Rural Anesthesiology Practice Smoking and Chronic Pain

Volu M e 94 Nu 94 e M ber 3 ber Mi NNesotaMedici Ne

also inside: A Sleeper Career: Rural Anesthesiology Practice

Smoking and Chronic Pain

Ultrasound-Guided Regional Anesthesia March 2011 March

MinnesotaMinnesota Medical Medical association association February March 2011 2011 MinnesOta MeDiCal assOCiatiOn

MarCH 2011 taBle Of COntents

COVer stOrY Safety First By Kate ledger How anesthesiologists launched the patient- 22 safety movement.

COMMentarY 27 The Evolution of Safety in Anesthesiology t h e i n v e n - By Mark a. Warner, M.D. tion of the pulse oximeter was a major Standardized anesthesia care and patient step forward in patient safety, monitoring have made surgery safer. The as it allows anesthesiologists to monitor oxygen satura- next step is for anesthesiologists, surgeons, tion in a patient’s blood and quickly prevent a crisis. and hospital staff to work together on pre- Photo by Clare Pix Photography • www.clarepix.com and postoperative care. 29 Anesthesiology Education: A New CliniCal & HealtH af fairs Emphasis 31 Multimodal Clinical Pathways, Perineural Catheters, By Mojca remskar Konia, M.D., and Kumar G. and Ultrasound-Guided Regional Anesthesia: The Belani, M.B.B.s., M.s. Anesthesiologist’s Repertoire for the 21st Century Why medical schools and residency programs By adam D. niesen, M.D., and James r. Hebl, M.D. are having to rethink their approach to training future anethesiologists. 35 Smoking and Chronic Pain: A Real-but-Puzzling Relationship By toby n. Weingarten, M.D., Yu shi, M.D., M.P.H., Carlos B. Mantilla, M.D., Ph.D., W. Michael Hooten, M.D., and David O. Warner, M.D 38 Postoperative Nausea and Vomiting in Pediatric Patients Discomfort, Delirium, and POnV in infants and Young Children Undergoing enD nOtes strabismus surgery 56 A Look Back By anne M. stowman, erick D. Bothun, M.D., and Kumar G. Belani, The role of the M.B.B.s., M.s. nurse anesthetist at Postoperative nausea and Vomiting in infants and Young Children following Mayo Clinic. Urologic surgery the Mayo brothers By Preeta George, M.B.B.s., M.D., Kumar G. Belani, M.B.B.s., M.s., and entrusted the task of aseem shukla, M.D. administering anesthesia to nurses. alice 43 Safe and Sound: Pediatric Procedural Sedation Magaw was their primary anesthetist Photo courtesy of Mayo Clinic and Analgesia for many years. Charles Mayo eventually By Patricia D. scherrer, M.D. dubbed her the “mother of anesthesia.” 48 Pediatric Chronic Pain: There Is Hope By tracy Harrison, M.D. March 2011 • Minnesota Medicine | 1 MarCH 2011 taBle Of COntents minnesota PUlse 6-15 MEDICINE 20 11 MMA Officers Owner and Publisher President Minnesota Medical association Sleeper Career Patricia J. lindholm, M.D. Editor in Chief President-Elect Charles r. Meyer, M.D. Not many anesthesiologists practice in rural lyle J. swenson, M.D. Managing Editor areas. Mark Gujer is trying to change that. Chair, Board of Trustees Carmen Peota David C. thorson, M.D. Associate Editor Secretary/Treasurer Kim Kiser David e. Westgard, M.D. MMA News Anti-Smoking Prophet Speaker of the House scott smith Mark liebow, M.D. Graphic Designers David Warner believes anesthesiologists should Vice Speaker of the House Janna netland lover Michael start help patients quit. robert Moravec, M.D. Past President Publications Assistant Benjamin H. Whitten, M.D. Kristin Drews MMA Chief Executive Officer Advisory Committee Better than Laughing Gas robert K. Meiches, M.D. Zubin argawal Maria Carrow Since posting a music video on YouTube, a group MMA Board of Trustees Donald l. Deye, M.D. of singing nurse anesthetists has found fame and Northwest District Barbara elliott, Ph.D. robert a. Koshnick Jr., M.D. Jon s. Hallberg, M.D. a lot of new fans. Northeast District neal Holtan, M.D. Peter J. Kernahan, M.D. Michael P. Heck, M.D. robert K. Meiches, M.D. Paul B. sanford, M.D. Gregory Plotnikoff, M.D. Abbott’s Pain Patrol North Central District Martin stillman, M.D., J.D. Wade t. swenson, M.D., M.P.H. Barbara P. Yawn, M.D. Anesthesiologists at one Twin Cities hospital now Patrick J. Zook, M.D. anjali Wilcox Twin Cities District therese Zink, M.D., M.P.H. routinely use regional anesthesia to control pain Michael B. ainslie, M.D. during and after surgery. Beth a. Baker, M.D., M.P.H. Copyright & Post Office Entry Carl e. Burkland, M.D. Minnesota Medicine (issn 0026-556X) is Benjamin W. Chaska, M.D. published each month by the Minnesota V. stuart Cox iii, M.D. Medical association, 1300 Godward Donald M. Jacobs, M.D. street ne, suite 2500, Minneapolis, Mn roger G. Kathol, M.D. 55413. Copyright 2 011. Permission to Charles G. terzian, M.D. reproduce editorial material in this maga- David C. thorson, M.D. zine must be obtained from Minnesota Southwest District Medicine. Periodicals postage paid at Cindy firkins smith, M.D. Minneapolis, Minnesota, and at addi- MMa neWs 20-21 Keith l. stelter, M.D. tional mailing offices. POstMaster, Southeast District send address changes to Minnesota Medicine, 1300 Godward street, ste David C. agerter, M.D. • Dayton Budget avoids Clinic Payment Cuts 2500, Minneapolis, Mn 55413. Daniel e. Maddox, M.D. • MMa releases review of Medica’s associate Gabriel f. sciallis, M.D. Subscriptions Douglas l. 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To the Edge and Back

ou saved my life.” Anybody approximate brainstem death, because who has practiced medicine patients are unconscious, have depressed “Yfor any length of time has brain-stem reflexes, do not respond to heard those dramatic words. Although I nociceptive stimuli, have no apneic drive, frequently think the comment is the result and require cardiorespiratory and thermo- more of perception than reality, it is true regulatory support.” that our patients sometimes walk the preci- Placing a patient in a state of brain- pice between life and death and that some- stem death is quite a responsibility. So it’s

ott Walker ott times we successfully yank them back. But no wonder that anesthesiology has been at sc occasionally, we put them on that cliff only the leading edge of the patient safety move- to, we hope, pull them back to safety. ment. Long before “patient safety” was the Photo by by Photo I remember the first time I partici- buzzword it is today, anesthesiologists bor- Primary care internists pated in the cardioversion of a patient with rowed lessons from the airline industry and atrial flutter. Clearly, the patient needed to looked at what they did each day, analyzed don’t have to endure be “rescued” from the rapid heart rhythm when and why things went wrong, and that was causing his dropping blood pres- built systems to prevent things from going many heart-stopping, sure and shortness of breath. Yet, I shud- wrong. Those systems have cut the rate of dered when, after the electrical shock was complication and death associated with all anxiety-riling, applied, his EKG showed a flat line for forms of anesthesia, which should make what seemed like an eternity. Finally, his patients a whole lot more comfortable with gray-hair-promoting heart kicked in with a normal rhythm that that doctor behind the mask. restored his blood pressure and cleared his Increasingly, those masked doctors moments. But for symptoms. A few seconds of jeopardy fol- do a whole lot more than put people to anesthesiologists, lowed by a “save.” sleep. Using ultrasound to find nerves long Luckily, primary care internists since forgotten from anatomy lessons, they this is their daily fare. don’t have to endure too many of these administer innovative regional anesthesia, heart-stopping, anxiety-riling, gray-hair- which minimizes narcotic use and short- promoting moments. But for anesthesi- ens recovery time. The mushrooming of ologists, this is their daily fare. Consider outpatient procedures has forced anesthe- what happens with general anesthesia: siologists to adjust and adapt, retooling the A conscious and alert person lies down education of students and residents and on a bed and allows a masked person in bringing their equipment and skills into a funny-looking shower cap, whom they new environments such as interventional just met, to place them in a state of deep radiology suites and pain clinics. sleep for the next minutes or hours using Part of the drama of saving lives is the toxic chemicals. They trust that this same very undramatic focus on patient safety. person will have the skill, knowledge, and Whether they are sitting in the OR squeez- inclination to wake them up and restore ing the bag or in the clinic tackling pain, them to their previous self. A recent New anesthesiologists will continue to teach, England Journal of Medicine review of the preach, and practice safe medicine. physiology of general anesthesia put it in stark terms: “At levels appropriate for sur- Charles r. Meyer, M.D., editor in chief, can gery, general anesthesia can functionally be reached at [email protected]

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Having served as the only anesthesiologist in Crosby, Minnesota, since to tertiary care facilities, they 2006, Mark Gujer is looking forward to will have to have an anesthesi- having a colleague. ologist,” he says. esthesiologists (ASA), only 5 And that’s precisely what percent of practicing anesthe- Cuyuna’s administration siologists work in rural parts wanted to do in 2006 when it of the United States. Gujer hired Gujer. wants to see that number increase and touts the merits of Staying Close rural practice to job candi- to Home dates, residents, and medical At the time, Cuyuna was be- students. coming known as a regional Whether that 5 percent leader in minimally invasive figure represents a shortage surgery. Although its sur- of anesthesiologists in rural geons had the expertise to America isn’t exactly clear. A perform complex procedures, 2010 report by RAND Health they were limited in the ex- found that the United States tent to which they could do and Minnesota are experienc- them, as the hospital served ing a shortage of anesthesia a largely elderly population, providers including both an- many of whom had comor- esthesiologists and certified bidities. “They may have car- registered nurse anesthetists diac challenges or other health (CRNAs). But the RAND re- problems that make them an port tells only part of the story. operative risk,” says Howard “In Minnesota, on paper there’s McCollister, M.D., chief of no real shortage of rural anes- surgery and co-director of the thesiologists because no one’s hospital’s minimally invasive putting jobs out there for them surgery center. to apply for,” Gujer says. “Peo- McCollister approached the ple put their hands up a long hospital’s board and adminis- time ago and said, ‘We can’t get tration about hiring an anes- Photo courtesy of Cuyunathem’ regional Medical Center and stopped trying.” thesiologist who was experi- n Rural Anesthesiology Instead, most hospitals in enced with medically complex greater Minnesota (most an- patients—in particular those Sleeper Career esthesiologists in rural areas with cardiac problems—so Not many anesthesiologists practice in rural areas. Mark work for hospitals) began rely- that they wouldn’t have to ing on CRNAs after Gov. Jesse send them to the Twin Cities Gujer is trying to change that. | BY KiM Kiser Ventura in 2002 took advan- for surgery. “We needed an tage of a change in the federal M.D. to bring a broader focus ark Gujer, M.D., is preparing to sell the merits of Crosby, Medicare rules that allowed in dealing with people who MMinnesota. On a Friday in early January, he is getting states to exempt hospitals have physiologic problems, so ready to drive to Brainerd to pick up a physician from Anchor- from requiring that physicians we could safely do operations age, Alaska, who is interviewing for an anesthesiology position at supervise CRNAs. Currently, on people that most rural fa- Cuyuna Regional Medical Center, a 25-bed hospital in the town 16 states have adopted the cilities, including bigger ones of 2,000. exemption. close to us, can’t do,” he says. Gujer has his work cut out for him. “We had 30 applicants Gujer believes the use of But making the financial and extended four interviews, which in our industry is doing CRNAs doesn’t alleviate the case for hiring an anesthesiolo- quite well for a rural practice. These [positions] are difficult to need for anesthesiologists. “If gist to serve a rural hospital can recruit for,” he explains. a hospital’s goal is to build its be tricky. “They have to find a As the only anesthesiologist in Crosby—and for that matter, surgical capabilities and do way to get more bang for the one of only a handful in northern Minnesota—Gujer is some- more complex cases so they buck out of you because you what of a lone wolf. According to the American Society of An- don’t have to transfer patients might not generate the revenue

6 | Minnesota Medicine • March 2011 pulse | the way a Minneapolis anesthe- “in Minnesota, on paper very personal,” he says. “The siologist can,” Gujer says. same doc comes back every The fact that Cuyuna is day and checks on you.” certified as a Medicare Criti- there’s no real shortage Gujer says being able to cal Access Hospital made hir- get to know his patients per- ing one more feasible. Critical of rural anesthesiologists sonally and care for them Access Hospitals receive cost- throughout their hospital stay based reimbursement from because no one’s is what keeps him in Crosby. Medicare in order to keep “I couldn’t go back to another them financially viable; they putting jobs out there.” model,” he says. also are able to hire physicians, But that doesn’t mean work- who may not have a full-time —Mark Gujer, M.D. ing in a rural area isn’t without case load, to oversee services challenges. such as surgery, the ICU, and anesthesiologists come to the medical problems learns he or There’s the potential for the ambulance service. hospital in the morning, are she needs surgery. He sees that professional isolation, for ex- Gujer, who met McCollister assigned their room, then meet patient before the procedure is ample. One reason Gujer is while working as an EMT in their first patient. They review scheduled, does an assessment, looking forward to having a Virginia, Minnesota, before the patient’s medical history, reviews their medical history, partner is to have someone to going to medical school, was formulate an anesthetic plan, and communicates with their consult with and serve as his hired as medical director of go back to the OR and put primary care physician. Other back up. “If you’re the only perioperative services—a job the patient under, then reverse specialists may be brought in surgeon in town or the only that involves managing patient the anesthesia after surgery to consult and help formulate anesthesiologist, you’re very flow in the surgical area as and follow up with patients in an operative and anesthesia isolated, you’re the only one well as caring for patients be- recovery. Also, one anesthesi- plan. On the day of surgery, doing what you do,” Gujer fore, during, and after surgery. ologist may see patients before Gujer again meets with the pa- says. “It’s not sustainable.” (He is also designing a new surgery, another may take over tient, administers anesthesia in And anesthesiologists may perioperative suite in order to in the OR, and yet another the OR, reverses it, and con- have to prove themselves in increase the hospital’s physical might follow up in the ICU. tinues to monitor the patient ways they don’t have to in capacity for surgery.) Gujer’s work starts the mo- in recovery and throughout urban areas. “Anesthesiology is Since Gujer joined Cuyuna, ment a patient with complex his or her hospitalization. “It’s different from primary care,” the hospital has added a urologic surgeon and another orthopedic surgeon, bringing the Working with CRNAs total number of surgeons to 13; it now does approximately although there is tension between anesthesiologists and certified registered nurse 4,000 procedures a year, and anesthetists (Crnas) in some parts of the country, it hasn’t been the case in Crosby, has gained Center of Excel- Minnesota. Mark Gujer, M.d., the sole anesthesiologist at Cuyuna regional Medi- lence status for bariatric sur- cal Center, has found that anesthesiologists and Crnas can complement each gery from both the American other’s work in rural institutions. College of Surgeons and the Before Gujer joined Cuyuna five years ago, Crnas were the only ones providing American Society of Metabolic anesthesia services at the hospital. But surgeons in the community wanted to be and Bariatric Surgery. In addi- able to do more complex procedures and work with sicker patients who were more tion, it is one of 117 teaching difficult to treat. they convinced the hospital to hire Gujer. centers nationwide with a fully today, patients are triaged along two tracks. Gujer sees more medically complex accredited fellowship in mini- patients. the hospital’s four Crnas (they’re recruiting a fifth) independently handle mally invasive surgery. the others. “the Crnas may call me and ask for assistance or my opinion, but for Comprehensive the majority of cases, they function independently without input from me,” he says. Caregiving “We have a fabulous collaboration. they’re happy, they’re fulfilled, they do a won- Gujer says his job is very dif- derful job, and they’re willing to concede that some patients are severely ill and ferent from that of many of his would benefit from having a physician with advanced monitoring capabilities at the colleagues in urban areas. He head of the table.”—K.K. explains that typically, urban

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A Look at the Numbers

% 25 % 12.5 5%

Percent of Percent of areas Percent of the u.s.rural areas in rural areas anesthesiologists population living in surgeons practicing practicing in rural

source: american society of anesthesiologists

says David Beebe, M.D., di- is now doing his residency at rector of the anesthesiology the University of Wisconsin, residency program at the Uni- said the experience opened his versity of Minnesota. “You eyes to the idea of working in might go into an area and be a rural area. “If that experience the first anesthesiologist, and is never one that’s provided you’re dealing with nurse anes- or even available in medical thetists, surgeons, and other school and residency, it’s hard doctors you don’t know. You for a person to think of it as a need to show that you’re add- viable option when in actual- ing something.” ity for me it might be the best option given the quality of life Spreading the Word and kind of practice I want to Gujer, however, remains com- have,” he says. mitted to promoting the posi- Eiler was so impressed with tives of practicing in a rural the experience that he and community. Three years ago, Gujer convinced the medi- he joined the ASA’s Rural Ac- cal school to award credit to cess to Anesthesia Committee, students who do the fellow- which established a fellowship ship. Gujer also has worked for medical students interested with the university to create a in rural anesthesiology. Gujer rural anesthesiology rotation is one of five mentors. During for residents. The three- to the last two years, he has had four-week rotation has been two medical students shadow approved, Beebe says. He ex- him for four-week periods. pects residents to sign up for it The idea, he says, is to expose starting next fall. students to a side of anesthesi- “My goal is to reach out and ology they otherwise may not get even more people inter- experience. ested in rural anesthesiology,” Jake Eiler, M.D., a 2010 Gujer says. “I need to convince University of Minnesota anesthesiologists that this is Medical School graduate, did a viable, rewarding place to a fellowship with Gujer in the practice, and that they should fall of 2009. Eiler, who grew be out there selling themselves up in Morris, Minnesota, and to hospitals.” n

March 2011 • Minnesota Medicine | 9 pulse |

David Warner believes surgery is the best time for doctors to talk to patients about quitting smoking.

other drugs such as opioids following surgery. Warner says patients are motivated to abstain when they learn that it will speed their recovery. Research—the best of which comes from Scandinavia—has shown for some time that bones heal more slowly and wounds are more likely to become infected in people who smoke. “What’s relatively new is the knowledge that if you can get people to quit, the complication rate goes down,” he says, adding that even if they quit for a brief period, their outcomes can improve. Warner is now working to convince fellow physicians to start talking to surgical patients about quitting smoking. He says anesthesiologists and surgeons often think discussing smoking is not their job; that they don’t have time for it; that they don’t know how to help; that what they Photo courtesy sayMayo Clinic isn’t going to have an effect; and that n Smoking and Surgery patients will be offended if they try to bring it up. “I spend most of my time in Anti-Smoking Prophet my research trying to knock down those misconceptions,” he says. David Warner believes anesthesiologists can help patients quit. | BY CarMen PeOta His research has shown that patients aren’t offended when surgeons and anes- ayo Clinic anesthesiologist David that people facing surgery are more aware thesiologists talk to them about smoking. MWarner, M.D., has a message for of their health and willing to take steps to “In fact,” he says, “if there’s something his fellow physicians: Use the time just improve it. Also, his research has shown they can do to improve their chances of before surgery to encourage patients who that smokers have fewer cravings and with- having a good outcome after surgery, they smoke to quit. drawal symptoms when they quit around want us as physicians to tell them.” And Warner says his thinking about this the time of surgery compared with when he ’s identified an approach that is effective began about 12 years ago when he started they quit at other times. He speculates this and simple for busy physicians to do. You researching ways to reduce risk factors might be because they are removed from simply ask patients about smoking, advise for lung problems in surgical patients. things in the environment that normally them to quit for as long as possible (he He quickly realized that stopping smok- cue them to smoke or because they take recommends at least a week starting the ing before surgery was the single best thing they could do. He also learned something else: If a smoker underwent a major surgical procedure, his chances of Smoke Free for Surgery successfully quitting were doubled, even without assistance. “There’s something in 2006, david Warner, M.d., convinced the american society of anesthesiolo- very powerful about the surgical experi- gists (asa) to encourage its members to talk to patients about quitting smok- ence that motivates patients to take that ing before surgery. With the help of a task force led by Warner, the asa has step that most of them want to take any- made a number of resources for patients available on its website including way,” he says. brochures and information cards, a PowerPoint presentation, and a video that Just why that is isn’t entirely clear. explain the benefits of quitting smoking. there’s also a brochure for physicians But Warner thinks it’s probably because of that explains how to talk to patients about smoking. for more information, go a combination of factors, one of which is to www.asahq.org/stopsmoking.

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What To Say anesthesiologist david Warner, M.d., knows that physicians sometimes strug- gle with how to talk to patients about quitting smoking. he starts by asking if they smoke, even if he already knows the answer. if they say yes, he advises them to quit for as long as possible before and after surgery, or to at least try to fast from cigarettes the morning of surgery and the week after. he explains that this will help them avoid complications such as infection and lung problems. then he tells them, “if you’ve thought about quitting for good, surgery is an excellent time to do it because you may be more motivated to do things to improve your health, and you may even find it easier to quit.” he then hands patients a card with the telephone number 800/QuitnOW, which can connect them with free counseling. Warner says the conversation takes no more than a minute.—C.P.

night before surgery), and refer them to quit smoking is not widely accepted. smoking-cessation services. Yet Warner remains convinced that About five years ago, Warner took talking to patients is the right thing to do. his ideas to the American Society of Anes- And he’s hoping that he and others can thesiologists (ASA), which then launched spread this message within and beyond the the Be Smoke-Free for Surgery initiative. anesthesiology community. He notes that Although the ASA has embraced his ideas patients have at least five points of contact and a pilot study involving several private with health care providers around the time anesthesiology practices in Minnesota and of surgery. He’d like to see the nurses, pri- around the country showed they were fea- mary care doctors, surgeons, and anesthe- sible, individual anesthesiologists haven’t siologists who see them at those points all necessarily adopted them. “I’m not the deliver the message about quitting. “It’s a lone voice crying in the wilderness,” War- matter of having an opportunity at a time ner says, but he acknowledges that the idea when we know that people are more recep- that anesthesiologists can help patients tive to these messages,” he says. n

n Local Anesthesia Warmer Welcome our patient will thank you for warming up that local anesthetic before injecting it. YWhy? The injection will hurt less. So concluded researchers from the University of Toronto, who recently studied the issue. The researchers looked at 18 studies involving more than 800 patients and found warming an anesthetic prior to injecting it consistently reduced patients’ pain, regardless of whether the anesthetic had been buffered or not, whether the shot was administered subcutaneously or intradermally, or whether the amount of anesthetic was large or small. The authors did not recommend the best way to warm an anesthetic. But they listed using a baby food warmer, a warming tray, and water baths among the methods used in the studies they analyzed. The study was published in the February 11, 2011, issue of the Annals of Emergency Medicine.

March 2011 • Minnesota Medicine | 11 n Licensure Doctors Only 1996 survey published in the American Association A of Nurse Anesthetists Journal found that nurses administer anesthesia in 107 countries around the world, including the United States. The United Kingdom is an exception. That’s because case law from the 19th century established that only physicians could administer anesthesia there. The other Commonwealth jurisdictions followed this precedent. Thus, in Canada, Australia, New Zealand, and Hong Kong, anesthetics are administered only by physicians. Japan follows a similar practice.

sources: Mcauliffe Ms, Henry B. Countries where anesthesia is administered by nurses, aana J. 1996;64(5):469-79.

n Global Oximetry Project

The Next n The Laryngopasms Little Thing Better than Laughing Gas he pulse oximeter is a Since posting a music video on YouTube, a group of singing Tstandard tool for an- nurse anesthetists has found fame and a lot of new fans. esthesiologists in wealthy | BY KiM Kiser countries. But it’s a rarity in other parts of the world. An article last year in The Lan- he setting for the video nurse anesthetists (CRNAs) as cet called attention to the Tis an OR at WestHealth’s well as members of the singing fact that between 60 and 70 surgery center in Plymouth. group the Laryngospasms. percent of operating rooms But instead of surgeons and Their schtick is parodying © beerkoff - fotolia.com the lifebox project brings pulse oximeters to in Sub-Saharan Africa do OR staff huddled over the oldies, changing lyrics to poke hospitals in poor countries. not have the devices, which body of a patient, you see a fun at the serious business of are credited with dramati- blue drape. Suddenly, five guys medicine. For example, they’ve cally reducing anesthesia mortality. In the United States and in scrubs pop up from behind turned Jan and Dean’s “Little England, for example, the rate is now one in 185,000; it re- it as the introduction to Neil Old Lady from Pasadena” mains as high as one in 133 in the world’s poorest countries. Sedaka’s “Breaking Up Is Hard into a song about a little old An effort known as the Lifebox project is attempting to to Do” plays. They begin to lady with a fractured femur, make pulse oximeters more widely available. Its organizers, sing: Johnny Cash’s “Ring of Fire” including noted writer and surgeon Atul Gawande, M.D., into a song about the pain of challenged manufacturers to come up with a pulse oximeter Patients going down hemorrhoids, and Jerry Lee that was cheap (less than $250), met International Organi- do be do down down, Lewis’s “Great Balls of Fire” zation for Standardization requirements, and could be used Patients going down into … you get the idea. in settings with few resources. A Taiwan company’s model do be do down down, The Laryngospasms, which was selected, and 2,000 of its pulse oximeters have been pur- Waking up is hard to do. got their start at a Christmas chased for delivery to various countries this year. The group’s party for students at the Min- ultimate goal is to deliver 70,000. The singers are strangers to neapolis School of Anesthesia neither the spotlight nor the in 1990, have had 15 mem- OR. All are certified registered bers over 20 years and have

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from left: richard leyh, Gary Cozine, Keith larson, and Doug Meuwissen ham it up before shooting the video for “ring of fire” at lakeview Hospital. Waking Up Is Hard to Do ing their third album in the don’t take my tube away from me spring. And they’ll perform i’m trying to breathe, oh can’t you see their first gig in front of a non- take it out and i’ll turn blue medical audience. “We’ll test ‘Cuz waking up is hard to do the market to see how much it appeals to the general public,” i beg of you, please give me one more try he says, adding that the group i’m only 90 much too young to die gets a lot of emails from people i put all my faith in you who come across their videos. ‘Cuz waking up is hard to do So what keeps four middle- aged guys, who spend their (Chorus) days watching over sedated pa- They say that waking up is hard to do tients, writing lyrics and prac- Now I know, I know that it’s true ticing their dance moves? “You Don’t say that this is the end get to be rock stars for a day,” Instead of waking up I think my incision’s opened Leyh says. n up again. The Current i am in such misery Members… feels like my eyes are taped and i can’t see Photo by Jane McMullen, lakeview Hospital if i wake i’m going to sue and where you might find them ‘Cuz waking up is hard to do when they’re not on stage performed at meetings and Richard Leyh, lakeview Hospital (Repeat Chorus) conferences across the United States. The group gained a Gary Cozine, the only now i’m awake, i can breathe and see wider following after posting original member, now works My bladder’s full and i’ve got to pee the “Waking Up Is Hard to in Meriden, Ct now i think i’ll throw upon on you Do” video on YouTube two Doug Meuwissen, Cuz waking up is hard to do years ago. “It went viral,” says Woodwinds Hospital Richard Leyh, CRNA, who has been with the group since Keith Larson, northfield Hospital 1998, explaining that it’s had more than 8 million views. That led to appearances on CNN and CBS as well as on n Global Warming local television stations. They auditioned for “America’s Got Anesthesia Contributes Talent” in 2009, and 3,700 people are following them on to Climate Change Facebook. nesthesia has an effect on the earth’s atmosphere each This year, the Laryngo- Ayear similar to that of CO2 emissions from a coal plant spasms are scheduled to play or a million cars, according to research published in the online for the American Association version of the British Journal of Anaesthesia last October.

of Nurse Anesthetists in Wash- ©istockphoto/imagePixel Researchers detailed properties of gases commonly used in anesthe- ington, D.C., the Operating sia to calculate their effect on global warming. Three—isoflurane, desflurane, and sevoflurane— Nurses Association of Can- were found to have climate-changing potential. ada—their first international The worst offender was desflurane, which is used in inhaled general anesthesia. The effect of performance—in Regina, Sas- each pound that enters the atmosphere is equal to that of 1,620 lbs. of carbon dioxide. The other katchewan, and the OR Man- two gases had much less impact. agers’ Conference in Chicago. source: sulbaek andersen MP, sander sP, nielsen OJ, Wagner Ds, sanford tJ, Wallington tJ. inhalation anaesethics and Leyh says they plan on releas- climate change. British J Anaesthesia. Published online October 8, 2010.

March 2011 • Minnesota Medicine | 13 pulse | Photo by steveWewerka n Perioperative Care guin, having just completed a fellowship in chronic pain Abbott’s Pain Patrol management, was aware of the Anesthesiologists at one Twin Cities hospital now routinely use regional anesthesia to control benefits of regional anesthesia and had done nerve blocks. pain during and after surgery. | BY CarMen PeOta He had read studies that showed that patients who un- lthough it’s a good the patient can expect after the hand has gone to sleep. derwent nerve blocks for cer- hour before surgery, surgery in terms of pain con- This is the second case of tain surgeries tended to have Athe doctors and nurses trol. He tells the man he’ll be the day for Mrachek, direc- less acute pain, were less likely attending to the gray-haired sent home with a week’s worth tor of Abbott’s acute pain to develop chronic pain, and man scheduled for a shoul- of Percocet, which he may service, a unique approach to had shorter hospital stays than der procedure on a Thursday not need. The patient already anesthesiology practice in the those who received general an- morning in February are al- knows that he’ll also go home Twin Cities. The service is esthesia followed by narcotics. ready focused on control- with a pain pump the size of a the realization of an idea that And if they avoided narcotics, ling the pain he’ll face after grapefruit. had been brewing for years at patients also avoided their side the operation. After a nurse When Norberg finishes, an- Abbott. effects—nausea, constipation, anesthetist does a consent esthesiologist John Mrachek, dizziness, itching, and respira- check, orthopedic surgeon M.D., takes his place beside Growing Interest tory depression. Frank Norberg, M.D., enters the patient and injects anes- In 2000, when anesthesiologist Holguin began doing nerve the room in the basement of thetic into his neck and places Gerald Holguin, M.D., joined blocks at Abbott and inspired Abbott Northwestern Hos- the catheter that will deliver Northwest Anesthesia, which a few others in the group to pital in Minneapolis and ex- medication after the surgery. staffs two suburban surgery do them as well. “We kind of plains what the arthroscopic By the time he is finished, the centers and Abbott’s ORs, the pushed each other along,” he synovectomy he’s about to patient has difficulty raising group’s doctors were primarily says. But the anesthesiologists perform will entail and what his arm and remarks that his using general anesthesia. Hol- struggled with the logistics

14 | Minnesota Medicine • March 2011 | pulse

John Mrachek, M.D., in one of the cotics, that’s a major change rooms where he and other anesthesi- A Model to Replicate ologists from northwest anesthesia from what they’re used to,” do ultrasound-guided nerve blocks. anesthesiologist John Mrachek, M.d., says any Mrachek says. Furthermore, hospital in the twin Cities could create a pro- the other staff needed to know gram similar to the acute pain service at abbott that many patients would be of both doing nerve blocks, northwestern. But he cautions that it requires a sent home immediately after which required them to attend commitment from the anesthesiologists. “taking their surgeries. to patients ahead of their sur- on the responsibility of these patients while the Mrachek and his team also gery, and directing the care of nerve catheters are in place means being available had to make changes in their patients during surgery. Hol- 24/7,” he says. “it sounds burdensome. if i were processes, one of which was guin realized they needed a talking to colleagues across town, this is the part related to scheduling. Because better system. where they’d be like, ‘i don’t know if we want to patients would need their re- Mrachek, who joined the do this.’” But Mrachek says that on average, he gional anesthetic to take ef- group in 2006, was also inter- and his colleagues receive less than one page per fect just before their surgeons ested in doing nerve blocks. night (for both inpatients and outpatients). he says were ready to begin operating, By this time, anesthesiolo- that’s because of the extensive patient education the anesthesiologists needed to gists elsewhere were doing the nurses on the team do before patients are sent sync the timing of the nerve ultrasound-guided blocks with home or to the wards. blocks to the timing of the good results. In addition, he his colleague Gerald holguin, M.d., agrees. “the surgeries. Even now, Holguin was interested in doing more one thing i can’t overemphasize is that this kind says, “it can be very stress- patient care. “We put them of a service can’t happen without the help of ful in terms of time manage- to sleep, we woke them up, dedicated acute pain service nurses,” he says. the ment.” To make it work, the we gave them to a nurse to three nurses who support the anesthesiologists nurses, doctors, and other take care of them afterward, at abbott educate new nurses on the floors about staff intently watch monitors and that was it,” he says of how to manage patients with peripheral nerve that track the progress of cases the way anesthesiologists had catheters and pain pumps, assist with pain rounds, in each of Abbott’s 45 ORs. long worked. As he saw it, an- and troubleshoot peripheral catheters that may When they see that a surgeon esthesiologists were uniquely not be providing adequate pain relief. “they allow is within 30 to 40 minutes equipped to help patients with us to efficiently manage the service in a safe and of starting a new case, they’ll pain, not just during surgery comprehensive manner,” he says. “they act as our start the nerve block for that but after. The others in the advocates and educators.”—C.P. patient. group encouraged him to take In addition, the acute pain what Holguin had started to service team has had to figure the next level. out how to inform patients The next step was to bring learned. Mrachek also devel- about this new style of anesthe- A Matter of Logistics all the members of the group oped a four-hour session that sia. “A lot of patients who are Mrachek, fresh out of resi- up to speed on regional anes- included having his colleagues coming to Abbott to have their dency, agreed to take on the thesia techniques. At first, only use ultrasound on live mod- shoulder work done might be project, which turned out Mrachek, Holguin, and a few els to practice finding certain caught off guard by an anes- to be a tremendous amount other anesthesiologists were nerves. thesiologist who tells them he of work. The first issue was confident in their abilities to The anesthesiologists soon wants to stick a needle in their finding space. The anesthesi- do ultrasound-guided nerve realized they needed to in- neck and make their shoulder ologists would need procedure blocks. “If we were going to form the surgeons, hospital- numb,” Mrachek says. “If you rooms where they could have deliver this service, we needed ists, and nurses who cared for weren’t anticipating that, you’d their equipment and do the to deliver it around the clock patients after surgery that pa- say, ‘Why are you going to do blocks. Abbott offered a for- every day of the week. To get tients weren’t going to need that, and tell me more about mer cardiac intensive care unit to that point, we had to have as many narcotics as they had it.’” next to its operating suites. In a critical mass of docs doing in the past. “If you’re used to And there were a host of addition, the hospital agreed this,” Mrachek says. He, always giving a lot of narcot- other smaller changes that had to purchase ultrasound equip- Holguin, and others worked ics to patients who’ve had their to be made such as revamp- ment for the group and hire elbow-to-elbow with col- knee replaced, and now we’ve ing order sets, updating forms, nurses to support the physi- leagues who were less skilled, done a nerve block and they and figuring out how to man a cians. showing them what they had don’t require hardly any nar- phone line 24/7. 9

March 2011 • Minnesota Medicine | 15 pulse |

n National Leader “A lot of patients might Safety be caught off guard by an Advocate anesthesiologist who tells Anesthesiologists Minnesotan is heading the them he wants to stick a A American Society of An- esthesiologists (ASA) this year. needle in their neck and make Mark A. Warner, M.D., dean of the Mayo School of Graduate their shoulder numb.” Medical Education and a pro-

fessor of anesthesiology at the Society ofAmerican courtesy Photo —John Mrachek, M.D. Mayo Clinic College of Medi- Mayo Clinic’s Mark Warner, M.D. cine, was installed as president A Win-Win-Win ous side effects of those drugs of the ASA during the organization’s annual meeting last Mrachek was confident the such as respiratory depres- October. new system would work. But sion, which can be particu- Warner’s focus during his term is advancing the cause of other anesthesiologists needed larly troublesome for people patient safety (see p. 27). He currently directs both the An- to be convinced. He says it with respiratory problems. esthesia Patient Safety Foundation and the Foundation for wasn’t until many of his col- Mrachek points out that Anesthesia Education and Research. leagues began to do “pain payers and the hospital have Warner has also served as the president of the Minnesota rounds” (they now visit all pa- been supportive of the new Society of Anesthesiology, president of the American Board C tients in the recovery room or acute pain service because it of Anesthesiology, and editor of the journal Anesthesiology. M on the wards, not just those reduces the length of hospital Y who had a problem in the OR) stays. He says patients require CM and saw how well their patients less physical therapy because were doing that they fully they’re able to do more sooner MY bought into the new approach. because they have less pain. CY He describes patient satisfac- And they are less likely to de- CMY tion as “through the roof.” velop chronic pain. Mrachek K Holguin says the benefits explains that in sedated pa- to patients are “huge.” “You tients or those under general minimize all the side effects anesthesia, the cellular signal- of general anesthesia,” he says. ing that can damage nerves He explains that patients who and cause chronic pain is still have regional anesthesia are less occurring. Doing the blocks likely to develop blood clots or stops those mechanisms. “If emboli relative to those who you give a 30-year-old a nerve have general anesthesia. He block, you can save millions says it is especially appropri- over a lifetime,” he says. ate for patients with heart and “We’re doing what every- lung diseases. “When you in- one in the world wants us to tubate someone who smokes, do right now—physicians, has COPD, or has asthma, policymakers, payers. We’re there is greater potential for delivering high-quality care bronchospasms during or after that is safer and is costing less. Please visit www.pedsedation.org surgery,” he explains. It’s a win-win-win situation,” for submission guidelines and registration information Holguin adds that pain Mrachek says. And he thinks control is much better under it simply makes sense: “Instead regional anesthesia, and that of putting a drug through your patients who receive it need whole body, if your knee hurts, SPS

SOCIETY FOR PEDIATRIC SEDATION fewer narcotics afterward. why not put the medicine in safe and sound Thus they avoid the danger- your knee instead?” n

16 | Minnesota Medicine • March 2011 viewpoint |

The Times Demand We All Weigh In

his winter has been colder and of social and health care safety net pro- snowier than average in Min- grams. We are concerned about the regres- Tnesota. A good thing about this sive “provider tax” that has funded health Wewerka weather is that it reminds us that only care and been used in the past to balance

eve by relying on each other and pulling to- the budget. We are concerned also that we st gether—as neighbors and as larger com- may not be able to afford to care for Medi-

Photo by munities—are we able to thrive in this cal Assistance patients because of the low Patricia J. Lindholm, M.D. climate. That’s a lesson we as doctors can payments we receive. MMA President apply as we anticipate upcoming budget In February, several MMA leaders at- battles. tended the AMA National Advocacy Con- We face a foreboding forecast with ference in Washington, D.C. We met with We must confront regard to the state and federal budgets, es- members of our congressional delegation. pecially in the area of health and human We advocated for eliminating the SGR for- services. We must confront the reality of mula that causes the yearly anxiety about the reality of billion- billion-dollar state and trillion-dollar fed- Medicare payments and access to care for eral budget deficits. The economy is slowly our senior citizens. Tor t reform was also on dollar state and recovering, but we’re not likely to see huge the agenda. It is clear that Congress will increases in tax revenues this year. What to not tackle Medicare reform in this session. trillion-dollar federal do? It would be nice to have the wisdom of But we will be watching carefully as the Solomon at such a time. Affordable Care Act is challenged in the budget deficits. Although we may not feel we have courts and the political arena. that kind of wisdom, we doctors do have I have been impressed with the large unique knowledge and a valuable perspec- number of students and residents who are tive. We need to make sure that our voices engaged in the political process at both the are heard and that we share our insights state and national levels this year. These in order to help our legislators make wise future colleagues have wisdom and leader- decisions. ship skills that bode well for the future of In January, a number of MMA mem- our profession. I encourage us all to get en- bers participated in the MMA Day at the gaged in the discussions that will affect our Capitol in St. Paul. It was heartening to state and nation. And I further encourage see so many physicians, residents, and us veteran physicians to mentor a student, medical students making time to go to resident, or new physician as we advocate St. Paul to weigh in on these and other is- for our patients. sues that affect patients and health profes- Together we can support innovative sionals in this difficult time. policies that will help us deliver high-qual- We met many newly elected freshman ity health care fairly and cost-efficiently to legislators, who need our advice in order all of our neighbors. Don’t allow yourself to make decisions about health care fund- to be marginalized as important decisions ing priorities. We told them the MMA is are being made. The MMA is counting on concerned about the potential weakening all of you. Let us hear your voices.

18 | Minnesota Medicine • March 2011 mma news | Dayton Budget Avoids Clinic Payment Cuts

ov. Mark Dayton’s proposed budget, released in February, Gcuts payments to hospitals, nurs- Health Care Reform ing homes, and managed care plans but dayton’s proposed budget maintains current MinnesotaCare and includes Medical Assistance reimbursement levels Gov. Mark Dayton for clinics. The budget plan relies heavily $2.5 million in state matching on tax increases to minimize the cuts and dollars to jumpstart a health preserve programs and services. insurance exchange “the governor’s The MMA commended Dayton for $20 million a year for the proposal seeks to proposing a budget that took a balanced statewide health improve- approach to resolving the state’s $6.2 bil- ment Program, a state public balance the state lion deficit. “The governor’s proposal health initiative aimed at re- budget by using a seeks to balance the state budget by using ducing smoking and obesity a combination of new revenues and cuts— combination of new an approach that the MMA believes is revenues and cuts— preferable to a cuts-only budget fix,” says President Patricia Lindholm, M.D. Indirect Effects an approach that the The MMA is concerned, however, Although physician reimbursements were MMa believes is that Dayton’s budget plan disproportion- not directly affected in the budget outline, ately cuts spending on health care com- reductions in other areas could result in preferable to a cuts- pared with other areas. The governor’s lower payments for doctors who provide proposal includes $12 billion for health care to people enrolled in public health in- only budget fix.” and human services in fiscal year 2012-13, surance programs. which is about 3 percent or $350 million Specifically, the budget proposes —Patricia lindholm, M.D. less than what was forecast in November. reforms to the Medical Assistance and MMa President Health and human services account for MinnesotaCare managed care programs about 30 percent of the state’s general fund that would generate savings of $115 mil- payment rates reduced by 2 percent. Home expenditures. lion over the biennium. It also includes and community-based services would face The budget plan also eliminates ac- a 2.75 percent cut in payments to health a 4.5 percent rate cut. Hospitals would cess to MinnesotaCare for 7,200 adults plans starting in 2012 with the assumption lose about $130 million due to a delay with incomes above 200 percent of pov- that the plans can recoup their losses by of the rebasing of payment rates in 2013- erty or an annual income of $21,780. implementing provider payment reforms. 2015. The state also would cut hospitals’ “It is disappointing the governor The proposed budget also would withhold current outpatient service payments by did not do more to protect the health some money from health plans that would 0.5 percent. care safety net, since his proposal is the be returned to them if they reduce hospital Hospitals, nursing facilities, and starting point for the budget discus- readmissions. It is not clear whether health health plans also would face increased sion,” says Dave Renner, the MMA’s plans would ultimately pass along those Medical Assistance surcharges that would director of state and federal legislation. cuts to providers. generate $627 million for the state. Pro- “It is likely that Republican lawmakers In addition, the governor’s budget viders would recoup some, but not all, of will propose even larger cuts to health and would reduce payments to hospitals and those surcharges through higher Medical human services.” nursing homes. Nursing facilities would see Assistance reimbursement rates.

20 | Minnesota Medicine • March 2011 | mma news MMA Releases Review of Medica’s Associate Clinic Participation Agreement review of Medica’s asso- it is otherwise terminated. They found several items of •Medica’s having access to Aciate clinic participation The agreement encompasses concern: patient records 10 years after agreement is now available all of Medica’s fully insured •Language saying provid- the contract is terminated; to MMA members online at group and individual products ers must refer members to and www.mnmed.org/medicacon- and some self-insured group other providers within the •A requirement that clin- tract. products. network; ics wanting to renegotiate Medica requires providers to The MMA worked with the • A prohibition against clinics or terminate their contract accept the agreement as a con- Twin Cities Medical Society contracting with or employ- notify Medica at least 125 dition of joining its network. and the Minnesota Medical ing individuals or entities ex- days prior to the end of the The agreement automatically Group Management Associa- cluded from participating in contract. renews every two years unless tion to review the agreement. Medicaid and Medicare;

Board Approves Lawmakers Learn Physician Wellness About the MMA Recommendations MA Director of Health Policy Janet Silversmith testified Mbefore the House Health and Human Services Finance he MMA Board of Trustees approved a recommendation Committee last month about the MMA’s twin goals of making Tat its January meeting that the MMA develop a plan for Minnesota the healthiest state in the nation and the best place in promoting physician wellness. The recommendation was made the country to practice medicine. by the 20-member Physician Well-Being Task Force, which was In an effort to educate lawmakers, Silversmith shared a brief charged with exploring the topics of physician burnout, unsup- overview of physician demographics in the state and the MMA’s portive or abusive work environments, work-life balance, and history and mission. She also described the MMA’s goals of re- resilience, and developing recommendations on how the MMA forming the care delivery system, promoting access to care by can support, foster, and promote health and well-being among ensuring the financial viability of public health programs, and Minnesota physicians. creating a payment system that rewards value rather than volume. The plan will likely include: •Work to improve the culture of medicine and prevent breakdowns in collegiality among medical students, residents, and physicians; •Efforts to promote awareness of the prevalence of physi- Five Facts about Physicians cian burnout and ways to prevent it and help physicians in Minnesota cope; and 1. Minnesota has about 19,600 physicians. • Educational programs for members about the importance 2. Minnesota is ranked 13th in the nation in terms of num- of physician well-being. ber of physicians per capita, with a rate of 264 practic- MMA President Patricia Lindholm, M.D., who has made ing doctors per 100,000 residents. promoting physician health and wellness a focus of her presi- 3. Minnesota’s office-based physicians directly and indi- dency, says now that the board has taken action, the next step is rectly contributed $16.3 billion to the state’s economy to figure out the specifics of the plan. in 2009. “For me, this means that physician well-being is going 4. each office-based physician in Minnesota supports to be an ongoing focus and activity of the MMA, and people 5.8 jobs (including his or her own). who are looking for resources and help can go to the MMA,” 5. sixty-three percent of the state’s physicians are in prac- she says. tices with more than 100 doctors.

sources: Minnesota Board of Medical Practice; 2009 state Physician Workforce Data Book; the lewin Group; “the economic impact of Office- Based Physicians in Minnesota;” and MMa Physician Database.

March 2011 • Minnesota Medicine | 21 cover story | safety

firstBy Kate Ledgeredger

How anesthesiologists launched the patient-safety movement.

or Mayo Clinic anesthesiologist Mark Warner, M.D., one of the most harrowing moments of his career also turned out to Fbe among the most significant. It happened in 1988, as War- ner began administering an anesthetic to a 60-year-old patient who was undergoing surgery to remove bladder tumors. The anesthetic was sodium pentothal, which was then widely used in the OR. What nobody could have anticipated was that the patient would have a severe allergic reaction to the anesthetic, sending him into cardiac collapse. The OR team conducted CPR for an hour and 15 minutes, to no avail. They were about to conclude their resuscitation efforts when Warner recalled an article he’d read just days before that offered another lifesaving tactic. It explained how a large quantity of epinephrine (more than 5 mg) could treat anesthesia-related anaphylactic shock. “It was a much larger dose than I’d ever given,” Warner re- members. But he turned to this technique as a last-ditch effort to save the man’s life. It worked. Widespread use For Warner, that close call in the OR underscored the impor- of the pulse oximeter has led to a tance of a new movement that was underway. Only three years ear- dramatic drop in lier, the American Society of Anesthesiologists (ASA) had established anesthesia-related the Anesthesia Patient Safety Foundation (APSF). Leaders of the two mishaps. Photo by organizations had begun to gather reports of adverse events such as Clare Pix Photography allergic reactions to anesthetics, equipment malfunctions during sur- www.clarepix.com

22 | Minnesota Medicine • March 2011 | cover story gery, and tragic medical errors and oversights. They had begun to narrowly avoiding an incident during surgery. “Often, patients publish articles about those events and see them as trends requir- didn’t actually suffer permanent harm, but they were very close ing rigorous study. “Until then,” says Warner, who recently be- to it,” he says, noting that the day-to-day work environment for came president of the ASA, “incidents would happen in isolated anesthesiologists was markedly tense. “I think we had a sense that settings. Each event might prompt a change in an approach; but you were always close to the edge [of something unwanted hap- nobody was pulling all the cases together and looking at entire pening], or not knowing how close to the edge you really were.” systems and asking, What can we do better?” He recognized that Adding to the tension was the fact that liability payouts unprecedented, and potentially life-saving, information was be- from anesthesia accidents were exorbitant. The cost of malprac- coming available to the field. What he only could have guessed tice insurance for anesthesiologists was among the highest of all at the time was that the new focus on patient safety would have medical fields, ranging from $35,000 to $50,000 a year across a major impact not only on the practice of anesthesiology but on the country in the mid-1980s. “Insurance was in range of other other medical specialties as well. specialties that were considered high-risk, including neurosurgery and obstetrics,” says Steve Sanford, president of Preferred Physi- An Age-Old Hazard cians Medical, a Kansas company that specializes in coverage for The notable dangers of anesthesia go back to the beginning of anesthesiologists. What many anesthesiologists realized was that modern surgery. In the 1920s, a patient had a one in 10 chance the burdensome rates turned talented medical students off to the of surviving a procedure such as an appendectomy because of discipline. the risks of anesthesia as well as of postoperative infections. Bringing the Worst Survival rates eventually im- “nobody was pulling all the to Light proved. But even 40 years ago, The turning point for the anesthesia-related mishaps field occurred in 1982, when in Minnesota and across the cases together and looking then-president of the ASA, country were more common Harvard’s Ellison “Jeep” than anyone wished. at entire systems and asking, Pierce, M.D., focused atten- Some were the result of tion on what had long been human mistakes. In one case What can we do better?” an unspoken issue. Pierce from the late 1970s, a 45-year- had an interest in patient old woman with severely dis- —Mark Warner, M.D. safety, stemming from a lec- figuring rheumatoid arthritis ture he delivered as a junior died on the operating table faculty member in 1962. during an orthopedic procedure on her shoulder. The anesthe- He had even saved clippings over the years about anesthesia ac- siologist had placed an oxygen tube through her nose into her cidents. But when the prime time television program “20/20” trachea. At the time, physicians ascertained placement of the tube warned consumers in 1982 about the great risks of dying or suf- by listening with a stethoscope for the flow of air. Despite what fering brain damage from modern-day anesthesia, Pierce took the sounded like air going in and out of the woman’s lungs, the tube opportunity to show that his field could step up. He pushed for was misplaced. the creation of a safety committee within the ASA. Other problems arose from equipment in the OR. Some had That same year, a seminal article appeared. It compared components that made it possible for an anesthesiologist to in- human error in aviation accidents to errors in anesthesia. When advertently turn on two potent anesthetic gases at once. In the the paper was presented at an international conference in Boston, 1980s, such a mishap caused the death of a 20-year-old patient anesthesiologists from all over the world were captivated. A group who received both enflurane and halothane at once. In another of them, including Pierce, gathered after the conference ended case, a canister of volatile gas was knocked over and then put back and decided to create the APSF, which would be funded by the on a shelf. The tipping caused too much gas to flow into the can- ASA along with companies that produced machines and drugs ister’s vaporizing compartment; as a result, a pediatric patient re- for anesthesia. The new organization would sponsor studies of ceived an excessive dose of anesthesia. Similar adverse events were anesthetic injuries, encourage the creation of programs aimed at happening throughout the country. (In some cases, they resulted reducing accidents, and get the word out swiftly about the causes in the manufacturer swiftly making improvements to anesthesia of injuries and ways to prevent them. machinery.) By some accounts, as many as 6,000 people in the A subcommittee of the ASA also established what was called United States were being harmed each year. the Closed Claim Project, working with insurance companies to More common than accidental deaths were “near misses,” release anesthesia information from malpractice cases. The com- recalls Richard Prielipp, M.D., chair of anesthesiology at the Uni- mittee reviewed hundreds of disastrous anesthesia events and versity of Minnesota. Most anesthesiologists had stories about began to publish articles about recurrent problems. Suddenly, in-

March 2011 • Minnesota Medicine | 23 cover story | Simulating Surgery n the mid-1990s, anesthesiologists in San Fran- Icisco began developing high-fidelity computerized mannequins that stand in for patients and can be used for training. More sophisticated than the familiar resuscitation dummies used for First Aid training, these computerized models have a pulse, can open their eyes, and can make breathing motions. And they react with physical responses such as plummeting blood pressure, which can be modi- tal mPO r

fied by computer to represent si crisis scenarios. Use of such technology is taking off at many academic

institutions around the coun- of courtesy Photo try, and Minnesota is home to in the University of Minnesota’s simPOrtal (simulation PeriOperative resource for teaching and learning) lab, medical a number of simulation centers students, residents, and trainees in other fields practice skills that can save lives. including one at Mayo Clinic, entire health care teams. At the physicians and nurses from people how to prevent fires by one at the University of Minne- university, a simulation lab of- around the country to run avoiding certain solutions or to sota, and one at Regions Hospi- fers OR personnel the oppor- through worst-case scenarios. employ precautionary measures tal in St. Paul, which is owned tunity to run through patient One event that can be simu- like using lower oxygen flows, by HealthPartners. crises. The university is work- lated is a patient experiencing and then, in spite of all preven- The idea of simulation— ing to get approval from the anaphylaxis. Another is a fire tative efforts, if it happens, to actually practicing how to American Society of Anesthesi- in the surgical suite caused by react by turning the oxygen off, respond in the rarest of ad- ologists to make the site a na- gases igniting in the presence disconnecting the source of ox- verse events—has broadened tionally recognized simulation of electricity. “We have a sce- ygen, and putting the fire out,” beyond anesthesia to include training center that will draw nario that specifically teaches says anesthesiologist Mojca formation was becoming available, such as the article about high- events was dramatic,” Warner notes of the introduction of these dose epinephrine that Warner had encountered. devices. The newly abundant and unflinching literature also led to Information from the Closed Claim Project also led to the development of new technology designed to improve patient new studies. One at Mayo, for instance, investigated more than monitoring and safety. Two critical breakthroughs immediately 200,000 nationally reported occurrences of pulmonary aspira- became the standard of care. One was the introduction of the tion during surgery, looking at the frequency of food and acidic pulse oximeter, which had been in production for several years fluid from the stomach entering the airways and blocking breath- but hadn’t yet been introduced to clinical settings. The finger- ing or causing inflammation in the lungs. Researchers looked clip that detects the percentage of oxygen saturation in the blood specifically at timing: When, in the process of surgery, did aspira- enabled anesthesiologists to easily monitor a patient and stem a tion occur? They established guidelines to determine how long crisis quickly. The second was a device that could measure the before surgery patients could safely eat and also found, contrary quantity of carbon dioxide in a patient’s exhalation, finally offer- to previously held beliefs, that drinking water before surgery can ing a scientific means to determine whether breathing tubes had be helpful for patients. In a range of anesthesia journals, research- been properly placed. “The decrease in the number of adverse ers began publishing articles about safety issues, from dangerous,

24 | Minnesota Medicine • March 2011 | cover story

Konia, M.D., clinical direc- to other locations including tor of the anesthesiology and hospitals in western Wiscon- “there’s more awareness that critical care simulation lab. sin and Maple Grove to run Fidelity to realism is criti- teams through simulated wrong-site anesthesia is a cal, says Mayo anesthesiolo- emergencies. “Besides clinical gist Laurence Torsher, M.D., skills, we’re testing teams’ ap- reportable occurrence.” co-director of the Mayo proaches to communication Clinic Multidisciplinary and how their system of care —Julie Apold, Simulation Center. Since it is designed in order to make it Minnesota Hospital Association opened in 2005, approxi- more efficient and safe,” says mately 31,000 health care Carl Patow, M.D., M.P.H., practitioners from through- executive director of Health- the Minnesota Alliance for Patient Safety and began meeting to out the Mayo system have Partners Institute for Medical determine what could be done to reduce accidents and adverse been trained at the center, Education. Last year, Health- events. Three years later, Minnesota became the first state in the which has six standard pa- Partners used its simulation country to require hospitals to report occurrences of 28 different tient rooms, a task-trainer resources to train more than adverse events (26 states have since adopted a mandatory report- room, and three rooms that 4,300 providers and students. ing system; one has a voluntary system). “The reporting system can be set up as exact repli- Although data about serves to hold facilities’ feet to the fire,” says Diane Rydrych, as- cas of an OR, an emergency whether simulation reduces sistant director of the Minnesota Department of Health’s division room, or an intensive care adverse events is still being of health policy. “It also gives consumers information that they unit, complete with the clin- collected, Torsher and a can use to ask questions about what’s being done about events ical equipment and medica- team from Mayo recently and what’s being done to prevent them. But we really look at what tions found in each site. “You published a case study in we can learn from the data all the time; we’re always looking to can read about what to do in the journal Anesthesia and see if there are trends.” an adverse event, but when Analgesia describing what One unfortunate problem that turned up in Minnesota in you’re in that situation, your happened when a sedated recent years is conducting surgery on the wrong part of the body. hands need to know how to patient suddenly experienced Across the state last year, 31 wrong-site procedures took place. open the medication you cardiac toxicity and required Approximately 30 percent of them were anesthesia-related prob- need,” Torsher says. resuscitation in the recov- lems such as performing a regional block for pain on the wrong In addition to offering ery room. The team had re- knee. A statewide initiative is now in place to work on eliminat- training in its 7,000-square- cently practiced exactly that ing wrong-site procedures. More than 100 hospitals and surgery foot simulation center, called scenario in the simulation centers are currently involved. HealthPartners Clinical center. “The resuscitation of In the past, surgeons typically marked the operating site with Simulation, HealthPartners the patient went seamlessly,” initials. Now, anesthesia is being brought into the loop, with an- has taken its high-fidelity Torsher says.—K.L. esthesiologists viewing documentation before surgery and also mannequins and equipment marking the location where drugs will be administered. What’s more, the entire OR team—surgeons, anesthesiologists, and nurses—now conduct periodic “time out” pauses in which mem- volatile gas interactions to infections caused by anesthesia equip- bers of the team stop what they’re doing to review the identity of ment. the patient and the location of the procedure site. Since the collaborative effort known as the Safe Site State- Organized and Diligent wide Initiative was launched three years ago, hospital adherence In 1999, the Institute of Medicine recognized the APSF as an or- to “best practices” (the steps to reduce wrong-site procedures) has ganization that had made significant advances in patient safety; in increased: The percentage of hospitals with safety steps now in fact, the APSF became the model for the National Patient Safety place has jumped from 59 percent to 96 percent. Many believe Foundation, a similar organization touching all disciplines that the reason the number of adverse events has not yet dropped is was founded that same year. that heightened awareness of the problem has increased hospi- In Minnesota, the growing national push to improve safety tal reporting of these incidents, particularly those involving an- measures turned into specific statewide expectations for hospi- esthesia. “There’s more awareness that wrong-site anesthesia is a tals. In 2000, a committee that included representatives from the reportable occurrence and that we can learn from it and to try to Minnesota Medical Association, the Minnesota Hospital Associa- eliminate it,” says Julie Apold, director of patient safety for the tion, and the Minnesota Department of Health gathered to form Minnesota Hospital Association. 9 March 2011 • Minnesota Medicine | 25 cover story |

Practicing Safety University of Minnesota, says Barbara Gold, M.D., vice presi- There’s no doubt anesthesia’s focus on patient safety has pro- dent of clinical safety with University of Minnesota Physicians. duced improvements: Nationally, the number of deaths per an- “We’ve adopted many proven methodologies, borrowing heavily esthesia administration plummeted from one in 10,000 in the from the aviation industry and others that have a narrow margin mid-1980s to one in nearly 200,000 today. In addition, surgeries for safety. We’ve also looked to human factors analysis, a branch have become safer because the drugs have improved. “We have of industrial engineering that looks at the interface of humans better, shorter-acting anesthetic and adjuvant drugs with fewer and machines, how the behavior of humans can be managed to side effects,” says the University of Minnesota’s Prielipp. With reduce error,” she says. Teamwork, which anesthesia has always agents such as propofol that induce anesthesia quickly and nar- promoted, has evolved as a necessity for safety. cotics and muscle relaxants that don’t linger, “we can now titrate the endpoints of anesthesia much more precisely,” he says. The Aiming Low technological advances in patient monitoring have decreased the Anesthesiologists agree that there’s still work that needs to be done “near misses” and improved the tenor of the work environment. to improve patient safety. Some changes that need to happen are And annual malpractice insurance premiums for anesthesiolo- simple ones such as having mandatory preoperative meetings—a gists have plummeted since the mid-1980s; they now average sort of team huddle to review the surgical plan and to discuss about $18,000 nationally. Prielipp says that has boosted interest any comorbidities the patient has that may complicate the case. in the field among trainees. Others are more complex such as using a bar-code reader (still in As an organization, the ASA has continued to actively spread development) that verifies drugs in order to prevent the delivery its message about patient safety. As part of the World Federation of the wrong medication. “We’re shooting for a zero-defect ser- of Societies of Anesthesiology, it has been trying to raise approxi- vice, using the language of industry,” Prielipp says, “and we won’t mately $80 million to make life-saving devices such as the pulse be satisfied until no patients suffer any harm or injury associated oximeter available in hospitals all over the world. with surgical and perioperative anesthesia.” MM In this country, guidelines that involve the use of checklists, Kate ledger is a st. Paul writer and frequent contributor to preoperative team meetings, and periodic time outs in the OR Minnesota Medicine. are now in place in many operating rooms, including those at the

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26 | Minnesota Medicine • March 2011 | commentary

The Evolution of Safety in Anesthesiology standardized anesthesia care and patient monitoring have made surgery safer. the next step is for anesthesiologists, surgeons, and hospital staff to work together on pre- and postoperative care.

By Mark A. Warner, M.D.

hen I first started in medicine during the mid- have markedly reduced the frequency of anoxic brain injury 1970s, the risk of a relatively healthy patient dying and other major complications. within 24 hours of a surgical procedure was ap- The APSF is now in its 25th year and continues to spon- W 1 proximately one in 10,000. That risk has since decreased at sor workshops in which key stakeholders meet to share ideas least 12-fold; the best estimates now suggest that the frequency on topics such as medication errors and fire safety. Through is one in 120,000 or better.2 In fact, a large Minnesota study the APSF, government agencies, equipment and pharmaceuti- published in the Journal of the American Medical Association in cal manufacturers, surgeons, anesthesiologists, other anesthesia 1993 found that it was safer to undergo outpatient anesthesia providers, nurses, and patients work together to review prob- and surgery than it was to travel to and from the surgical center lems, develop innovative processes, and make recommenda- by car.3 I believe the increased safety of anesthesia and surgery tions that will likely result in safety improvements. during this period is one of the great achievements in modern medicine. Unfinished Business There are many reasons why safety has improved so With all of these efforts and the resulting improvements, why steadily. Surgical procedures have become less invasive, and do we continue to focus on patient safety? Because we still have many surgical techniques now result in much less blood loss a ways to go. For example, each year, hundreds of patients in and tissue trauma and fewer postoperative complications. The the United States either die or suffer anoxic brain injury from drugs used intraoperatively for anesthesia, postoperatively for opioid-related postoperative respiratory depression. This is a analgesia, and perioperatively for infection prevention and problem we can solve: 1) We know many of the patient charac- treatment also have improved remarkably. However, one sig- teristics and surgical and anesthetic risk factors associated with nificant effort stands out for its contribution to better patient postoperative respiratory depression; 2) we know that opioid safety—the work of the American Society of Anesthesiologists analgesics play a role in nearly all instances of postoperative (ASA) to standardize anesthesia care and patient monitoring. respiratory arrest; and 3) we have equipment and systems that The society’s contributions were noted by the Institute of Med- can detect postoperative respiratory depression. Despite our icine (IOM) in its 2000 treatise “To Err is Human: Building a knowledge and the availability of needed technology, we still Safer Health System.”4 In fact, the ASA was the only specialty have patients dying from or significantly impaired as a result of organization recognized by the IOM for its success in improv- this problem. Sadly, we are missing the union of forces that is ing patient safety. necessary to address it. In 1985, the ASA instituted the Anesthesia Patient Safety Resolution of postoperative respiratory depression will Foundation (APSF). The work of the foundation and the ASA require anesthesiologists to work with surgeons, nurses, phar- has resulted in a number of standardized practices, including macists, and health care facility administrators, as each group is the use of pulse oximetry and end-tidal carbon dioxide moni- responsible for overlapping pieces of the process. Anesthesiolo- toring for anesthetized patients. These now-required practices gists often use opioid analgesics intraoperatively while closely

March 2011 • Minnesota Medicine | 27 commentary | monitoring patients but then do not insist on similar postopera- depression, surgical site infections, postoperative thromboembo- tive monitoring for patients who continue to receive these anal- lism, and medication errors. Eliminating these preventable com- gesics. Surgeons often provide oversight of postoperative analge- plications will require nurses, surgeons, anesthesiologists, and sia, frequently using delivery systems such as patient-controlled others to work together in ways they have not before. No one pumps, but they do not require the use of technologies to moni- wants patients to develop disabling or life-threatening complica- tor respiration. Administrators may not support the purchase, de- tions. That’s why we can, and we must, do better. MM ployment, and upkeep of the number and array of monitors that Mark Warner is a professor of anesthesiology at Mayo Medical school would detect early respiratory depression. The problem is that no and dean of the Mayo school of Graduate Medical education. He also single group owns the entire perioperative period or is responsible is president of the american society of anesthesiologists. for the entire set of steps associated with preventing postoperative respiratory depression. REFERENCES We need to change that for a number of compelling reasons. 1. tiret l, Desmonts JM, Hatton f, Vourc’h G: Complications associated with First, it will prevent injuries and save lives. Second, it will save anaesthesia—a prospective survey in france. Can anaesth soc J. 1986;33: money. Complications are costly. A simple case of postoperative 336-44. 2. liu G, Warner M, lang B, Huang l, sun l: epidemiology of anesthesia-related pneumonia has recently been estimated to cost the health care mortality in the United states, 1999-2005. anesthesiology. 2009;110:759-65. system more than $25,000 on average.5 Care for a patient who 3. Warner Ma, shields se, Chute CG: Morbidity and mortality after ambulatory surgery. JaMa. 1993;270:1437-41. survives a pulmonary embolism has been projected to cost more 4. Kohn l, Corrigan JM, Donaldson Ms (eds): to err is Human: Building a safer than $80,000 in the first year.6 Health system. institute of Medicine, national academy Press, Washington, DC, 2000. And complications matter to facilities and health systems. 5. thompson Da, Makary Ma, Dorman t, Pronovost PJ: Clinical and economic It is estimated that there are now more than 1,000 online health outcomes of hospital-acquired pneumonia in intra-abdominal surgery patients. ann surg. 2006;243:547-52. care quality or safety rating sites. Although the validity of many 6. MacDougall Da, feliu al, Boccuzzi sJ, lin J: economic burden of deep-vein of these sites is questionable, and it appears that anyone who thrombosis, pulmonary embolism, and post-thrombotic syndrome. am J Health system Pharmacy. 2006;63:s5-15. can afford a website can establish a rating system for physicians 7. Groves rH, Holcomb BW, smith Ml: intensive care telemedicine: evaluating a model for proactive remote monitoring and intervention in the critical care set- and health care facilities and systems, there is no doubt that the ting. stud Health technol inform 2008;131:131-46 public reads and uses this information. Publicly reported rates of complications are significant components of many rating systems—and they do influence patients’ perception of physicians, hospitals, and clinics. Minnesota anesthesiologists are committed to furthering efforts to reduce the complications of surgery and improve patient safety. The 350 practicing members of the Minnesota Society of Anesthesiologists strongly support the discovery of novel thera- pies, improvements in perioperative care, and studies that will Laboratory Diagnosis allow the prediction of postoperative complications and development of effective interventions. They are also applying their of Fungal Infections: expertise in new ways. At our major academic centers and some The Last Course community hospitals, anesthesiologists are now involved in preoperative and postoperative care and work in intensive care units,  REGISTER NOW hospice medicine, and palliative care programs. For example, at Mayo Clinic, 17 anesthesiologists provide primary intensive care November 16–18, 2011 Kahler Grand Hotel for more than 100 patients daily. These same anesthesiologists Rochester, Minnesota also respond to all rapid response requests and cardiac arrests, 24 hours a day, seven days a week. Over the next several years, additional anesthesiology intensivists will begin to provide electronic oversight of critical care services throughout Mayo Health Sys- tem’s hospitals. This new service will provide continuous expertise in the care of critically ill patients, even in rural hospitals. Initial studies of this remote oversight model suggest that the frequency For complete conference information of death and severe complications such as ventilator-associated and to register, visit the course Web site: 7 pneumonia and sepsis can be reduced by more than half. MayoMedicalLaboratories.com/education/mycology In addition, the ASA and APSF have made perioperative Questions? Call our Education Department at 800-533-1710 or safety a priority and will start a three-year initiative this year to 507-266-3074 or e-mail our o ce at [email protected]. reduce—or, even better, eliminate—postoperative respiratory

28 | Minnesota Medicine • March 2011 | commentary

Anesthesiology Education a new emphasis Why medical schools and residency programs are having to rethink their approach to training future anesthesiologists.

By Mojca Remskar Konia, M.D., and Kumar G. Belani, M.B.B.S., M.S.

nesthesiology has long been closely linked to surgery. concerns that are unique to their environment, educational Major advances in surgical care have prompted major programs have sought to help students and residents learn the Aadvances in anesthesia care and vice versa. Thus, for skills involved in process and quality improvement. years training in anesthesiology focused mainly on intraopera- Another change in medical practice that has had an impact tive care. Now, however, both advances in surgery and changing on anesthesiology education is an emphasis on interdisciplinary dynamics in health care delivery are dictating that anesthesi- teamwork and communication.5 Teamwork is especially impor- ologists play a broader role—that they serve as perioperative tant in high-acuity environments such as critical care units and physicians.1 As a result, anesthesia training programs have had emergency and operating rooms. Thus, in the department of to change. The American Board of Anesthesiology has offered anesthesiology at the University of Minnesota, we are exploring subspecialty certification in critical care since 1985 and in pain ways to teach students and residents how to be valued team management since 1991. (Both are components of periopera- members. We have found one of the most effective ways of tive medicine.) There are now fellowships in cardiothoracic an- doing this is through simulation. esthesia and pediatric anesthesia, and the Board is considering allowing specialty certification in these fields as well. Recently, Simulation as a Teaching Tool the Society for Ambulatory Anesthesia approved a competency- Anesthesiologists were among the first in medicine to use com- based curriculum for a fellowship program in ambulatory and puterized simulation, including interactive, high-fidelity man- office-based anesthesia that includes training in business mannequins, to train medical students, residents, and faculty. One agement, leadership, and informatics, as anesthesiologists often advantage of simulation training is that it exposes students to serve as directors of free-standing facilities.2 Both the specialty realistic clinical situations without posing any risk to a real pa- and the programs that educate providers are having to evolve in tient. Participants can learn techniques and practice new skills order to adapt to changing times.3,4 without feeling pressed for time. With repetition, they can One change in medical practice that has had a huge impact develop proficiency that they can then transfer into real clini- on the practice of anesthesiology is the patient safety move- cal environments.6 In addition, students can see what happens ment. Anesthesiology has long been a champion of patient when a situation goes awry and what they can do about it with- safety. The Anesthesia Patient Safety Foundation was the first out putting the patient’s life in danger. multidisciplinary organization to focus solely on uncovering, Our department has designed its own exercises that replicate analyzing, and eliminating risks to patients including those re- real-world clinical scenarios. In addition, our residents take part lated to human error. To equip future anesthesiologists to fur- in simulation exercises developed by other departments including ther that work, anesthesiology training now stresses the value surgery, critical care, emergency medicine, interventional radiol- of dynamic patient monitoring, the importance of verification ogy, pediatrics, and neonatology. Thus, simulation is a key tool of drug dosing, better communication among members of the for exposing students and residents to the unique skills of other surgical team, and other practices that minimize the risk of professionals and helping them understand the importance of error and improve the quality of care. In addition, as hospitals interdisciplinary teamwork. and health systems have looked for practical solutions to safety We also use simulation to teach providers what to do in

March 2011 • Minnesota Medicine | 29 commentary | OCB088611 HC MBA Medicine_Layout1c_Layout 1 2/22/11 10:24 AM Page 1 emergencies such as when a fire breaks out in the operating room. Jeff Schiff, M.D. We have developed a simulated exercise about fire during trache- ’05 M.B.A., ostomy that explores factors that might lead to this problem, ac- medical director, Health Care tions that can decrease the likelihood of it happening, and what Programs, to do if such a complication occurs. We include attending physi- Minnesota Department of cians, medical students, nurses, anesthesia technicians, and others Human Services. in this exercise. Another benefit of simulation exercises is that they show students, residents, and physicians the importance of clear and respectful communication in high-pressure situations. Commu- nication is especially important in settings such as the operating room, where decisions often must be made quickly.

Changing the Culture Our department is striving to make a culture shift. We are trying to move from having a single-specialty focus to having an interdisciplinary view. We are making changes to adapt to what is happening in the practice of anesthesiology and in medicine as a whole. We know future anesthesiologists will be perioperative medicine physicians who will need to understand their role in promoting patient safety and preventing problems. They will need to be able to work as members of teams and to communicate clearly and effectively with the other physicians and staff involved in a patient’s care. To ensure that these things happen, anesthesia training programs must continue to change with the times. MM

Mojca remskar Konia is program director and Kumar Belani is a professor in the department of anesthesiology at the University of reTHINK your Minnesota. leadership role REFERENCES Build the business foundation you need to 1. adesanya aO, Joshi GP. Hospitalists and anesthesiologists as perioperative physicians: are their roles complementary? Proc Bayl Univ Med Cent. impact your career and create positive change 2007;20(2):140-2. in the system. 2. Coursin DB, Maccioli Ga, Murray MJ. Critical care and perioperative medicine. How goes the flow? anesthesiol Clin north america. 2000;18(3):527-38. 3. Beattie C. training perioperative physicians. anesthesiol Clin north america. The Health Care MBA program at the University 2000;18(3):515-25, v-vi. of St. Thomas offers the executive-style format 4. shangraw re, Whitten CW. Managing intergenerational differences in academic anesthesiology. Curr Opin anaesthesiol. 2007;20(6):558-63. and flexibility you need to achieve your leadership 5. Boulet Jr, Murray DJ. simulation-based assessment in anesthesiology: goals while continuing to meet your professional requirements for practical implementation. anesthesiology. 2010;112(4): 1041-52. and personal commitments. 6. nishisaki a, Keren r, nadkarni V. Does simulation improve patient safety? self- efficacy, competence, operational performance, and patient safety. anesthesiol Application deadline for Fall 2011: June 1 Clin. 2007;25(2):225-36. Learn more at http://cob.stthomas.edu/HealthCareLeadership

30 | Minnesota Medicine • March 2011 | clinical & health affairs

Multimodal Clinical Pathways, Perineural Catheters, and Ultrasound-Guided Regional Anesthesia the anesthesiologist’s repertoire for the 21st Century

By Adam D. Niesen, M.D., and James R. Hebl, M.D. n Regional anesthesia is making a comeback because of improved technology and research that shows that its use results in less discomfort for patients and shorter hospital stays. This article provides a brief history of regional anesthesia, describes current techniques for administering it, and discusses potential benefits associated with it. It also describes Mayo Clinic’s Total Joint Regional Anesthesia Clinical Pathway, a comprehensive care plan for patients undergoing joint replacement surgery that uses peripheral nerve blockade and multimodal analgesia.

otal hip and total knee ar- gional anesthesia.” Although these had mastered the German technique throplasty are two of the techniques are still essential tools, anes- of transcutaneous regional anesthetic most commonly performed thesiologists now have at their disposal blockade. Pauchet’s pupil, Gaston Labat, surgeries in the United an array of options. As technology and M.D., was finishing his training and TStates. Medicare pays for more of these techniques have improved and as both provided anesthesia while Mayo and procedures than any others.1,2 Patients clinical use and indications have ex- Pauchet operated. Mayo was so im- undergoing total joint arthroplasty ex- panded, regional anesthesia has under- pressed with these regional techniques perience significant postoperative pain. gone a renaissance of sorts. The most that he recruited Labat to Mayo Clinic. Failure to provide adequate analgesia significant advancements have occurred In October 1920, Labat began his work impedes the start of physical therapy, in the use of continuous peripheral nerve in Rochester, where he taught regional which is important for maintaining catheters (for both inpatients and outpa- anesthesia to physicians at Mayo Clinic joint range-of-motion, prolongs hospital tients) and ultrasound-guided regional and wrote the book Regional Anesthesia: stays, and increases hospital expendi- anesthesia techniques. Its Technic and Clinical Application. The tures. Traditionally, analgesia following popular book helped propagate interest total joint replacement surgery has been Historical Perspective in regional anesthesia across the United provided by patient-controlled intrave- Regional anesthesia and the use of pe- States. nous analgesia. However, the new stan- ripheral nerve blockade have evolved Use of regional anesthesia waxed dard for managing pain in these patients greatly since the discovery of cocaine as and waned during the ensuing decades; is through multimodal clinical pathways an effective local anesthetic by Austrian but during the 21st century it has again with an emphasis on regional anesthesia ophthalmologist Carl Koller, M.D., in become popular as both the technol- and the use of perineural catheters. 1884. In 1920, Charles Mayo, M.D., ogy and the reliability of the equipment Spinal blocks and epidurals are traveled to Paris to visit his surgical col- used for its administration have im- probably the first techniques that come league Victor Pauchet, M.D., and to proved. With this resurgence has come to mind when reading the words “re- learn new surgical techniques.3 Pauchet an awareness on the part of clinicians

March 2011 • Minnesota Medicine | 31 clinical & health affairs |

Figure 1 local anesthetics and peripheral nerve Femoral Nerve Catheter Placement catheter techniques, many of these techniques are now being used for providing postoperative analgesia for days following surgery, especially for patients undergoing orthopedic procedures. In an attempt to maximize the benefits of regional anesthesia, the Mayo Clinic department of anesthesiology in collaboration with the department of orthopedic surgery developed the Mayo Clinic Total Joint Regional Anesthesia (TJRA) Clinical Pathway. The TJRA Clinical Pathway is a comprehensive care plan for patients undergoing major joint replacement surgery that emphasizes the use of multimodal analgesia and peripheral nerve blockade and perineural catheters. Multimodal analgesia involves the use of several analgesic agents in limited doses that act through different physiologic mechanisms. The advantage of a multimodal regimen is that Figure 2 it capitalizes on the synergistic effects of Surface Landmarks for Posterior Lumbar Plexus Catheter these medications (ie, enhanced analgesia) Placement while minimizing or eliminating adverse side effects because of the limited doses administered. Patients undergoing total knee arthroplasty receive a preoperative femoral nerve catheter with an initial bolus of local anesthetic (Figure 1). Select patients also receive a single-injection sciatic nerve block. Total hip arthroplasty patients receive a posterior lumbar plexus (psoas compartment) perineural catheter with an initial bolus of local anesthetic (Figure 2). Preoperative oral adjuvants include extended release oxycodone (age-dependent dosing), celecoxib, and gabapentin. Preop- erative medications are modified or omit- ted at the discretion of the anesthesiologist based on the patient’s comorbidities. In- source for figures 1 and 2: Hebl Jr, lennon rl. Mayo Clinic atlas of regional anesthesia and Ultrasound- Guided nerve Blockade. rochester (Mn) and new York: Mayo Clinic scientific Press and Oxford University traoperative management includes either Press; 2010. reprinted with permission from the Mayo foundation for education and research. spinal or general anesthesia, once again based on patient comorbidities and pa- and patients of the benefits of regional Neuraxial techniques include spinal, epi- tient preference. Intraoperative opioid ad- anesthesia, many of which are now being dural, and caudal blockade, and periph- ministration is limited and done at the dis- described in the literature. eral techniques encompass blockade in all cretion of the attending anesthesiologist. other regions. Most peripheral techniques No intravenous opioids are administered Regional Anesthesia Techniques were initially used as a form of intraopera- during the postoperative period. Rather, a Regional anesthesia is categorized as cen- tive anesthesia for a particular part of the postoperative multimodal analgesic regi- tral (ie, neuraxial) and peripheral based on body (eg, the arm or lower leg). However, men is initiated. Options used during the the anatomic location of the nerve block. with the development of longer-acting postoperative period are listed in the table.

32 | Minnesota Medicine • March 2011 | clinical & health affairs

All perineural catheters remain in situ so Table that local anesthetic can be infused a min- Postoperative Multimodal Analgesic Options for Total Joint imum of 36 hours postoperatively. Most Arthroplasty* perineural catheters are discontinued on the morning of the second postoperative Ketorolac (Toradol) 15 mg IV every six hours PRN for pain rated more than 4 or patient comfort goal (maximum of four doses) day. Patients receiving the Mayo Clinic Celecoxib (Celebrex) 200 mg PO BID for five days (avoid use in conjunction with Ketorolac) TJRA Clinical Pathway experience superior analgesia with fewer opioid-related Acetaminophen 1,000 mg PO three times daily (administer prior to physical (Tylenol) therapy sessions) side effects when compared with control patients.4 Visual analog pain scores are Oxycodone 5 to 10 mg PO every four hours PRN. Give 5 mg if patient reports pain and rates their pain score less than 4; give significantly lower among TJRA patients 10 mg if patient complains of pain rated 4 or greater both at rest and during physical therapy Tramadol (Ultram) 50 to 100 mg PO every six hours (may be used in select sessions throughout their hospital stay. opioid-sensitive patients) Opioid requirements are also significantly less among TJRA patients. Opioid-related *Postoperative analgesic options are selected based on each patient’s associated comorbidities. side effects such as nausea, vomiting, and urinary retention are also significantly reduced throughout most of the perioperative dysfunction (defined as disorientation the TJRA Clinical Pathway were found to tive period.4 to person, place, or time, hallucinations, be greatest among patients with a higher Postoperative milestones such as the or any other cognitive condition requiring number of associated comorbidities (ie, ability to transfer from bed-to-chair and further assessment by a physician) during older, sicker patients).6 eligibility for discharge are achieved sig- their hospitalization.5 The use of regional anesthesia tech- nificantly sooner in patients receiving niques and perineural catheters is not the multimodal TJRA Clinical Pathway The Financial Impact of Clinical limited to inpatients undergoing surgery. when compared with those who are not Pathways In fact, outpatients having procedures given the pathway. Discharge eligibility is Changes in patient management and (eg, rotator cuff repair, anterior cruciate achieved a mean of 1.7±1.9 days sooner improved perioperative outcomes may ligament repair) with regional anesthesia among TJRA patients when compared decrease costs associated with joint re- also have improved pain scores, decreased with matched controls. At the time of placement surgery by reducing hospital need for opioids, less postoperative nau- hospital discharge, TJRA patients have stays and services needed during hospi- sea and vomiting, and fewer hospital re- better joint range of motion than others; talization (ie, resources needed to manage admissions than those who receive other these gains in range of motion persist to side effects or complications). The cost of forms of anesthesia. In addition, many are the six-week to eight-week surgical follow- treating patients using the TJRA Clinical discharged to home hours sooner and re- up visit.4 Pathway at Mayo Clinic is $1,999 less per port a higher degree of satisfaction.7 Con- Severe postoperative complications surgical episode when compared with the tinuous peripheral nerve blockade also (eg, neurologic injury, myocardial infarc- cost of treating patients who do not use may be used in the outpatient setting for tion, renal dysfunction, localized bleed- it.6 Analysis of the components of cost more painful procedures such as anterior ing, deep venous thrombosis/pulmonary (hospital and physician charges) found cruciate ligament reconstruction or uni- embolism, joint dislocation, and wound that hospital-related costs were signifi- compartmental knee arthroplasty. Dispos- infection) are similar between TJRA cantly less within the TJRA cohort and ac- able local anesthetic infusion devices allow patients and patients receiving patient- counted for the majority of the total sav- patients to go home after ambulatory sur- controlled analgesia. However, postopera- ings. The difference in hospital costs was gery with superior analgesia lasting a pro- tive ileus occurs significantly more often attributed primarily to significant reduc- longed period of time. The small diameter among control patients receiving intrave- tions in medical and surgical supply costs, and flexible nature of perineural catheters nous opioids, resulting in delayed postop- operating room costs, and anesthesia sup- allows them to be easily removed by the erative feedings.4 In addition, significantly ply costs. Although room and board and patient at the end of their local anesthetic fewer TJRA patients experience postoper- pharmacy costs were also lower among infusion. ative urinary retention and postoperative the TJRA cohort, these costs were not cognitive dysfunction when compared found to be statistically significant. Over- Potential Benefits of Regional with matched controls. Approximately all, physician costs were not found to be Anesthesia 15% of control patients and 1% of TJRA significantly different between groups. In During the perioperative period, opioids patients experience postoperative cogni- addition, the cost savings associated with and the stress associated with surgery can

March 2011 • Minnesota Medicine | 33 clinical & health affairs |

3 Ultrasound-Guided Regional Anesthesia anesthesia. In 1922, William J. Mayo, M.D., regional anesthesia is successful only when anesthetic can be accurately and reli- wrote “Regional anesthesia is here to stay.” ably placed in the vicinity of nerves. During the early 20th century, anesthesiologists Clearly, this prediction is as true today as relied solely on anatomic surface landmarks to approximate neural targets, which are it was nearly a century ago. MM commonly located near vascular structures. Clinicians would deposit local anesthetic in the vicinity of peripheral nerves while hoping to avoid major vascular structures (eg, adam niesen is an instructor in anesthesi- vertebral artery or subclavian artery). However, as nerve localization techniques have ology and James Hebl is an associate evolved, ultrasound guidance has become the technique of choice for many clinicians. professor of anesthesiology at the Mayo Clinic College of Medicine. Ultrasound technology has advanced to the point where peripheral nerves, blood vessels, tissue planes, and other anatomic landmarks easily can be visualized (see figure). furthermore, it allows for real-time visualization of needle advancement, tra- REFERENCES jectory angles, and the local anesthetic as it is injected around peripheral nerves. this 1. Bozic KJ, Beringer D. economic considerations allows anesthesiologists to accurately place the needle adjacent to neural targets in minimally invasive total joint arthroplasty. Clin while avoiding nearby anatomic structures such as major vessels or the pleura. these Orthop relat res. 2007;463:20-5. 2. Defrances CJ, Podgomik Mn. 2004 national advantages may improve block success while reducing potential complications such Hospital Discharge survey. Centers for Disease as intravascular injection or pneumothorax. Control and Prevention Division of Health Care statistics. 2006;371:1-20. 3. Hebl Jr, lennon rl. Mayo Clinic atlas of regional anesthesia and Ultrasound-Guided nerve Blockade. rochester (Mn) and new York: Mayo Clinic scientific Press and Oxford University Press; 2010. 4. Hebl Jr, Dilger Ja, Byer De, et al. a pre- emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. reg anesth Pain Med. 2008;33(6):510-7. 5. Hebl Jr, Kopp sl, ali MH, et al. a comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint surg. 2005;87 (suppl 2):63-70. 6. Duncan CM, long KH, Warner DO, Hebl Jr. the economic implications of a multimodal analgesic regimen for patients undergoing major orthopedic surgery. reg anesth Pain Med. 2009;34(4):301-7. 7. Jacob aK, Walsh Mt, Dilger Ja. role of region- Ultrasound-guided axillary blockade. Corresponding anatomical illustration. al anesthesia in the ambulatory environment. anesthesiology Clin. 2010;28(2):251-66. reprinted with permission from the Mayo foundation for education and research. 8. Gottschalk a, sharma s, ford J, Durieux Me, tiouririne M. the role of the perioperative period in recurrence after cancer surgery. anesth analg. 2010;110(6):1636-43. 9. exadaktylos aK, Buggy DJ, Moriarty DC, Mascha suppress the immune system. This is of they suggest one more way that anesthetic e, sessler Di. Can anesthetic technique for primary particular concern in patients undergoing technique may affect patient outcomes. breast cancer surgery affect recurrence or metasta- ses? anesthesiology. 2006;105(4):660-4. cancer surgery, as changes in the immune Further study is needed to more clearly 10. Biki B, Mascha e, Moriarty DC, fitzpatrick system may increase their risk of cancer re- define the association between regional JM, sessler Di, Buggy DJ. anesthetic technique for radical prostatectomy surgery affects cancer currence. Regional anesthesia is known to anesthesia and cancer recurrence. recurrence: a retrospective analysis. anesthesiology. reduce the need for opioids. In addition, it 2008;109(2):180-7. 11. Christopherson r, James Ke, tableman M, attenuates the stress response by blocking Conclusion Marshall P, Johnson fe. long-term survival after 8 colon cancer surgery: a variation associated with afferent neural transmission. Preliminary Today, there is renewed interest in the choice of anesthesia. anesth analg 2008;107(1): investigations have suggested that these use of regional anesthesia for a number 325-32. benefits of regional anesthesia may have of reasons. Advances in perineural cath- a significant clinical impact. For example, eter techniques, nerve localization, block patients receiving thoracic paravertebral success, and overall safety have dramati- blockade prior to breast cancer surgery cally improved patients’ perioperative out- have been found to have a longer cancer- comes, satisfaction, and quality of life. De- free survival interval and a lower incidence spite recent progress, additional research of cancer recurrence when compared with is needed to better define the impact of patients not receiving a regional tech- regional anesthesia techniques on major nique.9 Similar evidence exists for patients clinical (eg, cancer recurrence) and finan- undergoing epidural anesthesia for pros- cial (eg, direct medical costs) outcomes. tate cancer and colon cancer surgery. 10,11 Thus far, however, evidence suggests a Although these are preliminary studies, bright and promising future for regional

34 | Minnesota Medicine • March 2011 | clinical & health affairs

Smoking and Chronic Pain a real-but-Puzzling relationship

By Toby N. Weingarten, M.D.,Yu Shi, M.D., M.P.H., Carlos B. Mantilla, M.D., Ph.D., W. Michael Hooten, M.D., and David O. Warner, M.D. n Smoking produces profound changes in physiology beyond those associated with the delivery of nicotine to the bloodstream. It has long been known that these changes put patients at risk for heart disease, cancers, and lung diseases. More recently, it has been discovered that smoking is a risk factor for chronic pain. Robust epidemiological evidence is showing that smokers not only have higher rates of chronic pain but also rate their pain as more intense than nonsmokers. Because the relationship between smoking and pain is of relevance to clinicians in many specialties, researchers at Mayo Clinic are examining this relationship in depth. This article describes some of what they and others have discovered in recent years about the interactions between smoking and chronic pain.

ecent evidence suggests that smokers are more Center, Outpatient Pain Clinic, Orofacial Pain Clinic, and Fi- likely than nonsmokers to experience chronic bromyalgia and Chronic Fatigue Clinic consistently show that pain.1-6 In fact, it appears that chronic pain is even smokers report greater pain intensity and greater functional more prevalent among former smokers than it is impairment than nonsmokers.7-10 In addition, their scores on Ramong those who have never smoked.6 In addition, smokers measures of life interference were worse. For example, smokers with chronic pain indicate that their pain is more intense than with fibromyalgia missed more days of work; reported worse that of nonsmokers and say that their pain is associated with sleep, greater anxiety, and depression; and had more pain, stiff- more occupational and social impairment.7-10 These observa- ness, and fatigue than nonsmokers with fibromyalgia.9 tions are even more interesting given that they are contrary to Because nicotine has analgesic properties and smoking a what would be expected because of nicotine’s known analgesic cigarette can blunt pain perception,11 the higher prevalence and properties. Thus, the relationship between pain and smoking increased severity of chronic pain in smokers as compared with is a fascinating phenomenon that has a considerable number nonsmokers may seem surprising. Researchers are exploring of clinical implications. Although it is not fully understood, this apparent paradox. They have found that nicotine-habitu- research is beginning to shed light on how smoking and pain ated animals undergoing nicotine withdrawal demonstrate in- interact. creased sensitivity to pain stimuli.12 They have also found that when human smokers are deprived of nicotine, they perceive The Many Interactions between Smoking pain stimuli earlier and have reduced tolerance for pain.13,14 and Chronic Pain Thus, some postulate that nicotine withdrawal could increase Findings from recent prospective studies suggest a causal re- a smoker’s perception of pain and even the intensity of chronic lationship between smoking and chronic pain. For example, pain. one study found that Finnish adolescents who smoke at age Heightened awareness of pain in response to nicotine 16 were more likely to develop pain symptoms by age 18.4 withdrawal could, in turn, further encourage smoking because Another one found that adolescent smokers were at increased it reduces a person’s perception of pain and/or helps them cope risk for hospitalization for low-back pain later in life and that with the pain or mitigates anxiety associated with increased male smokers were at increased risk for lumbar discectomy.3 A pain. For example, in at least one study, smokers reported that longitudinal study of 9,600 twins found a dose-response re- feeling pain made them want to smoke.15 Current research at lationship between the number of cigarettes smoked and the Mayo Clinic is examining if and how pain motivates female development of back pain.1 smokers with fibromyalgia to smoke. Smokers with chronic pain are more adversely affected Researchers are also attempting to identify the mecha- by their pain than nonsmokers with chronic pain. Studies of nisms that might lead to increased pain in smokers. Some patients presenting to the Mayo Clinic Pain Rehabilitation point to the changes that occur in the neuroendocrine system

March 2011 • Minnesota Medicine | 35 clinical & health affairs |

The Benefits of Cognitive Behavioral Therapy could contribute to functional impairment from chronic pain. Another consideration is that current and former heavy smokers respond as well as nonsmokers to cognitive behav- smokers are more likely to use prescription analgesics.18 We ob- ioral therapy for the treatment of chronic pain. for example, served that more smokers than nonsmokers admitted to our Pain smokers who completed an intense three-week cognitive be- Rehabilitation Center used opioid analgesics and used them at havioral therapy rehabilitative program for patients with severe higher doses.18 In addition, we discovered that male smokers con- chronic pain at Mayo Clinic’s Pain rehabilitation Center experi- 19 enced equal or better responses than nonsmokers and were as sumed the greatest quantities of opioid analgesics. Smokers are able to successfully taper off opioids, despite greater pain and known to have higher rates of drug abuse, and smoking is almost functional impairment at program entry.1 similar observations ubiquitous among opioid abusers. have been made in smokers with fibromyalgia and who were We also know that smoking alters the pharmacokinetics of treated with cognitive behavioral therapy at Mayo’s fibromyal- opioids. A study comparing the effects of hydrocodone on both gia and Chronic fatigue Clinic. smokers and nonsmokers with back pain found that the smokers

1. Hooten WM, townsend CO, Bruce BK, Warner DO. the effects of smoking used more hydrocodone tablets yet continued to report greater status on opioid tapering among patients with chronic pain. anesth analg. pain. Interestingly, despite taking higher doses of hydrocodone, 2009;108(1):308-15. they had lower serum hydrocodone levels.20 An explanation for this may be that the polycyclic aromatic hydrocarbons, substances in response to long-term smoking. In the nonsmoker, the physi- in cigarette smoke, induce P450 enzymes involved in morphine ologic stress that results from pain activates the sympathetic ner- metabolism. This could account for the higher consumption of vous system and the hypothalamic-pituitary-adrenal (HPA) axis. opioids in male smokers with chronic pain. The increased sympathetic output blunts pain perception. How- ever, the HPA system is down-regulated in smokers, which may Tobacco Cessation in Chronic Pain Patients increase their perception of pain. Current guidelines recommend that clinicians advise tobacco Another potential explanation may be that smoking accel- users to quit and provide them with the assistance to do so at erates degenerative changes such as those from osteoporosis and every encounter. Certainly chronic pain patients would benefit lumbar disc disease, and impairs bone healing. Such changes from stopping smoking. However, given the imperfectly under- could predispose smokers to injury, impede healing, and subse- stood relationship between pain and smoking, it is not clear how quently increase their risk for future chronic pain. tobacco abstinence affects chronic pain. In the short term, nico- Psychosocial factors also may have an effect. Current scien- tine abstinence has the potential to make it worse, and stopping tific understanding of biological processes and neural pathways smoking would remove a mechanism that smokers perceive as suggests a link between depression and pain. It is known that useful in coping with anxiety. Yet, in the long term, recovery from smokers have higher rates of mood disorders such as depression the effects of smoking might improve chronic pain. and anxiety than nonsmokers and that patients with these mood Smokers who suffer from chronic pain have the same moti- disorders have more chronic pain. We also know that patients vation to quit as smokers who do not have pain.21 However, we with chronic pain have higher rates of mood disorders. We re- found that very few patients enrolled in our Pain Rehabilitation cently reviewed a national data set and found that smoking in- Center who smoked could successfully quit despite receiving to- creased the likelihood of pain in older adults but only in those bacco-intervention services.10 We need to find ways to help smok- who were also depressed.16 However, in a recent analysis of pa- ers with chronic pain quit successfully. One approach might be to tients treated at our Pain Rehabilitation Center, we found that help them adopt coping strategies other than smoking such as re- pain severity was independently associated with depression sever- laxation techniques and behavior modifications. Clearly, we need ity but not smoking status.17 Obviously, the interactions between additional research to better understand the effects of nicotine smoking, depression, and chronic pain are not completely under- abstinence on chronic pain in order to develop effective interven- stood and are complex. However, the clinician who encounters tions that can be readily applied in the clinical setting. a smoker with chronic pain should strongly consider that mood disorders also may be present. Conclusion Research is also examining how income and marital status Chronic pain is among the many health problems associated with play into this issue. Smokers tend to be less educated, poorer, and smoking. When smokers develop chronic pain, their symptoms more likely to be unemployed and divorced than nonsmokers. In and disability are often worse than those of nonsmokers with addition, as smoking rates decline, smokers are becoming increas- chronic pain. The reasons for these observations are likely multi- ingly marginalized in society. Weingarten et al. reported that 50% factorial; but as yet they are not clear. Clinicians should provide of smokers presenting to our outpatient tertiary pain clinic were tobacco-cessation interventions to their patients with chronic unemployed or disabled, compared with 18% of nonsmokers.8 pain who use tobacco even though more research is needed re- These differences suggest smokers are more isolated and lacking garding how smoking cessation might affect their pain and how in social support than nonsmokers. It is thought that these factors best to help them quit. MM

36 | Minnesota Medicine • March 2011 | clinical & health affairs toby Weingarten is an assistant professor of anesthesiology, Yu shi sity, and functional interference in patients with chronic pain. Pain Physician. is a research fellow, Carlos Mantilla is an associate professor of 2008;11(5):643-53. 9. Weingarten tn, Podduturu Vr, Hooten WM, thompson JM, luedtke Ca, Oh anesthesiology and physiology, W. Michael Hooten is an assistant tH. impact of tobacco use in patients presenting to a multidisciplinary outpatient professor of anesthesiology, and David Warner is a professor of treatment program for fibromyalgia. Clin J Pain. 2009;25(1):39-43. anesthesiology at Mayo Clinic. 10. Hooten WM, townsend CO, Bruce BK, et al. effects of smoking status on immediate treatment outcomes of multidisciplinary pain rehabilitation. Pain Med. 2009;10(2):347-55. The authors’ research is funded by the Mayo Foundation. 11. Girdler ss, Maixner W, naftel Ha, stewart PW, Moretz rl, light KC. Cigarette smoking, stress-induced analgesia and pain perception in men and women. Pain. 2005;114(3):372-85. 12. Biala G, Budzynska B, Kruk M. naloxone precipitates nicotine abstinence R E F E R E N C E S syndrome and attenuates nicotine-induced antinociception in mice. Pharmacol 1. Hestbaek l, leboeuf-Yde C, Kyvik KO. are lifestyle-factors in adolescence rep. 2005;57(6):755-60. predictors for adult low back pain? a cross-sectional and prospective study of 13. Perkins Ka, Grobe Je, stiller rl, et al. effects of nicotine on thermal pain young twins. BMC Musculoskelet Disord. 2006;7:27. detection in humans. exper Clin Psychopharmacol. 1994;2(1):95-106. 2. leboeuf-Yde C. smoking and low back pain. a systematic literature review 14. silverstein B. Cigarette smoking, nicotine addiction, and relaxation. J Pers of 41 journal articles reporting 47 epidemiologic studies. spine. 1999;24(14): soc Psychol. 1982; 42(42):946-50. 1463-70. 15. Ditre JW, Brandon tH. Pain as a motivator of smoking: effects of pain induc- 3. Mattila VM, saarni l, Parkkari J, Koivusilta l, rimpela a. Predictors of low tion on smoking urge and behavior. J abnorm Psychol. 2008;117(2):467-72. back pain hospitalization--a prospective follow-up of 57,408 adolescents. Pain. 16. shi Y, Hooten WM, roberts rO, Warner DO. Modifiable risk factors for inci- 2008;139(1):209-17. dence of pain in older adults. Pain. 2010;151(2):366-71. 4. Mikkonen P, leino-arjas P, remes J, Zitting P, taimela s, Karppinen J. is smok- 17. Hooten WM, shi Y, Gazelka HM, Warner DO. the effects of depression and ing a risk factor for low back pain in adolescents? a prospective cohort study. smoking on pain severity and opioid use in patients with chronic pain. Pain. spine. 2008;33(5):527-32. 2011;152(1):223-9. 5. Miranda H, Viikari-Juntura e, Punnett l, riihimaki H. Occupational loading, 18. John U, alte D, Hanke M, Meyer C, Volzke H, schumann a. tobacco smok- health behavior and sleep disturbance as predictors of low-back pain. scand J ing in relation to analgesic drug use in a national adult population sample. Drug Work environ Health. 2008; 34(6):411-9. alcohol Depend. 2006;85(1):49-55. 6. Palmer Kt, syddall H, Cooper C, Coggon D. smoking and musculoskeletal dis- 19. Hooten WM, townsend CO, Bruce BK, Warner DO. the effects of smok- orders: findings from a British national survey. ann rheum Dis. 2003;62(1):33-6. ing status on opioid tapering among patients with chronic pain. anesth analg. 7. Weingarten tn, iverson BC, shi Y, schroeder Dr, Warner DO, reid Ki. impact 2009;108(1):308-15. of tobacco use on the symptoms of painful temporomandibular joint disorders. 20. ackerman We 3rd, ahmad M. effect of cigarette smoking on serum hydroco- Pain. 2009;147(1-3):67-71. done levels in chronic pain patients. J ark Med soc. 2007;104(1):19-21. 8. Weingarten tn, Moeschler sM, Ptaszynski ae, Hooten WM, Beebe tJ, Warner 21. Hahn eJ, rayens MK, Kirsh Kl, Passik sD. Brief report: pain and readiness to DO. an assessment of the association between smoking status, pain inten- quit smoking cigarettes. nicotine tob res. 2006;8(3):473-80.

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March 2011 • Minnesota Medicine | 37 clinical & health affairs |

Postoperative Nausea and Vomiting in Pediatric Patients

ostoperative nausea and vomiting (PONV) is a Although our understanding of PONV risk factors has common problem following surgery. In addi- improved dramatically since the early 1990s, we still have tion to making the patient feel uncomfortable, much to learn about the pathophysiology of PONV. We it can lead to dehydration, electrolyte imbalance, have even more to learn about PONV in children. Thus, andP longer hospital stays. Despite new guidelines, treatment it has been a focus of recent research at the University of strategies, and better anesthetics, the incidence of PONV in Minnesota. The following brief articles present the findings children and adults has remained constant (20% to 35%) from two studies, one of children up to 2 years of age who over the past 30 years.1-3 underwent strabismus surgery and the other of children ages Postoperative nausea and vomiting encompasses three 1 month to 16 years who underwent urologic procedures. main symptoms that may occur separately or in combina- These studies looked at the incidence of PONV in tion: nausea, vomiting or emesis, and retching. One of the both groups during the first 24 hours following surgery. The goals of anesthesia care is to minimize the likelihood that pa- strabismus study also looked at the incidence of discom- tients will experience these symptoms. To achieve that, efforts fort and emergence agitation/delirium in infants and young are being made to minimize the use of opioids by adopting children. —Kumar Belani, M.B.B.S., M.S. regional analgesic techniques and nonopioid medications for Professor, Department of Anesthesiology perioperative pain control, use a total intravenous anesthesia University of Minnesota plan for those with a history of severe PONV, and adopt a 3,4 prophylactic strategy for PONV prevention. REFERENCES

In addition, antiemetics are also being widely used. Be- 1. White Pf. Prevention of postoperative nausea and vomiting—-a multimo- cause no single drug effectively blocks all the neural inputs dal solution to a persistent problem. n engl J Med. 2004;350(24):2511-2. 2. Gan tJ, Meyer ta, apfel CC, et al. society for ambulatory anesthesia that may trigger nausea and vomiting, practitioners com- guidelines for the management of postoperative nausea and vomiting. monly prescribe two or more in combination, for example, a anesth analg. 2007;105(6):1615-28. 3. Collins Ce, everett ll. Challenges in pediatric ambulatory anesthesia: serotinin antagonist (ondansetron) with an inhibitor of pros- kids are different. anesthesiol Clin. 2010:28:315-28. taglandin synthesis (dexamethasone). 4. Habib as, White WD, eubanks s, Pappas tn, Gan tJ: a randomized comparison of a multimodal management strategy versus combination antiemetics for the prevention of postoperative nausea and vomiting. anesth analg. 2004;99(1):77-81.

38 | Minnesota Medicine • March 2011 | clinical & health affairs

Discomfort, Delirium, and POnV in infants and Young Children Undergoing strabismus surgery

By Anne M. Stowman, Erick D. Bothun, M.D., and Kumar G. Belani, M.B.B.S., M.S. n This article presents the results of a retrospective analysis of anesthesia care and notes in the PACU and phase II recovery perioperative outcomes in children up to 2 years of age who underwent strabismus charts. Emergence agitation/delirium was surgery during a five-year period at the University of Minnesota Amplatz Children’s graded according to noted observations Hospital. We reviewed the charts of 74 children to determine perioperative outcomes— and translated to the Pediatric Anesthe- namely discomfort, emergence agitation/delirium, and postoperative nausea and sia Emergence Delirium (PAED) scale, vomiting (PONV). We found that although PONV was not an issue in this age group, as which takes into consideration the extent it was with older children, discomfort and emergence agitation/delirium do need to be to which 1) the child makes eye contact considered during their care. with the caregiver, 2) the child’s actions are purposeful, 3) the child is aware of his or revious studies have reported sota Amplatz Children’s Hospital between her surroundings, 4) the child is restless, that up to 80% of children August 1, 2004, and July 29, 2009. and 5) the child is inconsolable.2 who are treated surgically for Detailed patient information was ex- Statistical analysis was performed strabismus suffer from post- tracted from the medical record including using tables of descriptive frequencies with operativeP nausea and vomiting (PONV),1 the anesthesia record, post-anesthesia care basic measures of mean, minimum, maxi- a serious complication that can lead to unit (PACU) report, phase II recovery mum, count, and standard deviation. The discomfort, dehydration, electrolyte im- room report, and 24-hour post-discharge Student’s T-test was used for evaluation of balance, and delayed hospital discharge. information obtained by telephone. The statistical significance (P <0.05). Although efforts have focused on reducing extracted information included the pa- the incidence of PONV in children ages 3 tient’s age, gender, weight, past medical Results through 8 years, there are no published re- history, and American Society of Anesthe- We analyzed the records of 74 infants ports detailing perioperative outcomes in siologists physical status; laterality of the younger than 2 years of age who under- younger children undergoing ambulatory surgery; duration of surgery and anesthe- went strabismus procedures. Sixty percent strabismus surgery. The purpose of our sia; time in the operating room, PACU, were female and 40% were male, with a study was to summarize perioperative out- and phase II recovery room; presence of a mean age of 14.8±5.0 months (range: comes—namely discomfort, emergence parent during induction; medications and 5 to 23 months). All patients came to the agitation/delirium, and PONV follow- dosages administered including induction hospital on the day of surgery with their ing strabismus surgery in children up to agents, antiemetics, neuromuscular block- caregivers understanding that they would 2 years of age. ers and reversal drugs, and anti-anxiety be discharged that same day. medications; method of induction; pres- The anesthesiology care team evalu- Methods ence of pain, PONV, and emergence ated all of the patients before surgery in Our study was conducted after it was ap- agitation/delirium; blood pressure and order to develop an anesthesia care plan. proved by the Institutional Review Board heart rate; other significant side effects; All patients followed the ASA’s NPO at the University of Minnesota and found medications given; and hospital admission guidelines prior to surgery. Twenty-nine to meet all applicable Health Informa- following surgery. Because the patients (39.2%) received midazolam for anxiety tion Portability and Accountability Act in this study were too young to report orally; another 9.5% received it intrave- requirements. We conducted a cohort symptoms, discomfort was recorded as nously intraoperatively, and 9.5% received chart review of all patients up to 2 years crying and irritation that responded to an- it postoperatively in the PACU to treat of age who underwent outpatient strabis- algesic administration. Emergence agita- emergence agitation/delerium. Only three mus surgery at the University of Minne- tion/delirium was recorded from nursing were given the antinausea drug ondanse-

March 2011 • Minnesota Medicine | 39 clinical & health affairs |

Table lessness and inconsolability (part of the Postoperative Problems Noted following Strabismus Surgery in emergence delirium determination crite- Infants and Young Children (N=74) ria) were indicated in the nursing notes. None of the infants and young chil- Outcomes Number % Patients dren experienced PONV. Although we Pain and discomfort 53 71.6 cannot be sure that none of the patients Emergence agitation/delerium 33 44.6 experienced nausea because of their in- Respiratory symptoms 12 16.2 ability to communicate such a sensation, no obvious signs or symptoms of nausea Needing supplemental O2 6 8 such as retching, gagging, or vomiting Severe laryngospasm 2 2.7 were documented by the nursing staff in Postextubation pulmonary edema 1 1.3 the perioperative care units or reported by Hospital admission 5 6.8 caregivers at home during the telephone Tachycardia 3 4.1 follow-up. We believe the low incidence of PONV may have been the result of ad- tron prior to surgery. tients (95%) for pain. Morphine and al- ministration of antiemetics. Nearly all of Anesthesia was induced with sevo- fentanil were also used. Forty-nine percent the patients (92%) received prophylaxis flurane in all but one child. That child of the patients received rectal acetamino- for postoperative nausea and vomiting. received nontriggering agents (total intra- phen postinduction. Despite receiving Use of antiemetics prophylactically should venous anesthesia with propofol, fentanyl opioids intraoperatively, two-thirds of the be considered in future studies. and rocuronium) because of a family his- children (67.1%) required additional an- Emergence delirium was determined tory of malignant hyperthermia. Desflu- algesics (fentanyl 27%, morphine 23%, by the PAED scale. Although a number of rane was used as the maintainence agent and acetaminophen 17%). patients displayed restlessness (n=12) and in 53% of the children; sevoflurane was During emergence from anesthesia, inconsolability (n=9), all had purposeful used in 35%; and isoflurane in 12%. 36 of the 47 patients given nondepolariz- movement, seemed aware of their sur- Fifty-one patients received glycopyrrolate, ers were reversed in the OR and, with the roundings, and were able to identify their and 12 received atropine at the onset of exception of two patients, were extubated caregiver through eye contact. the procedure. The majority of children in the OR. Those two were extubated in Discomfort and agitation were most were intubated. Cuffed endotracheal tubes the PACU. prevalent postoperatively. Agitation was were used in 62 children (age 14.3±5.1 Pain and discomfort and emergence experienced by 44.6% of patients, but it months); 10 (age 16.7±7.3 months) had agitation/delerium were noted in the was never a reason for hospital admission, uncuffed endotracheal tubes (P >0.05). A PACU. Discomfort was noted in 53 chil- nor did it ever extend beyond the time laryngeal mask airway (LMA) device was dren (Table). None had emergence agita- in the PACU. Although all patients were used in two babies. Nondepolarizing mus- tion/delirium. There were no episodes of administered analgesics intraoperatively cle relaxants were used in 47 (64%) chil- vomiting. (n=74), nearly half (n=33) experienced dren (rocuronium in 25; cisatracurium in agitation postoperatively despite adminis- 17; vecuronium in five). Of those, only 36 Discussion tration of opioids and/or acetaminophen were reversed with neostigmine and glyco- We found a much lower incidence of intraoperatively. The absence of hypother- pyrrolate. The ophthalmologists provided PONV in our group than earlier studies of mia, as indicated by intraoperative and topical analgesia with tetracaine 0.5% to older children. This may have been due in postoperative arrival and departure tem- 30 children; six received topical lidocaine, part to the age of our patients and because perature averages, discounts the idea that and one received tropicamide 0.17% plus of the use of prophylactic antiemetics. lowered body temperature was the reason cyclopentolate. In addition to PONV, our study for agitation. The idea that it may be as- Prior to awakening and extubation, examined both emergence agitation/de- sociated with the use of a particular anes- 68 (92%) received prophylaxis for PONV. lirium and discomfort following strabis- thetic agent is also less relevant, as 81% of Fifty-eight of those patients received mus repair. In all instances, nursing notes our patients received sevoflurane. We were ondansetron; of those, 37 also received differentiated between crying and discom- unable to determine whether there was a dexamethasone and one received dexa- fort, restlessness, inconsolability, and agi- correlation between IV induction versus methasone and droperidol. Eight patients tation. We interpreted crying and irrita- mask induction and agitation, as only one received only dexamethasone and two re- bility without agitation as discomfort. In of our patients underwent an IV induc- ceived only droperidol. most cases, over-the-counter medications tion. The reason for high rates of agitation Intraoperatively, the anesthesia care alleviated the patients’ discomfort. We de- needs to be further investigated. team used fentanyl in the majority of pa- termined a child was agitated when rest- Discomfort was perhaps the biggest

40 | Minnesota Medicine • March 2011 | clinical & health affairs concern for patients. Seventy-two percent cried on and off, were fussy, and were easily consoled by being held or rocked or having a parent present. These patients were given analgesics postoperatively and had a predictable response. One of the limitations of our study was lack of thorough documentation in the patients’ charts. Because our review Postoperative nausea and Vomiting in was done retrospectively, details regarding the care a patient received and a pa- infants and Young Children following tient’s behavior had to be extracted from Urologic surgery the notes taken by staff. In future studies, it would be prudent to have staff watch By Preeta George, M.B.B.S., M.D., Kumar G. Belani, M.B.B.S., M.S., for certain symptoms and behaviors and and Aseem Shukla, M.D. consistently document them as well as the status of the patient throughout the opera- n This article presents a cohort review of anesthesia-related perioperative outcomes tive and postoperative phases. of children undergoing ambulatory urologic surgery using a combination of general and regional anesthesia. We analyzed the charts of 123 patients who underwent hypo- Conclusion spadias repair and circumcision between July 1, 2006, and January 2, 2009, for cases This study of infants and young children of postoperative nausea and vomiting. We found the incidence to be quite low. We demonstrates that PONV was not com- believe the low incidence may have been related to the prophylactic use of antiemetics mon following strabismus surgery and along with an opioid-sparing technique for anesthesia care. that the incidence may have been reduced through the prophylactic use of antiemet- ostoperative nausea and vom- gional anesthesia. ics along with insoluble newer anesthetic iting (PONV) is a distress- Included were all infants and children agents. We found that discomfort and ing postsurgical problem in between the ages of 1 month and 16 years emergence agitation/delerium during the children. Despite new guide- who underwent hypospadias repair or cir- postoperative period are of greater con- lines,P treatment strategies, and better cumcision. All surgeries were performed cern. anesthetics, the incidence of PONV has by the same surgeon. Excluded from the remained constant (20% to 35%) over study were those patients who were not anne stowman is in the department the past three decades.1,2 We studied the ambulatory patients. Anesthesia and post- of anesthesiology, erick Bothun is in the departments of ophthalmology and incidence of PONV in a segment of pa- anesthesia care records were reviewed in pediatrics, and Kumar Belani is a professor tients undergoing ambulatory urologic detail to record the anesthesia plan and in the department of anesthesiology at the surgery who received a combination of the use of antiemetics. All patients had University of Minnesota. general and regional anesthesia. The goal a complete clinical evaluation at least 30 of this study was to identify cases in which days prior to surgery and were assessed REFERENCES PONV occurred within the first 24 hours on the day of surgery by an anesthesiolo-

1. Madan r, Bhatia a, Chakithandy s, et al. after surgery. The presence of PONV was gist. The 24-hour postoperative phone call Prophylactic dexamethasone for postoperative nau- defined as at least one episode of nausea notes by our ambulatory nurse specialist sea and vomiting in pediatric strabismus surgery: a dose ranging and safety evaluation study. anesth (any degree, including mild) or vomiting were reviewed for instances of nausea and analg 2005;100(6):1622-6. or retching, or any combination of these vomiting. 2. sikich n, lerman J. Development and psychomet- 3 ric evaluation of the pediatric anesthesia emergence symptoms. delirium scale. anesthesiology 2004;100(5): 1138-45. Results Methods A total of 72 children (ages 40±46 months) Following approval by our Institution Re- underwent circumcision and another 51 view Board, we analyzed data from a group (26±43 months) had hypospadias repair. of pediatric patients who underwent am- All followed the American Society of Anes- bulatory circumcision or hypospadias re- thesiologists’ NPO guidelines; the major- pair at the University of Minnesota Am- ity received a general anesthetic that con- platz Children’s Hospital between July sisted of mask induction with sevoflurane. 1, 2006, and January 2, 2009. Patients Nine patients had intravenous induction received a combination of general and re- with propofol. Desflurane or sevoflurane

March 2011 • Minnesota Medicine | 41 clinical & health affairs |

Table this may be the reason only two of those Incidence of Postoperative Nausea and Vomiting (PONV) following patients experienced PONV. We did not Urologic Surgery find any association between the use of reversal and PONV. PONV during Following surgery, patients and their Total number of first six hours PONV six to 24 families had access to a 24-hour telephone Time patients postop hours postop follow-up service. During the 24 hours Hypospadias group 51 following discharge, only one patient had Nausea *5 1 an episode of nausea and vomiting. He Vomiting 0 1 was not treated with any medication and Circumcision group 72 was managed conservatively. We also did Nausea 4 0 not find a relationship between the time Vomiting 0 0 of antiemetic administration and the incidence of PONV. Patients who received *P=0.487 versus circumcision group (not significant) antiemetics during the first half of the surgery had a similar incidence of PONV as were used for maintenance. Nitrous oxide ics were given only if the pain was severe. those who received them during the latter was used in 16 patients in the circumci- Postoperatively, five circumcised children half of the surgery. sion group and seven in the hypospadias received fentanyl, five received morphine, group for induction only. In the circum- and two received both. Ten of the chil- Conclusion cised group, 26 children had a laryngeal dren who underwent hypospadias repair We found the incidence of PONV follow- mask airway (LMA) device, 32 were in- received fentanyl, six received morphine, ing ambulatory urologic surgery in infants tubated, and 14 were managed with a and one received both. Upon discharge, all and young children to be quite low. The facemask. All but two of the children who were given a prescription for acetamino- low incidence was most likely related to were circumcised received a penile block. phen/hydrocodone (500/7.5 mg per 15 the prophylactic use of antiemetics along One did not receive a caudal; the other mL) elixir or acetaminophen alone to be with limited use of opioids during anes- had no regional block. Opioids were used used as needed every four to six hours. thesia care as well as use of a caudal or sparingly. Sixty-five children received in- penile block for perioperative pain traoperative fentanyl (2.27±1.28 mcg/kg). Discussion control. MM In the hypospadias group, five children The cohort review in this subset of pedi- Preeta George and Kumar Belani are in had an LMA, three received mask ventila- atric patients was carried out because the the department of anesthesia, and aseem tion, and 43 were intubated. Twenty-eight incidence of PONV had not been exclu- shukla is in the department of urology at the received a caudal and 23 were given a pe- sively studied in such children. We found University of Minnesota. nile block. Forty-three received fentanyl the incidence of PONV to be lower than

(2.88±3.13 mcg/kg). had been previously reported in infants REFERENCES Seventy-five percent of the children and children.2 Several factors may be re- 1. Kovac al. Management of postoperative nau- in each group were given the antiemetic sponsible for this. For one thing, the use sea and vomiting in children. Paediatr Drugs. ondansetron intraoperatively. Thirty-three of opioids was minimized for the majority 2007;9(1):47-69. 2. Drake r, anderson BJ, Persson Ma, tHompson percent of the children in the circumci- of patients because simple regional tech- JM. impact of an antiemetic protocol on postop- sion group and 51% in the hypospadias niques were used instead. Pain and opi- erative nausea and vomiting in children. Paediatr anaesth. 2001;11(1):85-91. group also received dexamethasone. Post- oids work through different pathways to 3. apfel CC, roewer n, Korttila K. How to study postoperative nausea in the recovery room potentiate PONV. Hence, incorporating operative nausea and vomiting. acta anaesthesiol scand. 2002;46(1):921-928. and before discharge was noted in four of a regional anesthetic would circumvent 72 (5.6%) circumcised children and five both factors. In addition, approximately of 51 (9.8%) children who underwent 75% of patients received the antiemetic hypospadias repair (Table). No episodes ondansetron, and a good number received of vomiting were reported. All children dexamethasone intraoperatively, both of were discharged home. During the first which may have contributed to the low 24 hours after surgery, one child in the incidence of PONV. The majority of in- hypospadias group had both nausea and fants and young children received the an- vomiting. None returned to the hospital tiemetic during the first half of surgery. for PONV. Postoperative pain was mainly Even though nitrous oxide was used in controlled with acetaminophen. Narcot- 23 infants, it was used only for induction;

42 | Minnesota Medicine • March 2011 | clinical & health affairs

Safe and Sound Pediatric Procedural sedation and analgesia

By Patricia D. Scherrer, M.D. lor drug choices to the child’s needs and n Providing procedural sedation for pediatric patients presents unique challenges. the providers’ skill sets. Children’s hospitals have protocols in place to provide safe, high-quality sedation care delivered by specialists in pediatric sedation and anesthesiology. However, Initial Considerations the demand for procedural sedation for diagnostic and therapeutic procedures is When planning sedation and/or pain increasing. This article describes some of the key components involved in establish- management for a child, knowing what ing a protocol for safe and effective pediatric sedation services including screening level of responsiveness needs to be techniques for patients at higher risk for complications and appropriate monitoring achieved during the procedure or test and rescue plans. We also review medications commonly used for pediatric seda- is essential for choosing the appropriate tion and pain management and discuss resources available to physicians who pro- medication regimen. Painful procedures vide pediatric sedation. that require relative immobility generally mandate a deeper level of sedation ommy is a 3-year-old with a his- urgent care technician is concerned that than noninvasive radiological tests. Each tory of speech delay and staring she may have an abscess. Anna begins to sedation plan should take into account Tspells. His primary care physi- scream and pull away when the tech tries the age, developmental level, and person- cian has ordered a brain MRI to evaluate to clean the area. ality of the child. Seven-year-old Anna, him for underlying anatomic issues. The Three different scenarios, three dif- for example, may require deep sedation MRI will take approximately 45 minutes ferent children who may not be able to for incision and drainage of her abscess; and will require him to lie nearly motion- receive the care they need without seda- local analgesia alone may be sufficient for less. Tommy squirms and fights when his tion and/or pain control. Such situations another child her age undergoing such a dad tries to put him on the MRI table. arise daily in medical centers around the procedure. Jasmine is a 6-month-old who has country. Although most children’s hospi- In an effort to clarify sedation goals, failed two newborn hearing screenings. tals have specialized sedation programs to the American Society of Anesthesiolo- Her audiologist needs to perform fur- address the needs of their patients, many gists (ASA) has defined a continuum for ther testing, which requires Jasmine to regional and rural medical centers have levels of sedation.1 Minimally sedated be quiet for 30 to 60 minutes. When the sporadic experience with pediatric seda- children may have an impaired level audiologist attempts the test, Jasmine tion. Nevertheless, demand for sedation of cognitive functioning but maintain begins to cry, and the test cannot be is growing, and many hospitals and clin- their airway protective reflexes and car- completed. ics are seeking to expand their capabili- diorespiratory status. For example, for Anna is a 7-year-old who suffered ties. To ensure patient safety, physicians children undergoing voiding cystoure- some “road rash” on her left knee after and health systems must develop pedi- thrograms, this level of sedation is often falling from her bike. She presents to a atric sedation protocols that recognize achieved through use of inhaled nitrous local urgent care with an inflamed, swol- higher-risk situations, provide appropri- oxide. Moderate sedation is associated len area on her knee a week later, and the ate supervision and monitoring, and tai- with blunted-but-purposeful responses

March 2011 • Minnesota Medicine | 43 clinical & health affairs | to verbal or tactile stimulation. There may support.4,5 Physicians should carefully airway placement more likely. be subtle alterations in ventilation, but consider the following questions before Physicians should also be aware of airway reflexes and cardiovascular func- embarking on a sedation plan: What is underlying medical conditions that in- tion are generally unchanged. Infants who the skill set of the team that will be with crease the potential for airway compro- receive chloral hydrate often reach a mod- the child at all times? If the primary team mise during sedation. A number of genetic erate level of sedation. In contrast, deeply needs help, who will respond? How long syndromes are associated with anatomic sedated children may have inadequate will it take the rescue team to arrive? Is a and/or developmental airway differences spontaneous ventilatory drive and/or sig- member of the rescue team an anesthesia as well as altered respiratory mechanics; nificant upper airway obstruction and specialist who is capable of providing reli- several excellent articles describe these.6,7 may require airway intervention. During able advanced airway support to children? Infants born prematurely have immature deep sedation (as opposed to general an- Satisfactory answers are critical to ensur- respiratory drive physiology, increasing esthesia), purposeful responses to painful ing safety. the likelihood of sedation-related apnea in stimulation remain intact. The combina- the first months of life. Currently, many tion of an opioid and a benzodiazepine Patient Evaluation sedation programs choose to monitor in- often results in deep sedation. What “red flags” should providers look fants less than 60 weeks post conceptual The definitions of these levels of se- for when evaluating a child who would age for a longer time period than they do dation remain somewhat arbitrary. Unfor- benefit from sedation for a painful or older children prior to discharge. For ex- tunately, there is no clear physiologic de- anxiety-provoking procedure? Although ample, at Children’s Hospitals and Clinics marcation between each level. Because the identifying every possible risk factor can of Minnesota, we monitor these infants various levels of sedation are not specific be challenging even for the most seasoned for a 12-hour period, discharging them to to any particular drug or regimen, physi- pediatric anesthesiologist, there are spe- home only if they have not had any epi- cians must understand that it is impossible cific patient characteristics that have been sodes of apnea during that time. Changes to reliably predict the effect that a given associated with increased complications. A in respiratory physiology during proce- dose of a particular drug will have on a thorough health history and physical ex- dural sedation can aggravate underlying patient. Because of the potential altera- amination can reveal many of them. asthma or bronchopulmonary dysplasia, tions in airway and respiratory mechanics First, the provider should find out potentially leading to bronchospasm and/ that may occur, the different levels of se- why the child is having the procedure or or desaturation. dation require different levels of expertise test. The provider should then find out Physical examination should focus in patient management. Therefore, Joint whether the child has medical issues that on findings that could affect the course of Commission guidelines state that a seda- could put him or her at increased risk for the child’s sedation. The physician should tion provider should be able to “rescue” complications. Recent upper respiratory look for craniofacial abnormalities that a patient from sedation one level deeper illness symptoms, especially coughing, could be problematic if the patient would than that which is intended.2 wheezing, or nasal congestion, can increase need BMV or endotracheal intubation. For most children, titration between the risk of airway irritability and respira- These include, but are not limited to, fa- moderate and deep sedation can be tricky. tory complications, including hypoven- cial anomalies such as retrognathia that can Pediatric sedation providers should be tilation, desaturation, and laryngospasm. prevent good mask seal and interfere with prepared to provide airway intervention Similarly, a history of recent vomiting or airway visualization, tonsillar hypertrophy maneuvers such as bag mask ventilation symptomatic gastroesophageal reflux can that can prevent adequate air entry, and (BMV) and even endotracheal intubation be cause for concern, as emesis during limited neck mobility that can prevent ad- in order to rescue deeply sedated children. sedation, when airway protective reflexes equate airway positioning. Physicians also A hospital’s sedation protocol should may be blunted, could lead to aspiration should remember to look for braces and clearly define standards of performance and initiate laryngospasm. Significant other orthodontia. Many neuromuscular and competencies for sedation providers, obesity, an increasing problem in the pe- disorders are associated with decreased and these skills should be demonstrated diatric population, may be associated with ability to handle oral secretions; these se- by satisfactory performance in an observed an increased risk of airway obstruction, cretions can pool in the hypopharynx and clinical or simulation setting.3 especially with deeper levels of sedation. lead to coughing, laryngospasm, or aspi- Perhaps the most important factor Overt obstructive sleep apnea symptoms ration when airway reflexes are blunted. for ensuring safety during pediatric proce- are clearly associated with airway obstruc- Children who have obvious wheezing or dural sedation is the immediate availabil- tion during sedation; however, many fam- other respiratory difficulties should have ity of skilled rescue resources. Adverse pe- ilies are unable to say how frequently or their test or procedure rescheduled. If the diatric sedation events are most common how badly their children snore. Even occa- procedure or test is deemed to be emer- in facilities that lack adequately trained sional audible snoring makes the need for gent, an anesthesia consultation should be personnel and reliable emergency response airway repositioning and nasopharyngeal sought. Significant abdominal distension

44 | Minnesota Medicine • March 2011 | clinical & health affairs can increase the risk of vomiting and as- PHARMACY—sedative analgesic minutes. Midazolam may be administered piration. medications, reversal agents, emergency via many different routes: IV, orally, rec- Although the need for strict NPO resuscitation and airway medications; tally, intramuscularly, or intranasally. Al- guidelines for urgent and emergent seda- MONITORS—pulse oximetry, cardio- though the combination of midazolam tions continues to be a topic of debate, respiratory monitor with ECG and BP and an opioid analgesic can provide ex- most physicians should plan to adhere to capability, stethoscope, end tidal carbon cellent sedation and analgesia for painful the recommended ASA guidelines.1 These dioxide monitor; and procedures, the combination is also associ- suggest the following NPO times: ExTRAS—intravenous access cath- ated with a higher incidence of respiratory • Clear liquids—two hours eters, isotonic resuscitation fluid, emer- depression. • Breast milk—four hours gency drug sheet, calculator. Nitrous oxide, a longtime favorite • Infant formula, other nonhuman The type of procedure being per- sedative/analgesic agent for dental proce- milk, solids—six hours formed may also dictate other equipment dures, is becoming increasingly popular • Full meal—eight hours needs. as a minimally sedating agent for a vari- For children requiring sedation who Documentation of sedation encoun- ety of pediatric procedures, including IV do not meet the ASA NPO guidelines, ters should include informed consent, catheter placements, VCUGs, lumbar recommended options include delaying postsedation instructions, and contact punctures, and other brief, painful proce- the procedure or seeking an anesthesia information for the parent or guardian. A dures. Nitrous is delivered as either a fixed consultation. focused history and physical examination 50/50 mixture with oxygen or in titratable should be performed and documented at concentrations of 30% to 70%. Onset of Monitoring, Equipment, and the time of the sedation. The plan for pro- action generally takes place within two to Documentation cedural sedation as well as an assessment three minutes, and its effect rapidly ends The single best way to monitor a sedated of the child’s sedation risks and ASA clas- when the gas is discontinued. Nitrous may child is continuous direct observation by sification should be included in the docu- also be combined with an opioid analgesic one or more trained providers not directly mentation.8 Time-based recording of vital for more painful procedures such as joint involved with the procedure itself. Beyond signs, sedation scores, and administered taps; but this combination can induce this basic tenet, the frequency and inten- medications is required. Also, any adverse moderate or even deep levels of sedation. sity of monitoring depend on the depth of events and associated interventions should The incidence of nausea and vomiting the sedation being performed. At a mini- be noted. following nitrous administration is ap- mum, all sedated patients should be mon- proximately 5%.9 Challenges with inhala- itored with continuous pulse oximetry. Sedatives and Analgesics— tion equipment and appropriate waste gas The ASA also recommends that respira- A Potpourri of Choices scavenging have limited the use of nitrous tory function be continuously monitored A number of medications are used for pe- oxide in some locations. by observation, auscultation, and/or cap- diatric procedural sedation. There is rarely Chloral hydrate has been employed nography. Electrocardiography should be a right or wrong choice with regard to as a sedative hypnotic agent for more than used, and blood pressure should be mea- medication selection; however, the physi- 100 years. It is particularly useful for insured intermittently during deep sedation. cian’s familiarity and experience with vari- ducing a sleep state in children younger Equipment needs are based on pa- ous agents are important considerations. than 2 years of age for a nonpainful proce- tient management and rescue. A number Many of the more commonly used seda- dure such as a CT/MRI scan or an audi- of mnemonics can help the sedation pro- tion agents have no analgesic component, tory brainstem response test for hearing. vider remember the essentials; one of the so adding a medication for pain control or Chloral hydrate is administered orally, most popular is “SOAPME”: choosing a different regimen may be more with an onset of action usually within SUCTION—appropriately sized large- appropriate for painful procedures. 20 to 30 minutes, although onset can be bore suction catheters, smaller catheters Benzodiazepines have been a main- somewhat variable. Duration of action for nasal or endotracheal suctioning, func- stay of procedural sedation for years. A can be even more unpredictable. Most tional vacuum apparatus; drug in this class can be used as a single children sleep for 60 to 120 minutes, but OxYGEN—adequate supply, func- agent for brief, nonpainful procedures and the long elimination half life of chloral hy- tioning flow meters; as an adjunct in combination with opioids drate occasionally can result in prolonged AIRWAY EqUIPMENT—appropriately or ketamine for more painful ones. The sedation states that can last more than 12 sized masks, self-inflating or anesthesia pharmacokinetics of midazolam make hours. Because of the unpredictable du- BVM systems, nasopharyngeal and oro- it most suited for procedural sedation. ration of action, there have been reports pharyngeal airways, laryngeal mask air- Onset of action occurs in less than 60 of serious adverse events and even death ways, laryngoscope blades and handles, seconds when administered intravenously following discharge for children who endotracheal tubes; (IV), and its duration is usually 15 to 30 received chloral hydrate for sedation.10

March 2011 • Minnesota Medicine | 45 clinical & health affairs |

Rates for successful sedations are between neurologists prefer dexmedetomidine for most commonly utilized agent for pediat- 85% and 95%. In rare instances, younger children who require sedation for success- ric procedural sedation, it is used both as children never achieve the depth of seda- ful completion of EEGs. Dexmedetomi- a single agent for nonpainful procedures tion required to complete the associated dine has also proven to be useful for se- such as CT, MRI, and ABR testing, and in procedure. The rate of failed sedation dation of children with autism or other combination with analgesics such as ket- increases markedly for children over the developmental concerns; as the recovery amine and fentanyl for a variety of pain- age of 3 years. Although chloral hydrate period seems to be associated with a much ful procedures. Propofol is administered administration is generally associated with less troublesome emergence.13 Most often, intravenously, and its many advantages a moderate level of sedation and rarely dexmedetomidine is administered as an IV include onset in 30 to 60 seconds, offset with respiratory depression, the incidence agent, with a slow initial bolus over five to generally in five to 15 minutes, and ease of of respiratory complications is higher in titration to effect. For longer procedures, infants, especially those younger than 2 bolus propofol is used for induction, and months of age.11 Resources for Physicians deep sedation is maintained by a continu- Barbiturates, most commonly pento- Pediatric sedation is an evolving ous IV infusion. Propofol use is associated barbital, have also been mainstays of seda- specialty. Currently, the practice with a high incidence of respiratory de- tion for nonpainful pediatric procedures of sedating children crosses many pression, and induction can easily lead to in the past. Although the use of pentobar- disciplines, and this can generate rapid loss of airway reflexes and apnea. 14 bital has been largely supplanted by newer confusion, fear, and even conflict Physicians who administer propofol must agents such as propofol and dexmedetomi- within medical systems. in an effort be able to rescue patients from a general dine, it is still used for moderate sedation to provide multidisciplinary leader- anesthetic state and have expertise in for procedures such as MRI scans. Advan- ship in the advancement of pediat- both BVM ventilation and endotracheal tages of pentobarbital include its one- to ric sedation practice, the society intubation. Because of the risk of rapid for Pediatric sedation was formed two-minute IV onset time, the ability to respiratory decompensation, some hospi- in 2007 to promote safe, high- provide repeat dosing in as little as five to tals restrict use of propofol to anesthesia quality care, innovative research, 10 minutes, and limited respiratory and and quality professional education. providers. In addition, propofol can lead hemodynamic effects in otherwise healthy the society’s membership is com- to bradycardia and hypotension, although children. However, children with under- posed of physicians and nurses these effects are typically mild and do not lying respiratory or cardiovascular issues from pediatric anesthesiology, pedi- become clinically significant in otherwise may be more susceptible to associated atric emergency medicine, pediatric healthy children. cardiopulmonary instability. Although critical care medicine, and pediatric For decades, opioids have been the children can become quite deeply sedated, hospital medicine. it also includes most commonly administered analge- and even anesthetized, with pentobarbital, pediatric dentists, child life special- sic medications. Although they have no it does not provide any analgesic effects. ists, and a variety of other individu- inherent amnestic qualities and limited The disadvantages of using pentobarbital als. its website, www.pedsedation. sedative effects when used independently, org, offers a number of resources for procedural sedation include its po- they may be used in combination with for providers and parents including tential for prolonged deep sedation and sedative/hypnotic agents to facilitate deep article reviews, practice guidelines, unpredictable recovery time, which can and links to other programs and ref- sedation for painful procedures. Fentanyl range from 60 minutes to more than 12 erences. the society’s 2011 meeting is the most commonly used procedural hours, as well as its association with recov- will be held in Minneapolis in May opioid because of its pharmacokinetic ery dysphoria and agitation (unaffection- and is co-sponsored by Children’s profile and low cost. The onset of an IV ately labeled “pentobarb rage”).12 Hospitals and Clinics of Minnesota. dose of fentanyl occurs within two to three Dexmedetomidine is a relatively new minutes, with peak effect at five minutes,. highly selective central alpha 2 agonist This more rapid onset allows for more with both sedative and analgesic proper- 10 minutes followed by a continuous infu- titratable dosing for procedural analgesia ties. Already in use as an ICU sedative an- sion; it also can be given orally or buccally than morphine, which has an onset of algesic, dexmedetomidine has migrated to with good success. Dexmedetomidine can action of five to 10 minutes. As with all the procedural sedation arena, where it is be associated with clinically significant opioids, fentanyl leads to dose-dependent a preferred agent for many providers be- cardiovascular effects, especially bradycar- respiratory depression, especially when cause of its limited effects on respiration. dia, because of its effects on cardiac con- used in combination with another seda- Dexmedetomidine is generally associated duction times. tive agent. with a moderate level of sedation that, ac- Many children’s hospitals have built Ketamine is a favorite medication to cording to electroencephalogram, mimics their sedation programs around the seda- facilitate sedation for painful procedures normal sleep. Therefore, many pediatric tive/anesthetic agent propofol. By far the in the emergency department. Ketamine

46 | Minnesota Medicine • March 2011 | clinical & health affairs

analysis of medications used for sedation. Pediatrics. is a derivative of phencyclidine, and it follow-up medical care if needed. 2000;106(4):633-44. is uniquely associated with sedative, dis- 11. litman rs, soin K, salam a. Chloral hydrate sedation in term and preterm infants: an analysis sociative, amnestic, and analgesic prop- Conclusion of efficacy and complications. anesth analg. 2010; erties. At lower doses, ketamine leads Pediatric sedation requires careful con- 110(3):739-46. 12. Mallory MD, Baxter al, Kost si, et al. Propofol primarily to anxiolytic and analgesic ef- sideration of the balance between the vs pentobarbital for sedation of children undergoing magnetic resonance imaging: results from the fects. With higher doses, ketamine pro- patient’s risk factors, the procedure being Pediatric sedation research Consortium. Pediatr duces antegrade amnesia and a dissocia- performed, and the provider’s experience anesth. 2009; 19(6):610-11. 13. lubisch n, roskos r, Berkenbosch JW. tive state of sedation/anesthesia. Upon and expertise. With appropriate prepara- Dexmedetomidine for procedural sedation in children awakening, children often report having tion, physicians can offer safe and effec- with autism and other behavior disorders. Pediatr neurol. 2009; 41(2):88-94. experienced very vivid dreams or halluci- tive procedural sedation to meet the needs 14. Cravero JP, Beach Ml, Blike Gt, et al. the inci- nations. Ketamine may be administered of their pediatric patients. Minnesota is dence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures via IV, intramural, oral, rectal, or nasal home to a number of institutions whose outside the operating room: a report from the routes. Deep levels of sedation are gen- physicians have extensive expertise in pe- Pediatric sedation research Consortium. anesth analg. 2009; 108(3):795-804. erally achieved. Typically, patients main- diatric sedation and anesthesiology. These 15. Wathen Je, roback MG, Mackenzie t, et al. Does tain spontaneous respiratory drive and specialists should be considered a resource midazolam alter the clinical effects of intravenous ketamine sedation in children? a double-blind, ran- adequate airway protective reflexes, al- for providers who seek to establish a pedi- domized, controlled emergency department trial. ann emerg Med. 2000; 36(6):579-88. though ketamine is a sialagogue, and the atric sedation protocol or who wish con- 16. langston Wt, Wathen Je, roback MG, et al. additional saliva it produces can increase sultation for a specific pediatric sedation effect of ondansetron on the incidence of vomiting associated with ketamine sedation in children: a the risk for laryngospasm. Ketamine also case. MM double-blind, randomized, placebo-controlled trial. leads to increased heart rate, blood pres- ann emerg Med. 2008; 52(1):30-4. Patricia scherrer is a pediatric intensivist sure, and cardiac output in previously with Children’s respiratory and Critical Care hemodynamically stable children. Unique specialists, P.a., and medical director for Call for Papers side effects associated with ketamine in- pediatric sedation services at Children’s clude a potential increase in intracranial Hospitals and Clinics of Minnesota. she Minnesota Medicine is seeking sub- missions from readers on the fol- and intraocular pressure as well as nega- is also a member of the executive board lowing topics: tive neuropsychiatric effects with emer- of directors of the society for Pediatric sedation. gence delirium and significant agitation. The incidence of vomiting with ket- Aviation Medicine articles due april 20 amine sedation ranges from 12% to 25% REFERENCES but does seem to be decreased with co- 1. Gross JB, Bailey Pl, Caplan ra, et al. Practice guidelines for sedation and analgesia by non-anes- Medicine and the Arts administration of midazolam and/or thesiologists: a report by the american society 15,16 articles due May 20 ondansetron. of anesthesiologists task force on sedation and analgesia by non-anesthesiologists. anesthesiology. 2002; 96(4):1004-17. Postsedation Recovery and 2. Joint Commission on accreditation of Healthcare Diabetes Organizations. Comprehensive accreditation manual articles due June 20 Discharge for hospitals. Oakbrook terrace, il: Joint Commission Ongoing monitoring and observation are on accreditation of Healthcare Organizations, 2005. 3. Cravero JP, Blike Gt. review of pediatric sedation. critical during recovery from procedural anesth analg. 2004;99(5)1355-64. Hospitals sedation and should continue until the 4. Coté CJ, notterman Da, Karl HW, et al. adverse articles due July 20 sedation events in pediatrics: a critical incident child’s vital signs and level of interaction analysis of contributing factors. Pediatrics. 2000; 105(4):805-14. Drugs have returned to their presedation base- 5. Blike Gt, Christoffersen K, Cravero JP. a method lines. Significant adverse events can occur for measuring system safety and latent errors asso- articles due august 20 ciated with pediatric procedural sedation. anesth during emergence, especially if medica- analg. 2005; 101(1):48-58. tions with longer half lives were used. The 6. Butler MG, Hayes BG, Hathaway MM, et al. Ears, Noses, Throats specific genetic diseases at risk for sedation/anes- articles due september 200 recovery area should be equipped with thesia complications. anesth analg. 2000; 91(4):837- the same monitoring and resuscitation 55. 7. Butler MG, Hayes BG, Hathaway MM, et al. equipment as the sedation and procedural Congenital malformations: the usual and the Communication area itself, and the same rescue resources unusual. asa refresher Courses in anesthesiology. articles due October 20 2001;29123-33. should be available. Children should 8. Coté CJ, Wilson s, et al. Guidelines for monitoring Send your manuscripts to cpeota@ be discharged only when they have met and management of pediatric patients during and after sedation for diagnostic and therapeutic proce- mnmed.org. For more informa- specific pre-established recovery criteria dures: an update. Pediatrics. 2006; 118(6):2587-602. tion, go to www.minnesota and after the family has received detailed 9. Zier Jl, tarrago r, liu M. level of sedation with nitrous oxide for pediatric medical procedures. medicine.com or call Carmen instructions for postsedation care, in- anesth analg 2010; 110(5):1399-1405. Peota at 612/362-3724. 10. Coté CJ, Karl HW, notterman Da, Weinberg Ja, cluding instructions about how to seek McCloskey C. adverse sedation events in pediatrics:

March 2011 • Minnesota Medicine | 47 clinical & health affairs |

Pediatric Chronic Pain there is Hope

ByTracy Harrison, M.D. n Chronic pain is prevalent in children and can limit their ability to attend school, Evaluating Chronic Pain socialize with peers, and participate in physical activity. This article describes the Children with pain usually present first advantages of using a multidisciplinary approach to evaluating and treating chil- to their primary care physician. If their dren with chronic pain and discusses medications and techniques for managing pain proves to be chronic and is beyond pain and restoring functionality. the scope of their primary care provider, they should be seen by a specialist with hronic pain is prevalent in Suffering from pain daily can limit experience in evaluating and treat- the pediatric population. a child’s ability to attend school, social- ing particular pain syndromes to rule It has been estimated that ize with peers, and participate in physi- out life-threatening or readily treatable between 25% and 46% of cal activity. In fact, well-meaning health conditions. For example, children with Cpatients younger than 18 years of age care providers and school personnel chronic headaches should be evaluated throughout the world have experienced often recommend that children not at- by a neurologist, those with abdominal pain on a daily basis for more than three tend school or participate in other activi- pain by a gastroenterologist, and those months.1 Although no specific figure is ties while they are attempting to manage with musculoskeletal pain by a rheuma- available regarding the cost associated their pain. Ironically, this can exacerbate tologist or neurologist. If pain continues with treating chronic pain in the pedi- the child’s pain. When children don’t at- despite a negative workup, patients and atric population, it is reasonable to es- tend school, they can feel stress both be- providers often may insist on further timate that it is significant because the cause they are isolated and because they evaluation with the thought that a treat- medical cost for adults with chronic are worried about keeping up with their able condition may have been missed. pain is nearly $70 billion per year. When schoolwork. The added stress can make Thus begins a cycle of extensive workup factoring in the lost productivity that re- their pain worse. In addition, for chil- and more medical treatment that may sults from their inability to work, the an- dren who are used to being active, physi- prolong debility and further convince nual overall cost for adults with chronic cal inactivity can lead to deconditioning, the patient that he or she is sick. pain climbs to $140 billion per year.2 which may cause a child to feel dizzy and One of the challenges in dealing Research on children who were seen lightheaded when moving from a supine with patients who have chronic pain is at a pediatric chronic pain clinic suggests to upright position. This subsequent in- that the symptoms may not have a spe- headache, abdominal pain, and muscu- crease in sympathetic nervous system ac- cific physical cause. For that reason, they loskeletal pain are the most common tivity may cause pain to increase as well. may benefit from being seen at a pediat- complaints.3 In addition, investigators Clearly, chronic pain often starts a ric chronic pain center, where they can found that adolescents who experienced vicious cycle of social isolation, avoid- be evaluated by an interdisciplinary team pain for more than one year also had ance of school and physical activity, and of specialists who view pain and disabil- anxiety and depression.3 The quality of further pain. Thus, it is not surprising ity as a complex and dynamic interac- life for children with chronic pain has that evaluating and treating a patient tion among physiologic, psychologic, been compared to that of young people with chronic pain can be challenging. and social factors.2 At Mayo Clinic, for with cancer and other chronic diseases.4 example, pediatric chronic pain patients

48 | Minnesota Medicine • March 2011 | clinical & health affairs may be evaluated and treated by a team fore, before prescribing opioids, the ben- that includes pain physicians, clinical psy- efits and the risks need to be evaluated for Treating Pediatric Chronic Pain chologists, clinical practice nurses, physi- each patient—both adult and pediatric. cal therapists, pharmacists, biofeedback Medications such as tricyclic anti- Patients at Mayo Clinic technicians, and occupational therapists depressants and anticonvulsants can be Children with chronic pain who come to (see box). safely used for analgesic purposes in the Mayo Clinic are evaluated by providers pediatric population under the guidance with a special interest in pediatric pain A Multimodal Approach of an experienced provider. (Their use management. Children whose pain is rel- to Treatment may be beyond the scope of many pro- atively new and who may not have been exposed to many treatment modalities Medications alone are unlikely to signifi- viders.) Patients using these medications are usually seen in the Pediatric Chronic cantly benefit children with chronic pain. must be monitored, as these drugs can Pain Clinic by a team that includes a pe- For that reason, it is important to take a be associated with side effects such as in- diatric anesthesiologist who completed a multidisciplinary approach to treatment creased suicidal thinking. A thorough his- pain fellowship, an adolescent psycholo- early on. A number of modalities from tory should be obtained before prescribing gist, and a physiatrist in an outpatient various specialties can benefit patients them. In addition, these medications take setting. with chronic pain. These modalities need time to work. Usually, a six-month trial is those patients who are more functionally to be applied concurrently for the greatest prescribed. During that time, health care disabled from their pain may be referred effect. providers and family members should be to the Pediatric Pain rehabilitation Pro- A number of medications can be vigilant about watching for development gram. staffed by a team that includes a used to manage chronic pain. A physi- of adverse side effects. pain physician, clinical psychologist, clinician initially should try over-the-counter In addition to oral medications, ste- cal practice nurses, physical therapists, medicines before prescribing more potent roid injections may be indicated to mini- pharmacists, biofeedback technicians, drugs. The World Health Organization mize suspected inflammation around a and occupational therapists, the pro- analgesic ladder recommends starting nerve that may be responsible for pain. gram primarily serves patients between with over-the-counter analgesics such as These are usually performed by pain the ages of 13 and 20 years whose pain acetaminophen and nonsteroidal anti- physicians, primarily anesthesiologists, has limited their ability to attend school and participate in physical activity and inflammatory medications for mild pain. physiatrists, or neurologists. Injections negatively affected their mood and psy- It is important to remember that these are often used in conjunction with physi- chological functioning. the three-week medications may not eliminate pain. In cal therapy to lessen pain so patients can hospital-based outpatient program intro- addition, with some pain syndromes such work on gaining mobility and strength. duces a variety of strategies and activi- as headache, continuous use of these med- In a subgroup of patients with complex ties to restore functionality and minimize ications may contribute to rebound pain regional pain syndrome, for example, the effect of pain on patients’ lives. Of and, in effect, perpetuate the problem. epidural infusions may facilitate more ac- the 150 patients who successfully com- Studies of adults have found opioids tive involvement in physical therapy. For pleted the program during the past three such as oxycodone, hydrocodone, ultram, headaches, supraorbital or occipital nerve years, virtually all returned to school full fentanyl, and morphine can lead to a 40% injections may be considered. Patients time immediately after. they also report to 50% improvement in chronic pain.5 with abdominal pain often have a mus- improvement in measures of depression, anxiety, and pain catastrophizing, However, opioid medications may affect culoskeletal component to their pain and and increased activity. the patient’s short-term memory, abil- may benefit from a trigger point injection. ity to retain information, and reflexes. Various nonpharmacologic strate- Patients also can become physiologically gies also can be helpful to children who dependent on these medications. There have chronic pain. Techniques including these strategies and that patients practice is currently controversy among pain man- diaphragmatic breathing, guided imagery, them daily. agement providers regarding the use of progressive muscle relaxation, and bio- Finally, returning the patient to opioids for chronic nonmalignant pain in feedback have proven helpful for alleviat- physical activity is an important part of adults (there is no literature pertaining to ing headache, nausea and vomiting, and treating their chronic pain, as it reverses opioid use for chronic pain in children). other conditions.6 These make use of the deconditioning caused by inactivity and These medications appear to be benefi- patient’s own ability to alter their physi- results in improved functioning. Activity cial for some adult patients. However, few ology to minimize their pain and involve should be reintroduced gradually under studies have looked at whether their use bringing the sympathetic and parasym- the supervision of a physical therapist so leads to improvement in functioning (ie, pathetic nervous systems into balance. It that the patient does not overdo it. return to gainful employment, ability to is recommended that a consultation with perform activities of daily living). There- a psychologist take place to introduce 9

March 2011 • Minnesota Medicine | 49 clinical & health affairs |

Conclusion With Wapiti Medical Group What Do You Believe? Chronic pain can have a significant im- It is... We believe that highly rewarded physicians pact on a child’s ability to attend school, Your Practice produce outstanding results. Making you interact with peers, participate in regular happy, our patients well cared for, and our Your Life company sound. physical activity, and lead the kind of life Join our team of Hospitalists in Minnesota he or she wishes. It cannot be treated in and Wisconsin with no need to relocate. the same way as acute pain. Waiting for You’ll enjoy working again...and get your the complete resolution of pain before life back! having a child return to school or regular Receive Top Compensation Leadership on your side physical activity can lead to great debility Full and Part Time ER opportunities in Humane Workloads and increased stress, which increases pain. Minnesota, Wisconsin, Iowa & the Dakotas Flexible Schedules Paid Malpractice Chronic pain is best approached by No Need to Relocate a multidisciplinary team that specializes • Earn $180,000/yr working just six in treating pediatric pain patients. In all 24 hour ER shifts per month. cases, parental involvement is imperative • Low to Medium Volume ER’s. and attention should be paid to other • Flexible Scheduling. stressors that may affect pain. Pain and • NO Need to RELOCATE. disability should be viewed as a complex • Physician Owned/Physician Run. and dynamic interaction among physi- • Paid Malpractice. ological, psychological, and social fac-

tors, and the goal of treatment should be Contact: restoring function, rather than alleviating Dr. Brad McDonald, CEO 888-733-4428 or Wapiti For More Information Contact: pain. MM [email protected] Medical www.erstaff.com Group Troy Kastrup 888-733-4428 tracy Harrison is an instructor in the [email protected] department of anesthesiology, director of Connecting Quality Healthcare to Rural America www.connecthealthinc.com the pediatric acute pain and palliative care service, and medical director of the pediatric pain rehabilitation center at Mayo Clinic. St. Cloud VA Medical Center REFERENCES is accepting applications for the 1. Perquin CW, Hazebroek-Kampschreur aa, Hunfeld following full or part-time positions: Ja, et al. Pain in children and adolescents: a common experience. Pain. 2000;87(1):51-8. 2. Gatchel rJ, Okifuji a. evidence-based scientific • Dermatology • Geriatrician • Neurology data documenting the treatment and cost-effective- (St. Cloud) (St. Cloud) (St. Cloud) ness of comprehensive pain programs for chronic nonmalignant pain. J Pain. 2006;7(11):779-93. • ENT • Hematology/Oncology • Psychiatry 3. Vetter tr. a clinical profile of a cohort of patients (St. Cloud) (St. Cloud) (St. Cloud) referred to an anesthesiology-based pediatric chronic pain medicine program. anesth analg. • Family Practice • Internal Medicine 2008;106(3):786-94. (Montevideo & St. Cloud) (Montevideo & St. Cloud) 4. Gold Ji. Pediatric chronic pain and health-related *Positions available in Internal Medicine or Family Practice for one time disability quality of life. J Ped nursing. 2009;24(2):141-50. assessments (compensation and pension exams) 5. turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. US Citizenship required or candidates must have proper Clin J Pain. 2002;18(6):355-65. authorization to work in the US. 6. Penzien DB. Behavioral management of recurrent headache: three decades of experience and empir- Physician applicants should be BC/BE. Applicant(s) selected for a position may icism. applied Psychophys Biofeed. 2002;27(2): be eligible for an award up to the maximum limitation under the provision of the 163-83. Education Dept Reduction Program. Possible relocation bonus. EEO Employer. Excellent benefit package including: Favorable lifestyle Competitive salary 26 days vacation 13 days sick leave CME days Liability insurance Interested applicants can mail or email your CV to VAMC Sharon Schmitz ([email protected]) 4801 Veterans Drive St. Cloud, MN 56303 Or fax: 320-255-6436 or Telephone: 320-252-1670, extension 6618

50 | Minnesota Medicine • March 2011 end notes |

the role of the nurse A Look Back anesthetist at Mayo Clinic.

thick pad of moistened cotton placed over the eyes, and the anaesthetic preferred by the surgeon commenced. The inhaler we use at present and have for some time is the Esmarch mask with two thicknesses of stockinette. We sent to the mills and had a bolt of stockinette woven loosely for this purpose; it has more body than the regular surgeon’s gauze. We usually put two thicknesses of the gauze over the mask and get both ether and chloroform ready, and give whichever is best for the conditions observed. If we start out to give ether we commence with the drop method as care- Photo courtesy of Mayo Clinic Mayo of courtesy Photo alice Magaw administering anesthesia during surgery. Charles Mayo called her the “mother of anesthesia.” fully and with as much air as though it were chloroform, until the patient’s face he debate about who should administer anesthesia was already underway in is flushed, when we have a large piece of Tthis country by the time William J. and Charles H. Mayo began doing surgery at surgeon’s gauze of several thicknesses and saint Marys Hospital in rochester in the late 1800s. at the time, anesthesia was ad- about the size of a towel convenient, and ministered by medical students, nurses, interns, general practitioners, and surgeons keep adding a few more layers of the gauze themselves. the Mayo brothers were among those who decided to enlist nurses to and giving the ether a trifle more faster until the patient is asleep, then remove the do the work—a decision that may have unwittingly fostered acceptance of the idea of gauze and continue with the same cover- the nurse as anesthetist. William Worrall Mayo, founder of the Mayo Clinic, launched ing as at the start and the drop method. ... one of the country’s first formal training programs for nurse anesthetists in 1889. The great secret of giving an anaes- alice Magaw, who served as the Mayos’ primary anesthetist from 1893 until thetic of any kind is not to feel hurried 1908, gained such expertise that she lectured and wrote on the topic. Her first paper and to have the operator say occasionally, appeared in 1899 in the medical journal northwestern lancet, a precursor to Minne- “there is no hurry, lots of time.” There is sota Medicine. these excerpts offer a glimpse into the techniques of the day and the such a difference in patients; some will be as calm and fall asleep as easily and quickly relationship between nurses and doctors in the Or.—Carmen Peota as babes, while others are nervous and can not give up and when you try to crowd the anaesthetic you are lost. Nothing is ever aving been educated only as a there is high arterial tension from any made by crowding the anaesthetic; I have nurse, I am not expected to cause chloroform is selected. Ether should tried it: rather than crowd ether, it is best Hmake the choice of an anaes- be given as an anaesthetic pure and simple to give a few drops of chloroform. The thetic. The Drs. Mayo prefer ether as and not combined with asphyxia, as has surgeon should not hurry the anaesthe- the anaesthetic of choice; they, as well been recommended and is now practiced tist, neither should he begin the operation as many other surgeons, believe ether to in many hospitals ... If given with plenty until the patient and the anaesthetizer are be safer. Chloroform is given as a rule to of air, there will not be the cyanosis and ready. … MM old people and children, also when there stertorous breathing which too often char- sources: History of Anesthesia with Emphasis on the is pulmonary trouble and in most cases acterizes its use. ... Nurse Specialist by Virginia thatcher. “Observations in anesthesia” by alice Magaw, Northwestern where there is kidney disease. Whenever The face is anointed with vaseline, a Lancet. 1899;19:207-10.

56 | Minnesota Medicine • March 2011