MM, Absalom AR, Struys MM. Administration and
monitoring of intravenous anesthetics. Curr Opin Anaesthesiol.
2010;23(6):734-740.
5. Struys MM, Sahinovic M, Lichtenbelt BJ, Vereecke HE,
Absalom AR. Optimizing intravenous drug administration
by applying pharmacokinetic/pharmacodynamic concepts.
Br J Anaesth. 2011;107(1):38-47.
6. Glen JB, White M. A comparison of the predictive
performance of three pharmacokinetic models for propofol
using measured values obtained during target-controlled
infusion. Anaesthesia. 2014;69(6):550-557.
7.
Egan TD, Shafer SL. Target-controlled infusions for
intravenous anesthetics: surfing USA not! Anesthesiology.
2003;99(5):1039-1041.
8.
Absalom AR, De Keyser R, Struys MM. Closed loop
anesthesia: are we getting close to finding the holy grail?
Anesth Analg. 2011;112(3):516-518.
9. Glass PS. Automated control of anesthesia ten years later:
futuristic novelty or present day reality. Can J Anaesth.
2010;57(8):715-719.
effect-site concentration (and therefore the infusion

rate) to keep the BIS value within the reference range.
Several studies have reported the safety and efficacy of
closed-loop anesthesia systems.
In summary, TIVA techniques have several benefits
but are not widely used in the U.S. probably because of
lack of familiarity and unavailability of TCI devices.
Although closed-loop controlled general anesthetic
systems show promise, the tools used to measure the
level of hypnosis and antinociception need to be refined
before implementation in routine clinical practice.
References:
1. Eikaas H, Raeder J. Total intravenous anaesthesia techniques

for ambulatory surgery. Curr Opin Anaesthesiol. 2009;22(6):
725-729.
2.
Sneyd JR, Holmes KA. Inhalational or total intravenous
anaesthesia: is total intravenous anaesthesia useful and
are there economic benefits? Curr Opin Anaesthesiol.
2011;24(2):182-187.
August 2015
Volume 79
Number 8
57
payment and practice management
Expand Your Medicaid Knowledge

Samia Ayoobi, CCA
The Affordable Care Act (ACA) has introduced many

milestones in health care reform, including Medicaid
expansion. What is Medicaid expansion? ACA offers states the
funding to expand their individual Medicaid programs to cover
adults under the age of 65 with incomes up to 133 percent of the
federal poverty level. States that have expanded their Medicaid
programs now offer free or low-cost health care plans to lowincome individuals, regardless of other factors that are usually
taken into account when deciding on Medicaid eligibility (e.g.,
disability, financial resources, family dynamic).
As of February 2015, 27 states and the District of Columbia
have expanded their Medicaid programs. As we dive into a
completely new health care structure (Medicaid expansion,
Federal Marketplace, Sustainable Growth Rate [SGR] repeal), it
is important that anesthesia practices understand the Medicaid
policy and payment rates applicable to them. Medicaid payment
and policies vary by state. It is not uncommon to see a Medicaid
policy in one state be completely different than its neighboring
states or other states in the region.
Federal and state governments jointly fund Medicaid
programs. The federal government provides funding for program
costs. This is formally known as the Federal Medical Assistance
Percentage (FMAP). FMAP rates vary by state and are published
each year in the Federal Register.
The federal government grants states the authority to create
their own payment methodologies, as long as the state adheres to
federal requirements. In order to monitor consistency with the
Social Security Act as well as other regulations, the Centers for
Medicare & Medicaid Services (CMS) evaluates state payment
methodologies.
Due to the fact that states are responsible for creating their
own payment methods, anesthesia and pain medicine Medicaid
payment policies differ across the nation. This means an
anesthesia conversion factor in one state could be significantly

different than a neighboring state or a pain service covered in
one state is not covered in another.
Disclaimer: State payment rates and policies mentioned in this article are
accurate as of May 2015.
Anesthesia Conversion Factor

Medicaid programs establish their own anesthesia conversion
factors. Notable anesthesia conversion factor trends include:
A single conversion factor for all providers and modifiers
State

(current as of May 2015)
Kentucky
$21.53
Different conversion factors for different modifiers

State

(current as of May 2015)
Georgia
AA (Personally Performed by
Anesthesiologist) = $16
QK (Medical direction of 2, 3 or 4
concurrent anesthesia procedures
involving qualified individuals) and
QY (Medical direction of one certified
registered nurse anesthetist
[CRNA] by an anesthesiologist) = $5.58,
QX (CRNA service: with medical
direction by a physician) = $10.42 QZ
(CRNA service: without medical
direction by a physician) = $15.84
Physical Status Modifiers and Qualifying

Circumstance Codes
Physical Status Modifiers and Qualifying Circumstance
CPT codes are used to describe additional information about
an anesthesia service. Depending on the state policy, physician
anesthesiologists may receive additional payment for complex
situations if they report these codes and modifiers appropriately.
Although Medicare does not follow this policy, some
Medicaid programs and private payers do.
Samia Ayoobi, CCA, is ASA Payment

and Practice Management Specialist.
58
August 2015
Volume 79
Number 8
Physical Status Modifier/ Qualifying Circumstance Examples
Physical Status Modifiers

Recently, the ASA House of Delegates (HOD) approved
guidelines for the ASA Physical Status Classification System.
The statement is available on ASAs webpage at http://www.
asahq.org/quality-and-practice-management/standards-andguidelines.
Modifier
ASA Physical
Status
Classification
P1
ASA I
A normal, healthy
patient.
P2
ASA II
A patient with mild

systemic disease.
P3
ASA III
A patient with severe

systemic disease.
ASA IV
A patient with severe

systemic disease that
is a constant threat
to life.
ASA V
A moribund patient
who is not expected
to survive without the
operation.
A declared braindead patient whose

organs are being
removed for donor
purposes.
P4
P5
P6
Definition
ASA VI
Base
Unit
Value
Description
99116
Anesthesia complicated
by utilization of total body
hypothermia.
99135
by utilization of controlled
hypotension.
99140
by emergency conditions
(specify).
Volume 79
Number 8
Alabama Medicaid only makes additional

payments for qualifying circumstance
codes.
Arkansas
Arkansas Medicaid makes additional

payments for both physical status modifiers
and qualifying circumstance codes.
Colorado
Colorado Medicaid does not make

additional payment for physical status
modifiers and qualifying circumstance
codes.
Georgia
Georgia Medicaid only makes additional

payments for physical status modifiers.
State
OB Anesthesia Medicaid Payment Policy
Mississippi
Mississippi Medicaid pays a flat rate for OB

anesthesia codes. OB Anesthesia codes
and payments include:
01961 (Anesthesia for cesarean delivery
only): $551.64
01967 (Neuraxial labor analgesia/anesthesia
for planned vaginal delivery (this includes
any repeat subarachnoid needle placement
and drug injection and/or any necessary
replacement of an epidural catheter during
labor): $597.45
Base
Unit
Value
Anesthesia for patient of

extreme age, under 1 year
and over 70.
Alabama
OB anesthesia codes are paid at a flat rate
99100
August 2015
Physical Status Modifier/Qualifying

Circumstance Medicaid Policy
Obstetric (OB) Anesthesia

Different Medicaid programs use different payment
methodologies for OB anesthesia codes. Notable trends include:
Qualifying Circumstance Codes

Qualifying Circumstance Codes are used to report conditions
that have a significant impact on an anesthesia service.
Qualifying
Circumstance
CPT Code
State
01968 (Anesthesia for cesarean delivery

following neuraxial labor analgesia/
anesthesia [List separately in addition to
code for primary procedure performed]):
$184.60
01969 (Anesthesia for cesarean
hysterectomy following neuraxial labor
analgesia/anesthesia [List separately in
addition to code for primary procedure
performed]): $307.71
59
programs grow in size, it is likely that state payment rates will

fluctuate. As we move forward with health care reform, it is
important that you stay up to date with your states anesthesia
and pain medicine payment policies.
If you have specific questions pertaining to Medicaid, please
contact Samia Ayoobi, ASA Payment and Practice Management
Specialist, at s.ayoobi@asahq.org.
OB anesthesia payments are based on face-to-face time spent with

the patient
State
OB Anesthesia Medicaid Payment Policy
Nebraska
Physician anesthesiologists must only

report face-to-face time with the patient.
North Dakota
North Dakota provider can only submit

the number of minutes that the provider is
physically present with the recipient.
Ohio
Ohio Medicaid only pays a maximum

of 4 hours of face-to-face time for OB
anesthesia codes.
Sources:
1. www.medicaid.gov.
ASA has a growing library of shorter articles

on topics relevant to Payment and Practice
Management. Timely Topics in Payment and
Practice Management are available at:
http://www.asahq.org/quality-and-practicemanagement/practice-management/timelytopics-in-payment-and-practice-management
Pain Medicine
Pain medicine policies differ often markedly from state
to state. Policies specific to your states program are available via
your states Medicaid program webpage. Examples include:
State
Pain Medicine Payment Policy
Arizona
Arizona Medicaid allows postoperative

pain block on the same day as surgery.
Arizona Medicaid also pays for regional
nerve blocks for the purpose of
postoperative pain control. The program
follows ASA guidelines and Medicare
policies for blocks.
Georgia
Minnesota
June 2015
Ten Questions to Ask Yourself about ICD-10-CM
Georgia Medicaid does not make

separate payments for pain
management.
David Letterman is gone but his Top 10 list lives on. As we move closer to the October 1,
2015 transition from ICD-9-CM to ICD-10-CM/PCS, here is a list of 10 questions you should
be asking yourself:
1. Is your billing system ready?

The Centers for Medicare and Medicaid Services (CMS) recently announced the
results of the April 27-May 1, 2015 end-to-end testing,
http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2015-April-TestingResults.pdf The acceptance rate for this round of testing was 88% which was
higher than the results from the January testing period. At this point there is no
further opportunity to register for end-to-end testing but you still can and should do
acknowledgement testing with CMS. Information on how to do that is available on
your Medicare Administrative Contractors website. Look for opportunities to
confirm that your commercial payers will be able to properly receive and process
claims from your practice that include ICD-10-CM codes
Minnesota Medicaid covers medically

necessary daily pain management
services. The service must be conducted
face to face.
2. Are you clear on the details of the transition?

Claims for services provided on/after October 1, 2015 will require ICD-10-CM codes.
ICD-9-CM codes must be used on claims for services provided before October 1,
2015. When an anesthesia service begins before midnight on Sept 30, 2015 and
ends on October 1, 2015, CMS has specified that claims for such services should use
ICD-9-CM codes. Per MLN Matters Number: SE1408,
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1408.pdf
A handful of state Medicaid programs post payment policies and

other important documents on their state Medicaid webpages.
Keywords to look for include Fee Schedule and Physician
Manual. A few programs provide physicians with an online
provider portal.
In summary, as Medicaid expansion grows, it is important
to monitor physician payment rates and coverage policies both
now and in the future. Health care coverage for newly enrolled
adults is entirely funded by the federal government, a policy
that started in 2014 and which will continue for the next three
years. By 2020, funding will phase down to 90 percent. As the
Medicaid policyholder population increases and Medicaid
Anesthesia procedures that begins on 9/30/2015 but end on 10/1/2015 are

to be billed with ICD-9 diagnosis codes and use 9/30/2015 as both the FROM
and THROUGH date.
3. Do you know where to find resources to assist you in planning and executing
the transition?
CMSs Road to 10 is chock full of information, resource and tools to assist you and
your practice. Visit http://www.cms.gov/Medicare/Coding/ICD10/index.html to
take advantage of these excellent materials.
4. Have all physicians and staff received training appropriate to their role and
function in the practice?
Many experts have agreed that the optimum time for coders to receive training in
ICD-10-CM is 6-9 months before implementation. If you have been putting this off,
you need to address it now. The transition delays may have interfered with your
training schedule. If members of your billing/coding staff were trained 6-9 months
60
August 2015
Volume 79
Number 8
subspecialty news
FAER/SNACC Resident Scholar Program

Chanannait Paisansathan, M.D., Chair
Scientific Affairs Committee, Society for Neuroscience in Anesthesiology and Critical Care (SNACC)
Mentorship is known to be an influential factor for

career development. Mentoring during residency is viewed
as beneficial for career planning, specialty selection and the
pursuit of academic medicine.1 Traditionally, mentoring has
been related to a successful research career; however, it also
contributes to both clinical and educational skill development
in medical practice. Lack of exposure to academic medicine and
research in the early phases of physician training might lead to
fewer graduates choosing academic careers.2 Furthermore, the
lack of mentoring may also decrease the supply of clinicianscientists and impede the growth of our specialty. Research
in anesthesiology has lagged behind many other medical
specialties. Effective mentoring and residency research
involvement might reverse this trend. Sakai et al. reported an
increase in research productivity by anesthesiology residents
after a series of structured research initiatives and facilitative
faculty mentorship.3
One of the remaining obstacles to mentorship is a limited
pool of available and skilled mentors in the same institution.
Networking with establishing mentors in different institutions
can be a valuable resource. The concept of speed mentoring
has emerged and resulted in a successful initiation of the
mentoring process. Junior faculty members had the opportunity
to interact with potential mentors using multiple, short (five10 min) encounters. Although the development of long-term
mentoring relationships may be difficult to establish because
of the time barrier, this speed mentoring is rated highly by
those who have participated in it. In addition, mentees have the
option to contact mentors for further discussion.4 This concept
is easy to organize and can be modified to promote resident/
mentor relationships in our specialty.
The Foundation for Anesthesia Education and Research

(FAER) established the Resident Scholar Program in 1989,
which selects anesthesiology residents for the opportunity
to attend the ASA ANESTHESIOLOGY annual meeting.
SNACC has partnered with FAER and welcomed residents
to attend the SNACC Annual Meeting. The FAER/SNACC
resident scholar program has been very successful, receiving
great feedback from resident scholars. The interest in the FAER/
SNACC resident scholar program continues to grow. Last year,
SNACC welcomed 12 anesthesia residents to our 42nd annual
meeting in New Orleans.
SNACC has developed a mentoring session that starts
on the afternoon before the annual meeting with a focus on
early career development; research development, including
grant preparation; and how to navigate a career in academic
anesthesiology. The session is designed to guide junior faculty,
fellows and residents interested in pursuing academic careers.
Invited speakers are well established physician-scientist SNACC
members. FAER/SNACC resident scholars are encouraged
to attend. The past participants found this SNACC session
highly informative and valuable for career development. The
SNACC mentoring workshop was noted to be highly organized
and aimed at guiding individuals on how to be a successful
investigator. The title for the 2015 mentoring workshop at the
SNACC Annual Meeting in San Diego is Getting Ready for
Tomorrow Transition from Training to Practice. Again, we
expect that it will be well attended, and the FAER/SNACC
resident scholars will take advantage of this session to prepare
for a career in neuroscience in anesthesiology.
Recognizing the benefit of a mentoring relationship,
SNACC pairs each resident scholar with a successful mentor.
Residents have the option to choose their mentor. All mentors
are SNACC members who are established basic science, clinical
or translational investigators. Residents are encouraged to
initiate the relationship prior to attending the annual meeting
in order to gain benefit from the mentoring experience. The
FAER/SNACC resident scholars and mentors participate in
the educational activities together during the meeting, which
Chanannait Paisansathan, M.D., is

Associate Professor, Department of
Anesthesiology, University of Illinois,
Chicago.
62
August 2015
Volume 79
Number 8
allows for networking with other residents and their mentors.

A broad and varied network of strong mentors is critical in an
individuals development into an academic anesthesiologist and
an NIH-funded physician scientist.
I would like to share a story of one recent FAER/SNACC
resident scholar who decided to pursue a neuroanesthesia
fellowship and enter academic medicine after his experience
with the program. One resident, Muhammad Y. Qadri, M.D.,
Ph.D., continued the relationship with his SNACC mentor,
frequently receiving guidance from him. He was later able to
develop a network of mentors at different institutions. His work
on Assessing differential microglial activation states in acute
and chronic pain was awarded a FAER research fellowship
grant. Dr. Qadri stated that this single interaction through
the FAER/SNACC resident scholar program provided him
with an opportunity to pursue a career in academic medicine.
He believed that being a FAER/SNACC resident scholar
and attending the mentoring workshop gave him a unique
opportunity; he benefited not only from vertical mentoring
but also from horizontal mentoring. Hearing about other
peoples paths, discussing opportunities with other mentees and
trading stories, thoughts and concerns with those at his level of
training were very useful for the development of his framework

and direction.
Residency can be a busy time and sometimes can limit your
vision of the future. Exploring a small group event or workshop
in a subspecialty such as SNACC is a great way to enhance
your academic potential. I look forward to welcoming more
FAER/SNACC resident scholars at our 2015 SNACC Annual
Meeting. See you in San Diego.
References:
1. Yehia BR, Cronholm PF, Wilson N, et al. Mentorship and pursuit

of academic medicine careers: a mixed methods study of residents
from diverse backgrounds. BMC Med Educ. 2014:14:26. doi:
10.1186/1472-6920-14-26.
2. Sakushima K, Mishina H, Fukuhara S, et al. Mentoring the next
generation of physician-scientists in Japan: a cross-sectional survey
of mentees in six academic medical centers. BMC Med Educ.
2015;15:54. doi: 10.1186/s12909-015-0333-2.
3. Sakai, T, Emerick TD, Metro DG, et al. Facilitation of resident
scholarly activity: strategy and outcome analyses using historical
resident cohorts and a rank-to-match population. Anesthesiology.
2014;120(1):111-119.
4. Flexman AM, Gelb AW. Mentorship in anesthesia. Curr Opin
Anaesthesiol. 2011;24(6): 676-681.
Vice President for Scientific Affairs
Since an announcement was made in the April

NEWSLETTER, 12 ASA members have declared
their candidacies for elected offices. In August, the
Candidates for Office page will be available on the
ASA website at www.asahq.org/candidates/approve.
A members announcement of candidacy does not
constitute a formal nomination to an office, nor is it a
prerequisite for being nominated. Formal nominations
are made from the floor of the House of Delegates
at the first session, as prescribed by the ASA Bylaws
(section 1.6.1.1). Those who have declared they are
seeking office are:
Beverly K. Philip, M.D.
Secretary
Linda J. Mason, M.D.
Treasurer
Mary Dale Peterson, M.D.
Assistant Secretary
John F. Dombrowski, M.D.
Assistant Treasurer
Michael Champeau, M.D.
Steven Hattamer, M.D.
James M. West, M.D.
President-Elect
Jeffrey Plagenhoef, M.D.
Speaker, House of Delegates
First Vice President
James D. Grant, M.D.
Vice Speaker, House of Delegates
Vice President for Professional Affairs
Stanley W. Stead, M.D., M.B.A.
August 2015
Volume 79
Number 8
63
asa news
Candidates Announce for Elected Office
anesthesiology in the news
ANESTHESIOLOGY
ASA Members write for KevinMD
IN
THE
NEWS
U.S. Navy Physician Anesthesiologists

in Afghanistan
ASA contributes an article each month to

Kevinmd.com. Paul Yost, M.D., highlighted physician
anesthesiologists contributions to high-quality
patient care in a March article, and Fred Shapiro, D.O.,
wrote about patient safety and education. James
D. Grant, M.D. authored What does it mean to be a
health care leader? in April. Jesse M. Ehrenfeld,
M.D., M.P.H.A., reported on his experience as a
physician anesthesiologist during his eight-month
deployment in Afghanistan in May, and
Jay Mesrobian, M.D., chair of the Committee on
Practice Management, wrote an article that inquired
if physician anesthesiologists are ready for success
by evolving their practice infrastructure.
ASA member Jesse M. Ehrenfeld, M.D., U.S. Navy

Lt. Cmdr., who recently completed an eight-month
deployment, described the role of physician
anesthesiologists at the NATO ROLE 3 Multinational
Medical Unit on Kandahar Airfield, Afghanistan. The
video aired around the world on DefenseTV this April.
WKZO Radio Discussion on Childhood

Immunizations
Kenneth Elmassian, D.O., discussed the importance

of childhood vaccinations in February on the
Wayne Powers Show on WKZO radio, in Kalamazoo,
Mich. Dr. Elmassian explained that vaccinations are
safe and should be encouraged as the best way to
prevent disease.
Civility Among the Anesthesia Care Team

Featured on The Health Care Blog
Dr. Abenstein Discusses JAMA Study

with Modern Healthcare
Karen Sibert, M.D., wrote an article in March for

The Health Care Blog, that discussed the need for
civility among anesthesia providers and how care
team members should work together.
ASA President J.P. Abenstein, M.S.E.E., M.D.,

was quoted on a Journal of the American Medical
Association study regarding administering sedatives
prior to surgery in March. Talking through a
procedure with my patients is oftentimes a more
powerful relief of anxiety than any drug I have.
Anesthesia and Brain Development

Showcased in The New York Times
In March, ASA members Randall P. Flick, M.D.,

Alex S. Evers, M.D., Charles Berde, M.D., Ph.D.,
and Santhanam Suresh, M.D., were quoted in a
New York Times article discussing the effects of
anesthesia on children and brain development,
calling for additional research on the topic.
Pain and Opioid Abuse on CNN, Everyday Health

and BYU radio
Anita Gupta, D.O., Pharm.D, discussed pain related to

Angelina Jolies surgery decision to have her ovaries
and fallopian tubes removed. The April interview
aired on CNN Tonight with Don Lemon. Dr. Gupta also
wrote about chronic pain for Everyday Health and
discussed opioid abuse and the importance of drug
education on Top of Mind, a show on BYU Radio.
Misleading hospital ads discussed

in the Washington Post
FAER fellow Mariah Kincaids research on online

health information was featured in the Washington
Post this March. Dr. Kincaids study examined online
advertisements for hospitals and how they could be
misleading to consumers.
Legislation Editorial in ABQ Journal
New Mexico Society of Anesthesiologists President

Cameron E. Burrup, M.D., wrote an op-ed for the
ABQ Journal, urging the passage of a bill that would
expand anesthesiologist assistants practice in New
Mexico. At a time when improving access to quality
health care and safe pain management for medical
procedures in New Mexico is of extreme importance,
hospitals throughout the state should be given all the
tools available to deliver it.
ASA checklist featured in San Francisco

Chronicle, Milwaukee-Journal Sentinel
ASA distributed a mat release on outpatient surgery

for Patient Safety Awareness Week 2015, March 8-14.
The release was featured in the San Francisco
Chronicle, Milwaukee Journal-Sentinel and the
Houston Chronicle, among other outlets.
64
August 2015
Volume 79
Number 8
Drug Shortages in Medscape
ASA Vice President of Scientific Affairs Beverly

Philip, M.D. spoke in March about the General
Accountability Office report regarding drug
shortages. Drugs may not be interchangeable,
with different strengths and doses, and
alternatives can be hard to find.
Hospitals & Health Networks Support

sustainability in the O.R.
ASA President J.P. Abenstein, M.S.E.E., M.D.,

Kate Huncke, M.D., Lauren Berkow, M.D., and
Susan Ryan, M.D., Ph.D., discussed greening
the O.R. in March with Hospitals & Health
Networks. Hospital sustainability programs
have a financial impact that can enhance the
quality of patient care.
Surgery Tips in Womens Health
ASA was mentioned in April regarding smoking

cessation in an article on surgery preparation.
People who smoke have an increased chance of
complications during and after surgery.
ASA Members Featured in

Pediatric Anesthesia Article
Leah Templeton, M.D., and Charles Cote, M.D.,

were featured in an April story on pediatric
anesthesia care in a small community setting
in North Carolina. Dr. Templeton advocates
for the multidisciplinary team approach.
Chronic pain treatment on MSN.com
ASA member Neel Mehta, M.D., described

transcutaneous electrical nerve stimulation
(TENS) treatment for those who suffer from
chronic pain on MSN.com this April. According
to Dr. Mehta, the electrical impulses relieve
chronic muscle pain for about 50 percent of
those who try it.
PSH Featured in Health Affairs
Zeev Kain, M.D., and Jason Hwang, M.D., authored

an article in April on the inclusive and highly
collaborative Perioperative Surgical Home model
of care. The article highlighted the importance of
standardizing care
ASA Member Searches for Cause of SIDS
Daniel Rubens, M.D., was featured this April in

the Puget Sound Business Journal for his research
on Sudden Infant Death Syndrome (SIDS) at
Seattle Childrens Hospital. Dr. Rubens discovered
a connection between babies with inner-ear
problems and SIDS.
August 2015
Volume 79
Number 8
Precision Medicine Initiative

appointment in Crains
ASA member Sachin Kheterpal, M.D., was

appointed to a working group for President Barack
Obamas Precision Medicine Initiative this April.
The appointment was featured in Crains Detroit,
Beckers ASC Review and MedCity News.
Nature journal highlights blood transfusions
Aryeh Shander, M.D., and Steven Frank, M.D., were

mentioned in the April edition of Nature regarding
their research on blood transfusions. Transfusions
are lifesaving, but less is more said Dr. Frank.
FAER study featured on NPR
Study author and ASA member Catherine Chen,

M.D., discussed preoperative testing before
cataract surgery on NPR this April. Cataract
surgery is a low-risk procedure and clinical guidelines stipulate no preoperative testing is needed.
Marketing 101 for Physician Anesthesiologists

An Anesthesiology News reporter detailed the
presentation by Amr Abouleish, M.D., at
PRACTICE MANAGEMENT 2015 where
he discussed marketing and branding. Dr.
Abouleish stated the significance of physician
anesthesiologists promoting their practice and
values in the April issue.
New QCDR Measures Approved
Physician anesthesiologists who participate

in the ASA QCDR have 18 new reporting measures
to choose from. The measures, developed by ASA
and the Anesthesia Quality Institute (AQI), were
approved by the Centers for Medicare & Medicaid
Services (CMS), which was featured in Aprils
Anesthesiology News, News-Medical.net and
Phys.org, among other outlets.
ASA Member on NPR
Indiana State Health Commissioner and

ASA member Jerome Adams, M.D., M.P.H.,
discussed the HIV outbreak in his state
this May. He is dedicated to ensuring
recovery and treatment to those affected.
Drug-Discovery Research Featured

in Philadelphia Inquirer
Roderic G. Eckenhoff, M.D., discussed his research

on a new drug-discovery method that could lead
to increased patient safety this May. The new drugdiscovery process Dr. Eckenhoff and his colleagues
developed uses a robotic system to screen several
hundred drug candidates from a library of
compounds at the National Institutes of Health.
65
CALL FOR NOMINATIONS FOR ASA RESIDENT COMPONENT

GOVERNING COUNCIL OFFICERS
It is time to make a call for candidates for the
ASA Resident Component Governing Council.
The program directors letter should clearly state that the
Officer positions to be selected by the Resident
attend all of the meetings and perform the responsibilities
resident will have ample protected time to prepare for and
Component House of Delegates on Sunday, October 25,
of each respective office. The duties and requirements
2015, include: President-Elect, Secretary, Alternate
are listed in the ASA Resident Component Bylaws found

at www.asahq.org/about-asa/component-societies/
Delegate to the AMA Resident and Fellow Section

and Junior Co-Editor. Any resident with 18 months or
asa-resident-component/bylaws. Resident candidates
more left in residency or fellowship is eligible to run for
are encouraged to contact current officers to discuss
office. Of note, the President-Elect, Alternate Delegate to
the duties and responsibilities and to ask any questions.
the AMA Resident and Fellow Section, and Junior Co-
A list of current officers and contact information can
Editor are two-year positions; this allows for one year of
be found on the ASARC website at www.asahq.org/
working closely with the senior officer before assuming
about-asa /component-societies /asa-resident-
full responsibilities. The Secretary position is a one-year
component/officers.
CA-3s pursuing a fellowship.
Residents interested in representing their state in the
Candidates should submit an application along with a
their state societies to determine the process for being
position. PGY-1s, CA-1s and CA-2s are eligible, as are
Resident Component House of Delegates should contact
one-page personal statement of interest, a one-page
elected or appointed to the Resident Component House
summary of qualifications and platform statement and
of Delegates.
curriculum vitae (as a Word document), which can be:

E-mailed to: residentcomponent@asahq.org
Faxed to:
(847) 825-1692
Attention: Resident Component
Mailed to:
ASA
Attention: Resident Component
1061 American Lane
Schaumburg, IL 60173.
The Junior Co-Editor must also submit a 500- to 700word writing sample on a topic of his or her choice. These
materials are due September 18, 2015, to be included in

the annual meeting Handbook for Delegates posted on
the Resident Component website. In addition, a strong

letter of support from the candidates residency program
director should accompany these documents.
66
August 2015
Volume 79
Number 8
There is no debate: we anesthesiologists must actively

strive to limit infections in our patients. The benefits
of successful infection prevention are numerous to patients,
medical facilities, insurers, governments and future infection
control. Our journals, especially the April 2015 issue of
Anesthesia & Analgesia1 (A&A), present numerous articles
related to hospital-acquired infections. Implementing many of
the techniques supported by several of their relevant studies
provide a rational answer and possible resolution to the
ever-present issue of drinking in the O.R. Presently, neither
published studies nor any evidence-based practices have
been presented in journals or meetings that demonstrate an
association between infection and anesthesiologists drinking
water or coffee in the O.R. Nonetheless, as a result of
generally non-physician restrictions imposed by O.R. nursing
organizations, hospital committees, federal military guidelines
and, in Britain by the National Health System criteria,
drinking in the O.R. is a near-universal prohibition.
But there is an answer if we use the practices suggested by
our anesthesia journals, especially A&A, April 2015: frequent
hand-washing, double-gloving, cleaning surfaces after use and
having a dedicated area away from the direct surgical field.
Then, when applied to drinking a cup of water or coffee in
the O.R., we may have an appropriate guideline. If we wipe
our cups after being held by double-gloved hands; if we use an
area of the O.R. removed from the direct surgical field; if we

turn away from the surgical field while drinking; and if we use
a cup-holder to prevent spills, then, perhaps drinking in the
O.R. will be accepted until research demonstrates any actual
risks to our patients.
Until prospective studies are published, drinking in the
O.R. will continue despite the threat of fines, reprimands and
uninvited criticism.
High O.R. temperatures for pediatric, trauma and burn
patients; long cases; medications requiring appropriate fluid
intake for anesthesiologists; and other exigencies often
necessitate the drinking of fluid while in the O.R. If done
discreetly and in accordance with the above recommendations,
perhaps we anesthesiologists do have a rational answer to a
research-unsupported and rigidly imposed prohibition.
Steve Serlin, M.D.
Clinical Professor of Anesthesiology
University of Arizona
Reference:
1. Featured article collection: hospital-acquired infections. Anesth

Analg. 2015;120(4):697-705, 807-887.
The views and opinions expressed in the Letters to the Editor are those of the authors and do not necessarily reflect
the views of ASA or the NEWSLETTER Editorial Board. Letters submitted for consideration should not exceed 300 words in length.
The Editor has the authority to accept or reject any letter submitted for publication. Personal correspondence to the Editor by letter or
e-mail must be clearly indicated as Not for Publication by the sender. Letters must be signed (although name may be withheld on
request) and are subject to editing and abridgement. Send letters to newsletter_editor@asahq.org.
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August 2015
Volume 79
Number 8
67
letter to the editor
Anesthesiologists: Time for a Drink?
residents review
What Is the Value of the ASA Resident Component?

Daniel A. Hansen, M.D., President-Elect
ASA Resident Component
Matt C. Gertsch, M.D., President
ASA Resident Component
A good hockey player plays where the puck is. A great hockey
player plays where the puck is going to be. Wayne Gretzky
Recently, ASA President-Elect Daniel Cole, M.D., quoted
the famous hockey star and venerable philosopher
in reference to the actions and motivations of ASA in the
context of modern health care. These days, it is almost clich
to comment on how the health care landscape is changing
beneath our very feet. Nevertheless, the importance of
adapting and positioning ourselves for the (yet-to-bedetermined) future of medicine cannot be overstated.
As anesthesiology residents, we are the youngest members
of our specialty and therefore have the most at stake with
any changes that are made. ASA serves more than 50,000
physician anesthesiologist members. The ASA Resident
Component (ASARC) focuses specifically on ASAs nearly
7,000 anesthesiology residents, ensuring their concerns are
addressed.
Allow us to elaborate on a few issues we are working on
within the ASARC:
Advocacy: More than at any time in history, legislative actions
are directly impacting how and where we practice. After
spending years studying, training and honing our cognitive and
technical abilities, we are increasingly faced with legislative
fiats that can jeopardize our abilities to deliver quality care to
patients. Other anesthesia providers are aggressively lobbying
for unrestricted scope of practice. The current slogan for the
American Association of Nurse Anesthetists is The Future of
Anesthesia Care Today. As residents, we find this aggressive
Daniel A. Hansen, M.D., is a

CA-1 resident, Mayo Clinic Arizona.
He is past chair of the
ASA Medical Student Component.
posturing troubling. We feel the established safety and success

of modern anesthesia are at risk. As members of the RC, we had
a strong presence at the ASA LEGISLATIVE CONFERENCE
2015 in May and were proud to see many residents visiting with
legislators and staff on Capitol Hill. We have been working with
the ASA Political Action Committee (ASAPAC) to increase
resident participation and awareness and create a network of
ASAPAC representatives throughout the country who can
serve to disseminate information, organize local advocacy
efforts and motivate their fellow residents to get involved.
Resources: We have helped to develop a new website and
list of resources for Young Physicians. This new section of
the ASA website focuses on the transition from residency/
fellowship to practice and has useful information to help
navigate the transition. We are constantly working to improve
the information/resources available in the ASA resident
section. Additionally, we have helped secure a number of
free practice management resources for our members. Topicspecific lectures are available through the Education portion
of the ASA website and include such things as Evaluating a
practice and Basics of coding and billing. Lastly, we have
been working to increase the value we offer our ASARC
members and have negotiated a three-month trial period
with access to the Wolters Kluwer LWW Health Library. This
deal will allow RC members unrestricted access to the entire
online library. The offer became available this summer to all
RC members.
Matthew C. Gertsch, M.D., is a

CA-3 resident, Massachusetts
General Hospital, Boston.
68
August 2015
Volume 79
Number 8
ANESTHESIOLOGY 2015 annual meeting: The RC

has been working to ensure that a focused resident-specific
track is available at the ANESTHESIOLOGY 2015 annual
meeting in San Diego this October. We have been arranging
a variety of speakers, panels and social engagements to ensure
any resident attending this years conference has a worthwhile
time. Additionally, we are working to incorporate fellowship
opportunities, private practice and academic networking
opportunities into the annual meeting. As a highlight of the
academic year, we are working to ensure maximum participation
by residents and want to guarantee an enjoyable, academically
rewarding time to all residents.
Leadership Opportunities: The RC represents an opportunity

to get involved in organized medicine and help shape the future
of our specialty. We encourage our members to run for office
and/or participate in local and national advocacy efforts and
training. We understand that an engaged membership with
grassroots participation is crucial to continued success within
ASA. Leadership opportunities within the RC include serving
on the RC Governing Council, acting as a Delegate or Alternate
Delegate to represent your residency program/state, or standing
as an ASAPAC representative.
Anesthesiology, like all medicine specialties, is bound to
change during our lifetimes. As the youngest members of the
specialty, we are working to ensure our voice is heard, and we
are actively involved and advocating throughout residency. The
landscape of our future practices will undoubtedly look different
than those of the past, and we are committed to ensuring
our future remains bright. While our focus is on learning the
clinical side of anesthesiology and medicine during residency,
we cannot overlook the importance of being involved in the
bigger picture. The ASARC is the premier vehicle for residents
to get, and stay, involved.
Financial Awareness: While financial considerations have

always been a part of residency and transitioning into practice,
in the current era, residents are saddled with more educational
debt that ever, while entering a market where future income
is uncertain and professional expenses are higher. The RC
is helping raise awareness among residents and is arranging
additional opportunities to voice concerns and learn more about
managing the potential financial challenges we may face. At
the ANESTHESIOLOGY 2015 annual meeting, we will offer a
session devoted to debt management, insurance considerations
and other relevant financial topics.
ANESTHESIA HISTORY ASSOCIATION ANNOUNCES

2015 C. RONALD STEPHEN, M.D. HISTORY ESSAY CONTEST
Open to physicians in residency or
fellowship and medical students
who compose an essay on any
topic related to the history of
anesthesiology, pain medicine
or critical care.
Local expenses, meals and registration, but not travel,

will be reimbursed. Essays will be judged on originality,
quality of research, writing and bibliography.
Essays must be received no later than
September 28, 2015.
Essays should be composed
using Microsoft Word and
submitted via email to
jmckeown@uab.edu.
Illustrations should be
in JPG or PDF format.
Essays must be previously unpublished

and less than 3,500 words in length.
A prize of $1,000 will be awarded
for the winning essay.
The winner is required to present an
abstract of his or her work at the
2016 Annual Spring Meeting
of the AHA, April 28-30, 2016,
in Indianapolis.
W.T.G. Mortons First Inhaler
All submissions will be peerreviewed for possible publication in

the Journal of Anesthesia History.
Correspondence to Jason McKeown, M.D. at jmckeown@uab.edu

Full contest rules available at www.ahahq.org n Follow the AHA on Twitter @AnesHistAssoc
August 2015
Volume 79
Number 8
69
FAER Report
$1.75 Million for Anesthesiology Research Funding:
Grants Awarded to 14 Physician Anesthesiologists
Joy L. Hawkins, M.D.
FAER Board of Directors
The Foundation for Anesthesia Education and Research

(FAER) Board of Directors approved $1.75 million to fund
the research of 14 anesthesiologists and trainees, who represent
11 academic institutions and medical centers. With this funding,
FAER, an ASA-related organization, will have committed
nearly $30 million to anesthesiology and perioperative research
since 2000.
The awards included Mentored Research Training Grants

($175,000) and Research Fellowship Grants ($75,000) in basic
science, clinical, translational or health services research, as well
as Research in Education Grants ($100,000).
Mentored Research Training Grant Basic Science
James Rhee, M.D., Ph.D., Massachusetts General Hospital
Role of GAPDH in the cardio-metabolic response to ischemia
Mentor(s): Anthony Rosenzweig, M.D.; Wei Chao, M.D., Ph.D.
The discoveries this group of awardees will

make throughout their careers will allow us
to be better doctors, train better doctors and
provide the highest quality care imaginable.
Vivianne L. Tawfik, M.D., Ph.D., Stanford University

Monitoring and modulating microglial cell activation in pain
Mentor(s): Sean Mackey, M.D., Ph.D.;
David J. Clark, M.D., Ph.D.
The purpose of FAER grant funding is to develop the

research careers of anesthesiologists who seek to answer
important questions and make scientific discoveries in the areas
of anesthesiology, perioperative medicine, health care delivery
and medical education research. Anesthesiologists who have
received FAER grant funding often go on to have successful
careers as independently funded physician scientists who
advance medicine through newfound knowledge.
The anesthesiologists who receive FAER grants represent
the future of medicine and will bring about improvements in
patient care. The discoveries this group of awardees will make
throughout their careers will allow us to be better doctors, train
better doctors and provide the highest quality care imaginable.
Brant M. Wagener, M.D., Ph.D.,

University of Alabama at Birmingham
Mechanisms of lung immunosuppression after traumatic brain injury
Mentor(s): Jean-Francois Pittet, M.D.; Sadis Matalon, Ph.D.
Gene T. Yocum, M.D., Columbia University
GABA-A alpha4 subunit mediates lung inflammation
and bronchoconstriction
Mentor(s): Charles W. Emala, M.D., M.S.;
Jeanine DArmiento, M.D., Ph.D.
Mentored Research Training Grant
Clinical or Translational
Lorenzo Berra, M.D., Massachusetts General Hospital
Stored blood transfusion and nitric oxide
Mentor: Warren M. Zapol, M.D.
Mentored Research Training Grant
Health Services Research
Helen H. Lee, M.D., M.P.H.,
University of Illinois at Chicago
Improving access to care for the pediatric dental
general anesthesia population
Mentor(s): Anthony T. Lo Sasso, Ph.D.; Daniel Sessler, M.D.
Joy L. Hawkins, M.D., is Professor of

Anesthesiology, Vice Chair for Education
and Director of Obstetric Anesthesia,
University of Colorado School of
Medicine, Aurora.
70
August 2015
Volume 79
Number 8
Research in Education Grant

Christopher L. Cropsey, M.D.,
Vanderbilt University Medical Center
Effects of an electronic decision support tool on team performance
during in-situ simulation of perioperative cardiac arrest
Mentor: Matthew D. McEvoy, M.D.
Upcoming Funding
Opportunities
ASA members have the opportunity
to apply for FAER research grant
funding twice annually. The next two
deadlines are August 15, 2015 and
February 15, 2016.
Sara N. Goldhaber-Fiebert, M.D.,

Stanford University School of Medicine
Adoption of emergency manuals: Facilitators, barriers,
and characteristics of clinical use
Mentor(s): David M. Gaba, M.D.; Steven Asch, M.D., M.P.H.
For more information on FAER grant

opportunities and to apply, visit
FAER.org/research-grants.
Robina Matyal M.D., Beth Israel Deaconess Medical Center

Fundamentals of ultrasound course with verification of proficiency
Mentor(s): Feroze Mahmood, M.D.; Stephanie Jones, M.D.
Annette Rebel, M.D., University of Kentucky
Anesthesia resident skill development assessed by competitive
OSCE event: Anesthesia olympics
Mentor(s): Randall M. Schell, M.D., MACM;
Marjorie Stiegler, M.D.
lead medicine
into the future
Research Fellowship Grant

Eric L. Vu, M.D., Baylor Medicine/Texas Childrens Hospital
Three-dimensional ST instability: Clinical evaluation of
novel ST segment monitoring in single ventricle physiology
Mentor(s): Ken Brady, M.D.; Craig Rusin, Ph.D.
FAER is committed to ensuring physician

anesthesiologists lead medicine into the future
and advance patient care through scientific
discovery and the creation of new knowledge.
To support these efforts, please make a
contribution to FAER, a 501(c)3 non-profit
and related organization of the ASA.
Visit FAER.org/donate to make a gift.
M. Yawar J. Qadri, M.D., Ph.D.,

University of North Carolina at Chapel Hill
Assessing differential microglial activation states in acute
and chronic pain
Mentor(s): Ru-rong Ji, Ph.D.; Thomas Van de Ven, M.D., Ph.D.
Thank you for your support!
Weifeng Song, M.D., Ph.D.,

University of Alabama at Birmingham
Low molecular weight hyaluronan mediated airway
hyperresponsiveness in aspiration-induced acute lung injury
Mentor(s): Sadis Matalon, Ph.D.; Jean-Francis Pittet, M.D.
Nathan H. Waldron, M.D., Duke University
Temporary autonomic blockade to prevent atrial fibrillation
after cardiac surgery
Mentor(s): Joseph P. Mathew, M.D., MHSc, M.B.A.;
Jonathan Piccini, M.D., MHSc
August 2015
Volume 79
Number 8
71
NEWSLETTER
2015 Classified Advertising
POSITIONS AVAILABLE PROFESSIONAL
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MEETINGS TUTORING VACATION RENTALS
PROFESSIONAL SERVICES
Anesthesia Business Consultants is the most comprehensive practice
management company specializing in the practice of anesthesia & pain management.
See our cover tip ad or visit us @ www.anesthesiallc.com.
LINE RATES
$30 per line or fractional line, 42 characters per line,

including spaces. 5 line minimum charge.
$100 additional charge for border around ad.
BLACK & WHITE DISPLAY AD RATES

1/3 page
Frequency 1/12 page 1/6 page
1x
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COLOR DISPLAY ADS
Please contact Rhonda Truitt, Advertising Manager

at Walchli Tauber Group, Inc., for details at
rhonda.truitt@wt-group.com or call 443-512-8899, Ext. 106.
ASA MEMBER BENEFIT

30% discount off Line Rate. Display Ad rate discount
available. Please contact Wes French, Advertising
Coordinator, at w.french@asahq.org for details.
MECHANICAL REQUIREMENTS
Submission of Ads: We prefer and strongly recommend

the submission of display ads via Acrobat PDF files:
Save with basic Distiller settings; No OPI; No ICC profiles;
embed all fonts; effective resolution minimum 300 DPI;
include bleed. Microsoft Word documents are accepted
(for text only). For any other media, call for information.
Ads must be complete and sized at 100%. Ads must be
saved as high resolution for print publication (minimum
300 DPI). Laser proof must accompany all digital file
submissions.
Electronic Transfer: E-mail (for file sizes 5 MB or less).
Please contact Corporate Development Manager prior to
submitting file via e-mail.
DISPLAY SIZES:
1/12 page
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CLOSING DATES:
Issue Deadline
JANUARY
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December 20
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January 30
APRIL
February 26
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March 25
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SALES:
Rhonda Truitt, Advertising Manager
The Walchli Tauber Group, Inc.
Phone: 443-512-8899, Ext. 106
Email: rhonda.truitt@wt-group.com
REACH MORE QUALIFIED
ANESTHESIA CANDIDATES.
Advertise online at careers.asahq.org.
EDUCATIONAL OFFERINGS
the Illinois Society presents:
Leading Anesthesiology into

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A unique meeting designed to help

sharpen your leadership skills and
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Saturday, September 26th

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72
Discover the latest innovations in

anesthesiology
Stay on the cutting-edge of the specialty with the
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in Anesthesiology
The American Society of Anesthesiologists, Inc.
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EDITOR
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ASSOCIATE EDITORS
Amanda R. Burden, M.D.
John F. Butterworth IV, M.D.
Samuel H. Wald, M.D.
Order today
asahq.org/rca
The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical
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Latest in science and technology

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Volume 79, Number 8

Total Intravenous Anesthesia:

Establishing and Reinforcing a

Kristina Goff, M.D.

Director, Publications and Digital Content

Postanesthesia Discharge Scoring System

Pain Management in the

Preoperative Evaluation for

Aditee Ambardekar, M.D., M.S.Ed.

The Latest Science in Anesthesiology......... 30

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Society for Neuroscience in Anesthesiology

All You Need

3M 2015. All Rights Reserved. 3M and Tegaderm are trademarks of 3M.

Part of the Full Line of Tegaderm Brand I.V. Site Dressings

As Drs. Mason and Mahmoud

N. Martin Giesecke, M.D.

our care, our surgeons are presenting us

anesthetic and be extubated at the end of

a candidate for a procedure outside the O.R. It will be

water at the lakefront. After that, my duties in the House of

Run For The Warriors

1. Mason KP, Mahmoud M. Establishing and reinforcing a culture of

Steven L. Sween, M.D.

Last May, my wife Barbara and I shared the unique and

How can we as a physician community, a medical specialty

Steven L. Sween, M.D., is Chair and

marked by significant change and uncertainty. In fact, Dean

Perri Klass, M.D., Professor of Journalism and Pediatrics at

The competencies of future physicians,

In the face of certain and possibly transformative change to

Id like to share with you some of what we learned. First,

Up is not an easy direction. It defies gravity, both cultural and

Id like to thank Chief Quality Officer Richard Dutton,

The results also reflect a trend toward younger members

We were very pleased not only with high level of participation,

of the newLMS will have features incorporated in the coming

This diversity in membership motivation in ASA is a

total intravenous anesthesia: Present and Future

Girish P. Joshi, M.B.B.S., M.D., FFARCSI, Chair

The availability of short-acting sedative-hypnotics

anesthesia provider. Furthermore, because of the complexity

Girish P. Joshi, M.B.B.S., M.D., FFARCSI,

Eric Rosero, M.D., M.Sc., is Assistant

are equipped with software (i.e., pharmacokinetic models)

There is evidence that hemodynamic stability, recovery time

Furthermore, because of the complexity

In practice, during TCI, instead of selecting bolus doses and

1. Mason KP, Mahmoud M. Establishing and reinforcing a culture of

The competencies of future physicians,

Up is not an easy direction. It defies gravity, both cultural and

Furthermore, because of the complexity

The workforce and processes in this

stablish, Oversee and

upport Staff and Patients/Families

In the event that a preoperative blood pressure was not

The use of criteria that are simple,

1. Rabbitts JA, Groenewald CB, Moriarty JP, Flick R. Epidemiology of