UpToDate: Hypoglossal nerve stimulation for adult patients with obstructive sleep apnea. April 2024
StatPearls: Hypoglossal Stimulation Device. July 2023
Things that worked for me:
Are you healthy enough for surgery?
Calculators:
MDCalc: Revised Cardiac Risk Index for Pre-Operative Risk
2018 Prevention Guidelines Tool CV Risk Calculator
The Big Papers:
UpToDate: Evaluation of cardiac risk prior to noncardiac surgery. March 2024.
StatPearls: Cardiac Risk Stratification. May 2023.
Preoperative Cardiac Risk Assessment. Am Fam Physician. 2002;66(10):1889-1897.
Infographics:
A policy has been passed by our hospital that would allow APNs ability to perform elective cardioversions in our EP department.
Two studies from the United Kingdom demonstrated safe and effective performance of CVs when directed by nurses with advanced training 5, 6. In a study by Boodhoo et al. (5) in 2004, nurses who performed CVs had at least 1 year of coronary care unit experience, were Advanced Cardiac Life Support (ALS) certified, and had performed a minimum of 20 supervised CVs. In their hospital, the nurses administered the sedation without an anesthesiologist present. Although, as the authors suggest, this sedation approach reduces costs, a cardiac registered nurse in the United States would not be granted hospital privileges to independently provide moderate sedation. In the study by Currie (6), an anesthesiologist rather than a nurse administered sedation, but unlike the present study, patients who were considered high risk due to advanced heart disease, presence of a pacemaker, or severe obesity, were excluded from the nurse-directed CV approach.
The only published study based on U.S. experience with nurse-led CVs is a retrospective study by Norton et al. (7) that compared the outcomes of CVs performed by physicians alone, those by physicians with a nurse practitioner, and those of nurse practitioners independently. They found comparable success rates in each group, with a success rate of 93% in the nurse practitioner group, and there were no complications in any of the CV groups. Unlike the present study, however, the nurse practitioner was certified in ICD interrogation and reprogramming, performed the CV completely independently, and billed for the procedures. The APP who performed the CVs in the present study is a salaried employee of the hospital where the procedures were performed and did not bill independently for procedures.
In addition, the findings of the present study are only applicable to practices where sedation for CVs is administered by an anesthesiologist.
Outcomes Associated With Electrical Cardioversion for Atrial Fibrillation When Performed Autonomously by an Advanced Practice Provider. JACC: Clinical Electrophysiology, Volume 3, Issue 12, 2017, Pages 1447-1452.
In these studies, they looked specifically at having anesthesiologists be present as well as removing potentially complex cardioversion cases.
It seems all of these studies are done in an academic practice or NHS type hospital environment. Are there studies where it shows cost effectiveness for private practice groups?
How much of the safety burden is placed on anesthesiologists for managing instability for the procedure?
Where do we see anesthesia going as well as reimbursements?
Medicare’s geographic adjustment for a particular physician payment locality is determined using three geographic practice cost indices (GPCI) that correspond to the three components of a Medicare fee–physician work, practice expense, and malpractice expense.
Physician work–the financial value of physicians’ time, skill, and effort that are associated with providing the service.
Practice expense–the costs incurred by physicians in employing office staff, renting office space, and buying supplies and equipment.
Malpractice expense–the premiums paid by physicians for professional liability insurance. Each RVU measures the relative costliness of providing a particular service.
These GPCIs adjust physician fees for variations in physicians’ costs of providing care in different payment localities. Specifically, they raise or lower Medicare fees depending on whether a payment locality’s average cost of operating a physician practice is above or below the national average. CMS is required to review the GPCIs at least every 3 years and, at that time, may update them using more recent data. The major data source used in calculating the GPCIs, the decennial census, provides new data once every 10 years. The GPCIs were last updated in 2005 and CMS is scheduled to review and, if necessary, update them again in 2008. Concerns have been raised in Congress and among stakeholders, including state medical associations, that the geographic boundaries of some payment localities do not accurately address variations in the costs of operating a private medical practice. If they do not, beneficiaries could potentially experience problems accessing physician services.
From https://www.govinfo.gov/content/pkg/GAOREPORTS-GAO-07-466/html/GAOREPORTS-GAO-07-466.htm
More than half of the current physician payment localities had at least one county within them with a large payment difference–that is, there was a payment difference of 5 percent or more between physicians’ costs and Medicare’s geographic adjustment for an area. Overall, there were 447 counties with large payment differences–representing 14 percent of all counties. These counties were located across the United States, but a disproportionate number were located in five states. Specifically, 60 percent of counties with large payment differences were located in California, Georgia, Minnesota, Ohio, and Virginia. Large payment differences occur because many payment localities combine counties with very different costs, which may be attributed to several factors. For example, although substantial population growth has occurred in certain geographic areas, potentially leading to increased costs, CMS has not revised the payment localities to reflect these changes.
From https://www.govinfo.gov/content/pkg/GAOREPORTS-GAO-07-466/html/GAOREPORTS-GAO-07-466.htm
Perhaps insurance company data could be used to help discover discrepancies in cost and apply new findings to these geographic areas.
CMS Physician Fee Schedule — Anesthesia specific
ASA: Anesthesia Payments –> The 33% Problem — AnesthesiaExperts:33% Rule
AnesthesiaExperts: Q&A on the 33% problem
AnesthesiaLLC.com: The Low, Low Anesthesia Conversion Factor
Lawmakers Ask HHS to Review Medicare Rates for Anesthesia Services, Sept 2010
Anesthesia Subsidies from a Hospital’s Perspective
ECG Management Consultants:
AnesthesiaLLC.com: Today’s Anesthesia Economics Coping with New Realities.
TEE has been bundled into certain anesthesia services where TEE is necessary for a successful procedure. This basically means the qualified anesthesiologist does not get reimbursed for his or her expertise in guiding placement of a device, monitoring, or generating a report.
CMS Billing and Coding for TEE
MediCal California anesthesias billing
Code 59 If the TEE is performed for diagnostic purposes by the same anesthesiologist who is providing the anesthesia service, modifier 59 should be appended to the TEE code to note that it is distinct and independent from the anesthesia service.
Center for Medicare Services policy that defines reimbursable indications for intraoperative TEE “The interpretation of TEE during surgery is covered only when the surgeon or other physician has requested echocardiography for a specific diagnostic reason (e.g., determination of proper valve placement, assessment of the adequacy of valvuloplasty or revascularization, placement of shunts or other devices, assessment of vascular integrity, or detection of intravascular air). To be a covered service, TEE must include a complete interpretation/report by the performing physician.
Duke TEE Billing Codes
Procedure Coding: When to use modifier 59
AAPC Anesthesia and TEE billing in same procedure
TEE Documentation Requirements Crucial for Anesthesia Billing
TEE Documentation Requirements from AnesthesiaLLC.com
Watchman Reimbursement guide: pg. 11
UnitedHealthcare Anesthesia Billing
Based on our review of the analysis, the most interesting findings include:
ASA Survey Results for Commercial Fees Paid for Anesthesia Services – 2015. ASA Monitor October 2015, Vol. 79, 48–54.
- ■ The national average conversion factor increased from a range of $66.98-$71.79 in 2014 to a range of $69.64-$74.29. Also, the median conversion factor range broadened from $63.88-$69.00 in 2014 to $65.00-$69.00.
- ■ Conversion factors across the country are similar, with the Eastern Region still having the highest mean of $77.96.
- ■ Every region and nearly every contract category had a reported conversion factor high of at least $82.00. The highest conversion factor reported was $195.00.
It seems that ever since that advent of dexmedetomidine, propofol has been pushed aside as the sedation drug of choice for sedation during and post-open heart surgery. But is the literature changing with the effects of dexmedetomidine on rates of atrial fibrillation?
In patients older than 60 years with low baseline risk of postoperative delirium admitted to the ICU after cardiac surgery and extubated within 12 h of ICU admission, a post-extubation nighttime dose of dexmedetomidine may reduce the incidence of delirium on postoperative day one.
Nighttime dexmedetomidine for delirium prevention in non-mechanically ventilated patients after cardiac surgery (MINDDS): a single-centre, parallel-arm, randomised, placebo-controlled superiority trial. The Lancet, eClinicalMedicine: Volume 56, 101796, February 2023.
The study results showed no statistically significant difference between both groups with regard to age and body mass index. Group P patients were more associated with lower MAP and HR than Group D patients. There was no statistically significant difference between groups with regard to ABG findings, oxygenation, ventilation, and respiratory parameters. There was significant difference between both the groups in midazolam and fentanyl dose requirement and financial costs with a value of P < 0.05.
From Sedation Effects by Dexmedetomidine versus Propofol in Decreasing Duration of Mechanical Ventilation after Open Heart Surgery. Ann Card Anaesth. 2018 Jul-Sep; 21(3): 235–242.
Meta-analysis studies on the use of DEX during cardiac surgery also showed a reduction in the risk of atrial fibrillation, ventricular tachycardia and cardiac arrest [7, 12].
Our findings suggest that DEX may reduce short term postoperative pulmonary complications, time on mechanical lung ventilation, ICU and hospital stay following CABG surgery compared to propofol.
From Comparison between dexmedetomidine and propofol on outcomes after coronary artery bypass graft surgery: a retrospective study. BMC Anesthesiology volume 22, Article number: 51 (2022).
When compared with propofol, dexmedetomidine sedation reduced incidence, delayed onset, and shortened duration of POD in elderly patients after cardiac surgery. The absolute risk reduction for POD was 14%, with a number needed to treat of 7.1.
From Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery: A Randomized Controlled Trial. Anesthesiology February 2016, Vol. 124, 362–368.
Dexmedetomidine did not significantly impact ICU length of stay compared with propofol, but it significantly reduced the duration of mechanical ventilation and the risk of delirium in cardiac surgical patients. It also significantly increased the risk of bradycardia across ICU patient subsets.
From Outcomes of dexmedetomidine versus propofol sedation in critically ill adults requiring mechanical ventilation: a systematic review and meta-analysis of randomised controlled trials. British Journal of Anaesthesia, 129 (4): 515e526 (2022).
The use of dexmedetomidine for sedation after cardiac surgery was associated with a lower incidence of atrial fibrillation and hence decreased the duration of intensive care stay.
Dexmedetomidine versus propofol in reducing atrial fibrillation after cardiac surgery. Egyptian Journal of Anaesthesia, 38:1, 72-77.
This trial demonstrated that dexmedetomidine sedation may be better able to improve microcirculation in cardiac surgery patients during the early postoperative period compared with propofol.
Dexmedetomidine Versus Propofol Sedation Improves Sublingual Microcirculation After Cardiac Surgery: A Randomized Controlled Trial. Journal of Cardiothoracic and Vascular Anesthesia, Vol 30, No 6 (December), 2016: pp 1509–1515.
Adding low-dose rate dexmedetomidine to a sedative regimen based on propofol did not result in a different risk of in-hospital delirium in older patients undergoing cardiac surgery. With a suggestion of both harm and benefit in secondary outcomes, supplementing postoperative propofol with dexmedetomidine cannot be recommended based on this study.
Propofol plus low-dose dexmedetomidine infusion and postoperative delirium in older patients undergoing cardiac surgery. British Journal of Anaesthesia Volume 126, Issue 3, March 2021, Pages 665-673.
Dexmedetomidine infusion, started at anaesthetic induction and continued for 24 h, did not decrease postoperative atrial arrhythmias in patients recovering from cardiac surgery. Dexmedetomidine also worsened delirium, although not by a significant amount, possibly by provoking hypotension. Dexmedetomidine worsened kidney injury, but again not by a significant amount. The incidence of persistent surgical pain was similar in each group. Dexmedetomidine should be used cautiously in cardiac surgical patients with attention to preventing hypotension, and should not be given in expectation of reducing atrial fibrillation or delirium.
Dexmedetomidine for reduction of atrial fibrillation and delirium after cardiac surgery (DECADE): a randomised placebo-controlled trial. The Lancet Volume 396, Issue 10245, 18–24 July 2020, Pages 177-185.
Dexmedetomidine-based sedation resulted in
Propofol-Based Versus Dexmedetomidine-Based Sedation in Cardiac
achievement of early extubation more frequently than propofol-
based sedation. Mean postoperative time to extubation and
average hospital LOS were shorter with dexmedetomidine-
based sedation and met a statistical level of significance. There
was no difference in ICU-LOS or in-hospital mortality between
the two groups. Total hospital charges were similar, although
slightly higher in the propofol group.
Surgery Patients. Journal of Cardiothoracic and Vascular Anesthesia, Vol 27, No 6 (December), 2013: pp 1289–1294.
Basics: Blood Transfusion, StatPearls
Massive transfusion: a review. Vol 7 (June 30, 2022).
One means of achieving a balanced resuscitation is with the use of WB instead of component therapy. The combination of plasma, PLT and PRBC components in a 1:1:1 ratio is estimated to result in a HCT of 25%, coagulation factor activity of 62%, platelet concentration of 50×109/L, and fibrinogen concentration of 75 mg/dL. In comparison, a unit of fresh WB has a HCT of 45%, 100% activity of all coagulation factors, platelet concentration of 200×109/L, and fibrinogen concentration of 150 mg/dL
Massive transfusion: a review. Vol 7 (June 30, 2022).
OB Hemorrhage
The American College of Obstetricians and Gynecologists (ACOG) recommends fixed product ratios (65). This practice is supported by retrospective studies that demonstrate, in combination with a comprehensive post-partum hemorrhage protocol, MTP is associated with improvement in transfusion needs and peri-partum hysterectomy (66–68). Additionally, obstetric hemorrhage protocols should focus on repletion of fibrinogen via early administration of CRYO or fibrinogen concentrate, as fibrinogen is the first coagulation factor to diminish in post-partum hemorrhage
Massive transfusion: a review. Vol 7 (June 30, 2022).
Adjuncts to MTP
In addition to blood transfusion during MTP, several useful pharmacologic adjuncts to resuscitation have been identified. These include calcium repletion, tranexamic acid (TXA), factor VII concentrate, prothrombin complex concentrate (PCC), and arginine vasopressin (AVP). In addition to pharmacologic adjuncts, the use of viscoelastic testing can help improve blood product utilization and outcomes.
Massive transfusion: a review. Vol 7 (June 30, 2022).
Adverse Effects of MTP
One in 455 blood components transfused is associated with an adverse event, but the risk of serious adverse reactions (1 in 6,224) and transfusion-transmitted infections (1 in 255,400) is extremely low in the United States (117). The most common non-infectious reactions include febrile non-hemolytic transfusion reactions, allergic transfusion reactions, transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), and acute or delayed hemolytic reactions (118). The effects of blood preservation and storage also cause changes in the quality of the blood over time, including decreased pH, increased potassium, decreased 2,3-diphosphoglycerate (2,3-DPG), and decreases in erythrocyte and platelet function, all of which may affect resuscitation and oxygen delivery (119).
Massive transfusion: a review. Vol 7 (June 30, 2022).
Internet Book of Critical Care: Massive Transfusion Protocol
Trigger for FFP and/or PCC in Clinical Recommendations
In the Society of Cardiac Anesthesiology recommendations, transfusion of 10 to 15 ml/kg of FFP or a low dose of PCC (not defined) is recommended when clotting time in tissue factor–activated ROTEM or the reaction time in heparinase TEG is significantly prolonged (table 2).13 Of note, the European recommendations for hemostatic resuscitation in trauma recommend a dose of 25 IU/kg of a PCC, whereas in cardiac surgery patients, an initial dose of 12.5 IU/kg (similar to that suggested by the U.S. recommendations) should be considered because of the inherent risk of thromboembolism.20 In the European trauma guidelines, the authors point out the possible influence of hypofibrinogenemia on clotting time in tissue factor–activated ROTEM.14 Therefore, PCC should be given only when fibrinogen levels are less than 1.5 g/l (corresponding to a fibrinogen ROTEM maximal clot firmness of less than 10 mm), and clotting time in tissue factor–activated ROTEM is prolonged or remains prolonged after replacement of fibrinogen.
Viscoelastic Coagulation Testing: Use and Current Limitations in Perioperative Decision-making. Anesthesiology August 2021, Vol. 135, 342–349.
Trauma Quality Improvement Program: MTP in Traumas
Massive Transfusion Protocol In: LITFL – Life in the FastLane, Accessed on April 20, 2023.
Canadian Blood Services: Massive hemorrhage and emergency transfusion
Massive Transfusion Protocol Template
UCSF Massive Transfusion Protocol
Washington State: Massive Transfusion Protocol
Red Cross: Transfusion Guidelines
WB RECOMMENDATIONS
Whole Blood Transfusion, Military Medicine, Volume 183, Issue suppl_2, September-October 2018, Pages 44–51.
- − SWB, which will in U.S. military practice be LTOWB, is the preferred product for resuscitation of severe bleeding (both pre-hospital and in-hospital). SWB simplifies the logistics of the transfusion and may facilitate more rapid resuscitation of casualties, and may enhance a facility’s capacity to manage mass casualty (MASCAL) challenges.
- − The indication for SWB is life-threatening hemorrhage. The assessment that a hemorrhage is life-threatening is mainly established clinically, and should be driven by an assessment of the patient’s vital signs, hemodynamics, physical exam, mechanism of injury and laboratory measures of shock and hemostasis if available. The use of FWB should be reserved for when SWB or full component therapy is unavailable.
- − Blood component therapy (1:1:1) is an acceptable option for treating life-threatening hemorrhage when SWB is not available. The potential reduced efficacy, safety, and logistical aspects of blood component therapy should be taken into consideration when choosing between resuscitation strategies (Table I).
The utility of cerebral oximetry
Recent advances in cerebral oximetry – 2017
Products:
Cerebral oximetry. BJA Education, Volume 16, Issue 12, December 2016, Pages 417–421.
Cerebral oximetry in cardiac anesthesia. J Thorac Dis. 2014 Mar; 6(Suppl 1): S60–S69.
Sleepy Time 