BACKGROUND & AIMS: Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA), as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated healthcare delivery system with a capitated payment model.
METHODS: We performed a retrospective cohort study using multi-level logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 Veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities.
RESULTS: The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% CI, 1.09-1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, though the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, though again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use.
CONCLUSIONS: In retrospective study of Veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically-meaningful patient factors.
Anti-Obesity and Weight Loss (1) Obstructive Sleep Apnea (1), Obesity (1), more mentions
BACKGROUND & AIMS: The increase in use of anesthesia assistance (AA) to achieve deep sedation with propofol during colonoscopy has significantly increased colonoscopy costs without evidence for increased quality and with possible harm. We investigated the effects of AA on colonoscopy complications, specifically bowel perforation, aspiration pneumonia, and splenic injury.
METHODS: In a population-based cohort study using administrative databases, we studied adults in Ontario, Canada undergoing outpatient colonoscopy from 2005 through 2012. Patient, endoscopist, institution, and procedure factors were derived. The primary outcome was bowel perforation, defined using a validated algorithm. Secondary outcomes were splenic injury and aspiration pneumonia. Using a matched propensity score approach, we matched persons who had colonoscopy with AA (1:1) to those who did not. We used logistic regression models under a generalized estimating equations approach to explore the relationship between AA and outcomes.
RESULTS: We analyzed data from 3,059,045 outpatient colonoscopies; 862,817 of these included AA. After propensity matching, a cohort of 793,073 patients who had AA and 793,073 without AA was retained for analysis (51%, female; 78% were age 50 years or older). Use of AA did not significantly increase risk of perforation (odds ratio [OR], 0.99; 95% CI, 0.84 - 1.16) or splenic injury (OR, 1.09; 95% CI, 0.62 - 1.90]. Use of AA was associated with an increased risk of aspiration pneumonia (OR, 1.63; 95% CI, 1.11 - 2.37).
CONCLUSIONS: In a population-based cohort study, AA for outpatient colonoscopy was associated with a significantly increased risk of aspiration pneumonia but not bowel perforation or splenic injury. Endoscopists should warn patients, especially those with respiratory compromise, of this risk.
Regional anesthesia is of benefit for outpatient surgery given its demonstrated improvement in analgesia and decrease in complications, resulting in shorter average recovery room ... the United States.We identified all cases from the National AnesthesiaClinical Outcomes Registry that were performed as an outpatient surgery... analyzed by using logistic regression.Of the 12,911,056 outpatient surgeries in the National AnesthesiaClinical Outcomes Registry, 3,297,372 (25.5%) were amenable to a ...
OBJECTIVE/BACKGROUND: The first paper in this series observed that pre-operative baroreceptor dysfunction and poorly controlled hypertension were independently predictive for identifying patients who went on to require treatment for post-endarterectomy hypertension (PEH). The second paper examines the influence of intra-operative patient, transcranial Doppler (TCD) ultrasound, and anaesthetic variables on the incidence of PEH.
METHODS: In total, 106 patients underwent carotid endarterectomy (CEA) under general anaesthesia. Systolic blood pressure (SBP) changes, anaesthetic and vasoactive agents, analgesia, and post-operative pain scores, as well as TCD derived changes in middle cerebral artery (MCA) velocity during surgery were recorded. Patients who met pre-existing unit criteria for treating PEH after CEA (SBP > 170 mmHg without symptoms or SBP > 160 mmHg with headache/seizure/neurological deficit) were treated according to an established and validated protocol.
RESULTS: In total, 40/106 patients (38%) required treatment for PEH following CEA (26 in theatre recovery [25%], 27 back on the vascular surgery ward [25%]), whereas seven (7%) had SBP surges > 200 mmHg on the ward. Patients requiring treatment for PEH had significantly higher pre-induction SBP (174 ± 21 mmHg vs. 153 ± 21 mmHg; p < .001), the greatest decreases in SBP after induction of anaesthesia (median decrease 100 ± 32 mmHg vs. 83 ± 24 mmHg; p = .01) and were significantly more likely to experience moderate/severe pain scores post-operatively (p = .003). Logistic regression analysis of the pre- and intra-operative data revealed that higher pre-induction mean SBP and lower pre-operative (impaired) BRS were the only independent predictors of PEH.
CONCLUSION: This analysis of intra-operative variables has demonstrated that patients with poorly controlled and/or labile hypertension at induction of general anaesthesia were those at greatest risk of requiring treatment for PEH in the post-operative period after CEA. No other variables, including use of vasopressors, treatment of hypotension, anaesthetic agents, or changes in MCA velocity after clamp release and restoration of flow were able to predict who might go on to require treatment for PEH. Identification of at-risk individuals and aggressive blood pressure control in the post-operative period remains the mainstay of treatment.
AbstractText: Previous literature has shown that propofol has ideal anesthetic properties for patients undergoing colonoscopy, a common procedure at outpatient surgery centers ... evaluate patient satisfaction with propofol compared with nonpropofol (fentanyl/midazolam) anesthesia for outpatient colonoscopies... prefer propofol over a combination of fentanyl/midazolam as their anesthetic for outpatient colonoscopies.
In these countries, patient identifiable data will be used to link prospectively collected data with national registers of death and inpatient administrative data. The study findings will be disseminated using a multimedia approach with the support of our lay collaborators, to patients, public, policy-makers, clinical and academic audiences Keyword: anaesthetics. Keyword: epiemiology.
... analysis, the authors evaluated the pain during scaling and root planing with use of topical anesthetic versus that with the use of injected anesthetic in adult patients AbstractText: The authors searched 6 databases for randomized clinical trials in which the investigators compared the clinical effectiveness of intrapocket and injectable anesthetics.
INTRODUCTION: Recent studies have shown that deep anaesthesia is associated with poor outcomes. However, no randomised controlled trials have been conducted to test the causality in patients undergoing brain tumour resection.
METHODS AND ANALYSIS: DEPTH is a multicenter, randomised, parallel-group, blind trial. The depth of general anaesthesia will be monitored using the bispectral index (BIS). Patients elected for supratentorial tumour resection will be randomly allocated to the deep or the light anaesthesia group in which the target BIS value is 35 or 50, respectively. BIS will be maintained at the target value for more than 90% of the total anaesthesia period. The primary outcome is the disability-free survival rate at postoperative 30 days and 1 year. The secondary outcomes are the mortality and morbidity within 30 days after surgery.
ETHICS APPROVAL AND DISSEMINATION: Ethical approval has been granted by the Medical Ethics Committee of Beijing Tiantan Hospital, Capital Medicine University. The reference number is KY2016-059-02. The results of this study will be disseminated through presentations at scientific conferences and publication in scientific journals.
TRIAL REGISTRATION: NCT03033693.
National data were obtained from interviews with KATH personnel, correspondence with Ghana's anesthesia society, and review of public records.The practice of anesthesia at KATH incorporated preanesthesia clinics, intraoperative management, and critical care. However, there were not enough physicians to consistently supervise care, especially in postanesthesia care units (PACUs) and the critical care unit (CCU.
At one center, 161 consecutive patients scheduled for collagenase injection were assigned to two groups by alternating outpatientclinics; 78 received collagenase without local anesthesia using a modified method (injecting 0.80 mg in multiple spots in the cord) and 83 received local anesthesia injected in the proximal palm before collagenase ...
Muscular and Skeletal Diseases (1) Contracture (3), more mentions
Methods -The NCDR STS/ACC TVT Registry was used to characterize the anesthesia choice and clinical outcomes of all U.S. patients undergoing elective percutaneous transfemoral TAVR between April 1, 2014 and June 30, 2015. Raw and inverse probability of treatment weighted (IPTW) analyses were performed to compare general anesthesia patients with conscious sedation patients on an intention-to-treat ...
The reported clinical outcome measures for procedures done under general anesthesia (GA) compared to traditional local anesthetic (LA) technique are quite heterogeneous and difficult to compare. The aim of this systematic review and metaanalysis was to determine whether the clinical outcome after STN-DBS insertion under GA is comparable to that under LA in patients with Parkinson's disease.The databases ...
Neurological and Central Nervous System Diseases (4) Parkinson Disease (4), more mentions
We performed a systematic review and meta-analysis of studies comparing clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group).A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate ...
Cardiovascular Diseases (5) Stroke (5), Intracranial Hemorrhages (1), more mentions
... in the PLN of 54 consecutive patients, 34 of whom presented with a nodule of less than 20mm. 76% of procedures were performed under local anesthesia, on an outpatient basis. Median long and short axis diameters of nodules were 15mm (9-20mm) and 11mm (6-20mm), respectively, with 31 of 34 nodules exhibiting a short axis of less than 15mm.
This combined procedure is preferentially performed in an outpatient setting under monitored anesthesia care and nerve blocks AbstractText: This study was a 14-year retrospective review of a single surgeon's technique and outcomes using transabdominal breast augmentation through a low transverse abdominoplasty incision in select patients requesting simultaneous abdominoplasty and ...
Smoking Cessation (1), Anti-Obesity and Weight Loss (1) Seroma (1), Infections (1), more mentions
However, whether sedation and/or analgesia can benefit the clinical outcome of the patients with interface intolerance is still unclear.A ... P = 0.008), and the length of ICU stay after extubation.This clinical study suggests that sedation and/or analgesia treatment can decrease the rate of NIPPV failure, hospital mortality rate ...
... did not differ between groups AbstractText: In female patients undergoing elective laparoscopic gynaecological surgery, dexamethasone administration appears to attenuate inflammation and to alter immune cell counts at 24 h, with no effects identified after this time. The importance of these changes for postoperative immune function is unknown AbstractText: Australia and New Zealand Clinical Trials Registry (ACTRN12608000340336) Keyword: anaesthesia. Keyword: dexamethasone.
The purpose of this article is to review complications and unplanned hospital admissions in patients presenting for ambulatory procedures requiring anesthesia care in the gastrointestinal endoscopy, bronchoscopy, and radiology suites.The range of ambulatory diagnostic and therapeutic procedures being undertaken in the gastrointestinal endoscopy, bronchoscopy, and radiology suites is expanding ...
Anti-Obesity and Weight Loss (1) Obstructive Sleep Apnea (2), Obesity (1), more mentions
Outpatient surgery, minimally limited mobility, sutureless incisions, and topical anesthesia also have become key components of standard treatment. The author envisions availability of medications for nuclear sclerosis and presbyopia, expansion of lens surgery for refractive purposes with post-surgical adjustment and unprecedented precision, increased mechanization of lens removal with emphasis on uncomplicated surgery rather than refractive precision, and accommodating IOLs ...