OSA Spring Meeting at Salishan 2008
Meeting report submitted by Angela Kendrick, MD
The Oregon Society of Anesthesiologists returned to Salishan Resort for the Spring Meeting May 17th and 18th. The meeting opened Saturday morning with a new format for us; the Problem Based Learning Discussion. Many of you have participated in this format at the ASA. Dr. Dawn Dillman, Assistant Program Director for OHSU's APOM, helped the residents organize for their presentations and then she led the case discussions. Dr. Scott Kennedy, a CA 1 resident at OHSU, presented the first case scenario; an obese asthmatic patient needing to undergo lithotripsy for renal calculi. Dr. Dillman circulated with a microphone through the audience to allow us to participate in the work-up and management of the case. Dr. J. Sax Gilbert presented the second case, a male for repeat aorto-bifemoral bypass who suffered a severe allergic transfusion reaction during the operative course.
This discussion segued nicely into to the first talk by Dr. Aryeh Shander. Dr. Shander is a Clinical Professor of Anesthesiology at the Mt. Sinai School of Medicine and the current Chief of Anesthesiology and Critical Medicine at Englewood Hospital in Englewood, NJ. He is nationally known for his innovations and skill in advancing bloodless procedures. His first talk was on surgical blood management. It included an overview of the processing of blood from donation at the Red Cross (which isn't just the philanthropic organization they'd have us believe) through its delivery to the patient. He reviewed transfusion "triggers" and morbidity after transfusions. He discussed the Koch et al "Duration of red cell storage and complications after cardiac surgery" article from the March 2008 NEJM which did show increased post op complications and decreased survival in patients transfused with old (stored for>2 weeks) PRBCs.
Dr. Roger Moore, president-elect of the ASA, reviewed the significant regulatory issues that the ASA has worked on in the last few years. These included Medicare payment, both overall and the teaching rule particularly. He highlighted Norm Cohen's recent successful persuasion of CMS to increase our RVU value. He addressed upcoming areas of emphasis for our national organization including physician wellness and support for the expert witness testimony program. Dr. Moore reminded us that politics is local and becoming active at the local level helps carry our message of patient safety and physician value to legislators and to the public.
Dr. Shander closed the Saturday morning session with a discussion of artificial blood components, including how they have been developed and where components are in the regulatory approval process. HBOC (hemoglobin–based oxygen carrier) trials have been looked at in Natanson et al's systematic review in April 2008 JAMA. In this meta review, HBOCs were found to have a 30% increase in the risk of death.
Saturday afternoon saw some of the nicest weather ever recorded at the beach. (Honest) The evening reception was hosted at the home of John and Maryam Evans. Chris Swide, MD the current OSA president and Per Jarnberg, MD functioned as sommeliers to guide us through the wine selections.
Sunday morning opened with Dr. Trish Michels, a CA2 resident, presenting her case: an anticoagulated patient with significant medical problems who needed to undergo a below knee amputation. Dr. Dillman led the audience through the case discussion . Dr. Chris Swide presided over the business meeting. The ASA Legislative Conference is up coming in June. The fall meeting will be held in conjunction with the OHSU Airway workshop in Portland on Sept 13th. Dr. Andy Ovassapian returns as the Haugen Lecturer. Dr. Chris Swide will be organizing an online survey of our members to get feedbackabout our meetings, including suggestions for timing and content.Send Sondra your email so you can be part of the survey. Your address will not be made public.At the Oct 2008 ASA, Dr. Mark Gilbert will become a delegate and Dr. Angela Kendrick will step out of this role. Chris actively encourages members to become involved with the OSA.We especially need and want representation at the leadership level from outside the Portland Metro area.
Dr. Michael Hutchens, Assistant Professor of Anesthesiology at OHSU, gave the final two talks on Sunday morning. He is on the critical care faculty, and he used his expertise to speak about advances in critical care.The overview included the use of dexmetatomidine for sedation (0.2 mcg/kg/hr to 0 .7 mcg/kg/hr) of the intubated patient to produce a level of sedation that allows cooperation/examination when needed . ACLS update: chest compression is key to restoring perfusion pressure to the coronary arteries. Cooling patients after they have suffered a cardiac arrest has been shown to improve neurological outcome. Tube feeding: patients in the ICU do better with enteral nutrition. We talked about NG tube feeding vs NJ tube. What are guidelines for NPO times with these tubes? Any difference in aspiration rates in the OR? Answer: No data. The more distally placed feeding tube should be more protective, but the tube crosses the pylorus. He can't recommend that we change our 6 hour guidelines until data exists. He discussed the ARDSNET Data ( information from a consortium of clinical centers established in 1994) published in NEJM and JAMA 2000 which showed improvement in outcomes with ventilation at lower tidal volumes (6 ml/kg vs 12/ml/kg). The ARDSNET continues to conduct multicenter trials. He also brought ANZICS to our attention. ANZICS is the Australian—New Zealand intensive care society which is a world leader in clinical trials.
In 2002, a new internal consensus for classification of acute renal injury was developed. The RIFLE (Risk, Injury, Failure , Loss, and End Stage) criteria defines three grades of severity - risk ( class R), injury (class I) and failure ( class F). The criteria can be found here.
There are international guidelines published in Critical Care Medicine in 2004 and updated in 2008 for "Surviving Sepsis". These guidelines grade the evidence for therapeutic interventions in the ICU. Activated protein C administration was administered to septic patients in the PROWESS trial and seemed to help the sickest patients (NEJM 2002).The final topic was a review of the use of direct thrombin inhibitors for anticoagulation. These agents are finding their place in clinical care, not just for FDA approved use in patients with Heparin Induced Thrombocytopenia ( HIT) .