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Current Opinion in Cardiology Nov 2018As our population ages and cardiovascular disease increases in prevalence, a growing number of patients will be candidates for coronary artery bypass grafting (CABG).... (Review)
Review
PURPOSE OF REVIEW
As our population ages and cardiovascular disease increases in prevalence, a growing number of patients will be candidates for coronary artery bypass grafting (CABG). Outcomes from this common surgery can be improved by a coordinated team approach involving physicians, nurses, and healthcare professionals from multiple specialties. This review will discuss the role cardiovascular anesthesiologists play in the perioperative care of these complex patients.
RECENT FINDINGS
Cardiovascular anesthesiologists may play a variety of important roles throughout the entire perioperative period of patients undergoing CABG. This may include identification and optimization of preoperative comorbidities, employment of enhanced recovery pathways, perioperative echocardiographic assessment of complex cardiovascular states, management of patients on cardiopulmonary bypass, and others. There is growing evidence that each of these areas contributes to better care and improved outcomes.
SUMMARY
Care of the patient undergoing CABG requires a team approach. Optimal team dynamics translate into better care for patients and improved outcomes. The cardiovascular anesthesiologist is an integral member of this team whose role is central in the coordination of all aspects of perioperative care. Preoperative optimization begins the process, which continues throughout surgery, cardiopulmonary bypass, and into the postoperative period.
Topics: Anesthesia; Anesthesiologists; Clinical Competence; Coronary Artery Bypass; Coronary Artery Disease; Disease Management; Humans; Perioperative Period
PubMed: 30303853
DOI: 10.1097/HCO.0000000000000570 -
Anesthesiology Clinics Mar 2019
Topics: Anesthesiologists; Day Care, Medical; Humans; Wounds and Injuries
PubMed: 30711238
DOI: 10.1016/j.anclin.2018.11.001 -
Journal of Clinical Anesthesia Nov 2022
Topics: Anesthesiologists; Curriculum; Humans
PubMed: 35961225
DOI: 10.1016/j.jclinane.2022.110947 -
Policy, Politics & Nursing Practice Nov 2019The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered... (Review)
Review
The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered nurse anesthetists (CRNAs), and team-based approaches incorporating anesthesiologist supervision or direction of CRNAs. Despite data demonstrating very low risk of death and complications associated with anesthesia, debate among professional societies and policymakers persists over the superiority or equivalence among these models. The American Society of Anesthesiologists uses published findings as evidence for claims that anesthesia is safer when anesthesiologists lead in providing care. The American Association of Nurse Anesthetists cites its own research on safety and cost-efficiency outcomes to defend against these claims. We review and critique studies of the safety outcomes and cost-effectiveness of anesthesia delivery that have been cited in the Federal Trade Commission comment letters related to competition in health care, where each profession has laid out their case for how they ought to be recognized in the market for anesthesia services. The Federal Trade Commission has a role in protecting consumers from anticompetitive conduct that has the potential to impact quality and cost in health care. Thus, it is important to evaluate the evidence used to make claims about these topics. We argue that while research in this area is imperfect, the strong safety record of anesthesia in general and CRNAs in particular suggest that politics and professional interests are the main drivers of supervision policy in anesthesia delivery.
Topics: Anesthesia; Anesthesiologists; Cost-Benefit Analysis; Delivery of Health Care; History, 19th Century; History, 20th Century; History, 21st Century; Humans; Nurse Anesthetists; Patient Safety; Politics; Scope of Practice; Societies, Medical; Societies, Nursing; United States; United States Federal Trade Commission
PubMed: 31510877
DOI: 10.1177/1527154419874410 -
Journal of Cardiothoracic and Vascular... Mar 2021Many children born today with congenital heart disease can expect to live long into adulthood. Improvements in surgical technique and anesthetic and perioperative care... (Review)
Review
Many children born today with congenital heart disease can expect to live long into adulthood. Improvements in surgical technique and anesthetic and perioperative care have significantly increased the number of survivors. Unfortunately, as these patients progress through life they frequently require further interventions. Although surgical intervention may be required frequently, these patients can be managed in the cardiac catheterization or electrophysiology laboratory. Surgical correction of tetralogy of Fallot can leave patients with pulmonary valve dysfunction later in life. A percutaneous approach is now available for these patients, which can obviate the need for resternotomy. During deployment of the valve, anesthesiologists should be aware that compression of coronary arteries can occur. Adult congenital heart disease (ACHD) patients often require pacemaker/implantable cardioverter- defibrillator (ICD) insertion or ablation therapy. These patients may have altered cardiac anatomy, which can make endovascular procedures extremely challenging. Recent developments have made these procedures safer and more efficient. A number of congenital cardiac conditions can also be associated with orofacial abnormalities. ACHD patients, as a result, can present with challenging airways. The catheterization laboratory may not be the optimum environment for the anesthesiologist to manage a difficult airway. The requirement of transesophageal echocardiography for some cath eterization procedures needs to be considered when deciding on an airway management plan. Knowledge of the underlying cardiac anatomy and the planned procedure is advised when providing anesthesia for this complex patient group outside the theater setting.
Topics: Adult; Anesthesiologists; Cardiac Catheterization; Cardiology; Child; Defibrillators, Implantable; Heart Defects, Congenital; Humans
PubMed: 32762881
DOI: 10.1053/j.jvca.2020.07.037 -
Anesthesiology Feb 2019Guidelines for obstetric anesthesia recommend neuraxial anesthesia (i.e., spinal or epidural block) for cesarean delivery in most patients. Little is known about the...
BACKGROUND
Guidelines for obstetric anesthesia recommend neuraxial anesthesia (i.e., spinal or epidural block) for cesarean delivery in most patients. Little is known about the association of anesthesiologist specialization in obstetric anesthesia with a patient's likelihood of receiving general anesthesia. The authors conducted a retrospective cohort study to compare utilization of general anesthesia for cesarean delivery among patients treated by generalist versus obstetric-specialized anesthesiologists.
METHODS
The authors studied patients undergoing cesarean delivery for live singleton pregnancies from 2013 through 2017 at one academic medical center. Data were extracted from the electronic medical record. The authors estimated the association of anesthesiologist specialization in obstetric anesthesia with the odds of receiving general anesthesia for cesarean delivery.
RESULTS
Of the cesarean deliveries in our sample, 2,649 of 4,052 (65.4%) were performed by obstetric-specialized anesthesiologists, and 1,403 of 4,052 (34.6%) by generalists. Use of general anesthesia differed for patients treated by specialists and generalists (7.3% vs. 12.1%; P < 0.001). After adjustment, the odds of receiving general anesthesia were lower among patients treated by obstetric-specialized anesthesiologists among all patients (adjusted odds ratio, 0.71; 95% CI, 0.55 to 0.92; P = 0.011), and in a subgroup analysis restricted to urgent or emergent cesarean deliveries (adjusted odds ratio, 0.75; 95% CI, 0.56 to 0.99; P = 0.049). There was no association between provider specialization and the odds of receiving general anesthesia in a subgroup analysis restricted to evening or weekend deliveries (adjusted odds ratio, 0.76; 95% CI, 0.56 to 1.03; P = 0.085).
CONCLUSIONS
Treatment by an obstetric anesthesiologist was associated with lower odds of receiving general anesthesia for cesarean delivery; however, this finding did not persist in a subgroup analysis restricted to evening and weekend deliveries.
Topics: Adult; Anesthesia, General; Anesthesia, Obstetrical; Anesthesiologists; Cesarean Section; Cohort Studies; Female; Humans; Pregnancy; Retrospective Studies; Specialization
PubMed: 30601216
DOI: 10.1097/ALN.0000000000002534 -
Journal of Cardiothoracic and Vascular... Nov 2023
Topics: Humans; Anesthesiologists; Point-of-Care Systems; Ultrasonography; Point-of-Care Testing
PubMed: 36639259
DOI: 10.1053/j.jvca.2022.12.018 -
JAMA Surgery May 2021Intraoperative anesthesiology care is crucial to high-quality surgical care. The clinical expertise and experience of anesthesiologists may decrease the risk of adverse...
IMPORTANCE
Intraoperative anesthesiology care is crucial to high-quality surgical care. The clinical expertise and experience of anesthesiologists may decrease the risk of adverse outcomes.
OBJECTIVE
To examine the association between anesthesiologist volume and short-term postoperative outcomes for complex gastrointestinal (GI) cancer surgery.
DESIGN, SETTING, AND PARTICIPANTS
This population-based cohort study used administrative health care data sets from various data sources in Ontario, Canada. Adult patients who underwent esophagectomy, pancreatectomy, or hepatectomy for GI cancer from January 1, 2007, to December 31, 2018, were eligible. Patients with an invalid identification number, a duplicate surgery record, and missing primary anesthesiologist information were excluded.
EXPOSURES
Primary anesthesiologist volume was defined as the annual number of procedures of interest (esophagectomy, pancreatectomy, and hepatectomy) supported by that anesthesiologist in the 2 years before the index surgery. Volume was dichotomized into low-volume and high-volume categories, with 75th percentile or 6 or more procedures per year selected as the cutoff point.
MAIN OUTCOME AND MEASURES
The primary outcome was a composite of 90-day major morbidity (with a Clavien-Dindo classification grade 3-5) and readmission. Secondary outcomes were individual components of the primary outcome. The association between exposure and outcomes was examined using multivariable logistic regression models, accounting for potential confounders.
RESULTS
Of the 8096 patients included, 5369 were men (66.3%) and the median (interquartile range [IQR]) age was 65 (57-72) years. Operations were supported by 842 anesthesiologists and performed by 186 surgeons, and the median (IQR) anesthesiologist volume was 3 (1.5-6) procedures per year. A total of 2166 patients (26.7%) received care from high-volume anesthesiologists. Primary outcome occurred in 36.3% of patients in the high-volume group and 45.7% of patients in the low-volume group. After adjustment, care by high-volume anesthesiologists was independently associated with lower odds of the primary outcome (adjusted odds ratio [aOR], 0.85; 95% CI, 0.76-0.94), major morbidity (aOR, 0.83; 95% CI, 0.75-0.91), unplanned intensive care unit admission (aOR, 0.84; 95% CI, 0.76-0.94), but not readmission (aOR, 0.87; 95% CI, 0.73-1.05) or mortality (aOR, 1.05; 95% CI, 0.84-1.31). E-values analysis indicated that an unmeasured variable would unlikely substantively change the observed risk estimates.
CONCLUSIONS AND RELEVANCE
This study found that, among adults who underwent complex gastrointestinal cancer surgery, those who received care from high-volume anesthesiologists had a lower risk of adverse postoperative outcomes compared with those who received care from low-volume anesthesiologists. These findings support organizing perioperative care to increase anesthesiologist volume to optimize patient outcomes.
Topics: Aged; Anesthesiologists; Clinical Competence; Critical Care; Databases, Factual; Digestive System Neoplasms; Esophagectomy; Female; Hepatectomy; Humans; Male; Middle Aged; Ontario; Pancreatectomy; Patient Readmission; Postoperative Complications; Retrospective Studies; Time Factors; Treatment Outcome
PubMed: 33729435
DOI: 10.1001/jamasurg.2021.0135 -
Asian Journal of Anesthesiology Jun 2018
Topics: Anesthesiologists; Anesthetists; Humans; Terminology as Topic
PubMed: 30286557
DOI: 10.6859/aja.201806_56(2).0001 -
JAMA May 2018
Topics: Anesthesiologists; Death; Family; Grief; Humans; Teaching Rounds
PubMed: 29801015
DOI: 10.1001/jama.2018.4307