Friday, August 1, 2008

Not So Fast, Sugammadex



Saturday, May 24, 2008

DepoDur Warnings

I was preparing to submit a pharmacy request to add DepoDur (liposomally encapsulated epidural morphine) to our formulary what I ran across this nugget:

FDA Warns of Settings That Increase Risk for Respiratory Depression From Morphine Sulfate Extended-Release Liposome Injection (DepoDur)

On December 14, 2007, the FDA approved safety labeling revisions for morphine sulfate extended-release liposome epidural injection (DepoDur; Skye Pharma Inc) to warn of settings associated with an increased risk for respiratory depression.

Although the formulation is intended for administration by the epidural route only, postmarketing reports have included cases of intrathecal use. In all cases, signs of prolonged respiratory depression required use of a narcotic antagonist (naloxone) or ventilatory support.

Because a breached dural membrane can lead to intrathecal leakage, particularly when the epidural drug is administered in a bolus, vigilant monitoring of respiratory function for a prolonged period (48 hours) is advised when extended-release morphine sulfate liposome injection is administered after a recent dural puncture. Provision should be made for emergency ventilation to minimize the risk for serious respiratory depression.

Subarachnoid puncture during epidural administration of the product has also been linked to cases of prolonged and serious respiratory depression or apnea, occurring within 12 hours of injection and after apparent recovery from anesthesia. Respiratory depression can be successfully treated with a naloxone bolus or, more commonly, a naloxone infusion; intubation and mechanical ventilation may be necessary in some cases.

Morphine sulfate extended-release liposome injection is indicated for single-dose epidural administration at the lumbar level to treat postoperative pain; it is given before surgery or after clamping the umbilical cord during cesarean delivery. The injection is not intended for intrathecal, intravenous, or intramuscular administration.



Saturday, April 19, 2008

Excellent resource on screening for von Willebrand Disease

From the National Heart Lung and Blood Institute: The Diagnosis, Evaluation and Management of von Willebrand Disease [PDF]


Saturday, March 29, 2008

ASA: Details on Malignant Hyperthermia

From our national organization, the American Society of Anesthesiologists, Details on Malignant Hyperthermia which may in part explain the recent tragic death of a high school student.
"In light of the recent tragic death of a Florida teenager from a reported case of malignant hyperthermia, ASA recognizes the importance for patients to know the facts behind the occurrence of this rare genetic disorder...."


Friday, March 7, 2008

Anesthesiology: Adverse Respiratory Events in Children Who Are Obese.

Incidence and Risk Factors for Perioperative Adverse Respiratory Events in Children Who Are Obese.

"[O]bese children had a higher incidence of difficult mask ventilation, airway obstruction, major oxygen desaturation (>10% of baseline), and overall critical respiratory adverse events. Logistic regression analysis revealed several risk factors for adverse events, including procedures involving the airway, obesity, age younger than 10 yr, and a history of obstructive sleep apnea."



Wednesday, February 27, 2008

Aetna doing the right thing (at least temporarily)

Aetna to Still Pay for Colonoscopy Drug

"Bowing to critics who contended it was putting profits before patients, Aetna said Wednesday that it has suspended — at least temporarily — a plan to stop paying for routine use of a powerful anesthetic in a procedure to screen for colon cancer. "



Tuesday, February 12, 2008

JAMA: Effectiveness and Efficiency of Root Cause Analysis in Medicine

Effectiveness and Efficiency of Root Cause Analysis in Medicine

"Not all actions aimed to mitigate risk are equal. Some actions, like redesigning a product or process, are strong and have a high probability of reducing harm. Other actions, like reeducation or writing a policy, the 2 most common recommendations in health care RCA, are weak and have a low probability of reducing risk."

(Via JAMA current issue.)



Monday, February 11, 2008

Aetna, Colonoscopy, and Money

I suspect that there is much more to Aetna's recent decision (pdf) to stop paying for Propofol for all (exceptions exist) colonoscopies than either Propofol or colonoscopies. At first glance it just look like they're trying to save themselves the additional cost the anesthetist or anesthesiologist that is needed if endoscopists want their patients to receive propofol adds. But I think there's more to it than that.

Let me state at the outset that my practice does not derive significant income from providing anesthesia for colonoscopies. The vast majority of colonoscopies done with propofol use RN's with anesthesia training (CRNA's) to provide the service. I point this out because it seems that having any financial involvement at all is cause for discounting ones opinion--it should not be, but it is.

Using propofol allows colonoscopies to be done without patient awareness of discomfort, true, but the real advantage is that patients recover from the drug fast. By way of example, if a colonoscopy is done the 'old fashioned way' using the sedative midazolam and the narcotic demerol or fentanyl, the patient will likely need to remain in the center for one to two hours before they meet discharge criteria (assuming they don't have any nausea). Propofol allows them to go home in about 30-45 minutes. Roughly twice as fast from completion of colonoscopy to discharge. That means they occupy a recovery bed for less time and that's the limiting step for many centers. Once all the recovery beds are full, you can't do any more procedures until one opens up. Being able to quickly discharge patients after their exam allows much greater throughput in terms of exams per day that can be done .

Here is where I think the policy change will have its real effect. Either endoscopy centers will continue to provide the option of propofol sedation but charge the patient for it (in which case the insurance company will pay less), will provide it as part of the facility fee as a way to compete more effectively for patients (in which case the insurance company will pay less), or centers will go back (and I do mean back) to using older drugs but sacrifice throughput (in which case the insurance company will pay less).

Is having a colonoscopy easier with propofol? Don't take my word for it. Ask any endoscopy nurse which way he or she would prefer having a colonoscopy done.

Aside from cost and cost savings there's the issue of who decides what appropriate care is. If insurance companies are allowed to dictate who can and cannot get a certain kind of anesthesia, what will they do next? Get rid of anesthesia payments for cataract surgery? How about for trigger finger releases and carpal tunnel surgery. Vasectomy? See where I'm going with this?



Saturday, February 2, 2008

iPods and Pacemakers

iPods and Pacemakers: "

(Via Medgadget.)

Good summary on BIS

Is there a consensus concerning the routine use of BIS monitoring during general anesthesia?



Wednesday, January 30, 2008

My MacBook Air shipped!

"MACBOOK AIR 13/1.6/2GB/80GB-USA
Shipment Date: Jan 30, 2008
Delivers by: Feb 04, 2008 "
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