Clinical practice. Lowering cardiac risk in noncardiac surgery.
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Adrenergic alpha-Agonists↗
Biomedical subjects
L A Fleisher
Publications and source records attributed to L A Fleisher.
A decision analysis of anesthesia management for cataract surgery.
PURPOSE: To compare the trade-offs in cost and preference of various anesthesia management strategies for cataract surgery. METHODS: Six strategies, differing in sedation, local anesthetic, and monitoring approach, were chosen for comparison. For each strategy, potential complications, and conversions to different anesthesia approaches were modeled. A panel of physicians and anesthetists, well versed in the literature and practice of the anesthesia management of cataract surgery, assigned preference values to the strategies and potential outcomes (0 to 1 scale). Probability estimates were obtained from a study of 19,557 cataract surgeries and from the panel. Cost estimates were derived from several sources. The model was analyzed to determine the strategies associated with the highest expected preference and lowest expected cost. RESULTS: The strategy associated with the highest net preference was intravenous sedation with block anesthesia and an anesthesiologist present throughout the case. The expected net preference for this strategy was 19% greater than the net preference for the next most preferred strategy, oral sedation with block anesthesia and an anesthesiologist on call (0.88 versus 0.74), but the expected anesthesia costs per case were much greater ($324 versus $42). Results were sensitive to plausible variation in the preference values assigned to the six initial management strategies and to the cost of topical versus block anesthesia. CONCLUSION: This analysis emphasizes that cost and preference are important considerations when choosing an anesthesia management strategy for cataract surgery. For some surgeries, substantial cost savings may be available for a small change in preference.
Anesthesia, Local↗
Effect of local anesthetics on patient recovery after transrectal biopsy.
OBJECTIVES: To determine the analgesic efficacy of local anesthetics injected lateral to the seminal vesicles before prostate biopsy, during and immediately after the procedure, because pain is a common side effect of transrectal ultrasound-guided prostate biopsy. METHODS: Patients were randomized to receive 5 mL of either 1% lidocaine or sterile normal saline injected (under ultrasound guidance) lateral to the seminal vesicles bilaterally before performance of the prostate biopsies, with the patient and physician unaware of the treatment group. Five minutes after the injection, a series of 12 prostate biopsies were performed. A visual analog scale (VAS) for pain at rest and with activity was obtained before the biopsy (preprocedure VAS) and immediately (intraprocedure VAS) and 30 minutes (postprocedure VAS) after the biopsy. Surveys examining the patients' expectations for biopsy pain were administered before and immediately after the biopsy. RESULTS: No significant differences were found between the groups with regard to demographic data, VAS pain scores at rest and with activity, and survey results. CONCLUSIONS: Injection of lidocaine lateral to the seminal vesicles before prostate biopsy did not diminish biopsy-associated pain.
Aged↗
The methodologic quality of clinical trials on regional anesthesia for cataract surgery.
OBJECTIVE: To assess the methodologic quality of published randomized trials of regional anesthesia management strategies for cataract surgery. DESIGN: Literature review and analysis. METHOD: We performed a systematic search of the literature to identify all articles pertaining to regional anesthesia for cataract surgery on adults. Overall quality scores and scores for individual methodologic domains were based on the evaluations of two investigators experienced in methodologic research who independently reviewed all relevant articles using a quality abstraction form. MAIN OUTCOME MEASURES: Study quality in each of five domains: representativeness, bias and confounding, intervention description, outcomes and follow-up, and statistical quality and interpretation. RESULTS: Eighty-two randomized clinical trials were identified with a mean overall quality score of 44%. The mean domain scores ranged from 37% for representativeness to 58% for outcomes and follow-up. Forty percent or fewer studies received the maximum score for reporting the setting, the population, and the start and end dates; describing the inclusion and exclusion criteria; adequately randomizing subjects; and adequately masking individuals participating in the study. Key outcomes were often inadequately reported, including the distribution of patient-reported pain scores and the mean surgical time. CONCLUSIONS: Greater attention to methodologic quality and detailed reporting of study results will improve the ability of readers to interpret the results of clinical trials assessing regional anesthesia for cataract surgery.
Adult↗
Synthesis of the literature on the effectiveness of regional anesthesia for cataract surgery.
OBJECTIVE: To synthesize the findings of the randomized trials of regional anesthesia management strategies for cataract surgery. DESIGN: Literature review and analysis. METHOD: The authors performed a systematic search of the literature to identify all articles pertaining to regional anesthesia during cataract surgery on adults. One investigator abstracted the content of each article onto a custom-designed form. A second investigator corroborated the findings. The evidence supporting the anesthesia approaches was graded by consensus as good, fair, poor, or insufficient. MAIN OUTCOME MEASURES: Evidence supporting the effectiveness of different forms of regional anesthesia. RESULTS: There was good evidence that retrobulbar and peribulbar blocks provide equivalent akinesia and pain control during cataract surgery. Additionally, sub-Tenon's blocks were at least as effective as retrobulbar and peribulbar blocks. There was good evidence that retrobulbar block provides better pain control during surgery than topical anesthesia, and there was fair evidence that peribulbar block provides better pain control than topical anesthesia. CONCLUSIONS: This synthesis of the literature demonstrates that currently used approaches to anesthesia management provide adequate pain control for successful cataract surgery, but there is some variation in the effectiveness of the most commonly used techniques. Data are needed on patient preferences to determine the optimal strategies for anesthesia management during cataract surgery.
Anesthesia, Local↗
Adverse intraoperative medical events and their association with anesthesia management strategies in cataract surgery.
OBJECTIVE: To compare adverse medical events by different anesthesia strategies for cataract surgery. DESIGN: Prospective cohort study. PARTICIPANTS: Patients 50 years of age and older undergoing 19,250 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997. INTERVENTION: Local anesthesia applied topically or by injection, with or without oral and intravenous sedatives, opioid analgesia, hypnotics, and diphenhydramine (Benadryl). MAIN OUTCOME MEASURES: Intraoperative and postoperative adverse medical events. RESULTS: Twenty-six percent of surgeries were performed with topical anesthesia and the remainder with injection anesthesia. There was no increase in deaths and hospitalizations associated with any specific anesthesia strategy. No statistically significant difference was observed in the prevalence of intraoperative events between topical and injection anesthesia without intravenous sedatives (0.13% and 0.78%, respectively). The use of intravenous sedatives was associated with a significant increase in adverse events for topical (1.20%) and injection anesthesia (1.18%), relative to topical anesthesia without intravenous sedation. The use of short-acting hypnotic agents with injection anesthesia was also associated with a significant increase in adverse events when used alone (1.40%) or in combination with opiates (1.75%), sedatives (2.65%), and with the combination of opiates and sedatives (4.04%). These differences remained after adjusting for age, gender, duration of surgery, and American Society of Anesthesiologists risk class. CONCLUSIONS: Adjuvant intravenous anesthetic agents used to decrease pain and alleviate anxiety are associated with increases in medical events. However, cataract surgery is a safe procedure with a low absolute risk of medical complications with either topical or injection anesthesia. Clinicians should weigh the risks and benefits of their use for individual patients.
Adjuvants, Anesthesia↗
Does functional ability in the postoperative period differ between remifentanil- and fentanyl-based anesthesia?
STUDY OBJECTIVES: To compare patients' functional ability in the 24-hour postoperative period following a remifentanil compared to a hypnotic-fentanyl-treated anesthesia regimen using a 24-Hour Functional Ability Questionnaire. DESIGN: Prospective, 1:1 single-blind, randomized, controlled effectiveness study. SETTING: Multicenter study including 156 hospitals and ambulatory surgery facilities. PATIENTS: 2438 patients (1496 outpatients and 942 inpatients) 18 years of age or older, scheduled for elective surgeries under general endotracheal anesthesia, with an expected duration of unconsciousness of > or =30 minutes. INTERVENTIONS: Patients were randomized to receive either intravenous remifentanil (0.5 microg/kg/min for induction and intubation; with the infusion rate decreased to 0.25 microg/kg/min after intubation) or fentanyl (administered according to anesthesiologists' usual practice) as the opioid during surgery. Concomitant hypnotic drugs were propofol and/or isoflurane (with or without nitrous oxide) titrated according to protocol. Transition analgesia with either morphine or fentanyl was given in the remifentanil patients and at the discretion of the anesthesiologists in the fentanyl patients. MEASUREMENTS: A validated set of measurements of functional ability, rather than more traditional clinical psychological methods, to compare the recovery of patients from remifentanil- and fentanyl-treated anesthetic regimens up to 24 hours after surgery. MAIN RESULTS: Remifentanil was statistically superior to fentanyl for the four functional assessments evaluated: walking without dizziness, thinking clearly, concentration, and communicating effectively. These differences reflect events occurring within the first 24 hours after anesthesia and surgery. CONCLUSIONS: A remifentanil-treated anesthetic demonstrated earlier return to some functions than a fentanyl-treated technique. Although functional assessment is a field that is still in its infancy, a questionnaire to assess functional ability during the 24 hours after anesthesia may provide more practical information about anesthetic recovery than previously used, traditional psychomotor evaluations.
Analgesics, Opioid↗
Hemodynamics and emergence profile of remifentanil versus fentanyl prospectively compared in a large population of surgical patients.
STUDY OBJECTIVE: To compare the responses to, and hemodynamics associated with surgical stress, recovery profiles, and anesthesiologists' satisfaction following balanced general anesthesia using either remifentanil or fentanyl in a large-scale population. DESIGN: Prospective, 1:1 single blind, randomized, controlled effectiveness study in which patients received either remifentanil or fentanyl in combination with a hypnotic-based anesthesia regimen of either isoflurane or propofol. SETTING: Multicenter study including 156 hospitals and ambulatory surgery facilities. PATIENTS: 2,438 patients (1,496 outpatients and 942 inpatients), 18 years of age or older, scheduled for elective surgeries under general endotracheal anesthesia, with an expected duration of unconsciousness > or =30 minutes. INTERVENTIONS: Patients were randomized to receive either intravenous (IV) remifentanil (0.5 microg/kg/min for induction and intubation, with the infusion rate decreased to 0.25 microg/kg/min after intubation) or IV fentanyl (administered according to anesthesiologists' usual practice) as the opioid during surgery. Concomitant hypnotic drugs were either propofol and/or isoflurane (with or without nitrous oxide) titrated according to protocol. Transition analgesia with either morphine or fentanyl was given to the remifentanil patients and, at the anesthesiologists' discretion, in the fentanyl patients. MEASUREMENTS: Vital signs, adverse events, and emergence profiles were assessed and recorded. Recovery profile was assessed by recording time spent in the postanesthesia care unit and step-down recovery unit, number and timing of adverse events, timing and dosage of rescue medications, and time to eligibility for discharge (to home or to hospital room). Anesthesiologists' satisfaction with the anesthetic regimen was assessed at the end of surgery. MAIN RESULTS: Remifentanil-treated patients exhibited lower systolic and diastolic blood pressures (by 10-15 mmHg) and lower heart rates (by 10-15 bpm) intraoperatively compared to the fentanyl-treated patients. This difference promptly disappeared on emergence. Remifentanil-treated patients responded to verbal command, left the operating room, and (for outpatients) were discharged home sooner than fentanyl-treated patients. Anesthesiologists rated the predictability of response to intraoperative titration, assessment of hemodynamic profiles, and the quality of anesthesia higher in the remifentanil-treated patients. CONCLUSIONS: This study confirms previous observations on the hemodynamic properties associated with remifentanil and extends these to a wider context than previously reported. These characteristics provide clinicians with an alternative in opioid-based anesthesia.
Adult↗
Routine laboratory testing in the elderly: is it indicated?
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Aged↗
Risk indices: what is their value to the clinician and patient?
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Anesthesia↗
Secondary prevention of coronary artery disease in patients undergoing elective surgery for peripheral arterial disease.
The purpose of the study was to assess the implementation of secondary prevention guidelines of coronary artery disease (CAD) in patients undergoing peripheral revascularization surgery. The design was a descriptive study of the prevalence of cardiac risk factors and preventive pharmacological therapy in vascular surgical patients set in an academic medical center between July 1996 and February 1999. A total of 237 patients were recruited, 82 (35%) having carotid surgery and 155 (65%) having lower extremity bypass. Data were collected from an existing database of a study examining perioperative cardiac events in vascular surgery patients. The majority of patients were hypertensive and 58% of patients had a blood pressure >140/90 mmHg. Most patients (81%) reported a history of tobacco use and 23% were active smokers. Of the 41% of patients who were diabetic, 46% had a random glucose >140 mg/dl. Half of the patients took aspirin, 35% a lipid-lowering medication, 30% a beta-blocker. Patients with lower extremity disease were less likely than patients with carotid disease to be on aspirin (45% vs. 62%), a lipid-lowering agent (30% vs. 45%), or a beta-blocker (26% vs. 39%) (all p<0.05). Of patients with heart disease, more men than women were on aspirin (62% vs. 45%) (p<0.05). In conclusion, our findings suggest that patients presenting for vascular surgery have a high prevalence of modifiable CAD risk factors that are not being adequately managed. Preoperative examination of vascular patients is an important opportunity to assess and implement neglected secondary prevention measures.
Adult↗
Injectable versus topical anesthesia for cataract surgery: patient perceptions of pain and side effects. The Study of Medical Testing for Cataract Surgery study team.
OBJECTIVE: To compare patient reports of intraoperative pain and postoperative side effects by different anesthesia strategies for cataract surgery. DESIGN: Prospective cohort study. PARTICIPANTS: Men and women 50 years of age and older undergoing 19,250 cataract surgeries at nine centers in the United States and Canada from June 1995 through June 1997. INTERVENTION: Topical anesthesia or anesthesia with injection, with or without sedatives, opioid analgesia, hypnotics, and diphenhydramine (Benadryl). MAIN OUTCOME MEASURES: Patient ratings of intraoperative pain, satisfaction with pain management, and early postoperative side effects (drowsiness, nausea, vomiting, or a combination thereof). RESULTS: Twenty-six percent of surgeries were performed using topical anesthesia alone, and the remainder were performed with peribulbar, retrobulbar, or facial nerve block, or a combination thereof. Local anesthesia by injection with sedatives and diphenhydramine resulted in the lowest reporting of any intraoperative pain (1.3%), with postoperative drowsiness (9.6%) and nausea, vomiting, or both (1.5%) comparable with those administered topical anesthesia alone. Among those receiving topical anesthesia, use of sedatives and opioids reduced reports of any pain during surgery by 56% (95% confidence interval [CI], 34%, 70%), but increased nausea and vomiting (odds ratio, 2.27; 95% CI, 1.26, 4.09) compared with those administered topical anesthesia alone, after adjusting for age, gender, race, American Society of Anesthesiologists risk class, self-reported health status, and duration of surgery. Among those receiving local injections, use of opioids reduced reports of any pain among those receiving sedatives by 37% (95% CI, 15%, 54%), but did not increase postoperative side effects. The use of diphenhydramine among those receiving sedatives decreased reports of any pain by 59% (95% CI, 33%, 75%) and also reduced drowsiness and nausea and vomiting by 57% (95% CI, 48%, 65%) and by 60% (95% CI, 36%, 75%), respectively. Use of hypnotics with sedatives was associated with increased reports of any pain during surgery and increased nausea and vomiting after surgery. CONCLUSIONS: Patient reports of any pain during cataract surgery (5%) and postoperative side effects (16% drowsiness and 4% nausea and vomiting) were low, but varied by anesthesia strategy. Patient perceptions of pain and side effects can be helpful in guiding the appropriate choice of anesthesia strategy.
Administration, Topical↗
Outcomes in perioperative medicine and anesthesiology. Into the next millennium.
Although the development of outcomes research in perioperative medicine and anesthesiology has focused on traditional clinical outcomes, there seems to be a transition toward more global assessments of patient-related outcomes. Present trends in outcomes research and EBM may promise an improvement in individual patient and overall quality of care. New roles and opportunities in perioperative medicine and anesthesiology provide additional venues for outcomes research in this millennium.
Anesthesiology↗
Effectiveness of remifentanil versus traditional fentanyl-based anesthetic in high-risk outpatient surgery.
STUDY OBJECTIVE: To determine if remifentanil would offer a superior hemodynamic and recovery profile compared to the current standard of care, which implements a fentanyl-based technique. DESIGN: Randomized, single-blind study. SETTING: Outpatient center associated with tertiary care center. PATIENTS: 75 outpatients undergoing microsuspension laryngoscopy. INTERVENTIONS: Patients were randomized to either a remifentanil induction (0.5 microg/kg/min) and maintenance (0.25 microg/kg/min) versus fentanyl (maximum of 250 microg) as the only opioid. All patients received propofol as part of the induction and maintenance with or without the use of nitrous oxide. MEASUREMENTS: Assessment of hemodynamics [heart rate (HR) and blood pressure(BP)], presence of perioperative myocardial ischemia on ambulatory electrocardiographic monitoring, and time to discharge. MAIN RESULTS: Significantly fewer patients in the remifentanil group demonstrated episodes of tachycardia (HR > 100 beats per min) compared to the fentanyl group (14% vs. 40%, p<0.05), with significantly fewer episodes of tachycardia and hypertension per patient. Recovery profiles between the two groups did not show clinically significant differences. CONCLUSIONS: Remifentanil, a new short-acting opioid, offers excellent hemodynamic control for brief, intense outpatient procedures performed in high-risk patients; however, its use was not associated with any improvement in recovery profiles.
Aged↗
Heart rate variability as a predictor of autonomic dysfunction in patients awaiting liver transplantation.
Chronic liver disease, both alcoholic and nonalcoholic, has been shown to be associated with autonomic neuropathy, as well as other hemodynamic and circulatory disturbances. In a longitudinal study, the presence of autonomic neuropathy and the severity of liver disease were independent risk factors for mortality. The aim of this study was to determine whether the severity of liver disease correlated with measures of heart rate variability. We studied 21 patients being evaluated for liver transplantation to determine if severity of disease correlated with heart rate variability and compared them to seven healthy controls. Heart rate variability was determined for a series of 500 consecutive R-R intervals during quiet breathing. Standard deviation, pNN50, a marker of parasympathetic function, and approximate entropy (ApEn), a recently described measure of regularity, were calculated. Four standard tests of autonomic function were also performed. pNN50 was significantly reduced in all liver disease patients compared to controls (P < 0.05). Both standard deviation and ApEn were significantly reduced in Child's class C patients suggesting a generalized dysfunction in cardiovascular homeostasis. ApEn was significantly lower in the nonsurvivors during follow-up than the survivors (P < 0.05). In conclusion, increasing severity of liver failure is associated with a reduction in total heart rate variability and regularity. Measurement of heart rate variability offers a simple, noninvasive means of assessing the cardiovascular and autonomic effects of liver disease, particularly in those awaiting liver transplantation.
Adult↗
Comparing methods of clinical measurement: reporting standards for bland and altman analysis.
UNLABELLED: In this era of medical technology assessment and evidence-based medicine, evaluating new methods to measure physiologic variables is facilitated by standardization of reporting results. It has been proposed that assessing repeatability be followed by assessing agreement with an established technique. If the "limits of agreement" (mean bias +/- 2SD) are not clinically important, then one could use two measurements interchangeably. Generalizability to larger populations is facilitated by reporting confidence intervals. We identified 44 studies that compared methods of clinical measurement published during 1996 to 1998 in seven anesthesia journals. Although 42 of 44 (95.4%) used the limits of agreement methodology for analysis, several inadequacies and inconsistencies in reporting the results were noted. Limits of agreement were defined a priori in 7.1%, repeatability was evaluated in 21.4%, and relationship (pattern) between difference and average was evaluated in 7.1%. Only one of the articles reported confidence intervals. A computer macro for the Minitab statistical package (State College, PA) is described to facilitate reporting of Bland and Altman analysis with confidence intervals. We propose standardization of nomenclature in clinical measurement comparison studies. IMPLICATIONS: A literature review of anesthesia journals revealed several inadequacies and inconsistencies in statistical reports of results of comparison studies with regard to interchangeability of measurement methods. We encourage journal editors to evaluate submissions on this subject carefully to ensure that their readers can draw valid conclusions about the value of new technologies.
Anesthesiology↗
Assessing a tool to measure patient functional ability after outpatient surgery.
UNLABELLED: The "24-Hour Functional Ability Questionnaire" (24hFAQ) was developed to measure final recovery and satisfaction 24 h after surgery. We used structured interviews preoperatively to measure baseline patient concerns, and up to 24 h after discharge, to assess patient function and satisfaction. The primary objective was to assess the validity of the newly developed 24hFAQ in the postoperative outpatient setting. The criteria assessed were 1) CONTENT: comparison with expert opinion and patients' views and response frequency distributions for asymptotes and irrelevance, 2) Construct: contribution of cognitive, physical, and satisfaction domains to postoperative functional ability, 3) Discrimination: comparing mean clinical end points with patient satisfaction, and 4) Criterion (predictive) validity: testing that related constructs are best correlated. CONTENT validity was supported by the appropriate frequency distribution of subject responses, by the lack of floor or ceiling effects, and by <2% of responses indicating irrelevance. Construct validity was supported by moderate-to-strong positive interitem correlations within the cognitive and physical domains as predicted a priori. Discriminant validity support was mixed: key symptoms were associated with adverse patient satisfaction, but operating room and postanesthesia care unit residence times were unrelated. Criterion validity was supported by the finding that preoperative concern with key symptoms was independent of postoperative outcomes. The validity assessment presented was the first assessment of the measurement capability of the 24hFAQ in an outpatient postoperative population. These results provide overall support for the validity of the 24hFAQ for use in outpatient populations. IMPLICATIONS: This study assessed the validity of a novel functional ability questionnaire that measured functional status after recovery from anesthesia and satisfaction 24 h after outpatient surgery. The content, construct, discriminant, and criterion (predictive) validities demonstrated the utility of this assessment instrument in the outpatient setting.
Activities of Daily Living↗
Outcomes research in regional anesthesia and analgesia.
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Analgesia↗