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contents
Volume 78, Number 9

September 2014
features
The Subspecialty of Ambulatory

Anesthesia........................................ 10
Thomas W. Cutter, M.D., M.A.Ed.
Safe Anesthesia in the Office-Based

Surgical Setting................................. 14
Brian M. Osman, M.D.
Fred E. Shapiro, D.O.
Adult Patient for Ambulatory Surgery:

Are There Any Limits?........................... 18
Alan Romero, M.D.
Girish P. Joshi, M.B.B.S., M.D., FFARCSI
Editor
N. Martin Giesecke, M.D., Chair
Assistant Editors
Doris K. Cope, M.D., M.A.
Susan G. Curling, M.D.
Kenneth Elmassian, D.O.
Uday Jain, M.D., Ph.D.
Girish P. Joshi, M.B. B.S., M.D.
Sadeq A. Quraishi, M.D.
Vernon H. Ross, M.D.
Karen S. Sibert, M.D.
Mary Ann Vann, M.D.
Anna M. Weyand, M.D.
(Senior Residents Review Co-Editor)
Kristina L. Goff, M.D.
(Junior Residents Review Co-Editor)
Editorial Staff
Terri Navarrete
Jamie Reid
Roy A. Winkler
Send general NEWSLETTER questions

to communications@asahq.org or call
Jamie Reid at (847) 268-9112
Advertising
Julie OHeir
Tel: (847) 268-9184
Fax: (847) 825-5658
E-mail: j.oheir@asahq.org
POSTMASTER: Send address changes to the

ASA NEWSLETTER, 1061 American Lane,
Schaumburg, IL 60173-4973;
(847) 825-5586.
Copyright 2014 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.
Hernando De Soto, M.D.
Outpatient Continuous Peripheral

Nerve Blocks .................................... 24
Elie Joseph Chidiac, M.D.
Management of MH in the
Ambulatory Environment....................... 28
Andrew Herlich, D.M.D., M.D., FAAP
articles
Euroanesthesia 2014:
Part of ASAs Growing International Focus... 30
Henrik Kehlet, M.D., Ph.D. to Receive

2014 Excellence In Research Award.......... 38
Scientific and Educational Exhibits at

ANESTHESIOLOGYTM 2014...................... 31
Francesco Carli, M.D., M.Phil., FRCA, FRCPC
Dean F. Connors, M.D., Ph.D.
John B. Neeld, Jr., M.D. 2013 Recipient

of ASA Distinguished Service Award .......... 32
Mark A. Warner, M.D.
Rebecca A. Aslakson, M.D., Ph.D.

to Receive 2014 Presidential
Scholar Award.................................... 34
Daniel Nyhan, M.D.
Peter J. Pronovost, M.D., Ph.D., FCCM
SEE Question..................................... 40
A Case Report From the Anesthesia
Incident Reporting System..................... 42
ACE Question..................................... 45
Subspecialty Societies at
ANESTHESIOLOGYTM 2014 ...................... 46
Amr E. Abouleish, M.D., M.B.A.
Sarah L. Braun
Beverly K. Philip, M.D.
departments
Observations....................................... 4
Whats New In ...
Administrative Update........................... 6
Committee on Trauma and

Emergency Preparedness ......................... 56
CEO Report......................................... 8
Society for Ambulatory Anesthesia................ 62
Paul Pomerantz
Residents Review............................... 64
N. Martin Giesecke, M.D.

James D. Grant, M.D.
Committee News
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.
30 Anesthetics on the Same Child Really!

Pediatric Ambulatory Anesthesia
for Proton Radiation ........................... 22
Committee on Economics......................... 50
Quality and Regulatory Affairs............... 52

Maureen Amos, M.S.
Matthew T. Popovich, Ph.D.
State Beat........................................ 54
Erin A. Sullivan, M.D.
Subspecialty News
Anesthesiology in the News................... 66

ASA News......................................... 68
In Memoriam..................................... 68
Letters to the Editor............................ 69
FAER Report...................................... 70
Classified Ads.................................... 72
SUBSTANCE ABUSE HOTLINE: Contact the ASA Office at (847) 825-5586 to obtain the addresses and
telephone numbers for state medical society programs and services that assist impaired physicians.
THE PERFECT COMBINATION.

ASA INDUSTRY SUPPORTERS
ASA Corporate Supporters help create

opportunities for members to learn
and connect with one another at the
ANESTHESIOLOGY 2014 annual
meeting in New Orleans.
Together with their support, we can
continue to grow and advance the specialty.
ASA ANNUAL MEETING SUPPORTERS
Thank you
asahq.org/corporatesupport
14-139
observations
Pilots and Safe Outpatient Anesthesia Care
Likely, youve read about my first

job after residency a solo private
practice in Victoria, Texas. When
Susan and I moved there in 1989,
Victoria was a city of around 50,000
citizens. About eight other physician
anesthesiologists shared call with
me, and we covered a varied group of
private practice surgeons, working at
three hospitals and one independent
outpatient surgery center. Twenty-five
years ago, even that outpatient surgery
center had a physician anesthesiologist
as its medical director. Ill come back
to that.
As mentioned above, the physician
anesthesiologists provided care for the
patients of many different surgeons.
After I had been there a while, my
practice took on a comfortable routine.
On Mondays, I provided anesthesia for
the patients of a general surgeon. Before
completing his schedule, we might
have worked at all four of the facilities
mentioned above. Tuesdays saw me
providing anesthesia for the cardiac
surgeons. I was doing peribulbar blocks
for an ophthalmologist and his patients
on Wednesdays. On Thursdays, at least
initially, I covered obstetrical anesthesia.
Fridays, my patients were those of an oral
surgeon. Since the oral surgeon usually
only had one or two cases, the rest of my
day was filled with caring for the patients
of any other surgeon who wished to
schedule with me.
My first two weeks in Victoria, I
picked up the schedule of two of the
other solo physician anesthesiologists
N. Martin Giesecke, M.D.

Editor, ASA NEWSLETTER
who went on vacation. For a brief time

after that, it took a while before the
weekly rhythm of my collaboration with
the surgeons was established. During
this time, I was able to work with many
different practitioners. One of those
was actually an elderly family medicine
physician who still did appendectomies,
inguinal hernia repairs, etc. This doctor
was reasonably skilled in the O.R. At
work one day he told me he was a pilot.
He had a single-engine prop plane that
he enjoyed flying around the Texas
coastal bend country. At the end of the
conversation, he invited me to go flying
with him one weekend.
Being somewhat cautious about such
an opportunity, it did not take me long
to discuss this invitation with some of
the other physician anesthesiologists.
They told me this surgeon pilot was on
his fourth plane. He had crashed three
others on landing. And if I remember
correctly, not all of those had been walkaway crashes. He had been injured in
one, though by the time I knew him, he

was well recovered. My anesthesiologist
buddies warned me away, and I never did
go flying with the family practitioner.
Im not a pilot, but thinking about
this accomplished physician, who
was maybe not equally skilled at his
avocation of flying, made me recall a
computer game I played a couple years
earlier, as an anesthesiology resident. I
owned an early Macintosh computer,
and I had a P-51 Mustang flying game.
In this game, I played the part of a fighter
pilot in the U.S. Armys Eighth Air
Force during World War II. I had the
option of choosing from one of several
English airfields, from which I took off
and headed south or east, or both, to
engage the enemy. The graphics and the
control of the P-51 were rudimentary
compared to todays video games, but it
was enjoyable to take off and fly over the
English and French countryside. What is
most memorable is that of all the times I
flew this video game Mustang, I always
crashed it on landing, doing a noseover without fail. So despite continued
simulation, and the ability to control
the plane while in flight, it was still
impossible for me to land safely.
Lets return now to that nonaffiliated outpatient surgery center
where I occasionally worked. You
will recall that this facility had a
physician anesthesiologist, Dr. Tony
Jirka, as its medical director. This made
excellent sense to me. As physician
anesthesiologists, we have long been
key promoters of patient safety. By that
time, the ASA Closed Claims Project
(www.asaclosedclaims.org) was already
well under way, with its first report being
September 2014
Volume 78
Number 9
About to fly in the real thing

a P-51 Mustang.
published in 1988.1 And even prior

to that, ASAs initial Standards for
Basic Anesthetic Monitoring were first
approved by the House of Delegates in
October 1986. It was already proven
to me that physician anesthesiologists
had the education and training to

manage the perioperative environment
in a manner that would lead to improved
patient outcomes. At this surgery
center, that meant less postoperative
nausea and vomiting, decreased length
of time to discharge, etc. We remain
at the forefront of patient safety, as is
evidenced in the article in this
NEWSLETTER by Maureen Amos,
ASA Director of Quality and Regulatory
Affairs, and Matthew T. Popovich,
Ph.D., ASA Quality Specialist.2
One thing we did for staff
development at this outpatient surgery
center was play out rare scenarios. In this
manner, we were using a tried-and-true
method of commercial pilot simulation
training introducing uncommon
settings and developing the cognitive
ability to manage an otherwise stressful
situation. In these training exercises,
we enlisted all of the staff to play or
watch. In one situation, we played out

an O.R. fire. An actual O.R. fire is rare,
but like the rarely occurring malignant
hyperthermia crisis, fires can occur
in outpatient surgery centers. In fact,
with the amount of plastic surgery and
otolaryngology performed in outpatient
centers, the risk of fire may actually be
increased over a typical general O.R.
suite at a hospital. Practicing these
situations gave us, and the staff at the
surgery center, the knowledge we needed
to safeguard our patients, and ourselves.
References:
1. Caplan RA, Ward RJ, Posner K, Cheney

FW. Unexpected cardiac arrest during
spinal anesthesia: a closed claims analysis
of predisposing factors. Anesthesiology.
1988;68(1):5-11.
2. Amos M, Popovich M. Anesthesiologists
among top performers in PQRS. ASA
Newsl. 2014;78(9):52-53.
P-51 Mustang
September 2014
Volume 78
Number 9
administrative update
Health Care Will Follow Our Lead

ASA Treasurer
Our world is becoming increasingly complex, but coming

changes in health care give us the opportunity to mold
our future. The challenges we face are increased bureaucratic
hurdles, more regulation, pressure to reduce costs and increased
demands by sophisticated patients. The future is as bright as we
make it we should be building our future and not be afraid of
it. Physicians, and anesthesiologists in particular, need to be at
the core of creating the agenda, not reacting to it.
We have three options:
1. We can resist change and yearn for the way things were;
2. We can submit to change and let someone else make all the
decisions; or
3. We can drive change and take the lead in shaping the
practice of medicine and the delivery of health care.
But from where will we lead this change? We will lead it

from the exam room. We will lead it from the operating room.
And, yes, we will lead it from the corner office. Physicians need
to take greater roles in health care leadership. Health system
reform needs to be led by physicians building common goals
and leading teams that effectively move health care delivery
in the right direction. Physician anesthesiologists are seen as
leaders and visionaries who have a keen understanding of the
complexities of health care systems.
In 2009, of the 6,500 hospitals in the country, only 235
were led by physicians. That number doesnt seem to have
changed greatly; this translates to about 3.6 percent of the
nations hospitals. But as the complexities of health care
change, and as we develop a stronger focus on quality, outcomes
and value-based care, the number of physician leaders is sure
to rise. Just a few years ago, a study showed that hospitals with
physician leaders had overall quality scores 25 percent higher
than organizations not led by physicians. Actually, of the top
18 hospitals in the 2013 U.S. News and World Report, 10 were
led by physicians.
As health care becomes more complex, we are going to need
leaders who understand more than balance sheets and buildings,
but also a deep understanding of the clinical arena and the
entire spectrum of patient care. Because of our backgrounds and
focus on quality, safety and operational efficiencies, physician
anesthesiologists are uniquely qualified to lead systems, and
we are very proud of ASA members who have taken the lead
throughout the country. ASA members Steven Allen, M.D.,
CEO of Nationwide Childrens Hospital in Columbus, Ohio,
and Joanne Conroy, M.D., the newly appointed CEO of the
Lahey Hospital and Medical Center in Boston, are examples
of physician anesthesiologists who now lead major systems.
Health care organizations are increasingly complex systems of
care whose problems require solutions that address the
organizational and political environment as well as the institutional
norms and standards. This is the world that anesthesiologists
have cut their teeth on in training and makes them well positioned
for leadership, said Dr. Conroy. ASA member, critical care
specialist and now hospital CEO, Steve Allen shares this:
While leaders arise from a variety of backgrounds, Ive found
anesthesiology has provided experiences invaluable in my eight
years of running a hospital. The remarkable breadth of
The world is surely changing before our eyes. Look at what

has become part of our daily vocabulary: patient value,
patient experience, population management, shared risk,
bundled payments. Physicians have a great opportunity
to mold a better health care system for patients. Maureen
Bisognano, president and CEO of the Institute for Health
Care Improvement, said it very well: Its a wonderful sign that
physicians are expanding from clinical care to learning what it takes
to be a good leader. When you can marry the clinical background
and the leadership skills, you have an opportunity to lead in a very
different and distinct way. When you get someone who knows what
quality looks like and pair it with a curiosity about new ways to
think about leading, you produce leaders who are providing dramatic
innovations in the field.
James D. Grant, M.D. is Chair,

Department of Anesthesiology,
Beaumont Health System,
Royal Oak, Michigan, and
practices with American
Anesthesiology of Michigan.
September 2014
Volume 78
Number 9
On the state level, there are two physician anesthesiologists

currently serving as legislators. ASA Immediate Past President
John M. Zerwas, M.D. is currently in his fourth term as a
member of the Texas House of Representatives. In addition,
ASA member and 2012 president of the Tennessee Society
of Anesthesiologists Steve Dickerson, M.D. serves in the
Tennessee Senate.
Leadership does not start in the corporate suite or in
legislative chambers. It starts at the local level. You took the
first step toward being a leader by joining ASA. Wherever you
practice, get involved whether in hospital affairs, community
issues, or your state component or medical society. Be sure to
show the vital role that physician anesthesiologists play in the
fabric of the places you practice. Each day, as we talk to our
patients, they see us as leaders. When you talk to legislators,
policymakers and community leaders, they see you as a leader.
Thank you for your leadership and for caring about our
specialty, our patients and our profession. Together, we will
all be leaders who continually work to build a patient-focused
system based on quality, safety, outcomes and value.
contemporary anesthesiology is founded on the tenet that

patients are best served when we function as a team. Listening to
constructive information from every team member is as important
to leading a health care institution as it is to the safe and efficient
care of any aspect of our specialty.
Physician leaders of change are not only emerging in the
corporate suites, but also joining the halls of Congress at an
exponential rate. The New York Times recently reported on
a Johns Hopkins study which found that from 1960 to 2004,
only 24 physicians served in Congress. In our current Congress
alone, there are 20 people with medical degrees on both sides
of the aisle who come from diverse medical backgrounds. As
this trend continues, the 2014 election cycle has 26 physician
candidates for both the U.S. House of Representatives and
Senate. ASA member Andy Harris, M.D. (R-MD) is one of
those 20 and the first physician anesthesiologist to serve in
Congress. It is truly refreshing to know there is a voice in
the House of Representatives who not only has a first-hand
understanding of the issues affecting the health care of all
Americans, but also those concerns specific to anesthesiology.
Our metrics were good.

We were operationally sound.
We had enormous value.
We knew it was time to sell.
We wanted clinical autonomy, financial reward and a partner with
experience and size. TeamHealth gave us the whole package.
~Alan Gwertzman, M.D.

Teaneck, NJ
Is it time to consider a sale or merger?

Rich Berube 865.293.5638 or Janette Stephenson 954.377.2924
rich_berube@teamhealth.com
janette_stephenson@teamhealth.com
TeamHealth Anesthesia is the premier partner for anesthesia groups. It is part of TeamHealth, one of the largest providers of outsourced
physician services offering integrated clinical solutions to hospitals in the areas of emergency medicine, hospital medicine, specialty
hospitalists, anesthesia, urgent care and pediatrics.
teamhealthanesthesia.com
September 2014
Volume 78
Number 9
CEO report
An Update From ASA HQ
Paul Pomerantz, CEO
As I write this report, much of the ASA staff is busy

preparing for the ANESTHESIOLOGY 2014 annual
meeting, which takes place in New Orleans next month.
Although the meeting certainly is an enormous undertaking
and is the centerpiece of the societys initiatives every year,
I want to take this opportunity to update you on a few other
important projects weve been working on in 2014. As CEO
of your professional society, my overriding goal and the force
that drives all our societys actions is to provide you with the
resources you need to help you do your job. Here are some of
the ways were helping to do that:
Strategic Plan
Because so much uncertainty exists regarding the future of
health care in the U.S., its important that ASA move forward
under the direction of a strong, carefully considered strategic
plan. I believe our three-year strategic plan developed this year
under the leadership of President-Elect John P. Abenstein,
M.S.E.E., M.D. and the Administrative Council will help
focus our priorities and leverage both our volunteer and staff
talent and resources. Above all, the current plan makes the
organization adaptable to a variety of external contingencies
and to the changing nature of ASA members needs. Our
overall mission is advancing the practice and securing the
future. And our very top priority is to grow and more fully
engage ASA membership. Details of the strategic plan will be
shared publicly at our October House of Delegates meeting in
New Orleans.
Perioperative Surgical Home (PSH) Learning Collaborative

With each passing day, were seeing more real-world
examples of PSH initiatives being instituted in practices
across the United States. Specifically, the PSH Learning
Collaborative has already surpassed our expectations, as a total
of 44 provider organizations have joined the collaborative, the
goal of which is to provide for shared learning of the PSH in
real-world settings. Working groups have been formed around
metrics, clinical guidelines and payment. You will recall that
this initiative is an outgrowth of recommendations from
the Committee on Future Models of Anesthesia Practice,
under the leadership of Michael P. Schweitzer, M.D., which
were approved at the October 2013 meeting of the House
of Delegates. PSH Executive Celeste Kirschner said she
is very pleased with the interchange of ideas between the
collaborative members, who are fine-tuning the parameters of
the PSH to meet the specific needs of individual participants.
The Learning Collaborative concludes in June 2015 and we
look forward to sharing its results with the entire membership
at that time.
Specifically, the PSH Learning

Collaborative has already surpassed
our expectations, as a total of 44
provider organizations have joined
the collaborative, the goal of which
is to provide for shared learning of
the PSH in real-world settings.
Building External Relationships

This is the first year ASA has had a presence at the
American Hospital Associations (AHAs) Leadership Forum.
Held in San Diego in July, the 2014 forum was a highlight
of ASAs broad efforts to build relationships with important
stakeholders from all areas of the health system. As a
Paul Pomerantz is ASA

Chief Executive Officer.
September 2014
Volume 78
Number 9
co-sponsor of the event, ASA was recognized by AHA

President Richard Umbdenstock in front of 1,800 attendees
at the conference opening. Several physician anesthesiologists
attended the meeting in their roles as hospital/medical
executives. A PSH session held during the Physician
Leadership Forum on innovative models of care was
particularly well received by an interdisciplinary audience
of physicians, health system executives, national and state
association leaders, and AHA Fellows.
member volunteer groups and feedback from the membership

overall, we are building a state-of-the-art web experience with
a responsive design that will work flawlessly with any platform,
whether youre using a phone, tablet or PC. Ive personally
previewed the site and cant wait for you to use it. Stop by the
ASA Resource Center at the annual meeting for a sneak peak.
The official launch will take place in January 2015.
ANESTHESIOLOGY 2014 Annual Meeting
We strive to make each annual meeting better than the
one that came before it. And we can only do that with your
input and feedback. So as you go about your activities during
ANESTHESIOLOGY 2014 next month, make sure you
let us know what you think weve done right, and what we
could do better. That being said, I believe youll agree that
Michael F. OConnor, M.D., F.C.C.M. and the Committee
on Annual Meeting Oversight have created a great program
this year. Weve leveraged technology so that participation
in educational sessions and CME is more efficient than ever
before, weve lined up talks with some of the best minds in
medicine, and our international outreach initiatives continue
to grow nearly 25 percent of meeting attendees will come
from outside the U.S. Dont miss the Opening Session
on Saturday morning, which focuses on the disruptive
innovations altering the course of health care and the
opportunities offered through the PSH model of care.
I look forward to working with you at the annual meeting,
and beyond.
AQI Certified QCDR

As you may have already heard, the Anesthesia Quality
Institutes (AQIs) National Anesthesia Clinical Outcomes
Registry (NACOR) was designated a Qualified Clinical
Data Registry (QCDR) by CMS this year. One of just a
handful of entities granted this designation, NACOR now
allows participants to submit data to the Physician Quality
Reporting System (PQRS) on up to 19 measures. This is
a huge member benefit. CMS projects that use of registrybased or QCDR mechanisms in 2015 will jump from 47,000
eligible professionals to around 165,000. QCDR reporting is
free to ASA members participating in NACOR. Expect to
hear a lot more about the QCDR reporting mechanism in the
coming months.
New Website
During the ANESTHESIOLOGYTM 2014 annual meeting,
you can get a preview of our redesigned website. Through
collaboration between the Committee on Electronic Media
and Information Technology, the Ad Hoc Committee on Web
Oversight, Ad Hoc Committee on Information Resources,
Were pleased to welcome Louisiana Governor Bobby Jindal to the

ANESTHESIOLOGY 2014 annual meeting. A potential GOP presidential
candidate in 2016, Governor Jindal helped transform Louisianas health
care system and has been lauded for his efforts in education and ethics
reform. Dont miss his talk during the meetings Opening Session on
Saturday, October 11.
I look forward to seeing you all in New Orleans!
September 2014
Volume 78
Number 9
The Subspecialty of Ambulatory Anesthesia
Thomas W. Cutter, M.D., M.A.Ed.
Because of advances in techFigure 1

nology (e.g., short-acting anesthetics and minimally invasive
surgical techniques) and changes
in remuneration,1 ambulatory
anesthesia comprises greater
than 70 percent of all anesthetics administered in the
United States (Figure 1). In 2006,
53 million surgical and non-surgical
procedures were performed in an
ambulatory setting, with 57 percent
performed in a hospital as opposed
to a freestanding center.1 This
relationship has remained essentially
constant through 2013 (Figure 2).
Although ambulatory anesthesia
is the most widely practiced
subspecialty of anesthesia in the
Percentage of cases identified as ambulatory anesthetics in the National Anesthesia Clinical
nation, relatively few physicians
Outcomes Registry, Anesthesia Quality Institute, 2010-14 (personal communication, Richard
identify themselves as ambulatory
Dutton, M.D., Executive Director, Anesthesia Quality Institute, May 2014).
anesthesiologists by membership in
a professional society. The Society of
is added because of the ambulatory setting. But ambulatory
Cardiovascular Anesthesiologists has 5,000 members2 and the
anesthesiologists and post-anesthesia care nurses will tell you
American Society of Regional Anesthesia and Pain Medicine
that certain methods result in better outcomes and certain
has 4,000 members,3 but the Society for Ambulatory Anesthesia
anesthesiologists achieve those outcomes more often than
(SAMBA) has only 1,600 members.4 There is a perception
others. Optimal results in the ambulatory setting are a product
that anesthetics administered in outpatient centers simply
of specialized knowledge and techniques.
draw from a common knowledge base to which nothing unique
Preoperatively, most ambulatory anesthesiologists have
encountered a patient who is deemed unsafe for an ambulatory
procedure because of comorbidities, so one aspect of ambulatory
practice is the painstaking selection of appropriate patients.
Experienced ambulatory anesthesiologists are often asked for a
list of criteria to determine suitable patients for the outpatient
setting. Among the questions asked are: What is the maximum
patient weight for an ambulatory procedure? Should I care for
Thomas W. Cutter, M.D., M.A.Ed. is
Professor, Associate Chairman,
a patient with a known difficult airway? Is a spinal anesthetic
Anesthesia and Critical Care,
acceptable? Are patients with an implantable cardiac
Pritzker School of Medicine, University
defibrillator (ICD) appropriate? While there may be value in
of Chicago, and Medical Director for
creating an ambulatory checklist, there are problems as well. To
Perioperative Services, University of
uniformly refuse care in an ambulatory center to all individuals
Chicago Medical Center.
10
September 2014
Volume 78
Number 9
Figure 2
Facility type for ambulatory

cases reported to the National
Anesthesia Clinical Outcomes
Registry, Anesthesia Quality
Institute, 2010-14 (personal
communication, Richard Dutton,
M.D., Executive Director,
Anesthesia Quality Institute,
May 2014).
with a given condition may unduly limit patient access and

reduce the facilitys value to providers. Rather than a checklist
that is limited to patient characteristics, consideration also must
be given to the providers, the procedure and the place. We have
to integrate the comorbidities of the patient, the skill-sets of
and access to the providers, the procedure itself, the availability
of equipment and the location of the facility in terms of its
proximity to advanced care.
Facilities (place) in which ambulatory anesthesia is
practiced may include hospitals with a designated suite of
operating rooms or individual rooms throughout the general
suite. Alternatively, a separate building may be dedicated to
ambulatory procedures, referred to as an on-campus setting.
Outpatient procedures also can be performed in a freestanding
surgicenter located some distance from a hospital. The final
location is the office, which is probably the ne plus ultra of
ambulatory anesthesia. Each of these settings has its advantages
and limitations in terms of the ability to care for a patient
with a complex medical condition having a given procedure.
Equipment and the proximity to other facilities for support or
patient transfer are important factors to consider here.
The number of providers and their level of training also
impact the selection process. The skill-sets of the ancillary
staff are important, especially for postanesthesia care. Having
a receptionist with no medical training who also serves as the
individual who monitors a patient after a procedure limits the
complexity of the procedure and anesthetic technique. Utilizing
September 2014
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Number 9
trained and capable post-anesthesia care nurses may mean that

more complex procedures and anesthetics may be performed.
Having an anesthesia technician provides for superior
equipment support so that more sophisticated techniques
(e.g., fiberoptic bronchoscopy) may be performed, as well as the
benefit of having someone who can serve as a trained assistant
familiar with anesthesia practices. Having an anesthesiologist
participate in the anesthetic (i.e., perform, medically direct or
supervise) is also advisable. Thus, the caliber and quantity of
primary and support personnel should influence the selection
process.
The procedure is another important part of the equation.
In the 1990s, criteria for an acceptable procedure included
minimal blood loss or fluid shift, procedure time of less than
90 minutes with simple equipment, minimal postoperative
care and postoperative pain that could be treated with oral
medications.5 Today, the only requirement is that the patient
goes home the same day or, in some settings, within 23 hours.
There are no hard and fast rules to distinguish an ambulatory
procedure from an inpatient procedure other than the patients
ability to go home safely the same day. When an anesthesiologist
administers an anesthetic from which the patient can recover
within a few hours with minimal side effects, the limiting feature
becomes the postoperative care associated with the procedure.
The final factor in the equation is the patient. Some may
believe that only ASA Physical Status (ASA-PS) 1 or 2 patients
Continued on page 12
11
Continued from page 11
should be cared for in an ambulatory setting, but others

are more discerning. In one survey, more than 90 percent
of Canadian anesthesiologists responded that they would
administer an anesthetic to an ASA-PS 3 ambulatory
patient,6 including those with stable congestive heart
failure, asymptomatic valvular heart disease or a previous
myocardial infarction older than six months. More than 90
percent of the anesthesiologists considered patients with
unstable angina or morbid obesity with cardiovascular
or respiratory complications unsuitable for ambulatory
procedures. Yet such patients may be suitable if the place,
the procedure and the personnel are also considered. For
example, a patient with obstructive sleep apnea can
safely receive a lower-extremity regional anesthetic with
intravenous sedation and analgesia in many ambulatory
facilities. There is little, if any, evidence that an otherwise
healthy patient with a body mass index above a certain
level is at increased risk for an ambulatory procedure, if
the operative table is able to support the patients weight.
Although some anesthesiologists may refuse to care for
a patient with an ICD in an office-based practice or
a surgicenter, performing a procedure for this patient
in an on-campus or integrated facility may be entirely
appropriate. Thus, one must assimilate a variety of factors
into a meaningful whole before selecting a patient for admission
to an ambulatory setting. Figures 3 and 4 illustrate this principle
with overlapping circles indicating suitability. Guidelines may
Figure 3
Patient, providers, procedure and place all overlap: proceed.
follow when more data from the National Anesthesia Clinical

Outcomes Registry (NACOR) and the SAMBA Clinical
Outcomes Registry (SCOR) become available, but for now we
must depend on our clinical acumen.
Figure 4
Since the defining aspect of an ambulatory
anesthetic is the patients ability to safely and
comfortably leave the facility the same day, the
anesthesiologist must not only carefully select
the patient, but also the intraoperative and
postoperative techniques to avoid sequelae that
would delay discharge to home. These barriers
to discharge include pain, postoperative nausea
and vomiting, excessive sedation and physiologic
derangement.
Pain has been regarded as the most common
and most important adverse postoperative
outcome after ambulatory surgery.7-9 Multimodal
therapy using low-dose opioids, non-steroidal antiinflammatory drugs and regional anesthesia can
serve to mitigate pain. Postoperative nausea and
vomiting is another impediment and can often be
prevented or treated with a multimodal approach.
Because excessive sedation also results in delayed
discharge,10,11 preoperative and intraoperative
sedative-hypnotics and intraoperative and
Patient, providers, procedure and place do not all overlap: do not proceed.
12
September 2014
Volume 78
Number 9
postoperative opioids should be used judiciously. Morbid

events such as cardiac ischemia, hyperglycemia, a cerebral
vascular accident or persistent hypotension also may
delay discharge or result in admission to an inpatient
facility. Preventing the sequelae of comorbidities, surgical
and anesthetic side effects, and other complications is
of paramount importance to ensuring a safe and timely
discharge to home.
Ambulatory anesthesia is a subspecialty, just as are
cardiac, pediatric or obstetric anesthesia. Patients,
procedures, facilities and providers are diverse, the
combinations and permutations are many, and correct
decisions are critical. The uniqueness of ambulatory
anesthesia arises not just from the patient and the
procedure, but also from the breadth and complexity of the
problems and their solutions.
References:
1. Cullen KA, Hall MJ. Golosinskiy A. Ambulatory surgery in

the United States, 2006. Natl Health Stat Report. 2009;(11):128. http://www.cdc.gov/nchs/data/nhsr/nhsr011.pdf. Published
January 28, 2009. Revised September 4, 2009. Accessed July
16, 2014.
2. Society of Cardiovascular Anesthesiologists website. http://
www.scahq.org/default.aspx. Accessed May 28, 2014.
3. American Society of Regional Anesthesia and Pain Medicine
website. http://www.asra.com/membership.php. Accessed
May 28, 2014.
4.
Society for Ambulatory Anesthesia website. http://www.
sambahq.org/p/cm/ld/fid=11. Accessed May 28, 2014.
5. White PF. Ambulatory anesthesia and surgery: past, present
and future. In: White PF, ed. Ambulatory Anesthesia and Surgery.
Philadelphia: WB Saunders; 1997.
6.
Friedman Z, Chung F, Wong DT: Ambulatory surgery
adult patient selection criteria - a survey of Canadian
anesthesiologists. Can J Anaesth. 2004;51(5):437-443.
7.
Macario A, Weinger M, Truong P, Lee M: Which clinical
anesthesia outcomes are both common and important to
avoid? The perspective of a panel of expert anesthesiologists.
Anesth Analg. 1999;88(5):1085-1091.
8.
Swan BA, Maislin G, Traber KB. Symptom distress and
functional status changes during the first seven days after
ambulatory surgery. Anesth Analg. 1998;86(4):739-745.
9. Chung F, Un V, Su J. Postoperative symptoms 24 hours after
ambulatory anaesthesia. Can J Anaesth. 1995;43(11):1121-1171.
10. White PF, Song D. New criteria for fast-tracking after
outpatient anesthesia: a comparison with the modified
Aldretes scoring system. Anesth Analg. 1999;88(5):1069-1072.
11.
Atiyeh L, Philip BK. Adverse outcomes after ambulatory
anesthesia: surprising results [abstract A30]. Presented
at: American Society of Anesthesiologists 2002 Annual
Meeting; October 12-16, 2002; Orlando, Florida. http://
w w w.asaabs tr ac ts.com/s tr ands/asaabs tr ac ts/abs tr ac t .
htm;jsessionid=69F 0 DB1B D 495734 0 DC 7F 28C84994
D2AD?year=2002&index=1&absnum=796.
Accessed
July 17, 2014.
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Medical Education (ACCME) 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. Physicians should claim only the credit commensurate with the extent
of their participation in the activity.
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AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent
of their participation in the activity.
14-156
September 2014
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13
Safe Anesthesia in the Office-Based Surgical Setting
Brian M. Osman, M.D.
Fred E. Shapiro, D.O.

Committee on Ambulatory Surgical Care
Committee on Patient Safety
The rapid growth in volume and complexity of office-based

medical and surgical procedures over the last 25 years
represents a profound change in how health care is delivered
in the United States. Initially, cosmetic, gastrointestinal
and ophthalmologic procedures made up the bulk of officebased surgeries, but this has expanded to many other medical
specialties such as interventional radiology, cardiology, vascular
surgery, gynecology and podiatry.1,2 In fact, nearly half as
many outpatient hospital procedures are being performed; the
caseload in offices and surgicenters has more than doubled.1,2
The advantages of this shift to the office-based setting include
greater ease of scheduling, better overall patient satisfaction,
and decreased costs to providers and the patients than if
performed in a hospital.
These potential issues have made office-based safety

the focus of several publications and professional societies.
The number of reported adverse events has garnered enough
attention to warrant regulations at the federal and state level.
Government regulations are attempting to heighten awareness
and level the playing field across a variety of surgical sites
to ensure a standard of care. Whereas the federal government
is racing to keep up with the boom of office-based procedure
expansion, the regulation of medical office suites is primarily
done at a state level.3
Office-based safety: current literature
Interest in patient outcomes regarding morbidity and
mortality has prompted numerous retrospective studies that
compare how patients fare in the office versus the hospital
setting. To date, there is little evidence that measures how
procedures in the office setting affect patient safety outcomes.
The landmark retrospective studies, despite limitations, have
offered an important foundation for the development of
effective office-based safety strategies. One of the earliest studies
performed by Vila et al. involved a collection of case reports
from 2000-02 that opened the eyes of the medical community,
focusing on the risk procedures performed outside of the
hospital pose to patients.5,6 Coldiron et al. collected data from
2000-07 suggesting that generalizations made about location
and type of anesthesia are not as important as the type
of surgery performed in the office. From 2001-06, the
American Association for Accreditation of Ambulatory
Surgery Facilities collected data that suggest the mortality
How safe is anesthesia in the office-based setting?

Despite the numerous advantages of performing procedures
outside the hospital, the office environment can introduce
significant concerns over patient safety and well-being.
First, private offices may lack the necessary resources should
an anesthetic or surgical emergency arise: difficult airway and/
or rapid resuscitation equipment. Other issues could include
personnel adequately trained to handle emergencies, having
reliable transfer resources, plans and policies, and the proximity
to a nearby hospital capable of handling serious complications.
The capabilities and scope of practice of an office or surgicenter
can be stretched, given the increased volume and complexity of
cases and being faced with the chronic medical conditions of an
aging population.
Fred E. Shapiro D.O. is Chair,

ASA Committee on Patient Safety
and Education; Assistant Professor
of Anesthesia, Harvard Medical
School, Beth Israel Deaconess
Medical Center, Boston.
Brian M. Osman, M.D. is

Instructor in Anaesthesia,
Harvard Medical School, Beth Israel
Deaconess Medical Center, Boston.
14
September 2014
Volume 78
Number 9
rate in office-based procedures is extremely rare at a rate of

0.002 percent the most common cause of morbidity and
mortality being postoperative pulmonary embolus.7 Further
studies attempted to pinpoint whether the type of anesthesia
used makes any difference in injury during procedures performed
in the office-based setting. Whereas the debate continues
regarding the safety of MAC versus general anesthesia, facility
accreditation, practitioner board certification and scope of
practice have become important areas of scrutiny.
were corroborated by Starling et al. looking at six years of

adverse event reporting in the state of Alabama.8 A movement
to improve the uniformity and adverse event reporting in
offices could shed light on the importance of certification and
accreditation in office-based patient safety.
From ASA: appropriate patient and procedure selection
Anesthesiology providers are expected to be gatekeepers for
the appropriate selection of patients for office-based anesthesia.
There are some patients who may have disease or comorbidities
that will place them at a higher risk for morbidity and mortality
within the office-based setting. ASA has addressed this issue by
endorsing a general set of criteria for patient selection in order to
standardize patient care irrespective of the procedure location.9
A detailed medical history, labs and preoperative testing should
preferably be done ahead of the scheduled procedure date along
with any optimization of chronic medical conditions.10
Selecting the proper procedure for patients involves assessing
the capabilities of the facility and the type of surgery being
performed, with attention given to duration and complexity.
The physician should practice within his or her scope of practice
and the procedure should allow for appropriate recovery and
discharge times. Issues such as excessive blood loss, postoperative
pain or the possibility of extreme nausea/vomiting need to be
considered as well as the facilitys ability (i.e., equipment and
staff) to handle surgical emergencies.
Does facility accreditation and board certification

improve safety?
The mantra behind this question is standardization of the
quality of care provided by facilities and practitioners while also
keeping providers and offices operating within their usual scope
of practice. Similar processes are already in place at ambulatory
surgery centers and hospital-based facilities, and new state
mandates are requiring offices performing medical and surgical
procedures to obtain accreditation.3 In fact, accreditation
is being required for office-based surgery activities by nearly
30 states in the U.S., with more states to follow.3
Conversely, there is a lack of solid evidence suggesting that
board certification and/or accreditation can make a difference
in patient outcomes. A closer look at some of the adverse office
surgical outcomes by Coldiron et al. in the state of Florida
from 2000-07 showed that almost 40 percent of deaths and
hospital transfers occurred from accredited sites where the
majority of physicians were board certified.5,6 These findings
September 2014
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15
A recent review of the literature suggested that cosmetic and

dental procedures are potentially high-risk interventions in the
office setting. Keyes et al. suggested that abdominoplasty can
be associated with a higher risk of deep venous thrombosis and
death from pulmonary embolism.7,11 The American Society of
Plastic Surgeons responded by setting certain limitations to the
number of cosmetic procedures performed at one time as well as
the duration of surgeries to help mitigate these risks.12
consequently, the claims resulted in larger payment.13 Review

of the closed claims data has shown that regardless of the type
of anesthesia employed, general anesthesia and monitored
anesthesia care (MAC) may carry a similar risk profile.14
However, given that MAC is frequently used for office-based
procedures, commonly reported issues that have plagued
anesthesia in both the inpatient and outpatient settings have
warranted closer review for comparison of adverse events during
office-based procedures. Studies examining claims involving
respiratory and airway events, hypoxia from over-sedation and
O.R. fires have suggested that the implementation of better
monitoring equipment and better vigilance by the provider
could have prevented injury.13 Bhananker et al. revealed that
facial plastic surgery represented 26 percent of MAC liability
incidents.14 Most of the evidence-based literature related
to office-based safety comes from the plastic surgery field.11
Significant advancements in patient

safety can be made with a national
standard of care, safety checklists and
enforcement of professional practice
guidelines. As data emerges from
effective, large administrative
databases, we will be able to make
more definitive conclusions about
patient safety and outcomes.
Dental procedures pose a unique set of challenges for

the physician anesthesiologist, including the potential for
ventilation and airway problems, smaller work areas compared to
an operating room, and also the responsibility to ensure that all
appropriate back-up and rescue equipment is readily available.
Some state dental boards are now requiring additional licensing
in order to administer anesthesia.1
Data collection from the Society for Ambulatory Anesthesia

(SAMBA) from 2008-10 involved a large number of cases
from a multitude of specialties.11 They reported very low overall
complication rates and suggested that office-based anesthesia
sites compared favorably with safety and outcome data from the
ambulatory and hospital practices, in spite of a low number of
self-selected voluntary reporting of outcomes.15 Implementation
and expansion of clinical outcome registries have begun to
address this issue and improve event reporting and accuracy of
data guiding improvements in office-based anesthesia practices
and patient safety.
Methods for quality improvement and

monitoring outcomes
Due to the lack of randomized controlled trials assessing
the safety of office-based anesthesia, our best literature to date
comes from the ASA Closed Claims Database. Despite the
three- to five-year lag between an event and its appearance
in the database, the claims represent a window to the distinct
vulnerabilities within the office-based setting.11 Early studies
reported that the severity of injury for office-based claims
was worse than in other ambulatory anesthesia settings and,
16
September 2014
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Number 9
Future directions in office-based procedural

and surgical safety
Improvements to the quality of large-scale outcome
reporting have become a focus of entities such as the SAMBA
Clinical Outcomes Registry (www.scordata.org) and the ASA
Anesthesia Quality Institute data registries (www.aqihq.org).11
Recently, an office-based anesthesia-specific checklist template
has been developed based on the World Health Organization
checklist as a means to further improve patient safety.16
Whereas several states are regulating office-based practices,
some are already requiring accreditation by entities such as
the Accreditation Association for Ambulatory Health Care
(AAAHC), and it would seem logical that involvement of the
government at the federal level is rapidly approaching.17 In
2012 and 2013, government agencies such as the Government
Accountability Office (GAO) and Centers for Medicare &
Medicaid Services (CMS) have initiated new regulation in
ambulatory care centers, such as mandatory data collection
and quality reporting, that could result in payment penalties
for failure to properly report quality measures to CMS.18,19 One
might speculate that these regulations will certainly find their
way into office-based surgical facilities in the near future.
Office-based anesthesia continues to expand rapidly, and
the procedures are becoming more complex. The literature
related to this topic is in its adolescence, but the similar risk
profiles with other practice locations is drawing attention to
the fact that office-based anesthesia should be held to the same
standard of care as ambulatory surgicenters and hospitals. With
patient safety and outcomes under increasing scrutiny, legislative
mandates involving credentialing, qualifications, licensing
and facility accreditation should be expected in the future.
Significant advancements in patient safety can be made with a
national standard of care, safety checklists and enforcement of
professional practice guidelines. As data emerges from effective,
large administrative databases, we will be able to make more
definitive conclusions about patient safety and outcomes.11
5. Coldiron B, Shreve E, Balkrishnan R. Patient injuries from surgical

procedures performed in medical offices: three years of Florida
data. Dermatol Surg. 2004;30(12, pt 1):1435-1443.
6. Coldiron BM, Healy C, Bene NI. Office surgery incidents: what
seven years of Florida data show us. Dermatol Surg. 2008;34(3):285291.
7. Keyes GR, Singer R, Iverson RE, et al. Mortality in outpatient surgery.
Plast Reconstr Surg. 2008;12(1)2:245-250.
8. Starling J 3rd, Thosani MK, Coldiron BM. Determining the safety of
office-based surgery: what 10 years of Florida data and 6 years of
Alabama data reveal. Dermatol Surg. 2012;38(2):171-177.
9. Taghinia AH, Liao EC, May JW Jr. Randomized controlled trials in
plastic surgery: a 20-year review of reporting standards, methodologic
quality, and impact. Plast Reconstr Surg. 2008;122(4):1253-1263.
10. Ahmad S. Office basedis my anesthetic care any different?
Assessment and management. Anesthesiol Clin. 2010;28(2):369-384.
11. Shapiro FE, Punwani N, Rosenberg NM, et al. Office-based
anesthesia: safety and outcomes. Anesth Analg. 2014; 119:276-85.
12. Iverson RE; ASPS Task Force on Patient Safety in Office-Based
Surgery Facilities. Patient safety in office-based surgery facilities: I.
Procedures in the office-based surgery setting. Plast Reconstr Surg.
2002;110(5):1337-1342.
13. Domino KB. Office-based anesthesia: lessons learned from the
closed claims project. ASA Newsl. 2001;65(6):9-11.
14. B hananker 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):228-34.
15. Walsh MT, Kurrek MM, Desai M. Anesthesia outcomes in officebased anesthesia [abstract A798]. Presented at: American Society
of Anesthesiologists 2010 Annual Meeting; October 18, 2010;
San Diego, California. http://www.asaabstracts.com/strands/
asaabstracts/search.htm;jsessionid=6CDD7A91159C9CAA33485B
DCA991766A. Accessed July 18, 2014.
16. Rosenberg NM, Urman RD, Gallagher S, Stenglein J, Liu X, Shapiro
FE. Effect of an office-based surgical safety system on patient
outcomes. Eplasty. 2012;12:e59. http://www.eplasty.com/index.
php?option=com_content&view=article&id=725&catid=173:volu
me-12-eplasty-2012&Itemid=121. Published December 25, 2012.
Accessed July 18, 2014.
17.
Florida Department of Health, Board of Medicine. Standard of
Care for Office Surgery. Florida Administrative Code & Florida
Administrative Register website. https://www.flrules.org/gateway/
ruleno.asp?id=64B8-9.009. Accessed July 18, 2014.
18. Government Accountability Office. Patient safety: HHS has taken
steps to address unsafe injection practices, but more action is
needed. GAO-12-712. http://www.gao.gov/assets/600/592406.pdf.
Published July 13, 2012. Accessed July 18, 2014.
19. Medicare and Medicaid Programs: Hospital Outpatient Prospective
Payment; Ambulatory Surgical Center Payment; Hospital ValueBased Purchasing Program; Physician Self-Referral; and Patient
Notification Requirements in Provider Agreements. Fed Regist.
2011;76(230):74122-74584. Codified at 42 CFR Parts 410, 411,
416, 419, 489, and 495. http://www.gpo.gov/fdsys/pkg/FR-2011-1130/pdf/2011-28612.pdf. Published November 30, 2011. Accessed
July 18, 2014.
References:
1. Kurrek MM, Twersky RS. Office-based anesthesia: how to start an

office-based practice. Anesthesiol Clin. 2010;28(2):353-367.
2. Koenig L, Doherty J, Dreyfus J, Xanthopoulos J; KNG Health
Consulting. An Analysis of Recent Growth of Ambulatory Surgery
Centers. Rockville, MD: KNG Health Consulting; June 5, 2009.
3. Accreditation Handbook for Office-Based Surgery. Skokie, IL:
Accreditation Association for Ambulatory Health Care (AAAHC);
2013.
4. Vila H Jr, Soto R, Cantor AB, Mackey D. Comparative outcomes
analysis of procedures performed in physician offices and ambulatory
surgery centers. Arch Surg. 2003;138(9):991-995.
September 2014
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17
adult patient for ambulatory surgery:
Are There Any Limits?

Alan Romero, M.D.

Improvements in surgical and anesthesia practice as

well as economic pressures have increased the number
of procedures being performed on an outpatient basis.
Surgical procedures and patients once considered inappropriate
for ambulatory surgery are now considered appropriate. For
example, painful, invasive surgical procedures (e.g., major
orthopedic surgery such as shoulder surgery and total knee
arthroplasty) are increasingly being performed in an ambulatory
setting1 due to improvements in surgical and local/regional
analgesia techniques2 and modifications in postoperative/
post-discharge care. As older and sicker patients undergo more
complex surgical procedures in an ambulatory setting, patient
selection has become the cornerstone of safe and efficient
perioperative care.
Clearly, identifying a patient suitable for an ambulatory
procedure is a dynamic process that depends on the complex
interplay between patient characteristics (e.g., coexisting
medical conditions), invasiveness of the procedure
(e.g., need for postoperative observation, blood loss requiring
blood transfusion, need for parenteral therapy, including
analgesics), anesthetic technique (e.g., local/regional versus
general anesthesia) and post-discharge factors such as ability
to manage pain and availability of a responsible caregiver. In
addition, it is necessary to consider the ambulatory setting
(i.e., office-based, free-standing ambulatory surgery center,
hospital-based ambulatory surgery center or short-stay), as it
will influence the ability to manage complex patients based

upon the availabilities of personnel and equipment. Although it
may be difficult to quantify, appropriateness of patient selection
may also depend upon the experience and skill of the surgeon
and the physician anesthesiologist. Therefore, attempts to
address individual factors without consideration of others is
fraught with flaws.
Overall, the literature on optimal patient selection for
ambulatory surgery is sparse and of limited quality. However,
there is a general agreement that patients with a high burden of
comorbidities, particularly those with poorly stabilized medical
conditions, are not suitable for ambulatory surgery. A recent
study used the American College of Surgeons National Surgical
Quality Improvement Program (NSQIP) database to assess
the morbidity and mortality within 72 hours after ambulatory
surgery in adults (n=244,397).3 The incidence of perioperative
morbidity and mortality was 0.1 percent (1 in 1,053 cases). The
independent risk factors for increased perioperative morbidity,
after controlling for surgical complexity, included high body
mass index (BMI), chronic obstructive pulmonary disease,
history of transient ischemic attack/stroke, hypertension,
previous cardiac surgical intervention and prolonged operative
time. The most common morbidities included unplanned
postoperative intubation, pneumonia and wound disruption.
One of the limitations of this study is that the observed
complication rate was low, resulting in inability to detect some

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

at University of Texas Southwestern
Medical Center, Dallas.
18
September 2014
Volume 78
Number 9
of the clinically meaningful risk factors.3 Furthermore, these

retrospective analyses may not always be relevant in the current
rapidly changing surgical and anesthetic practice environment.
Another recent study reported that the predictors of
unplanned hospital admission included length of surgery
more than one hour, high ASA Physical Status classification
(ASA 3), advanced age (>80 years) and increased BMI.
The authors suggest that, despite its inter-rater variability, the
ASA Physical Status classification could be used as a marker
of perioperative risk rather than attributing risk to a specific
disease process.4
optimized comorbid conditions could safely undergo

ambulatory surgery. On the other hand, super obese (i.e.,
BMI >50 kg/m2) may not be suitable for ambulatory surgery.5
Because 60-70 percent of morbidly obese patients have sleepdisordered breathing (i.e., obstructive sleep apnea [OSA] and
obesity-related hypoventilation syndrome), it is necessary to
consider the presence of OSA when determining suitability for
ambulatory surgery, as it has also been associated with increased
perioperative complications.
A review of published literature assessing perioperative
complications in patients with OSA undergoing ambulatory
surgery revealed that OSA patients with inadequately treated
co-morbid conditions are not suitable for ambulatory surgery.6
Patients with a known diagnosis of OSA (who are typically
prescribed positive airway pressure [PAP] therapy) may be
considered for ambulatory surgery if their comorbid medical
conditions are optimized and they are able to use a PAP device
in the postoperative period. It appears that postoperative PAP
therapy may be protective against opioid-induced respiratory
depression. Patients who are unable or unwilling to use a PAP
device after discharge may not be appropriate for ambulatory
surgery. Patients with a presumed diagnosis of OSA, based on
screening tools such as the STOP-BANG questionnaire, can be
considered for ambulatory surgery if their comorbid conditions
are optimized and if postoperative pain relief can be provided
predominantly with non-opioid analgesic techniques. Of note,
no guidance could be provided for OSA patients undergoing
upper-airway surgery due to limited evidence.6 ASA recently
published updated guidelines regarding perioperative
management of OSA patients, including selection for
ambulatory surgery.7
Patients with diabetes mellitus often have several
comorbidities; however, it is not a contraindication to
ambulatory surgery. It is necessary that the surgical facilities
Overall, the literature on optimal

patient selection for ambulatory
surgery is sparse and of limited
quality. However, there is a general
agreement that patients with a high
burden of comorbidities, particularly
those with poorly stabilized medical
conditions, are not suitable for
ambulatory surgery.
Most studies have identified obesity as a risk factor for

perioperative complications. However, a systematic review
revealed that BMI alone does not influence perioperative
complications or unplanned admission after ambulatory
surgery.5 Morbidly obese patients (BMI>40 kg/m2) with
September 2014
Volume 78
Number 9
19
caring for this patient population have the necessary equipment

to monitor blood glucose levels. The Society for Ambulatory
Anesthesia (SAMBA) has published a consensus statement on
perioperative blood glucose management, which provides some
guidance on preoperative care of diabetic patients.8
Scheduling patients who are susceptible to malignant
hyperthermia (MH) at a freestanding ambulatory surgery center
remains controversial. There appears to be a higher rate of
mortality for MH patients who are transferred from other health
care facilities, including ambulatory surgery centers.9 Therefore,
all anesthetizing facilities should prepare for the eventuality of
an MH event if a triggering agent is being used. It is generally
accepted that MH patients can undergo ambulatory surgery as
long as the anesthesia machine is prepared properly and a triggerfree anesthetic can be provided.10 Increasing complexity of the
newer anesthesia machines may increase the role for charcoal
filters, which are able to filter inhaled anesthetics to lower
than five parts per million.10 Of note, prophylactic dantrolene
administration is not warranted, and postoperative discharge
times do not need to be prolonged as long as a non-triggering
anesthetic was given and the patient otherwise has no signs that
can be attributed to an MH manifestation.
References:
1. Lovald S, Ong K, Lau E, Joshi G, Kurtz S, Malkani A. Patient selection

in outpatient and short-stay total knee arthroplasty. J Surg Orthop
Adv. 2014;23(1):2-8.
2. Joshi GP, Kehlet H. Procedure-specific pain management: the
road to improve postsurgical pain management? Anesthesiology.
2013;118(4):780-782.
3. Mathis MR, Naughton NN, Shanks AM, et al. Patient selection for
day case-eligible surgery: identifying those at high risk for major
complications. Anesthesiology. 2013;119(6):1310-1321.
4.
Whippey A, Kostandoff G, Paul J, Ma J, Thabane L, Ma HK.
Predictors of unanticipated admission following ambulatory surgery:
a retrospective case-control study. Can J Anaesth. 2013;60(7):675683.
5. Joshi GP, Ahmad S, Riad W, Eckert S, Chung F. Selection of patients
with obesity undergoing ambulatory surgery: a systematic review of
the literature. Anesth Analg. 2013;117(5):1082-1091.
6. Joshi GP, Ankichetty S, Chung F, Gan TJ. Society for Ambulatory
Anesthesia consensus statement on preoperative selection of
patients with obstructive sleep apnea scheduled for ambulatory
surgery. Anesth Analg. 2012;115(5):1060-1068.
7. American Society of Anesthesiologists Task Force on Perioperative
Management of Patients with Obstructive Sleep Apnea. Practice
guidelines for the perioperative management of patients with
obstructive sleep apnea. Anesthesiology. 2014;120(2):268-286.
8.
Joshi GP, Chung F, Vann MA, et al.; Society for Ambulatory
Anesthesia. Society for Ambulatory Anesthesia consensus statement
on perioperative blood glucose management in diabetic patients
undergoing ambulatory surgery. Anesth Analg. 2010;111(6):13781387.
9.
Rosero EB, Adesanya AO, Timaran CH, Joshi GP. Trends and
outcomes of malignant hyperthermia in the United States, 2000 to
2005. Anesthesiology. 2009;110(1):89-94.
10.
Litman R, Joshi GP. Malignant hyperthermia in the ambulatory
surgery center: how should we prepare? Anesthesiology. 2014;120(6):
1306-1308.
Summary
Developing and implementing protocols also known as
clinical pathways is the best way to improve perioperative
outcome. Uniform practice improves safety and efficiency.
This requires a multidisciplinary approach in which the
physician anesthesiologist takes the lead in collaborating with
surgeons and perioperative nurses. The first step in determining
appropriate patient selection includes preoperative assessment
and identification of any comorbid conditions, which should
be optimized to minimize risks. The social situation should be
evaluated to determine whether the patient has help at home
for postoperative care. Also, it is necessary that we are involved
with the post-discharge care, which includes education of
patients and their caregivers regarding the need for increased
vigilance after discharge home. Patients should receive written
pre- and postoperative instructions and be discharged to the
care of a responsible adult. In the near future, as more surgical
procedures and patients are moved from inpatient facilities to
outpatient facilities, it will be appropriate to develop exclusion
criteria, rather than inclusion criteria, for patients who are not
candidates for ambulatory surgery.
20
September 2014
Volume 78
Number 9
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30 Anesthetics on the Same Child Really!
Pediatric Ambulatory Anesthesia for Proton Radiation
Hernando De Soto, M.D.
Proton therapy, a type of external-beam

radiation therapy, was first proposed
by Robert Wilson in a 1946 article that
described the unique physical properties
of protons and their potential application
in oncology.1 The first proton centers were
actually high-energy research facilities
built in the 1950s. Clinically, patients first
received proton radiation therapy in 1958.
These early centers, although primitive in
their design, demonstrated the potential
for normal-tissue sparing with more
accurate tumor targeting. Consequently,
the technology mushroomed and in the past 10 years proton
therapy has gained favor for pediatric malignancies. This is
for two primary reasons: First, it is well-recognized that the
developing organs of pediatric patients are especially sensitive
to the damaging effects of ionizing radiation. Second, recent
advances in pediatric oncology mean that more children are
cured of their cancer, and survivors functional and quality-oflife endpoints are of highest importance. According to a recent
patterns-of-care study,2 the total number of children treated at
U.S. proton centers increased 33 percent between 2010 and 2012
(from 465 patients in 2010 to 694 patients in 2012). In 2012,
the three most commonly treated pediatric tumors were
brain tumors (ependymoma, 106 patients; medulloblastoma,
89 patients; and low-grade glioma [LGG], 78 patients).
Pediatric Ambulatory Anesthesia

Outside the O.R.
Recently, we have seen an increasing
demand to perform anesthesia on children
outside the O.R.3 This new development
creates significant, exciting professional challenges for the physician anesthesiologist.
Patients having procedures performed in such
distant locations as radiology suites, emergency
rooms, burn units, GI labs, pulmonary labs,
etc., will require sedation and/or anesthesia
for diagnostic and therapeutic procedures.
Children requiring such anesthesia outside the
O.R. need to have the same anesthesia requirements as those
having surgery in the main O.R. Patient safety protocols need
to be established, including a thorough preoperative evaluation,
preparation for intraoperative course and a suitable location for
postoperative care.4 Appropriate consultations and laboratory
work-ups should be obtained as needed. A working system to
admit the ambulatory patient or to transfer patients to the
hospital (in a freestanding facility) need to be in place in
the event of a complication or side-effect from the procedure.
Most physician anesthesiologists in the U.S. do not have
admitting privileges to hospitals, and this admitting dilemma
needs to be sorted out before the commencement of the
anesthesia service in that location.
Pediatric patients scheduled for surgery in such locations
often represent significant anesthesia challenges5 such as upperrespiratory infection, asthma, obstructive sleep apnea, heart
murmur, prematurity, sickle-cell disease and cancer. Also,
some children may be born with specific syndromes, especially
craniofacial, that may complicate airway management and
may include increased intracranial pressure. However, the
children can be anesthetized safely as long as their medical
condition is optimized.
Hernando De Soto, M.D. is an

Associate Professor, Department
of Anesthesiology, University
of Florida, Jacksonville; Director of
Pediatric Anesthesia, UF Health
Jacksonville, Chief of Anesthesiology
Services, UF Proton Therapy Institute,
Jacksonville.
The Child With Cancer

The procedure being performed may contribute to the
complexity of the situation.6 Often these procedures can
be painful (i.e., bone marrow examinations and lumbar
punctures). Procedure-related pain is a major source of distress
to many children and their families, and it is often viewed as
22
September 2014
Volume 78
Number 9
the worst aspect of the entire cancer experience. For years,

physician anesthesiologists have been called upon to provide
sedation or general anesthesia to alleviate the discomfort.
Another challenging situation in the ambulatory center
is that of children who must return daily for several weeks
to receive radiation therapy. They must lie still for 15 to 45
minutes with the physician anesthesiologist outside the room.
ASA standard monitoring guidelines should be used, including
pulse oximetry, end-tidal CO2, EKG and non-invasive blood
pressure measurements.7 Depending on the patient and the
procedure, the physician anesthesiologist must decide what
technique for sedation/anesthesia is best for the patient, e.g.,
spontaneous versus controlled ventilation, intubation versus
laryngeal mask airway (LMA) versus non-invasive methods of
airway management. Several techniques are commonly utilized
for both proton and conventional radiation therapy. These
techniques include general anesthesia (GA) with inhalation
agents only, GA with a combination of an inhalation agent
and a sedative drug (ketamine, propofol, dexmedetomidine,
midazolam), or total intravenous anesthesia (TIVA), especially
with propofol and/or dexmedetomidine.8-10
followed by LMA placement and inhalation maintenance with

sevoflurane. With the LMA, intubation is not necessary; the
airway is maintained with the child breathing spontaneously,
and minimal experience is needed for successful mask
placement. There has been no airway trauma secondary to the
use of an LMA in any of the children treated at the institute.
TIVA also has been used in the rest of the supine cases with
success. These techniques have not prolonged the outpatient
stay and have reduced the postoperative incidence of nausea
and vomiting and emergence delirium to very low levels. For
spine tumor patients required to be in a prone position for
their treatment, the only change to the above protocol is that
endotracheal intubation is performed every day for the duration
of the treatments. Again, no airway trauma or complications
have been seen in any of the children.
Although most children are healthy and can safely undergo
ambulatory surgery and anesthesia, occasionally the physician
anesthesiologist is faced with management dilemmas. Children
with cancer often undergo frequent outpatient procedures both
diagnostic and therapeutic. The anesthetic approach should
be aggressive toward pain management (if pain exists) and
anesthetics and techniques that cause minimal side-effects in
the context of repeated administration.
Florida Proton Therapy Institute (FPTI) Experience

The FPTI in Jacksonville has been treating children since
March 2007. As of April 2014, the institute has treated
303 children with anesthesia. The median age was 3.3
years old (range, 0.5-18.8 years old). Children from many
parts of the world come for radiation treatment, including
the United States, England, Scotland, Ireland, Holland,
Norway, Finland, Bulgaria and Mexico, to name a few. The
FPTI is involved in several treatment protocols from St. Jude
Childrens Hospital, and many of their patients are treated
here. The anesthesia team is directed by physician
anesthesiologists specializing in the care of children.
References:
1. Wilson RR. Radiological use of fast protons. Radiology. 1946;47(5):

487-491.
2. Indelicato DJ, Chang AL. Pediatric proton therapy: patterns of care
in 2012 across the United States. Presented at: Fall 2013 Childrens
Oncology Group Meeting; October 8-12, 2014; Dallas, TX.
3.
Cravero JP. Risk and safety of pediatric sedation/anesthesia for
procedures outside the operating room. Curr Opin Anaesthesiol.
2009;22(4): 509-513.
4. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH; Pediatric
Sedation Research Consortium. The incidence and nature of adverse
events during pediatric sedation/anesthesia with propofol for
procedures outside the operating room: a report from the Pediatric
sedation Research Consortium. Anesth Analg. 2009;108(3):795-804.
5.
Collins CE, Everett LL. Challenges in pediatric ambulatory
anesthesia: kids are different. Anesthesiol Clin. 2010; 28(2): 315-328.
6. L atham GJ. Anesthesia for the child with cancer. Anesthesiol Clin.
2014;32(1):185-213.
7. Cot CJ, Wilson S. Guidelines for monitoring and management
of pediatric patients during and after sedation for diagnostic and
therapeutic procedures: an update. Pediatrics. 2006;118(6):25872602.
8. Buchsbaum JC, McMullen KP, Douglas JG, et al. Repetitive pediatric
anesthesia in a non-hospital setting. Int J Radiat Oncol Biol Phys. 2013;
85(5):1296-1300.
9. Griffiths MA, Kamat PP, McCracken CE, Simon HK. Is procedural
sedation with propofol acceptable for complex imaging? A
comparison of short vs. prolonged sedations in children.
Pediatr Radiol. 2013;43(10): 1273-1278.
10. Seiler G, De Vol E, Khafaga Y, et al. Evaluation of the safety and
efficacy of repeated sedations for the radiotherapy of young children
with cancer: a prospective study of 1033 consecutive sedations.
Int J Radiat Oncol Biol Phys. 2001;49(3):771-783.
Anesthesia Protocol
Children are initially screened by a registered nurse and
evaluated by a pediatric anesthesiologist to determine the best
and safest anesthesia for the child. The parents are questioned
extensively and an honest explanation is given to them about
the risks and benefits of the anesthesia. The majority of the
children receive approximately 30 radiation treatments, usually
over a span of six weeks. They all have a port placed before
starting treatments for I.V. medications. The same anesthesia
technique is performed throughout the treatments, albeit with
minor modifications in drug dosages based on patient needs.
Approximately 10,000 anesthesia sessions, including CT
simulations and PET scans, have been performed over the last
seven years at the FPTI. The most frequent anesthesia technique
in more than 95 percent of procedures in patients receiving
treatment in the supine position has been a propofol induction
September 2014
Volume 78
Number 9
23
Outpatient Continuous Peripheral Nerve Blocks
Elie Joseph Chidiac, M.D.
Despite the focus on pain as the fifth vital sign, some

outpatients are still going home with moderate to severe
postoperative pain.1 This is especially true for outpatient
orthopedic surgery.2 Single-shot peripheral nerve blocks
(PNBs) can control pain, but they are time-limited by the
duration of action of the local anesthetic and adjuvants.
Continuous peripheral nerve blocks (CPNBs), however, can
prolong pain relief well into the first postoperative day and
beyond. This article will focus on the benefits of home CPNB
following ambulatory surgery, what to tell naysayers who may
be against a CPNB program at your institution and tips for a
successful home CPNB service.

Quality of sleep: Sending patients home with CPNB
decreases insomnia and the number of awakenings at
night.7,9,10
n
Opioid use: In a meta-analysis of 19 randomized trials, CPNB
provided better postoperative pain control compared to oral
opioids at 24 hours, 48 hours and 72 hours postoperatively in
all catheter locations.11 In those studies where patients were
allowed to supplement the pain control from CPNB with
oral opioids, there was a statistically significant decrease in
the overall amounts needed, compared to those patients
without CPNB. One recent study where CPNB was used for
48 hours showed that, for a full week, this group continued
to have better pain relief than those with single-shot PNBs.10
n
Benefits of Home CPNB

The first CPNBs were reported in 1946 by Ansbro.3 This
study involved a series of inpatients with a needle placed
through a cork and into the supraclavicular area, with rubber
tubings, a glass syringe, a metal stopcock and a beaker filled
with procaine. Rather than a continuous infusion, patients
received intermittent injections. In 1977, Selander reported
the first CPNBs with a catheter,4 and in 1998 the first report
was published on sending patients home with CPNBs and a
disposable pump.5 Since then, anesthesia has become safer
and the focus has shifted from the traditional outcomes of
mortality and severe morbidity to patient-oriented outcomes,6
helping to highlight the benefits of CPNBs. They have been
shown to improve the following:
n
Patient satisfaction: When comparing initial interscalene7
and popliteal8 blocks followed by a CPNB with ropivacaine
versus placebo, patient satisfaction was greatly increased in
the ropivacaine groups.
Compared to single-shot PNBs,

the surgeons office staff have
said they are receiving fewer
phone complaints about severe
postoperative pain at home
and are seeing a drop in
readmissions for pain control.

Hospital length of stay: Traditionally, joint replacement
surgeries have necessitated postoperative admission for pain
control and physical therapy. With a multimodal technique,
including CPNB, there have been situations where patients
were able to reach home-readiness one full day ahead of
schedule12 or even go home on the day of surgery after more
limited joint arthroplasties.13
n
Other benefits: There are isolated case reports of at-home
CPNB improving adhesive capsulitis of the shoulder,
attenuating CRPS symptoms and abolishing phantom
limb pain.
n
Elie Joseph Chidiac, M.D. is Chief,

Regional Anesthesia Section and
Residency Program Director,
Detroit Medical Center/
Wayne State University, Detroit.
24
September 2014
Volume 78
Number 9
Naysayers and What to Tell Them

About CPNB Benefits in Outpatients
Our program began in 2003 with one orthopedic surgeon,
as others felt that a CPNB program would have a low success
rate or delay the start of surgery. Very soon, everyone embraced
it and started scheduling many major surgeries with home
CPNB for their patients. Some procedures that once required
postoperative admission for two to three days of pain control are
now performed on an outpatient basis. Compared to single-shot
PNBs, the surgeons office staff have said they are receiving fewer
phone complaints about severe postoperative pain at home and
are seeing a drop in readmissions for pain control. One of the
last barriers to the home CPNB program had been the concern
with sending patients home with a numb lower extremity, where
there is a chance they might fall down. We tell surgeons it is
better to go home with a numb non-weight-bearing leg than to
go home groggy (from opioids) with an immobilized painful leg.
Best is to give patients crutch training, place a knee immobilizer
and instruct them about fall prevention. The newer adductor
canal technique, which spares most of the nerve supply to the
quadriceps muscles, can also decrease this complication.14
Another group of naysayers were ambulatory facility
administrators, who complained about the cost of ultrasound
and disposable equipment. First, we made sure the facility can
charge for the use of ultrasound guidance, which then amortized
the cost of the machines. We also pointed out to them the
cost savings of a shorter length of stay in the recovery room10

and the lower readmission rate for severe pain. And a metaanalysis showed cost savings when comparing the disposable
equipment needed for CPNB to the cost of opioids and nausea
management.11
Physician anesthesiologist naysayers tend to worry about
infection risk at the catheter site, local anesthetic toxicity
and phrenic nerve paralysis with interscalene catheters.
However, true infections are extremely uncommon, despite a
high incidence of catheter colonization. Risk factors include
prolonged catheter placement, ICU admission, absence of
antibiotic prophylaxis, frequent dressing changes, and femoral
or axillary location.15 As to local anesthetic toxicity during
home CPNB, unbound local anesthetic concentrations stay
below toxic levels.16 Finally, compared to single-shot PNBs, the
incidence of phrenic nerve paralysis with interscalene blocks is
decreased with use of dilute infusions in home CPNB.17 Still,
it is best to avoid interscalene catheter placement in patients
with known respiratory compromise (severe emphysema or
prior contralateral lung surgery) or those patients who cannot
compensate for mild decreases in pulmonary function. At our
institution, if the benefits are seen to outweigh this risk, we
have placed catheters and given short-acting local anesthetics
through the catheter. In the recovery room, if we suspect any
compromise from phrenic nerve paralysis, we can choose to
Placement of interscalene catheter, May 2014. Left to right, Dr. Chidiac, Dr. R. Rahal (CA-3) and L. Kirk (medical student).
September 2014
Volume 78
Number 9
25
discontinue the catheter and monitor them until appropriate for

discharge from the ambulatory center.
continue patient interactions well into the postoperative period,

thus expanding his/her role as a true perioperative physician.
Tricks for Success

Patients first encounter with the concept of home CPNB
occurs in the surgeons offices. There, they receive a letter
from the physician anesthesiologists telling them what to
expect. In the preoperative holding room, in the presence of
the responsible adult accompanying the patient, we explain
catheter placement and the planned discharge with a home
pump. When feasible, we invite this responsible adult into the
block room, just after catheter placement but before taping, and
have him/her watch us secure the catheter. We have found this
helps them understand that the removal of the catheter at home
(usually at 72 hours) is not harmful to their loved one.
Prior to home discharge, we attach the disposable home
infusion pump to the catheter and again discuss issues with
the patient and responsible adult. We train both to recognize
side-effects, tell them what to expect, instruct them regarding
catheter removal, give them a way to reach us at all hours and
confirm two contact numbers where we can reach them. We
call the patients every day until one day after catheter removal,
asking them specific questions regarding pain control,
numbness, fluid leakage, signs of infection and pump
malfunction. For patients who have programmable pumps or
pumps with a patient-controlled bolus capability, we explain
this feature to them prior to discharge and again reinforce it
with our daily phone calls. If, prior to discharge from the
ambulatory center, their extremity is still numb from the highconcentration local anesthetic, we point out to them that the
difference in concentration will be noticeable later in the day,
and they should expect less numbness (and possibly more pain)
when the high-concentration initial bolus wears off. If the
infusion may compromise the phrenic nerve (e.g., interscalene
or supraclavicular placements), we inquire about any feeling of
shortness of breath. If the infusion may affect the quadriceps
muscle (e.g., femoral or adductor canal placements), we make
sure to reinforce our previous instructions to avoid episodes of
falling down. Some patients are so comfortable that they are
anxious to remove the catheter and tape as soon as possible,
assuming that the catheter is not needed on the second
postoperative day. We tell them: You are in control of your
own pain control and we suggest temporarily shutting off the
infusion, rather than removing the catheter. If pain recurs,
they can restart the pump on their own.
In conclusion, a home CPNB program can offer numerous
benefits for ambulatory surgical patients and allow certain cases
to be performed in an outpatient center rather than an inpatient
facility. For the physician anesthesiologist, it is a chance to
References:
1.
Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain
experience: results from a national survey suggest postoperative
pain continues to be undermanaged. Anesth Analg. 2003;97(2):534540.
2. Rawal N, Hylander J, Nydahl PA, Olofsson I, Gupta A. Survey
of postoperative analgesia following ambulatory surgery. Acta
Anaesthesiol Scand. 1997;41(8):1017-1022.
3. Ansbro FP. A method of continuous brachial plexus block. Am J Surg.
1946:71(6):716-722.
4.
Selander D. Catheter technique in axillary plexus block. Acta
Anaesth Scand. 1977;21(4):324-329.
5. Rawal N, Axelsson K, Hylander J, et al. Postoperative patientcontrolled local anesthetic administration at home. Anesth Analg.
1998;86(1):86-89.
6. Wu CL, Fleisher LA. Outcomes research in regional anesthesia and
analgesia. Anesth Analg. 2000;91(5):1232-1242.
7.
Mariano ER, Afra R, Loland VJ, et al. Continuous interscalene
brachial plexus block via an ultrasound-guided posterior approach:
a randomized, triple-masked, placebo-controlled study. Anesth
Analg. 2009;108(5):1688-1694.
8. White PF, Issioui T, Skrivanek GD, Early JS, Wakefield C. The use
of a continuous popliteal sciatic nerve block after surgery involving
the foot and ankle: does it improve the quality of recovery? Anesth
Analg. 2003;97(5):1303-1309.
9.
Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK.
Continuous interscalene brachial plexus block for postoperative
pain control at home: a randomized, double-blinded, placebocontrolled study. Anesth Analg. 2003;96(4):1089-1095.
10. Salviz EA, Xu D, Frulla A, et al. Continuous interscalene block in
patients having outpatient rotator cuff repair surgery: a prospective
randomized trial. Anesth Analg. 2013;117(6):1485-1492.
11. R ichman JM, Liu SS, Courpas G, et al. Does continuous peripheral
nerve block provide superior pain control to opioids? A metaanalysis. Anesth Analg. 2006;102(1):248-257.
12. Ilfeld BM, Mariano ER, Girard PJ, et al. A multicenter, randomized,
triple-masked, placebo-controlled trial of the effect of ambulatory
continuous femoral nerve blocks on discharge-readiness following
total knee arthroplasty in patients on general orthopaedic wards.
Pain. 2010;150(3):477-484.
13. Dervin GF, Madden SM, Crawford-Newton BA, Lane AT, Evans
HC. Outpatient unicompartment knee arthroplasty with indwelling
femoral nerve catheter. J Arthroplasty. 2012;27(6):1159-1165.
14. Jger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus
femoral nerve block for analgesia after total knee arthroplasty:
a randomized, double-blind study. Reg Anesth Pain Med.
2013;38(6):526532.
15. Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous
peripheral nerve blocks. Anesthesiology. 2009;110(1):182-188.
16. B leckner L, Solla C, Fileta BB, Howard R, Morales CE, Buckenmaier
CC. Serum free ropivacaine concentrations among patients
receiving continuous peripheral nerve block catheters: is it safe for
long-term infusions? Anesth Analg. 2014;118(1):225-229.
17.
Renes SH, van Geffen GJ, Rettig HC, Gielen MJ, Scheffer GJ.
Minimum effective volume of local anesthetic for shoulder
analgesia by ultrasound-guided block at root C7 with assessment of
pulmonary function. Reg Anesth Pain Med. 2010;35(6):529-534.
26
September 2014
Volume 78
Number 9
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14-164
Management of MH in the Ambulatory Environment:

Recent Literature That Aids in Diagnosis, Treatment and Outcomes

Frequently, questions arise as to the necessity of

dantrolene availability in the office-based practice or the
ambulatory surgery center that does not use volatile agents.
Succinylcholine is only maintained in the same facility for
airway rescue. In order to answer these important questions,
we must turn to available data. Recent additions to the
literature have pointed to a greater understanding of malignant
hyperthermia (MH) events. Succinylcholine was once thought
to be an exceedingly rare trigger of MH events in the absence
of inhaled volatile agents. A recent article searched a Canadian
database for MH triggers and characteristics.1 The investigators
found that succinylcholine was identified as a sole agent
trigger in greater than 15 percent of the 129 patients in the
database. Additionally, the investigators found that 13 percent
of patients had uneventful prior anesthetics. The authors of the
Canadian study emphasized that despite the low likelihood of
succinylcholine alone triggering MH, dantrolene needs to be
stocked for that rare event. The first probability assessment of
such an event and the need for dantrolene rescue was a full supply
of dantrolene. A newer, 2014 cost-effectiveness assessment of
maintaining an amount of dantrolene recommended by the
Malignant Hyperthermia Association of the United States
(MHAUS) was published, reaffirming the importance of a full
supply.2 When compared to the likelihood of a fatal outcome
from MH in an ambulatory surgical facility, the availability of
dantrolene was deemed to be very cost effective. The authors
acknowledged that the study had limitations due to the lack
of true long-term data, true incidence of MH and the rates of

administration of dantrolene in cases of MH.3 However, the
authors emphasized that the fatality of MH prior to the use of
dantrolene was acknowledged to be about 80 percent. Since
dantrolene therapy was introduced, the case fatality of MH
decreased to 10 percent. Current estimates suggest that the case
fatality may be even less than 5 percent due to improved patient
monitoring and availability of dantrolene.4
Dantrolene should not be the only treatment for MH episodes
irrespective of the location of the event. Active cooling, control
of the dysrhythmias, hyperkalemia and metabolic acidosis are
also requisite. If possible, the patient should be stabilized in
preparation for transfer to a hospital. However, transfer should
not be delayed in order to get the patient to the hospital.
MHAUS has helped to develop transfer guidelines available for
both ambulatory surgery centers as well as the office.5 These are
easily found on its website.6
MHAUS Hotline consultants are frequently called during a
suspected crisis by caregivers asking for assistance in diagnosis.
Perioperative temperature elevation has many causes.7 If there
is uncertainty, it is wiser to treat with dantrolene and other
critical treatments. Then, as previously mentioned, proceed
with transfer to a hospital setting. Although the complications
of treatment with dantrolene are not common, it is associated
with muscle weakness, phlebitis and abdominal pain.
Respiratory failure is a less frequent complication of dantrolene
treatment.8
Most of the data for MH incidence and specific demographics in ambulatory settings are from ambulatory surgical
centers. Data from office-based setting are scarce at best.
Office-based MH episodes seem to be only known when a death
or other severe outcome is publicized such as in the death of an
18-year-old female in Florida a number of years ago.
Recent studies have analyzed more specifics with respect
to agents, gender and rates/severity of complications. The
investigators found that, overall, there were lower rates of
complications and severity. However, the complication rates
were increased when there was an increased interval from
identification of an MH event to implementation of treatment.
Males were found to be more affected than females.1 Pediatric

is Professor and Vice-Chair for Faculty
Development, Department of
Anesthesiology, University of
Pittsburgh School of Medicine.
28
September 2014
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Number 9
MH from the North American Malignant Hyperthermia

Registry shows no phenotypic variation with respect to age.
MH is manifest differently in three age groups. Infants up to
24 months had the most mottling and metabolic acidosis.
Patients from the middle pediatric range up to 12 years of age
had a lower ETCO2 and PaCO2 than either the younger age
group or the older age group. Patients older than 12 had the
greatest incidence of hyperkalemia and diaphoresis. The oldest
group was also the group with the longest onset time.9
Ambulatory and office-based anesthetic practices are likely
to use a single volatile agent, if one is used at all, in order to
reduce costs. Sevoflurane is the likely agent to be used due to a
combination of lower costs, best tolerance for mask induction
for children and low airway irritability. Although desflurane is
quite useful for rapid emergence, its irritating airway properties
as well as cost makes it a less desirable agent for these practices.
Isoflurane is the least expensive of the volatile agents; however,
its undesirable airway irritation also makes it a less desirable
agent for use in the ambulatory and office-based practice. Despite
the advantages of sevoflurane, it is the agent most commonly
associated with an earlier onset of MH in contrast to desflurane
and isoflurane.10
Concerns of scheduling patients who are known to be
MH-susceptible or have suspicious family history persist.
As summarized in the August 2013 ASA NEWSLETTER,
MH-susceptible patients routinely undergo endoscopy,
colonoscopy, and dental and ophthalmologic procedures
without incident.11 Fear of triggering MH in patients who have
not received triggering agents is unwarranted. The location of
scheduling of MH-susceptible patients should be based upon
medical co-morbidities and not the fear of triggering MH.
If laryngospasm occurs, other methods of relieving
laryngospasm besides the administration of succinylcholine
exist. Deepening the anesthetic with propofol, positive pressure
ventilation and the use of a transtracheal block with local
anesthesia will also relieve laryngospasm. MH-susceptible
patients should remain in the PACU or recovery area for
1.5 hours after the procedure. The exceedingly rare patient
with a history of central core disease (CCD) has the potential
for spontaneous triggering of MH. Patients with CCD are
usually known to the surgical and anesthesia teams prior
to scheduling. Patients with CCD also undergo procedures
using local anesthesia or minimal to moderate sedation in
ambulatory settings and office settings without problems.
Interestingly, in one publication it was noted that children who
have had episodes of MH seem to have more co-morbidities
and hospital diagnoses.12 Nevertheless, the pediatric patient
should be scheduled similarly as an adult patient. The childs
co-morbidities, aside from MH-susceptibility, should dictate the
location of the care.
September 2014
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Number 9
Finally, a new preparation of dantrolene has been approved

by the FDA in July 2014.13 This preparation is concentrated as a
lyophilized powder in 5 ml. When reconstituted, the preparation
will have 10 ml. If approved, this preparation will add another
possible approach to the administration of dantrolene during an
MH episode. Storage of this preparation may be easier in a small
pharmacy area of an ASC or office-based environment.
References:
1. Riazi S, et al. Malignant hyperthermia in Canada: characteristics

of index anesthetics in 129 malignant hyperthermia susceptible
probands. Anesth Analg. 2014;118(2):381-387.
2. Dexter F, Epstein RH, Wachtel RE, Rosenberg H. Estimate of the
relative risk of succinylcholine for triggering malignant hyperthermia.
Anesth Analg. 2013;116(1);118-122.
3.
Aderibigbe T, Lang BH, Rosenberg H, Chen Q, Li G. Costeffectiveness analysis of stocking dantrolene in ambulatory surgery
centers for the treatment of malignant hyperthermia. Anesthesiology.
2014;120(6):1333-1338.
4.
Kim DC. Malignant hyperthermia. Korean J Anesthesiol.
2012;63(5):391-401.
5. Larach MG, Dirksen SJ, Belani KG, et al; Society for Ambulatory
Anesthesiology; Malignant Hyperthermia Association of the United
States; Ambulatory Surgery Foundation; Society for Academic
Emergency Medicine; National Association of Emergency Medical
Technicians. Creation of a guide for the transfer of care of the
malignant hyperthermia patient from ambulatory surgery centers
to receiving hospital facilities. Anesth Analg. 2012;114(1);94-100.
6. Malignant Hyperthermia Association of the United State website.
http://www.MHAUS.org. Accessed July 18, 2014.
7. Herlich A. Perioperative temperature elevation: not all hyperthermia
is malignant hyperthermia. Pediatr Anesth. 2013;23(9):842-850.
8. Brandom BW, Larach MG, Chen MS, Young MC. Complications
associated with the administration of dantrolene 1987 to 2006: a
report from the North American Malignant Hyperthermia Registry
of the Malignant Hyperthermia Association of the United States.
Anesth Analg. 2011;112(5):1115-1123.
9. Nelson P, Litman RS. Malignant hyperthermia in children: an analysis
of the North American Malignant Hyperthermia Registry. Anesth
Analg. 2014;11(2)8:369-374.
10. Visoiu M, Young MC, Wieland K, Brandom BW. Anesthetic drugs
and onset of malignant hyperthermia. Anesth Analg. 2014;118(2):388396.
11. Li G, Brady JE, Rosenberg H, Sun LS. Excess co-morbidities associate
with malignant hyperthermia diagnosis in pediatric hospital discharge
records. Paediatr Anaesth. 2011;21(9):958-963.
12. Herlich A. Malignant hyperthermia in the ASC and office-based
setting: recent developments in preparation and management.
ASA Newsl. 2013;77(8):26-27.
13.
Root C. Eagle Pharmaceuticals Announces FDA acceptance Of
NDA for ryanodex in malignant hyperthermia. Clinical Leader
website. http://www.clinicalleader.com/doc/eagle-pharmaceuticalsannounces-fda-acceptance-of-nda-for-r yanodex-in-malignanthyperthermia-0001. Published April 2, 2014. Accessed August 18,
2014.
29
Euroanesthesia 2014:
Part of ASAs Growing International Focus

Once again in 2014, ASA had the honor of
participating at Europes largest anesthesiologyrelated conference, Euroanaesthesia 2014, which
took place in June in Stockholm, Sweden. The European
Society of Anaesthesiology (ESA) shares an agreement
with ASA in which the two societies present educational
panels at each others annual meetings, an arrangement
now celebrating its fourth year.
ASA President Jane C.K. Fitch, M.D. introduced
this years panel, which included Michael F. OConnor,
M.D., Audre A. Bendo, M.D. and Karen B. Domino,
M.D. After Dr. Bendo discussed the evidence that
supports avoiding or using medications in specific clinical
scenarios, Dr. Domino described ASAs Closed Claims
Database and outlined how it can be used for research
to improve patient outcomes. Finally, Dr. OConnor
outlined the social construction of medical accidents
using the perspective of human-factors research.
ASA Presence in
Euroanaesthesia 2014
Exhibit Hall
ASA was well represented in the exhibit hall at
Euroanaestheia 2014, where staff promoted both the
ANESTHESIOLOGYTM 2014 annual meeting and
ASA membership.

I believe that the messaging at the booth was on
point, said Moser. More than 1,500 attendees visited
the booth to learn about the 2014 annual meeting as well
as future years and to talk about opportunities with ASA
for physician anesthesiologists from around the world.
As a recognized world leader in anesthesiology
education, ASA continues to reach out to broaden
its global membership base and is committed to
supporting and adding value for its members by building
on relationships with international societies with
common issues.
While attending Euroanaesthesia 2014, ASA
leadership, including Dr. Fitch, president-elect John
P. Abenstein, M.D., and First Vice President Daniel J.
Cole, M.D., were able to meet with officers from ESA
and other international societies, including the World
Federation of Societies of Anaesthesiologists (WFSA),
the Chinese Society of Anesthesiology (CSA), the
Association of Anaesthetists of Great Britain and Ireland
(AAGBI) and the International Anesthesia Research
Euroanaesthesia 2014 was host to 7,000 attendees

from 105 countries. Staff representing ASA this year
included Paul Pomerantz, ASA chief executive officer,
Chris Wehking, chief program officer, Sara Moser,
director of marketing and corporate development, and
Julie OHeir, corporate development manager.
30
September 2014
Volume 78
Number 9
scientific and educational exhibits at
ANESTHESIOLOGY 2014
Dean F. Connors, M.D., Ph.D., Chair
Committee on Scientific and Educational Exhibits
The ANESTHESIOLOGY 2014 annual

meeting this October in New Orleans
will feature 24 scientific and educational exhibits as well as more
than 1,000 poster cases of the
increasingly popular Medically Challenging Cases. Many of the exhibits
will focus on airway management, pain
management and peripheral nerve blocks,
including use of ultrasound techniques
and exhibits that educate through the
use of computer-based learning, advanced
communication technology, handheld
devices, videos and simulators. Exhibits
portraying practical aspects of patient
care such as vascular access, perioperative
management issues and echocardiography will also be
highlighted this year. Administrative exhibits will provide
information on technology and anesthesia. The scientific
exhibits will be evaluated by the committee for originality,
clinical relevance, scientific merit and visual impact. Judging
of the scientific exhibits will occur on Saturday, October 11.
The Medically Challenging Cases continue to grow in
popularity, with more than 1,100 submissions this year. The
cases will be presented in Hall B1 at the Morial Convention
Center, Saturday, October 11, through Tuesday, October 14,
from 8 a.m. to 4 p.m. The Medically Challenging Cases will
all be presented in an electronic format without the use of a
poster board and with a facilitator/moderator to allow interaction
and facilitate discussion.
These sessions have allowed presentation of interesting
and challenging cases that facilitate interaction from providers
around the world. They have also served as a springboard
for research clinical protocols that have emanated from the
interaction of colleagues. The sessions continue to be received
with great enthusiasm.
Thanks go to the members of the Committee on
Scientific and Educational Exhibits for all their hard work:
Zvi Grunwald, M.D., vice chair, Wendy K. Bernstein, M.D.,
Sujatha P. Bhandary, M.D., Edward Deal, D.O., Stuart Forman,
M.D., Ph.D., Michael Goldberg, M.D., Anthony T. Han, M.D.,
Ph.D., Vidya T. Raman, M.D., Andrew D. Rosenberg, M.D.,
Kristopher M. Schroeder, M.D., Shaheen F. Shaikh, M.D.,
David R. Sinclair, M.D. and John E. Tetzlaff, M.D.
September 2014
Volume 78
Number 9
Medically Challenging Cases at ANESTHESIOLOGY TM 2013.
2013 First-Place Scientific Exhibit winners, University of Michigan:

High-Dose Opioid Taper Initiative.
Dean F. Connors, M.D., Ph.D. is

Associate Professor of Clinical
Anesthesia, The Ohio State University
Department of Anesthesia, Columbus.
31
John B. Neeld, Jr., M.D.

2013 Recipient of
ASA Distinguished Service Award
Mark A. Warner, M.D.
2011 ASA President
John B. Neeld, Jr., M.D.

2013 DISTINGUISHED
SERVICE AWARD
John B. Neeld, Jr., M.D. will receive the ASA Distinguished

Service Award (DSA) at the ANESTHESIOLOGY 2014 annual
meeting in New Orleans. The DSA is the highest award given by
our society for meritorious service and achievement. First given in
1945, the DSA recognizes the unique contributions made by the
recipient to the advancement of the specialty and to ASA which have
helped transform how we practice, what we do and who we are. The
DSA has been given annually nearly every year since 1945. A list of
the specialtys luminaries who have received this award may be found
at
http://www.asahq.org/for-members/about-asa/asa-governance/
distinguished-service-award.aspx.
Dr. Neeld received his undergraduate and medical degrees from
Vanderbilt University, the latter being earned in 1966. He was a
surgical intern at the same institution the following year. After his
internship, he served as a general medical officer in the U.S. Army.
During his military time, he had a remarkable tour of duty in Vietnam
where he earned a Purple Heart, Bronze Star and Combat Medical
Badge, among other awards. Upon completion of his military duty
in 1970, he undertook an anesthesiology residency and research
fellowship at Emory University in Atlanta, finishing these in 1973. He
received his certification from the American Board of Anesthesiology
the subsequent year.
presented at the
Emery A. Rovenstine
Memorial Lecture
OCTOBER 13, 2014
10:15 - 11:20 a.m.
Ernest N. Morial
Convention Center
New Orleans
Mark A. Warner, M.D. is Executive Dean,
Mayo Clinic College of Medicine,
Rochester, Minnesota.
32
September 2014
Volume 78
Number 9
Remaining in Atlanta, Dr. Neeld spent his professional

career in private practice at Northside Hospital from 1973
through 2010. During his tenure, he served as department chair
for 21 years from 1986 through 2007, building the largest
anesthesiology department in Georgia. A proponent of
developing mutually productive, positive relationships with
institutions, he served on the Northside Hospital Board of
Directors from 1991 through 2009, chairing that board from
1995-97.
(2012-14), which had oversight responsibility for the design

and construction of ASAs new headquarters. Additionally,
Dr. Neeld served as a member of the board of directors of the
Wood Library-Museum of Anesthesiology from 2004-12.
Few ASA members have stepped outside the specialty
to represent anesthesiology with the strength and passion
Dr. Neeld has shown. He has represented anesthesiology to
the American Medical Association as a member of the ASA
delegation for nearly two decades and counting. A natural
leader, he has chaired this delegation since 2003 and continues
in this important role. His commitment to serving organized
medicine was recognized by his appointment to the board of
directors of the American Medical Association Political Action
Committee (AMPAC) from 2004-12. Not surprisingly, he
also chaired the AMPAC from 2006-08. At AMA, his efforts
to create opportunities for young physicians to advance in
specialty and state delegations within the House of Delegates
was recognized by the Young Physicians Section with its
Young at Heart award in 2014.
A strong supporter of the physician anesthesiologist-led
care team practice model, Dr. Neeld has been an advocate
for anesthesiologist assistants (AAs), testifying successfully
before legislative committees in Florida and North Carolina for
their licensure. He served as president of the Association for
Anesthesiologist Assistants Education (AAAE) from 2000-03
and has been a member of the board of directors of the National
Commission for Certification of Anesthesiologist Assistants
(NCCAA) since 2000.
Given his long record of service to ASA and the AMA, it is
not surprising that other organizations have also selected him for
positions of responsibility. He served on the board of directors
of the Medical Association of Georgia Mutual Insurance Co.
(1998-2012), chaired the Vanderbilt Medical Center Advisory
Board (1993-98) and served as president of the Vanderbilt
Medical Alumni Association (2004-06). He has also received
the DSA of the Medical Association of Atlanta in 2000.
Dr. Neeld acknowledges that his long service to ASA and
all of organized medicine would not have been possible without
the support, advice, encouragement and limitless patience of his
wife, Gail.
The DSA will be presented to Dr. Neeld at the time of the
Emery A. Rovenstine Memorial Lecture at 10:15-11:20 a.m. on
October 13 in New Orleans. Please join me at that time as the
society recognizes Dr. Neeld for his unparalleled service to our
country, specialty and ASA.
Few ASA members have

stepped outside the specialty
to represent anesthesiology
with the strength and passion
Dr. Neeld has shown.
Throughout his career Dr. Neeld has been a consistent

advocate for the development of a strengthened, forwardlooking ASA to better serve its members and our patients.
During more than 30 years of service to ASA, he has served
as President (1998-99), Treasurer (1993-96), Alternate
Director for District 25 (1983-91) and member of the House of
Delegates (1982-1991). He was honored as the 2013 Emery
A. Rovenstine Memorial lecturer. He has been appointed to
many positions of note, including service on six reference
committees at our annual meeting. Additional appointments
that recognized his commitment to ASAs organizational
development have included chair of the Administrative
Council Task Force on the Structure and Function of ASA
(1992), chair of the Task Force on Strategic Planning
(1997-98), chair of the Ad Hoc Committee on Strategic Planning
(1998-99), chair of the Presidents Committee on Executive
Office Oversight (2007), chair of the Ad Hoc Committee on
Strategic Land Use (2010), which recommended the site on
which our new headquarters was built, and membership on the
Ad Hoc Committee on Headquarters Building Construction
September 2014
Volume 78
Number 9
33
REBECCA A. ASLAKSON, M.D., Ph.D.

to Receive 2014 Presidential Scholar Award
Daniel Nyhan, M.D.
Peter J. Pronovost, M.D., Ph.D., FCCM
In the current funding environment, success in academic

research is difficult. While there are clear elements of luck
and right place, right time to any success, Benjamin Franklin
contended that diligence is the mother of good luck. Hard work
and a clear focus are necessary yet not sufficient. A successful
research career is a complex adaptive journey and a function of
critical interrelated variables, including the identification of a
recognized mentor, the acquisition of necessary formal training
and the provision of adequate protected research time.
All potentially successful researchers need advice on what
to do (or not to do) from a skilled mentor who fosters mentee
growth and development. Designing and completing highquality research requires more than the knowledge acquired
in medical school and in residency training. It also requires
rigorous research-related coursework in areas such as study
design, epidemiology, biostatistics and biomedical writing.
Although some faculty do succeed without formal training,
most high-impact research is conducted by faculty who have
devoted the time to acquire the skills necessary to conduct
high-impact research. These skills include asking important,
impactful and answerable questions; designing and conducting
studies to answer these questions; analyzing data; and preparing
manuscripts. To produce successful researchers, academic
department leaders need to work to secure resources to ensure
that junior faculty can obtain formal training and protected
time. Career development awards such as T or K awards are
essential because they generally provide resources for a mentor,
formal training and protected time for the mentee.
Rebecca A. Aslakson, M.D., Ph.D.
Daniel Nyhan, M.D. is Interim Chair

of Anesthesiology and Critical Care
Medicine, Johns Hopkins Medicine,
Baltimore.
Peter J. Pronovost, M.D., Ph.D., FCCM is

Senior Vice President, Patient Safety and
Quality, Director, Armstrong Institute,
Johns Hopkins Medicine, Baltimore.
34
September 2014
Volume 78
Number 9
In the setting of effective mentorship and training and with the

provision of protected time, a disciplined faculty member in a
nurturing environment will usually develop into a competent
academic researcher. In rare circumstances, you get an
exceptional researcher, such as this years 2014 ASA Presidential
Scholar Rebecca A. Aslakson, M.D., Ph.D. A passionate,
innovative and skilled researcher, she spearheaded pioneering
work into how best to deliver patient- and family-centered care
and palliative care to severely ill patients and their families,
particularly during the perioperative period.
of her Ph.D. dissertation a pilot of a communication-based

intervention for long-stay surgical ICU patients and their families.
Her interest in this patient cohort expanded to palliative care
in other patient groups. Recognizing the importance of formal
training and protected time for her research work, Dr. Aslakson
completed clinical training with the Johns Hopkins Kimmel
Cancer Center Pain and Palliative Care team and became
board-certified in palliative care in 2010. She has published
important work detailing more effective integration of palliative,
critical and perioperative care.1 Moreover, she described barriers
that impede this integration2-4 and quality improvement and
interventions to improve patient outcomes.*5-8
As Dr. Aslaksons research matured, she complemented
her quantitative research skills with qualitative skills. She
completed a two-year study funded by the Foundation for
Anesthesia Education and Research exploring the palliative
care-related experiences of patients and families in surgical
critical care units. She showed that while patients and families
prioritize humanistic and relationship-related aspects of care,
surgical clinicians focus on technical aspects of care, e.g.,
following standards and providing cutting-edge technology.
Based on this work, Dr. Aslakson was awarded a K08 grant
from the Agency for Healthcare Research and Quality. The
work focused on patient-centered metrics as a basis for providing
quality palliative care in the ICU. She was concurrently
awarded a three-year, $1.5 million contract from the PatientCentered Outcomes Research Institute. The latter consists of
leading physicians, nurses and public health investigators who
work with families and patients preparing for high-risk surgeries.
Dr. Aslakson is a core faculty member of the Armstrong
Institute for Patient Safety and Quality at Johns Hopkins.
The Armstrong Institute grew from and is intimately
connected to the department of anesthesiology and critical
care medicine. The institute draws upon 18 different disciplines
across Johns Hopkins University. Its goal is to partner with
patients, their families and others to eliminate preventable
harm, improve outcomes and experience, and eliminate
waste. Dr. Aslaksons work erases boundaries, aligns multiple
disciplines around common goals and demonstrates how
anesthesia researchers can impact patients, families and other
providers both within and beyond the perioperative experience.
Dr. Aslaksons work erases

boundaries, aligns multiple
disciplines around common goals
and demonstrates how anesthesia
researchers can impact patients,
families and other providers
both within and beyond the
perioperative experience.
Dr. Aslakson is a seminal example of an academic physician

investigating and significantly advancing an important area
in health care and doing so in a rigorous scientific manner.
Moreover, both Dr. Aslakson and her environment recognize
the skill-sets necessary to advance her important area of interest.
The first female to receive this award since its inception in
2003, Dr. Aslaksons work highlights the expanding breadth of
anesthesia research and the impact physician anesthesiologists
and intensivists can have on patient care.
Dr. Aslakson obtained her undergraduate degree from
Washington University in St. Louis and her M.D. from Harvard
Medical School-Massachusetts Institute of Technology Health,
Sciences and Technology Program in Boston. She completed
her anesthesia residency at the Massachusetts General Hospital
and her surgical critical care fellowship at The Johns Hopkins
Hospital, Baltimore. After completing her fellowship in 2008,
she was recruited to our faculty and concurrently pursued a
Ph.D. in Clinical Research from the Johns Hopkins Bloomberg
School of Public Health, Baltimore. Utilizing a T32 research
fellowship award with its inherent requirements, she completed
novel, foundational work exploring the influence of the quality
of communication on prognosis in long-stay surgical intensive
care unit (ICU) patients. This evolved into the core project
September 2014
Volume 78
Number 9
*Dy SM, Aslakson R, Wilson RF, Fawole OA, Lau BD, Martinez KA,
Vollenweider D, Apostol C, Bass EB. Interventions to Improve Health

Care and Palliative Care for Advanced and Serious Illness. Closing
the Quality Gap: Revisiting the State of the Science. Evidence Report
No. 208. (Prepared by the Johns Hopkins University Evidence-based
Practice Center under Contract. No. 290-2007-10061-I.) AHRQ
Publication No. 12-E014-EF. Rockville, MD: Agency for Healthcare
Research and Quality. October 2012. www.effectivehealthcare.ahrq.
gov/reports/final.cfm.
35
illustrates the need for mentorship, appropriate formal training

and protected time in order to develop successful academicians.
For example, a systematic review9 found that proactive

palliative care in the ICU shortens both ICU and hospital
length of stay without changing mortality or family member
satisfaction. This important finding was endorsed by the Society
of Critical Care Medicine (SCCM), the American College of
Surgeons, the American Academy of Hospice and Palliative
Medicine, and the The Oncology Report.
Dr. Aslakson is a founding and current member of the
ASA Subcommittee on Palliative Medicine. Within the
SCCM, she is part of a small international group of researchers
revising SCCM guidelines for family-centered care within the
ICU. Dr. Aslakson is also active in the American Academy of
Hospice and Palliative Medicine (AAHPM) and the National
Palliative Care Research Center, and serves on the national
AAHPM research committee. She founded and co-chairs an
ICU special interest group with AAHPM.
Dr. Aslaksons accomplishments and successes in the area
of palliative care are to be honored, especially when viewed in
the context of patient safety and preventable harm. Preventable
harm is the third leading cause of death in the United States
and is associated with large costs. Moreover, her focus on
communication with patients and families is apt considering
that 20 percent of patients feel disrespected and 50 percent
feel they are not listened to.
Dr. Aslaksons success is a testament to her intrinsic qualities.
Her work highlights the potential expanded role of physician
anesthesiologists and anesthesiology departments. It also
References:
1. A slakson R, Pronovost PJ. Health care quality in end-of-life care:

promoting palliative care in the intensive care unit. Anesthesiol Clin.
2011;29(1):111-122.
2. Shander A, Gandhi N, Aslakson RA. Anesthesiologists and the
quality of death. Anesth Analg. 2014;118(4):695-697.
3. A slakson RA, Wyskiel R, Shaeffer D, et al. Surgical intensive care
unit clinician estimates of the adequacy of communication regarding
patient prognosis. Crit Care. 2010;14(6):R218.
4. A slakson RA, Wyskiel R, Thornton I, et al. Nurse-perceived barriers
to effective communication regarding prognosis and optimal endof-life care for surgical ICU patients: a qualitative exploration.
J Palliat Med. 2012;15(8):910-915.
5.
Fawole OA, Dy SM, Wilson RF, et al. A systematic review of
communication quality improvement interventions for patients with
advanced and serious illness. J Gen Intern Med. 2013;28(4):570-577.
6.
Dy SM, Apostol C, Martinez KA, Aslakson RA. Continuity,
coordination and transitions of care for patients with serious and
advanced illness: a systematic review of interventions. J Palliat Med.
2013;16(4):436-445.
7. Martinez KA, Aslakson RA, Wilson RF, et al. A systematic review of
healthcare interventions for pain in patients with advanced cancer.
Am J Hosp Palliat Care. 2014;31(1):79-86.
8. L au BD, Aslakson RA, Wilson RF, et al. Methods for improving the
quality of palliative care delivery: a systematic review. Am J Hosp
Palliat Care. 2014;31(2):202-210.
9. Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ, Pronovost
PJ. Evidence-based palliative care in the intensive care unit: a
systematic review of interventions. J Palliat Med. 2014;17(2):219-235.
Huddle Up for
Cesarean Safety
The Society for Obstetric Anesthesia and Perinatology
has initiated a campaign to promote a brief meeting
among the obstetrician, nurse and physician
anesthesiologist prior to a cesarean delivery. The
purpose of this meeting is to improve communication
and identify concerns from the various teams. This
meeting is referred to as a huddle. Information and
details on the huddle may be found at soap.org.
After all, every woman who delivers by cesarean
deserves a huddle.
36
September 2014
Volume 78
Number 9
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14-159
Henrik Kehlet, M.D., Ph.D.

to Receive 2014 Excellence in Research Award
Francesco Carli, M.D., M.Phil., FRCA, FRCPC
Henrik Kehlet, M.D., Ph.D. is perhaps the most wellknown surgeon among physician anesthesiologists
around the world due to his substantial contributions toward
the understanding of surgical pathophysiology. Dr. Kehlet
completed his medical studies and surgical residency at the
University of Copenhagen, Denmark. He then enrolled in a
Ph.D. program within the same institution, authoring a thesis
pertaining to the study of the hypothalamic-pituitaryadrenocortical function in glucocorticoid-treated surgical
patients. Dr. Kehlet served as the Chief of Surgery and Professor
of Surgery, Copenhagen University at Hvidovre University
Hospital from 1989 to 2004. He was subsequently appointed
as a Professor of Perioperative Therapy and Head of the
Section for Surgical Pathophysiology at the Rigshospitalet in
Copenhagen. Dr. Kehlet continues to be an extremely prolific
writer, having authored more than 950 scientific articles
covering topics of surgical pathophysiology, acute pain
physiology and pharmacotherapy, surgical stress response,
regional anesthesia and analgesia, perioperative immune
function, fast-track surgery and the transition from acute to
chronic pain. His work has been cited thousands of times,
and he currently holds an H-index of 80. For his outstanding
contributions to research, Dr. Kehlet has received numerous
honorary awards from distinguished learned societies such
as the Royal College of Anaesthetists of Great Britain, the
American College of Surgeons and the American Surgical
Association. He has also been invited worldwide to lecture
and has given revered eponymous lectures such as the Bonica
lecture, the Labat lecture, the Carl Koller lecture and the
Simpson Memorial lecture.
Henrik Kehlet, M.D., Ph.D.

From Surgical Stress Response to Multimodal Analgesia
I had the personal fortune of meeting Dr. Kehlet for
the first time in the late 1980s at the European Society of
Regional Anaesthesia and Pain Therapy. At the time, he was
investigating the effect of regional anesthesia on stress, pain
and postoperative outcome. This original and ambitious
research resulted in our current understanding of the effect
of central neuraxial blockade on the endocrine and catabolic
response to surgery. Dr. Kehlet demonstrated that a negative
postoperative nitrogen balance could be attenuated by
epidural blockade with local anesthetics. He then subsequently
demonstrated the association between optimal perioperative
pain relief in particular (the effects of regional anesthetic
techniques) on surgical outcomes. Building on these results,
Dr. Kehlet hypothesized that a multimodal analgesia approach,
combining different analgesics with synergistic or additive
effects, could provide better perioperative pain control and
reduce side effects. Dr. Kehlet and others would go on to validate
this groundbreaking hypothesis, effectively transforming the
manner by which perioperative analgesia is administered.
Francesco Carli, M.D., M.Phil., FRCA,

FRCPC is Professor and Staff
Anesthesiologist, McGill University,
Montreal, Quebec, Canada.
38
September 2014
Volume 78
Number 9
Pre-emptive Analgesia and Transition

From Acute to Chronic Pain
Dr. Kehlet and co-workers are credited with proposing and
evaluating the concept of pre-emptive analgesia, whereby
analgesic administration commences prior to surgical injury, in
order to decrease the intensity and duration of postoperative
pain. His development of several randomized studies with
subsequent reviews and editorials provided critical analysis
of this pre-emptive concept, later resulting in the principle
of preventive analgesia. The high-level evidence found
in Dr. Kehlets studies also served as the introduction to our
understanding of how acute postoperative pain could possibly
persist into chronic pain, a finding later confirmed through
large epidemiological studies in Denmark. Dr. Kehlets research
in this area provided one of the first risk factor assessments for
the development of persistent postsurgical pain. Dr. Kehlet
also investigated how surgical treatments such as hernia mesh
removal and neurectomy in the setting of neuropathic pain
could assist in the treatment of chronic postoperative pain
following hernia surgery.
stay. The success of the fast-track methodology is based

upon provision of effective, dynamic pain relief (non-opioid,
multimodal analgesia allowing early mobilization and early
feeding), thus reducing perioperative organ dysfunction and
catabolic stress and accelerating postoperative recovery. From
colonic surgery Dr. Kehlet has recently focused on fast-track
hip and knee replacement surgery in multicenter collaboration
with a focus on detailed assessment of early recovery aspects
and minimizing morbidity. Since its introduction, Dr. Kehlets
fast track concept has been met with universal acclaim,
resulting in the implementation of fast-track surgery protocols
throughout the Western hemisphere. Recognizing that success
of fast-track protocols requires a stronger collaboration among
surgeons and physician anesthesiologists, Dr. Kehlet established
evidence-based, procedure-specific guidelines for perioperative
pain management, also called PROSPECT. The aim of this
collaboration has been to provide procedure-specific evidence
for optimal analgesia, thus identifying appropriate and best
analgesic techniques with minimal side effects.
Establishing Prospective Patient Databases
In addition to his contributions to perioperative pain
management, Dr. Kehlet is responsible for establishing the first
nationwide hernia database in Denmark, with the purpose of
optimizing outcome and documenting various approaches to
improve care. The database has been widely recognized as an
outstanding example of knowledge translation and has served
as the model for other patient databases across Europe and
North America.
Dr. Kehlets record of insatiable intellectual curiosity and
impeccable scientific merit serves as an excellent model for
future leaders in surgery and anesthesia who are actively
involved in investigating perioperative pathophysiology and
surgical outcomes. Despite his astonishing contributions,
Dr. Kehlet continues to be academically active and devotes
his time to mentoring young physicians. When he is not
challenging lingering surgical dogmas, Dr. Kehlet shares his
passion for art and music with his wife, Susanne, and tries to find
the time to leave Copenhagen and take refuge in their ocean
cottage. Henrik is a great friend, an outstanding colleague and
a passionate debater. I can think of few people more deserving
of this fine award.
The high-level evidence found

in Dr. Kehlets studies also
served as the introduction to
our understanding of how acute
postoperative pain could possibly
persist into chronic pain, a
finding later confirmed through
large epidemiological studies
in Denmark.
Fast-track Surgery
Following a natural evolution from his studies on surgical
stress response, Dr. Kehlet launched in the mid-1990s the
concept of fast-track surgery: a multimodal, evidence-based
approach to surgical care. Through a series of prospective cohort
studies and randomized controlled trials initially employing
the model of colonic surgery, Dr. Kehlet demonstrated that
modifying the perioperative surgical stress response and
revising traditional surgical care could have a dramatic impact
on postoperative recovery and shorten length of hospital
September 2014
Volume 78
Number 9
39
Self-Education and Evaluation
SEE Question
One of your patients requires increasing doses of morphine for postoperative pain control. According to a recent study,
what is the most likely outcome if this patient receives intravenous (I.V.) magnesium perioperatively?
q (A) The total dose of magnesium administered will correlate with this patients total morphine dose.
q (B) The total morphine dose will decrease.
q (C) The time to first analgesic request will be shorter.
q (D) This patient will be more sedated.
I.V. magnesium potentiates morphine analgesia and is thought to have
other analgesic properties through its action on calcium regulation and
N-methyl-d-aspartate antagonism. It may, however, increase sedation,
prolong neuromuscular blockade, and contribute to cardiac arrhythmia.
The authors of a recent systematic review and meta-analysis examined
the published literature on perioperative magnesium usage to provide
an evidence-based attestation of the use of magnesium for perioperative
pain control. They only included articles that compared placebo to
I.V. magnesium. The total dose of I.V. morphine or its equivalent at
24 hours postoperatively was the primary end point; secondary end
points were magnesium-related side effects. The primary end point
was further analyzed depending on the type of surgery and the mode of
magnesium administration.
A total of 43 trials were identified; 23 trials (1,461 patients) met
the authors inclusion criteria. Of the patients included in the study,
48 percent underwent abdominal surgery, 24 percent underwent
hysterectomy, and 24 percent underwent orthopedic surgery. A single
I.V. bolus of magnesium (3050 mg/kg) was administered in six trials;
a bolus followed by an infusion was administered in 15 trials; and
magnesium as an infusion only was administered in two trials. The total
magnesium dose ranged from 1.03 g to 23.5 g.
The findings of this study were as follows:
n
Time to first analgesic request was not significantly different between
the placebo and magnesium groups.
n
Magnesium administration was associated with 24 percent less
morphine consumption.
n
The total dose of magnesium administered did not correlate with
postoperative morphine consumption.
n
The
mode of magnesium administration (bolus, infusion, or both)

had no effect on postoperative morphine consumption.
n
The reduction in morphine consumption occurred in all types of
surgery investigated (abdominal, gynecological, orthopedic) with
orthopedic surgery demonstrating the largest decrease.
n
Mean pain scores at rest and with activity were reduced by

4.2 and 9.2 out of 100, respectively, in patients receiving
magnesium compared to patients receiving placebo.
n
More patients receiving magnesium experienced bradycardia

compared to control. Bradycardia was always responsive to first-line
therapy (e.g., atropine).
n
Hypotension and sedation rates were similar between the groups.
In conclusion, the findings of this review show that perioperative
magnesium administration seems to decrease morphine consumption
at 24 hours postoperatively, irrespective of method of administration
(one-time I.V. bolus, infusion, or both). The optimal magnesium dose
for this effect could not be established, but it was suggested that a bolus
of between 40 and 50 mg/kg might be needed. Although the reported
side effects were minor, this study was not sufficiently powered to address
the safety issues of magnesium administration at the suggested doses.
Bibliography:

Albrecht E, Kirkham KR, Liu SS, Brull R. Perioperative intravenous
administration of magnesium sulphate and postoperative pain: a metaanalysis. Anaesthesia. 2013;68(1):79-90.
Hurley RW, Wu CL. Acute postoperative pain. In: Miller RD, ed. Millers
Anesthesia. 7th ed. Philadelphia, PA: Elsevier/Churchill Livingstone;
2010:2757-2781.
Answer: B
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.
September 2014
Volume 78
Number 9
40
New in 2014
FRIDAY - TUESDAY
DECEMBER 12 -16, 2014
MARRIOTT MARQUIS
NEW YORK
Thoracic Symposium
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Program and Registration Highlights:

m Internationally Renowned Speakers
m Scientific Panels & Focus Sessions
m Hands-on Workshops
m Mini Workshops
m Medically Challenging Case Reports
m Problem-Based Learning Discussions
m Scientific Exhibits
m Poster Presentations
m Technical Exhibits
m Resident Research Contest
m Hospital Visits
m 3,500 Anesthesiologists in Attendance
m More than 5,000 Registrants
m Holiday Shopping & New York City Tours
m Broadway Shows, Jazz Clubs & Opera
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N E W Y O R K C I T Y USA
ONL I NE R E GI ST R AT I ON :
The New York State Society of

Anesthesiologists, Inc., is accredited by
the Accreditation Council for Continuing
Medical Education to provide continuing
medical education for physicians.
www.nyssa-pga.org
Up to 54.75 AMA PRA Category 1 CreditsTM
Sponsored by:
Featuring programs in conjunction with:
The New York

State Society of
Anesthesiologists, Inc.
Detailed review of unusual cases is a cornerstone of anesthesiology education. Each month, the
AQI-AIRS Steering Committee will provide a detailed discussion based on a case submission to the Anesthesia
Incident Reporting System (AIRS). Feedback regarding this item can be sent by email to r.dutton@asahq.org. Report incidents
in confidence or download the free AIRS mobile application (Apple or Android) at www.aqiairs.org.
Case: To Test or Not To Test, That is the Question
for Preanesthesia Evaluation stated that pregnancy testing

may (our emphasis) be offered to female patients of childbearing
age and for whom the result would alter the patients management.6
Further, only 7 percent of consultants and 17 percent of ASA
members polled felt that pregnancy testing should be mandatory
for all.
A woman of child-bearing age presented for dilatation

and curettage of the uterus due to a history of chronic, heavy
menstruation. A pre-op pregnancy test was reportedly negative.
The D&C was performed, at which time it was identified that
the patient was approximately eight weeks pregnant. It was
later discovered that the patients pre-operative assessment was
populated with a previous negative test result, rather than the
later positive result.
Little information exists about the

impact of electronic anesthesia records
on misinformation due to copying.
An estimated 75 percent of academic
anesthesia practices will have an
anesthesia information management
system by the end of 2014, suggesting
that a large number of patients are
at risk for this type of error.
Discussion:
This is a very sad case, in which a pregnancy that was
desired by the patient was lost due to inaccurate pre-op data. It
highlights three separate but important patient safety concepts.
Pre-operative pregnancy testing is the first and most obvious.
The incident reporter indicated under lessons learned that
all women of child-bearing age should have a current negative
pregnancy test before entering the O.R. Despite decades of
conversation within the anesthesia community, this remains a
controversial issue. Unsuspected pregnancy occurs in 0.3-2.6
percent of women undergoing elective surgery,1-3 suggesting that
testing might be indicated for all. The vast majority of cases in
which an unsuspected pregnancy test is found have a subsequent
change in care, usually cancellation or delay of surgery. In the case
described above, the pregnancy test results would have altered
the surgical plan.
However, issues of cost and ethics must also be considered.
In 2003, a task force of members from the ASA Committee
on Ethics and the Committee on Standards and Practice
Parameters indicated that the state of pregnancy is very personal
information that belongs to the patient, and it does not alter her right
to proceed with anesthesia and surgery if she so desires,4 and that a
pregnancy test should be offered, but not required unless there is
a medical need to know the results. Similarly, the 2006 results of
an electronic mailing list poll of members of the ASA Committee
on Practice Management demonstrated significant differences of
opinion and practice.5 Most recently the ASA Practice Advisory
The corroboration of medical information, especially the

information available in electronic health records (EHRs), is
the second patient safety issue. The use of the phrase previous
test populated the patients pre-operative assessment suggests
that the data were either copied and pasted, or automatically
filled into an electronic pre-op assessment. The proliferation of
EHRs has greatly increased the ease (and likely frequency) of
copying patient data from one note to another. With a simple
control C and control V, one can complete an entirely
new note, complete with all the errors present in the source.
42
September 2014
Volume 78
Number 9
References:
A study from the Veterans Administration system published

seven years ago demonstrated that 25 percent of patients
charts had evidence of copying.7 More recently, Thornton et
al. found that 74 percent of ICU notes contained more than 20
percent copied information.8 Weir et al. found an average of
more than one error per copied patient note, demonstrating
the potential for dangerous proliferation of misinformation
when using this technique.9 Health information technology,
including corroboration of results, was the leading patient
safety concern in 2013.10
Little information exists about the impact of electronic
anesthesia records on misinformation due to copying. An
estimated 75 percent of academic anesthesia practices will have
an anesthesia information management system by the end of
2014,11 suggesting that a large number of patients are at risk
for this type of error. Wilbanks12 and Driscoll13 each found high
rates of missing information within anesthesia records, most
commonly gas flow rates, medication administration times
and neuromuscular function testing,12 and even potentially
critical information such as depth of ETT placement, ease
of mask ventilation and laryngoscopic view.13 These do not
directly relate to patient history but do suggest concerns about
accurate charting in general. Some copying or auto-populating
of EHRs is likely helpful to improve efficiency and decrease
transcription errors. However, much is still to be learned
about the best ways to confirm the accuracy of this information
and to prevent misinformation from moving forward in
patients charts.
The final patient safety issue highlighted in this case relates
to how practitioners respond to adverse events. The discovery
that the patient was pregnant was likely very stressful to the
care providers. The strong emotional response to these events
by providers has been coined the second victim effect.14
The emotional impact of these events tends to proceed along
a relatively predictable path.15 The desire to prevent future
episodes of the event, both for patient safety and to protect
oneself from future emotional distress, is understandable. The
reporter of the case above stated that all women should have
a pregnancy test prior to any surgery and anesthesia. Clearly
this is not the consensus view, but would likely prevent any
future instances of this event. As humans, we are all victims
of our anecdotes. Quality and safety experts are trained to
look beyond emotional issues and identify the root cause(s)
of adverse events, to look for system-based fixes and,
hopefully, to care for the second victims involved in adverse
events (see the AIRS Pro:Con article on Root Cause Analysis
in the June 2014 ASA NEWSLETTER).
September 2014
Volume 78
Number 9
1.
Kasliwal A, Farquharson RG. Pregnancy testing prior to
sterilisation. BJOG. 2000;107(11):1407-1409.
2. Manley S, de Kelaita G, Joseph NJ, Salem MR, Heyman HJ.
Pre-operative pregnancy testing in ambulatory surgery.
Incidence and impact of positive results. Anesthesiology.
1995;83(4):690-693.
3. Wheeler M, Cote CJ. Pre-operative pregnancy testing in a
tertiary care childrens hospital: a medico-legal conundrum.
J Clin Anesth. 1999;11(1):56-63.
4. Palmer SK, Jackson S. Ethics: hot issues in legally sensitive
times. ASA Newsl. 2003;67(10):30-31.
5. Bierstein K. Pre-operative pregnancy testing: mandatory or
elective? ASA Newsl. 2006;70(7):37.
6. Apfelbaum JL, Connis RT, Nickinovich DG, et al.; American
Society of Anesthesiologists Task Force on Preanesthesia
Evaluation. Practice advisory for preanesthesia evaluation.
Anesthesiology. 2012;116(3):522-538.
7. Thielke S, Hammond K, Helbig S. Copying and pasting of
examinations within the electronic medical record. Int J Med
Inform. 2007;76(suppl 1):S122-S128.
8.
Thornton JD, Schold JD, Venkateshaiah L, Lander B.
Prevalence of copied information by attendings and residents
in critical care progress notes. Crit Care Med. 2013;41(2):382388.
9.
Weir CR, Hurdle JF, Felgar MA, Hoffman JM, Roth B,
Nebeker JR. Direct text entry in electronic progress
notes. An evaluation of input errors. Methods Inf Med.
2003;42(1):61-67.
10.
Denham CR, Classen DC, Swenson SJ, Henderson MJ,
Zeltner T, Bates DW. Safe use of electronic health records
and health information technology systems: trust but verify.
J Patient Saf. 2013;9(4):177-189.
11. Stol IS, Ehrenfeld JM, Epstein RH. Technology diffusion of
anesthesia information management systems into academic
anesthesia departments in the United States. Anesth Analg.
2014;118(3):644-650.
12. Wilbanks BA, Moss JA, Berner ES. An observational study of
the accuracy and completeness of an anesthesia information
management system: recommendations for documentation
system changes. Comput Inform Nurs. 2013;31(8):359-367.
13.
Driscoll WD, Columbia MA, Peterfreund RA. An
observational study of anesthesia record completeness
using an anesthesia information management system. Anesth
Analg. 2007;104(6):1454-1461.
14. Wu AW. Medical error: the second victim. The doctor who
makes the mistake needs help too. BMJ. 2000;320(7237):
726-727.
15. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J,
Hall LW. The natural history of recovery for the healthcare
provider second victim after adverse patient events. Qual
Saf Health Care. 2009;18(5):325-330.
43
As of 2012, every day 2.5 exabytes (2.51018)

of data were created. The question is how do
we use these data to promote patient safety in
the perioperative environment. Over the past 5
years, through the leadership and vision of Rick
Dutton, AQI has made a significant contribution
for the advancement of perioperative patient
safety and by proxy the specialty of
Anesthesiology.
Zeev Kain, M.D., M.B.A., Chancellors Professor
of Anesthesiology & Pediatrics & Psychiatry
The Anesthesia Quality Institute has moved

into the forefront with its development of a large
clinical depository of case data, the National
Anesthesia Clinical Outcomes Registry (NACOR).
NACORs designation by CMS as a Qualified
Clinical Data Registry (QCDR) recognizes
anesthesiologys importance and contribution
towards quality of care for our patients.
Stan Stead, M.D., M.B.A., ASA VP of
Professional Affairs
AQI fills the information gap that most hospitals
and clinically integrated networks have about
the impact of anesthesia on perioperative care
to ensure continued progress of their highly
reliable organizations journey to improve patient
experience, health outcomes and decease
costs.
Mike Schweitzer, M.D., M.B.A., Chair on ASA
Committee on Future Models of Anesthesia
Practices
Cerner Corporation would like to congratulate
AQI on 5 years of providing an invaluable service
to the anesthesia profession. As the largest
data registry in the country, AQI continues to
gather and synthesize volumes of perioperative,
quality improvement data, enabling our clients
to benchmark their performance against peers
at the national, regional and facility level. This
contribution to optimizing quality improvement in
the perioperative environment is essential to the
advancement of anesthesiology.
Jason Boatright, Cerner Anesthesia
Healthcare Executive
AQI exists to improve patient care.
We make the measuring stick that
anesthesiologists use to show their
growth over time, and their improvement
relative to others. We help our specialty
understand itself: both what we do
and how we do it. And we educate
anesthesiologists every day on the
science of quality improvement and on
practical ways to improve patient safety.
Richard P. Dutton, M.D., M.B.A.
Executive Director,
Chief Quality Officer, ASA
In my view, the explosive growth and

relevance of AQI in just 5 years is
remarkable. We started with just an
idea that gathering practice data would
be useful to our profession. Because
of the hard work and dedication of Dr.
Dutton, the AQI staff, and many physician
anesthesiologists throughout the United
States, AQI has gathered almost 20
million cases. Recently, AQI has been
recognized by CMS as a Qualified Clinical
Data Repository allowing practices
that are reporting to AQI to fulfill their
Physician Quality Reporting System (PQRS)
requirements. I believe this will be the
tipping point for participation in AQI. I
expect, in just a few short years that few
anesthesiology practice will choose not to
report their data to AQI. Our patients and
our profession will only benefit from this
success.
JP Abenstein, MSEE, M.D.
ASA President Elect
I am honored to know Dr. Dutton and
proud to have my company be a preferred
vendor of the AQI. The potential of
the AQI, when started five years ago,
seemed straightforward. It would help
anesthesiologists provide greater value to
patients and hospitals.
Today, the AQI has become more vital and
the platform is providing a way for our
specialty to remain relevant in a time of
uncertainty. The work done over the past five
years has laid an incredible foundation and I
look forward to contributing in the future any
way I can. Thanks Rick.
David Bergman, ePREOP, LLC CEO, DO
The outcomes research that will be
driven by massive aggregation of data
accumulated by AQI will exponentially
drive our ability to improve quality of care
and patient safety.
Jeff Apfelbaum, M.D., Chair, ASA
Committee on Standards & Practice
Parameters
AQI has done more over the first five years
of its existence to advance the quality &
safety of our practice than any other recent
addition. Happy Birthday, AQI!
Jane C.K. Fitch, M.D.
President, ASA
Anesthesiology Continuing Education

ACE Question
A 4-year-old child has a history of difficult intravenous (I.V.) access and a fear of needles. A eutectic mixture of local
anesthetic (EMLA) cream is applied to both hands and both feet and then covered with an occlusive dressing by the
parents 90 minutes prior to arriving for a scheduled outpatient radiologic procedure under sedation. On arrival the child is
noted to be lethargic and cyanotic. A pulse oximetry measurement reads 85 percent. Which of the following is the most
likely explanation?
q (A) Methemoglobinemia
q (C) Cyanide toxicity
q (B) Lidocaine toxicity
q (D) An acute allergic reaction
A eutectic mixture of local anesthetic (EMLA) cream is

a mixture of 2.5 percent lidocaine and 2.5 percent prilocaine
that is applied to intact skin for local anesthetic effects. Topical
application has been shown to significantly reduce pain and
can be particularly useful in infants and children undergoing
dermal procedures. The beneficial effects of EMLA cream
require sufficient time between placement on the skin and the
procedure. Typically it is applied under an occlusive dressing
approximately one hour prior to a procedure, but slightly longer
application times (one to three hours) can result in better
analgesia. However, EMLA cream is often inappropriately
applied too far in advance of a planned procedure, which can
result in substantial systemic absorption and the potential
for toxicity. Methemoglobin is normally produced within
erythrocytes during the oxidation of hemoglobin and is then
reduced back to regular hemoglobin by NADH-cytochrome
b5 reductase. Young children, especially neonates, can be at
risk for methemoglobinemia because of an increased
amount of hemoglobin oxidation and decreased capacity for
methemoglobin reduction.
Prilocaine is metabolized mainly in the liver to orthotoluidine. Accumulation of ortho-toluidine is responsible for
oxidation of hemoglobin to methemoglobin. Very young patients,
patients with glucose-6-phosphate dehydrogenase deficiency, and
those taking oxidizing drugs (e.g., sulfonamides) are at increased
risk of methemoglobinemia. The half-life of prilocaine can also be
increased in those with renal or hepatic dysfunction. Lidocaine

toxicity will typically result in central nervous system (CNS)
symptoms such as seizures. It may progress to CNS depression
and cardiac dysrhythmias. Cyanide toxicity will result in a normal
pulse oximetry reading in the absence of carbon monoxide
toxicity. Cyanide toxicity can result in agitation, confusion,
rapid loss of consciousness, cardiac depression, and coma. Allergic
reactions to EMLA cream usually present as local reactions
including rash, erythema, and/or edema.
Because methemoglobin absorbs an equal amount of the
two wavelengths of light used in conventional pulse oximetry,
the reported value of Spo2 tends toward 85 percent.
Bibliography:
Shachor-Meyouhas Y, Galbraith R, Shavit I. Application of topical

analgesia in triage: a potential for harm. J Emerg Med. 2008;35(1):
39-41.
Couper RT. Methaemoglobinaemia secondary to topical lignocaine/
prilocaine in a circumcised neonate. J Paediatr Child Health. 2000;
36(4):406-407.
Touma S, Jackson JB. Lidocaine and prilocaine toxicity in a patient
receiving treatment for mollusca contagiosa. J Am Acad Dermatol.
2001; 44(2, pt 2):399-400.
Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed.
New York: Lange Medical Books/McGraw-Hill; 2006:141, 268-269,
563.

Miller RD, ed. Millers Anesthesia. 6th ed. Philadelphia: Elsevier/
Churchill Livingstone; 2005:589-590, 596.
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.
45
Subspecialty Societies at ANESTHESIOLOGY 2014

Amr E. Abouleish, M.D., M.B.A., Chair
ASA Committee on Specialty Societies
Sarah L. Braun
ASA Intersociety Relations Manager
ASA Vice President for Scientific Affairs
Even with the broad variety of educational offerings that

ASA provides, many ASA members also have specialized
clinical, research or educational interests; hence, a variety of
subspecialty societies exist. The perspective of ASA leaders is
that there exists a natural synergy between ASA and many of
these subspecialty societies that ASA members find value in
both a strong society and strong subspecialty societies. With
this perspective in mind, ASA leadership has made it a priority
in the past year to improve relations with existing affiliated
subspecialty societies.
Existing affiliated societies are those with House of Delegate

representation:
n American Society of Regional Anesthesia and
Pain Medicine (ASRA)
n Society for Ambulatory Anesthesia (SAMBA)
n Society of Cardiovascular Anesthesiologists (SCA)
n Society for Neuroscience in Anesthesiology and
Critical Care (SNACC)
n Society for Obstetric Anesthesia and Perinatology (SOAP)
n Society of Critical Care Anesthesiologists (SOCCA)
n Society for Pediatric Anesthesia (SPA)
And also the educational societies:
n Society for Education in Anesthesia (SEA)
n Society of Academic Anesthesiology Associations (SAAA)
n Association of University Anesthesiologists (AUA)
Further, ASA recognizes there are additional subspecialty
societies, and ASA is developing pathways to recognize and
enhance relationships with them.
Some of the collaborations offered by ASA to the affiliated
subspecialty societies include officer representation at affiliated
subspecialty meetings and subsidized CME services for
their society meetings through the ASA Joint Providership
Program. This spring, executive leadership took part in the
annual meetings of ASRA, AUA, SAMBA, SCA, SOCCA,
SOAP and SPA, providing an ASA Update and answering
Amr E. Abouleish, M.D., M.B.A.

is Professor, Department of
Anesthesiology, University of Texas
Medical Branch, Galveston.
Beverly K. Philip, M.D. is Professor

of Anaesthesia, Harvard Medical
School, and Founding Director,
Day Surgery Unit, Brigham and
Womens Hospital, Boston.
Sarah L. Braun is ASA Intersociety

Relations Manager.
46
September 2014
Volume 78
Number 9
Table 1
Affiliated Subspecialty Society
Meeting/Location
AUA: Association of University

Anesthesiologists
Committee Meeting October 12, 2014

Hilton New Orleans Riverside and Convention Center
SAMBA: Society for Ambulatory

Anesthesia
2014 Mid Year Meeting October 10, 2014

Renaissance New Orleans Arts Hotel
SEA: Society for Education in

Anesthesia
2014 SEA Fall Meeting October 10, 2014

JW Marriott New Orleans
SNACC: Society for Neuroscience

in Anesthesiology and Critical Care
42ND Annual Meeting October 9-11, 2014

SOAP: Society for Obstetric

Anesthesia and Perinatology
Board of Directors Meeting October 10-11, 2014

Hotel Monteleone
SPA: Society for Pediatric

Anesthesia
28TH Annual Meeting - October 10, 2014

Subspecialty Society
Meeting/Location
ISPCOP: International Society of Perioperative Care

of the Obese Patient
Annual Symposium October 13, 2014

Loews Hotel
SAGA: Society for the Advancement of Geriatric Anesthesia
Annual Meeting October 13, 2014

Location TBD, please contact SAGA for information
SASM: Society of Anesthesia and Sleep Medicine
4TH Annual Meeting October 9-10, 2014

Hotel Monteleone
STA: Society of Technology in Anesthesia
Board of Directors Meeting October 10, 2014

Hotel Monteleone
TAS: Trauma Anesthesiology Society
Annual Meeting Friday, October 10, 2014

New Orleans Downtown Marriott at the
Convention Center
September 2014
Volume 78
Number 9
47
questions about the ongoing relationship between ASA and

the subspecialty societies.
In addition to these formal activities, informal opportunities
to work together often arise from specific issues. Such issues may
include responding to governmental regulations, addressing
payment policy and regulations of both government and
private payers, providing information from member inquiries,
and developing quality initiatives and educational activities.
Further, ASA recognizes there are

additional subspecialty societies,
and ASA is developing pathways
to recognize and enhance
relationships with them.
The initial inquiry may come from ASA (staff or committee) or

a subspecialty society. Finding the right person(s) to contact in
either society can be daunting. For this reason, ASA leadership
created a new position, the Intersociety Relations Manager,
and hired Sarah Braun (s.braun@asahq.org). Sarah is actively
working on strengthening existing relations and developing
new collaborations. Sarahs primary focus is communicating,
advocating and working with anesthesiology subspecialty,

academic and related organizations. She partners with the
ASA staff in the Governance Support Unit, Member Services,
Marketing, Education and Meetings departments to assist in
all collaborative and support efforts in relation to subspecialty
societies and anesthesia-related organizations.
This synergy between ASA, subspecialty societies
and anesthesia-related organizations can be seen at the
ANESTHESIOLOGY 2014 annual meeting. ASA members
will find educational offerings by subspecialty societies as
well as attend meetings of some of these societies and other
organizations before the start of the meeting (Tables 1, 2).
A new initiative for the ANESTHESIOLOGY 2014
annual meeting is the Affiliated Subspecialty Society Pavilion
in the exhibit area. Located in Booth #111, this will be a
dedicated exhibit space for the affiliated subspecialty societies
where they can promote their meetings and activities, meet
with members and potential members, and answer questions.
ASA recognizes the need for affiliated subspecialty society
presence at the annual meeting and views this pavilion as a
key opportunity to provide this service to our members.
Look for it in the exhibit area this October!
A listing of additional anesthesia-related meetings taking
place at the ANESTHESIOLOGYTM 2014 annual meeting can
be found at www.asahq.org/Annual%20Meeting/Network/
Subspecialty%20Meetings.
SCHEDULE BY SESSION
Table 2
SUBSPECIALTY PANELS
Date
Saturday,
Oct. 11
Sunday,
Oct. 12
Monday,
Oct. 13
Tuesday,
Oct. 14
Time
7-8:15 a.m.
7-8:15 a.m.
7-8:15 a.m.
7-8:15 a.m.
Track
OB
Fee Code
601
Speaker
(SOAP) Caring for Our Own: Focusing on the Care
Provider to Optimize Safety for Our Patients
(ASRA) Advancing Safety and Risk Management
Strategies in Pain Medicine
(STA) How Can Mobile Technology Help Me Help
My Patients?
(SOCCA) Trauma and Critical Care Pearls for the
Non-Intensivists
(SAMBA) TIVA in 2014
PN
602
FA
603
CC
604
AM
605
NA
606
PI
607
CA
609
PD
610
(SPA) The Child With Congenital Heart Disease

Presenting for Non-Cardiac Surgery
Track
CC
Fee Code
101
AM
102
FA
103
Speaker
Speaker
Sepsis Current Concepts, Guidelines and
Mark Nunnally M.D.
Perioperative Management
F.C.C.M.
Current Controversies in Adult Outpatient
Jeffrey Apfelbaum M.D.
Anesthesia
Arterial Blood-Gas Analysis: Interpretation and
Steven Barker Ph.D. M.D.
Application
48
September 2014 n Volume
Anesthesia for the Morbidly Obese Parturient
Brenda Bucklin M.D.
Clinical Evaluation and Treatment of Neuropathic
Timothy Lubenow M.D.
(SNACC) Anesthesia for Acute Stroke

Management: Method, Timing and Hemodynamics
(SEA) Technology Today: Testing, Training and
Learning
(SCA) Cardiac Anesthesia
Speaker
Robert Gaiser, M.D.
Location
Room 231-232
David Provenzano, M.D.
Room 238-239
Maxime Cannesson, M.D.,

Ph.D.
Daniel Brown M.D., Ph.D.
Room 228-230
Steven Butz, M.D.
Room 238-239
Rafi Avitsian, M.D.
Room 231-232
Ira Todd Cohen, M.D.,

M.Ed.
Colleen Koch, M.D., M.S.,
M.B.A.
Shobha Malviya, M.D.
Room 238-239
Room 231-232
Room 231-232
Room 238-239
RCL - REFRESHER COURSE LECTURE

Date
Saturday,
Oct. 11
Time
8-9 a.m.
OB
PN
104
105
Location
Rivergate
Room E-1
Room E-2
78
Number 9
Room E-3
Room 260-262
Who is your guide?
mom
teacher
coach
professor
residency director
ASA
mentor
At every stage in your development, youve had a guide: from family members
to teachers to coaches; from professors to residency directors to mentors. As you progress in your
professional career, the ASA is honored to help fill that role. On behalf of the Society and its 52,000
members, thank you for your commitment to the specialty and your colleagues.
The ASA Membership Department is always available to you. Anytime you have a question
or concern, wish to pay your dues, or have inquiries about products or services, please feel free to
contact Member Services by phone at 847.825.5586 or via email at membership@asahq.org.
OUR MEMBERS ARE
LEADERS IN PATIENT SAFETY

www.asahq.org
committee news
RUC Review of Misvalued Codes

Marc L. Leib, M.D., J.D.
Chair, ASA Committee on Economics
Among the many activities in which

the Committee on Economics and
its members participate is the
American Medical Association/
Specialty Society Relative Value
Update Committee (RUC). In addition
to recommending values for new and
revised Current Procedural Terminology
(CPT) codes for Medicare, the RUC
is frequently asked to provide updated
recommendations of values for CPT
codes that the Centers for Medicare &
Medicaid Services (CMS) believes may
be misvalued. Since many of the codes
were valued some time ago, the valuation
may or may not reflect current practice
with respect to either physician work or
associated practice expenses. Although
misvalued codes may be valued either
too high or too low, in most cases CMS
believes the correct value of these
services should be lower than the current Relative Value Units
(RVUs) assigned to the codes describing those services.
Since 2009, CMS has identified codes it believed were
misvalued as part of its regulatory oversight of the Medicare
program, identifying the codes in the Proposed Rule or Final
Rule outlining changes to the Medicare Physician Fee Schedule
(MPFS) each year. These are usually published around the
beginning of July and November and become effective on
January 1 of the following year. Once CMS publishes its list
of potentially misvalued codes, the RUC usually requests that
specialty societies representing the various groups of physicians
who perform those procedures develop an action plan on how to
address CMS concerns. Action plans range from stating that

the current value of the identified code is valid and requesting
that CMS reaffirm that value, to agreeing to conduct a new
survey of society members to develop current estimates of the
appropriate RVU value for work and practice expenses (PEs)
associated with providing the service.
In the most recent Proposed Rule for the MPFS, CMS notes
that it has identified and reviewed more than 1,250 potentially
misvalued codes. Congress had previously required CMS to
examine potentially misvalued services under seven different
categories:
n
Codes and families of codes for which there has been the
fastest growth;
n Codes and families of codes that have experienced substantial
changes in PEs;
n
Codes that are recently established for new technologies or
services;
n Multiple codes that are frequently billed in conjunction with
furnishing a single service;
n Codes with low relative value that are often billed multiple
times for a single service;
n
Codes that have not been reviewed since the inception
of the Resource-Based Relative Value System, commonly
referred to as Harvard-Valued Codes; and
n Other codes determined to be appropriate by the secretary.
Marc L. Leib, M.D., J.D., is Chair,

ASA Committee on Economics.
50
September 2014
Volume 78
Number 9
Section 220(c) of the Protecting Access to Medicare Act of

2014 (PAMA), the most recent temporary Sustainable Growth
Rate formula fix, added nine additional statutorily required
categories of codes the Agency must examine to identify
potentially misvalued codes:
n
Codes that account for the majority of spending under the
MPFS;
n Codes for services that have experienced a substantial change
in the hospital length of stay or procedure time;
n Codes for which there may be a change in the typical site of
service since the code was last valued;
n Codes for which there are significant differences in payment
for the same service between different sites of service;
n
Codes for which there may be anomalies in relative values
within a family of codes;
n
Codes for services where there may be efficiencies when a
service is furnished at the same time as other services;
n Codes with high intra-service work per unit of time;
n Codes with high PE RVUs; and
n Codes with high cost supplies.
Codes that have experienced substantial changes in PE:

Recent changes in CMS RVUs for intra-laminar epidural
injections (CPT codes 62310, 62311, 62318 and 62319)
reflect changes in PEs associated with those procedures.
When those codes were originally valued, fluoroscopic
guidance was commonly provided in a fluoro room, a leadlined room with built-in fluoroscopic equipment. That type
of facility was much more costly than todays typical practice
of using a mobile C-arm fluoroscope. The change in PE inputs
significantly decreased the total unit value of intra-laminar
injections. With respect to these codes, CMS also decreased
the work RVUs for 2014 significantly below the values
recommended by the RUC. However, due to the thousands
of comments CMS received regarding the reductions in the
values of these codes, it has decided to revert to the 2013
work RVUs and PE inputs for 2015 and reconsider how it
values these four codes. Even though CMS will revert to the
2013 values for these four codes for 2015, it will prohibit
billing for imaging guidance in conjunction with intralaminar epidural injections. CMS will also identify these
codes as potentially misvalued codes for reconsideration by
the RUC in the future.

These are a few examples of the issues the RUC team and the
Committee on Economics address on behalf of ASA members.
We anticipate that with the new categories of potentially
misvalued codes Congress identified this year, there will likely
be more such issues arising in the future. Even though Medicare
and other payers are trying to move away from a fee-for-service
system of paying for each individual service, valuing these
services correctly is necessary for the short term while fee-forservice still predominates. Changes in payment models make
correct valuations important in the long term, as the values
assigned to the codes will likely form the basis of determining
payments for bundled services. Without accurate values for the
individual services, calculating bundled payment fees becomes a
difficult, if not meaningless, activity.
n
Without accurate values for the

individual services, calculating bundled
payment fees becomes a difficult,
if not meaningless, activity.
The ASA RUC team, including supporting ASA staff,
devotes hundreds of hours collectively preparing responses to
CMS regarding codes used by physician anesthesiologists that
the agency believes are misvalued and providing the assessment
at the RUC meetings. Over the last several years, most of these
have involved codes describing pain medicine procedures rather
than codes describing primary anesthesia care.
The most common categories of codes ASA has been asked
to review include:
n Codes that have experienced the fastest growth: Examples
of codes in this category are those describing nerve blocks
used to provide postoperative pain management, such as
femoral nerve blocks following total knee arthroplasties.
These services have increased during recent years as patients,
surgeons, hospitals and even some payers have realized that
patients recover more quickly, ambulate sooner, use less
narcotics, go home sooner and are more satisfied with their
care than those relying on IM or I.V. injections of pain
medications. ASA maintains that the savings to the system
from these advantages outweigh the costs of the block itself
and that the codes are valued correctly.
September 2014
Volume 78
Number 9

Codes billed in conjunction with providing a single service:
This has been one reason CMS has bundled imaging
guidance with spinal injection procedures in recent years,
using a single code to describe the injection procedure and
various imaging services used to guide and document needle
placement and injection. One advantage for CMS bundling
these services into a single code is to minimize the potential
duplication of pre-service and post-service work when two or
more codes are used to report the service.
51
quality and regulatory affairs
Anesthesiologists Among Top Performers in PQRS

Maureen Amos, M.S.
Matthew T. Popovich, Ph.D.
Each year, the Centers for Medicare & Medicaid Services

(CMS) releases a summary of practitioner participation
in the Physician Quality Reporting System (PQRS) and the
eRx Incentive Program. The document contains significant
data on these programs and illustrates participation variances
among specialties. In its 2012 Reporting Experience Including
Trends (2007-2013) report released earlier this year, physician
anesthesiologists were among PQRSs top participants, with
61.3 percent (some 28,318 practitioners) submitting quality
data for the program. Physician anesthesiologists 2012 numbers
were the latest in a steady increase in participation since
2009, when 41.3 percent of physician anesthesiologist eligible
professionals (EPs) took part. Other top participating specialties
included emergency medicine (68.0 percent), interventional
radiologists (58.1 percent), ophthalmology (55 percent) and
cardiology (53.5 percent).
The PQRS reporting program combines incentive
payments and payment adjustments to promote reporting of
quality information by EPs. In 2012, the payment incentive
for successfully reporting measures was 0.5 percent, with an
average payment of $457 per individual EP and $5,736 per
practice. Physician anesthesiologists received more than
$4.9 million of these incentives, with an average payment
excluding Maintenance of Certification Program (MOCP) of
$212 and a maximum incentive payment of $8,153. Eighty-two
percent of participating anesthesiologists, some 23,461 EPs,
received the payment incentive in 2012.
In addition to valuable information on physician
anesthesiologists participation in PQRS, the report provides a
variety of data segmented by various topics such as specialty,
geographic region and reporting method. While such data can
be useful to identify performance trends and provide indicators

of future performance, PQRS incentives, adjustments and
available reporting measures have changed frequently over
the past two years. The 2012 CMS incentive payments were
based on successfully reporting three PQRS measures; in 2014,
that requirement increased to nine across three National
Quality Strategy (NQS) domains. In 2014, CMS retained the
Measure-Applicability Validation (MAV) process for claimsbased reporting but expanded it to apply to registry-based
reporting as well.
The methods available for PQRS participation have also
changed. In 2012, physician anesthesiologists could report
measures via claims, registry, Electronic Health Record (EHR)
or the Group Reporting option (GPRO). Of note, more
than 85 percent of anesthesiologists reported measures via
the claims mechanism in 2012. This year, CMS added the
Qualified Clinical Data Registry (QCDR) reporting option,
allowing PQRS participants to report on measures already part
of the program as well as specialty-based, registry-developed
measures. The Anesthesia Quality Institutes (AQIs) National
Anesthesia Clinical Outcomes Registry (NACOR) is a
CMS-approved QCDR.
In 2012, the five most reported measures by physician
anesthesiologists in order of frequency were:
n PQRS #30: Timing of Prophylactic Antibiotic
Administering Physician
n PQRS #193: Perioperative Temperature Management
n PQRS #76: Prevention of Catheter-Related Bloodstream
Infections (CRBSI): Central Venous Catheter (CVC)
Insertion Protocol
Maureen Amos, M.S. is ASA Director,

Quality and Regulatory Affairs.
Matthew T. Popovich, Ph.D. is

ASA Quality Specialist.
52
September 2014
Volume 78
Number 9

PQRS #124: Health Information Technology (HIT):
Adoption/Use of Electronic Health Records (EHR)
n PQRS #130: Documentation of Current Medications in the
Medical Record.
EPs who do not avoid the payment adjustment in 2014 under

PQRS or are non-PQRS participants may be subject to an
additional 2 percent downward adjustment through the ValueBased Payment Modifier program.
While PQRS participation is voluntary, payment adjustments
for reporters and non-reporters may impact future anesthesiology
practice payments. Physician anesthesiologists are encouraged
to explore PQRS reporting options for the remainder of 2014,
as well as for calendar year 2015.
For information on reporting PQRS measures, please contact
the ASA Department of Quality and Regulatory Affairs at
(202) 289-2222 or via e-mail qra@asahq.org.
PQRS measures are reviewed annually by CMS, with some

being retired or removed. PQRS #124, for example, a top
reported measure for EPs in 2012, has since been retired.
Participation in PQRS also offers physician anesthesiologists
the opportunity to review submitted quality data and identify
problems in their submissions. Each year, CMS provides
feedback reports for individual participants packaged at the TINlevel, with individual reporting (or NPI-level) and performance
information for each EP who reported under that TIN during
the reporting year. This information includes reporting rates,
Quality-Data Coding errors, clinical performance, incentives
and whether the participant went through the MAV process.
Such reports also detail the potential impact of the MAV process
on incentive eligibility.
Although physician anesthesiologists are among the
strongest participants in PQRS, nearly 40 percent still do not
participate. The year 2014 marks the final reporting period
where PQRS incentives will be available to satisfactory reporters
and, as such, non-participating EPs risk losing up to 2 percent
on their Medicare Part B Fee-For-Service payments (a payment
adjustment) in 2016. Further, physician groups with 10 or more
Additional resources:
The 2012 Reporting Experience Including Trends (2007-2013)
report may be downloaded here: http://www.cms.gov/Medicare/
Quality-Initiatives-Patient-Assessment-Instruments/PQRS/
Downloads/2012-PQRS-and-eRx-Experience-Report.zip.
Physician Quality Reporting Program
http://www.cms.gov/pqrs
ASA Physician Quality Reporting System Online Tools:
https://www.asahq.org/For-Members/Patient-Quality-andSafety/Physician-Quality-Reporting-System.aspx
AQI NACOR Qualified Clinical Data Registry (QCDR):
http://www.aqihq.org
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Call: 847-825-5586
14-080
September 2014
Volume 78
Number 9
53
state beat
Get Into a State of High Involvement

Erin A. Sullivan, M.D., Chair
Committee on Governmental Affairs
I said Somebody should do something about that. Then I realized

I am somebody. Lily Tomlin
who is in charge of opt-outs in your state as well as other

crucial issues for our profession. Most of the state primaries have
taken place by this point, so we can identify which candidates
are moving forward to the general election.
What if each one of us got to know our own districts
candidates or incumbent? Considering ASAs membership,
if all 52,000 of us forged relationships with state candidates,
we would arguably cover most of the state legislators (and
definitely all the governors) across the country. In turn for our
efforts, hopefully these candidates (and soon-to-be legislators
or governors) would be comfortable contacting us as experts on
health care issues.
Each day is simply packed with things to do at work and

at home, people to see and places to go. Family, work,
extracurricular activities (if we have time to enjoy them) all vie
for our attention. They are all positive aspects of our lives, but
they can become overwhelming at times. When legislative or
regulatory issues arise that might be injurious to our profession
or even worse, to patient safety it is easy to say shouldnt
somebody do something about that!? Sometimes were angry
when someone doesnt do anything about it and the
legislation or regulation passes or goes into effect.
When it comes to protecting our patients and our profession,
I have realized that somebody means me. If I dont do
something, who will? The answer is no one. Each of us could ask
ourselves the same question and come to the same conclusion:
we must each be that somebody, even if the actions we are
able to take seem small.
This year, there are countless opportunities to do something
to protect our patients and further our calling as physicians.
One of the easiest ways to make a difference is to get to know
(and hopefully make friends with) your districts candidate or
incumbent running for state legislature.
2014 is a monumental mid-term election year. Every state
other than Nebraska has two legislative chambers, meaning
there are 99 legislative chambers altogether. A whopping 87
of the 99 chambers are holding state legislative elections on
November 4, 2014. Here are those numbers in a different,
possibly mind-blowing way: there are 6,055 state legislative
seats up for election this November. Additionally, there are
36 gubernatorial races this year, and these races determine
Similarly, if you have interest in

regulatory matters, you could
frequently check your states board
of medicine, board of nursing and
department of health websites to
find out what theyre up to.
How do I become somebody to these candidates? Free
time is hard to come by for all of us, but volunteering for a
state legislative candidate can take as little or as much time as
you want it to, depending on how you offer your services as a
volunteer. Many candidates need volunteers to go door to door
with literature or to make phone calls; if you offer to do this
and dont want to spend your entire weekend or day off doing
this, call the campaign office (usually readily available through
the candidates website) and say Im available on X date from
2-4 p.m. (or other finite time period). How can I help? If the
candidates campaign is worth two hoots, they will immediately
give you a task to fill just that time period. Later on when you
visit a new lawmaker, you can truthfully say, Oh, I volunteered
for your campaign doing ______. Im so glad you won and please
let me be a resource for you and your staff on health care issues!
Do you like to eat breakfast? What about brunch? Throwing
a breakfast or brunch reception or fundraiser for your candidate
of choice is probably the easiest (and least expensive!) fundraiser
there is. To make things easy, breakfast fundraisers can be held
just about anywhere your home, your office (with permission
of your office or hospital, of course), or even at a local restaurant.
If you hold one at your home, dont feel like you must provide
Erin A. Sullivan, M.D. is Associate

Professor of Anesthesiology, and
Director, Division of Cardiothoracic
Anesthesiology, University of
Pittsburgh, Pennsylvania.
54
September 2014
Volume 78
Number 9
lavish food or drink. The candidate is mainly there to make

contacts and pick up campaign contributions muffins, bagels
and coffee will suffice. Holding a morning fundraiser also keeps
prices low since no one (well, almost no one) expects alcohol
early in the morning!
If you hold a fundraiser for a candidate, there is a chance
you might need to report this to your state election authority; a
candidates campaign staff can usually help you figure out what
(if anything) you must report. Usually, such a fundraiser held by
an individual (or group of individuals) is only reported by the
candidates campaign, and not you. If you have any questions
regarding this issue, though, please check with your states
election authority, which is usually the states secretary of state.
In addition to becoming friends with your state legislators
and governors, you could also be somebody by becoming one
of your states legislative or regulatory watchdogs. By checking
out your state legislatures website and doing a search for
anesthesia, anesthesiologist, anesthesiologist assistant,
nurse anesthetist or pain management, you can find the
pieces of legislation that are going to be key for our profession
in your state. Relay the bill numbers to your state component
society and ask if they are taking any action; if they are taking
action, how can you help?
Similarly, if you have interest in regulatory matters, you

could frequently check your states board of medicine, board of
nursing and department of health websites to find out what
theyre up to. Sometimes these boards (especially the boards
of nursing) prefer to circumvent the legislative process; weve
seen this time and time again in many states. By consistently
monitoring the boards website, you could become a Tim
Howard of the regulatory world and help block goals being
made by opposition. Taking a see something, say something
approach to monitoring your state legislatures and regulatory
boards would definitely make you a somebody!
We are all in this together, but each of us has a part to play
in actively advocating for our patients. While we do this every
day in our jobs, taking it to the next level and becoming that
somebody who takes advocacy beyond the doors of the clinic
or hospital becomes a hero to patients everywhere. You can be
somebody. You can be a hero.
For more ideas on how to be involved in your state,
contact Jason Hansen at j.hansen@asahq.org or Erin Philp at
e.philp@asahq.org.
REACH NEW HEIGHTS ONE

STEP AT A TIME
The ASA Self-Education and Evaluation (SEE) program takes your
continuing education to the top with this self-assessment product
based on emerging knowledge in anesthesiology.
Start today
MOCA
see.asahq.org

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 60 AMA
PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
14-131
September 2014
Volume 78
Number 9
55
whats new in ...
Difficult Airway Management Algorithm in Trauma

Updated by COTEP
Carin A. Hagberg, M.D., Chair
Committee on Trauma and Emergency Preparedness
Olga Kaslow, M.D., Ph.D.

Committee on Trauma and Emergency Preparedness
Airway management presents a challenge for health care

providers involved in the resuscitation of trauma victims.
It requires vigilance, sound judgment and experience in
performing various interventions for airway control throughout
the spectrum of maneuvers from simple positioning to invasive
techniques. Physician anesthesiologists involved in trauma care
remain at the forefront of research and education, developing
guidelines for establishing an airway in the trauma setting.
In 2005, W. C. Wilson et al.1 modified the 2003 ASA Difficult
Airway (DA) Algorithm2 and developed DA algorithms for
various trauma settings.
ASA originally developed practice guidelines for
management of DA in 1993.3 Since then, these guidelines have
been updated twice, in 2003 and 2013,2,4 following an extensive
analysis of the scientific literature, thorough review of new
evidence, and collected opinions of both experts and randomly
selected ASA members. While the 2013 DA algorithm and
guidelines for management of the DA proposed by the ASA
DA task force continue to serve as an excellent starting point
for trauma airway management, modifications in the trauma
setting remain necessary.
In recognition of such need, the ASA Committee on Trauma
and Emergency Preparedness (COTEP) recommends various
modifications of these guidelines. Over the past decade, airway
management techniques in the trauma setting have expanded
to encompass modalities such as video-assisted laryngoscopy
(VAL), supraglottic airway devices (SGA), cricothyrotomy
and others. Currently, there are insufficient outcome data that
demonstrate an advantage of one technique over another, and
it will not likely become available due to the need for the
very large sample size necessary to conduct such a trial.

Consequently, the following recommendations were developed
based on current scientific literature and expert opinion.
General Comments:
The patient with trauma presents unique challenges for
airway management, including:
n Time pressure
n Hemodynamic instability
n Altered airway anatomy
n Associated injuries, including face, neck and brain injuries
n Lack of patient cooperation
n Risk of aspiration
n Need for cervical spine protection
n Positioning concerns
n Rapidly evolving, possibly competing, clinical priorities
n Trauma team dynamics
n Pre-hospital scene safety
n Triage, equipment, and mass casualty considerations.
Several strategies differ from the ASA DA algorithm, and
the following issues should be considered when managing the
airway in trauma patients:
1. Waking up the patient or canceling the procedure is rarely
an option, as the need for emergent airway control will
presumably remain.
2. A surgical airway may be the first/best choice in certain
conditions (e.g., significant oromaxillofacial trauma).
3.
The following conditions commonly occur when an
unconscious or recently induced trauma patient must be
intubated:
Carin A. Hagberg, M.D. is

Joseph C. Gabel Professor and Chair,
Department of Anesthesiology,
UTHealth, University of Texas
Health Science Center at Houston.
Olga Kaslow, M.D., Ph.D. is

Director, Trauma Anesthesia
Service, and Associate Professor
of Anesthesiology, Medical
College of Wisconsin, Milwaukee.
56
September 2014
Volume 78
Number 9
8. Manual in-line stabilization (MILS) of the cervical spine

during intubation is recommended in patients with suspected
cervical injury. The aim of MILS is to prevent any flexion,
extension or rotation of the cervical spine when laryngoscopy
is performed. However, MILS may worsen laryngoscopic
view, causing the person intubating to apply greater pressure
(which may be transmitted to the cervical spine), or result in
longer time or failure to secure the airway. One must balance
the benefits of MILS against the risk for hypoxic damage if
intubation and adequate ventilation cannot be accomplished.
Therefore, as was noted for CP, MILS may be altered or
discontinued if its use impedes tracheal intubation.6,7
9.
VAL is now frequently used in patients with known or
suspected cervical injury, as it appears to reduce cervical
motion during intubation compared to direct laryngoscopy
(DL), or in patients with predictors of a difficult airway.8-12
Some of the limitations of VAL are facial trauma leading
to a jaw lock or limited mouth opening and difficulty in
obtaining an adequate view in an oropharynx soiled with
blood and secretions.13 Furthermore, the use of VAL in the
trauma setting has been associated with longer intubation
times and affecting neither intubation first-pass success rate
nor survival to hospital discharge.14 Therefore, although the
introduction of video laryngoscopes has expanded the airway
armamentarium, these devices have not yet replaced DL in
the trauma setting.
A. The clinician fails to recognize a DA in evaluation prior

to the induction of anesthesia.
B. The patient has an obvious DA but is hemodynamically
unstable (e.g., shock) or refuses to cooperate with an
awake intubation (e.g., children, the intellectually
disabled, intoxicated or head-injured adults).
4.
If a tracheal intubation attempt fails and the patient is
apneic or is rendered as such through anesthetic induction,
O2-enriched bag-valve mask (BVM) ventilation should
be initiated. If BVM ventilation is adequate, a variety of
intubation techniques may be employed.
5. If BVM is inadequate, placement of an SGA should be
attempted.
6. Cricoid pressure (CP) should be applied throughout induction
and intubation attempts until the airway is secured. However,
if necessary, CP should be altered or removed to ease BVM
ventilation, insertion of an SGA or tracheal intubation,
since maintaining patent airway takes precedence over the
potential risk of aspiration.5
7. Gentle BVM ventilation performed at pressures <20 cm of
H2O prior to intubation is beneficial in trauma patients in
whom it may be difficult to achieve adequate preoxygenation
due to clinical urgency, uncooperativeness or limited
functional residual capacity (e.g., lung injury, obesity).5
Establishing BVM ventilation is especially important after a
failed attempt at intubation.
Difficult Airway Management Algorithm in Trauma

1. Assess the likelihood and clinical impact of basic
management problems:

Difficulty with patient cooperation and consent

Difficult mask ventilation

Difficult supraglottic airway placement

Difficult direct laryngoscopy

Difficult intubation

Difficult surgical airway access.
2. Adhere to Basic Anesthetic Monitoring standards.
3. Actively pursue opportunities to deliver supplemental
oxygen throughout the process of DA management.
4. Consider the relative merits and feasibility of basic
management choices:
Awake intubation vs. intubation after induction of
general anesthesia (GA)
Non-invasive techniques vs. invasive techniques
for the initial approach to intubation
VAL as an initial approach to intubation
Preservation vs. ablation of spontaneous ventilation.
5. Develop primary and alternative strategies:
(see Figure 1, page 59).
September 2014
Volume 78
Number 9
57
ASA DA Algorithm Applied to Specific Trauma Conditions

Closed Head Injury Algorithm:
Key Points:
A. In patient with a DA, perform awake intubation if the patient
is awake (Glasgow Coma Scale [GCS] 9), cooperative,
hemodynamically stable and able to maintain adequate O2
saturation.
B. Keep cerebral perfusion pressure at 50-70 mm Hg.
C. Avoid hypoxia and hypercarbia.
dislodge foreign bodies (teeth, bony fragments, blood clot)

into the airway or create a false passage. Blind nasal attempts
in the setting of midface fracture may lead to violation of the
cranial vault.
G. Nasal intubation is not contraindicated in a patient with
lateral or posterior skull base fractures; FSI could be safely
performed even if the fracture occurred in the central anterior
skull base.16 Risk vs. benefit discussion for choosing nasal
route for intubation should be documented in a patients
record.
H. If initial oral intubation interferes with the surgical approach,
it can be converted later to submental or nasal intubation.
Airway Disruption Algorithm:

Key Points:
A. Perform awake intubation if major laryngeal or tracheal/
bronchial tear, provided the patient is awake, cooperative,
hemodynamically stable and able to maintain adequate
O2 saturation.
B. If patient uncooperative and DA is not otherwise suspected,
consider rapid sequence intubation (RSI) using VAL and FIS.
Consider intubation and airway evaluation with VAL
if a supralaryngeal defect is present. VAL has the added
benefit of allowing multiple viewers, aiding in examination
and surgical planning

For infralaryngeal and tracheal injury, consider RSI
followed by DL and insertion of a FIS (with appropriately
sized endotracheal tube [ETT] already loaded over it)
through the larynx to rapidly evaluate for possible airway
injury. The ETT is then introduced over the FIS and the
cuff positioned below the level of injury.6,15
C.
Avoid positive pressure ventilation and transtracheal jet
ventilation proximal to tear.
D. If bronchial disruption is suspected, consider lung separation
via placement of a double lumen tube or bronchial blocker.
E. Consider cardiopulmonary bypass.
Cervical Spine Injury (CI) Algorithm:

Key Points:
A. High level of suspicion is required for patients with a CI in
the trauma bay and other acute care areas (particularly
patients with blunt multi-system trauma, altered
consciousness level/low GCS, injury above the clavicle,
maxillofacial and head trauma).
B. If injury is at or above C5, intubation and ventilation are
often required.7 In the post-traumatic period, progressive
neck swelling due to edema and pre-vertebral hematoma
expansion may further compromise the airway,17 even in the
absence of changes to the surface anatomy examination.
C. Intubation should minimize cervical movement to prevent
further neurological deterioration in a potential or actual
spinal cord injury.
D. Perform RSI, MILS with the front of the cervical collar
removed, CP and gentle DL/VAL.
VAL may be a preferred tool in patients with known or
suspected CI
CP should be applied during induction and maintained
through intubation until tube placement is confirmed; it
may be applied through the anterior opening in cervical
collar before the collar is temporarily removed
Both MILS and CP should be altered or removed if they
impede adequate ventilation or intubation.6,7
Oral and Maxillofacial Trauma Algorithm:

Key Points:
A. Radiological results are crucial to discern anatomic distortion
and airway integrity.
B. Limited mouth opening and accumulated blood, secretions
and foreign bodies can all obscure visualization and
compromise DL, VAL and FSI.13
C.
Perform awake intubation if patient is cooperative,
stable and able to clear airway; this will maintain both
spontaneous ventilation and O2 saturation.
D. If awake, intubation fails, airway compromise occurs or the
patient is agitated, an awake tracheostomy may be the best
approach.
E. BVM ventilation may be difficult and result in displacement
of facial fractures or even airway compromise.
F.
Blind intubation (oral and nasal) is discouraged: it may
Airway Compression Algorithm:

Key Points:
A.
Awake intubation is recommended if the patient is
cooperative, stable and can maintain spontaneous
ventilation, airway patency and adequate O2 saturation.
B.
Personnel able to perform a surgical airway should be
prepared to immediately intervene should life-threatening
airway obstruction occur.
C. Consider opening the wound if an expanding postoperative
neck hematoma is suspected.
58
September 2014
Volume 78
Number 9
Figure 1
Recognized DA
Cooperative patient
Hemodynamically stable
Maintains adequate O2
Unrecognized DA
Uncooperative patient
Hemodynamically unstable
Life-threatening emergency
AWAKE INTUBATION
with FIS or VAL
Initial Intubation
attempt successful*
INTUBATION AFTER INDUCTION OF GA:

CP, MILS, RSI with DL or VAL
Initial Intubation attempts

UNSUCCESSFUL
UNSUCCESSFUL (a)
Invasive Airway Access (b)
Initial Intubation
attempt successful*
1. Call for help

2. BVM ventilation
3. Maintain delivery of
supplemental O2
4. Maintain CP
BVM VENTILATION ADEQUATE
BVM VENTILATION NOT ADEQUATE
CONSIDER/ATTEMPT SGA (e)
SGA ADEQUATE*
NON-EMERGENCY PATHWAY
Ventilation adequate, intubation unsuccessful
SGA NOT ADEQUATE or NOT FEASIBLE
EMERGENCY PATHWAY
Ventilation not adequate, intubation unsuccessful (d)
Alternate approaches to intubation (c)
Success*
FAIL (d)
Emergency Invasive Airway Access (f)
September 2014
Volume 78
Number 9
59
References:
D. Maintain spontaneous ventilation with induction of GA.

E. Position tracheal tube below level of obstruction.
Fiberoptic confirmation may be required.
F. SGA is not recommended.
G. VAL and FSI are good choices as long as they
allow visualizing airway.
1.
Wilson WC. Trauma: airway management. ASA Newsl. 2005;69
(11):9-16.
2. American Society of Anesthesiologists Task Force on Management
of the Difficult Airway. Practice guidelines for management of the
difficult airway. Anesthesiology. 2003;98(5):1269-1277.
5. Grissom TE, Varon AJ. Airway management controversies in trauma
care. ASA Newsl. 2013;77(4):12-14.
6. Diez C, Varon AJ. Airway management. In: Varon AJ, Smith CE, eds.
Essentials of Trauma Anesthesia. Cambridge: Cambridge University
Press; 2012:28-42.
7. Dagal A. Acute care of traumatic spinal cord injury [abstract RCL08] Presented at: IARS 2014; May 17-20, 2014; Montreal, Quebec.
8. Enomoto Y, Asai T, Arai T, Kamishima K, Okuda Y. Pentax-AWS,
a new videolaryngoscope, is more effective than the Macintosh
laryngoscope for tracheal intubation in patients with restricted
neck movements: a randomized comparative study. Br J Anaesth.
2008;100(4):544-548.
9. Koh JC, Lee JS, Lee YW, Chang CH. Comparison of the laryngeal
view during intubation using Airtraq and Macintosh laryngoscopes
in patients with cervical spine immobilization and mouth opening
limitation. Korean J Anesthesiol. 2010;59(5):314-318.
10. Lim Y, Yeo SW. A comparison of the GlideScope with the Macintosh
laryngoscope for tracheal intubation in patients with simulated
difficult airway. Anaesth Intensive Care. 2005;33(2):243-247.
11.
Malik MA, Maharaj CH, Harte BH, Laffey JG. Comparison
of Macintosh, Truview, EVO2, Glidescope, and Airwayscope
laryngoscope use in patients with cervical spine immobilization.
Br J Anaesth. 2008;101(5):723-730.
12. Robitaille A, Williams SR, Tremblay MH, Guilbert F, Thriault M,
Drolet P. Cervical spine motion during tracheal intubation with
manual in-line stabilization: direct laryngoscopy versus GlideScope
videolaryngoscopy. Anesth Analg. 2008;106(3):935-941.
13. K aslow OY, Gollapudy S. Anesthetic considerations for ocular and
maxillofacial trauma. In: Varon AJ, Smith CE, eds. Essentials of Trauma
Anesthesia. Cambridge: Cambridge University Press, 2012:198-208.
14. Yeatts DJ, Dutton RP, Hu PF, et al. Effect of video laryngoscopy
on trauma patient survival: a randomized controlled trial. J Trauma
Acute Care Surg. 2013;75(2):212-219.
15. Desjardins G, Varon AJ. Airway management for penetrating neck
injuries. The Miami experience. Resuscitation. 2001;48(1):71-75.
16.
Goodisson DW, Shaw GM, Snape L. Intracranial intubations in
patients with maxillofacial injuries associated with base of skull
fractures? J Trauma. 2001;50(2):363-366.
17. L azott LW, Ponzo JA, Puana RB, Artz KS, Ciceri DP, Culp WC, Jr.
Severe upper airway obstruction due to delayed retropharyngeal
hematoma formation following blunt cervical trauma. BMC
Anesthesiol. 2007;7:2.
Trauma algorithm footnotes (for Figure 1, page 59):

*Confirm ventilation, tracheal intubation or SGA placement with
standard confirmatory techniques (exhaled CO2, misting of tube,
auscultation of breath sounds, improving SpO2). If perfusion (and
exhaled CO2) absent, use additional confirmation methods (e.g.,
repeat laryngoscopy, bronchoscopy, esophageal detector device,
chest X-ray).
a. Other options in ASA algorithm:
Ventilation with a face mask or SGA might be difficult or
impossible in a patient with maxillofacial trauma
Local anesthesia infiltration or regional nerve blockade
are of limited value in extensive trauma surgery.
b.
Invasive airway access includes surgical or percutaneous
cricothyrotomy or tracheostomy, transtracheal jet ventilation
and retrograde intubation.
c. Alternative difficult intubation approaches include (but are
not limited to): VAL, SGA (e.g., laryngeal mask airway [LMA]
as an intubation conduit with or without flexible scope
guidance), flexible scope intubation (FSI), intubating stylet
or tube changer, and light wand. Blind intubation (oral or
nasal) is discouraged in patients with maxillofacial trauma and
laryngeal or tracheal injury.
d. Aborting the case and awakening the patient to optimize and
re-attempt intubation via a different airway technique (e.g.,
awake intubation) is impractical in most trauma cases due to
the emergent condition of the patient.
e. Emergency non-invasive airway ventilation consists of SGA.
f. Surgical airway kit should be immediately available.
Abbreviations:
BVM ..................................................................................................bag-valve mask
CI...............................................................................................cervical spine injury
CP......................................................................................................cricoid pressure
DA........................................................................................................difficult airway
DL..............................................................................................direct laryngoscopy
ETT............................................................................................. endotracheal tube
FIS.................................................................................. flexible intubation scope
FSI.................................................................................. flexible scope intubation
GA............................................................................................... general anesthesia
GCS......................................................................................Glasgow Coma Scale
LMA....................................................................................laryngeal mask airway
MILS......................................................................... manual in-line stabilization
RSI..............................................................................rapid sequence intubation
SGA......................................................................... supraglottic airway devices
VAL........................................................................video-assisted laryngoscopy
60
September 2014
Volume 78
Number 9
Register early and save!

ASA members mark your calendars and
dont miss the ASA Quality Meeting.
Learn from leading national experts on how to use
quality management data to improve patient
outcomes and measure performance.
Learn more
education.asahq.org/AQM
Accreditation and Credit Designation
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 Credits.
14-165
subspecialty news
SAMBA 2014 Update

Brian M. Parker, M.D., President
Society for Ambulatory Anesthesia (SAMBA)
Thirty years ago, the idea of a society for ambulatory

anesthesia was considered novel, as new anesthetic agents
on the horizon promised faster recovery and fewer side effects
after outpatient surgery. Fast forward to today, and the focus is
now on patient outcomes and cost. With the development of
the SAMBA Clinical Outcomes Registry (SCOR), SAMBA
has positioned itself to allow clinical practices to evaluate their
performance and patient outcomes. It seems that what the new
frontier was then has become the expectation today from both
our patients and payers.
Over the years, the mainstay of SAMBAs mission has
always been education. The society has accomplished this
predominantly through holding several CME meetings each
year, including our annual meeting in the spring and our mid
year meeting held the Friday immediately preceding the ASA
annual meeting. Several years ago, we elected to also offer
an annual meeting solely focused on office-based anesthesia
(OBA) practice. Clinical practice guidelines, consensus
statements and webinars targeted at residents have rounded out
our educational offerings.
So what changes are going on within SAMBA to provide
value to its membership? First, were finalizing the creation
of partnerships with specific companies through our new
Corporate Affinity Program. The goal is to provide improved
access to and discounts on various products and business
solutions for SAMBA members in a streamlined and easy-tonavigate fashion. Second, we recently distributed a SAMBA
Membership Needs Assessment Survey to better understand
what the society does well and what it can do better. Once those
responses are in and tallied, well use this information to drive
improvements for our membership. Third, were revisiting our
strategic plan that was initiated almost 2.5 years ago (under
then-SAMBA President John Dilger, M.D.) to make sure we
stay on target with our goals and ensure we continue to remain
financially healthy.
With the development of the SAMBA

Clinical Outcomes Registry (SCOR),
SAMBA has positioned itself to allow
clinical practices to evaluate their
performance and patient outcomes. It
seems that what the new frontier was
then has become the expectation today
from both our patients and payers.
SAMBA recognizes that ambulatory anesthesia as a

practice encompasses much more than what occurs solely in an
ambulatory surgery center. Office-based anesthesia also has its
home within SAMBA and in many ways represents today what
ASCs did decades ago; there is no doubt that OBA practices will
continue to evolve in the coming years. Remote or non-O.R.
anesthesia is also making its presence known within SAMBA
as hospital-based practices realize ambulatory anesthetic
techniques can greatly improve patient care and efficiency in
these off-site locations.
To remain relevant over the next 30 years, SAMBA will
have to evolve to best serve its members. However, the focus on
excellence in education and patient outcomes will remain at the
forefront of SAMBAs mission.
Brian M. Parker, M.D. is Medical

Director, Hospital Operations,
Cleveland Clinic; Associate Professor
of Anesthesiology, Cleveland Clinic
Lerner College of Medicine of Case
Western Reserve University.
62
September 2014
Volume 78
Number 9
MAKE STRIDES
Study at your own pace and test your knowledge with this
go-anywhere, online program that allows you to pinpoint areas of
pain medicine where you excel and areas where you may benefit
from further study. Close the gaps in your knowledge while making
progress toward meeting CME and MOCA requirements at the
same time.
Where will your education take you?
MOCA
Learn more
education.asahq.org/12sampm

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.
14-072
residents review
Learning to Cope
Shortly after I made the decision to specialize in

anesthesia, my mother gave me a copy of a book she had
just started reading, Oxygen by Carol Cassella, and suggested
I might enjoy it as well. After all, the main character is a young
anesthesiologist. At the risk of sounding a bit book-clubish,
I absolutely loved it tearing through its pages as only the
refreshed mind of a fourth-year medical student can, picturing
my own future career. But as the story developed, I became
acutely conscious of an aspect of my profession to which I had
paid little attention before, and as residency approached, I found
the book seemed to haunt me.
The plot revolves around an intraoperative error and its
wide-reaching ramifications, both professionally and
emotionally, for its main character. In those last few bright
days of relative innocence as medical school drew to a close,
it dawned on me that, in but a short time, I would be making
choices unlike any I had made before, choices that would affect
my patients lives much more than they would affect mine.
These are choices that, if flawed, could well be irrevocably
harmful to another human being. I was, of course, always aware
that a physician carries great responsibility in this regard, but I
was aware of it more in the way that a person is aware that an
elephant is very heavy, having only ever seen one in the zoo.
As I began writing my first orders as an intern and, as a matter
of course, making my first mistakes, I began to actually feel the
weight, as if that elephant had raised its massive foot and placed
it squarely over my midsection.
As physicians, coping with our own mistakes is not an easy

task. Mistakes, and the subsequent feelings of anxiety and
inadequacy they cause, contribute significantly to physician
burnout and dissatisfaction. They can be motivating factors
behind major career changes and have been linked to posttraumatic stress disorder, depression and substance abuse among
physicians as well.
A classmate of mine recently asked one of our faculty
members to share with us how he deals with mistakes. He is
a much-admired anesthesiologist both in our department and
across the country someone I can only with difficulty imagine
actually making a mistake. Hearing his honest reflections on
some of the more challenging moments in his career was both
eye-opening and reassuring. At least in my limited realm of
experience, it has been rare that a discourse on this subject take
place, and I found my classmates question extremely thoughtful
and indicative of a need for more structured education and
training in how to cope after making a mistake.
Spurred on by a well-known 1999 report by the Institute of
Medicine called To Err Is Human, numerous publications over
the last decade have studied the best ways to address medical
errors. My medical school, like many, offered a curriculum in
Kristina L. Goff, M.D. is an

Anesthesia Critical Care fellow,
University of Washington, Seattle.
64
September 2014
Volume 78
Number 9
medical ethics, which addressed dealing with errors, the best

ways to share information with patients and their families,
and whether and how to apologize to them. While all of
this information is valuable in guiding physicians in their
interactions with patients and patients families, unfortunately,
the focus has very infrequently turned inward.
In recent years, some strides have been made toward

educating physicians and opening forums for discussion with
a focus more on the physician psyche. It would be prudent to
incorporate this during residency training as well. The M&M
conference is a familiar enough entity, in which we review cases
with poor outcomes, hoping to find ways to improve our decisionmaking for the future. A newer concept, termed the Schwartz
Center Rounds program, provides for an interdisciplinary
discussion centered around an identified case, but focusing on
the more human elements involved, including the frustrations
and doubts a physician, nurse or other health care worker may
feel in carrying out his or her job. In this way, physicians may
find more support in their work environment.
It is also important to identify mentors early in training,
and it should be incumbent on both the faculty mentor and the
residency program to help foster this relationship and encourage
a non-judgmental, open dialogue between advisor and advisee.
The subject of mistakes should be broached with each trainee
in a non-threatening way so that residents feel more inclined to
seek guidance in coping.
Residents should be made aware of the resources available to
them through employee health and graduate medical education
should they feel the need to seek additional help. Many
physicians dealing with anxiety can benefit from counseling and
behavioral therapy, and this must be a readily available option.
In Carol Cassellas words, to be an excellent physician you
must accept the possibility of failure. A doctor who considers
himself infallible is a most dangerous creature. Knowing this is
the case, should we not also invest time in educating ourselves
so that we may better cope with our mistakes?
As physicians, coping with our

own mistakes is not an easy task.
Mistakes, and the subsequent feelings
of anxiety and inadequacy they cause,
contribute significantly to physician
burnout and dissatisfaction.
We receive little coaching on how to process the emotional

impact of our mistakes and move forward. Furthermore, it
is often intimidating to seek help or advice after a misstep
during residency, and even more so thereafter because of the
implicit admission of guilt required in doing so. Aside from the
embarrassment factor, many physicians are also concerned about
the potential legal consequences of discussing such issues. We
are essentially all in this same boat, struggling with the same
issues rather blindly, resulting in a self-perpetuating culture of
isolation that is harmful to both our patients and ourselves.
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September 2014
Volume 78
Number 9
65
anesthesiology in the news
ANESTHESIOLOGY
Perioperative Surgical Home Model
in Modern Healthcare
IN
THE
NEWS
Scope-of-Practice Issue on NPR Affiliate
Michigan Radio, part of the NPR digital network,

featured the scope-of-practice issue in June. ASA
member and Committee on Communications Chair
Kenneth Elmassian, D.O. discussed how more
authority for nurses will lead to slower care for
Michiganders. Dr. Elmassian said that autonomy
will end in nurses wanting to practice independently
from physicians.
ASA President Jane C.K. Fitch, M.D. authored a

column in Modern Healthcare in July proposing the
Perioperative Surgical Home (PSH) model of care.
Dr. Fitch suggested the PSH as a solution to our
countrys fragmented hospital surgery system.
The article ran in the print and online editions
of the magazine.
The PSH was also featured on KevinMD.com in a
guest column authored by Dr. Fitch in June, where
she discussed how the model leads to better
outcomes and lower costs.
What Should You Ask Your

Physician Anesthesiologist?
On the local NBC Chicago affiliate station, ASA

member David Rosen, M.D. gave advice to patients
about to have surgery. Dr. Rosen recommended
patients ask if there will be an attending physician
anesthesiologist, and ask any questions they have
before going in for the procedure. He emphasized
that patients should be honest with their physician
anesthesiologists, particularly when they forget to
heed preoperative instructions.
Widespread Chronic Pain in Veterans
In July, ASA member and pain specialist at

Pittsburghs VA Medical Center, Michael Mangione,
M.D., discussed widespread chronic pain among
veterans with a local CBS Pittsburgh affiliate.
Dr. Mangione stressed the prevalence and severity
of chronic pain in those who have served and how
comprehensive treatment is imperative to quality
care for this patient population.
Traveling with Chronic Pain
ASA member John Dombrowski, M.D. gave

advice to summer travelers with chronic pain on
Healthline.com in June. Dr. Dombrowski told
Healthline that many people who suffer from
chronic pain do not know they can get long-lasting
injections to ease their discomfort. He suggested
that travelers plan ahead for their medical care
just as they do with their airline tickets and
travel insurance.
Epidural Myths Debunked in Chicago Tribune
Paloma Toledo, M.D., M.P.H. explained myths and

realities about epidurals during labor in an article
published by the Chicago Tribune. Dr. Toledo
provided facts about epidurals to help readers
make their decision regarding pain management
during pregnancy. The article was published on more
than 1,000 websites, including the San Francisco
Chronicle and the Milwaukee Journal Sentinel.
Anesthesiology Study Identifies

New Compound to Treat Depression
Same-Day Surgery Advice in Readers Digest
ASA member Steven Gayer, M.D. was quoted in a

Readers Digest story about what patients should do
before same-day surgery. Dr. Gayer advised patients
to make sure their fingernails are polish-free, as the
pulse oximeter must be able to send and receive light
through the fingertip, and acrylics and other nail
coatings interfere.
Researchers identified a compound,

hydroxynorketamine, which treats symptoms
of depression as effectively and rapidly as ketamine,
without unwanted side effects. The study was
featured in several outlets, including The Times
(London), Medscape and Science World Report.
66
September 2014
Volume 78
Number 9
GHO Heads Back to Rwanda
ASA member Michael Heine, M.D. led a trip to

Rwanda in July to provide education and training
in anesthesia. The mission was featured on several
websites, including KyForward, Beckers ASC
Review and News-Medical.net. Dr. Heine previously
volunteered in Africa with ASAs original outreach
initiative Overseas Training Program, then run by
founder Dr. Nicholas M. Greene.
PONV Prevention and Treatment
ASA member Steven Gayer, M.D. authored an

article in the July issue of Outpatient Surgery
Magazine on the prevention of PONV. Dr. Gayer
stressed the importance of planning ahead for
surgical patients and potentially new and better
treatments for the nausea and vomiting some
patients endure after surgery.
Avoiding Intubation Trauma Among Patients
In the July issue of Outpatient Surgery Magazine,

ASA member Robin Elwood, M.D. discussed
intubation trauma. Dr. Elwood covers a number
of topics in the article, including occurrence rates
of intubation trauma, recognizing vulnerable
patients and alternative options, such as video
laryngoscope.
Surgical Patients More Likely to Comply

with an Instruction Sheet
A study in the July issue of Anesthesiology

revealed that patients who receive a simple,
multicolor, standardized medication instruction
sheet before surgery are more likely to comply
with their physicians instructions and experience
a significantly shorter post-op stay in recovery.
The study was picked up in Medscape,
OutpatientSurgery.net and DailyRx.
ASA Applauded for Malpractice

Lawsuit Assessment
ASA was applauded for conducting a

comprehensive assessment in 1982 and
ultimately revamping procedures, training,
machines and safety devices on KevinMD.com
in June. The article mentioned the mortality
rate from anesthesia dropped from 1 in 6,000
administrations to 1 in 200,000 during a
10-year period, and physician anesthesiologists
malpractice insurance rates fell to among
the lowest of any specialty.
One Members Story of Challenge, Success

and Heartbreak in Kenya
Donna-Ann Thomas, M.D. authored a guest

column on KevinMD.com in May about her mission
trip to Kenya. Dr. Thomas discussed her experience
in the East African country, including a number of
challenges she encountered, such as the physician
strike over wages and equipment. Due to the
strike, Dr. Thomas was the only health care team
available in the area aside from private hospitals.
Choosing Wisely List of Tests and

Procedures to Avoid
The list released in 2013 as part of the ABIM

Foundations Choosing Wisely campaign
continues to garner coverage. The list featured
five common tests and procedures patients should
avoid and was published in JAMA Internal
Medicine in June. ASA member and senior author
of the article Lee Fleisher, M.D. was interviewed
on Tampa Bay WHNZ radios Health, Wealth and
Wisdom, where he discussed the campaign and
its relevance to patients.
September 2014
Volume 78
Number 9
67
asa news
Candidates Announced for Elected Office

Since an announcement was made in the April
NEWSLETTER, 10 ASA members have declared their
candidacies for elected offices. In August, the Candidates
Vice President for Scientific Affairs
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:
Linda J. Mason, M.D.
Secretary
Treasurer
Assistant Secretary
John F. Dombrowski, M.D.
Assistant Treasurer
Mary Dale Peterson, M.D.
President-Elect
Speaker, House of Delegates
Daniel J. Cole, M.D.
Steven L. Sween, M.D.
First Vice President
Vice Speaker, House of Delegates
Jeffrey Plagenhoef, M.D.
Ronald L. Harter, M.D.
Vice President for Professional Affairs

Stanley W. Stead, M.D., M.B.A.
IN MEMORIAM
Lafe W. Bauer, M.D.
Prairie Village, Kansas
March 14, 2014
Glen C. Hutchison, M.D.

Hays, Kansas
May 9, 2014
S. R. Sellaro, D.O.
Erie, Pennsylvania
June 20, 2014
James J. Berny, M.D.

Boardman, Ohio
November 19, 2013
Jordan Katz, M.D.

Solana Beach, California
June 28, 2014
Byron G. Sherman, Jr., M.D.

Manchester Center, Vermont
July 29, 2013
Brad N. Brian, M.D.

St. George, Utah
May 7, 2014
Jay W. Lang, MD.

Carmel, Indiana
July 8, 2014
David H. Skinner, M.D.

Laguna Hills, California
July 30, 2014
Chad Cripe, M.D.

Philadelphia, Pennsylvania
February 1, 2014
Hugh S. Mathewson, M.D.

Overland Park, Kansas
November 26, 2012
Raymond D. Sphire, M.D.

Grosse Pointe Farms, Michigan
November 5, 2013
Gifford V. Eckhout, Jr., M.D.

Tyler, Texas
June 22, 2014
Thomas McCaughey, M.D.

Montreal, Quebec, Canada
December 23, 2013
Kenneth Sugioka, M.D.

Chapel Hill, North Carolina
June 19, 2014
Eduardo M. Figallo, M.D.

Pittsburgh, Pennsylvania
April 15, 2014
Robert D. McKay , M.D.

Bristol, Tennessee
May 19, 2014
Hildegard Wessel-Manitsas, M.D.

McLean, Virginia
April 24, 2014
68
September 2014
Volume 78
Number 9
Response From Drs. Warner

and Berge:
Thank you for your comment, which prompted us to

re-examine our data, originally analyzed by grouping
those who used either cocaine or marijuana. Although
most marijuana use was associated with the use of other
drugs, of the eight individuals whose records indicated only
marijuana use for their initial episode of substance use disorder,
two (25 percent) achieved board certification, and two
(25 percent) relapsed, proportions similar to that observed
for the entire group of 384 residents. We also note that of the
56 individuals with a history of substance use prior to use in
residency, 24 (43 percent) had used marijuana. Fortunately,
none of these individuals died. Although it is difficult to make
comparisons with such low numbers (which is why we originally
grouped the categories for analysis), these data suggest that the
consequences of marijuana use can be serious.
In their otherwise valuable article Substance Use

Disorder in Anesthesiology Residents: Still a Serious
Problem in the July ASA NEWSLETTER, Drs. Warner
and Berge assert that intravenous opioid use is [not]
any more dangerous than any other substance, including
alcohol and illicit drugs such as cocaine and marijuana. Since
there are few, if any, deaths attributable to marijuana, this
statement seems prejudicial and belief-based, not factual.
Lucille Mostello, M.D.
Silver Spring, Maryland
David O. Warner, M.D.

Rochester, Minnesota
Keith Berge, M.D.
Rochester, Minnesota
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.
September 2014
Volume 78
Number 9
69
letters to the editor
Reader Wants Beliefs Weeded Out

of Facts on Marijuana
FAER Report
2015 Research Grant Funding and Medical Student Fellowship
Opportunities Announced Applications Open This Fall
Denham S. Ward, M.D., Ph.D.
Coming off of the heels of its commitment to fund $2.5

million in new research grants in 2014 and awarding the firstever year-long medical student research fellowships, the board
of directors of the Foundation for Anesthesia Education and
Research (FAER) is pleased to announce FAERs 2015 research
grant funding and medical student fellowship opportunities.
FAER provides research grant funding for physician
anesthesiologists, anesthesiology trainees and medical
students to gain additional training in basic science, clinical
and translational, health services and education research. For
early-career anesthesiologists interested in pursuing careers as
physician-scientists, FAER grants can be an important starting
point. These grants aim to help physician anesthesiologists
develop the skills and preliminary data they need to become
independent investigators.
Mentored Research Training Grants

Research Areas: Basic Science (MRTG-BS)

Clinical and Translational (MRTG-CT)

Health Services Research (MRTG-HSR)
Purpose: To help physician anesthesiologists develop
the skills and preliminary data to become
independent investigators
For Whom: Faculty members who completed core
anesthesiology residency within the
past 10 years
Funding:
$175,000
Duration:
Two years
Percent Research: 75%
Research Fellowship Grant
Research Areas: Basic Science, Clinical and Translational,
Health Services or Education
Purpose: To provide significant training in research
techniques and scientific methods
For Whom:
Anesthesiology trainee after the CA-1 year
Funding:
$75,000
Duration:
One year
RESEARCH GRANT FUNDING

2015 OPPORTUNITIES
The following research grant funding opportunities are
available to physician anesthesiologists and anesthesiology
trainees. The application website for the 2015 grant funding
cycle will open November 1, 2014. The deadline for applications
is February 15, 2015.
For more information regarding FAER grants and eligibility
requirements, visit FAER.org/research-grants or call the
FAER office at (507) 266-6866.
Research in Education Grant

Research Areas: Education Research
Purpose: To improve the quality and impact of
anesthesiology education research
For Whom: Faculty member of any rank
(junior or senior faculty)
Funding:
$100,000
Duration:
Two years
Denham S. Ward is President and CEO,

Foundation for Anesthesia Education
and Research, and Emeritus Professor
of Anesthesiology and Biomedical
Engineering, University of Rochester
Medical Center, Rochester, New York.
RESEARCH GRANT APPLICATION KEY DATES

Online application opens November 1, 2014
Applications due February 15, 2015
Award notifications made by May 15, 2015
Project start date July 1, 2015 or January 1, 2016
70
September 2014
Volume 78
Number 9
RESEARCH GRANT ELIGIBILITY CRITERIA

UPDATED FOR 2015
The FAER Grant Management Committee has made a few
changes and clarifications to the eligibility criteria and rules for
research grant funding.
n Applicants may submit only one grant application per award
cycle.
n Tuition is not allowed in the budget for any grant.
n The applicant and the primary mentor for the grant must be
at the same institution.
Medical Student Anesthesia Research Fellowship

(MSARF) Year-Long Program
FAERs year-long medical student fellowship is for those who
would like to spend a year focusing on anesthesiology research
and receive additional training, and who have completed their
core clinical rotations but have not yet graduated. Students who
participate in the 2015-16 program will present their research at
the 2016 ASA annual meeting.
Through the program, medical student fellows can expect:
n One year of full-time research in anesthesiology.
n
A formal mentor-protg relationship with an experienced
investigator.
n Training in scientific methods and research techniques.
n
A $32,000 stipend, plus additional funding to cover
relocation, housing, health insurance, travel to a national
meeting and other related expenses.
To view the complete eligibility requirements and application

guide, visit FAER.org/research-grants.
MEDICAL STUDENT FELLOWSHIPS

2015 OPPORTUNITIES
FAERs Medical Student Anesthesia Research Fellowships
provide funding to support medical students over a summer or a
year in focusing on anesthesiology research, training in scientific
methods and techniques, and learning how to incorporate
research into a medical career.
Medical student anesthesia research fellowships are awarded
through an annual application cycle.
For more information about the MSARF program and
eligibility requirements, visit FAER.org/MSARF.
Student Application Key Dates (Year-Long Program)

Applications due December 31, 2014
Award notifications made by February 15, 2015
Fellowships take place starting late spring/summer 2015
Medical Student Anesthesia Research Fellowship

(MSARF) Summer Program
The summer fellowship provides medical students with
an eight-week research experience within an academic
anesthesiology department. During the fellowship, students
participate in research and training activities, as well as clinical
anesthesia activities. In addition, medical student summer
fellows have the opportunity to make a scientific presentation
at the ASA annual meeting. Students receive a stipend during
the fellowship.
You can create a better future for anesthesiology by

making a donation to FAER. When you give, you enable
the careers and education of anesthesiologists who
will bring about new knowledge, scientific discoveries
and progress in patient care.
Here are ways you can make your gift today:
Online: Visit FAER.org/donate to make a gift
using our secure gift form.
Student Application Key Dates (Summer Program)

Applications due December 15, 2014
Award notifications made by January 31, 2015
Fellowships take place throughout late spring / summer 2015
By Mail: Mail your donation to FAER at

P.O. Box 157, Rochester, MN 55903-9941
By Phone: Call FAERs office at (507) 266-6866 to
make your gift. Our business hours are
Monday through Friday, 8 a.m. to 5 p.m. CT.
Host Department Application Key Dates (Summer Program)

Online application opens September 1, 2014
Applications due October 1, 2014
Match results announced by January 31, 2015
Fellowships take place throughout late spring/summer 2015
September 2014
Volume 78
Number 9
Donate to Support Research

in Anesthesiology
Thank you for your generosity!
71
NEWSLETTER
PROFESSIONAL SERVICES
2014 Classified Advertising

POSITIONS AVAILABLE PROFESSIONAL
SERVICES FELLOWSHIPS SEMINARS
MEETINGS TUTORING VACATION RENTALS
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.
Anesthesia
Business
Consultants
is the most comprehensive practice

management
company
specializing
in the practice of anesthesia & pain
management. See our ad on page 21 or
visit us @ www.anesthesiallc.com.
BLACK & WHITE DISPLAY AD RATES

1/3 page
Frequency 1/12 page 1/6 page
1x
$1,033 $1,840
$3,230
3x
$1,000 $1,780
$3,120
COLOR DISPLAY ADS
Euroanesthesia 2014
ASA MEMBER BENEFIT
MECHANICAL REQUIREMENTS
Society (IARS). These societies will be exhibiting and conducting

educational sessions at the ANESTHESIOLOGY 2014 annual
meeting in New Orleans.
Please contact Julie OHeir, Corporate Development

Manager for details.
30% discount off Line Rate. Display Ad rate discount
available. Please contact Julie OHeir, Corporate
Development Manager for details.
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
1/6 page
1/3 page
2 x 2 2 x 4 4 3/4 x 4
CLOSING DATES:
Issue Deadline
JANUARY
November 21
FEBRUARY
December 20
MARCH
January 30
APRIL
February 26
MAY
March 25
JUNE
April 25
JULY
May 24
AUGUST
June 24
SEPTEMBER July 26
OCTOBER
August 26
NOVEMBER
September 24
DECEMBER
October 29
Extending ASAs Global Reach

With a growing international presence at its annual meeting (25
percent of attendees in 2013), ASA acknowledges its role as a world
leader in anesthesia education and plans to offer multiple sessions with
a global perspective at this years meeting, themed Global Leaders in
Outcomes, Education, Safety and Discovery. ASA will also participate
in influential anesthesia meetings around the globe.
ESAs panel at the ANESTHESIOLOGYTM 2014 annual meeting
in New Orleans, titled Challenges in Anesthesiology: A European
Perspective, will take place on Saturday morning, October 11.
Four additional international panels will be featured at the
ANESTHESIOLOGYTM 2014 annual meeting, including the
WFSA panel Government Funded Healthcare and Anesthesia: An
International Perspective on Successes and Failures on Sunday
morning, Professionalism An International Perspective, and
Perioperative Management of Patients with Endocrine Disease:
A Global Perspective, also on Sunday, and International Forum on
Patient Safety and Quality Outcomes on Monday morning.
Correspondingly, ASA plans to participate in the 2014 CSA
Academic Annual Meeting in Chengdu, China, Euroanaesthesia
2015 in Berlin, IARS 2015, and the WFSA WCA 2016 meeting in
Hong Kong.
SALES:
Christine Kenney, National Sales Manager
The Walchli Tauber Group, Inc.
Mobile: 443-252-0571
Phone: 443-512-8899, ext. 115
Email: christine.kenney@wt-group.com
REACH MORE QUALIFIED
ANESTHESIA CANDIDATES.
Advertise online at careers.asahq.org.
72
Mark your calendars for the premier educational event for physician anesthesiologists and
practice administrators:
Learn from leading experts about critical topics such as Group Governance,
Risk Management, and Bundled Payments
Gain insight into current healthcare regulations, legislation and how changes may affect
your anesthesiology practice
Obtain strategies to improve practice performance and your bottom line
Join us
education.asahq.org/pm
14-140
This activity has been approved for AMA PRA Category 1 Credit. Directly Sponsored by the American Society of Anesthesiologists.
Interested in conducting
your own research?
Consider the Merck Investigator Studies Program.
What is MISP?
The mission statement of the Merck Investigator
Studies Program (MISP) is to advance science and
improve patient care by supporting, through the
provision of drug/vaccine and total/partial funding,
high-quality research that is initiated, designed,
implemented and sponsored by external investigators.
Who Can Participate?
The Merck Investigator Studies Program is open
to all academic and community-based physicians,
anesthesiologists, surgeons, and researchers
worldwide who are interested in conducting their
own research.
How to get started:

To learn more about the areas of interest for
anesthesia and requirements for submission visit
http://engagezone.merck.com/anesthesia.html.
There are two review cycles for anesthesia
submissions:
First cycle deadline is in early

February 2015.
Second cycle deadline is in early
April 2015.
How Does the Program Work?

This program consists of committees of medical and
scientific staff from different therapeutic areas who
meet regularly to review Merck investigator study
proposals. Support and funding are provided
based on the scientific merit of the proposal as well
as whether it is in alignment with the published areas
of interest.
Copyright 2014 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
All rights reserved. Printed in USA ANES-1124773-0000 07/14
ANES-1124773-0000.indd 1
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Improve patient outcomes and practice efficiency

with ASA quality improvement resources

Register now for the premier educational event

28th Annual Meeting - Oct. 10

SNACC: Society for Neuroscience in

42nd Annual Meeting - Oct. 9-11

SAMBA: Society for Ambulatory

2014 Mid Year Meeting - Oct. 10

SEA: Society for Education in

2014 SEA Fall Meeting - Oct. 10

SOAP: Society for Obstetric

Board of Directors Meeting - Oct. 10-11

AUA: Association of University

Committee Meeting - Oct.12

Volume 78, Number 9

The Subspecialty of Ambulatory

Safe Anesthesia in the Office-Based

Adult Patient for Ambulatory Surgery:

Send general NEWSLETTER questions

POSTMASTER: Send address changes to the

Hernando De Soto, M.D.

Outpatient Continuous Peripheral

Henrik Kehlet, M.D., Ph.D. to Receive

Scientific and Educational Exhibits at

Francesco Carli, M.D., M.Phil., FRCA, FRCPC

Dean F. Connors, M.D., Ph.D.

John B. Neeld, Jr., M.D. 2013 Recipient

Rebecca A. Aslakson, M.D., Ph.D.

Whats New In ...

Committee on Trauma and

Society for Ambulatory Anesthesia................ 62

N. Martin Giesecke, M.D.

30 Anesthetics on the Same Child Really!

Quality and Regulatory Affairs............... 52

Kristina L. Goff, M.D.

Anesthesiology in the News................... 66

THE PERFECT COMBINATION.

ASA Corporate Supporters help create

ASA ANNUAL MEETING SUPPORTERS

Likely, youve read about my first

N. Martin Giesecke, M.D.

who went on vacation. For a brief time

one, though by the time I knew him, he

About to fly in the real thing

published in 1988.1 And even prior

had the education and training to

watch. In one situation, we played out

1. Caplan RA, Ward RJ, Posner K, Cheney

James D. Grant, M.D.

Our world is becoming increasingly complex, but coming

But from where will we lead this change? We will lead it

The world is surely changing before our eyes. Look at what

James D. Grant, M.D. is Chair,

On the state level, there are two physician anesthesiologists

contemporary anesthesiology is founded on the tenet that

Our metrics were good.

~Alan Gwertzman, M.D.

Is it time to consider a sale or merger?

Paul Pomerantz, CEO

As I write this report, much of the ASA staff is busy

Perioperative Surgical Home (PSH) Learning Collaborative

Specifically, the PSH Learning

Building External Relationships

Paul Pomerantz is ASA

1. Caplan RA, Ward RJ, Posner K, Cheney

Specifically, the PSH Learning

1. Cullen KA, Hall MJ. Golosinskiy A. Ambulatory surgery in

Significant advancements in patient

5. Coldiron B, Shreve E, Balkrishnan R. Patient injuries from surgical

1. Kurrek MM, Twersky RS. Office-based anesthesia: how to start an

Overall, the literature on optimal

1. Lovald S, Ong K, Lau E, Joshi G, Kurtz S, Malkani A. Patient selection

1. Wilson RR. Radiological use of fast protons. Radiology. 1946;47(5):

Compared to single-shot PNBs,