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Evolving financial and medical constraints fueled by the increasing repertoire of nonoperating room cases and widening scope of patient comorbidities are discussed. The need to integrate finances and care approaches is detailed, and strategic suggestions for broader collaborative practice are suggested.

The anesthesia market continues to undergo disruption. Financial margins are shrinking, and buyers are demanding that anesthesia services be provided in an efficient, low-cost manner. To help anesthesiologists analyze their market, Drucker and Porter's framework of buyers, suppliers, quality, barriers to entry, substitution, and strategic priorities allows for a structured analysis. Once this analysis is completed, anesthesiologists must articulate their value to other medical professionals and to hospitals. Anesthesiologists can survive and thrive in a value-based health care environment if they are capable of providing services differently and able to deliver cost-effective care.

Moderate sedation outside the operating room is performed for a variety of medical and surgical procedures. It involves the administration of different drug combinations by nonanesthesia professionals. Few data exist on risk stratification and patient outcomes in the adult population. Current literature suggests that sedation can be associated with significant adverse outcomes. The aims of this study were to evaluate the nature of adverse events associated with moderate sedation and to examine their relation to patient characteristics and outcomes. In this retrospective review, 52 cases with moderate sedation safety incidents were identified out of approximately 143,000 cases during an 8-year period at a tertiary care medical center. We describe types of adverse events and the severity of associated harm. We used bivariate and multivariate analyses to examine the links between event types and both patient and procedure characteristics. The most common adverse event and unplanned intervention were oversedation leading to apnea (57.7% of cases) and the use of reversal agents (55.8%), respectively. Oversedation, hypoxemia, reversal agent use, and prolonged bag-mask ventilation were most common in cardiology (84.6%, 53.9%, 84.6%, and 38.5% of cases, respectively) and gastroenterology (87.5%, 75%, 87.5%, and 50%) suites. Miscommunication was reported most frequently in the emergency department (83.3%) and on the inpatient floor (69.2%). Higher body mass index was associated with increased rates of hypoxemia and intubation but lower rates of hypotension. Advanced age boosted the rates of oversedation, hypoxemia, and reversal agent use. Women were more likely than men to experience oversedation, hypotension, prolonged bag-mask ventilation, and reversal agent use. Patient harm was associated with age, body mass index, comorbidities, female sex, and procedures in the gastroenterology suite. Providers should take into account patient characteristics and procedure types when assessing the risks of harmful sedation-related complications.

Purpose of review The nonoperating room environment presents a number of distinct challenges for anesthesiologists in the implementation of electronic health records (EHRs). These include documentation compliance, billing, and room design. Recent findings EHRs offer multiple opportunities for improved continuity of care, expedited preoperative evaluation, and seamless transitions between anesthesia and nonanesthesia providers. Additionally, data gathered through adoption of EHRs provide the promise of future analysis and research, allowing for data-driven improvements in quality of care and value optimization. Institutions adopting a new EHR in areas where anesthesia is provided outside of the operating room should plan wisely to address these matters. Summary The needs of anesthesiology practice should be carefully incorporated into future EHR builds as demands for anesthesia care outside of the operating room expand.

As the need for Anesthesiology Services expands beyond the operating room to Gastroenterology venues, collaborative practice standards become increasingly necessary. Goal alignment is critical to assure patient safety, comfort, and optimized outcomes. Anesthesia standards of care and the normal cadence of running a gastrointestinal suite must achieve integration on both an operational and medical level. This becomes more difficult as procedural and patient complexity increase. Significant challenges discussed here include costs and format of preoperative assessment, mutually acceptable scheduling platforms, limitations of non-operating room venues, and management of costs and revenues.

As health care bears the simultaneous burdens of rapid technological development and increasing financial constraints, there has been significant increase in the number and types of procedures performed outside of the operating room. The broadening scope and complexity of noninvasive procedures, along with increasing acuity of patients, often make deeper sedation, general anesthesia, and robust hemodynamic monitoring both necessary and challenging. Anesthesiologists are more frequently called upon to provide care for medically complex patients undergoing novel, unfamiliar procedures in nontraditional locations. As technology advances, the number of procedure areas and the need for anesthesia services proliferates. The landscape of anesthesiology, therefore, is changing; new challenges and opportunities have emerged. This chapter provides an overview of these challenges, including assessing locations, equipment considerations, integrating care teams, safety guidelines, preprocedural patient evaluation and postprocedure care, commonly encountered problems, and financial considerations.

Invasive cardiology procedures have changed dramatically over the past 5–10 years. With technological advancement, diagnostic and therapeutic procedures have become broader in scope and complexity, and patient acuity has escalated dramatically. In parallel, the involvement of anesthesiologists has grown. In this chapter, we present an overview of the laboratory environment(s), the evolution and future pathways of current practice(s), cases performed in each venue, and current anesthetic approaches. In this new and changing arena, collaboration and planning between cardiologists and anesthesiologists maximizes patient safety and increases the probability of procedural success. A thorough understanding of the procedure to be performed is required in order for anesthesiologists to define and delineate the extent of their involvement, and is a clear prerequisite for the formulation of a safe and effective anesthetic plan. A common knowledge base and mutual respect for each contributing discipline form the basis for integration of cardiology and anesthesia services in pursuit of optimized patient care.

Background Radiofrequency ablation of ventricular tachycardia (VT) may be performed with general anesthesia (GA) or conscious sedation; however, comparative data are limited. Objective The purpose of the study was to assess the effects of GA on VT inducibility and stability. Methods A retrospective comparison of 226 patients undergoing radiofrequency ablation for scar-related VT under GA or intravenous conscious sedation was performed. Data were then prospectively collected in 73 patients undergoing noninvasive programmed stimulation (NIPS) while awake, followed by GA and invasive programmed stimulation for VT induction. Results In the retrospective study, groups did not differ in VT inducibility, complications, or abolition of clinical VT. Intravenous hemodynamic support was used more often in the GA group. In the prospective group, 12 patients (16%) were noninducible with NIPS. Of the 61 patients with inducible VT with NIPS, 5 (8%) were noninducible with GA, 25 (41%) were inducible with more aggressive simulation, and 31 (51%) were inducible with the same or less aggressive stimulation. Of the 56 patients who were inducible with NIPS and under GA, 28 (50%) had the same induced VTs and 28 (50%) had different induced VTs. In 23 of 56 patients, the clinical VT morphology was known. The clinical VT was reproduced with NIPS in 17 of 23 patients (74%) and under GA in 13 of 23 patients (59%). Under GA, nonclinical VTs were more often induced in patients with a lower ejection fraction and nonischemic cardiomyopathy. Conclusion GA does not prevent inducible VT in the majority of patients. GA is associated with an increased use of hemodynamic support, but this did not adversely affect VT stability or procedure outcomes.

Evolving financial and medical constraints fueled by the increasing repertoire of nonoperating room cases and widening scope of patient comorbidities are discussed. The need to integrate finances and care approaches is detailed, and strategic suggestions for broader collaborative practice are suggested.

Uncorrected congenital interatrial septal defect can be found in nearly a third of all adults and are associated with significant morbidity, including pulmonary hypertension, right-heart failure, atrial arrhythmias, and paradoxical embolic stroke. With advancing technology, percutaneous closure of atrial septal defects has become a viable alternative to open surgical repair. In this review, the authors provide 3 examples in which 3-dimensional interventional transesophageal echocardiogram effectively provided more precise visualization of the dynamic surface and geometry of the atrial septum and related structures than 2-dimensional TEE, permitting accurate sizing and repair of the defects.

Chapter 19 discusses invasive cardiology procedures performed in the cardiac catheterization laboratory (CCL), the electrophysiology laboratory (EPL), and the transesophageal echocardiography laboratory, and which have become the purview of anesthesiologists. Common CCL procedures include the following: diagnostic cardiac catheterizations, percutaneous coronary interventions, peripheral vascular diagnostic and therapeutic procedures, implantation of percutaneous left ventricular assist devices, placement of septal occlusion devices, and percutaneous valve repair or replacement procedures. Common EPL procedures consist of EP studies, atrial and ventricular radiofrequency (RF) ablation procedures, implantation and removal of pacing and cardioverter defibrillator devices, and electrical cardioversion. TEE procedures include trans-esophageal echocardiography (TEE) and combined TEE/direct current cardioversions (DCCV). All of these procedures may require the involvement of anesthesiologists if the patient has significant comorbidities or if the procedure requires that the patient be absolutely still and/or asleep.

A 52-year-old man presented with progressive dyspnea on exertion and hemoptysis following unsuccessful cardioversion and radiofrequency ablation for paroxysmal atrial fibrillation 5 months earlier. He underwent magnetic resonance angiography and CT angiography to assess pulmonary venous anatomy and to rule out pulmonary embolism. Imaging demonstrated an occluded left-lower pulmonary vein (Figure A). Figure. A, An MRI image showing both arterial and venous phases of filling. A paucity of pulmonary vasculature is seen in the area normally supplied by the left-lower pulmonary vein (white arrow), suggesting occlusion. B, Real-time 3D TEE of the left pulmonary venous system (rotated image) revealing the origin of the occluded left-lower pulmonary vein (top orifice) in relation to the patent left-upper pulmonary vein (bottom orifice). C, Angiographic image revealing wire passage through an …

Purpose of review The cardiac catheterization lab has concerns for both patient care and for safety. As the cardiac catheterization lab continues to evolve, the demand for anesthesia services will certainly increase. The role of the anesthesiologist in the cardiac catheterization lab must be defined in this changing environment. Recent findings Procedures in the cardiac catheterization lab are more complex, take longer, and involve higher acuity patients. Many of these cases require general anesthesia rather than sedation, and require management of unstable hemodynamics. Knowledge of echocardiography and fluoroscopy is beneficial. Anesthesiologists should be active in developing sedation and practice management guidelines. Radiation exposure and safety is an important concern. Summary The anesthesiologist is becoming an integral part of the cardiac catheterization lab team, and an important element in maintaining a high level of patient care with minimal complications in the evolving modern day cardiac catheterization lab.

All physicians increasingly will encounter patients who have implanted cardioverter-defibrillators (ICDs) for protection from ventricular arrhythmias. This advisory provides a concise summary relevant to the assessment and management of patients with ICDs, including those who present to primary care or emergency department physicians with symptoms suggesting arrhythmia or ICD malfunction and those who require cardiac or surgical procedures.

We have previously demonstrated that the nitric oxide (NO) donor S-nitroso-N-acetylcysteine (SNAC) reversibly decreases the activity of creatine kinase (CK) in an isolated rat heart preparation, markedly suppressing myocardial contractile responsiveness to an inotropic challenge. We wished to further examine the role of exogenous and endogenous sources of NO species on S-nitrosation of CK and subsequent enzyme activity in adult rat ventricular myocytes (ARVM). Two S-nitrosothiol groups were formed in the CK dimer after nitrosation of rabbit skeletal muscle CK in solution. CK inactivation due to S-nitrosation was time- and concentration-dependent in solution and in ARVM lysate for both NO donors S-nitroso-N-acetylpenicillamine (SNAP) and SNAC, and was rapidly reversible with the sulfhydryl dithiothreitol (DTT). Similarly, SNAC or SNAP dose-dependently decreased CK activity in intact ARVM, which was further attenuated by increasing the metabolic activity of the cells with electrical pacing for 1 h. Co-cultures of ARVM with interleukin 1 beta (IL-1 beta)- and interferon gamma (IFN gamma)-pretreated cardiac microvascular endothelial cells (CMEC) caused no detectable decline in myocyte CK activity. Increasing GSH levels attenuated the decline in myocyte CK activity with SNAC, while decreases in myocyte GSH levels enhanced the inhibitory effect of SNAC on intact myocyte CK activity. These data indicate that the degree of inhibition of cardiac myocyte CK by NO is dependent on the extent of myocyte metabolic activity and the intracellular GSH content.

Cardiac myocytes express both constitutive and cytokine-inducible nitric oxide syntheses (NOS). NO and its congeners have been implicated in the regulation of cardiac contractile function. To determine whether NO could affect myocardial energetics, 31P NMR spectroscopy was used to evaluate high-energy phosphate metabolism in isolated rat hearts perfused with the NO donor S-nitrosoacetylcysteine (SNAC). All hearts were exposed to an initial high Ca2+ (3.5 mM) challenge followed by a recovery period, and then, either in the presence or absence of SNAC, to a second high Ca2+ challenge. This protocol allowed us to monitor simultaneously the effect of SNAC infusion on both contractile reserve (i.e., baseline versus high workload contractile function) and high-energy phosphate metabolism. The initial high Ca2+ challenge caused the rate-pressure product to increase by 74 +/- 5% in all hearts. As expected, ATP was maintained as phosphocreatine (PCr) content briefly dropped and then returned to baseline during the subsequent recovery period. Control hearts responded similarLy to the second high Ca2+ challenge, but SNAC-treated hearts did not demonstrate the expected increase in rate-pressure product. In these hearts, ATP declined significantly during the second high Ca2+ challenge, whereas phosphocreatine did not differ from controls, suggesting that phosphoryl transfer by creatine kinase (CK) was inhibited. CK activity, measured biochemically, was decreased by 61 +/- 13% in SNAC-treated hearts compared to controls. Purified CK in solution was also inhibited by SNAC, and reversal could be accomplished with DTT, a sulfhydryl reducing agent. Thus, NO can regulate contractile reserve, possibly by reversible nitrosothiol modification of CK.

Nitric oxide (NO) is a ubiquitous autocrine- and paracrine-acting signalling autacoid that, among other functions, has been shown to regulate cardiac contractile responsiveness to β-adrenergic and muscarinic cholinergic agonists. Cellular constituents of cardiac muscle, including ventricular myocytes as well as microvascular endothelial cells, have been shown to express the “endothelial constitutive” isoform of NO synthase (ecNOS or NOS III) in vivo, and both cell types also express the NO synthase isoform induced by specific inflammatory cytokines (iNOS or NOS II) in vivo and in vitro. While NO-dependent intracellular signalling in cardiac myocytes clearly involves the activation of guanylate cyclase and downstream signalling by cyclic guanosine monophosphate (cGMP), there is accumulating evidence that non-cGMP-dependent regulatory signalling events are also initiated by NO. In addition, decreased contractile responsiveness of cardiac myocytes to β-adrenergic agonists, following induction of NOS II by inflammatory cytokines, requires the presence of insulin and the coinduction of enzymes responsible for production of tetrahydrobiopterin, a NOS cofactor. Inappropriate or excessive production of NO by cardiac myocytes and by microvascular endothelial cells probably contributes to the cardiac contractile dysfunction characteristic of the systemic inflammatory response syndrome and cardiac allograft rejection.

BLOUNT DISEASE (tibia vara) ~ is a skeletal disorder characterized by bowed legs and tibial torsion. Radiographically, the affected extremities show enlargement or a beaktike projection of the medial aspect of the proximal metaphysis of the tibia (Fig. 1); the abnormality involves the medial portion of the proximal secondary center as well. Growth appears deficient medially, resulting in medial angulation of the diaphysis of the tibia. Because this line of weight bearing is through the medial aspect of the bone, its medial cortex becomes thickened. :5 Microscopic examination of affected areas demonstrates distorted bone trabeculae containing focal areas of cartilage that coincide with the radiolucent areas. ~-3 The causes of Blount disease are unknown. Females appear to be more frequently affected than males, ~,4 although agreement is not uniform? Age of onset distinguishes patients with the infantile type, with onset between one and 3 years of age, and the juvenile type with onset after 8 years of age~ 1,3, 4 The occasional appearance of more than one case in the same family suggests a hereditary component, 3,6 and an increased prevalence among West Indian children indicates the possibility of a racial predisposition? Affected children have no evidence of rickets and only rarely a history of trauma. ~' 2 Pathologic examination has shown no evidence of aseptic necrosis or inflammation. ~-~ Obesity has frequently been mentioned in association with the infantile type of the disease, ~-4.6 but the interrelationship of obesity and Blount disease has never been examined in detail. Two cases of the infantile type of Blount disease