A&A Case Reports 最新文献

{"title":"In the United States, \"Opt-Out\" States Show No Increase in Access to Anesthesia Services for Medicare Beneficiaries Compared with Non-\"Opt-Out\" States.","authors":"E. Sun, T. R. Miller, Nicholas M. Halzack","doi":"10.1213/XAA.0000000000000293","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000293","url":null,"abstract":"In the United States, anesthesia care can be provided by anesthesiologists or nurse anesthetists. Since 2001, 17 states have exercised their right to \"opt-out\" of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist, with the majority citing increased access to anesthesia care as the rationale for their decision. By using Medicare data, we found that most (4 of 5) cohorts of \"opt-out\" states likely experienced smaller growth in anesthesia utilization rates compared with non-\"opt-out\" states, suggesting that opt-out was not associated with an increase in access to anesthesia care.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"24 1","pages":"283-5"},"PeriodicalIF":0.0,"publicationDate":"2016-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76163031","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":"Anesthetic Management for Whole Lung Lavage in Patients with Pulmonary Alveolar Proteinosis.","authors":"Zihui Tan, K. T. Tan, R. Poopalalingam","doi":"10.1213/XAA.0000000000000283","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000283","url":null,"abstract":"Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by the deposition of lipoproteinaceous materials in the bronchoalveolar tree. Whole lung lavage was introduced in the 1960s and remains a treatment of choice for PAP. The main anesthetic challenge of whole lung lavage is maintaining adequate oxygenation during the procedure. We describe 2 interesting patients with PAP, the anesthetic challenges faced during the lung lavage, and discuss the management strategies adopted in each case.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"56 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85881918","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":"A Model for Better Leveraging the Point of Preoperative Assessment: Patients and Providers Look Beyond Operative Indications When Making Decisions.","authors":"Olivia Nelson, T. Quinn, Alexander F. Arriaga, D. Hepner, S. Lipsitz, Zara Cooper, A. Gawande, A. Bader","doi":"10.1213/XAA.0000000000000274","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000274","url":null,"abstract":"Previous literature on preoperative evaluation focuses on the impact on the day of surgery cancellations and delays; however, the framework of cancellations and delays at the time of the elective outpatient preoperative anesthesia visit has not been categorized. We describe the current model in the preoperative clinic at Brigham and Women's Hospital, examining the pattern of cancellations at the time of this preoperative visit and the framework used for categorizing the issues involved. Looking at this broader framework is important in an era of patient-centered care; we seek to identify targets to modify the preoperative assessment and adequately assess and capture the spectrum of issues involved. Elective cases evaluated in the preoperative clinic were reviewed over 10 months. Characteristics of cancelled and noncancelled cases were compared. In-depth analysis of issues related to cancellation was done; 1-year follow-up was completed. Cancellation patterns included categories encompassing clinical, financial, alignment with patient values and goals, compliance, and social issues. The period of preoperative assessment can therefore be leveraged to review a number of domains that can adversely affect surgical outcomes and improve patient-centered care. Also, our framework allows the institution to benchmark these patterns over time; increases in cancellations at the time of the preoperative anesthesia clinic visit for specific categories can prompt an opportunity to examine and improve preoperative workflow.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"54 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78814520","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":"Seizure After Abdominal Surgery in an Infant Receiving a Standard-Dose Postoperative Epidural Bupivacaine Infusion.","authors":"Peter E Shapiro, Hedwig Schroeck","doi":"10.1213/XAA.0000000000000286","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000286","url":null,"abstract":"We present the case of an otherwise healthy 12-month-old girl undergoing repair of a giant omphalocele, who experienced a postoperative seizure attributed to accumulation of bupivacaine from an epidural infusion. Whereas a standard dose was used, this patient experienced temporary liver dysfunction postoperatively, presumably from elevated intra-abdominal pressures, predisposing her to toxicity after a prolonged infusion. This case illustrates how the type of surgery can influence the margin of safety of routinely used neuraxial local anesthetic doses in infants and young children.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"7 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81765516","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":"Transient Intraoperative Central Diabetes Insipidus in Moyamoya Patients Undergoing Revascularization Surgery: A Mere Coincidence?","authors":"Joe C. Hong, Emilio Ramos, Curtis C Copeland, K. Ziv","doi":"10.1213/XAA.0000000000000287","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000287","url":null,"abstract":"We present 2 patients with Moyamoya disease undergoing revascularization surgery who developed transient intraoperative central diabetes insipidus with spontaneous resolution in the immediate postoperative period. We speculate that patients with Moyamoya disease may be predisposed to a transient acute-on-chronic insult to the arginine vasopressin-producing portion of their hypothalamus mediated by anesthetic agents. We describe our management, discuss pertinent literature, and offer possible mechanisms of this transient insult. We hope to improve patient safety by raising awareness of this potentially catastrophic complication.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"49 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84951946","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":"Normoglycemic Diabetic Ketoacidosis in a Pregnant Patient with Type II Diabetes Mellitus Presenting for Emergent Cesarean Delivery.","authors":"Bradford L. Cardonell, Barry A Marks, M. Entrup","doi":"10.1213/XAA.0000000000000290","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000290","url":null,"abstract":"The development of acute abdominal pain in a laboring parturient after a previous cesarean delivery is of concern and may be the result of a potentially life-threatening condition such as uterine rupture. We present a case of a parturient with type II diabetes mellitus, who had undergone 2 previous cesarean deliveries and now presented in labor with increasing abdominal pain. An emergency cesarean delivery was performed for probable uterine rupture. Intraoperatively, the patient was noted to be severely hypocarbic with significant metabolic acidosis, and the diagnosis of diabetic ketoacidosis was established.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"16 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78947966","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":"Twitter-Augmented Journal Club: Educational Engagement and Experience So Far.","authors":"Ankeet D. Udani, Daniel Moyse, C. A. Peery, J. Taekman","doi":"10.1213/XAA.0000000000000255","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000255","url":null,"abstract":"Social media is a nascent medical educational technology. The benefits of Twitter include (1) easy adoption; (2) access to experts, peers, and patients across the globe; (3) 24/7 connectivity; (4) creation of virtual, education-based communities using hashtags; and (5) crowdsourcing information using retweets. We report on a novel Twitter-augmented journal club for anesthesia residents: its design, implementation, and impact. Our inaugural anesthesia Twitter-augmented journal club succeeded in engaging the anesthesia community and increasing residents' professional use of Twitter. Notably, our experience suggests that anesthesia residents are willing to use social media for their education.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"15 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83725113","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":"The Diagnosis and Management of Patient with Delayed Symptoms from a Tracheal Tear.","authors":"N. B. Greilich, I. Gasanova, B. Farrell, G. Joshi","doi":"10.1213/XAA.0000000000000289","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000289","url":null,"abstract":"Development of subcutaneous emphysema after gastrointestinal endoscopy with general anesthesia presents a diagnostic conundrum. We discuss the management of a patient who experienced significant vomiting followed by neck and facial swelling with crepitus and shortness of breath after the endoscopic retrograde cholangiopancreatography. The presence of respiratory distress usually suggests that head and neck subcutaneous emphysema is most likely associated with pneumothorax and/or pneumomediastinum. We discuss the prevention, differential diagnosis, and current management of tracheal tears including subcutaneous emphysema.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"50 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86179604","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 the Modifier \"QZ\" Accurately Reflect Independent Nurse Anesthetist Practice: And Why Does It Matter?","authors":"E. Sun","doi":"10.1213/XAA.0000000000000254","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000254","url":null,"abstract":"220 cases-anesthesia-analgesia.org April 1, 2016 • Volume 6 • Number 7 Copyright © 2016 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000254 Given increases in health care spending in the United States and worldwide, it goes without saying that policy makers and payers are interested in finding ways to reduce costs without compromising quality of care. One effort that is receiving attention is whether midlevel providers, such as physician assistants, nurse practitioners, and nurse anesthetists, should play a greater role in care delivery.1,2 This question is particularly salient in the case of anesthesiology, where the degree to which nurse anesthetists should be supervised by physicians (typically an anesthesiologist, although occasionally the proceduralist) remains an area of active debate3 with important policy implications. For example, state-level efforts to “opt out” of federal regulations requiring anesthesiologist supervision of nurse anesthetists remain a continued area of contention and an object of great concern for both the American Society of Anesthesiologists and the American Association of Nurse Anesthetists. Therefore, characterizing the degree and extent to which nurse anesthetists require supervision by an anesthesiologist is a question with important policy implications. However, answering this question well is difficult. First, as demonstrated by others,4,5 “supervision” is a term describing a continuum of interactions between the anesthesiologist and the nurse anesthetist. On one extreme would be true independent practice (where the anesthesiologist neither sees the patient nor coordinates care with the nurse anesthetist), whereas the other extreme would involve neartotal involvement by the anesthesiologist, for example, the supervision accorded to new anesthesia trainees (i.e., new anesthesia residents or registrars). Therefore, it may be difficult to precisely measure what degree of supervision was provided on a given case. Second, “bad” outcomes in anesthesia are thankfully rare, which means that studies limited to a single institution, or even a group of institutions, may not have the power to determine clinically or statistically significant differences in outcomes. Administrative claims data, such as data from the United States Centers for Medicare and Medicaid Services (CMS), would seem to provide one way around this issue. These data sets have the advantage of being large, containing data for millions if not tens of millions of patients, allowing for statistical precision. Moreover, in the United States, the health care claim submitted by the anesthesia provider indicates whether a nurse anesthetist provided care, as well as a code, the modifier “QZ,” which indicates that the nurse anesthetist provided care without medical direction by an anesthesiologist. Indeed, a recent, widely publicized study using data from the CMS found no differences in outcomes when care was administered by nurse anesth","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"59 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2016-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79618850","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":"Advance Directives and Operating: Room for Improvement?","authors":"R. Hadler, M. Neuman, S. Raper, L. Fleisher","doi":"10.1213/XAA.0000000000000269","DOIUrl":"https://doi.org/10.1213/XAA.0000000000000269","url":null,"abstract":"Anesthesiologists and surgeons are frequently called on to perform procedures on critically ill patients with advanced directives. We assessed the attitudes of attending and resident surgeons and anesthesiologists at our institution regarding their understanding of and practice around the application of consenting critically ill patients with advance directives in the operating room. To do so, we deployed a survey after interdepartmental grand rounds, featuring a panel discussion of ethically complex cases featuring end-of-life issues.","PeriodicalId":6824,"journal":{"name":"A&A Case Reports ","volume":"23 ","pages":"204-7"},"PeriodicalIF":0.0,"publicationDate":"2016-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91463108","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}