CHALLENGES FOR THE ANESTHESIA PROVIDER
| ANESTHESIA INFORMATICS—David L. Reich, MD, Professor and Chair, Department of Anesthesiology,
Mount Sinai Medical Center, New York, NY
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| Computerized vs handwritten records: computerized records show that hemodynamic variations occur regularly
during surgery (to consternation of many anesthesiologists); handwritten records “grossly inaccurate”;
in one recent study, computer-recorded blood pressure (BP) dramatically higher than handwritten notes in
37% of cases, due possibly to physicians’ “bias against controversial numbers”; in another study, 23% to
37% of important data on respiration (tidal volume, respiratory rate, end-tidal volume, and fraction of inspired
oxygen) missing, and 1% to 6% “significantly in error”; 8% to 13% of data on BP and heart rate
missing, and 5% to 11% erroneous; data gathered during induction “dramatically erroneous”; in study of
anesthesiologists at Mount Sinai Medical Center (using computerized systems for 8 yr), only 3 handwritten
records noted diastolic BP <80 or >200 mm Hg (incidence in computerized records much higher); pulse
oximetry—in study of several thousand cases at Mount Sinai in late 1990s, 31% of patients undergoing
cardiac surgery had at least one 10-min gap in pulse oximetry recording; hypothermia significantly associated
with first pulse oximetry failures in any given case; hypertension as well as hypotension significantly
associated with pulse oximetry failure; conclusion—significant predictors of prolonged pulse oximetry
failure included American Society of Anesthesiologists (ASA) status 3, 4, or 5, and cardiac, orthopedic, or
vascular surgery; advanced age not risk factor
|
 | Morbidity and mortality: in study of 2149 patients undergoing coronary artery bypass at Mount Sinai and St.
Luke’s-Roosevelt hospitals from 1993 to 1995, significant intraoperative predictors of death included mean
pulmonary artery pressure >20 mm Hg before bypass, hypotension during bypass, and tachycardia and high
diastolic pressure after bypass
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| Confounder of data analysis: no universal standard of intraoperative hypotension
|
| Study of negative outcomes of noncardiac surgery: negative outcome defined as >10-day hospital stay after
surgery or death during hospitalization; predictors included duration of surgery >220 minutes, high preoperative
physiologic and operative severity score for enumeration of mortality and morbidity (POSSUM), intraoperative
tachycardia, and intraoperative systolic hypotension; in another study at Mount Sinai, BP drop
>40% during 10 min after induction significantly associated with preoperative hypotension, age >50 yr, use
of propofol for induction, increasing fentanyl dosage during induction, and higher ASA physical status; incidence
of negative outcome 13.3% with hypotension, 8.6% without it (significant difference); ASA physical
status significant predictor of postoperative mortality in at least one other large study; conclusion—
think of intraoperative hypotension as marker of sicker patients with higher risk for poor outcomes (eg, if
patient has disseminated cancer, physiologic debilitation may be cause of hypotension); intraoperative period
may yield additional information for managing patient’s course (whether ambulatory patient with unexpected
stormy intraoperative course, or perioperative patient otherwise expected to go to regular nursing
floor); data forthcoming whether stratification of patients intraoperatively into low-, medium-, or high-risk
categories can provide additional information beyond that obtained during preoperative period and beyond
that which can be altered by preoperative intervention, eg, β-blocker therapy
|
| Controlling data domain: time analyses—hospitals should encourage surgeons to finish operations on time,
even when supervising students or residents (may seriously impair efficiency otherwise); study at Mount Sinai
showed median time spent in postanesthesia care unit (PACU) for patients who received general anesthesia
115 min, monitored anesthesia care 80 min, and spinal anesthesia 181 min; such analyses allow hospitals
to identify and correct impediments to maximum efficiency; antibiotic compliance—most hospitals now also
monitor antibiotic compliance (soon to become pay-for-performance measure from Surgical Care Improvement
Program; also will be reported on several Web sites); anesthesia departments expected to be leaders in
area of antibiotic compliance for surgical infection prophylaxis; well-designed information systems incorporating
scripts or protocols can “be extraordinarily effective in positively affecting behavior”; failure of
communication—anesthesia department at Mount Sinai developed patient tracking system; improves communication
among various people involved in each patient’s care; also permits documentation and tracking of
problems that occur in PACU
|
| DO-NOT-RESUSCITATE STATUS AND ADVANCED DIRECTIVES—Gavin D. Divertie, MD, Chair, Department
of Critical Care Medicine, and Chair, Ethics Committee, Mayo Clinic Jacksonville, and Mayo Foundation,
Jacksonville, FL
|
| Ethics: one of 3 disciplines of philosophy; study of human actions; derived from Greek word for character
(ethike; also implies context); “the process that society or an individual goes through to discover and justify
morals”
|
| Casuistry: case-based reasoning; deciding each case on its individual merits; major criticisms tyranny of precedence
(why decide a particular case differently from an earlier similar one?) and slippery slope (eg, fears
that keeping abortion legal may ultimately result in physician-assisted suicide); elicits quest for another
type of ethical reasoning
|
| Sample case (inspired by real events): 76-yr-old man diagnosed with squamous cell cancer of esophagus; initially
underwent irradiation and chemotherapy, followed by esophagectomy 6 wk later; colleague left case
after induction of anesthesia; chart review reveals living will, durable power of attorney, and do-not-resuscitate
(DNR) order in event of cardiac arrest; after administration of antibiotic, patient develops rash and
begins wheezing severely, BP drops, and patient goes into ventricular fibrillation; dilemma—comply with
DNR? or begin cardiopulmonary resuscitation (CPR)? correct choice to administer CPR, as there had been
no preoperative discussion with patient (unknown whether colleague who started case had discussion); ethical/legal
considerations—when in doubt, err on side of preserving life, later trying to discern whether
DNR order obtained with informed consent; patient’s wishes should be honored if adequate informed consent
involved, despite wishes of next-of-kin
|
| Perioperative DNR policies: at speaker’s institution, policy states that “DNR orders will not be in effect during
the perioperative period. Standard anesthetic practice will be followed, including resuscitation;” DNR
policies always somewhat controversial (eg, since 1993, ASA has made 3 different statements involving
perioperative DNR policies, suggesting that they be written, unambiguous, and flexible); inform patient explicitly
if hospital policy to suspend DNR orders during perioperative period; in case being discussed, patient
resuscitated
|
| Postoperative course: uneventful until day 6, when patient transferred to intensive care unit (ICU) with mediastinitis,
pneumonia, and septic shock; multiple organ failure syndrome developed over ensuing month; affected
systems included cardiovascular, hematologic, respiratory, renal, and neurologic (suspected toxic
metabolic encephalopathy, based on EEG; no improvement of encephalopathy expected without improvement
of patient’s general condition); patient developed inoperable pyloric channel ulcer; supportive measures
— continuous transfusions; fluid boluses and dopamine also administered; tracheostomy performed;
patient placed on mechanical ventilator and received intermittent dialysis, tube feeding, and range-of-motion
exercises to keep him alive; prognosis—in unanimous opinion of all physicians involved, patient
would remain dependent on dialysis, transfusion, and ventilator, with life expectancy <6 mo; no hope of recovering
decision-making capacity; patient’s directives—patient’s advanced directive living will specifies
withdrawal or withholding of life-prolonging measures in event of terminal condition, end-stage medical
condition, or persistent vegetative state if no reasonable probability of recovery exists; patient’s wife, who
has durable power of attorney, not convinced his condition irreversible, objects to withdrawal of life support;
ethical dilemma—one of Hippocratic virtues fidelity (keeping faith with trust); this case represents
breakdown of trust between surrogate (wife) and physicians; does not promote healing relationship, which is
purpose of medicine; advisable to involve outside physician that family trusts to give independent opinion;
wife also claimed patient signed advanced directive involuntarily (said he was told he would not receive
treatment unless he signed, and did not understand consequences of signing); in Florida, living will takes
precedence over durable power of attorney; neither patient’s wife nor daughter knew his wishes concerning
end-of-life goals; surrogate’s role to honor and protect patient’s wishes, even if those wishes conflict with
his or her own
|
| Medical ethics: set of moral obligations derived from and particular to patient-physician relationship; main
principle autonomy (sovereignty over self); advanced directives, living wills, durable power of attorney
documents, and/or written statements from patient represent extensions of autonomy; without advanced directives,
look for repeated consistent statements made by patient; absent that, ask those who know patient
best what patient would want (substituted judgment); lacking that, consider medical utility
|
| Principles of medical utility: beneficence (acting in patient’s best interest); nonmaleficence (doing no harm to
patient)
|
| Justice: “to treat all persons fairly, to aid the worst off, to defend the vulnerable from exploitation”; principle
important in medical ethics because becoming patient (derived from Latin word meaning “one who suffers”)
puts one in vulnerable (ie, exploitable) state
|
| Relevance of principles to this case: without decision-making capacity, patient lacked autonomy; concerns existed
regarding volition and understanding of advanced directives (some elements of informed consent may
have been missing)
|
| Elements of informed consent: Nuremberg code (developed during Nuremberg trials as ethical blueprint for
human experimentation); states patient must be able to exercise free power of choice, without any use of
“force, fraud, deceit, duress, overreaching or other ulterior form of constraint or coercion”
|
| Revoking of advanced directive: patient may physically destroy document in front of witnesses, sign another
document revoking directive, or make verbal statements (ideally to multiple people); none done in this
case; surrogate may seek to have document declared invalid, based on “clear and convincing evidence of
impropriety” (burden on surrogate to show impropriety exists); physician should inform surrogate of intent
to proceed with orders in living will, giving surrogate 7 days to seek expedited judicial review; clinicians
also can simply accept relatives’ claim that patient did not understand what he or she was signing (risk that
courts could interpret this action as conspiring with family to violate patient’s autonomy)
|
| Solution: in this case, dilemma avoided; physicians changed prognosis; decided patient did not have end-
stage condition, thus negating need for living will; patient died 10 days later
|
Suggested Reading
Basanta WE: Advance directives and life-sustaining treatment: a legal primer. Hematol Oncol Clin North Am
16:1381, 2002; Crawley L, Singer MK: Racial, cultural, and ethnic factors affecting the quality of end-of-life
care in California. California Health Care Foundation, March, 2007. Available at: http://www.chcf.org/topics/
chronicdisease/index.cfm?itemID=13164. Grimaldo DA et al: A randomized, controlled trial of advanced
care planning discussions during preoperative evaluations. Anesthesiology 95:43, 2001; Hoffenberg R: Advance
healthcare directives. Clin Med 6:231, 2006; Jones JW, McCullough LB: Complying with advance directives
in the operating room. J Vasc Surg 36:199, 2002; Kheterpal S et al: Electronic reminders improve
procedure documentation compliance and professional fee reimbursement. Anesth Analg 104:592, 2007; Monk
TG et al: Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 100:4, 2005;
O’Reilly M et al: An anesthesia information system designed to provide physician-specific feedback improves
timely administration of prophylactic antibiotics. Anesth Analg 103:908, 2006; Reich DL et al: Development
of a module for point-of-care charge capture and submission using an anesthesia information management system.
Anesthesiology 105:179, 2006; Reich DL et al: Predictors of hypotension after induction of general anesthesia.
Anesth Analg 101:622, 2005; Reich DL: Future directions in cardiac and vascular anesthesia:
unanswered questions regarding variables controllable by anesthesic management. Semin Cardiothorac Vasc
Anseth 10:3, 2006; Samanta A, Samanta J: Advance directives, best interests and clinical judgement: shifting
sands at the end of life. Clin Med 6:274, 2006; Smith KA: Do-not-resuscitate orders in the operating room: required
reconsideration. Mil Med 165:524, 2000; Spring SF et al: Automated documentation error detection
and notification improves anesthesia billing performance. Anesthesiology 106:157, 2007; Webb AL, Flagg
RL, Fink AS et al: Reducing surgical site infections through a multidisciplinary computerized process for preoperative
prophylactic antibiotic administration. Am J Surg 192:663, 2006; White SM, Baldwin TJ: The Mental
Capacity Act 2005—implications for anesthesia and critical care. Anesthesia 61:381, 2006.
Educational Objectives
| The goals of this program are to encourage use of computerized systems for more accurate information recording
(eg, monitoring perioperative adverse events) and more comprehensive data analyses, and to increase
awareness of ethical dilemmas involved in end-of-life care. After hearing and assimilating this program, the clinician
will be better able to:
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| Identify intraoperative predictors of morbidity and mortality.
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| Describe the significance of intraoperative hypotension.
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| Record and analyze data in the hospital setting so that impediments to maximum efficiency can be identified
and corrected.
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| Explain the cardinal principle of medical ethics as it involves the patient-physician relationship.
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| Define terms such as casuistry, tyranny of precedence, surrogate, and Nuremberg code, and explain their
relevance to ethical decision-making in end-of-life care.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to
disclose relevant financial relationships within the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in
health care and not a proprietary business or commercial interest. For this program, the faculty reported nothing
to disclose.
Acknowledgements
Dr. Reich spoke at Challenges for Clinicians, held December 1-3, 2006, in Chicago, IL, and sponsored by the
University of Chicago Department of Anesthesia and Critical Care. Dr. Divertie was recorded at the 16th annual
Current Topics in Anesthesia—Symposium on Anesthesia and Perioperative Medicine, held February 22-
26, 2006, in Ft. Lauderdale, FL, and sponsored by the Mayo Clinic College of Medicine, Jacksonville, FL.
The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of
this program.
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