A M E R I C A N S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S Volume 16 Number 2 2004 www.ascca.org President’s Message On the Right Track: ASCCA in Good Hands T his is my last “President’s Message.” In October, Michael J. Breslow, M.D., takes over as ASCCA President, and I will move on to assume the position of Immediate Past President. Following Dr. Breslow will be Steven O. Heard, M.D., with Gerald A. Macci- oli, M.D., in the wings. ASCCA is in good hands. My tenure represents the first time that an ASCCA President has served a two-year term. That fact alone has made the job “in- teresting.” The Board of Directors, however, chose to lengthen all Executive Committee terms in the hope that continuity would in- crease productivity. I think that the strategy has been successful, but only time will tell. We have accomplished a great deal in two years. In this final column, I would like to re- view some of what has occurred and what I believe remains to be addressed. There have been two major themes in the last two years. The first has revolved around refocusing ASCCA’s mission. Our hope was that we could better define what our mem- bers sought from the organization and then alter our structure to better meet expecta- tions. What had become clear in recent years is that ASCCA had over-reached. We were trying to be all things to all people. As a small and entirely volunteer group (save for Executive Director Gary Hoormann and his assistants, who have been life-saving), we are limited in what we can accomplish. Our members lead busy, productive lives. If ASCCA could not determine what was most important to its members and focus on these specific issues, it would be superfluous. The process began at a hotel in Orlando in fall 2002. There, members were appointed to a task force to research our problems and formulate a blueprint for change. After a number of discussions with ASCCA mem- bers and anesthesiologist/intensivists who had declined to join or had left the organiza- tion, we met in Baltimore on a Saturday. At that meeting, Todd Dorman, M.D., Dr. Macci- oli, Dr. Breslow and I began by refocusing our mission statement. In particular we sought to limit the scope of ASCCA activity to something that could be managed by a small volunteer organization. In addition we re- fined the committee structure and set guid- ing principles, goals and objectives for the organization and for each committee and subcommittee. To reiterate, ASCCA’s mis- sion is to preserve and expand the pivotal role of critical care medicine, as practiced by intensivists in intensive care units, within the scope of practice of anesthesiology. This will be accomplished through education, advoca- cy and community. Our four guiding princi- ples are: 1. Intensivists are an integral component of the modern health care system because they improve the quality and cost-effec- tiveness of patient care. 2. Intensive care medicine is an essential subspecialty of anesthesiology practice because it enhances the overall quality of anesthesiology practice and care. 3. Anesthesiologists with special training and experience in intensive care medicine improve the quality of postoperative care by advancing our understanding of criti- cal illness. They also have contributed to major improvements in intraoperative management and outcomes. Continued participation in critical care medicine is essential to the future of the specialty and to continued improvements in periopera- tive care. 4. The present numbers of anesthesia inten- sivists are insufficient to meet current and future needs of patients and practices, By Clifford S. Deutschman, M.D. Philadelphia, Pennsylvania A n e s t h e s i o l o g y i s t h e O f f i c i a l J o u r n a l o f A S C C A Clifford S. Deutschman, M.D. Continued on page 3 What had become clear in recent years is that ASCCA had over-reached. We were trying to be all things to all people.
Transcript
A M E R I C A N S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S
Volume 16 Number 2 2004 www.ascca.org
President’s Message
On the Right Track: ASCCA in Good Hands
This is my last “President’s Message.” InOctober, Michael J. Breslow, M.D., takes
over as ASCCA President, and I will move onto assume the position of Immediate PastPresident. Following Dr. Breslow will beSteven O. Heard, M.D., with Gerald A. Macci-oli, M.D., in the wings. ASCCA is in goodhands.
My tenure represents the first time that anASCCA President has served a two-yearterm. That fact alone has made the job “in-teresting.” The Board of Directors, however,chose to lengthen all Executive Committeeterms in the hope that continuity would in-crease productivity. I think that the strategyhas been successful, but only time will tell.We have accomplished a great deal in twoyears. In this final column, I would like to re-view some of what has occurred and what Ibelieve remains to be addressed.
There have been two major themes in thelast two years. The first has revolved aroundrefocusing ASCCA’s mission. Our hope wasthat we could better define what our mem-bers sought from the organization and thenalter our structure to better meet expecta-tions. What had become clear in recent years
is that ASCCA had over-reached. We weretrying to be all things to all people. As asmall and entirely volunteer group (save forExecutive Director Gary Hoormann and hisassistants, who have been life-saving), we
are limited in what we can accomplish. Ourmembers lead busy, productive lives. IfASCCA could not determine what was mostimportant to its members and focus on thesespecific issues, it would be superfluous.
The process began at a hotel in Orlando infall 2002. There, members were appointed toa task force to research our problems andformulate a blueprint for change. After anumber of discussions with ASCCA mem-bers and anesthesiologist/intensivists whohad declined to join or had left the organiza-tion, we met in Baltimore on a Saturday. Atthat meeting, Todd Dorman, M.D., Dr. Macci-oli, Dr. Breslow and I began by refocusingour mission statement. In particular wesought to limit the scope of ASCCA activity tosomething that could be managed by a smallvolunteer organization. In addition we re-fined the committee structure and set guid-ing principles, goals and objectives for theorganization and for each committee andsubcommittee. To reiterate, ASCCA’s mis-sion is to preserve and expand the pivotalrole of critical care medicine, as practiced byintensivists in intensive care units, within thescope of practice of anesthesiology. This will
be accomplished through education, advoca-cy and community. Our four guiding princi-ples are: 1. Intensivists are an integral component of
the modern health care system because
they improve the quality and cost-effec-tiveness of patient care.
2. Intensive care medicine is an essentialsubspecialty of anesthesiology practicebecause it enhances the overall quality ofanesthesiology practice and care.
3. Anesthesiologists with special trainingand experience in intensive care medicineimprove the quality of postoperative careby advancing our understanding of criti-cal illness. They also have contributed tomajor improvements in intraoperativemanagement and outcomes. Continuedparticipation in critical care medicine isessential to the future of the specialty andto continued improvements in periopera-tive care.
4. The present numbers of anesthesia inten-sivists are insufficient to meet current andfuture needs of patients and practices,
By Clifford S. Deutschman, M.D.Philadelphia, Pennsylvania
A n e s t h e s i o l o g y i s t h e O f f i c i a l J o u r n a l o f A S C C A
Clifford S. Deutschman, M.D.
Continued on page 3
What had become clear in recent years is thatASCCA had over-reached. We were trying to beall things to all people.
2 Volume 16 Number 2
1 President’s Message
2 Editorial: A Small Society With Big Goals
6 2004 Annual Meeting Program
8 Critical Care Pathways for the Bariatric Patient WithObstructive Sleep Apnea
10 Minimally Invasive Hemodynamic Monitoring: A New Approach to the Treatment of Patients With Subarachnoid Hemorrhage andVasospasm
CONTENTS
MEMBERSHIP INFORMATION
EDITORIAL NOTES
E-mailYou may e-mail inquiries to ASCCA at the fol-lowing addresses: General inquiries:
MembershipMembership in ASCCA is open to all anesthe-siologists and residents in approved anesthe-siology programs. Membership applicationsmay be obtained by writing to ASCCA, 520 N.Northwest Highway, Park Ridge, IL 60068-2573 or through the ASCCA Web site at<www.ascca.org/membership.html>.
Web PageYou may visit the ASCCA World Wide Website at:
www.ascca.org
ASCCA DuesDues are $150 for active and associate mem-bers; $100 for international members and$50 for residents/fellows. Dues may be paidonline at <www.ascca.org/cart.html> bycredit card or by mailing payment to theASCCA office. Remember, payment of yourdues allows you to enjoy the full privileges ofASCCA membership.
Co-EditorMichael L. Ault, M.D.Assistant ProfessorDepartment of AnesthesiologyNorthwestern UniversityMedical SchoolChicago, IL [email protected]
Co-EditorKenneth G. Smithson, D.O., Ph.D.Assistant ProfessorAnesthesiology, Surgery andNeurosurgeryChief, Division of Critical Careand Perioperative MedicineVanderbilt UniversityNashville, Tennessee
Associate EditorsPaul R. Barach, M.D.Edward C. Bratzke, M.D.Robert A. Royster III, M.D.
Editorial PolicyThe opinions presented are those of the authors only, not of ASCCA. Drug dosages, accuracyand completeness of content are not guaranteed by ASCCA.
The ASCCA Interchange is published by the American Society of Critical Care Anesthesiologists, 520 N.Northwest Highway, Park Ridge, IL 60068-2573; (847) 825-5586. Deadlines are six weeks prior to the monthof publication (e.g., January 15 for an issue scheduled for March).
A Small SocietyWith Big Goals
Editorial
By Michael L. Ault, M.D.Editor
In this issue of theInterchange, read-
ers will find twotimely topics of im-portance to criticalcare medicine. Ad-ditionally, ASCCAPresident CliffordS. Deutschman,M.D., presents ex-citing new informa-tion on thedevelopment of critical care medicine withinthe American Society of Anesthesiologists(ASA). As gleaned from the information con-tained in his article, critical care medicinemay finally be getting its just reward for a
tradition that has long been present as a sub-specialty within the field of anesthesiology.Thus we are hopefully seeing an increase inpreservation of our subspecialty. Like otherendangered species, it was not until our pop-ulation reached a “critical” level that anesthe-siologists outside of our specialty becameconcerned about preserving this wonderful
Michael L. Ault, M.D.
Like other endan-gered species, it wasnot until our populationreached a “critical”level that anesthesiol-ogists outside of ourspecialty became con-cerned about preserv-ing this wonderfulsubspecialty.
Continued on page 13
ASCCA Interchange 3
thus the number of trainees needs to beincreased.
On the basis of this revised mission state-ment and these guiding principles, we de-rived a series of goals and objectives. Wepropose that ASCCA must:1. Enhance the understanding of the value
that intensivists bring to patient care;2. Educate the anesthesiology community in
particular and the health care communityin general as to the benefit that anesthesiaintensivists bring to clinical practice;
3. Increase the number of anesthesia inten-sivists;
4. Bring value to our members by providingeducational opportunities and via advoca-cy; and
5. Ensure the viability of our organization.
In addition we decided to have the com-mittees, each directed by a Board of Directorsmember, come up with their own strategies,plans and actions to meet the stated goals andobjectives, which would be submitted to theBoard of Directors for approval. The final stepof this process has been the development of astreamlined form for committee reports andrequests to the Board of Directors. In effect,we would like ASCCA to function in a morebusinesslike manner. We have recently circu-lated the first set of reporting forms to com-mittee chairs. Dr. Breslow will have theopportunity to report to you on the processand strategies and plans and actions that re-sult. It is my belief that we have been mod-estly successful in our attempts to modify thenature of ASCCA, but again, only time will tell.
The second theme has been to enhancethe footprint of critical care medicine withinthe anesthesiology community and of anes-thesiologist/intensivists within the criticalcare community. In this regard, we havebeen quite successful. The key to this suc-cess has resulted from five specific initia-tives. Two were initiated by the AmericanSociety of Anesthesiologists (ASA), a third bythe Residency Review Committee (RRC) forAnesthesiology and the last two represent acontinuation of processes started a numberof years ago.
As recounted in previous columns, ASArecently has become attuned to the impor-
tance of critical care medicine within thescope of anesthesiology practice. I initiallybecame aware of this when James E. Cottrell,M.D., became ASA President in 2002. Thereal credit for beginning an importantprocess, though, lies with ASA’s currentPresident, Roger W. Litwiller, M.D. I feel ob-ligated to state that anesthesiologist/inten-sivists have no better friend or strongersupporter in any organization anywhere. Dr.Litwiller formed a task force to formulate aconcrete plan as to how ASA could enhancethe role that critical care medicine plays with-in our specialty. The task force met in Chica-go, Illinois, and, during an intense day-longmeeting, hammered out an action plan.These recommendations started by specify-ing that ASA alter its committee structure toseparate critical care medicine and traumamedicine. Additional recommendations thenfocused on education, advocacy and investi-gation. These recommendations are detailedhere.
EducationASA should:
• Provide a resource for practices that pro-vide critical care services or for thosewho want to expand their scope of prac-tice.
• Provide practice management tools tosupport the integration of critical caremedicine into anesthesiology practices.
• Define financial opportunities and risks.• Develop business models to support crit-
ical care medicine within an anesthesiolo-gy practice, including determining whenand how to negotiate with the hospital formedical direction, call coverage or othermatters.
• Include critical care medicine topics in alleducational programs.
• Ensure that ASA appointees to the Amer-ican Board of Anesthesiology and theRRC understand and support critical caremedicine as an integral part of anesthesi-ology practice.
• Maintain an active liaison with academicanesthesiology programs through the Di-rector that represents academics on theASA Board of Directors.
• Include a critical care component in allASA-sanctioned educational programsand publications.
• Have the newly formed Committee on
Critical Care Medicine formally recom-mend a candidate group from which oneof the three ASA representatives to theRRC will be chosen.
AdvocacyASA should charge the ASA Washington
Office and Administrative Council to:• Establish formal liaison with other organ-
izations representing critical care physi-cians to key government agencies andpayers on issues of patient safety andphysician reimbursement in critical care.
• Ensure that the ASA Washington Officestaff is knowledgeable with respect to thepolitical and economic variables that im-pact critical care practice and reimburse-ment.
• Develop a formal legislative/lobbyingagenda in consultation with appropriateASA committees.
• Ensure that the annual ASA LegislativeConference include topics pertinent tocritical care medicine.
Further, the ASA President should consid-er having an intensivist as a member of allrelevant ASA standing committees. This en-sures broad input with regard to critical carebilling, reimbursement, education and prac-tice management. Intensivist representationon the committees on Economics, PracticeManagement and other committees is partic-ularly imperative.
InvestigationASA should charge either a task force or
the new Committee on Critical Care Medicinewith the design of studies examining:• Barriers to critical care anesthesiology
practice;• Barriers to seeking education in critical
care anesthesiology;• Current models of delivery of critical care;• Current economic models of critical care
practice; • Physician compensation for provision of
critical care services;• ASA should initiate a program to educate
members on the value of critical caremedicine to anesthesiology practice andon how to incorporate critical care medi-cine into individual and group practices.
Continued from page 1
Continued on page 4
On the Right Track: ASCCA in Good Hands
4 Volume 16 Number 2
This plan was submitted to Dr. Litwiller.He asked that we present it first to the ASAAdministrative Council and then to the ASABoard of Directors. These presentationswere conducted by Dr. Maccioli, ASCCA Sec-retary and Chair of the ASA Committee onCritical Care Medicine. At the most recentmeeting, the ASA Board of Directors ap-proved a resolution that will be submitted tothe House of Delegates in October. This res-olution is reproduced below.
The resolution covers most of the taskforce’s recommendations, but not all. It pro-poses alterations in the ASA committeestructure and charges the Washington Officewith aiding us in addressing legislative is-sues. It is to be hoped that the recommen-dations regarding education andinvestigation can be handled by the newlyformed Committee on Critical Care Medicine.Indeed Assistant Director of GovernmentalAffairs Karen Bierstein, J.D., has already con-tacted Dr. Maccioli regarding the next Con-ference on Practice Management. At thispoint, we await approval from the House ofDelegates. I urge each of you to contact yourdelegates and help line up support for thisresolution.
A second issue initiated by ASA involvesthe development of a critical care education-al track at the ASA Annual Meeting. While anumber of individuals were responsible forproposing such a change, Neal H. Cohen,M.D., in particular rates special mention. Dr.Cohen headed the task force that designedand implemented this curriculum. The resultis an exciting program that I hope will be wellattended. It includes some of the best mindsin our subspecialty and addresses topics inan up-to-date and innovative manner. Thereare refresher courses, pro-con debates, pan-els and scientific presentations. I urge all ofyou to take advantage of this remarkable ed-ucational opportunity.
Changes in the curriculum for anesthesi-ology residents have been proposed by theRRC, including a substantial increase in theamount of time residents will spend involvedin learning critical care medicine. Specifi-cally the new curriculum will require sixmonths of critical care medicine spread overthe four-year educational continuum. Thisnew requirement is a real breakthrough. It is
clear that the RRC recognizes that learningcritical care is important not only for thosewho will become practicing intensivists butfor all future anesthesiologists. As we all be-lieve, learning critical care medicine makesyou a better doctor, regardless of your prac-tice venue. There are, of course, significantbarriers to implementation. Among these arefinancing to allow tighter control of the PGY-1 year. These logistics need to be worked
out, and those of you in academic practicemay be called upon to assist. Again, yourinput is vitally important.
We have continued input into the issuessurrounding reimbursement for provision ofcritical care services. This input is a result ofthe leadership provided by our representativeto the Critical Care Working Group, ToddDorman, M.D., who increasingly is recog-nized as the “go-to guy” in this group and,
Continued from page 3
On the Right Track: ASCCA in Good Hands
A resolution on the future of critical care anesthesiology will be submitted to the House of Del-egates at the 2004 American Society of Anesthesiologists Annual Meeting in Las Vegas, Neva-da, this October.
ASCCA Interchange 5
indeed, within the entire critical care communi-ty. He has had substantial influence on the de-liberations of officials at the Centers forMedicare & Medicaid Services (CMS) as theywork to re-evaluate coding and definitions toallow for fair reimbursement for critical careservices. In response to the recommendationsof the task force, the ASCCA leadership hasbeen contacted by the ASA Washington Officeand Director of Governmental and Legal AffairsMichael Scott, J.D. We have referred them toDr. Dorman. It is to be hoped that interactionsbetween Dr. Dorman, the ASA Washington Of-fice and ASCCA will increase the success of Dr.Dorman’s remarkable efforts. The ultimate goalis that critical care medicine be reimbursed inan appropriate manner and that receiving pay-ment for services provided becomes easier andmore fair.
Finally, we believe that it is essential thatASCCA develop and maintain links with two es-sential groups of practitioners devoted to thepractice and advancement of critical care med-icine. The first is the Society of Critical CareMedicine (SCCM); the second is a linked body,the American College of Critical Care Medicine(ACCCM). SCCM is the group that best repre-sents those devoted to the growth of criticalcare medicine as a multispecialty discipline.Involvement allows us to interact closely withinternists, surgeons, pediatricians, neurolo-gists, nurses, respiratory therapists, nutrition-ists and all the other specialists who areessential to safe and effective critical care prac-tice. ACCCM has, among its charges, the de-velopment of guidelines to promote patientsafety in the intensive care unit. I am a mem-ber of the SCCM Council, and Dr. Maccioliserves as a Regent of ACCCM. In addition twoformer ASCCA presidents have prominent rolesin these organizations. Charles G. Durbin, Jr.,M.D., is the current SCCM Treasurer and willsoon become SCCM President. Steven Allen,M.D., also is an ACCCM Regent. Dr. Dorman
chairs the SCCM Committee on Advocacy and,as mentioned, has become quite well-known tomembers of the governmental health care es-tablishment.
Also important is the development andmaintenance of close ties with the internationalcritical care medicine community. In this re-gard, we are fortunate to have Heidi B. Kum-mer, M.D., Ph.D., as Chair of our Committee onLiaison and as a member of the ASCCA Boardof Directors. Dr. Kummer has spent years nur-turing relationships with anesthesiologist/in-tensivists around the world and is ourassurance that we have soul mates in othercountries. Of course she could always usesome assistance, and I encourage any of youwith contacts or an interest to get in touch withDr. Kummer.
So what is next? There are many issuesthat need to be addressed. I will mention onlya few. Frankly, one of my disappointments hasbeen my inability to deal with several problemsduring my tenure as ASCCA President. Themost important are those of membership andparticipation. At one time, ASCCA had nearly1,000 members. Today we have less than halfthat number. I believe that the foundation to re-verse that trend is in place. The emphasis oncritical care, as demonstrated by the actions ofthe medical establishment, third-party payers,CMS and the leaders of the anesthesiologycommunity, indicates that our subspecialty isabout to “boom.” There is a clear need for in-tensivists both in academia and especially inthe private sector. ASCCA, with ASA’s help, ispoised to aid those interested in the privatepractice of critical care medicine.
The renewed educational emphasis on criti-cal care medicine will soon pay dividends. In-deed it may be doing so already. Moreindividuals are choosing to pursue fellowshiptraining. In my own program at the Universityof Pennsylvania, nearly two-thirds of CA-3s areenrolling in a fellowship of some kind next year.
High-quality applicants to the critical care med-icine fellowship that I direct have increased ex-ponentially. Most gratifying of all are theresidents in our own program who have ap-plied.
Each individual choosing to train as an in-tensivist will, I hope, become a contributingmember of ASCCA. In addition I think thatASCCA’s mission, which is newly focused onspecific educational, political and investigativeinitiatives, will attract new members. Theframework is in place, and many of the toolshave been made available. I am confident thatDr. Breslow, Dr. Heard and Dr. Maccioli will putthem to good use.
Membership, however, is not the only issue.Equally important is participation. We are avolunteer organization, and we depend on ourmembers contributing time, effort and energy.More of you need to become involved. In ap-pointing committees, we have called on a num-ber of previously uninvolved individuals. Thisis a start, but only just that. Our new infra-structure makes it possible to accomplishmuch, but, ultimately, the effort of individuals isneeded.
In closing, if we have accomplished any-thing in the last two years, it is because of theefforts of a number of extraordinary people.Three deserve to be singled out: Dr. Cohen, Dr.Dorman and Dr. Maccioli. I have been lucky towork with them, and I am even luckier to havethem as friends. ASCCA and the fields of anes-thesiology and critical care medicine are luckyto have them as leaders.
There is a clear need for intensivists both in ac-ademia and especially in the private sector.ASCCA, with ASA’s help, is poised to aid those in-terested in the private practice of critical caremedicine.
7 a.m. Registration and Continental Breakfast
7:55 a.m. WelcomeWilliam E. Hurford, M.D.Michael F. O’Connor, M.D.
Scientific Session8 a.m. Oral Abstracts
Moderator:Michael H. Wall, M.D.Scientific Paper Chair8 a.m. Abstract 18:15 a.m. Abstract 28:30 a.m. Abstract 38:45 a.m. Abstract 4
9 a.m. Young Investigator AwardPresented by:Michael H. Wall, M.D.Scientific Paper Chair
9:30 a.m. Lifetime Achievement Award Presentation and LecturePresenter: Neal H. Cohen, M.D.
10:20 a.m. Coffee Break and Poster Viewing
Leadership Session10:40 a.m. Introduction of Research Award
Presenter: Robert N. Sladen, M.B.
10:50 a.m. Regional Effects of Alveolar Recruiting Strategies in Acute Lung InjuryGuido Musch, M.D.
11:20 a.m. Joint ASCCA/SCCM Anesthesia Section “Burchardi Award”Presenter: Heidi B. Kummer, M.D., Ph.D.Recipient: Douglas B. Coursin, M.D.
11:30 a.m. Address by ASA President-ElectEugene P. Sinclair, M.D.
12 noon Luncheon (sponsored by Hospira) Epidemiology and Pathophysiology of DeliriumGerald A. Maccioli, M.D.
Prevention and Treatment of DeliriumRobert N. Sladen, M.B.
1:20 p.m. The PA Catheter: Evidence Based?Avery Tung, M.D.
1:35 p.m. Question and Answer
1:40 p.m. Replacement Doses of Steroids in Sepsis: Who? When?Joel B. Zivot, M.D.
1:55 p.m. Question and Answer
2 p.m. Intentional Hypothermia Following In-HospitalCPR: What Should We Be Doing?Brenda G. Fahy, M.D.
2:15 p.m. Question and Answer
2:20 p.m. Protein C - Who Should Get It?Who Shouldn’t?Michael S. Avidan, M.B.,B.Ch.
2:35 p.m. Question and Answer
2:40 p.m. Beta Blockers — How Do They Really Work?Andrew J. Patterson, M.D.
2:55 p.m. Question and Answer
3 p.m. Coffee Break and Poster Viewing
Future Shocks Alternatively3:20 p.m. Private Practice Critical Care by
AnesthesiologistsGerald A. Maccioli, M.D.
3:50 p.m. Ventricular Assist DevicesAndrew D. Rosenberg, M.D.
4:20 p.m. Infusion Devices and SafetyMark E. Nunnally, M.D.
4:50 p.m. Reacting to Accidents in the ICU: Trying to Learn While Trying to RecoverRichard I. Cook, M.D.
5:20 p.m. ASCCA Business Meeting
7 p.m. Reception
ASCCA Interchange 7
Surgical treatment of morbid obesity andsuper-morbid obesity has developed into a
vital and exciting new surgical subspecialty.Bariatric surgery has allowed this once-ig-nored population of persons an opportunity toreceive medical treatment that is, to say theleast, life-saving. During the past five years,bariatric surgery has become one of the morecommonly performed procedures at medicalcenters throughout the United States. As dis-cussed in a previous article in this newsletter,anesthesiologists and critical care physicianswill very likely find themselves managing thecare of bariatric patients in increasing num-bers during the next decade.1
Despite advances in surgical options andtechniques, however, co-morbidities associ-ated with the bariatric patient present uniquechallenges. With the proliferation of bariatricsurgical cases being performed, several clini-cal trends have emerged in this patient popu-lation. One of the most ominous anddisturbing of these trends is the high inci-dence of respiratory complications associat-ed with patients undergoing bariatric surgery.A subset of the bariatric patient populationpossess obstructive sleep apnea (OSA), andthese patients are at a significantly higher riskof airway and respiratory compromise in theperioperative period.2 This subset of patientsdemands an additional level of care beyondthat required by the typical morbidly obesepatient undergoing bariatric surgery, and wewill explore critical care pathways that mayassist in optimizing the care of this patientpopulation.
Obstructive Sleep ApneaObstructive sleep apnea is a prevalent
medical disorder, and it is estimated that 4percent of all men and 2 percent of all womenpossess this syndrome. Prevalence rates of
OSA and snoring increase with age. Approxi-mately 80 percent to 90 percent of personswith OSA are undiagnosed.3 Obstructive sleepapnea is defined as cessation of airflow forgreater than 10 seconds, despite continuingventilatory effort, five or more times per hourof sleep and is usually associated with a de-crease in arterial oxygen saturation (SaO
2) of
more than 4 percent.4 The presence of obesi-ty (defined as a body mass index > 29 kg/m2)is another independent risk factor for OSA. Itis believed, however, that the mechanism forOSA in nonobese patients is attributed pre-dominantly to craniofacial and orofacial ab-normalities.
A presumptive diagnosis of OSA can bemade in patients who manifest the commonsigns and symptoms of airway obstruction,namely, snoring and/or apnea during sleep,
occasional snorting and daytime somnolenceor fatigue. A definitive diagnosis of OSA mustbe made by some form of sleep study; how-ever, traditional sleep studies are complex anddifficult to administer for a variety of reasons.Some clinicians have informally noted that theEpworth sleep scale does not correlate wellwith the presence of OSA.5
Clinical ImplicationsAlthough the majority of morbidly obese
and super-morbidly obese patients may nothave confirmed diagnoses of OSA, bariatricpatients who display classical signs andsymptoms of OSA should be treated in a sim-ilar way as those with a definitive diagnosis.
Recent retrospective analyses havedemonstrated that the administration of gen-eral anesthetics, opioid analgesia and seda-tive/hypnotics in the patient with OSA increasethe number of apneic events, hypoxic eventsand incidence of respiratory arrests in the pe-rioperative period.6,7,8
Preoperative EvaluationDuring the medical, surgical and anesthe-
sia preoperative evaluations, the clinicianshould focus on issues that serve to establisha history of OSA. One of the primary goalsduring the preoperative evaluation is to im-prove the identification and diagnosis of OSAin morbidly obese patients undergoingbariatric surgery so that an appropriate plan ofperioperative management may be initiated.In addition anesthesiologists should confirmany previous difficulties with intubation oranesthesia-related airway complications.
Some institutions have developed an OSAassessment tool in order to assist them inidentifying patients who would benefit frompolysomnography studies. These studies areuseful in making a definitive diagnosis of OSAand allow for appropriate supportive meas-
ures to begin prior to the date of surgery.Some medical centers have facilitatedprocesses that allow for patients with possibleOSA to undergo outpatient polysomnographystudies at least two weeks prior to the sched-uled date of surgery. Studies demonstratethat patients are more compliant with contin-uous positive airway pressue (CPAP) andbilevel positive airway pressure (BiPAP) treat-ment when the patient has had time to be-come accustomed to the device prior to theimmediate postsurgical period.9
should exercise judicious methods in develop-ing anesthetic plans for the morbidly obesepatient. Anesthesiologists should confer withthe primary surgeon and associated medicalconsultants in developing a reasonable plan tominimize adverse airway-related events. Pe-rioperative management should reflect an at-tempt to reduce the number of unplanned
Critical Care Pathways for the Bariatric Patient With ObstructiveSleep Apnea
8 Volume 16 Number 2
By Antonio T. Hernandez Conte, M.D.President and C.E.O.Florida Atlantic Anesthesia, Inc.Fort Lauderdale, FloridaMedical Director, Surgical ServicesHoly Cross HospitalFort Lauderdale, Florida
A definitive diagnosis of OSA must be made bysome form of sleep study; however, traditionalsleep studies are complex and difficult to admin-ister for a variety of reasons.
transfers to a critical care unit due to adverserespiratory-related events in the first 24 to 48hours after surgery.
A recent report by the Anesthesia AdvisoryPanel highlighted the occurrence of unex-plained respiratory arrests in hospitalized pa-tients with OSA who received parenteralopioids; therefore, anesthesiologists shoulduse extreme caution when administering opi-oids.8 Dosages of opioids should be conserv-atively administered and should be basedupon ideal body weight and/or lean bodyweight standards. In addition the anesthesiol-ogist must remain vigilant of any co-existingmorbidities that may negatively impact the re-sponse to anesthetic agents. The pharmaco-dynamics and pharmacokinetics of anestheticagents are highly unpredictable in the morbid-ly obese patient population.
There are a number of measures that areuseful in minimizing the occurrence of airway-related complications. For instance, patientsshould be extubated only when they are fullyawake and alert. In the event that a bariatricpatient is slow to awaken in the operatingroom, anesthesiologists should considertransporting the patients while intubated to thepostanesthesia care unit (PACU) to allow forfull awakening and reversal of agents. Pa-tients also may benefit from being extubatedin the upright position in order to minimize theeffects of obesity on respiratory capacity.
Bariatric patients with documented orunanticipated difficult ventilation and/or intu-bation perioperatively should be suspected ofpossessing OSA and should be consideredfor direct admission to a critical care unit. Itis important to recognize that morbidly obesepatients are at significantly greater risk thannonobese patients for untoward airwayevents under urgent and emergent conditionsoutside of the operating room.5 This findingis especially pertinent as some medical per-sonnel in critical care units or general patientcare wards may not be accustomed to man-aging this patient population and are notadept at quickly securing the airway of abariatric patient.
Postanesthesia Care Unit (PACU)All morbidly obese and super-morbidly
obese patients should be carefully monitoredin the PACU, and separate PACU discharge cri-
teria and clinical pathways for bariatric pa-tients may be necessary in order to optimallymanage this patient population. Examples ofthese may include:• Patients with history of utilizing CPAP
and/or BiPAP devices should be placed onthese devices immediately upon arrival toPACU.
• Patients demonstrating periods of oxygendesaturation or apnea in the PACU withneed for physical arousal for improvementin oxygen saturation should be re-evaluat-ed by an anesthesiologist prior to dis-charge from the PACU with possibletransfer to a critical care unit.
• Patients receiving reversal agents such asnaloxone or flumazenil in the PACU maynecessitate admission to the critical careunit.
• Consider transfer to critical care setting forpatients who have been given large quanti-ties of opioids intraoperatively and in thePACU.
• Carefully consider the use of patient-con-trolled analgesia devices in patients withOSA with possible avoidance of basal infu-sion of opioids.
• Avoid additional sedatives or hypnoticagents in patients with OSA during thepostoperative period.
Patient Care on Bariatric Nursing UnitsSince bariatric patients, especially those
manifesting OSA, are at high risk for respira-tory compromise in the postoperative period,it is important to establish monitoring proto-cols to allow for early detection with appropri-ate intervention for adverse airway andrespiratory-related events. It may be prudentto consider continuous pulse oximetry, end-tidal carbon dioxide monitoring and telemetryduring the first 48 hours after surgery. Nurs-ing personnel should become familiar with theuse of clinical pathways employing reversalagents and laboratory blood gas analysis if pa-tients are found to display respiratory depres-sion. Finally it is imperative that compliancewith existing basic vital sign monitoring be re-inforced.
ConclusionThe medical and anesthetic management
of the bariatric patient with OSA is a challeng-
ing endeavor and demands that multiple seg-ments of the surgical facility be well preparedand equipped to manage any surgical- and/oranesthetic-related adverse event. The devel-opment and utilization of clinical care path-ways mandating collaboration between thedepartments of nursing, anesthesiology, sur-gery and critical care are essential in optimiz-ing the care of this high-risk population.
References:1. Conte ATH. Critical challenges for patients
2. Sleep apnea and narcotic postoperativepain medication: A morbidity and mor-tality risk. The Doctor’s Company. Nov.27, 2003. <www.thedoctors.com/risk/bulletins/sleepapnea.asp>.
5. Conte ATH, Marema R, Scambeck F. Per-sonal communication and preliminaryfindings of retrospective review of 1,000patients undergoing bariatric surgery atHoly Cross Hospital, Fort Lauderdale, Flori-da, Nov. 2003.
6. Samuels SI, Rabinov W. Difficulty revers-ing drug-induced coma in a patients withsleep apnea. Anesth Analg. 1986; 65:1222-1224.
7. Ostermeier AM, Roizen MF, Hautkappe M,Klock PA, Klafta JM. Three sudden postop-erative respiratory arrests associated withepidural opioids in patients with sleepapnea. Anesth Analg. 1997; 85:452-460.
8. Lofsky A. Sleep apnea and narcotic postoper-ative pain medication: A morbidity and mor-tality risk. July 4, 2003. <www.gasnet.org/societies/apsf/newsletter/2002/summer/04sleepapnea.html>.
9. Rennotte MT, Baele P, Aubert G, Roden-stein DO. Nasal continuous positive airwaypressure in the perioperative managementof patients with obstructive sleep apneasubmitted to surgery. Chest. 1995;107(2):367.
ASCCA Interchange 9
10 Volume 16 Number 2
Aneurysmal subarachnoid hemorrhage(SAH) carries one of the most severe clin-
ical presentations in medicine today. Its inci-dence is estimated at 6 to 11 per 100,000persons per annum (18,000 cases a year inNorth America).1,2 It has a very high mortalityrate approaching 20 percent to 30 percent inthe first six months.2,3 Approximately 20 per-cent of those deaths occur within the first dayfrom direct effects of the initial hemorrhage.3
The complication accounting for the highestproportion (23 percent) of deaths followingsubarachnoid hemorrhage is vasospasm, acondition in which prolonged constriction ofthe cerebral arteries causes delayed neurolog-ical deficits.3 Prolonged neurological deficitsdue to vasospasm occur in 7 percent of pa-tients after SAH, and death from vasospasmoccurs in another 7 percent of SAH patients.4
The pathophysiology of vasospasm remainsunknown but is related to free blood in thesubarachnoid space coming into contact withthe cerebral arteries. Prolonged smooth mus-cle contraction occurs with hypertrophy, hy-perplasia and fibrosis of the vessel wall.5
Current experimental evidence has implicatedthe byproducts of hemolysis (oxygen, hemo-globin, oxygen free radicals) in the develop-ment of vasospasm.6,7
Current therapeutic strategies combineearly surgery (if reasonable) with the calcium-channel blocker nimodipine. Hyperperfusiontherapy, classically referred to as “triple-H”(hypervolemia, hemodilution and hyperten-sion), is often initiated if vasospasm is diag-nosed. These combined strategies havereduced the mortality rate of SAH by approxi-mately 10 percent to 15 percent since the early1980s.4 The benefit of “triple-H” in preventingdelayed ischemic neurologic deficits from va-sospasm, however, has remained controver-sial. There are no randomized, prospective,controlled clinical trials demonstrating that
this therapy improves short-term or long-termneurologic outcome or survival followingSAH. There also are potential life-threateningmedical complications that can result fromthis therapy such as congestive heart failureand myocardial infarction.
In spite of the controversy, hyperperfusiontherapy continues to be widely used in inten-sive care units because of the clear theoreticalbenefit of optimizing cerebral blood flowthrough narrowed arteries via increased cere-bral perfusion pressure, decreased viscosityor increased cardiac output. It has beenshown that optimizing cardiac output can ele-vate cerebral blood flow in the setting of va-sospasm without changes in mean arterialpressure.8 Because manipulation of cardiacoutput is thought to be much safer than sim-ply artificially elevating blood pressure, manyinstitutions place pulmonary artery (PA)catheters when initiating hyperperfusion ther-apy in order to monitor the administration offluid and inotropes.9
The placement of PA catheters also hashistorically been controversial, and some ob-servational studies have suggested an associ-ation with increased mortality.10-12 Recently alarge, randomized, controlled trial did notshow increased mortality when PA catheterswere used but could not find any clinical ad-vantage to therapy guided by a pulmonary ar-tery catheter as compared with standard carein the intensive care unit (ICU).13
Because of these concerns, we have begunusing noninvasive cardiac output monitoringin our neurosurgical intensive care unit as partof a standardized protocol approach to thetreatment of patients with subarachnoid hem-orrhage who develop vasospasm (see Figure 1on next page). Within this protocol, and onceclinical evidence of cerebral artery vasospasmhas been determined, either via focal neuro-logical changes on examination or elevatedtranscranial Doppler flow velocities, hemody-namic monitoring is initiated withPulseCo/lithium indicator dilution cardiac out-put (LiDCO) or pulmonary artery catheteriza-tion (PAC) at the discretion of the clinicalintensivist. Initially filling pressures are aug-mented using central venous pressure (CVP)or pulmonary capillary wedge pressure(PCWP) measurements to guide the adminis-tration of intravenous fluids. If no neurologic
improvement is seen once filling pressuresare optimized, the administration of inotropesis begun and titrated to augment cardiac out-put as measured by PulseCo/LiDCO or ther-modilution via PA catheter.
(LiDCO) measurement has become availablesubsequent to the miniaturization of ion-selec-tive electrodes. This method measures car-diac output by indicator dilution. Specificallya known dose (0.3 mmol bolus) of lithiumchloride is administered via a central or pe-ripheral intravenous catheter, and a lithium-sensitive electrode measures a lithium dilutioncurve sampled from a standard peripheral ar-terial catheter.14 This method has been shownto agree well with standard thermodilution viapulmonary artery catheter15,16 and with electro-magnetic flowmetry.15 Cardiac output meas-urements are comparable whether lithium isinjected via peripheral or central veins.17
Pulse-contour arterial pressure waveformanalysis also has been developed as a meansto continuously monitor cardiac output. Thismethod analyzes the systolic portion underthe arterial pressure waveform to determinestroke volume18 and thus provides beat-to-beat measurement of cardiac output. Cardiacoutput measurement by arterial pulse-contouranalysis has similarly been shown to be reli-
Minimally Invasive Hemodynamic Monitoring: A New Approach to the Treatment of Patients With SubarachnoidHemorrhage and Vasospasm
Robert A. Royster, M.D.
By Robert A. Royster, M.D.Associate Editor, ASCCA Interchange
Department of AnesthesiologySection of Critical Care MedicineNorthwestern UniversityFeinberg School of MedicineChicago, Illinois
Continued on page 12
ASCCA Interchange 11
Figure 1: Protocol for treatment of patients with cerebral vasospasm following subarachnoid hemorrhage
able when compared to standard transthoracicthermodilution methods, even in patients withprofound changes in cardiac output during pe-riods of hemodynamic instability.19,20 All com-mercially available systems (PiCCO, PulsionMedical, Munich, Germany; andPulseCo/LiDCO, LiDCO, Ltd., London, UnitedKingdom) require frequent calibration usingan indicator dilution technique (generallyevery 12 hours). The PiCCO system is limitedin that it recommends arterial catheter place-ment in the femoral or axillary sites.21 Poten-tial errors of the PulseCo/LiDCO system canbe minimized by proper calibration and re-striction of its use to good arterial waveforms.The PulseCo is not recommended for patientswith aortic valve regurgitation, intra-aortic bal-loon pumps, peripheral arterial disease or withhighly dampened arterial waveforms.21
It should be noted that although PulseCocan provide the intensivist with beat-to-beatcardiac output, stroke volume, systemic vas-cular resistance and systolic blood pressurevariation measurements, it cannot providesome information that is available via a PAcatheter. Systemic venous oxyhemoglobinsaturation (SvO
2), pulmonary artery pressures
and pulmonary capillary wedge pressures areunavailable via minimally invasive monitors.Trends involving these measurements may beimportant in caring for patients with other co-morbidities such as congestive heart failure ormultiple organ system failure.
ConclusionVasospasm is a highly lethal and debilitat-
ing complication following subarachnoid hem-orrhage. Current management techniqueshave improved mortality related to vasospasmand include the use of PA catheters to monitorcardiac output during “hyperperfusion thera-py.” PA catheterization has historically beenhighly controversial and possibly increasespatient morbidity through complications suchas pulmonary embolus, arrhythmias, valvulardamage, endocarditis or other infections. Atour institution, we have instituted the use ofminimally invasive hemodynamic monitoringsuch as PulseCo/LiDCO in a standardized ap-proach to the treatment of vasospasm as analternative to pulmonary artery catheterization.
We believe that in appropriate patients, thesemonitors can provide us with the same im-portant data while minimizing complicationsrelated to pulmonary artery catheter place-ment. In patients who have conditions thatlimit the accuracy of PulseCo/LiDCO, or inpatients with significant comorbidities whereknowledge of filling pressures or SvO
2would
be valuable, PA catheterization should still beconsidered by the clinical intensivist on anindividualized-patient basis.
References:1. Kurtze JF. Epidemiology of cerebrovascu-
lar disease. In: Cerebrovascular SurveyReport, 1985. McDowell FH, Caplan LR,eds. The National Institute of Neurologicaland Communicative Disorders andStroke. New York: Springer-Verlag.1985:1-34.
2. Kassell NF, et al. The International Coop-erative Study on the Timing of AneurysmSurgery. Part 1: Overall management re-sults. J Neurosurg. 1990; 73:18-36.
3. Solenski NJ, et al. Medical complicationsof aneurysmal subarachnoid hemor-rhage: A report of the multicenter, coop-erative aneurysm study. Crit Care Med.1995; 23:1007-1017.
4. Sen J, et al. Triple-H therapy in the man-agement of aneurysmal subarachnoidhaemorrhage. Lancet Neurol. 2003;2:614-621.
6. Fujita Y, et al. Noxious free radicals de-rived from oxyhaemoglobin as a cause ofprolonged vasospasm. Neurol Med Chir.1980; 20:137-144.
7. MacDonald RL, et al. A review of haemo-globin and the pathogenesis of cerebralvasospasm. Stroke. 1991; 22:971-982.
8. Kim DH, et al. Increases in cardiac outputcan reverse flow deficits from va-sospasm independent of blood pressure:A study using xenon computed tomo-graphic measurement of cerebral bloodflow. Neurosurgery. 2003; 53:1044-1052.
9. Corsten L, et al. Contemporary manage-ment of subarachnoid hemorrhage andvasospasm: The UIC experience. SurgicalNeurol. 2001; 56:140-148.
10. Connors AF, Jr, et al. The effectiveness ofright-heart catheterization in the initialcare of critically ill patients. JAMA. 1996;276:889-897.
11. Gore JM, et al. A community-wide as-sessment of the use of pulmonary arterycatheters in patients with acute myocar-dial infarction. Chest. 1987; 92:721-727.
12. Zion MM, et al. Use of pulmonary arterycatheters in patients with acute myocar-dial infarction: Analysis of experience in5,841 patients in the SPRINT Registry.Chest. 1990; 98:1331-1335.
13. Sandham JD, et al. A randomized, con-trolled trial of the use of pulmonary-arterycatheters in high-risk surgical patients. NEngl J Med. 2003; 348:5-14.
14. Linton R, et al. A new method of measur-ing cardiac output in man using lithiumdilution. Br J Anaesth. 1993; 71:262-266.
15. Kurita T, et al. Comparison of the accura-cy of the lithium dilution technique withthe thermodilution technique for meas-urement of cardiac output. Br J Anaesth.1997; 79:770-775.
16. Linton R, et al. Lithium dilution cardiacoutput measurement: A comparison withthermodilution. Crit Care Med. 1997;25:1796-1800.
17. Garcia-Rodriguez C, et al. Lithium dilutioncardiac output measurement: A clinicalassessment of central venous and periph-eral venous indicator injection. Crit CareMed. 2002; 30:2199-2204.
18. Wesseling KH, et al. A simple device forthe continuous measurement of cardiacoutput. Adv Cardiovasc Phys. 1983; 5:1-52.
19. Gödje O, et al. Reliability of a new algo-rithm for continuous cardiac output de-termination by pulse-contour analysisduring hemodynamic instability. Crit CareMed. 2002; 30:52-58.
20. Felbinger TW, et al. Comparison of pul-monary arterial thermodilution and arteri-al pulse contour analysis: Evaluation of anew algorithm. J Clin Anesth. 2002;14:296-301.
21. Peruzzi WT, et al. Minimally invasive he-modynamic monitoring. In: Yearbook ofIntensive Care and Emergency Medicine,2003. Vincent JL, ed. New York: Springer-Verlag. 2003:521-531.
Minimally Invasive Hemodynamic Monitoring: A New Approach to the Treatment of Patients With SubarachnoidHemorrhage and VasospasmContinued from page 10
12 Volume 16 Number 2
PresidentClifford S. Deutschman, M.D.Philadelphia, Pennsylvania
Immediate Past PresidentNeal H. Cohen, M.D.San Francisco, California
President-ElectMichael J. Breslow, M.D.Baltimore, Maryland
SecretaryGerald A. Maccioli, M.D.Raleigh, North Carolina
TreasurerSteven O. Heard, M.D.Worcester, Massachusetts
Jeffrey R. Balser, M.D., Ph.D.Nashville, Tennessee
Richard C. Prielipp, M.D.Winston-Salem, North Carolina
Eugene Y. Cheng, M.D.Milwaukee, Wisconsin
Todd Dorman, M.D.Baltimore, Maryland
Brian S. Kaufman, M.D.New York, New York
Heidi B. Kummer, M.D., Ph.D.Burlington, Massachusetts
AdvocacyTodd Dorman, M.D.Baltimore, Maryland
MembershipEugene Y. Cheng, M.D.Milwaukee, Wisconsin
CommunicationsBrian S. Kaufman, M.D.New York, New York
Research AwardsJeffrey R. Balser, M.D., Ph.D.Nashville, Tennessee
EducationRichard C. Prielipp, M.D.Winston-Salem, North Carolina
ExecutiveClifford S. Deutschman, M.D.Philadelphia, Pennsylvania
LiaisonHeidi B. Kummer, M.D., Ph.D.Burlington, Massachusetts
ASA DelegateVincent L. Hoellerich, M.D.Raleigh, North Carolina
ASA Alternate DelegateMark E. Nunnally, M.D.Chicago, Illinois
Officers
Directors
Committee Chairs
Ex-officios
ASCCA Interchange 13
subspecialty. We certainly owe a debt ofgratitude to Dr. Deutschman for assumingthe helm of a sinking ship. He has refo-cused our Society and did an excellent jobof enlisting the support of current ASAPresident Roger W. Littwiller, M.D., whohas been a strong advocate for our sub-specialty. We remain confident that
Michael J. Breslow, M.D., ASCCA Presi-dent-Elect, will continue to guide our Soci-ety through this difficult period.
As the ASA Annual Meeting approach-es, the utilization of subspecialty tracksthroughout the meeting will help thosemembers with an interest in critical care tomaximize their educational time invest-ment. Additionally the tracks will demon-strate to members that critical care
medicine remains an integral componentto the practice of anesthesiology. We lookforward to seeing you at the ASA AnnualMeeting on October 23-27 in Las Vegas,Nevada, and encourage members tospread the word for our small subspecialtySociety.
