{"title":"Procedural episode-based cost measures: anesthesia matters.","authors":"Alice A Tolbert Coombs","doi":"10.1097/ACO.0000000000000976","DOIUrl":"https://doi.org/10.1097/ACO.0000000000000976","url":null,"abstract":"<p><strong>Purpose of review: </strong>Episode-based cost measures (EBCM) is a method of combining all services related to a defined episode of care, identified as either a procedure, acute illness or chronic disease, and providing expected cost for that episode or bundle of care. Procedural EBCM has become a major scheme for payment methodology and patient quality of care evaluation. Anesthesiologists need to know how EBCM can impact their clinical practice.</p><p><strong>Recent finding: </strong>Centers for Medicare and Medicaid Services (CMS) pays physicians with fee-for-service payment for Clinical Episodes and, in 2020, the EBCM are increasing and currently, represents 4.5% of the total Medicare Part A and B spending [1]. With the recent changes in CMS, it is important, for anesthesia providers to know how cost attribution identifies the cost for all services and complications under anesthetic management.</p><p><strong>Summary: </strong>EBCM can impact the anesthesiologist's quality performance, efficiencies measures, and payment. To preserve practice viability, anesthesiologists must understand how their compensation is impacted by services ordered. Anesthesiologists will increasingly be expected to improve quality and efficiencies in EBCM.</p>","PeriodicalId":520600,"journal":{"name":"Current opinion in anaesthesiology","volume":" ","pages":"154-160"},"PeriodicalIF":2.5,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25390056","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Bruno Adler Maccagnan Pinheiro Besen, Bruno Martins Tomazini, Luciano Cesar Pontes Azevedo
{"title":"Mechanical ventilation in septic shock.","authors":"Bruno Adler Maccagnan Pinheiro Besen, Bruno Martins Tomazini, Luciano Cesar Pontes Azevedo","doi":"10.1097/ACO.0000000000000955","DOIUrl":"https://doi.org/10.1097/ACO.0000000000000955","url":null,"abstract":"<p><strong>Purpose of review: </strong>The aim of this study was to review the most recent literature on mechanical ventilation strategies in patients with septic shock.</p><p><strong>Recent findings: </strong>Indirect clinical trial evidence has refined the use of neuromuscular blocking agents, positive end-expiratory pressure (PEEP) and recruitment manoeuvres in septic shock patients with acute respiratory distress syndrome. Weaning strategies and devices have also been recently evaluated. The role of lung protective ventilation in patients with healthy lungs, while recognized, still needs to be further refined. The possible detrimental effects of spontaneous breathing in patients who develop acute respiratory distress syndrome is increasingly recognized, but clinical trial evidence is still lacking to confirm this hypothesis. A new concept of lung and diaphragm protective is emerging in the critical care literature, but its application will need a complex intervention implementation approach to allow adequate scrutiny of this concept and uptake by clinicians.</p><p><strong>Summary: </strong>Many advances in the management of the mechanically ventilated patient with sepsis and septic shock have occurred in recent years, but clinical trial evidence is still necessary to translate new hypotheses to the bedside and find the right balance between benefits and risks of these new strategies.</p>","PeriodicalId":520600,"journal":{"name":"Current opinion in anaesthesiology","volume":" ","pages":"107-112"},"PeriodicalIF":2.5,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38839211","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Hemodynamic support in septic shock.","authors":"Marina García-de-Acilu, Jaume Mesquida, Guillem Gruartmoner, Ricard Ferrer","doi":"10.1097/ACO.0000000000000959","DOIUrl":"https://doi.org/10.1097/ACO.0000000000000959","url":null,"abstract":"<p><strong>Purpose of review: </strong>The current article reviews recent findings on the monitoring and hemodynamic support of septic shock patients.</p><p><strong>Recent findings: </strong>The ultimate goal of hemodynamic resuscitation is to restore tissue oxygenation. A multimodal approach combining global and regional markers of tissue hypoxia seems appropriate to guide resuscitation. Several multicenter clinical trials have provided evidence against an aggressive fluid resuscitation strategy. Fluid administration should be personalized and based on the evidence of fluid responsiveness. Dynamic indices have proven to be highly predictive of responsiveness. Recent data suggest that balanced crystalloids may be associated with less renal failure. When fluid therapy is insufficient, a multimode approach with different types of vasopressors has been suggested as an initial approach. Dobutamine remains the firs inotropic option in patients with persistent hypotension and decrease ventricular systolic function. Calcium sensitizer and phosphodiesterase inhibitors may be considered, but evidence is still limited. Veno-arterial extracorporeal membrane oxygenation may be considered in selected unresponsive patients, particularly with myocardial depression, and in a highly experienced center.</p><p><strong>Summary: </strong>Resuscitation should be personalized and based on global and regional markers of tissue hypoxia as well as the fluid responsiveness indices. The beneficial effect of multimode approach with different types of vasopressors, remains to be determined.</p>","PeriodicalId":520600,"journal":{"name":"Current opinion in anaesthesiology","volume":" ","pages":"99-106"},"PeriodicalIF":2.5,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25429249","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Nicole C P Thompson, Zachary Weinerman, Jasmine Solola
{"title":"Ethical dilemmas in anesthesia mission trips.","authors":"Nicole C P Thompson, Zachary Weinerman, Jasmine Solola","doi":"10.1097/ACO.0000000000000962","DOIUrl":"https://doi.org/10.1097/ACO.0000000000000962","url":null,"abstract":"<p><strong>Purpose of review: </strong>Health inequities continue to exist globally especially when it comes to surgical and anesthesia services. Due to the lack of physician anesthesiologists in low- and middle-income countries, there has been an increase in the number of medical mission trips. Although these volunteers are attempting to fulfill a need they must be mindful and remember to adhere to ethical principles as they work collaboratively with host institutions. We will review the ethical dilemmas inherent in anesthesia mission trips.</p><p><strong>Recent findings: </strong>Physician volunteers for medical missions may cause significant harm to patients and host communities if they do not work in tandem with host institutions.</p><p><strong>Summary: </strong>Medical missions fulfill acute medical needs and have the opportunity to make a positive contribution to host communities by fulfilling local needs and supporting educational efforts for local providers.</p>","PeriodicalId":520600,"journal":{"name":"Current opinion in anaesthesiology","volume":" ","pages":"137-140"},"PeriodicalIF":2.5,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25348393","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Daniel De Backer, Francesco Ricottilli, Gustavo A Ospina-Tascón
{"title":"Septic shock: a microcirculation disease.","authors":"Daniel De Backer, Francesco Ricottilli, Gustavo A Ospina-Tascón","doi":"10.1097/ACO.0000000000000957","DOIUrl":"https://doi.org/10.1097/ACO.0000000000000957","url":null,"abstract":"<p><strong>Purpose of review: </strong>The aim of this study was to discuss the implication of microvascular dysfunction in septic shock.</p><p><strong>Recent findings: </strong>Resuscitation of sepsis has focused on systemic haemodynamics and, more recently, on peripheral perfusion indices. However, central microvascular perfusion is altered in sepsis and these alterations often persist despite normalization of various macro haemodynamic resuscitative goals. Endothelial dysfunction is a key element in sepsis pathophysiology. It is responsible for the sepsis-induced hypotension. In addition, endothelial dysfunction is also implicated involved in the activation of inflammation and coagulation processes leading to amplification of the septic response and development of organ dysfunction. It also promotes an increase in permeability, mostly at venular side, and impairs microvascular perfusion and hence tissue oxygenation.Microvascular alterations are characterized by heterogeneity in blood flow distribution, with adequately perfused areas in close vicinity to not perfused areas, thus characterizing the distributive nature of septic shock. Such microvascular alterations have profound implications, as these are associated with organ dysfunction and unfavourable outcomes. Also, the response to therapy is highly variable and cannot be predicted by systemic hemodynamic assessment and hence cannot be detected by classical haemodynamic tools.</p><p><strong>Summary: </strong>Microcirculation is a key element in the pathophysiology of sepsis. Even if microcirculation-targeted therapy is not yet ready for the prime time, understanding the processes implicated in microvascular dysfunction is important to prevent chasing systemic hemodynamic variables when this does not contribute to improve tissue perfusion.</p>","PeriodicalId":520600,"journal":{"name":"Current opinion in anaesthesiology","volume":" ","pages":"85-91"},"PeriodicalIF":2.5,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25362278","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Gender pay disparity in anesthesiology.","authors":"Yaqi Hu, Deanna Couser","doi":"10.1097/ACO.0000000000000972","DOIUrl":"https://doi.org/10.1097/ACO.0000000000000972","url":null,"abstract":"<p><strong>Purpose of review: </strong>The purpose of this review is to look at the historical and current gender pay gap in healthcare, specifically in the field of anesthesiology, as well as discuss some of the reasons for the difference in compensation and its consequences. Future aims and directions to bridge the gap will also be explored.</p><p><strong>Recent findings: </strong>Even though women have achieved equality in terms of admission to medical school and residency programs, disparities still exist in terms of compensation for equal or comparable work. However, institutional initiatives to close the pay gap have achieved success.</p><p><strong>Summary: </strong>In order to improve the gender pay inequality, there needs to be continuous efforts on the institutional level for recognition of the disparity, initiation of programs for mentorship and sponsorship for female faculties, and continuous monitoring of the effect of the programs.</p>","PeriodicalId":520600,"journal":{"name":"Current opinion in anaesthesiology","volume":" ","pages":"145-148"},"PeriodicalIF":2.5,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25389640","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Does thoracic epidural anaesthesia constitute over-instrumentation in video- and robotic-assisted thoracoscopic lung parenchyma resections?","authors":"Torsten Loop","doi":"10.1097/ACO.0000000000000975","DOIUrl":"https://doi.org/10.1097/ACO.0000000000000975","url":null,"abstract":"<p><strong>Purpose of review: </strong>Effective and sustained perioperative analgesia in thoracic surgery and pulmonary resection is beneficial to patients by reducing both postoperative pulmonary complications and the incidence of chronic pain. In this review, the indication of thoracic epidural anaesthesia in video- (VATS) and robotic-assisted (RATS) thoracoscopy shall be critically objectified and presented in a differentiated way.</p><p><strong>Recent findings: </strong>Pain following VATS and RATS has a negative influence on lung function by inhibiting deep respiration, suppressing coughing and secretion and favours the development of atelectasis, pneumonia and other postoperative pulmonary complications.In addition, inadequate pain therapy after these procedures may lead to chronic pain.</p><p><strong>Summary: </strong>Since clear evidence-based recommendations for optimal postoperative analgesia are still lacking in VATS and RATS, there can be no universal recommendation that fits all centres and patients. In this context, thoracic epidural analgesia is the most effective analgesia procedure for perioperative pain control in VATS and RATS-assisted surgery for patients with pulmonary risk factors.</p>","PeriodicalId":520600,"journal":{"name":"Current opinion in anaesthesiology","volume":" ","pages":"199-203"},"PeriodicalIF":2.5,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25404908","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Acute respiratory failure and burn patient outcomes.","authors":"Rami Maarouf, Cedric Campbell","doi":"10.1097/ACO.0000000000000973","DOIUrl":"https://doi.org/10.1097/ACO.0000000000000973","url":null,"abstract":"<p><strong>Purpose of review: </strong>Advances in the care of inhalational injuries have not kept pace with advances that have been seen in the treatment of cutaneous burns. There is not yet a standard of care for best outcomes for airway management of patients with known or suspected inhalational injuries. Clinicians must decide if to intubate the patient, and if so, whether to intubate early or late in their presentation. Unnecessary intubation affects morbidity and mortality. This review will summarize literature that highlights present practices in the treatment of patients with inhalation injuries.</p><p><strong>Recent findings: </strong>There have been promising investigations into biomarkers that can be used to quantify a patient's risk and better target therapies. Grading systems serve to better stratify the burn victim's prognosis and then direct their care. Special ventilator modes can assist in ventilating burn patients with inhalation injuries that experience difficulties in oxygenating.</p><p><strong>Summary: </strong>Inhalational injuries are a significant source of morbidity and mortality in thermally injured patients. Treatment modalities, such as modified ventilator settings, alteration in fluid resuscitation, and a standardized grading system may improve morbidity and mortality.</p>","PeriodicalId":520600,"journal":{"name":"Current opinion in anaesthesiology","volume":" ","pages":"180-186"},"PeriodicalIF":2.5,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25389641","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Epidemiology of sepsis and septic shock.","authors":"Catherine Chiu, Matthieu Legrand","doi":"10.1097/ACO.0000000000000958","DOIUrl":"https://doi.org/10.1097/ACO.0000000000000958","url":null,"abstract":"<p><strong>Purpose of review: </strong>The epidemiology of sepsis and septic shock has been challenging to study for multiple reasons. These include changing diagnostic definitions, as well a high concentration of sepsis-related studies published from high-income countries (HICs), despite a large global burden. This section attempts to address the incidence of sepsis throughout the years and worldwide.</p><p><strong>Recent findings: </strong>The incidence of sepsis and septic shock has continued to increase since the first consensus definitions (Sepsis-1) were established in 1991, and the latest definitions (Sepsis-3) provide a better reflection of mortality risk for a diagnosis of sepsis. Several studies argue that the incidence of sepsis is overreported in HICs, based on billing and coding practices, and may lead to overutilization of resources. However, recent estimates of the true global burden of sepsis, including low-income countries, are likely much higher than reported, with calls for better allocation of resources.</p><p><strong>Summary: </strong>The true epidemiology of sepsis worldwide continues to be a highly debated subject, and more research is needed among low-income countries and high-risk subpopulations.</p>","PeriodicalId":520600,"journal":{"name":"Current opinion in anaesthesiology","volume":" ","pages":"71-76"},"PeriodicalIF":2.5,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38792003","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Thomas Duning, Katharina Ilting-Reuke, Mara Beckhuis, Daniel Oswald
{"title":"Postoperative delirium - treatment and prevention.","authors":"Thomas Duning, Katharina Ilting-Reuke, Mara Beckhuis, Daniel Oswald","doi":"10.1097/ACO.0000000000000939","DOIUrl":"https://doi.org/10.1097/ACO.0000000000000939","url":null,"abstract":"<p><strong>Purpose of review: </strong>Postoperative delirium (POD) is one of the most severe complications after surgery.The consequences are dramatic: longer hospitalization, a doubling of mortality and almost all cases develop permanent, yet subtle, cognitive deficits specific to everyday life. Actually, no global guideline with standardized concepts of management exists. Advances in prevention, diagnosis and treatment can improve recognition and risk stratification of delirium and its consequences.</p><p><strong>Recent findings: </strong>Management of POD is a multiprofessional approach and consists of different parts: First, the detection of high-risk patients with a validated tool, preventive nonpharmacological concepts and an intraoperative anesthetic management plan that is individualized to the older patient (e.g. avoiding large swings in blood pressure, vigilance in maintaining normothermia, ensuring adequate analgesia and monitoring of anesthetic depth). In addition to preventive standards, treatment and diagnostic concepts must also be available, both pharmaceutical and nonpharmacological.</p><p><strong>Summary: </strong>Not every POD can be prevented. It is important to detect patients with high risk for POD and have standardized concepts of management. The most important predisposing risk factors are a higher age, preexisting cognitive deficits, multimorbidity and an associated prodelirious polypharmacy. In view of demographic change, the implementation of multidisciplinary approaches to pharmacological and nonpharmacological POD management is highly recommended.</p>","PeriodicalId":520600,"journal":{"name":"Current opinion in anaesthesiology","volume":" ","pages":"27-32"},"PeriodicalIF":2.5,"publicationDate":"2021-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38369652","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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