搜索结果：Journal of perioperative practice

PRACTICE advisories are systematically developed reports that are intended to assist decision-making in areas of patient care where scientific evidence is insufficient. Advisories provide a synthesis and analysis of expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Advisories are not intended as standards, guidelines, or absolute requirements. They may be adopted, modified, or rejected according to clinical needs and constraints.The use of practice advisories cannot guarantee any specific outcome. Practice advisories report the state of the literature and opinions derived from a synthesis of task force members, expert consultants, open forums and public commentary. Scientific literature and other documentation are summarized in practice advisories to provide an additional source of guidance. Practice advisories are not supported by scientific literature to the same degree as standards or guidelines because of the lack of sufficient numbers of adequately controlled studies. Practice advisories are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.The purposes of this advisory are to 1) educate American Society of Anesthesiologists (ASA) members, (2) provide a reference framework for individual practices, and (3) stimulate the pursuit and evaluation of strategies that may prevent or reduce the frequency of occurrence or minimize the severity of peripheral neuropathies that may be related to perioperative positioning of patients.Prevention of peripheral neuropathies is part of the larger process of perioperative care. This advisory specifically focuses on perioperative positioning of the adult patient, use of protective padding, and avoidance of contact with hard surfaces or supports that may apply direct pressure on susceptible peripheral nerves. This advisory does not focus on compartment syndromes or neuropathies that may be associated with anesthetic techniques (e.g. , spinal anesthesia).This advisory is intended to apply to adult patients who are or have been sedated or anesthetized. Areas in which these patients receive care include, but are not limited to, operating rooms and other anesthetizing locations, recovery rooms, intensive care units, outpatient procedural units, and office-based practices.This advisory is intended for use by anesthesiologists or other providers working under the direction of anesthesiologists. It also may serve as a resource for other health care professionals.The ASA appointed a task force of 10 members to (1) review the published evidence, (2) obtain consultant opinion from a representative body of anesthesiologists, nurse anesthetists, anesthesiology assistants, perioperative nurses, surgeons, and emergency medicine physicians, and (3) build consensus within the task force. The task force members consisted of anesthesiologists in both private and academic practices from various geographic areas of the United States and methodologists from the ASA Committee on Practice Parameters. The task force identified a group of 150 consultants from both the national and the international anesthesia communities who have expertise or interest in perioperative peripheral neuropathies.The task force met its objective in a five-step process. First, original published research studies relevant to these issues were reviewed. Second, consultants who practice or work in various settings (e.g. , academic and private practice) were asked to (1) participate in surveys of their opinions of the effectiveness of various positioning and protective strategies to prevent perioperative peripheral neuropathies and (2) review and comment on the initial draft report of the task force. Third, a random sample of anesthesiologists (n = 1,500) from the ASA Directory of Members (active members only) was surveyed regarding their impressions of various elements of the advisory. Fourth, the task force held an open forum at a major national anesthesia meeting to solicit input on its draft advisory from attendees of the meeting. Fifth, all available information was used to build consensus within the task force on the advisory.A summary of the consensus of the task force on all key issues pertinent to this advisory is presented in table 1. Practice advisories are developed by a systematic consensus-based process. Although they do not have the support of sufficient numbers of scientific studies, a source of guidance is provided by the summarization of scientific studies, case reports, descriptive literature, and other documentation. Consensus findings from consultant and ASA membership surveys are summarized and included in advisories in addition to task force opinion, open forum opinion, and public commentary.Preoperative History and Physical AssessmentCertain patient characteristics have been reported to be associated with perioperative neuropathies. Although this advisory found no studies examining the relationship between the performance of a preoperative history or physical assessment and the prevention of perioperative peripheral neuropathies, 25 studies reported postoperative peripheral neuropathies occurring in patients with specific preexisting conditions (e.g. , smoking, diabetes, vascular disease, and extremes of body weight, and age). 1–25Such conditions often are noted in a patient’s medical history or found during a physical assessment. These studies are not acceptable evidence of causation.Consultants and ASA Members. Ninety-three percent of the consultants who responded (n = 78/84) agree that a focused preoperative history may identify patients with an increased risk for the development of peripheral neuropathies during the perioperative period. Eighty-eight percent of the ASA membership respondents (n = 382/433) agree with the above statement. The majority of consultants and responding ASA members who agree with the above statement indicate that the following preexisting patient attributes are important to review: body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, and arthritis. Eighty-eight percent of the responding consultants (n = 72/82) agree that a focused preoperative physical assessment may identify patients with an increased risk for the development of peripheral neuropathies during the perioperative period. Eighty percent of the ASA membership respondents (n = 344/429) agree with the above statement.The task force consensus is that body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, arthritis, and gender (e.g. , male gender and its association with ulnar neuropathy) are important elements of a preoperative history. The task force consensus also indicates that, when judged appropriate, it would be helpful during a preoperative assessment to ascertain that patients can comfortably tolerate the anticipated operative position. Public commentary from an open forum and from Internet correspondence corroborates the task force opinions.Positioning Strategies to Reduce the Frequency of Perioperative Brachial Plexus NeuropathyNineteen articles were found that reported brachial plexus injuries. 26–44Fifteen were case reports or studies with descriptive information only. 26–40Six of the 15 articles reported brachial plexus neuropathies occurring with arm abduction greater than 90°, 26–31and four of the 15 reported brachial plexus neuropathies occurring with arm abduction equal to 90°. 32–35Four articles reported statistical comparisons, 41–44only one of which was a randomized clinical trial. 44Three of these four articles compared arm abduction less than or equal to 90°versus arms at side in supine patients. 41–43One article compared arm abduction less than 90°versus arm abduction equal to 90°. 44These articles do not provide sufficient data to identify a causal relationship between perioperative conditions and brachial plexus neuropathies.Ninety-two percent of the consultants (n = 75/82), and 96% of the ASA members (n = 411/431) agree that limiting abduction of the arm(s) in a supine patient may decrease the risk of brachial plexus neuropathy. Of those agreeing, 93% of the consultants (n = 67/72) and 84% of the ASA members (n = 342/405) indicate that the upper limit of abduction should be 90°. Seven percent of the consultants (n = 5/72) and 17% of the ASA members (n = 63/405) indicate an upper abduction limit of 60°.The task force consensus is that arm abduction should be limited to 90°. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA members. Eighty-eight percent of the consultants (n = 71/81) and 91% of the ASA members (n = 392/432) agree that limiting abduction of the arm or arms in a prone patient may decrease the risk of brachial plexus neuropathy. Of those agreeing, 67% of the consultants (n = 47/70) and 57% of the ASA members (n = 222/387) agree that the upper limit of abduction should be 90°.The task force notes that the prone position affects shoulder and brachial plexus mobility differently than does the supine position. These differences may allow patients to comfortably tolerate abduction of their arms greater than 90° when positioned prone. Public commentary from an open forum and from Internet correspondence corroborates the task force commentary.Positioning Strategies to Reduce the Frequency of Perioperative Ulnar NeuropathyFive articles were found that reported ulnar neuropathies. 20,25,45–47Three articles were case reports, 25,45,46one was a retrospective of and one was a of and articles do not sufficient data to identify a relationship between positioning strategies and ulnar percent of the consultants (n = and of the ASA members (n = agree that specific in a supine patient with an arm or arms on an may decrease the risk of ulnar neuropathy. Of those agreeing, of the consultants (n = and of the ASA members (n = the and task force consensus is that the should be positioned to decrease pressure on the of the or the position this Public commentary from an open forum and from Internet correspondence corroborates the task force percent of the consultants (n = and of the ASA members (n = agree that specific in a supine patient with an arm or arms at the side may decrease the risk of ulnar neuropathy. Of those agreeing, of the consultants (n = and of the ASA members (n = the task force consensus is that the should be in a position. Public commentary from an open forum and from Internet correspondence corroborates the task force percent of the consultants (n = and of the ASA members (n = agree that of the may the risk of ulnar neuropathy. Of those agreeing, of the consultants (n = and of the ASA members (n = indicate that of greater than 90° may the risk of ulnar task force consensus is that of the may the risk of ulnar but is no consensus on an acceptable degree of during the perioperative period. Public commentary from an open forum and from Internet correspondence corroborates the consultant and ASA membership Strategies to Reduce the Frequency of Perioperative case reports or studies were found perioperative positioning strategies to the and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that pressure in the of the from contact with a hard may the risk of neuropathy. The task force consensus is that pressure on the in the of the should be Public commentary from an open forum and from Internet correspondence corroborates the task force Strategies to Reduce the Frequency of Perioperative case reports or studies were found perioperative positioning strategies to the and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that of the in an supine patient the of that is during the preoperative may the risk of neuropathy. The task force consensus is that of the the that is during the preoperative assessment may the Public commentary from an open forum and from Internet correspondence corroborates the task force of case reports or studies were found assessment of patient position to the upper and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that upper position should be during The task force consensus is that periodic perioperative may of the position. Public commentary from an open forum and from Internet correspondence corroborates the task force Strategies to Reduce the Frequency of Perioperative case reports of postoperative were report noted of 90° in a the other reported perioperative and of in a position. reports are not acceptable evidence to indicate percent of the consultants (n = and 57% of the ASA members (n = agree that of the group the of that is during the preoperative assessment may the risk of neuropathy. The task force consensus is that that the group the that is during the preoperative assessment may the Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that the risk of in a patient who is positioned in a position may be the degree of is limited to and The task force consensus is that the or its both the and the and of both of these should be when the degree of Public commentary from an open forum and from Internet correspondence corroborates the task force Strategies to Reduce the Frequency of Perioperative case reports of postoperative were report found to in patients who were in a the other reported a patient with postoperative in a position with and reports are not acceptable evidence to indicate causation.Consultants and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that of the in an supine patient the of that is during the preoperative may the risk of neuropathy. percent of the consultants (n = and of the ASA members (n = were percent of the consultants (n = and of the ASA members (n = agree that the risk of may be the degree of is limited to 90°. percent of the consultants (n = and of the ASA members (n = agree that the risk of in a patient in a position is not increased with any degree of and The task force consensus is that of the the risk for neuropathy. Public commentary from an open forum and from Internet correspondence is regarding the risk of related to or Strategies to Reduce the Frequency of Perioperative case report of postoperative in a patient in a pressure and was reports are not acceptable evidence to indicate causation.Consultants and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that pressure the from contact with a hard or a support may the risk of neuropathy. and The task force consensus is that pressure on the at the should be Public commentary from an open forum and from Internet correspondence corroborates the task force is intended to the patient from perioperative neuropathies. articles were found that reported peripheral neuropathies occurring when upper protective was of these reported of brachial the other four reported of ulnar neuropathy. articles do not as a of the neuropathies. of these articles were case reports for one retrospective descriptive articles are not acceptable evidence of studies were found the relationship between the use of and the occurrence of peripheral neuropathies. studies were found the occurrence of peripheral neuropathies when protective was and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that may decrease the risk of upper neuropathies. and The task force consensus is that may decrease the risk of upper neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that the use of a under the in a patient who is positioned may decrease the risk of brachial plexus in the and The task force consensus is that the use of in the positioned patient may decrease the risk of upper neuropathy. Public commentary from an open forum Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that the use of specific or at the may decrease the risk of ulnar neuropathy. and The task force consensus is that at the may decrease the risk of upper neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and 91% of the ASA members (n = agree that the use of specific to prevent contact of the the with a hard may decrease the risk of neuropathy. The task force consensus is that that the use of specific to prevent pressure of a hard the at the may decrease the risk of neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that, in the use of may the risk of peripheral neuropathies. and The task force consensus is that the use of (e.g. , may the risk of perioperative neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force articles were found that the of or supports as a direct of perioperative peripheral neuropathies. upper neuropathies, articles were found that reported peripheral neuropathies occurring when upper contact was with or case reports or ulnar occurring when a pressure was used case reports brachial plexus neuropathies occurring when shoulder or were case report occurring in a prone patient with an arm a one case report occurring in a supine patient with an arm by a reports are not acceptable evidence to indicate use no use of a shoulder when patients were in a supine position for and found a frequency of brachial plexus when a shoulder was not the research of the does not provide acceptable evidence of articles were found that reported peripheral neuropathies occurring when contact was with or case reports or neuropathies occurring with the use of article reported a case of as a of the use of a article compared in a position with articles are not acceptable evidence of of the use of for research of the does not provide acceptable evidence of causation.Consultants and ASA on Ulnar percent of the consultants (n = agree (n = and are (n = that use of an pressure on the arm may the risk of ulnar neuropathy. percent of the ASA members (n = agree (n = and are (n = that the use of an pressure on the arm may the risk of ulnar on percent of the consultants (n = agree (n = and are (n = that use of an pressure on the arm may the risk of neuropathy. percent of the ASA members (n = agree (n = and are (n = that the use of an pressure on the arm may the risk of neuropathy. on percent of the consultants (n = agree (n = and are (n = that use of an pressure on the arm may the risk of neuropathy. percent of the ASA members (n = agree (n = and are (n = that the use of an pressure on the arm may the risk of and The task force consensus is that the use of pressure on the arm , above the does not the risk of upper neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that shoulder the to prevent a patient from when in a position may the risk of brachial plexus neuropathy. and The task force consensus is that use of shoulder in a position may the risk of perioperative neuropathies. Public commentary from an open forum and from Internet correspondence corroborates the task force articles were found that the relationship between the performance of a physical assessment in the care and the prevention of perioperative peripheral neuropathies. four case reports, four descriptive studies the of a peripheral during postoperative assessment. reports and descriptive studies do not provide acceptable evidence to indicate studies were and ASA Members. percent of the consultants (n = and 67% of the ASA members (n = agree that examining the patient in the may to of peripheral neuropathy. and The task force consensus is that a postoperative assessment of may to of peripheral neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force studies were found the of documentation of specific perioperative positioning related to peripheral and ASA Members. Eighty-eight percent of the consultants (n = and 93% of the ASA members (n = agree that documentation on an anesthetic of specific positioning during the care of a patient is of the majority of consultants and ASA members with the above statement indicates that, when appropriate, it is important to the (1) patient position (e.g. , or (2) position of (3) position of use of specific at the or the specific positioning or or used during the as by findings on the preoperative and or of or of peripheral in the and The task force consensus is that this documentation may be for may in by (1) the focus on relevant of patient positioning and (2) of positioning strategies that to in anesthesia Public commentary from an open forum and from the Internet corroborates the task force this a literature review was used in with consensus opinion to provide guidance to regarding positioning strategies and perioperative peripheral neuropathies. the literature review and consensus data were on the following or evidence These between patient positioning and perioperative peripheral neuropathies. are purposes of literature relevant clinical studies were identified and of the The a from The a of from were a of articles that related to the evidence review of the studies not provide direct evidence, and were of articles direct evidence studies with and statistical information to or report that in the published literature can be included as evidence in the development of an advisory it four to one or of these that a that not it for the process. The four are as the studies met the studies acceptable and that provided a of the between and of of the of studies, the published literature not be used as a source of studies should focus on that of the following for the of positioning techniques on perioperative peripheral neuropathies is (1) studies , one (2) and (3) of and examining the of positioning techniques on perioperative peripheral neuropathies, the be to and a patient’s preoperative of of and the perioperative position are not under the direct of the These perioperative may perioperative , peripheral but are when examining the of positioning techniques (e.g. , arm abduction 90°versus on the occurrence of peripheral the literature not been helpful in the of perioperative positioning techniques in the occurrence of peripheral neuropathies. additional controlled studies are evidence from other to be as data and the opinion of and It is that research on positioning techniques for the prevention of peripheral neuropathies focus on research and and on specific techniques under the direct of the during a was from (1) opinion from consultants who were on their or expertise in perioperative positioning and peripheral (2) opinions from a sample of members of the (3) from attendees of a open forum at a national Internet commentary, and task force opinion and The of was = for consultants, and = for membership of the surveys are reported in and in the of the The majority of consultants and ASA membership respondents with the following (1) a focused preoperative history and (2) a focused preoperative to identify patients at risk for the development of peripheral neuropathies during the perioperative (3) upper position should be during limiting abduction of the arm(s) in a supine or prone patient may decrease the risk of brachial plexus specific in a supine patient with an arm(s) at the side or on an may decrease the risk of ulnar pressure in the of the from contact with a hard may the risk of of the in an supine patient the of that is during the preoperative may the risk of pressure the from contact with a hard or a support may the risk of may decrease the risk of upper of a under the in a patient who is positioned may decrease the risk of brachial plexus in the specific (e.g. , or at the may decrease the risk of ulnar specific to prevent contact of the the with a hard may decrease the risk of in the use of may the risk of peripheral shoulder the to prevent a patient from when in a position may the risk of brachial plexus examining the patient in the may to of peripheral and documentation on an anesthetic of specific positioning during the care of a patient is where no majority was (1) of the may the risk of ulnar (2) of the group (e.g. , the of that is during the preoperative assessment may the risk of (3) of the in an supine patient the of that is during the preoperative (e.g. , may the risk of and the use of an pressure on the arm may the risk of or and ASA membership respondents who with the above responded to specific The majority of these respondents with the following (1) preexisting patient attributes that are important to review during a preoperative history include, but are not limited body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, and (2) in a patient it is important to to of in the of of an of of the and patients in a or to patients in a supine and of the group patients in a or (3) the upper limit of abduction of the arm(s) in a supine or prone patient should be in a supine patient with an arm(s) at the the in the position may decrease the risk of ulnar in a supine patient with an arm(s) on an the in the position may decrease the risk of ulnar greater than 90° may the risk of ulnar the risk of in a patient who is positioned in a position may be the degree of is limited to and it is important to patient position (e.g. , position of position of use of specific at the or the specific positioning or used during a as by findings on a preoperative and the or of or of peripheral in the majority was not for the following (1) gender as an important to review in a focused preoperative (2) of the group patients in a or as important to in a preoperative (3) the degree of for the risk of in a patient in a and the of used for a patient in a position as an important to

PRACTICE Advisories are systematically developed reports that are intended to assist decision-making in areas of patient care. Advisories provide a synthesis and analysis of expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Practice Advisories developed by the American Society of Anesthesiologists (ASA) are not intended as standards, guidelines, or absolute requirements, and their use cannot guarantee any specific outcome. They may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies.Practice Advisories are not supported by scientific literature to the same degree as standards or guidelines because of the lack of sufficient numbers of adequately controlled studies. Practice Advisories are subject to periodic update or revision as warranted by the evolution of medical knowledge, technology, and practice.This document updates the “Practice Advisory for Preanesthesia Evaluation: A Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation,” adopted by the ASA in 2001 and published in 2002.*The literature does not provide a standard definition for preanesthesia evaluation. For this Practice Advisory, preanesthesia evaluation is defined as the process of clinical assessment that precedes the delivery of anesthesia care for surgery and for nonsurgical procedures. For this Advisory, “perioperative” refers to the care surrounding operations and procedures. The preanesthetic evaluation is the responsibility of the anesthesiologist.Preanesthesia evaluation consists of the consideration of information from multiple sources that may include the patient's medical records, interview, physical examination, and findings from medical tests and evaluations. As part of the preanesthesia evaluation process, the anesthesiologist may choose to consult with other healthcare professionals to obtain information or services that are relevant to perioperative anesthetic care. Preoperative tests, as a component of the preanesthesia evaluation, may be indicated for various purposes, including but not limited to (1) discovery or identification of a disease or disorder that may affect perioperative anesthetic care; (2) verification or assessment of an already known disease, disorder, medical or alternative therapy that may affect perioperative anesthetic care; and (3) formulation of specific plans and alternatives for perioperative anesthetic care.The assessments made in the process of preanesthetic evaluation may be used to educate the patient, organize resources for perioperative care, and formulate plans for intraoperative care, postoperative recovery, and perioperative pain management.The purposes of this Advisory are to (1) assess the currently available evidence pertaining to the healthcare benefits of preanesthesia evaluation, (2) offer a reference framework for the conduct of preanesthesia evaluation by anesthesiologists, and (3) stimulate research strategies that can assess the healthcare benefits of a preanesthesia evaluation.A preanesthesia evaluation is considered a basic element of anesthesia care. Therefore the focus of this Advisory is the assessment of evidence pertaining to the content and timing of a preanesthesia evaluation. The interactions between the preanesthesia evaluation, preoperative testing, and perioperative care are beyond the scope and mandate of the Advisory. Informed consent, often undertaken at the same time as the preanesthesia evaluation, is also beyond the scope of this Advisory.This Advisory is intended for use by anesthesiologists and those who provide care under the direction of an anesthesiologist. The Advisory applies to patients of all ages who are scheduled to receive general anesthesia, regional anesthesia, and moderate or deep sedation for elective surgical and nonsurgical procedures. The Advisory does not address the selection of anesthetic technique; nor does it address the preanesthetic evaluation of patients requiring urgent or emergency surgery or anesthetic management provided on an urgent basis in other locations, (e.g. , emergency rooms).Any evaluations, tests, and consultations required for a patient are done with the reasonable expectation that such activities will result in benefits that exceed the potential adverse effects. Potential benefits may include a change in the content or timing of anesthetic management or perioperative resource use that may improve the safety and effectiveness of anesthetic processes involved with perioperative care. Potential adverse effects may include interventions that result in injury, discomfort, inconvenience, delays, or costs that are not commensurate with the anticipated benefits.The original Advisory was developed by an ASA-appointed task force of 12 members, consisting of anesthesiologists from various geographic areas of the United States and two methodologists from the ASA Committee on Standards and Practice Parameters.The Task Force developed the original Advisory by means of a six-step process. First, they reached consensus on the criteria for evidence of effectiveness of preanesthesia evaluation. Second, original published articles from peer-reviewed journals relevant to preanesthesia evaluation were evaluated. Third, consultants who had expertise or interest in preanesthesia evaluation and who practiced or worked in various settings (e.g. , academic and private practice) were asked to (1) participate in opinion surveys on the effectiveness of various preanesthesia evaluation strategies, and (2) review and comment on a draft of the Advisory developed by the Task Force. Fourth, additional opinions were solicited from active members of the ASA. Fifth, the Task Force held several open forums at three major national anesthesia meetings†to solicit input on the draft Advisory. Sixth, all available information was used to build consensus within the Task Force to finalize the Advisory. A summary of recommendations may be found in appendix 1.In 2009, the ASA Committee on Standards and Practice Parameters requested that scientific evidence for this Advisory be updated. The update consists of an evaluation of literature published after completion of the original Advisory. The draft of this updated document was made available for review on the ASA Web site.Preparation of this update used the same methodological process as was used in the original Advisory to obtain new scientific evidence. Opinion-based evidence obtained from the original Advisory is reported in this update. The protocol for reporting each source of evidence is described.Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described below. All literature (e.g. , randomized controlled trials, observational studies, case reports) relevant to each topic was considered when evaluating the findings. However, for reporting purposes in this document, only the highest level of evidence (i.e. , level 1, 2, or 3 identified below) within each category (i.e. , A, B, or C) is included in the summary.Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.Information from observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes.The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes.The lack of scientific evidence in the literature is described by the following terms.The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The literature either does not meet the criteria for content as defined in the “Focus” of the Advisory or does not permit a clear interpretation of findings due to methodological concerns (e.g. , confounding in study design or implementation).No identified studies address the specified relationships among interventions and outcomes.Numerous methodological concerns were encountered in the preanesthesia evaluation literature, including (1) lack of “no-test” controls, (2) failure to blind the practitioner to test results before and during the procedure, and (3) confounding of outcomes. These concerns limit the interpretability of published findings and are discussed in more detail in appendix 2.The original Advisory contained formal survey information collected from expert consultants and random samples of active members of the ASA. Additional information was obtained from open forum presentations and other invited and public sources. All opinion-based evidence relevant to each topic (e.g. , survey data, open-forum testimony, Internet-based comments, letters, and editorials) was considered in the development of the original Advisory. However, only the findings obtained from formal surveys are reported.Survey responses from Task Force-appointed expert consultants and specialty society members obtained during development of the original Advisory are summarized in the text and reported in appendix 2, tables 1–5.A preanesthesia history and physical examination precedes the ordering, requiring, or performance of specific preanesthesia tests and consists of (1) evaluation of pertinent medical records, (2) patient interview(s), and (3) physical examination. No controlled trials of the clinical impact of performing a preanesthesia medical records review or physical examination were found (Category D evidence ). Observational studies of asymptomatic or nonselected surgical patients reported associations between several preoperative patient characteristics (e.g. , age, health status) and postoperative morbidity and mortality (Category B2 evidence ).1–14Several observational studies reported perioperative complications (e.g. , cardiac, respiratory, renal, hemorrhagic) associated with specific preexisting conditions (e.g. , diabetes, pulmonary disease, chronic hypertension, previous myocardial infarction, history of smoking, high body mass index, extremes of age) (Category B2 evidence ).15–55These associations do not provide evidence regarding the clinical impact of perioperative interventions that may be derived from preoperative knowledge of a patient's condition. Additional studies were examined that reported changes in resource management based on preexisting conditions (e.g. , airway abnormalities, cardiopulmonary disorders) detected during a preanesthetic examination, interview, or questionnaire administration (Category B2 evidence ).56–61The activities encompassed by a preanesthetic history and physical examination occur over a variable period of time. The timing of an initial preanesthetic evaluation is guided by such factors as patient demographics, clinical conditions, type and invasiveness of procedure, and the nature of the healthcare system. Three options that practices use for the timing of an initial preanesthetic evaluation are: (1) always before the day of surgery, (2) either on or before the day of surgery, and (3) only on the day of surgery.Consultant and ASA member opinions regarding the timing of an initial assessment of pertinent medical records for high, medium, and low levels of surgical invasiveness, independent of medical condition, were obtained during development of the original Advisory and are reported in table 1(appendix 2). The majority of consultants and ASA members agree that for high surgical invasiveness, the initial assessment of pertinent medical records should be done before the day of surgery by anesthesia staff. For medium surgical invasiveness, the majority of consultants indicate that the initial assessment of pertinent medical records should be done before the day of surgery by anesthesia staff, although the majority of ASA members indicate that the initial assessment may be done on or before the day of surgery. For low surgical invasiveness, the majority of consultants and ASA members agree that the initial assessment may be done on or before the day of surgery.Consultant and ASA membership opinions regarding the timing of an initial preanesthetic interview and physical examination for high and low severities of disease are reported in table 2(appendix 2). The majority of consultants and ASA members agree that, for patients with high severity of disease, it is preferable that the interview and physical examination be done before the day of surgery by anesthesia staff. For low severity of disease and high surgical invasiveness, consultants and ASA members agree that it is preferable that the interview and physical examination should be done before the day of surgery. For patients with low severity of disease and medium or low surgical invasiveness, consultants and ASA members agree that the interview and physical examination may be done on or before the day of surgery.A majority of consultants and the ASA membership, respectively, agree that, at a minimum , a preanesthetic physical examination should include (1) an airway examination (100%, 100%), (2) a pulmonary examination to include auscultation of the lungs (88%, 85%), and (3) a cardiovascular examination (81%, 82%).The assessment of anesthetic risks associated with the patient's medical conditions, therapies, alternative treatments, surgical and other procedures, and of options for anesthetic techniques is an component of basic anesthetic may but are not limited the safety of perioperative care, resource and patient assessment of pertinent medical records with when should be as part of the preanesthetic evaluation before the day of surgery for with high surgical For with low surgical invasiveness, the review and assessment of medical records may be done on or before the day of surgery by anesthesia staff. The information obtained may but should not be limited (1) a of (2) treatments, including and alternative and (3) of the patient's medical The Task Force that the timing of such assessments may not be with the of resources provided in specific healthcare or initial patient interview, and physical examination should be before the day of surgery for patients with high severity of For patients with low severity of disease and those with high surgical invasiveness, the interview and physical should also be before the day of surgery. For patients with low severity of disease with medium or low surgical invasiveness, the initial interview and physical may be on or before the day of surgery. a minimum , a preanesthetic physical examination should include an assessment of the and with of Task Force it is the of the healthcare at a provide pertinent information to the anesthesiologist for the assessment of the severity of medical of the patient and invasiveness of the surgical in of the anticipated day of for all elective regarding controlled trials and test findings regarding the or of used preoperative tests are described below. For purposes of this Advisory, a test is defined as a test in the of a specific clinical or such as or are not considered as specific clinical or indicated test is defined as a test that is for a specific clinical or For assessment of therapy effects be considered an for specific studies report findings for asymptomatic or nonselected patients from to of patients (Category B2 evidence findings to of surgery or changes in management in of (Category B2 evidence studies report findings for that were as indicated tests in of to or changes in management in of (Category B2 evidence observational study with and practitioner found that preoperative were associated with intraoperative and postoperative myocardial for patients with disease scheduled for elective surgery (Category B2 evidence observational study reports findings in of asymptomatic or nonselected patients (Category B2 evidence observational study reports test in of asymptomatic or nonselected to a management change in of the (Category B2 evidence patients with observational studies report findings in of to of surgery in of (Category B2 evidence or indicated or test findings were reported for of to additional in of patients with findings (Category B2 evidence study of surgery patients a preoperative test reports a mortality with patients not a preoperative test (Category B2 evidence findings indicated low (e.g. , in of patients (Category B2 evidence findings were reported as in of asymptomatic or nonselected to or changes in management in of found to be (Category B2 evidence or indicated findings were reported in of to or changes in management in of the with findings (Category B2 evidence studies reported findings in of asymptomatic or nonselected patients (Category B2 evidence in clinical management were not or indicated pulmonary test findings were reported in of findings were reported in of patients (Category B2 evidence in clinical management were not asymptomatic or nonselected findings were reported in to of to or changes in management in of with findings (Category B2 evidence or indicated findings were reported in of patients (Category B2 evidence in clinical management were not asymptomatic or nonselected findings were reported in of to of surgery in of the with findings (Category B2 evidence asymptomatic or nonselected (i.e. , test results not were reported in of to changes in clinical management in of with findings (Category B2 evidence or indicated were reported in of to changes in clinical management in of the with findings (Category B2 evidence asymptomatic or nonselected (i.e. , or were reported in of to or changes in management in of with findings (Category B2 evidence or indicated findings were reported in of patients (Category B2 evidence in clinical management were not asymptomatic or nonselected were reported in of were reported in of were reported in of patients (Category B2 evidence in clinical management were not or indicated were reported in of patients (Category B2 evidence study preoperative 3 before surgery with at and found at (Category B2 evidence in clinical management were not asymptomatic or nonselected findings for not including testing, were reported in of to or changes in management in of the with findings (Category B2 evidence or indicated not including testing, were reported in of to changes in clinical management in of with findings (Category B2 evidence asymptomatic or nonselected patients (i.e. , not on the basis of test findings were reported in of to or changes in management in of the of (Category B2 evidence the original Advisory, consultants and ASA members were asked to whether specific preoperative tests (1) should be on a basis (i.e. , to patients of known or or (2) should be for patients or for of surgery, or (3) are not For the tests and ASA membership responses are reported in table 2). and ASA members were also asked to specific patient characteristics that a to or a preoperative For specific patient and ASA membership responses are reported in table and ASA members were asked whether or not they agree that preoperative test results are obtained from the patient's medical the patient's medical history not the test result was The of of consultants and ASA members are respectively, as other evaluation or studies and who that test findings be obtained from a patient's medical were asked the findings should be to be on test findings should be are reported in table tests should not be Preoperative tests may be or on a basis for purposes of or perioperative The for such should be and based on information obtained from medical records, patient interview, physical examination, and type and invasiveness of the Task Force that there is evidence to or for preoperative tests on the basis of specific clinical However, consideration of clinical characteristics may assist the anesthesiologist when to or preoperative The following clinical characteristics may be of although the anesthesiologist should not limit consideration to the characteristics clinical characteristics may include disease, disease, and type or invasiveness of surgery. The Task Force that may be more in patients and in patients with multiple The Task Force not consensus on a specific minimum in those patients specific The Task Force that may not be an for may be indicated for patients with known cardiovascular factors or for patients with factors identified in the of a preanesthesia evaluation may include with and ordering, requiring, or performing tests that from or tests (e.g. , to and assessment of and (e.g. , Anesthesiologists should the risks and costs of their characteristics to include cardiovascular factors and type of characteristics to include smoking, chronic pulmonary disease and The Task Force that may be in such patients but does not that extremes of age, smoking, disease, or should be considered for pulmonary evaluation other may include with and tests that from or tests (e.g. , pulmonary tests, to assessment of pulmonary (e.g. , Anesthesiologists should the risks and costs of their characteristics to include type and invasiveness of the surgical procedure, from previous evaluation, or and with or is not characteristics to as for such tests include type and invasiveness of procedure, patients with disease, extremes of age, and history of and other characteristics to for studies include and type and invasiveness of The Task Force that and alternative may an additional perioperative The Task Force that there were not to comment on the of tests before regional characteristics to before such tests include perioperative therapies, of and and use of or alternative The Task Force that may from at extremes of is not indicated for specific (e.g. , or when are may for anesthesia with The Task Force that the literature is to patients or on whether anesthesia harmful effects on may be to patients of and for the result the patient's management.The literature is not to permit an assessment of the clinical benefits or of the timing for preoperative The Task Force that there is evidence to or for preoperative tests on the basis of specific patient results obtained from the medical within of surgery are the patient's medical history not test results may be when the medical history or when a test results may a in the selection of a specific anesthetic (e.g. , regional anesthesia in the of preanesthesia evaluation the assessment of information from multiple including medical records, patient physical and findings from preoperative scientific literature does not information the of a preanesthesia evaluation to permit recommendations that are the Task Force observational literature, opinion surveys of and surveys of a random of members of the American Society of The focus of opinion surveys (1) the content of the preanesthesia evaluation, (2) the timing of the preanesthesia evaluation, and (3) the for specific preoperative following a synthesis of the opinion literature, and Task Force Task Force that in resources available to a specific healthcare or may affect the timing of the preanesthetic evaluation. The healthcare is to provide pertinent information to the anesthesiologist for the assessment of the invasiveness of the surgical and the severity of the patient's medical in of the anticipated day of for all elective this updated Advisory, a review of studies used in the development of the original Advisory was with a review of studies published to of the original Advisory. The updated literature review was based on evidence consisting of relationships between specific preanesthesia evaluation activities and clinical outcomes. The evidence interventions are and For purposes of literature relevant clinical studies were identified and of the The updated a period from The a period of time from new that to the evidence were These articles were and studies that not provide evidence were that were as evidence were with articles by the Advisory, in a of evidence contained sufficient literature with and information to conduct an analysis of aggregated studies (i.e. , A used to this updated Advisory, by is available as 2, study or report that in the published literature can be included as evidence in the development of an it to meet or more of criteria means that a study had that not it for The criteria are as (1) the study be to of the specified (2) the study report a clinical or of findings that can be or reports that only (3) the study report a clinical or of findings that can be identified as the of an original or report the reporting and of the same such as may occur in review articles or studies that previous and the study use research and that provide a clear test or of the between the and of of the studies in this updated Advisory all the published literature not be used as a source of evidence are to assess the studies not provide a clear of However, published studies were that provided the Task Force with evidence. For literature (i.e. , reports of or is often in an of the scope of a and case reports may be in the of preoperative tests for the literature not in the of specific preanesthesia evaluation activities in patient outcome. controlled studies are evidence from sources will to be such as and the opinion of and is that research on preanesthesia evaluation focus on the identification of preoperative tests or other activities in the of research when the original Advisory, consensus was obtained from multiple including (1) survey opinion from consultants who were based on their knowledge or expertise regarding preanesthesia or preoperative evaluation, (2) survey opinions from a of ASA members (3) from of three held open forums at national anesthesia commentary, and Task Force opinion and and ASA members to three surveys the following (1) the and of for evidence (2) the and to include for timing of the preanesthesia evaluation, and (3) surveys regarding the timing and content of the preanesthesia evaluation and for The survey of for consultants was of the ASA members responses for consultants and ASA members are in the text of the Advisory, and of survey responses are reported in tables the original Advisory, consultants were asked to indicate of the evidence change their clinical practices the Advisory was The of was of The of consultants change associated with each were as (1) review of medical records, or other (2) preanesthesia patient examination (3) patient for medical or anesthesia history timing of the preanesthesia evaluation or performing preanesthesia or performing other performing preanesthesia pulmonary tests performing preanesthesia performing preanesthesia tests and performing preanesthesia tests the indicated that the Advisory on the of time on a and indicated that there be a in the of time on a case with the of this Advisory.

PRACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.This document updates the “Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management,” adopted by the ASA in 2003 and published in 2004.*For these Guidelines, acute pain is defined as pain that is present in a surgical patient after a procedure. Such pain may be the result of trauma from the procedure or procedure-related complications. Pain management in the perioperative setting refers to actions before, during, and after a procedure that are intended to reduce or eliminate postoperative pain before discharge.The purpose of these Guidelines is to (1) facilitate the safety and effectiveness of acute pain management in the perioperative setting; (2) reduce the risk of adverse outcomes; (3) maintain the patient's functional abilities, as well as physical and psychologic well-being; and (4) enhance the quality of life for patients with acute pain during the perioperative period. Adverse outcomes that may result from the undertreatment of perioperative pain include (but are not limited to) thromboembolic and pulmonary complications, additional time spent in an intensive care unit or hospital, hospital readmission for further pain management, needless suffering, impairment of health-related quality of life, and development of chronic pain. Adverse outcomes associated with the management of perioperative pain include (but are not limited to) respiratory depression, brain or other neurologic injury, sedation, circulatory depression, nausea, vomiting, pruritus, urinary retention, impairment of bowel function, and sleep disruption. Health-related quality of life includes (but is not limited to) physical, emotional, social, and spiritual well-being.These Guidelines focus on acute pain management in the perioperative setting for adult (including geriatric) and pediatric patients undergoing either inpatient or outpatient surgery. Modalities for perioperative pain management addressed in these Guidelines require a higher level of professional expertise and organizational structure than “as needed” intramuscular or intravenous injections of opioid analgesics. These Guidelines are not intended as an exhaustive compendium of specific techniques.Patients with severe or concurrent medical illness such as sickle cell crisis, pancreatitis, or acute pain related to cancer or cancer treatment may also benefit from aggressive pain control. Labor pain is another condition of interest to anesthesiologists. However, the complex interactions of concurrent medical therapies and physiologic alterations make it impractical to address pain management for these populations within the context of this document.Although patients undergoing painful procedures may benefit from the appropriate use of anxiolytics and sedatives in combination with analgesics and local anesthetics when indicated, these Guidelines do not specifically address the use of anxiolysis or sedation during such procedures.These Guidelines are intended for use by anesthesiologists and individuals who deliver care under the supervision of anesthesiologists. The Guidelines may also serve as a resource for other physicians and healthcare professionals who manage perioperative pain. In addition, these Guidelines may be used by policymakers to promote effective and patient-centered care.Anesthesiologists bring an exceptional level of interest and expertise to the area of perioperative pain management. Anesthesiologists are uniquely qualified and positioned to provide leadership in integrating pain management within perioperative care. In this leadership role, anesthesiologists improve quality of care by developing and directing institution-wide, interdisciplinary perioperative analgesia programs.The original Guidelines were developed by an ASA appointed task force of 11 members, consisting of anesthesiologists in private and academic practices from various geographic areas of the United States, and two consulting methodologists from the ASA Committee on Standards and Practice Parameters.The Task Force updated the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to acute pain management were reviewed and evaluated. Third, expert consultants were asked to: (1) participate in opinion surveys on the effectiveness of various acute pain management recommendations and (2) review and comment on a draft of the updated Guidelines. Fourth, opinions about the updated Guideline recommendations were solicited from a sample of active members of the ASA. Fifth, opinion-based information obtained during an open forum for the original Guidelines, held at a major national meeting,†was reexamined. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the updated Guidelines. Seventh, all available information was used to build consensus to finalize the updated Guidelines. A summary of recommendations may be found in appendix 1.Preparation of these Guidelines followed a rigorous methodological process. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence.Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described below. All literature (e.g. , randomized controlled trials [RCTs], observational studies, case reports) relevant to each topic was considered when evaluating the findings. However, for reporting purposes in this document, only the highest level of evidence (i.e. , level 1, 2, or 3 within category A, B, or C, as identified below) is included in the summary.Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.Information from observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes.The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes.The lack of scientific evidence in the literature is described by the following terms.Inadequate: The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The literature either does not meet the criteria for content as defined in the “Focus” of the Guidelines or does not permit a clear interpretation of findings due to methodological concerns (e.g. , confounding in study design or implementation).Silent: No identified studies address the specified relationships among interventions and outcomes.All opinion-based evidence (e.g. , survey data, open-forum testimony, Internet-based comments, letters, editorials) relevant to each topic was considered in the development of these updated Guidelines. However, only the findings obtained from formal surveys are reported.Opinion surveys were developed for this update by the Task Force to address each clinical intervention identified in the document. Identical surveys were distributed to expert consultants and ASA members.Survey responses from Task Force-appointed expert consultants are reported in summary form in the text, with a complete listing of consultant survey responses reported in appendix 2.Survey responses from active ASA members are reported in summary form in the text, with a complete listing of ASA member survey responses reported in appendix 2.Opinion survey responses are recorded using a 5-point scale and summarized based on median values.§Strongly Agree: Median score of 5 (At least 50% of the responses are 5)Agree: Median score of 4 (At least 50% of the responses are 4 or 4 and 5)Equivocal: Median score of 3 (At least 50% of the responses are 3, or no other response category or combination of similar categories contain at least 50% of the responses)Disagree: Median score of 2 (At least 50% of responses are 2 or 1 and 2)Strongly Disagree: Median score of 1 (At least 50% of responses are 1)Open-forum testimony from the previous update, Internet-based comments, letters, and editorials are all informally evaluated and discussed during the development of Guideline recommendations. When warranted, the Task Force may add educational information or cautionary notes based on this information.Institutional policies and procedures include (but are not limited to) (1) education and training for healthcare providers, (2) monitoring of patient outcomes, (3) documentation of monitoring activities, (4) monitoring of outcomes at an institutional level, (5) 24-h availability of anesthesiologists providing perioperative pain management, and (6) use of a dedicated acute pain service.Observational studies report that education and training programs for healthcare providers are associated with decreased pain levels,1–4decreased nausea and vomiting,2and improved patient satisfaction1(Category B2 evidence ), although the type of education and training provided varied across the studies. Published evidence is insufficient to evaluate the impact of monitoring patient outcomes at either the individual patient or institutional level, and the 24-h availability of anesthesiologists (Category D evidence ). Observational studies assessing documentation activities suggest that pain outcomes are not fully documented in patient records (Category B2 evidence ).5–11Observational studies indicate that acute pain services are associated with reductions in perioperative pain (Category B2 evidence ),12–20although treatment components of the acute pain services varied across the studies.The consultants and ASA members strongly agree that anesthesiologists offering perioperative analgesia services should provide, in collaboration with other healthcare professionals as appropriate, ongoing education and training of hospital personnel regarding the effective and safe use of the available treatment options within the The consultants and ASA members also strongly agree that anesthesiologists and other healthcare providers should use to facilitate the and documentation of pain the of pain and by the The ASA members agree and the consultants strongly agree (1) anesthesiologists for perioperative analgesia should be available at all to with or other and should assist in evaluating patients who are with any of perioperative pain (2) anesthesiologists should provide analgesia services within the of an Acute Pain and participate in developing institutional policies and and (3) an to perioperative pain management (e.g. , and for pain outcomes quality should be used to offering perioperative analgesia services should provide, in collaboration with other healthcare professionals as appropriate, ongoing education and training to that hospital personnel are and with to the effective and safe use of the available treatment options within the content should from basic pain to pain management (e.g. , patient controlled and various and (e.g. , pain management, ongoing education and training are for to maintain and are and other healthcare providers should use to facilitate the and documentation of pain the of pain and by the risk for adverse that may require medical Anesthesiologists for perioperative analgesia should be available at all to with or other and should assist in evaluating patients who are with any of perioperative pain providing perioperative analgesia services should do within the of an Acute Pain and participate in developing institutional policies and An to perioperative pain management that includes and and for perioperative pain as well as outcomes and quality patient and is to perioperative pain management. is an for postoperative analgesia that pain management the perioperative care of to in a include type of of postoperative medical (e.g. , of respiratory or the for the available and a patient's or previous with the literature is insufficient regarding the of a pain a physical or with other healthcare providers (Category D evidence ), the Task Force the of these observational study in a intensive care unit that the of a pain management may be associated with time to and to (Category B2 evidence ASA members agree and the consultants strongly agree that a a physical and a pain should be included in the pain a physical and a pain should be included in the patient includes (1) or of may a (2) to reduce pain and (3) before as of a pain management and (4) patient and pain is insufficient literature to evaluate the impact of or of may an (Category D evidence ). there is insufficient literature to evaluate the of the of treatment either to reduce pain or as of a pain management (Category D evidence ). are regarding the impact of patient and education on patient and time to although of patient and education varied across the studies (Category evidence consultants and ASA members strongly agree that patient for perioperative pain management should include appropriate or of to an treatment of or of for postoperative pain management. The ASA members agree and the consultants strongly agree that anesthesiologists offering perioperative analgesia services should provide, in collaboration with as appropriate, patient and The consultants and ASA members agree that perioperative patient education should include in for of pain and for perioperative pain management should include appropriate or of to an treatment of or of for postoperative pain offering perioperative analgesia services should provide, in collaboration with as appropriate, patient and education regarding their in reporting and in use of the that the risk of adverse and should be education for use of analgesia and other such as include of these at the time of the and to patients about and at the during postoperative Such education may also include in for of pain and for postoperative pain management include are not limited to the following (1) (i.e. , opioid (2) with and (3) not limited to and local of opioid controlled trials report improved pain when use of or is with or intramuscular (Category evidence or or with report findings regarding pain (Category evidence or or with postoperative or are regarding postoperative pain (Category evidence of improved pain and of in of and (Category evidence findings for the of nausea or were (Category evidence ). of with intramuscular report improved pain and an of (Category evidence improved pain and use when is with no treatment (Category evidence improved pain when postoperative is with postoperative (Category evidence of improved pain and a higher of and urinary when postoperative is with intramuscular (Category evidence findings for nausea and are (Category evidence ). from are regarding the of postoperative with postoperative (Category evidence findings are for nausea and and (Category evidence with controlled trials report findings regarding the of with or intravenous analgesia (Category evidence of improved pain when is with intramuscular (Category evidence from of and are regarding (Category evidence from of use when with a of is with a (Category evidence findings were regarding pain nausea and vomiting, pruritus, and sedation (Category evidence these Guidelines, include (e.g. , or and of indicate that or with is associated with improved pain (Category evidence report improved pain and when or is with (Category evidence of report findings for pain and used when postoperative or are with (Category evidence controlled trials report pain findings when with are with (Category evidence of use when with are with (Category evidence findings are for nausea and (Category evidence ). of pain when and other are with no (Category evidence report findings for pain and use when and other are with or no (Category evidence report findings for pain and use when or local anesthetics are with (Category evidence of improved pain when of is with (Category evidence findings for use are (Category evidence of are for pain and use when of is with (Category evidence of pain score findings when of is with of (Category evidence of improved pain and use when of is with (Category evidence consultants and ASA members strongly agree that anesthesiologists who manage perioperative pain should use options such as or opioid and after the and for the individual they also strongly agree that these should be used in to intramuscular “as The consultants and ASA members also strongly agree that the should the individual as well as the for safe of the in each the consultants and ASA members strongly agree that should be when are as may to adverse who manage perioperative pain should use options such as (i.e. , opioid and after the and for the individual These should be used in to intramuscular “as The should the individual as well as the for safe of the in each includes the to and adverse that after of should be when are as may to adverse for pain management include the of two or that by for providing These may be the or by with of improved pain (Category evidence and findings for nausea and and (Category evidence when with local anesthetics is with of improved pain and when with local anesthetics is with (Category evidence findings are reported for nausea and and (Category evidence ). of improved pain pain and a higher of (Category evidence when with is with findings are reported for nausea and (Category evidence ). report findings when with is with (Category evidence of for the higher of (Category evidence findings for nausea and (Category evidence report findings for pain nausea and vomiting, pruritus, and when with is with (Category evidence of for pain (Category evidence and a higher of when with is with (Category evidence ). of is for pain when with is with (Category evidence with of improved pain and use (Category evidence when intravenous with is with intravenous findings are reported for nausea and (Category evidence ). of findings for pain or nausea when intravenous with is with intravenous (Category evidence ). report findings for pain and use when intravenous opioid analgesia with with findings for are (Category evidence of report pain and opioid use when with (i.e. , is with (Category evidence no differences in nausea or are reported (Category evidence consultants and ASA members strongly agree that anesthesiologists should use pain management The ASA members agree and the consultants strongly agree that should be considered as of a postoperative pain management the consultants and ASA members agree that and and should be considered as of a postoperative pain management the ASA members agree and the consultants strongly agree patients should an of or the consultants and ASA members strongly agree that (1) with local anesthetics should be considered as of a for pain (2) should be to the risk of adverse and (3) the of and of should be anesthesiologists should use pain management with local anesthetics should be patients should an of or should be to the risk of adverse The of and of should be patient are at risk for pain and require additional populations at risk include (1) pediatric (2) and (3) or or other patients who may The Task Force that and the pain and response to In addition, the Task Force that patient and to treatment as well as pain by healthcare Task Force that care for and (including to the of pain. specific patient differences in their and of pain and suffering, and their response to in the and hospital may regarding the of analgesia as well as and In the of a clear of pain or pain may that pain is not present and for providing analgesia are in pediatric patients for of respiratory of pain is in and of and may as as the surgical of injections intramuscular or other of the of analgesia before injections may not this of may be effective in providing analgesia in pediatric are the as for although (e.g. , are used in The Task Force that it is for to that pediatric patients require to perioperative ASA members and consultants strongly agree that (1) perioperative care for undergoing painful procedures or appropriate pain and (2) should and and should a and (3) are with it is that appropriate monitoring be used during the procedure and The ASA members agree and the consultants strongly agree that in the of should be and pain management is to the undertreatment of pain in Perioperative care for undergoing painful procedures or appropriate pain and should and and should a in the of should be and local anesthetics are all components of appropriate for painful are with it is that appropriate monitoring be used during the procedure and patients from such as or cancer that to surgery. The Task Force that pain is and individuals may be to the of such The physical, social, emotional, and associated with an impact on perioperative pain management. These patients may than adult patients in pain and appropriate the and local anesthetics are distributed and and effective in may also benefit patients an in adverse observational study that perioperative analgesics are provided in to than to (Category B2 evidence Task Force although the for perioperative in the are undertreatment of pain in is ASA members and consultants strongly agree that (1) pain and should be the perioperative care of (2) pain appropriate to a patient's should be and (3) should be to treatment adverse such as in this who may be other The ASA members agree and the consultants strongly agree that and and should be to that regarding and should be the perioperative care of Pain appropriate to a patient's should be and and may be to that regarding pain. Anesthesiologists should that patients may than patients to pain and of is to treatment adverse such as in this who are other (including and who are (e.g. , or who (e.g. , or present to perioperative pain management. The Task Force that that reduce to provide effective analgesia (e.g. , analgesia and may be for such and such as that of analgesics are for the The literature is insufficient to evaluate the of pain or pain management specific to these populations (Category D evidence consultants and ASA members strongly agree that anesthesiologists should that patients who are or may require additional interventions to perioperative pain management. the ASA members agree and the consultants strongly agree that anesthesiologists should a of an in patients with and or when other than pain should that patients who are or may require additional interventions to perioperative pain management. Anesthesiologists should a of an in patients with and or when other than pain these updated Guidelines, a review of studies used in the development of the original Guidelines was with studies published to of the original Guidelines in The scientific of these Guidelines was based on evidence or regarding relationships between clinical interventions and outcomes. The interventions were to assess their to a of outcomes related to the management of acute pain in the perioperative and for Perioperative Pain Management of the of the Perioperative for Pain Management or the literature relevant clinical studies were identified and of the The and a from than were identified a of that addressed related to the evidence the were studies not provide evidence and were A of evidence. A complete used to these Guidelines, by is available as 2, each reported in a study was as an evidence a or The were summarized to a for each evidence before formal to evidence categories studies with and information for These (1) or (2) (3) and (4) two or a or were obtained for and were obtained for were used as (1) the based on of the reported from the studies, and (2) the providing of the studies by each of the by the of the An procedure based on the for study using 2 2 was used with An level was at < for of the studies were to among the study were obtained when significant was found (P < for a was No for studies was and no for research were be as significant agree with of are In the of findings from the and agree with each other to be as the previous update of the Guidelines, among Task Force members and two methodologists was by using a for were as (1) type of study (2) type of (3) evidence and (4) literature for (1) study (2) type of (3) (4) literature These of the updated Guidelines, the two methodologists in the original Guidelines the literature findings of the literature were by the opinions of Task Force members after opinions from a of and from of the draft document on the ASA In addition, opinions obtained from consultant open forum commentary, and other used in the original Guidelines were reviewed and was obtained from (1) survey opinion from consultants who were based on their or expertise in acute pain management, (2) survey opinions solicited from active members of the (3) testimony from of a held open forum at a national Guidelines (4) commentary, and (5) Task Force opinion and The survey of was of for the consultants and surveys were from active ASA members the previous update of the Guidelines, an additional survey was to the expert consultants to indicate of the evidence their clinical practices the Guidelines were The of was of The of consultants no associated with each were as (1) (2) education and training (3) education or of patient and (4) monitoring or documentation (5) availability of anesthesiologists (6) institutional use of or use of organizational pediatric and of the that the Guidelines no on the of time spent on a and that there be an of the of time spent on a case with the of these Guidelines time that or training not be to the Guidelines, and that of the Guidelines not require in that

Developed by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies: Gregory A. Nuttall, M.D. (Chair), Rochester, Minnesota; Brian C. Brost, M.D., Rochester, Minnesota; Richard T. Connis, Ph.D., Woodinville, Washington; James S. Gessner, M.D., Chestnut Hill, Massachusetts; Chantal R. Harrison M.D., San Antonio, Texas; Ronald D. Miller, M.D., San Francisco, California; David G. Nickinovich, Ph.D., Bellevue, Washington; Nancy A. Nussmeier, M.D., Houston, Texas; Andrew D. Rosenberg, M.D., Roslyn Heights, New York; Richard Spence, M.D., Baltimore, Maryland.Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints.Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data.This update includes data published since the “Practice Guidelines for Blood Component Therapy” were adopted by the American Society of Anesthesiologists (ASA) in 1995; it also includes data and recommendations for a wider range of techniques than was previously addressed.Blood transfusion refers to the perioperative administration of blood and blood components (e.g. , autologous blood, allogeneic whole blood, red blood cells, fresh frozen plasma [FFP], platelets, and cryoprecipitate). Adjuvant therapies refer to drugs and techniques to reduce or prevent blood loss and the need for transfusion of allogeneic blood.The purposes of these Guidelines are to improve the perioperative management of blood transfusion and adjuvant therapies and to reduce the risk of adverse outcomes associated with transfusions, bleeding, or anemia. In addition, these Guidelines provide an update on the relative risks that cause morbidity and mortality associated with blood transfusion and adjuvant therapies.These Guidelines focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. This includes but is not limited to (1) patients undergoing cardiopulmonary bypass or cardiac surgery, urgent or emergent procedures, obstetric procedures, organ transplantation, and major noncardiac surgery; (2) patients with preexisting blood disorders or acquired deficiency secondary to massive bleeding; (3) critically ill patients; and (4) patients who elect not to undergo transfusion. Excluded from the focus of these Guidelines are neonates, infants, children weighing less than 35 kg, and nonsurgical patients.These Guidelines apply to both inpatient and outpatient surgical settings and to procedures performed in operating rooms as well as in other locations (e.g. , interventional radiology, critical care units) where blood transfusion or other adjuvant therapy is indicated. They are directly applicable to care administered by anesthesiologists and individuals who deliver care under the medical direction or supervision of an anesthesiologist. They are also intended to serve as a resource for other physicians and patient care personnel who are involved in the perioperative care of these patients.The ASA appointed a Task Force of 10 members to (1) review the published evidence, (2) obtain the opinion of a panel of consultants including anesthesiologists and nonanesthesiologist physicians concerned with perioperative blood transfusion, and (3) obtain opinions from practitioners likely to be affected by the Guidelines. The Task Force included anesthesiologists in both private and academic practices from various geographic areas of the United States, a surgeon, a pathologist specializing in transfusion medicine, an obstetrician, and two consulting methodologists from the ASA Committee on Practice Parameters.The Task Force developed the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence of effective blood transfusion and adjuvant therapies. Second, original published research studies from peer-reviewed journals relevant to the perioperative management of patients undergoing blood transfusions were reviewed. Third, the panel of expert consultants was asked to (1) participate in opinion surveys on the effectiveness of various perioperative management strategies and (2) review and comment on a draft of the Guidelines developed by the Task Force. Fourth, opinions about the Guideline recommendations were solicited from random samples of active members of the ASA. Fifth, the Task Force held open forums at two major national meetings to solicit input on its draft recommendations. National organizations representing specialties whose members typically care for patients undergoing perioperative transfusion were invited to participate in the open forums. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Seventh, all available information was used to build consensus within the Task Force to finalize the Guidelines.Preparation of these Guidelines followed a rigorous methodologic process. To convey the findings in a concise and easy-to-understand fashion, these Guidelines use several descriptive terms.When sufficient numbers of studies are available for evaluation, the following terms describe the strength of the findings.The lack of scientific evidence in the literature is described by the following terms.Formal survey information is collected from consultants and members of the ASA. The following terms describe survey responses for any specified issue. Responses are solicited on a five-point scale; ranging from 1 (strongly disagree) to 5 (strongly agree), with a score of 3 being equivocal. Survey responses are summarized based on median values as follows:Preoperative evaluation of a patient for blood transfusion and adjuvant therapies includes (1) reviewing previous medical records, (2) conducting a patient or family interview, and (3) reviewing laboratory test results. Although comparative studies are insufficient to evaluate the perioperative impact of reviewing medical records or conducting a patient interview, the literature reports certain patient characteristics that may be associated with blood transfusion complications. These characteristics include, but are not limited to, congenital or acquired conditions such as factor VIII deficiency, sickle cell anemia, idiopathic thrombocytopenic purpura, and liver disease. In addition, the literature suggests that some preoperative laboratory tests (e.g. , hemoglobin, hematocrit, coagulation profile) may predict the need for blood transfusion or excessive blood loss. The consultants and ASA members strongly agree that reviewing previous medical records, interviewing the patient, and reviewing hemoglobin/hematocrit test results should be part of a preoperative evaluation.†The consultants strongly agree and the ASA members agree that a coagulation profile should be reviewed.Preoperative evaluation should include reviewing previous medical records, conducting a physical examination of the patient, and an interview of the patient or family to identify risk factors for (1) organ ischemia (e.g. , cardiorespiratory disease), which may influence the ultimate transfusion trigger for red blood cells (e.g. , hemoglobin level), and (2) coagulopathy (e.g. , use of warfarin, clopidogrel, aspirin), which may influence transfusion of non–red blood cell components. In addition, a preoperative evaluation should include checking for the presence of congenital or acquired blood disorders, the use of vitamins or herbal supplements that may affect coagulation (appendix 2), or previous exposure to drugs (e.g. , aprotinin) that may, upon repeat exposure, cause an allergic reaction. Patients should be informed of the potential risks versus benefits of blood transfusion, and their preferences elicited. Available preoperative laboratory results including, but not limited to, hemoglobin, hematocrit, and coagulation profiles should be reviewed if they are appropriate and available. Additional laboratory tests should be ordered based on a patient's condition (e.g. , clinical coagulopathy) or institutional policy.Preoperative patient preparation includes (1) discontinuation or modification of anticoagulation therapy, (2) the prophylactic administration of drugs to promote coagulation and minimize blood loss (e.g. , aprotinin, ϵ-aminocaproic acid, tranexamic acid), and (3) prevention or reduction of allogeneic transfusion requirements.The impact of discontinuing anticoagulation therapy on blood loss has not been sufficiently addressed in the literature. In addition, the literature is insufficient to address the impact of delaying surgery until the effects of anticoagulation drugs have dissipated. The literature supports the use of aprotinin in reducing blood loss and in reducing the number of patients transfused in major surgical procedures (e.g. , selected cardiac and orthopedic procedures). In addition, the literature is supportive of the use of ϵ-aminocaproic acid and tranexamic acid in reducing blood loss; however, the impact of these drugs on reducing the number of patients transfused is equivocal. The literature is insufficient to evaluate the use of these drugs in a nonprophylactic manner. Some literature has reported adverse outcomes associated with the use of antifibrinolytic drugs such as graft thrombosis or closure and rare massive thrombosis. Severe anaphylactic reactions may occur with aprotinin reexposure.The efficacy of erythropoietin in reducing the volume of allogeneic blood transfused per patient as well as reducing the number of patients requiring such transfusions is supported by the literature in select populations (e.g. , renal insufficiency, anemia of chronic disease, refusal of transfusion). The literature is insufficient to address the effects of vitamin K.The efficacy of preadmission blood collection to reduce the volume of allogeneic blood transfused per patient and to reduce the number of patients requiring such transfusions is supported by the literature. However, the literature indicates that certain adverse outcomes (e.g. , transfusion reaction due to clerical errors, bacterial contamination) may still occur with the use of autologous blood.The consultants agree and the ASA members strongly agree that anticoagulation drugs (e.g. , warfarin, clopidogrel, aspirin) should be discontinued before elective or nonemergent surgery, and both agree that such surgery should be delayed until the anticoagulation effects wear off. They agree that, when significant blood loss is expected, antifibrinolytics should be administered. In addition, the consultants and ASA members agree that erythropoietin may be used to reduce the use of allogeneic blood. They agree that vitamin K should be administered preoperatively for reversal of warfarin to potentially avoid transfusion of FFP. The ASA members agree and the consultants are equivocal that preadmission donation of blood should be offered to patients when transfusion of autologous blood is required or preferred. They disagree that autologous blood should be administered to the patient who donated it if his or her hemoglobin is greater than 10 g/dl.If possible, the preoperative evaluation should be done well enough in advance to correct or plan for the management of risk factors associated with transfusions. For elective surgery, patient preparation should include discontinuing anticoagulation therapy for a sufficient time in advance of surgery, if clinically possible. If sufficient time has not elapsed, surgery should be delayed until the effects of these drugs dissipate. The Task Force notes that the effect of clopidogrel may last for approximately a week, and the effects of warfarin may last for several days depending on patient response and the administration of reversal agents (e.g. , vitamin K, prothrombin complex concentrate, recombinant activated factor VII, or FFP). The risk of thrombosis versus the risk of increased bleeding should be considered when altering anticoagulation status. Assure that blood and blood components are available for patients when significant blood loss or transfusion is expected.Antifibrinolytic therapy should not be routinely administered. However, such therapy may be used for reducing the volume of allogeneic blood transfused for patients at high risk of excessive bleeding (e.g. , repeat cardiac surgery). The risks and benefits of instituting antifibrinolytic therapy should be assessed on a case-by-case basis.Erythropoietin should be administered when possible to reduce the need for allogeneic blood in certain selected patient populations (e.g. , renal insufficiency, anemia of chronic disease, refusal of transfusion). The Task Force recognizes that erythropoietin administration is perceived as being expensive and requires time (in weeks) to induce a significant increase in hemoglobin concentration. Vitamin K or another warfarin antagonist should be used for reversal of warfarin to potentially avoid transfusion of FFP.Where autologous blood is required or preferred, the patient may be offered the opportunity to donate blood before However, the Task Force that preoperative anemia may be in to an increase in autologous or allogeneic transfusions, as well as and include red blood cell transfusion, management of and and of adverse effects of and management of potential or blood loss includes (1) the of blood (2) hemoglobin or hematocrit, (3) for the presence of and of (e.g. , blood blood and (4) transfusion of allogeneic red blood cells or autologous blood , and red blood cell literature is insufficient to evaluate the efficacy of specific or techniques for the presence of or of or as for the transfusion of red blood The literature supports the efficacy of as well as red blood cell in reducing the number of allogeneic transfused per patient in certain appropriate surgical procedures (e.g. , cardiac surgery, liver surgery, orthopedic However, the literature is equivocal the of to reduce the number of patients Although the practice is in the United States, the literature suggests that red blood cell reduce the number of patients a volume of that has been published since the last practice the information to when a blood transfusion should be is not available in the literature. Although have transfusion on patient the literature is insufficient to a transfusion trigger in surgical patients with blood consultants and ASA members strongly agree that a of the surgical and with the surgical should be done to assess the presence of excessive bleeding , The consultants and ASA members strongly agree that for the presence of and of should be They strongly agree that red blood cells should be administered when the hemoglobin is less than and strongly agree that red blood cells are when the is than 10 In addition, the consultants and ASA members agree that, when autologous blood is required or preferred, and or red blood cell are The consultants are equivocal and the ASA members agree that red blood cell is a in or allogeneic transfusion. they agree that and other laboratory may be a of significant blood of the surgical should be to assess the presence of excessive bleeding , for of blood loss (e.g. , and should be (e.g. , blood should be used to assess the of and of should be used when appropriate (e.g. , blood hemoglobin or when blood loss or any of organ ischemia blood cells should be administered when the hemoglobin is (e.g. , less than in a when the anemia is blood cells are when the hemoglobin is than 10 These may be in the presence of blood loss. The of hemoglobin , or red blood cell transfusion should be based on any of organ potential or bleeding and the patient's volume and the patient's risk factors for of These risk factors include a cardiopulmonary and high volume and blood with or until the criteria for red blood cell transfusion are of red blood cells should be transfused to organ or blood and other means to blood loss (e.g. , may be may also be and management of potential or coagulopathy includes (1) of the surgical and laboratory for (2) transfusion of platelets, (3) transfusion of (4) transfusion of administration of drugs to excessive bleeding (e.g. , and recombinant activated factor of the surgical is practice and of the presence of bleeding and the of blood includes or In a bleeding patient, coagulation tests is also and the literature suggests that coagulation test results with perioperative blood depending on the of used for volume The literature supports the use of and to excessive Although are insufficient numbers of published clinical the efficacy of recombinant activated factor in excessive bleeding , reports its efficacy as a when therapy has a volume of that has been published since the last practice the information to when transfusion of a blood should occur is not available in the literature. Although have transfusion on patient and transfusion in cardiac surgery, the literature is insufficient to specific transfusion for coagulopathy in surgical patients with blood consultants and ASA members strongly agree that, in to a of the surgical with the surgical should include an of the presence of The consultants and ASA members agree that, in a bleeding patient, should be administered when the is below They also agree that, in a bleeding patient, should be administered when or activated time is and that should be when are less than The consultants agree and the ASA members are equivocal that recombinant activated factor is an appropriate when have been The ASA members agree and the consultants are equivocal that should be administered when excessive bleeding the consultants and ASA members agree that (e.g. , or should be administered for the of excessive of the surgical should be by the and to excessive bleeding , coagulopathy) is for excessive blood loss should also include checking surgical and surgical for coagulopathy should include of prothrombin time or and tests may include of and possible, a should be before transfusion of in a bleeding patient, and a test of should be done in patients with or (e.g. , In surgical or obstetric patients with transfusion is if the is to be greater than and is when the is below in the presence of excessive or procedures associated with limited blood loss may be performed in patients with less than transfusion may be an if is or (e.g. , the presence of cardiopulmonary and of patients with and therapy, including prophylactic therapy, should be based on the potential for or bleeding, and the risk of bleeding a (e.g. , or the cannot be done in a in the presence of excessive bleeding , may be when is is due to increased (e.g. , idiopathic thrombocytopenic purpura, thrombocytopenic prophylactic transfusion is and possible, coagulation tests , or and should be before the administration of in a bleeding Transfusion of is not if and are transfusion is for (1) of excessive bleeding , coagulopathy) in the presence of a greater than or greater than or an greater than (2) of excessive bleeding secondary to coagulation factor deficiency in patients transfused with than blood volume and when or and cannot be in a (3) urgent reversal of warfarin (4) of coagulation factor for which specific are or in a patient requiring is not for of plasma volume or frozen plasma should be in to a of of plasma factor with administration of for urgent reversal of warfarin for which to 1 platelets, or 1 fresh whole a of coagulation factors to that in 1 possible, a should be before the administration of in a bleeding Transfusion of is if is greater than Transfusion of is (1) when the is less than in the presence of excessive bleeding, (2) to correct excessive bleeding in transfused patients when cannot be in a fashion, and (3) for patients with congenital possible, decisions patients with congenital should be in with the patient's The of patients with and therapy should be based on the potential for or bleeding and the risk of bleeding a (e.g. , or patients with should be with specific if available. If are not is indicated. of of it should be that of the of as or such as or should be considered when excessive bleeding for excessive bleeding , coagulopathy) have been recombinant activated factor should be effects of transfusions include, but are not limited to, bacterial of and transfusion of blood platelets, is the cause of from blood transfusions. The increased risk of bacterial is to a of blood are their If a patient a within platelets, from may be a is from of certain a transfusion. and transfusion and are in within and in the may is specific therapy other than transfusion and instituting critical care supportive patients in is of the of transfusion major adverse effect of transfusion therapy is the of For the and deficiency were allogeneic blood These risks are of the major for the in has been the use of acid The and be by this To disease, and cannot be may the of both and transfusion of reactions include and bleeding, but these may be to other in the The of a transfusion reaction in patients include or However, these may not be consultants and ASA members strongly agree that checking for and of a transfusion reaction should be done in the The consultants agree and the ASA members strongly agree that and should be the consultants and ASA members agree that should be assessed to for transfusion for and of bacterial and transfusion including increased and instituting therapy for transfusion the blood transfusion and appropriate scientific of these Guidelines was based on evidence or potential clinical and The below were to assess their impact on a of outcomes to perioperative blood transfusion and adjuvant they are not included in the focus of these areas of research include (1) the use of to improve making and reduce transfusion and (2) or other blood to reduce transfusion requirements. evidence was from research and evidence was from open and other (e.g. , For purposes of literature potentially relevant clinical studies were and of the literature. The and a from than were a of that addressed to the evidence review of the studies not provide evidence and were of reported in a was as an evidence a or equivocal. The results were summarized to obtain a for evidence before conducting a to evidence enough studies with and information sufficient for These were (1) erythropoietin versus (2) preadmission blood donation versus autologous blood (3) antifibrinolytics ϵ-aminocaproic acid tranexamic acid (4) transfusion of autologous blood red blood cell and versus or tests were for and were for tests were as (1) the values based on of the reported values from the and (2) the of the studies by of the by the of the based on the for results was used with was at for of the studies were to the results. were when significant was To for potential a was for studies was and tests for research results were results are reported in To be as significant agree with test results both of data are In the of findings from both the and tests agree with other to be as Task Force members and two methodologists was by a for were as (1) of (2) of (3) evidence and (4) literature for values were (1) (2) of (3) and (4) literature These values to high of was from including (1) survey opinion from consultants who were selected based on their or in perioperative blood transfusion and adjuvant (2) survey opinions from a selected of active members of the (3) from of two held open forums at two national commentary, and Task Force opinion and The survey of was of for and of for of the surveys are reported in and in the of the consultants were asked to if of the evidence their clinical practices if the Guidelines were The of was of The of consultants associated with were as preoperative discontinuation of anticoagulation and of drugs to perioperative drugs to promote coagulation and minimize blood preoperative autologous blood for and for transfusion transfusion of allogeneic red blood transfusion of autologous transfusion of transfusion of transfusion of of excessive and and laboratory for transfusion of the that the Guidelines have effect on the of time on a that be an increase in the of time they on a with the of these Guidelines. The of increased time by these from 5 to 10

Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints. Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data.Obstructive sleep apnea (OSA) is a syndrome characterized by periodic, partial, or complete obstruction of the upper airway during sleep. This, in turn, causes repetitive arousal from sleep to restore airway patency, which may result in daytime hypersomnolence or other daytime manifestations of disrupted sleep such as aggressive or distractible behavior in children. The airway obstruction may also cause episodic sleep-associated oxygen desaturation, episodic hypercarbia, and cardiovascular dysfunction. It is estimated that the adult prevalence of sleep disordered breathing, as measured in a sleep laboratory, is 9% in women and 24% in men, whereas the prevalence of overt OSA has been estimated to be 2% in women and 4% in men.1These figures are likely to increase as the population becomes older and more obese. In the perioperative period, both pediatric and adult patients with OSA, even if asymptomatic, present special challenges that must be systematically addressed to minimize the risk of perioperative morbidity or mortality. It is the opinion of the Task Force that the perioperative risk to patients increases in proportion to the severity of sleep apnea.Because procedures differ among laboratories, it is not possible to use specific values of indices (such as the apnea-hypopnea index [AHI]) to define the severity of sleep apnea. Therefore, for the purposes of these Guidelines, patients will be stratified using the terms mild , moderate , and severe as defined by the laboratory where the sleep study was performed.The purpose of these Guidelines is to improve the perioperative care and reduce the risk of adverse outcomes in patients with OSA who receive sedation, analgesia, or anesthesia for diagnostic or therapeutic procedures under the care of an anesthesiologist. The Task Force recognizes that it is not possible to determine with 100% accuracy whether a given patient will develop perioperative complications related to OSA. Therefore, these Guidelines should be implemented with the goal of reducing the likelihood of adverse outcomes in patients who are judged to be at the greatest risk, with the understanding that it may be impractical to eliminate OSA-related perioperative morbidity and mortality completely. However, it is hoped that the implementation of these Guidelines will reduce the likelihood of adverse perioperative outcomes in patients with OSA.These Guidelines focus on the perioperative management of patients with OSA who may be at increased risk for perioperative morbidity and mortality because of potential difficulty in maintaining a patent airway. This population includes but is not limited to patients who have sleep apnea resulting from obesity, pregnancy, and other skeletal, cartilaginous, or soft tissue abnormalities causing upper airway obstruction. Excluded from the focus of these Guidelines are patients with the following: (1) pure central sleep apnea, (2) abnormalities of the upper or lower airway not associated with sleep apnea (e.g. , deviated nasal septum), (3) daytime hypersomnolence from other causes, (4) patients younger than 1 yr, and (5) obesity in the absence of sleep apnea.These Guidelines apply to both inpatient and outpatient settings, and to procedures performed in an operating room, as well as in other locations where sedation or anesthesia is administered. They are directly applicable to care administered by anesthesiologists and individuals who deliver care under the medical direction or supervision of an anesthesiologist. They are also intended to serve as a resource for other physicians and patient care personnel who are involved in the care of these patients. In addition, these Guidelines may serve as a resource to provide an environment for safe patient care.The American Society of Anesthesiologists appointed a Task Force of 12 members to (1) review the published evidence, (2) obtain the opinion of a panel of consultants including anesthesiologists and nonanesthesiologist physicians and researchers who regularly care for patients with OSA, and (3) build consensus within the community of practitioners likely to be affected by the Guidelines. The Task Force included anesthesiologists in both private and academic practices from various geographic areas of the United States, a bariatric surgeon, an otolaryngologist, and two methodologists from the American Society of Anesthesiologists Committee on Practice Parameters.The Task Force developed the Guidelines by means of a six-step process. First, they reached consensus on the criteria for evidence of effective perioperative management of patients with OSA. Second, original published research studies from peer-reviewed journals relevant to the perioperative management of patients with OSA were evaluated. Third, the panel of expert consultants was asked to (1) participate in opinion surveys on the effectiveness of various perioperative management strategies for patients with OSA and (2) review and comment on a draft of the Guidelines developed by the Task Force. Fourth, the Task Force held open forums at two major national meetings to solicit input on its draft recommendations. National organizations representing most of the specialties whose members typically care for patients with OSA were invited to participate in the open forums. Fifth, the consultants were surveyed to assess their opinions on the feasibility and financial implications of implementing the Guidelines. Sixth, all available information was used to build consensus within the Task Force to finalize the Guidelines.Tables 1 and 2are meant to serve as examples of how patients with OSA might be identified and stratified with respect to their perioperative risk. While they were developed by the Task Force with input from the consultants and open forum participants, these tables are not evidence based and have not been clinically validated.Preparation of these Guidelines followed a rigorous methodologic process (appendix). To convey the findings in a concise fashion, these Guidelines use several descriptive terms that are easier to understand than the technical terms used in the actual analyses.When sufficient numbers of studies are available for evaluation, the following terms describe the strength of the findings.The lack of scientific evidence in the literature is described by the following terms.The following terms describe survey responses from the consultants for any specified issue. Responses were solicited on a five-point scale; ranging from 1 (strongly disagree) to 5 (strongly agree), with a score of 3 being equivocal.Preoperative evaluation of a patient for potential identification of OSA includes (1) medical record review, (2) patient or family interview, (3) physical examination, (4) sleep studies, and (5) preoperative x-rays for cephalometric measurement in selected cases. Although the comparative literature is insufficient to evaluate the impact of preprocedure identification of OSA status, it suggests that OSA is associated with airway characteristics that may predispose patients to difficulties in perioperative airway management.*The literature identified certain patient characteristics that are associated with OSA. These characteristics include such features as a higher body mass index, hypertension, and abnormal cephalometric measurements. Additional literature, although insufficient for statistical analysis, suggests that an association may exist between OSA and a larger neck circumference, a history of snoring or respiratory pauses, lower oxygen saturation values during sleep, clinical signs of difficult airway management, and certain congenital conditions (e.g. , Down syndrome, craniofacial abnormality, muscular dystrophy) or disease states (e.g. , diabetes mellitus, cerebral palsy).The consultants agree that, in the absence of a sleep study, a presumptive diagnosis of OSA may be made based on consideration of the following criteria: increased body mass index, a weight or body mass index greater than 95th percentile for age (pediatric patients), increased neck circumference, snoring, congenital airway abnormalities, daytime hypersomnolence, inability to visualize the soft palate, and tonsillar hypertrophy. They strongly agree that observed apnea during sleep is an additional criterion. The consultants agree that preprocedure identification of a patient’s OSA status improves perioperative outcomes, and they are equivocal regarding whether overall costs are decreased. The consultants agree that a patient’s perioperative risk depends on both the severity of the OSA and the invasiveness of the surgical procedure.Anesthesiologists should work with surgeons to develop a protocol whereby patients in whom the possibility of OSA is suspected on clinical grounds are evaluated long enough before the day of surgery to allow preparation of a perioperative management plan. This evaluation may be initiated in a preanesthesia clinic (if available) or by direct consultation from the operating surgeon to the anesthesiologist. A preoperative evaluation should include a comprehensive review of previous medical records (if available), an interview with the patient and/or family, and conducting a physical examination. Medical records review should include (but not be limited to) checking for a history of airway difficulty with previous anesthetics, hypertension or other cardiovascular problems, and other congenital or acquired medical conditions. Review of sleep studies is encouraged. The patient and family interview should include focused questions related to snoring, apneic episodes, frequent arousals during sleep (vocalization, shifting position, extremity movements), morning headaches, and daytime somnolence. A physical examination should include an evaluation of the airway, nasopharyngeal characteristics, neck circumference, tonsil size, and tongue volume. If any of these characteristics suggest that the patient has OSA, the anesthesiologist and surgeon should jointly decide whether to (1) manage the patient perioperatively based on clinical criteria alone or (2) obtain sleep studies, conduct a more extensive airway examination, and initiate indicated OSA treatment in advance of surgery. If this evaluation does not occur until the day of surgery, the surgeon and anesthesiologist together may elect for presumptive management based on clinical criteria or a last-minute delay of surgery. For safety, clinical criteria (table 1) should be designed to have a high degree of sensitivity (despite the resulting low specificity), meaning that some patients may be treated more aggressively than would be necessary if a sleep study were available.The severity of the patient’s OSA, the invasiveness of the diagnostic or therapeutic procedure, and the requirement for postoperative analgesics should be taken into account in determining whether a patient is at increased perioperative risk from OSA (table 2). The patient and his or her family as well as the surgeon should be informed of the potential implications of OSA on the patient’s perioperative course.Preoperative preparation is intended to improve or optimize an OSA patient’s perioperative physical status and includes (1) preoperative airway or or airway (2) preoperative use of or (3) preoperative or (4) preoperative weight is insufficient literature to evaluate the impact of the preoperative use of or on perioperative is insufficient literature to evaluate the of preoperative or weight However, the literature the of in respiratory index and oxygen saturation in the literature the of in reducing in consultants agree that preoperative use of airway or may improve the preoperative of patients who they are at increased perioperative risk from OSA, and they are equivocal regarding the of for these patients. The consultants agree that a preoperative should be made regarding whether surgery in patients at increased perioperative risk from OSA should be performed on an inpatient of should be if OSA is For patients who not to should be In addition, the preoperative use of or and preoperative weight should be A patient who has airway surgery (e.g. , surgical should be to at risk for OSA complications a sleep study has been and have not with or suspected OSA may have difficult and should be according to the Guidelines for of the patients at risk for perioperative complications from OSA, a preoperative must be made regarding whether surgery should be performed on an inpatient or outpatient in patients at increased perioperative risk from OSA include (1) of (2) airway management, and (3) patient The literature is insufficient to evaluate the of various on patients with OSA. the literature is insufficient to evaluate the impact of specific airway management (e.g. , or patient for patients with consultants agree that the use of anesthesia or than anesthesia improves outcomes in patients surgery. The consultants agree that the use of major anesthesia , or than anesthesia improves outcomes for surgery. The consultants are equivocal regarding the of major anesthesia than anesthesia for surgery. The consultants are equivocal regarding whether the use of and anesthesia improves consultants agree that patients at increased perioperative risk from OSA should be and they strongly agree that of should be before They agree that these patients should be in the for and consultants agree that respiratory should be used during moderate or sedation in these consultants agree that anesthesia with a airway is to sedation for and they are equivocal regarding whether anesthesia with a airway is to moderate sedation for The consultants agree that anesthesia with a airway is to moderate or sedation for patients with OSA procedures the upper airway (e.g. , upper of their for airway and sleep patients at increased perioperative risk from OSA are to the respiratory and airway of and in the potential for postoperative respiratory should be For should the use of anesthesia or with or moderate If moderate sedation is should be by or if because of the increased risk of airway obstruction in these patients. should or using an during sedation to patients treated with these anesthesia with a airway is to sedation a airway, for procedures that may the airway. anesthesia should be for is a medical or surgical patients at increased perioperative risk from OSA should be of should be before and should be in the or other in the management of patients with OSA include (1) analgesia, (2) (3) patient and (4) for respiratory include the and of of and invasiveness of surgical procedure, and the severity of the sleep apnea. In addition, of respiratory may occur on the or postoperative day as sleep are and literature is insufficient to evaluate the of various postoperative on patients with OSA. However, the literature is equivocal regarding the use of with or in reducing respiratory among surgical patients. The literature is insufficient to evaluate the of a to on the of patients with OSA. However, the literature the that a in an increased of in surgical consultants agree that than reduce the likelihood of adverse outcomes in patients at increased perioperative risk from OSA. The consultants agree that the of from postoperative as with which include The consultants agree that the use of adverse outcomes their The consultants are equivocal regarding whether with as with or In addition, the consultants are equivocal regarding whether a of in patients at increased perioperative risk from OSA the likelihood of adverse the literature is insufficient to evaluate the of postoperative oxygen in patients with OSA, it the use of oxygen to improve the oxygen saturation of surgical patients. is insufficient literature to evaluate the of or on the postoperative respiratory status of patients with OSA. However, the literature the of in consultants agree that oxygen should be administered as to oxygen saturation and that oxygen may be patients are to their oxygen saturation The consultants strongly agree that or should be administered as as surgery to patients with OSA who were it but they are equivocal regarding the of or in patients who were not treated with these The consultants are equivocal regarding whether patients postoperative or should have the in the patients are not literature an in adult patients with OSA sleep in the or than the in settings, but the literature is insufficient to provide for the postoperative The literature is insufficient to provide for of pediatric patients with OSA. The consultants agree that the should be possible during the of adult and pediatric patients who they are at increased perioperative risk from literature is insufficient to evaluate the of (e.g. , for or in the risk of adverse perioperative in patients with OSA. the literature is insufficient to the impact of postoperative (e.g. , or care for patients with or suspected OSA. The literature is insufficient to regarding the of postoperative respiratory in patients with consultants agree that in a or by the likelihood of perioperative complications among patients who they are at increased perioperative risk from OSA. They are equivocal regarding the of in an care or by a in a patient’s The consultants that patient The consultants agree that should be these patients are in They are equivocal regarding whether should be until these patients are They agree that should be until oxygen saturation during should be to reduce or eliminate the requirement for in patients at increased perioperative risk from OSA. If is the analgesia, for and from of using an or as with a If are should be used with or and other (e.g. , should be if to reduce requirements. are that the of (e.g. , increases the risk of respiratory and airway oxygen should be administered to all patients who are at increased perioperative risk from OSA until they are to their oxygen saturation The Task Force that oxygen may increase the of apneic and may of apnea, and by or with or should be administered (e.g. , patients are not to patients who were using these by the surgical with or may be if patients their to the patients at increased perioperative risk from OSA should be in the process. patients who are at increased risk of respiratory from OSA should have from the may be in a care or by on a or by a in the patient’s should be as long as patients at increased risk. or does not provide the of If frequent or severe airway obstruction or during postoperative of nasal or should be literature is insufficient to regarding which patients with OSA be on an outpatient as to an inpatient and the for of these patients from the surgical consultants agree that procedures typically performed on an outpatient in patients may also be performed on an outpatient in patients who they are at increased perioperative risk from OSA or anesthesia is administered (table The consultants are equivocal regarding whether procedures may be performed during anesthesia in at increased perioperative risk from OSA, but they that airway surgery (e.g. , should be performed on an outpatient in with OSA. They also that in younger than 3 with OSA should be performed on an outpatient and they are equivocal regarding outpatient in older children. The consultants strongly agree that patients at increased perioperative risk from OSA are as the should have difficult airway and they agree on the of respiratory care clinical laboratory They strongly agree that a with an inpatient should be in The Task Force that patients who are at increased risk of perioperative complications of 5 or greater on are not for surgery in a outpatient to outpatient the consultants agree that oxygen saturation should to its and they strongly agree that patients should not or have of clinical airway obstruction in the The consultants indicated that patients with OSA should be for a of 3 than their before from the They also indicated that of patients with OSA should for a of the of airway obstruction or in an patients at increased perioperative risk from OSA are to surgery, a should be made regarding whether a given surgical is most performed on a given patient on an inpatient or outpatient to be in determining whether outpatient care is include (1) sleep apnea status, (2) and abnormalities, (3) status of (4) of surgery, (5) of for postoperative patient of and of the outpatient The of difficult airway respiratory care clinical laboratory and a with an inpatient should be in making this patients should not be from the to an , or until they are at risk for postoperative respiratory of their to develop airway obstruction or central respiratory this may a as with patients of postoperative respiratory may be by patients in an they to be to that they are to their oxygen saturation scientific of these Guidelines was based on evidence or regarding potential between clinical and The below were to assess their to a of outcomes related to the management of patients with OSA in the perioperative evidence was from research literature, and evidence was from open and other (e.g. , For purposes of literature relevant clinical studies were identified and of the The and a from than were a of that addressed related to the evidence review of the studies not provide direct evidence and were A of direct in a study was as an evidence a or The were to obtain a for evidence before conducting a to evidence enough studies with and statistical information sufficient for These were (1) medical records review and body mass OSA and (2) focused physical examination associated with neck and various cephalometric (3) preoperative for OSA and respiratory index and oxygen saturation and (4) postoperative use and oxygen saturation postoperative use and respiratory and postoperative and (5) postoperative oxygen oxygen and and postoperative of patients or tonsil and or were for and were for were used as (1) The values based on of the values from the studies, and (2) the of the studies by of the by the of the based on the for study using tables was used with was at for of the studies were to among the study were was To for potential a was for studies was and for research were are in To be as must agree with both of are In the absence of findings from both the and must agree with other to be as among Task Force members and two methodologists was by using a for were as (1) of study (2) of analysis, (3) evidence and (4) literature for values were (1) study (2) of analysis, (3) and (4) literature These values moderate to high of was from including (1) survey opinion from consultants who were selected based on their or in perioperative management of patients with OSA, (2) from of two held open forums at two national anesthesia (3) Task Force opinion and survey opinions regarding the management of patients with or suspected OSA. The survey of was of of this survey are in in the of the survey opinions regarding the feasibility of implementing the Guidelines in to their clinical of this survey are below and in The of was of Responses by were as sleep or bariatric surgery, and The of the patients who have OSA is and they manage a of patients with OSA They obtain a sleep study for a of patients They would to obtain a sleep study for a of an additional patients to to these recommendations. The of a sleep study at their is They initiate or in preparation for surgery a of a and they that an additional of patients would or to to these Guidelines. They that a of additional patients would postoperative respiratory at their if the Guidelines were and they that the of for which such would be necessary is A of of the with OSA would to be as if the Guidelines were They a of 3 additional of that would be for a OSA patient before from their outpatient if the Guidelines were of the consultants that the sensitivity of the criteria in A of patients with OSA is whereas that they are not and that they are of the consultants indicated that the for of perioperative risk described in whereas that it is not and 4% that it is

PRACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.This update includes data published since the Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration were adopted by the ASA in 1998 and published in 1999.*For these Guidelines, preoperative fasting is defined as a prescribed period of time before a procedure when patients are not allowed the oral intake of liquids or solids. Perioperative pulmonary aspiration is defined as aspiration of gastric contents occurring after induction of anesthesia, during a procedure, or in the immediate period after surgery.The purposes of these Guidelines are to (1) enhance the quality and efficiency of anesthesia care, (2) stimulate evaluation of clinical practices, and (3) reduce the severity of complications related to perioperative pulmonary aspiration of gastric contents.Enhancements in the quality and efficiency of anesthesia care include, but are not limited to, the cost-effective use of perioperative preventive medication, increased patient satisfaction, avoidance of delays and cancellations, decreased risk of dehydration or hypoglycemia from prolonged fasting, and the minimization of perioperative morbidity.Clinical practices include, but are not limited to, withholding solids and liquids for specified time periods before surgery, and prescribing pharmacologic agents to reduce gastric volume and acidity.Complications of aspiration include, but are not limited to, aspiration pneumonia, respiratory disabilities, and related morbidities.These Guidelines focus on preoperative fasting recommendations, as well as recommendations regarding the administration of pharmacologic agents to modify the volume and acidity of gastric contents during procedures in which upper airway protective reflexes may be impaired. Prevention of perioperative pulmonary aspiration is part of the larger process of preoperative evaluation and preparation of the patient.Airway management techniques that are intended to reduce the occurrence of pulmonary aspiration are not the focus of these Guidelines. For example, a rapid-sequence induction/tracheal intubation technique or an awake tracheal intubation technique may be useful to prevent this problem during the delivery of anesthesia care. In addition, these Guidelines do not address the selection of anesthetic technique.The intended patient population for these Guidelines is limited to healthy patients of all ages undergoing elective procedures. These Guidelines do not apply to patients who undergo procedures with no anesthesia or only local anesthesia when upper airway protective reflexes are not impaired, and when no risk factors for pulmonary aspiration are apparent. These Guidelines are also not intended for women in labor.These Guidelines may not apply to, or may need to be modified for (1) patients with coexisting diseases or conditions that can affect gastric emptying or fluid volume (e.g. , pregnancy, obesity, diabetes, hiatal hernia, gastroesophageal reflux disease, ileus or bowel obstruction, emergency care, enteral tube feeding) and (2) patients in whom airway management might be difficult. Anesthesiologists and other anesthesia providers should recognize that these conditions can increase the likelihood of regurgitation and pulmonary aspiration. Additional or alternative preventive strategies may be appropriate for such patients.These Guidelines are intended for use by anesthesiologists and other anesthesia providers. They also may serve as a resource for other health care professionals who advise or care for patients who receive anesthesia care during procedures. Anesthesia care during procedures refers to general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia care). Throughout these Guidelines, preoperative should be considered synonymous with preprocedural, as the latter term is often used to describe procedures that are not considered operations.The original Guidelines were developed by a Task Force of 10 members, including anesthesiologists in both private and academic practice from various geographic areas of North America, and a consulting methodologist from the ASA Committee on Standards and Practice Parameters.The Task Force developed the original Guidelines by means of a six-step process. First, they reached consensus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to preoperative fasting were reviewed and evaluated. Third, expert consultants were asked (1) to participate in opinion surveys on the effectiveness of various preoperative fasting management recommendations and (2) to review and comment on a draft of the Guidelines. Fourth, the Task Force held open forums at a national meeting†to solicit input on the draft recommendations. Fifth, expert consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Sixth, all available information was used to build consensus within the Task Force to finalize the Guideline recommendations (appendix 1).In 2009, the ASA Committee on Standards and Practice Parameters requested that scientific evidence for these Guidelines be updated. This update consists of an evaluation of literature that includes new studies obtained after publication of the original Guidelines, new surveys of expert consultants, and a survey of a randomly selected sample of active ASA members.Preparation of this update used the same methodologic process as was used in the original Guidelines to obtain new evidence from two principal sources: scientific evidence and opinion-based evidence (appendix 2). The protocol for reporting each source of evidence is described below.Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described below. All literature (e.g. , randomized controlled trials, observational studies, case reports) relevant to each topic was considered when evaluating the findings. However, for reporting purposes in this document, only the highest level of evidence (i.e. , level 1, 2, or 3 within category A, B, or C) is included in the summary.Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.Level 1. The literature contains multiple randomized controlled trials. Aggregated findings are supported by meta-analysis.‡Level 2. The literature contains multiple randomized controlled trials, but there is an insufficient number of studies to conduct a viable meta-analysis for the purpose of these Guidelines.Level 3. The literature contains a single randomized controlled trial.Information from observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes.Level 1. The literature contains observational comparisons (e.g. , cohort, case-control research designs) of clinical interventions or conditions and indicates statistically significant differences between clinical interventions for a specified clinical outcome.Level 2. The literature contains noncomparative observational studies with associative (e.g. , relative risk, correlation) or descriptive statistics.Level 3. The literature contains case reports.The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes.Level 1. Meta-analysis did not find significant differences among groups or conditions.Level 2. The number of studies is insufficient to conduct meta-analysis, and (1) randomized controlled trials have not found significant differences among groups or conditions, or (2) randomized controlled trials report inconsistent findings.Level 3. Observational studies report inconsistent findings or do not permit inference of beneficial or harmful relationships.The lack of scientific evidence in the literature is described using the terms defined below.Silent. No identified studies address the specified relationships among interventions and outcomes.Inadequate. The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The literature either does not meet the criteria for content as defined in the “Focus” of the Guidelines or does not permit a clear interpretation of findings due to methodological concerns (e.g. , confounding in study design or implementation).All opinion-based evidence relevant to each topic (e.g. , survey data, open-forum testimony, Internet-based comments, letters, editorials) was considered in the development of the original Guidelines. New opinion surveys were developed to address each clinical intervention identified in the document, and identical surveys were distributed to both expert consultants and a random sample of active ASA members.Survey responses from Task Force–appointed expert consultants are reported in summary form in the text. A complete listing of consultant survey responses reported in a table in appendix 2.Survey responses from active ASA members are reported in summary form in the text. A complete listing of ASA member survey responses reported in appendix 2.Survey responses are recorded using a 5-point scale and summarized based on median values.§Strongly Agree. Median score of 5 (at least 50% of responses are 5).Agree. Median score of 4 (at least 50% of responses are 4 [or 4 and 5]).Equivocal. Median score of 3 (at least 50% of responses are 3—or no other response category or combination of similar categories contain at least 50% of responses).Disagree. Median score of 2 (at least 50% of responses are 2 [or 1 and 2]).Strongly Disagree. Median score of 1 (at least 50% of responses are 1).Open-forum testimony, Internet-based comments, letters, and editorials were all informally evaluated and discussed during the development of the original Guideline recommendations.No controlled trials were found that address the impact of conducting a preoperative assessment (e.g. , history, physical examination, survey/interview) on the frequency or severity of pulmonary aspiration of gastric contents during the perioperative period (Category D evidence ). Studies with observational findings suggest that certain predisposing conditions (e.g. , age, comorbid disease) may be associated with the risk of perioperative aspiration (Category B2 evidence ).1,2The consultants and ASA members strongly agree that a review of pertinent medical records, a physical examination, and patient survey or interview should be performed as part of preoperative evaluation. They also strongly agree that patients should be informed of fasting requirements, and the reasons for them, sufficiently in advance of their procedures. In addition, both the consultants and ASA members strongly agree that verification of patient compliance with fasting requirements should be assessed at the time of the procedure.A review of pertinent medical records, a physical examination, and patient survey or interview should be performed as part of preoperative evaluation. The history, examination, and interview should include pertinent assessment of gastroesophageal reflux disease, dysphagia symptoms, or other gastrointestinal motility disorders, potential for difficult airway management, and metabolic disorders (e.g. , diabetes mellitus) that may increase the risk of regurgitation and pulmonary aspiration. Patients should be informed of fasting requirements, and the reasons for them, sufficiently in advance of their procedures. Verification of patient compliance with fasting requirements should be assessed at the time of the procedures. When the fasting recommendations in these Guidelines are not followed, the practitioner should compare the risks and benefits of proceeding, with consideration given to the amount and type of liquids or solids ingested.Meta-analysis of randomized controlled trials3–10comparing fasting times of 2–4 4 report gastric and gastric in patients given clear liquids 2–4 before a procedure (Category evidence findings for gastric are (Category evidence of randomized controlled gastric (Category evidence and findings regarding differences in gastric volume for given clear liquids 2–4 before a procedure fasting for 4 before a procedure (Category evidence of clear liquids in the studies from to for and 2 to for clinical evidence is insufficient to address the between fasting times for clear liquids and the risk of or pulmonary aspiration (Category D evidence the consultants and ASA members strongly agree that for healthy 2 and fasting from the intake of clear liquids at least 2 before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia should be is appropriate to from intake of clear liquids at least 2 before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia care). of clear liquids include, but are not limited to, clear and These liquids should not include The volume of is the type of with observational findings are regarding the impact of 4 before a procedure on the risk of or of gastric contents during a procedure (Category evidence literature is insufficient to the of the of of and the perioperative of or pulmonary aspiration (Category D evidence consultants agree and the ASA members strongly agree that for healthy and fasting from the intake of at least 4 before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia should be is appropriate to from intake of at least 4 before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia study with observational findings is regarding the impact of 4 before a procedure on the risk of or of gastric contents during a procedure (Category evidence literature is insufficient to the of the of of and the perioperative of or pulmonary aspiration (Category D evidence the consultants and ASA members agree that for and fasting from the intake of at least before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia should be The consultants agree and the ASA members strongly agree that for fasting from the intake of at least before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia should be is appropriate to from intake of at least before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia randomized controlled a an of 4 before a procedure with fasting findings regarding gastric volume and for (Category evidence with findings for given 4 or before a procedure who for 4 report gastric (Category B2 evidence and gastric (Category evidence study with observational findings that fasting for may be associated with hypoglycemia in (Category B2 evidence literature is insufficient to the of the of of solids and and the perioperative of or pulmonary aspiration (Category D evidence consultants agree and the ASA members strongly agree that fasting from the intake of a (e.g. , and a clear or before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia should be the consultants and ASA members strongly agree that fasting from the intake of a that includes or or before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia should be the consultants and ASA members agree that for fasting from the intake of or before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia should be The consultants agree and the ASA members strongly agree that for and fasting from the intake of or before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia should be is appropriate to from intake of a or or before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia care). The Task Force that intake of or or may gastric emptying Additional fasting time (e.g. , or may be in these the amount and type of be considered when an appropriate fasting is similar to solids in gastric emptying the amount be considered when an appropriate fasting of randomized the of to reduce gastric volume (Category evidence is regarding the of on gastric acidity (Category evidence the perioperative The literature is insufficient to the of gastrointestinal on the perioperative of or pulmonary aspiration (Category D evidence the consultants and ASA members that gastrointestinal should be before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia in patients who have no increased risk for pulmonary preoperative use of gastrointestinal to the risk of pulmonary aspiration in patients who have no increased risk for pulmonary aspiration is not Meta-analysis of randomized trials the of to reduce gastric the perioperative period (Category evidence ). Meta-analysis of randomized the of to reduce gastric volume and acidity during the perioperative period (Category evidence ). trials that is in gastric volume and acidity (Category evidence controlled trials the of in gastric volume and acidity (Category evidence similar findings reported for (Category evidence literature is insufficient to the of either or on the perioperative of or pulmonary aspiration (Category D evidence the consultants and ASA members that should be before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia in patients who have no increased risk for pulmonary aspiration. The ASA members and the consultants strongly that should be before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia in patients who have no increased risk for pulmonary preoperative use of that gastric to the risks of pulmonary aspiration in patients who have no increased risk for pulmonary aspiration is not controlled trials that preoperative (e.g. , increase gastric during the perioperative period (Category evidence findings regarding gastric volume (Category evidence ). The literature does not sufficiently the between gastric acidity and the frequency of pulmonary aspiration or in does the literature sufficiently whether gastric acidity or volume is associated with decreased or in patients given preoperative who have gastric contents (Category D evidence consultants and ASA members both that preoperative should be before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia in patients who have no increased risk for pulmonary aspiration. The consultants and ASA members both strongly agree that only should be used when are for selected preoperative use of to the risks of pulmonary aspiration in patients who have no increased risk for pulmonary aspiration is not should be used when are for selected patients for purposes other the risk of pulmonary controlled trials that the preoperative administration of in and during the period after (Category evidence ). The literature does not sufficiently the between the preoperative use of and the frequency of pulmonary aspiration (Category D evidence consultants and ASA members both that preoperative should be before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia in patients who have no increased risk for pulmonary preoperative use of to reduce the risks of pulmonary aspiration in patients who have no increased risk for pulmonary aspiration is not trials are regarding the of reduce gastric volume or acidity (Category evidence ASA members and the consultants strongly that preoperative should be before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia to the risk of pulmonary use of to the risks of pulmonary aspiration is not controlled trials when (i.e. , are with gastrointestinal (i.e. , the of the two is in both gastric volume and acidity (Category evidence when with gastrointestinal are to in gastric acidity are when the are to gastrointestinal as the findings for gastric volume are controlled trials other single report inconsistent findings regarding gastric volume and (Category evidence ASA members and the consultants strongly that preoperative multiple agents should be before elective procedures general anesthesia, regional anesthesia, or sedation/analgesia (i.e. , monitored anesthesia in patients who have no risk for pulmonary preoperative use of multiple agents in patients who have no increased risk for pulmonary aspiration is not Fasting liquids 2 4 recommendations apply to healthy patients who are undergoing elective procedures. They are not intended for women in the Guidelines does not guarantee complete gastric The fasting periods apply to patients of all of clear liquids include clear and is similar to solids in gastric emptying the amount be considered when an appropriate fasting consists of and clear that include or or may gastric emptying Additional fasting time (e.g. , or may be in these the amount and type of be considered when an appropriate fasting recommendations are by type with In addition, of the are not for No No No No No No No No No No No No No No these Guidelines, a literature review is used in combination with opinions obtained from expert consultants and other (e.g. , American Society of Anesthesiologists members, open the literature review and opinion data are based on evidence or regarding potential relationships between clinical interventions and outcomes. The interventions were to assess their impact on pulmonary aspiration and other outcomes. for the interventions include, but are not limited to, pulmonary volume and acidity of gastric (e.g. , (e.g. , and other (e.g. , of in the literature relevant clinical studies were identified and of the For the original Guidelines, and a period from The literature for this update the period from and included review of that related to the evidence review of the studies did not provide evidence and were A of findings related to at least of the evidence No evidence literature with and information to conduct an analysis of aggregated studies (i.e. , A complete used to these Guidelines, by is available as 2, literature is according to the or of the to the an a study should either a or methodological (e.g. , for For these Guidelines, the of are pulmonary aspiration and these Guidelines focus on the between a preoperative intervention and the frequency of pulmonary and the between a preoperative intervention and the frequency or severity of an associated with aspiration (e.g. , However, the literature is insufficient to such The literature of relationships between preoperative interventions and of These of relationships are to as or a either between an intervention (e.g. , and a clinical or between two (e.g. , gastric volume and In the studies reviewed with the between of the identified interventions in the Guidelines and the of pulmonary aspiration was not a between an intervention of and pulmonary aspiration cannot be (e.g. , gastric were considered by the to be of a risk of pulmonary of such comparisons are not to provide 2 4 comparisons that for an outcome. For example, to the effectiveness of a on pulmonary the of the on gastric content as well as the occurrence of be content and are between the intervention and pulmonary aspiration. This be considered a 2 a in which or between the intervention and the of However, level 2 relationships do not the between an intervention of and the occurrence of pulmonary 3 contains of to the Guidelines (i.e. , 4 contains the other of to the Guidelines (i.e. , between an intervention and clinical from pulmonary that related to preoperative fasting and the administration of pharmacologic agents were insufficient to relationships that the interventions of in these Guidelines with the occurrence of pulmonary aspiration or the clinical from pulmonary the literature was not for assessment related to pulmonary findings for each intervention of regarding is each pertinent reported in a study is as an evidence a or These are summarized to obtain a assessment for each evidence before conducting a The literature to evidence studies with and information to conduct These evidence (1) preoperative fasting of liquids between 2 and 4 for (2) preoperative fasting of liquids between 2 and 4 for (3) preoperative preoperative and preoperative Meta-analysis was limited to gastric volume and acidity or are obtained for are obtained for are used as (1) the based on of the reported from the studies, and (2) the of the studies by each of the by the of the procedure based on the for study using 2 2 is used with frequency level is at a of for of the studies are to among study are obtained when significant is found (P < for potential a is No for studies was no for research were be as significant agree with both of data are In the of findings from the and agree with each other to be considered statistically the original Guidelines, among Task Force members and two was by using a for are as (1) type of study (2) type of (3) evidence and literature for (1) (2) (3) literature These to of was obtained from multiple (1) survey opinion from consultants who were selected based on their or in preoperative fasting and of pulmonary (2) survey opinions from active members of the American Society of (3) from of a held open forum for the original Guidelines held at a national anesthesia commentary, and Task Force opinion and The survey of was of for the consultants responses were from active American Society of Anesthesiologists members the original Guidelines, an survey was to the consultants to of the evidence their clinical practices the Guidelines were The of consultants no associated with each were as preoperative preoperative fasting of preoperative fasting of preoperative fasting of gastrointestinal pharmacologic of gastric and multiple of that the Guidelines have no on the amount of time on a For all the increase in the amount of time on a case was reported that the Guidelines increase the amount of time The time increase for these two was 5 and

PRACTICE advisories are systematically developed reports that are intended to assist decision-making in areas of patient care. Advisories are based on a synthesis of scientific literature and analysis of expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Advisories developed by the American Society of Anesthesiologists (ASA) are not intended as standards, guidelines, or absolute requirements, and their use cannot guarantee any specific outcome. They may be adopted, modified, or rejected according to clinical needs and constraints.The use of practice advisories cannot guarantee any specific outcome. Practice advisories summarize the state of the literature and report opinions obtained from expert consultants and ASA members. Practice advisories are not supported by scientific literature to the same degree as standards or guidelines because of the lack of sufficient numbers of adequately controlled studies. Practice advisories are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.This document updates the “Practice Advisory for the Perioperative Management of Patients with Cardiac Rhythm Management Devices: Pacemakers and Implantable Cardioverter-Defibrillators, adopted by the ASA in 2004 and published in 2005.*For this Advisory, a cardiac implantable electronic device (CIED) refers to any permanently implanted cardiac pacemaker or any implantable cardioverter-defibrillator (ICD). The term CIED also refers to any cardiac resynchronization device.†The purposes of this Advisory update are to (1) facilitate safe and effective perioperative management of the patient with a CIED and (2) reduce the incidence of adverse outcomes. Perioperative management refers to the preoperative, intraoperative, postoperative, or recovery period in any setting where an anesthesia provider will be delivering anesthesia care. Adverse outcomes associated with a CIED include, but are not limited to, damage to the device, inability of the device to deliver pacing or shocks, lead-tissue interface damage, changes in pacing behavior, electrical reset to the backup pacing mode, or inappropriate ICD therapies.‡Adverse clinical outcomes include, but are not limited to, hypotension, tachyarrhythmia or bradyarrhythmia, myocardial tissue damage, and myocardial ischemia or infarction. Other related outcomes may include extended hospital stay, delay or cancellation of surgery, readmission to manage device malfunction, or additional hospital resource utilization and cost.This updated Advisory focuses on the perioperative management of the patient who has a preexisting, permanently implanted CIED for treatment of bradyarrhythmia, tachyarrhythmia, or heart failure. Both inpatient and outpatient procedures are addressed by this update. This update does not address the perioperative management of any patient undergoing CIED implantation or revision. It is not applicable to any patient (1) without a permanently implanted pacemaker or ICD, (2) with a temporary CIED, (3) with a noncardiac implantable device (e.g. , neurologic or spinal cord stimulator), or (4) with an implantable mechanical cardiac assist device (e.g. , ventricular assist device). This updated Advisory does not address procedures where there are no known perioperative CIED concerns, such as plain radiography, fluoroscopy, mammograms, or ultrasound.This updated Advisory is intended for use by anesthesiologists and all other individuals who deliver or are responsible for anesthesia care. The update may also serve as a resource for other physicians and health care professionals who manage patients with CIEDs.The original Advisory was developed by an ASA-appointed task force of 12 members, consisting of anesthesiologists and cardiologists in private and academic practices from various geographic areas of the United States and two methodologists from the ASA Committee on Standards and Practice Parameters.The Task Force developed the original Advisory by means of a six-step process. First, they reached consensus on the criteria for evidence. Second, original published articles from peer-reviewed journals relevant to the perioperative management of cardiac rhythm management devices were evaluated. Third, consultants who had expertise or interest in CIEDs and who practiced or worked in various settings (e.g. , private and academic practice) were asked to (1) participate in opinion surveys on the effectiveness of various perioperative management strategies and (2) review and comment on a draft of the Advisory developed by the Task Force. Fourth, additional opinions were solicited from random samples of active members of both the ASA and the Heart Rhythm Society (HRS).§Fifth, the Task Force held an open forum at a national anesthesia meeting and at a major cardiology meeting to solicit input on the key concepts of this Advisory.∥Sixth, all available information was used to build consensus within the Task Force to finalize the Advisory.In 2009, the ASA Committee on Standards and Practice Parameters requested that scientific evidence for this Advisory be updated. The update consists of an evaluation of literature that includes new studies obtained after publication of the original Advisory.Preparation of this update used the same methodological process as used in the original Advisory to obtain new scientific evidence. Opinion-based evidence obtained from the original Advisory is reported in this update. The protocol for reporting each source of evidence is described below.Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described below. All literature (e.g. , randomized controlled trials, observational studies, and case reports) relevant to each topic was considered when evaluating the findings. However, for reporting purposes in this document, only the highest level of evidence (i.e. , levels 1, 2, or 3 identified below) within each category (i.e. , A, B, or C) is included in the summary.Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.The literature contains multiple, randomized controlled trials, and the aggregated findings are supported by meta-analysis.#The literature contains multiple, randomized controlled trials, but there is an insufficient number of studies to conduct a viable meta-analysis for the purpose of this Advisory.The literature contains a single, randomized controlled trial.Information from observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes.The literature contains observational comparisons (e.g. , cohort, case-control research designs) of clinical interventions or conditions and indicates statistically significant differences between clinical interventions for a specified clinical outcome.The literature contains noncomparative observational studies with associative (e.g. , relative risk and correlation) or descriptive statistics.The literature contains case reports.The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes.Meta-analysis did not find significant differences among groups or conditions.There is an insufficient number of studies to conduct meta-analysis, and (1) randomized controlled trials have not found significant differences among groups or conditions or (2) randomized controlled trials report inconsistent findings.Observational studies report inconsistent findings or do not permit inference of beneficial or harmful relationships.The lack of scientific evidence in the literature is described by the following terms:No identified studies address the specified relationships among interventions and outcomes.The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The literature either does not meet the criteria for content as defined in the Focus of the Advisory or does not permit a clear interpretation of findings because of methodological concerns (e.g. , confounding in study design or implementation).The original Advisory contained formal survey information collected from expert consultants, a random sample of members of the ASA, and a random sample of members of the HRS. Additional information was obtained from open-forum presentations and other invited and public sources. All opinion-based evidence relevant to each topic (e.g. , survey data, open-forum testimony, Internet-based comments, letters, and editorials) was considered in the development of the original Advisory.Survey responses from Task Force–appointed expert consultants are reported in summary form in the text, with a listing of consultant survey responses reported in appendix 3. In addition, survey responses from active ASA and HRS members are reported in summary form in the text, with a listing of survey responses reported in appendix 3.A focused preoperative evaluation of CIED patients consists of the following: (1) establishing whether a patient has a CIED, (2) defining the type of device, (3) determining whether a patient is CIED-dependent for antibradycardia pacing function, and (4) determining device function.Although no controlled trials of the clinical impact of performing a focused preoperative evaluation for CIED patients were found, case reports suggest that incomplete preoperative examination of patients with CIEDs may lead to adverse outcomes (e.g. , inhibited CIED function and asystole) (Category B3 evidence ).1,2The majority of consultants, ASA members, and HRS members agree that the above four preoperative evaluation activities should be conducted.**A focused preoperative evaluation should include establishing whether a patient has a CIED, defining the type of device, determining whether a patient is CIED-dependent for pacemaking function, and determining CIED function.Determining whether a patient has a CIED should be based on the following: (1) a focused history including, but not limited to, the patient interview, medical records review, and review of available chest x-rays, electrocardiograms, or any available monitor or rhythm strip information; and (2) a focused physical examination (i.e. , checking for scars and palpating for device).Defining the type of device is accomplished by (1) obtaining the manufacturer's identification card from the patient or other source, (2) ordering chest x-rays if no other data are available,††or (3) referring to supplemental resources (e.g. , manufacturer's databases, pacemaker clinic records, and consultation with a cardiologist).CIED dependence for pacemaking function may be determined by one or more of the following: (1) a verbal history or an indication in the medical record that the patient has experienced a bradyarrhythmia that has caused syncope or other symptoms requiring CIED implantation, (2) a history of successful atrioventricular nodal ablation that resulted in CIED placement, or (3) a CIED evaluation that shows no evidence of spontaneous ventricular activity when the pacemaking function of the CIED is programmed to VVI pacing mode at the lowest programmable rate.CIED function is ideally assessed by a comprehensive evaluation of the device.3If a comprehensive evaluation is not possible, then, at a minimum, confirm whether pacing impulses are present and create a paced beat. Consultation with a cardiologist or CIED service may be necessary. Contacting the manufacturer for perioperative recommendations may be a consideration.Preparation for patient safety and proper maintenance of the device during a procedure includes (1) determining whether electromagnetic interference (EMI) is likely to occur during the planned procedure; (2) determining whether preoperative reprogramming the CIED pacemaking function to an asynchronous pacing mode or disabling any special algorithms, including rate adaptive functions, is needed; (3) suspending antitachyarrhythmia functions if present; (4) advising the individual performing the procedure to consider use of a bipolar electrocautery system or ultrasonic (harmonic) scalpel to minimize potential adverse effects of EMI on the pulse generator or leads; (5) assuring the availability of temporary pacing and defibrillation equipment; and (6) evaluating the possible effects of anesthetic techniques on CIED function and patient-CIED descriptive studies and case reports suggest that the following procedures are likely to be associated with (1) (3) evidence with observational findings report the of EMI during other observational studies and case reports no EMI effects (Category evidence with observational findings report the of EMI during other observational studies and case reports no EMI effects (Category evidence studies were found that reported EMI during (Category evidence reports that pacing may occur as a of EMI effects between cardiac and CIEDs with active controlled trials of the clinical impact of the pacemaking function to an asynchronous mode for a procedure were found (Category evidence a case report that such reprogramming may be beneficial during reports that EMI may to (Category B3 evidence literature sufficient the potential perioperative impact of anesthetic techniques on CIED function (Category evidence majority of consultants, ASA members, and HRS members agree that should be determined whether EMI is likely to occur a planned The majority of consultants agree that a should be a the ASA and HRS members are The majority of consultants and HRS members that all CIEDs should be programmed to an asynchronous mode surgery, the ASA members are In addition, the majority of consultants and HRS members agree that CIEDs should be programmed to an asynchronous mode surgery, the ASA members are The majority of consultants, ASA members, and HRS members agree that (1) suspending antitachyarrhythmia functions if (2) advising the individual performing the procedure to consider use of a bipolar electrocautery system to minimize potential adverse effects of EMI on the pulse generator or (3) assuring the availability of temporary pacing and defibrillation and (4) evaluating the possible effects of anesthetic techniques on CIED function and patient-CIED are in patient safety and patients with The consultants and ASA members and HRS members are the of an ultrasonic procedures should include a of whether EMI is likely to occur for either or EMI is likely to the pacing function of a CIED should be by to an asynchronous pacing patients and suspending special algorithms, including may be accomplished by or a when the Task Force the use of the an addition, an antitachyarrhythmia functions should be if the ICD patient who on pacing function for of bradyarrhythmia, functions should be by as Consultation with a cardiologist or pacemaker ICD service may be all consider advising the individual performing the procedure to use a bipolar electrocautery system or an ultrasonic scalpel when pacing and defibrillation should be available and after a the Task Force that anesthetic techniques do not CIED However, changes (i.e. , cardiac or in the patient may CIED responses or the activities associated with management of a CIED include the following: (1) the of the (2) potential CIED and (3) performing or heart rate includes as as of the pulse (e.g. , of the of heart of a of pulse or pulse or no controlled trials were found that the clinical impact of or pulse for CIED case reports the of in the of pacemaker or cardiac for patients (Category B3 evidence majority of consultants, ASA members, and HRS members agree that (1) should be for all CIED patients and (2) pulse should be and pulse are of perioperative management of the patient with a should be as by ASA standards, from the of anesthesia the patient is of the with additional in the period as by the medical standards should to all CIED patients or or anesthesia care. pulse should be for all CIED patients or or anesthesia care. device are found, consider of the procedure the source of interference be or or may damage CIEDs or with CIED function, in adverse outcomes. of EMI are to specific and the management of each of potential EMI is reported of potential of EMI associated with electrocautery includes (1) assuring that the and the does not or the CIED pulse generator and leads; (2) of the electrical to the pulse generator or leads; (3) and at the lowest and (4) a bipolar electrocautery system or an ultrasonic (harmonic) scalpel if is insufficient literature to whether the from the CIED pulse generator and the of case one observational that EMI may occur in of the as as possible from the generator and (Category evidence case report that of electrocautery on the resulted in pacemaker (Category B3 evidence no studies were found the of at the lowest that may be in procedures without EMI interference (Category evidence case report pacemaker when of electrocautery were used (Category B3 evidence case reports suggest that for pacemaker patients may when bipolar electrocautery used (Category B3 evidence However, a case report pacemaker when bipolar electrocautery was used (Category B3 evidence majority of consultants, ASA members, and HRS members agree that the should be the does not or the CIED pulse generator or The majority of consultants, ASA members, and HRS members agree that between the electrocautery system and the CIED pulse generator or should be The majority of consultants, ASA members, and HRS members agree that should be The majority of consultants and ASA members agree that should be used when possible, and HRS members are The majority of consultants, ASA members, and HRS members agree that bipolar electrocautery should be used when Task Force that EMI be during procedures a of management The risk of interference from electrocautery may be by (1) the and the does not or the CIED (2) of the electrical to the pulse generator and including of the the (3) and at the lowest and (4) bipolar electrocautery or ultrasonic (harmonic) if or the individual performing the procedure to management techniques should be of potential of EMI associated with ablation the to as from the pulse generator and lead system as observational study reports 3 of 12 that resulted in a significant in on the pacemaker when ablation was used in to the (Category evidence case report that of the ablation no from the the procedure to (Category B3 evidence majority of consultants, ASA members, and HRS members agree that the individual performing the procedure should between the ablation and the CIED and and should the ablation as from the pulse generator and lead system as risk of interference from ablation may be by between the ablation and the pulse generator and and the to as from the pulse generator and as all consider with the individual performing the procedure any concerns the of the ablation to the CIED of potential of EMI associated with includes (1) of the the pulse generator and (2) disabling pacing if the system on the The literature is the of the from the pulse generator as as the of disabling pacing during (Category evidence majority of consultants, ASA members, and HRS members agree that the the pulse generator should be and all groups are whether pacing should be a procedure if the system on the the should not be focused the pulse the system on the pacing to be the is insufficient literature to the effects of specific management activities related to CIED patients (Category evidence studies and case reports suggest that the may be without EMI specific and with patient and (Category evidence other literature that is (Category evidence majority of consultants, ASA members, and HRS members agree that an is for all CIED is for CIED an be with the ordering the pacemaker or the and the CIED literature does not sufficient specific management activities related to CIED patients undergoing (Category evidence of the consultants or HRS members and only of the ASA members agree that is for all CIED of the consultants, of the HRS members, and of the ASA members agree that is for but not all CIED of the consultants, of the HRS members, and of the ASA members agree that is not for any CIED Task Force that be for CIED device be the of pulse will of pulse generator function during and at the of may include pacemaker and clinical studies were found that report EMI effects or CIED associated with (Category evidence study reports two where were but does not report the of the on ICD function (Category B3 evidence the indicates that treatment with be associated with significant cardiac changes (e.g. , and and may from and additional cardiac (e.g. , or may occur in patients with cardiac after such as a period of and by and a in may for cardiac in the extended period (i.e. , or after among patients with cardiac function.Although or myocardial and system effects may be associated with the Task Force that such may be to CIED patients without significant damage to a be with the ordering and the cardiologist to for the and All CIEDs should a comprehensive the ICD functions should be for during be to that occur to the effects of CIED-dependent patients may a temporary pacing system to cardiac rate and rhythm during the CIED may to asynchronous activity to of the device in the perioperative defibrillation or may for the CIED In this the is to minimize the the pulse generator and lead reports suggest that of the defibrillation or or may be an in the of adverse majority of consultants, ASA members, and HRS members agree that the defibrillation or as as possible from the pulse generator should be The majority of consultants, ASA members, and HRS members also agree that the should be used and that a should be used of the type of defibrillation or of the patient with an ICD and all of EMI should be and the to The patient should be for CIED the patient with an ICD and that have by consider the above activities to ICD function, with defibrillation or the above is the to and or and should be to this as as a guidelines for level and for possible, to minimize the the pulse generator and lead system by (1) the defibrillation or or as as possible from the pulse generator and (2) defibrillation or or to the major of the CIED pulse generator and to the possible by in an should be used of the of a CIED, and the should be as as be in an management of CIED patients consists of and CIED observational study and a case report that pacemaker the to pacing mode or other included ventricular pacing because of pacing (Category evidence case report also indicates that a of a pacemaker identified a safety mode they to EMI from observational study indicates that a ICD identified the of the from EMI during (Category evidence addition, this report EMI on the lead in both and and on the ventricular lead in patients with without significant to the majority of consultants, ASA members, and HRS members agree that patient management should include and CIED function in the care or the care rate and rhythm should be the pacing and should be available at all and of CIED function are of The CIED should be to assess device that CIED settings are the device should be to an ICD, all should be Consultation with a cardiologist or service may be pacemaker and were developed as by the American Society of and the and to the of the programmed settings on the CIED and this updated Advisory, a review of the studies used in the development of the original Advisory and published after were with studies published to of the original The updated literature review was based on evidence consisting of relationships between specific perioperative management activities and CIED function or clinical the literature review, relevant studies were identified electronic and of the The updated electronic a period from 2004 to The a period of from to CIEDs a technology, literature (i.e. , literature published was included in the evaluation of evidence for this Practice that addressed related to the evidence were articles were and with articles used in the original Advisory, in a of articles that contained evidence. was no sufficient literature with and information to conduct an analysis of aggregated studies (i.e. , contained in the evidence used to this updated Advisory, by is available as 1, the original Advisory, an among Task Force members and two methodologists was by levels a for were as (1) type of study to (2) type of to (3) evidence to and (4) literature for to were as (1) study (2) type of (3) and (4) literature levels of the original Advisory, consensus was obtained from including (1) survey opinions from consultants who were based on their or expertise in perioperative management of (2) survey opinions from samples of active members of the American Society of Anesthesiologists and active members of the Heart Rhythm (3) from of two open at a national anesthesia meeting and at a major cardiology (4) commentary, and (5) Task Force opinion and The survey rate of was for for the ASA and for the HRS 3 and the original Advisory, an additional survey was to the consultants to if of the evidence their clinical practices if the Advisory was The rate of was The of no associated with each were as preoperative preoperative patient of defibrillation or of and of CIED function, and management of EMI and of the that the Advisory have no on the of on a that there be an in the of they on a case with the of this The of by from

Developed by the American Society of Anesthesiologists Task Force on Perioperative Blindness: Mark A. Warner, M.D. (Chair), Rochester, Minnesota; James F. Arens, M.D., Houston, Texas; Richard T. Connis, Ph.D., Woodinville, Washington; Karen B. Domino, M.D., Seattle, Washington; Lorri A. Lee, M.D., Seattle, Washington; Neil Miller, M.D., Baltimore, Maryland; Sohail Mirza, M.D., Seattle, Washington; Nancy Newman, M.D., Atlanta, Georgia; David G. Nickinovich, Ph.D., Bellevue, Washington; Steven Roth, M.D., Chicago, Illinois; Peter Savino, M.D., Philadelphia, Pennsylvania; Philip Weinstein, M.D., San Francisco, California.Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.PRACTICE advisories are systematically developed reports that are intended to assist decision making in areas of patient care. Advisories provide a synthesis and analysis of expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Advisories are not intended as standards, guidelines, or absolute requirements. They may be adopted, modified, or rejected according to clinical needs and constraints.The use of practice advisories cannot guarantee any specific outcome. Practice advisories summarize the state of the literature and report opinions derived from a synthesis of task force members, expert consultants, open forums, and public commentary. Practice advisories are not supported by scientific literature to the same degree as standards or guidelines because of the lack of sufficient numbers of adequately controlled studies. Practice advisories are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.For this Advisory, perioperative visual loss refers to permanent impairment or total loss of sight associated with a spine procedure during which general anesthesia is administered. The perioperative period includes the time period from the immediate preoperative assessment through discharge from the acute healthcare facility. The conditions addressed in this advisory are posterior ischemic optic neuropathy [ION], anterior ION, and central retinal artery occlusion (CRAO). “High-risk patients” are defined as those who undergo spine procedures while positioned prone and who have prolonged procedures, experience substantial blood loss, or both.The purposes of this advisory are to enhance awareness of perioperative visual loss and reduce its frequency.This Advisory focuses on the perioperative management of patients who are undergoing spine procedures while they are positioned prone and receiving general anesthesia. This Advisory does not address the perioperative management of patients who receive regional anesthesia or sedation. This Advisory also does not include other causes of visual loss, such as cortical blindness. It does not include nonspine surgical procedures (e.g. , cardiac surgery, radical neck dissection). In addition, this advisory does not apply to young children because of the rarity of visual loss in children younger than 12 yr undergoing spine surgery.This Advisory is intended for use by anesthesiologists, spine surgeons, and all other individuals who deliver or who are responsible for anesthesia or perioperative care. These individuals may include orthopedic surgeons, neurosurgeons, ophthalmologists, neuro-ophthalmologists, neurologists, nurse anesthetists, perioperative nurses, and anesthesiology assistants. The Advisory may also serve as a resource for other physicians, nurses, and healthcare professionals who manage anesthetized patients.The American Society of Anesthesiologists (ASA) appointed a Task Force of 12 members to (1) review and assess currently available scientific literature, (2) obtain expert consensus and public opinion, and (3) develop a practice advisory. The Task Force members consisted of four anesthesiologists from various geographic areas of the United States, three neuro-ophthalmologists (one neurologist, two ophthalmologists), an orthopedic spine surgeon, a neurosurgeon, and two methodologists from the ASA Committee on Practice Parameters. Three physicians served as official liaisons from national organizations. They included a neuro-ophthalmologist (North American Neuro-Ophthalmology Society [NANOS]), an orthopedic surgeon (American Academy of Orthopedic Surgery), and a neurosurgeon (American Association of Neurologic Surgeons).The Task Force used a six-step process. First, it reached consensus on the criteria for evidence of effective perioperative interventions for the prevention of visual loss. Second, original published articles from peer-reviewed journals relevant to these issues were evaluated. Third, consultants who had expertise or interest in perioperative visual loss and who practiced or worked in various settings (e.g. , academic and private practice) were asked to (1) participate in opinion surveys on the effectiveness of various perioperative management strategies and (2) review and comment on a draft of the Advisory developed by the Task Force. Fourth, additional opinions were solicited from active members of the Society for Neurosurgical Anesthesia and Critical Care (SNACC), NANOS, and the North American Spine Society (NASS). Fifth, the Task Force held an open forum at a national anesthesia meeting to solicit input on the key concepts of this Advisory. Sixth, all available information was used to build consensus within the Task Force on the Advisory.The draft document was made available for review on the ASA Web site, and input was invited via e-mail announcement to all ASA members. All submitted comments were considered by the Task Force in preparing the final draft.Practice advisories are developed by a protocol similar to that of an ASA evidence-based practice guideline, including a systematic search and evaluation of the literature. However, practice advisories lack the support of a sufficient number of adequately controlled studies to permit aggregate analyses of data with rigorous statistical techniques such as meta-analysis. Nonetheless, literature-based evidence from case reports and other descriptive studies are considered during the development of the Advisory. This literature often permits the identification of recurring patterns of clinical practice.As with a practice guideline, formal survey information is collected from consultants and members of the ASA. The following terms describe survey responses for any specified issue. Responses are solicited from four response categories: agree, equivocal, disagree, and no opinion. Survey information is summarized in the text based on modal responses (e.g. , a modal response of “agree” will be listed in the text as an agreement).Additional information is obtained from open forum presentations and other invited and public sources. The advisory statements contained in this document are a distillation of the current spectrum of clinical opinion and literature-based findings.Visual loss after spine surgery is an uncommon occurrence.1–3Ophthalmic complications, including posterior ION, anterior ION, and CRAO, have been reported to occur in less than 0.2% of spine surgeries.4–6There are no clinical trials addressing the impact of performing a focused preoperative evaluation for perioperative visual loss.*However, one case–control study and several case reports suggest that preoperative anemia and vascular risk factors such as hypertension, glaucoma, carotid artery disease, smoking, obesity, and diabetes may be associated with perioperative visual loss.7–12The literature also suggests an association of perioperative visual loss with prolonged procedures, substantial blood loss, or both.4,6–22The consultants and specialty society members disagree that an ophthalmic or neuro-ophthalmic evaluation is effective in identifying patients at risk for perioperative visual loss. The consultants and specialty society members agree that vascular risk factors increase the risk of perioperative visual loss. In addition, they agree that (1) the preoperative presence of anemia, (2) prolonged procedures, (3) substantial blood loss, and (4) prolonged procedures combined with substantial blood loss all increase the risk of perioperative visual loss. The consultants and specialty society members consider procedures to be prolonged when they exceed an average of 6.5 h (range, 2–12 h) in duration. They consider blood loss to be substantial when the loss reaches an average of 44.7% (range, 10–200%) of estimated blood volume.Although the consultants and specialty society members agree that there are identifiable preoperative risk factors, at this time the Task Force does not believe that there are identifiable preoperative patient characteristics that predispose patients to perioperative ION. Further, the Task Force believes that there is no evidence that an ophthalmic or neuro-ophthalmic evaluation would be useful in identifying patients at risk for perioperative visual loss. The Task Force does, however, believe that the risk of perioperative ION may be increased in patients who undergo prolonged procedures, have substantial blood loss, or both. For the purposes of this advisory, the Task Force considers such patients (hereafter referred to as “high-risk patients”) to have a higher risk for perioperative visual loss than patients who do not undergo prolonged procedures, have substantial blood loss, or both. Consider informing patients in whom prolonged procedures, substantial blood loss, or both are anticipated that there is a small, unpredictable risk of perioperative visual loss. Because the frequency of visual loss after spine surgery of short duration is very low, the decision to inform patients who are not anticipated to be “high risk” for visual loss should be determined on a case-by-case basis.A number of intraoperative factors have been proposed to be associated with perioperative visual loss in patients undergoing spine surgery. These include hypotension, blood loss, anemia, hypovolemia, hypoxia, hemodilution, facial edema, pressure on the eye, use of vasopressors, prone and head-down positions, substantial fluid resuscitation, increased venous pressures, and prolonged surgery. Among these factors, only prolonged surgical duration and substantial blood loss have been present in a majority of patients who have experienced perioperative visual loss.7Blood pressure management of high-risk patients depends on multiple patient characteristics such as the preoperative presence of chronic hypertension, cardiac dysfunction, and renal and vascular disease. In addition, there are many intraoperative factors, such as fluid management, rate of blood loss, use of deliberate hypotension, and administration of vasopressors, that impact blood pressure management. Several case reports have reported perioperative visual loss after procedures in which substantial blood loss and hypotension occurred.9,15–17,21,23The consultants and specialty society members disagree with the survey statement “Deliberate hypotension techniques may be used in high-risk patients” (i.e. , for high-risk patients without preoperative chronic hypertension or for high-risk patients with well-controlled preoperative chronic hypertension). However, NASS members are equally split in their opinions between agree and disagree for patients without preoperative chronic hypertension. Consultants and specialty society members who agree that deliberate hypotension may be used in patients without preoperative chronic hypertension indicate that blood pressure should be maintained on average within 24% (range, 0–40%) of estimated baseline mean arterial pressure or with a minimum systolic blood pressure of 84 mmHg (range, 50–120 mmHg).Systemic blood pressure should be continually monitored in high-risk patients. The Task Force believes that the use of deliberate hypotensive techniques during spine surgery has not been shown to be associated with the development of perioperative visual loss. Therefore, the use of deliberate hypotension for these patients should be determined on a case-by-case basis.No studies were found that examined the impact of monitoring intravascular volume on the occurrence of visual loss among spine surgery patients. The consultants and specialty society members agree that intravascular volume should be continually monitored in high-risk patients. Although the use of large volumes of crystalloids has been shown to be associated with increased intraoperative ocular pressure, periorbital edema, and double vision,24no studies were found that addressed these issues in spine surgery patients. The consultants, SNACC members, and NANOS members agree that the balance between colloid and crystalloid fluid resuscitation and replacement has an impact on the potential for perioperative vision loss; the NASS members report no opinion. The consultants and SNACC members are equivocal regarding the preference of colloids over crystalloids for fluid resuscitation and replacement to reduce the potential for perioperative vision loss; the NANOS and NASS members report no opinion. The consultants, SNACC members, and NASS members agree that central venous pressure monitoring should be used in high-risk patients; the NANOS members report no opinion.Colloids should be used along with crystalloids to maintain intravascular volume in patients who have substantial blood loss. Central venous pressure monitoring should be considered in high-risk patients.No prospective studies were found that examined the intraoperative management of anemia during spine surgery. One retrospective comparison of patients who experienced perioperative visual loss after spine surgery with a matched control group found no difference in lowest recorded hematocrit values between groups.7The consultants and specialty society members agree that hemoglobin or hematocrit levels should be periodically monitored to detect anemia in high-risk patients. Those who agree indicate that intraoperative hemoglobin or hematocrit should be maintained at a minimum average of 9.4 g/dl (range, 6–13 g/dl) or 28% (range, 18–37%), respectively.Hemoglobin or hematocrit levels should be periodically monitored during surgery in high-risk patients who experience substantial blood loss. The Task Force believes that there is no documented lower limit of hemoglobin concentration that has been associated with the development of perioperative visual loss. Therefore, the Task Force believes a transfusion threshold that would eliminate the risk of perioperative visual loss related to anemia cannot be established at this time.No studies were found that examined the prolonged use of high-dose α-adrenergic agonists during spine surgery. The SNACC members agree that prolonged use of high-dose α-adrenergic agonists may reduce perfusion of the optic nerve in high-risk patients; the consultants are equivocal, and the NANOS and NASS members report no opinion.The Task Force consensus is that there is insufficient evidence to provide guidance for the use of α-adrenergic agonists in high-risk patients during spine surgery. Therefore, the decision to use α-adrenergic agonists should be made on a case-by-case basis.Several case reports suggest that direct pressure to eyes from the use of a sheet roll or headrest results in acute-onset ION or CRAO in spine surgery patients.17,23,25–31However, cases of perioperative visual loss also have been reported after patient head positioning without the use of a sheet roll or headrest (e.g. , head held with pins).13,17The consultants and specialty society members agree that direct pressure on the eye should be avoided to reduce the risk of CRAO and other ocular damage. The consultants and SNACC members agree that the patient’s head should be positioned level with or higher than the heart in high-risk patients; NANOS member opinion is equally split between agree and equivocal; and NASS member opinion is equally split among agree, equivocal, and no opinion. The consultants, SNACC members, and NASS members agree that the patient’s head should be placed in a neutral forward position in high-risk patients; the NANOS members report no opinion. The consultants, SNACC members, and NANOS members agree that the type of head positioning device is not associated with perioperative ION; the NASS members disagree. The consultants and all specialty society members agree that the use of a horseshoe headrest may increase the risk of ocular compression and perioperative CRAO. They all agree that the eyes of prone-positioned patients should be regularly assessed and documented. In addition, they all agree that perioperative facial edema is common in high-risk patients.The Task Force believes that there is no pathophysiologic mechanism by which facial edema can cause perioperative ION. There is no evidence that ocular compression causes isolated perioperative anterior ION or posterior ION. However, direct pressure on the eye should be avoided to prevent CRAO. The high-risk patient should be positioned so that the head is level with or higher than the heart when possible. The high-risk patient’s head should be maintained in a neutral forward position (e.g. , without significant neck flexion, extension, lateral flexion, or rotation) when possible.The majority of spine surgery patients who have development of perioperative ION undergo prolonged procedures with substantial blood loss while they are positioned prone. Although no studies were found that examined the impact of surgical staging on reducing the frequency of perioperative visual loss, one retrospective study reported an association between duration of anesthesia and frequency of eye injury after nonocular surgery.22The consultants and specialty society members agree that consideration should be given to staging procedures that are anticipated to be lengthy. Members of the specialty societies agree with the staging of procedures that are anticipated to have substantial blood loss; consultant opinion is equally split between agree and equivocal. All groups agree with the staging of procedures that are anticipated to be lengthy and have substantial blood loss. The consultants and specialty society members consider procedures to be prolonged when they exceed an average 6.5 h (range, 2–12 h) in duration. They consider blood loss to be substantial when the loss reaches an average of 44.7% (range, 10–200%) of estimated blood volume.Although the use of staged spine surgery procedures in high-risk patients may entail additional costs and patient risks (e.g. , infection, thromboembolism, neurologic injury), it also may decrease these risks and the risk of perioperative visual loss in some patients. Therefore, consideration should be given to the use of staged spine procedures in high-risk patients.No studies were found that examined the use of magnetic resonance imaging to assess the extent of visual loss after spine surgery in patients with posterior ION. However, the consultants and specialty society members agree that magnetic resonance imaging may be useful to detect causes of visual loss other than ION and CRAO (e.g. , cortical blindness, pituitary apoplexy). All groups agree that a high-risk patient’s vision should be assessed when the patient becomes alert. No studies were found that examined the impact of maintaining increased postoperative hematocrit and blood pressure on recovery of visual loss. Nevertheless, the consultants and specialty society members agree that, in high-risk patients for whom ION is suspected, hemoglobin or hematocrit levels should be adjusted upward, blood pressure should be increased, and oxygen should be administered.Although one case report was found that described the use of a 1-week course of high-dose steroids to treat a patient with ION after lumbar spinal fusion, no vision improvement was noted.21No studies were found that addressed the use of antiplatelet agents or intraocular pressure–lowering agents in the treatment of ION. The consultants and SNACC members are equivocal, NANOS member opinion is equally split between agree and equivocal, and the NASS members report no opinion regarding the statement that there is no role for steroids, antiplatelet agents, or intraocular pressure–lowering agents in the treatment of perioperative ION. All groups agree that there is no proven treatment for perioperative ION.The consensus of the Task Force is that a high-risk patient’s vision should be assessed when the patient becomes alert (e.g. , in the recovery room, intensive care unit, or nursing floor). If there is concern regarding potential visual loss, an urgent ophthalmologic consultation should be obtained to determine its cause. Additional management may include optimizing hemoglobin or hematocrit levels, hemodynamic status, and arterial oxygenation. To rule out causes of visual loss, consider magnetic resonance The Task Force believes that there is no role for antiplatelet agents, steroids, or intraocular pressure–lowering agents in the treatment of perioperative should be given to the use of staged spine procedures in high-risk patients.The of the Task Force are shown in They have been developed to provide on the perioperative care of patients who are undergoing spine procedures while they are positioned prone and receiving general this Advisory, a literature review was used in with opinions obtained from and other (e.g. , society members, open forums, to provide guidance to regarding the perioperative management of patients undergoing spine procedures who may be at risk of perioperative visual loss. the literature review and opinion data were based on evidence , of statements between specific perioperative management (i.e. , associated with a spine procedure during which general anesthesia is and permanent impairment or total loss of The interventions for the evidence are listed study or report that in the published literature is included in the development of an advisory the study (1) is related to one of the specified (2) reports a or of that can be or (e.g. , articles that only opinion are not and (3) is the of an original or report (i.e. , review articles or studies that summarize are not evidence are to assess of the studies and analyses to provide a of Therefore, the published literature not be used as a of support for the development of practice However, many published studies were that the Task Force with For descriptive literature (i.e. , reports of frequency or is often useful in an of the of a and case reports may be useful in identifying perioperative that may be to permanent visual impairment or total loss of the literature relevant studies were via and of the literature. The search a period from through The search a period from through than were a total of articles that addressed related to the evidence review of the studies not provide direct evidence and were total of articles contained direct No evidence contained studies with and statistical information to a analysis (i.e. , among Task Force members and two methodologists was established by levels a for were as (1) type of study (2) type of (3) evidence and (4) literature for values were (1) study (2) type of (3) and (4) literature These values to levels of was obtained from multiple including (1) survey opinion from consultants who were based on their or expertise regarding perioperative visual impairment or total loss of sight associated with a spine procedure during which general anesthesia is (2) survey opinions from of active members of NANOS, and (3) from of a held open forum at a national anesthesia (4) and Task Force opinion and The consultant survey rate of was of Survey results are in the text of the document and in

HEALTH CARE IN THE UNITED STATES: WHAT’S THE UNDERLYING PROBLEM? Health care has been a subject of national debate in the United States for the past decade, as we are facing a crisis in both the quality and the cost of delivered care. Why are health care costs in the United States so high, yet key quality indicators are lagging? The answer is complex and multifactorial, but perioperative care is one major example of the dilemma of high cost, low quality, and thus marginal value of health care in the United States. Indeed, it is generally accepted that our current perioperative system is plagued with high costs, complications, longer than necessary lengths of stay, excess readmissions, and financial incentives to perform surgery.1–6 The Perioperative Surgical Home (PSH)3,7 is a practice model that has been proposed as one of the potential solutions to our fragmented and costly perioperative system. The PSH is defined by the American Society of Anesthesiologists as “a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience”.a,3,7,8 The overall goal of the PSH is to provide improved clinical outcomes and better perioperative service at lower cost. The purpose of this The Open Mind is to detail how the PSH model will achieve these goals and how the specialty of anesthesiology may benefit from this practice model. THE SALIENT ELEMENTS OF PERIOPERATIVE SURGICAL HOME Conceptually, the PSH model aims to reduce variability in perioperative care given that variability increases the likelihood for errors and complications. One way in which this variability can be reduced is through assuring continuity of care and treating the entire perioperative episode of care as one continuum rather than discrete preoperative, intraoperative, postoperative, and postdischarge episodes. This can be achieved by having one team headed by anesthesiologists, to manage all aspects of this continuum from the time that the patient and the surgeon make the decision for surgery until 30 days after discharge. During this perioperative episode, the goal of the PSH is to ensure that best evidence/best practices are applied in a consistent and standardized way to every patient undergoing surgery. When best evidence/best practice does not exist or is not clear, the PSH team should develop an agreement for standardization of a particular practice that will be applied to all patients. In this situation, local systems and policies are highly important in decision making. At each step of this continuum from the decision to undergo surgery until 30 days after surgery, patients will be informed, educated, and involved in the decision making and treatment planning. By applying these concepts, anesthesiologists have a unique opportunity to improve outcomes, decrease length of stay and other metrics, and improve patient satisfaction. Figure 1 underlines the major differences between the current and the future perioperative care under a PSH model. Briefly, in the PSH model, patient-centered care and shared decision making would replace our current physician-centered care. This model considers patient’s preferences and values in all health care decisions, which in other settings has been associated with better outcomes, decreased utilization of expensive tests and procedures, and decreased postencounter discomfort.9 Expectation management, early discharge planning, standardized protocol-driven health and risk assessment, optimization of underlying medical conditions and perioperative standardized anesthetic/nursing/surgical protocols, and fluid management strategies are all determined in advance through the PSH pathway. Similarly, multimodal analgesia, postoperative targeted recovery plan, early ambulation, nutrition management, rescue from complications, and smooth transition of care to an appropriate discharge setting are all also part of a PSH pathway. Importantly, the aim of the PSH is not to replace the surgeon’s role in the postoperative period but rather to assure adherence to mutually agreed on recovery protocols and manage any medical issue that arises during the episode of care.Figure 1: Existing versus suggested perioperative flow system.RATIONALISTIC DATA TO SUPPORT THE EFFECTIVENESS OF PERIOPERATIVE SURGICAL HOME Currently, there is a paucity of data regarding the effectiveness of this new model. We can, however, draw from the literature on enhanced recovery after surgery (ERAS) and from our own experience at University of California (UC) Irvine Health and other institutions.8 ERAS is a perioperative clinical protocol model that includes implementation of 20 items such as standardized management of perioperative pain, nausea and vomiting, and goal-directed fluid administration10,11 (Table 1). This model has been shown to be effective and to result in improved patient satisfaction and postoperative outcomes, reduced length of stay, and reduced risk of hospital-acquired infections.12,13 A fully developed PSH will have many of the elements of ERAS, but will involve coordination of all aspects of perioperative care rather than just implementation of the specific items that are part of ERAS (Table 1). The PSH model also calls for adaptation to the local environment rather than strict implementation of the predefined ERAS items. It is also important to note that perioperative process standardization and clinical care pathways within the surgical context have been used in the past both in Great Britain and the United States. These pathways have been shown to improve clinical care and reduce complications. Unfortunately, these pathways have not achieved high levels of acceptance in the United States and have not been widely adopted.14–17Table 1: Main Items of the Enhanced Recovery after Surgery Care PathwaySince the concept of PSH was conceived, different versions of the model have been implemented in other institutions in the United States such as University of Alabama at Birmingham Health System.8 At UC Irvine Health, a PSH for primary joint replacement surgery (hip and knee) was implemented with the support of the Chairs of Orthopedics and Anesthesiology and Perioperative Care and the Chief Operating Officer of the hospital. Multidisciplinary teams consisting of anesthesiologists, surgeons, nurses, pharmacists, physical therapists, case managers, social workers, and information technology experts met weekly during the implementation phase. All team leaders underwent training in LEAN Six Sigma methodology, and value stream maps for all the perioperative processes were developed with evidence-based protocols used to standardize clinical care pathways. We have adopted the use of LEAN Six Sigma as a cornerstone for our PSH implementation because the perioperative process is very amenable to these processes. LEAN originated with Toyota, which revolutionized the car industry using rigorous standardization in their production lines.18 Conceptually. the perioperative environment could be paralleled to a car production line and standardization of all perioperative procedures could result in an error-free, high-quality process. Patient education, shared decision making, goal-oriented personal recovery pathway with a diary, and performance benchmarks were incorporated at every phase. The regional/acute pain team followed the patients on a daily basis and a “surgical home call system” was established to ensure continuity of care. A nurse navigator/case manager working with the PSH team ensured smooth transitions of care between home, hospital, and postdischarge facility. In April 2013, with the support of a UC Center for Health Quality and Innovation award, UC Irvine began the first phase of the Urological PSH, focusing on nephrectomy and cystectomy, bringing the PSH teams together, and building the clinical pathways. The success of the Joint Replacement PSH has led to enthusiasm in the institution, and the plan for 2014 is to include all elective inpatients and outpatients who undergoing surgery in newly developed PSH models. OPERATIONAL BARRIERS TO THE DEVELOPMENT AND WIDESPREAD IMPLEMENTATION OF A PERIOPERATIVE SURGICAL HOME The implementation of a PSH at UC Irvine Health was not without challenges. Our first attempt to convince a group of general surgeons to take part in such a model 3 years ago was met with skepticism and resistance. In 2012, with the endorsement of the Chair of Orthopedic Surgery, we recruited a new orthopedic surgeon who understood the potential benefits that PSH could offer as he started his practice. Eighteen months later, after the robust results of the PSH focused on the joint replacement service line, the hospital administrators and the surgeons are convinced of the effectiveness of this model and are now supporting it with appropriate resources. Looking to the future, one of our challenges is the management of patients in the postoperative period. Our current model of care for the postoperative period is based on our acute pain team. However, this model will not be sustainable once patient volume increases substantially. We are now moving to a model in which a designated anesthesiologist will supervise designated nurse practitioners who will manage the coordination of care and adherence to protocols of these patients. When moving to a PSH model, one needs to differentiate between the skills needed to build such a program and the skills needed to maintain it. For the development phase, anesthesiologists need to be skilled in team building, change management techniques, LEAN, and Six Sigma methodology.19 Although most anesthesiologists are not necessarily experts in these areas, most hospitals have resources that anesthesiologist PSH champions can access. We also suggest that in the future our residency programs should focus on these change management and performance improvement skills and indeed currently all our CA-1 residents undergo a 2-day training course in LEAN Sigma that is taught by instructors from the Center for Innovation of Johns Hopkins. Once a PSH program with multiple service lines is developed, the actual staffing of the program will be challenging as well. Most anesthesiologists think of themselves as perioperative clinicians. However, their skillsets in the postoperative management of complex surgical patients may be limited. We suggest that if the PSH is to be widely used, our residency training programs must include more training in perioperative medicine, with particular emphasis on postoperative care. Finally, one can accept the conceptual model of the PSH but still raise the question of the suitability of anesthesiologists to be the leaders. We believe anesthesiologists are uniquely qualified because of their involvement in all aspects of the preoperative, intraoperative, and postoperative periods. Furthermore, anesthesiologists are typically “system-thinkers” as demonstrated by the improvement we have made in patient safety.20 Surgeons are typically not interested in the medical management of their patients and are currently not involved in their preoperative optimization. It is our opinion that while hospitalists are interested in getting involved in the management of the PSH, they lack the fundamental understanding of perioperative physiology that results from the surgical experience and thus are not ideally positioned to deliver optimal postoperative care. FISCAL BARRIERS TO THE DEVELOPMENT AND WIDESPREAD IMPLEMENTATION OF A PERIOPERATIVE SURGICAL HOME Current financial constraints present a major barrier to a PSH model because the “extra services” provided by anesthesiologists cannot be reimbursed within the existing payment system. However, looking at the future state of medical payments, we suggest that we might be moving away from the fee-for-service system toward a “bundle payment” system, where anesthesiologists will no longer be paid based on time units but rather based on their “overall value” to the surgical episode. Under this new payment system, anesthesiologists will need to demonstrate value beyond just the operating rooms to maintain their current reimbursement level. One way for anesthesiologists to demonstrate their value is to move up in the value chain and become the leaders of the PSH model in their institutions. Even in the current fee-for-service model, anesthesiologists could be compensated for their role in PSH just like family practitioners get reimbursed for their role in “patient-centered medical home”.21 The Centers for Medicare and Medicaid Services has now recognized the concept of patient-centered medical home,22 which it defines as “a primary care model that aims to improve patient outcomes by adopting a patient-centered rather than disease-centered approach”.21,23 Such compensation would offset the costs associated with the implementation and maintenance of a PSH. Finally, once hospital administrators realize the savings achieved from improved outcomes with the PSH model, they may be motivated to compensate anesthesiologists for their role as leaders of the PSH. When one communicates with the hospital leadership, it may be worthwhile to indicate that the National Health Service in Great Britain estimates that ERAS generates a net savings of over $630 million every year.24 If PSH in the United States is as successful as the ERAS program in the United Kingdom, savings in the millions of dollars will be realized by hospitals. We do appreciate that at an early stage of implementation anesthesiology departments may need to absorb the costs of setting and maintaining a PSH model until hospitals and third party payers recognize its value. In our opinion, if anesthesiologists do not adopt the PSH model because of these initial set-up costs, bundle payments would become a reality with anesthesiologists locked into the operating rooms with intraoperative anesthesia provision becoming a commodity. We see the PSH as a way for anesthesiologists to move beyond the operating rooms and the traditional conflict with health care extenders to play a critical role in the changing environment. CONCLUSIONS AND THE FUTURE OF PERIOPERATIVE SURGICAL HOME Despite the current lack of definitive evidence that implementation of a PSH program leads to better clinical outcomes, better service to our patients, and reduced costs, the successes and validation of the ERAS program in Europe and results at the University of Alabama at Birmingham and at UC Irvine Health, and elsewhere in the United States, give cause for optimism. Clearly, significant research needs to be conducted to validate the assertions made in this review. The American Society of Anesthesiologists has recognized the need for such supportive data and has approved a budget of over $1 million to run a multihospital collaborative that will implement the PSH model and collect detailed outcome and process data. Only with such initiatives and the use of rigorous research methodology (Comparative Effectiveness Research),25 we will be able to examine whether the PSH is a valid perioperative care delivery model. Given the UC Irvine Health experience, we believe the PSH offers a very bright future for the field of anesthesia. RECUSE NOTE Dr. Maxime Cannesson is the Section Editor for Technology, Computing, and Simulation for the Journal. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Cannesson was not involved in any way with the editorial process or decision. DISCLOSURES Name: Zeev N. Kain, MD, MBA. Contribution: This author helped analyze the data and write the manuscript. Attestation: Zeev N. Kain approved the final manuscript. Conflicts of Interest: Zeev N. Kain lectures for Merck on team training and is funded by the National Institutes of Health. Name: Shermeen Vakharia, MD, MBA. Contribution: This author helped write the manuscript. Attestation: Shermeen Vakharia approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Leslie Garson, MD. Contribution: This author helped write the manuscript. Attestation: Leslie Garson approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Scott Engwall, MD, MBA. Contribution: This author helped write the manuscript. Attestation: Scott Engwall approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Ran Schwarzkopf, MD. Contribution: This author helped write the manuscript. Attestation: Ran Schwarzkopf approved the final manuscript. Conflicts of Interest: Ran Schwarzkopf received a research grant from Pacira Pharmaceutical, is a paid consultant for Smith & Nephew, and has stock options with Gauss Surgical. Name: Ranjan Gupta, MD. Affiliation: Department of Orthopedic Surgery, University of California Irvine, Irvine, California. Contribution: This author helped write the manuscript. Attestation: Ranjan Gupta approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Maxime Cannesson, MD, PhD. Contribution: This author helped write the manuscript. Attestation: Maxime Cannesson approved the final manuscript. Conflicts of Interest: Maxime Cannesson consulted for Edwards Lifesciences, received research funding from Edwards Lifesciences, consulted for Masimo Corp., and received research funding from Masimo Corp.

* Developed by the American Society of Anesthesiologists Task Force on Perioperative Transesophageal Echocardiography: Daniel M. Thys, M.D., Chair, New York, New York; Martin D. Abel, M.B.B.Ch., Rochester, Minnesota; Robert F. Brooker, M.D., Wausau, Wisconsin; Michael K. Cahalan, M.D., Salt Lake City, Utah; Richard T. Connis, Ph.D., Woodinville, Washington; Peggy G. Duke, M.D., Atlanta, Georgia; David G. Nickinovich, Ph.D., Bellevue, Washington; Scott T. Reeves, M.D., Charleston, South Carolina; Marc A. Rozner, Ph.D., M.D., Houston, Texas; Isobel A. Russell, M.D., San Francisco, California; Scott C. Streckenbach, M.D., Boston, Massachusetts; Pamela Sears-Rogan, M.D., Washington, DC (American Society of Echocardiography); and William J. Stewart, M.D., Cleveland, Ohio (American College of Cardiology).PRACTICE Guidelines are systematically developed recommendations that assist the practitioner and the patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.This update includes data published since the Practice Guidelines for Perioperative Transesophageal Echocardiography were adopted by the ASA and the Society of Cardiovascular Anesthesiologists in 1995 and published in 1996.1For these Guidelines, perioperative transesophageal echocardiography (TEE) refers to TEE performed on surgical patients before, during, or immediately after surgery, including the critical care setting. Evidence of effectiveness is discussed relative to specific settings where perioperative TEE is customarily used (e.g. , cardiac surgery, noncardiac surgery, and critical care).The purposes of these Guidelines are (1) to assist the physician in determining the appropriate application of TEE and (2) to improve the outcomes of surgical patients by defining the utility of perioperative TEE based on the strength of supporting evidence.These Guidelines focus on the application of TEE in surgical patients and potential surgical patients in the setting of cardiac surgery, noncardiac surgery, and postoperative critical care. The Guidelines do not apply to the assessment of nonsurgical patients or to postdischarge follow-up assessment of surgical patients.The Task Force believes that physician proficiency in the use of perioperative TEE is of paramount importance due to the risk of adverse outcomes resulting from incorrect interpretation. The Guidelines do not address training, certification, credentialing, and quality assurance, which are addressed elsewhere.2–5These Guidelines are intended for anesthesiologists and other physicians (e.g. , cardiologists, surgeons, and intensivists) who use TEE in the perioperative setting. Recommen- dations to perform TEE are not applicable when the procedure cannot be performed properly or safely nor do they apply when TEE equipment or skilled examiners are unavailable. The recommendations in this report are based on consideration of the risk benefit ratio for individual patients.The ASA and Society of Cardiovascular Anesthesiologists jointly appointed a task force of 13 members, including anesthesiologists in both private and academic practice from various geographic areas of the United States, two cardiologists (one representing the American College of Cardiology and the other representing the American Society of Echocardiography), and two consulting methodologists from the ASA Committee on Standards and Practice Parameters.The Task Force developed the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to TEE were reviewed and evaluated. Third, expert consultants were asked (1) to participate in opinion surveys on the effectiveness of TEE imaging and (2) to review and comment on a draft of the Guidelines developed by the Task Force. Fourth, opinions about the Guidelines recommendations were solicited from a sample of active members of the ASA who personally perform TEE as a part of their practice. Fifth, the Task Force held an open forum at a major international meeting†to solicit input on its draft recommendations. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Seventh, all available information was used to build consensus within the Task Force to finalize the Guidelines (appendix 1).Preparation of these Guidelines followed a rigorous methodologic process (appendix 2). Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence.Study findings from scientific literature published after 1994 (not excluding sentinel articles published prior to 1994) were aggregated and reported in summary form by evidence category, as described later. All literature (e.g. , randomized controlled trials, observational studies, and case reports) relevant to each topic was considered when evaluating the findings. For reporting purposes in this document, only the highest level of evidence (i.e. , levels 1, 2, or 3 identified below) within each category (i.e. , A, B, or C) is included in the summary.Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.Information from observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes.The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes.The lack of scientific evidence in the literature is described by the following conditions.All opinion-based evidence relevant to each topic (e.g. , survey data, open-forum testimony, Internet-based comments, letters, and editorials) was considered in the development of these Guidelines. However, only the findings obtained from formal surveys are reported.Opinion surveys were developed by the Task Force to address each clinical intervention identified in the document. Identical surveys were distributed to two groups of respondents: expert consultants and ASA members.Survey responses from Task Force–appointed expert consultants are reported in summary form in the text. A complete listing of consultant survey responses is reported in a table in appendix 2.Survey responses from a sample of members of the ASA are reported in summary form in the text. A complete listing of ASA member survey responses is reported in a table in appendix 2.Expert consultant and ASA membership survey responses are recorded using a 5-point scale and summarized based on median values.§Open-forum testimony, Internet-based comments, letters, and editorials are all informally evaluated and discussed during the development of Guidelines recommendations. When warranted, the Task Force may add educational information or cautionary notes based on this information.Cardiac and thoracic aortic procedures consist of cardiac and thoracic aortic surgery, and catheter-based intracardiac procedures.Cardiac and thoracic aortic surgery: For cardiac or thoracic aortic surgery patients, the literature reports variations in sensitivity, specificity, or positive and negative predictive values for the detection of abnormalities relating to valvular, coronary, aortic, congenital, and other cardiovascular disease (table 1in appendix 2). Examples of these abnormalities include mitral valve abnormalities, valvular abscesses, myocardial ischemia, aortic dissection, and atrial septal defect (Category B2 evidence ). The literature also reports a range of sensitivity, specificity, and positive and negative predictive values for the confirmation or refinement by TEE of the preoperative diagnosis (table 1in appendix 2). Examples include aortic dissection, aortic intramural hemorrhage, and valvular or mural infective endocarditis lesions (Category B2 evidence ). The ASA members agree and the consultants strongly agree that TEE should be used for all cardiac or thoracic aortic surgery patients.For adult patients without contraindications, TEE should be used in all open heart (e.g. , valvular procedures) and thoracic aortic surgical procedures and should be considered in coronary artery bypass graft surgeries to: (1) confirm and refine the preoperative diagnosis, (2) detect new or unsuspected pathology, (3) adjust the anesthetic and surgical plan accordingly, and (4) assess the results of surgical intervention. In small children, the use of TEE should be considered on a case-by-case basis because of risks unique to these patients (e.g. , bronchial obstruction).Catheter-based intracardiac procedures: Studies with observational findings confirm the utility of TEE or intracardiac echocardiography for guiding management of catheter-based intracardiac procedures (e.g. , occluder device placement, percutaneous valvular procedures, and intracardiac ablation procedures) (Category B2 evidence ). In addition, studies with observational findings report the detection of unsuspected abnormalities by TEE, such as aortic root abscess, atrial thrombi, atrial septal aneurysm, shunting, mitral valve/annular calcification and regurgitation, wall motion abnormalities, and tamponade (Category B2 evidence ). The detection of pericardial effusion is also reported (Category B3 evidence ).Both the consultants and ASA members agree that TEE should be used for patients undergoing transcatheter intracardiac procedures when general anesthesia is provided and intracardiac ultrasound is not used. The ASA members agree and the consultants strongly agree that TEE should be used for septal defect closure or atrial appendage obliteration. Both the consultants and ASA members strongly agree that TEE should be used during catheter-based valve replacement and repair. Finally, both the consultants and ASA members are equivocal regarding the use of TEE during dysrhythmia treatment.For patients undergoing transcatheter intracardiac procedures, TEE may be used.For noncardiac surgery patients, studies with observational findings or case reports note the detection of the following abnormalities by TEE: (1) venous air embolism and patent foramen ovale in neurosurgery (Category B2 evidence ); (2) pericardial effusion and compression of the cardiac chambers in liver transplantation (Category B3 evidence ); (3) intracardiac emboli and patent foramen ovale (Category B2 evidence ), mitral regurgitation, left ventricular hypertrophy, and left ventricular outflow tract obstruction in orthopedic surgery (Category B3 evidence ), (4) left ventricular segmental wall motion abnormalities (Category B2 evidence ), aortic lesions and atrial tumors in vascular surgery (Category B3 evidence ), and (5) atrial septal defect, myocardial ischemia, hypovolemia, pericardial tamponade, thromboembolic events (Category B2 evidence ), pericardial effusion, tamponade, and intrapulmonary emboli in other major surgery (i.e. , lung, renal, abdominal, and head/neck/chest wall surgeries) (Category B3 evidence ).The consultants and ASA members agree that TEE should be used for noncardiac surgical patients when the patient has known or suspected cardiovascular pathology that might result in hemodynamic, pulmonary, or neurologic compromise. The consultants and ASA members both strongly agree that TEE should be used during unexplained persistent hypotension. Further, both the consultants and ASA members agree that TEE should be used when persistent unexplained hypoxemia occurs. The ASA members agree and the consultants strongly agree that TEE should be used when life-threatening hypotension is anticipated.Both the consultants and ASA members agree that TEE should be used during either lung transplantation or major abdominal or thoracic trauma. The consultants agree although the ASA members are equivocal regarding the use of TEE during open abdominal aortic procedures and liver transplantation. Both the consultants and ASA members are equivocal regarding the use of TEE during: (1) endovascular aortic procedures, (2) neurosurgery in the sitting position, and (3) percutaneous cardiovascular interventions (e.g. , femoral artery stenting). Finally, the consultants and ASA members both disagree with the assertion that TEE should be used during orthopedic surgery.TEE may be used when the nature of the planned surgery or the patient's known or suspected cardiovascular pathology might result in severe hemodynamic, pulmonary, or neurologic compromise. If equipment and expertise are available, TEE should be used when unexplained life-threatening circulatory instability persists despite corrective therapy.Studies with observational findings for critically ill patients with an unexplained adverse postoperative clinical course report TEE detection for the following abnormalities: regurgitant valvular lesions, aortic or mitral valve vegetation, aortic dissection, intracardiac mass, tamponade, ventricular failure, and hypovolemia (Category B2 evidence ). Case reports of critically ill postoperative patients indicate that TEE detects abnormalities such as aortic root abscess, pericardial hematoma, atherosclerotic debris in the thoracic aorta, left ventricular hypertrophy, wall motion abnormalities, and ventricular masses (Category B3 evidence ).Both the consultants and ASA members strongly agree that TEE should be used for critical care patients when diagnostic information expected to alter management cannot be obtained by transthoracic echocardiography or other modalities in a timely manner. The ASA members agree and the consultants strongly agree that TEE should be used during unexplained persistent hypotension. They both agree that TEE should be used when persistent unexplained hypoxemia occurs.For critical care patients, TEE should be used when diagnostic information that is expected to alter management cannot be obtained by transthoracic echocardiography or other modalities in a timely manner.Studies with observational findings and case reports indicate that, although rare, potential complications associated with TEE may include esophageal perforation, esophageal injury, hematoma, laryngeal palsy, dysphagia, dental injury, or death (Category B2 evidence ). However, there is insufficient literature to assess whether there are contraindications for the use of TEE (Category D evidence ).Both the consultants and ASA members are equivocal with regard to whether there are no absolute contraindications to TEE other than previous esophagectomy or esophagogastrectomy. Those consultants and ASA members who do not agree that there are no absolute contraindications other than previous esophagectomy or esophagogastrectomy do agree that the following four conditions should be absolute contraindications to TEE: esophageal stricture, tracheoesophageal fistula, postesophageal surgery, and esophageal trauma. Both the consultants and ASA members disagree that the following four conditions should be absolute contraindications to TEE: Barrett esophagus, hiatal hernia, large descending aortic aneurysm, and unilateral vocal cord paralysis. Finally, both the consultants and ASA members are equivocal with regard to whether the following three conditions should be absolute contraindications to TEE: esophageal varices, postradiation therapy, and previous bariatric surgery. The consultants agree but the ASA members are equivocal that Zenker diverticulum and colonic interposition are absolute contraindications. Finally, the ASA members disagree and the consultants are equivocal that dysphagia is an absolute contraindication to TEE.TEE may be used for patients with oral, esophageal, or gastric disease, if the expected benefit outweighs the potential risk, provided the appropriate precautions are applied. These precautions may include the following: considering other imaging modalities (e.g. , epicardial echocardiography), obtaining a gastroenterology consultation using a smaller probe, limiting the examination, avoiding unnecessary probe manipulation, and using the most experienced operator.For these Guidelines, a literature review was used in combination with opinions obtained from expert consultants and other sources (e.g. , ASA members, open forums, Internet postings). Both the literature review and opinion data were based on evidence linkages or statements regarding potential relationships between clinical interventions and outcomes. The efficacy and outcomes from the use of TEE were examined for the following procedures:The impact of the use of perioperative TEE was assessed on the basis of the following:For the literature review, potentially relevant clinical studies published after 1994 were identified via electronic and manual searches of the literature. The electronic and manual searches covered a 16-yr period from 1994 through 2009. More than 8000 citations were initially identified, yielding a total of 861 nonoverlapping articles that addressed topics related to the evidence linkages. After review of the articles, 404 studies did not provide direct evidence and were subsequently eliminated. A total of 457 articles contained direct linkage-related evidence. A complete bibliography used to develop these Guidelines, organized by section, is available as Supplemental Digital Content 2, http://links.lww.com/ALN/A568.Literature reporting the detection of new abnormalities by TEE was summarized, followed by a summary of literature reporting the confirmation of previously diagnosed abnormalities by TEE. The sensitivity, specificity, and positive and negative predictive values for the efficacy of TEE in detecting new abnormalities and in confirming or redefining previous diagnoses were also obtained (table 1). Study findings reporting the misdiagnosis or limited effectiveness of TEE to detect pathology are also listed in table 1.Interobserver agreement among Task Force members and two methodologists was established by interrater reliability testing. Agreement levels using a κ statistic for two-rater agreement pairs were as follows: (1) type of study design, κ= 0.50–1.00; (2) type of analysis, κ= 0.50–0.83; (3) evidence linkage assignment, κ= 0.75–1.00; and (4) literature inclusion for database, κ= 0.78–1.00. Three-rater chance-corrected agreement values were as follows: (1) study design, Sav = 0.66, Var (Sav) = 0.006; (2) type of analysis, Sav = 0.66, Var (Sav) = 0.007; (3) linkage assignment, Sav = 0.83, Var (Sav) = 0.005; and (4) literature database inclusion, Sav = 0.84, Var (Sav) = 0.046. These values represent moderate to high levels of agreement.Consensus was obtained from multiple sources, including (1) survey opinion from consultants who were selected based on their knowledge or expertise in the perioperative use of TEE, (2) survey opinions solicited from active members of the ASA who personally perform TEE as part of their practice, (3) testimony from attendees of a publicly held open forum at an international anesthesia meeting, (4) Internet commentary, and (5) Task Force opinion and interpretation. The survey rate of return was 53% (n = 55 of 103) for the consultants, and 818 surveys were received from active ASA members who indicated that they personally performed TEE as part of their practice. Results of the surveys are reported in tables 2 and 3and summarized in the text of the Guidelines.The consultants were asked to indicate which, if any, of the recommendations would change their clinical practices if the Guidelines were instituted. The rate of return was 14% (n = 14 of 103). The percent of responding consultants expecting a change in their practice associated with each linkage topic was as follows: (1) major cardiac and thoracic aortic surgery, 7%; (2) transcatheter intracardiac procedures, 0%; (3) pacemaker and implanted cardioverter defibrillator lead extraction, 7% (4); neurosurgery, 7% (5); liver transplantation, 0% (6); orthopedic surgery, 7% (7); vascular/endovascular surgery, 7%, (8) other major surgery (i.e. , lung, renal, abdominal, and head/neck/chest wall), 14%; and (9) postoperative critical care, 21%. Eighty-six percent indicated that their clinical practice will not need new equipment, supplies, or training to implement the Practice Guidelines. Eighty-six percent indicated that the Guidelines would not require ongoing changes in their practice which will affect costs. One hundred percent of the respondents indicated that the Guidelines would have no effect on the amount of time spent on a typical case.

BACKGROUND: The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non-opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. OBJECTIVES: To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. SELECTION CRITERIA: We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. DATA COLLECTION AND ANALYSIS: We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS: We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after).The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies.IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) -0.50, 95% confidence interval (CI) -0.72 to -0.28; 29 studies, 1656 participants; very low-quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD -0.14, 95% CI -0.25 to -0.04; 33 studies, 1847 participants; moderate-quality evidence), and at late time points (48 hours) (SMD -0.11, 95% CI -0.25 to 0.04; 24 studies, 1404 participants; moderate-quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures.We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) -7.92 hours, 95% CI -12.71 to -3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD -4.52 mg morphine equivalents , 95% CI -6.25 to -2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes.The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low-quality evidence).IV Lidocaine compared to TEAThe effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI -0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI -1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD -1.66, 95% CI -10.88 to 7.56; 2 studies, 102 participants); all very low-quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low-quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low-quality evidence). AUTHORS' CONCLUSIONS: We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review.

BACKGROUND: Perioperative myocardial infarction is the most common cause of morbidity and mortality in patients who have had noncardiac surgery, but its diagnosis can be difficult. The present study was designed to determine whether the measurement of serum levels of cardiac troponin I, a highly sensitive and specific marker for cardiac injury, would help establish the diagnosis of myocardial infarction. METHODS: We obtained preoperative measurements of MB creatine kinase, total creatine kinase, and cardiac troponin I, in addition to base-line electrocardiograms and two-dimensional echocardiograms, in 96 patients undergoing vascular surgery and 12 undergoing spinal surgery. Blood samples were obtained every 6 hours for at least the first 36 hours after surgery, and electrocardiograms were obtained daily; a second echocardiogram was obtained approximately three days after surgery. The appearance of a new abnormality in segmental-wall motion on the postoperative echocardiogram (that is, an abnormality that had not been seen on the preoperative echocardiogram) was considered to be indicative of perioperative infarction. RESULTS: Eight patients who underwent vascular surgery had new abnormalities in segmental-wall motion and received a diagnosis of perioperative infarction. All eight had elevations of cardiac troponin I, and six had elevations of MB creatine kinase. Of the 100 patients without perioperative infarction detected by echocardiography, 19 had elevations of MB creatine kinase, and 1 had a slight elevation of cardiac troponin I. CONCLUSIONS: The measurement of cardiac troponin I is a sensitive and specific method for the diagnosis of perioperative myocardial infarction. It avoids the high incidence of false diagnoses associated with the use of MB creatine kinase as a diagnostic marker.

This is the first of 2 articles evaluating cardiac events in patients undergoing noncardiac surgery. In this article, we review the magnitude of the problem, the pathophysiology of these events, approaches to risk assessment and communication of risk. The number of patients undergoing noncardiac surgery worldwide is growing, and annually 500,000 to 900,000 of these patients experience perioperative cardiac death, nonfatal myocardial infarction (MI) or nonfatal cardiac arrest. Although the evidence is limited, a substantial proportion of fatal perioperative MIs may not share the same pathophysiology as nonoperative MIs. A clearer understanding of the pathophysiology is needed to direct future research evaluating prophylactic, acute and long-term interventions. Researchers have developed tools to facilitate the estimation of perioperative cardiac risk. Studies suggest that the Lee index is the most accurate generic perioperative cardiac risk index. The limitations of the studies evaluating the ability of noninvasive cardiac tests to predict perioperative cardiac risk reveals considerable uncertainty as to the role of these popular tests. Similarly, there is uncertainty as to the predictive accuracy of the American College of Cardiology/American Heart Association algorithm for cardiac risk assessment. Patients are likely to benefit from improved estimation and communication of cardiac risk because the majority of noncardiac surgeries are elective and accurate risk estimation is important to allow informed patient and physician decision-making.

BACKGROUND: Fasting before general anaesthesia aims to reduce the volume and acidity of stomach contents during surgery, thus reducing the risk of regurgitation/aspiration. Recent guidelines have recommended a shift in fasting policy from the standard 'nil by mouth from midnight' approach to more relaxed policies which permit a period of restricted fluid intake up to a few hours before surgery. The evidence underpinning these guidelines however, was scattered across a range of journals, in a variety of languages, used a variety of outcome measures and methodologies to evaluate fasting regimens that differed in duration and the type and volume of intake permitted during a restricted fasting period. Practice has been slow to change. OBJECTIVES: To systematically review the effect of different preoperative fasting regimens (duration, type and volume of permitted intake) on perioperative complications and patient wellbeing (including aspiration, regurgitation and related morbidity, thirst, hunger, pain, nausea, vomiting, anxiety) in different adult populations. SEARCH STRATEGY: Electronic databases, conference proceedings and reference lists from relevant articles were searched for studies of preoperative fasting in August 2003 and experts in the area were consulted. SELECTION CRITERIA: Randomised controlled trials which compared the effect on postoperative complications of different preoperative fasting regimens on adults were included. DATA COLLECTION AND ANALYSIS: Details of the eligible studies were independently extracted by two reviewers and where relevant information was unavailable from the text attempts were made to contact the authors. MAIN RESULTS: Thirty eight randomised controlled comparisons (made within 22 trials) were identified. Most were based on 'healthy' adult participants who were not considered to be at increased risk of regurgitation or aspiration during anaesthesia. Few trials reported the incidence of aspiration/regurgitation or related morbidity but relied on indirect measures of patient safety i.e. intra-operative gastric volume and pH. There was no evidence that the volume or pH of participants' gastric contents differed significantly depending on whether the groups were permitted a shortened preoperative fluid fast or continued a standard fast. Fluids evaluated included water, coffee, fruit juice, clear fluids and other drinks (e.g. isotonic drink, carbohydrate drink). Participants given a drink of water preoperatively were found to have a significantly lower volume of gastric contents than the groups that followed a standard fasting regimen. This difference was modest and clinically insignificant. There was no indication that the volume of fluid permitted during the preoperative period (i.e. low or high) resulted in a difference in outcomes from those participants that followed a standard fast. Few trials specifically investigated the preoperative fasting regimen for patient populations considered to be at increased risk during anaesthesia of regurgitation/aspiration and related morbidity. REVIEWER'S CONCLUSIONS: There was no evidence to suggest a shortened fluid fast results in an increased risk of aspiration, regurgitation or related morbidity compared with the standard 'nil by mouth from midnight' fasting policy. Permitting patients to drink water preoperatively resulted in significantly lower gastric volumes. Clinicians should be encouraged to appraise this evidence for themselves and when necessary adjust any remaining standard fasting policies (nil-by-mouth from midnight) for patients that are not considered 'at-risk' during anaesthesia.

Perioperative hypothermia is common and adversely affects clinical outcomes due to its effect on a range of homeostatic functions. Many of these adverse consequences are preventable by the use of warming techniques. A literature search was conducted to identify relevant published articles on perioperative hypothermia and warming. The databases searched include MEDLINE (1966 to February 2005), EMBASE (1974 to February 2005), CINAHL, the Cochrane library and the health technology assessment database. Reference lists of key articles were also searched. The primary beneficial effects of warming are mediated through increased blood flow and oxygen tension at tissue level. Reduction in wound infection, blood loss and perioperative pain with warming is promising. However, more evidence from good-quality prospective randomised controlled trials is needed to evaluate the role of warming in improving overall morbidity, mortality and hospital stay as well as to clarify its role as an adjunct to resuscitation and during the pre-hospital transport phase of critically ill patients. Awareness of the risks of perioperative hypothermia is the key to prevention. Achieving normothermia throughout the patient's journey is a worthwhile goal in surgical patients.

Neoadjuvant or adjuvant immunotherapy can improve outcomes in patients with resectable non–small-cell lung cancer (NSCLC). Perioperative regimens may combine benefits of both to improve long-term outcomes. Download a PDF of the Research Summary. We randomly assigned patients with resectable NSCLC (stage II to IIIB [N2 node stage] according to the eighth edition of the AJCC Cancer Staging Manual) to receive platinum-based chemotherapy plus durvalumab or placebo administered intravenously every 3 weeks for 4 cycles before surgery, followed by adjuvant durvalumab or placebo intravenously every 4 weeks for 12 cycles. Randomization was stratified according to disease stage (II or III) and programmed death ligand 1 (PD-L1) expression (≥1% or <1%). Primary end points were event-free survival (defined as the time to the earliest occurrence of progressive disease that precluded surgery or prevented completion of surgery, disease recurrence [assessed in a blinded fashion by independent central review], or death from any cause) and pathological complete response (evaluated centrally). A total of 802 patients were randomly assigned to receive durvalumab (400 patients) or placebo (402 patients). The duration of event-free survival was significantly longer with durvalumab than with placebo; the stratified hazard ratio for disease progression, recurrence, or death was 0.68 (95% confidence interval [CI], 0.53 to 0.88; P=0.004) at the first interim analysis. At the 12-month landmark analysis, event-free survival was observed in 73.4% of the patients who received durvalumab (95% CI, 67.9 to 78.1), as compared with 64.5% of the patients who received placebo (95% CI, 58.8 to 69.6). The incidence of pathological complete response was significantly greater with durvalumab than with placebo (17.2% vs. 4.3% at the final analysis; difference, 13.0 percentage points; 95% CI, 8.7 to 17.6; P<0.001 at interim analysis of data from 402 patients). Event-free survival and pathological complete response benefit were observed regardless of stage and PD-L1 expression. Adverse events of maximum grade 3 or 4 occurred in 42.4% of patients with durvalumab and in 43.2% with placebo. Data from 62 patients with documented EGFR or ALK alterations were excluded from the efficacy analyses in the modified intention-to-treat population. In patients with resectable NSCLC, perioperative durvalumab plus neoadjuvant chemotherapy was associated with significantly greater event-free survival and pathological complete response than neoadjuvant chemotherapy alone, with a safety profile that was consistent with the individual agents. (Funded by AstraZeneca; AEGEAN ClinicalTrials.gov number, NCT03800134.) QUICK TAKE VIDEO SUMMARYPerioperative Chemoimmunotherapy in Lung Cancer 02:08

AbstractAbstract This prospective observational study found that approximately 1 in 20 perioperative medication administrations, and every second operation, resulted in a medication error and/or an adverse drug event. More than one third of these errors led to observed patient harm, and the remaining two thirds had the potential for patient harm. Background The purpose of this study is to assess the rates of perioperative medication errors (MEs) and adverse drug events (ADEs) as percentages of medication administrations, to evaluate their root causes, and to formulate targeted solutions to prevent them. Methods In this prospective observational study, anesthesia-trained study staff (anesthesiologists/nurse anesthetists) observed randomly selected operations at a 1,046-bed tertiary care academic medical center to identify MEs and ADEs over 8 months. Retrospective chart abstraction was performed to flag events that were missed by observation. All events subsequently underwent review by two independent reviewers. Primary outcomes were the incidence of MEs and ADEs. Results A total of 277 operations were observed with 3,671 medication administrations of which 193 (5.3%; 95% CI, 4.5 to 6.0) involved a ME and/or ADE. Of these, 153 (79.3%) were preventable and 40 (20.7%) were nonpreventable. The events included 153 (79.3%) errors and 91 (47.2%) ADEs. Although 32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed ADE and an additional 70 (45.8%) had the potential for patient harm. Of the 153 errors, 99 (64.7%) were serious, 51 (33.3%) were significant, and 3 (2.0%) were life-threatening. Conclusions One in 20 perioperative medication administrations included an ME and/or ADE. More than one third of the MEs led to observed ADEs, and the remaining two thirds had the potential for harm. These rates are markedly higher than those reported by retrospective surveys. Specific solutions exist that have the potential to decrease the incidence of perioperative MEs.

BACKGROUND: Preoperative transfusions are frequently given to prevent perioperative morbidity in patients with sickle cell anemia. There is no consensus, however, on the best regimen of transfusions for this purpose. METHODS: We conducted a multicenter study to compare the rates of perioperative complications among patients randomly assigned to receive either an aggressive transfusion regimen designed to decrease the hemoglobin S level to less than 30 percent (group 1) or a conservative regimen designed to increase the hemoglobin level to 10 g per deciliter (group 2). RESULTS: Patients undergoing a total of 604 operations were randomly assigned to group 1 or group 2. The severity of the disease, compliance with the protocol, and the types of operations were similar in the two groups. The preoperative hemoglobin level was 11 g per deciliter in group 1 and 10.6 g per deciliter in group 2. The preoperative value for hemoglobin S was 31 percent in group 1 and 59 percent in group 2. The most frequent operations were cholecystectomies (232), head and neck surgery (156), and orthopedic surgery (72). With the exception of transfusion-related complications, which occurred in 14 percent of the operations in group 1 and in 7 percent of those in group 2, the frequency of serious complications was similar in the two groups (31 percent in group 1 and 35 percent in group 2). The acute chest syndrome developed in 10 percent of both groups and resulted in two deaths in group 1. A history of pulmonary disease and a higher risk associated with surgery were significant predictors of the acute chest syndrome. CONCLUSIONS: A conservative transfusion regimen was as effective as an aggressive regimen in preventing perioperative complications in patients with sickle cell anemia, and the conservative approach resulted in only half as many transfusion-associated complications.

BACKGROUND: Children, like adults, are required to fast before general anaesthesia with the aim of reducing the volume and acidity of their stomach contents. It is thought that fasting reduces the risk of regurgitation and aspiration of gastric contents during surgery. Recent developments have encouraged a shift from the standard 'nil-by-mouth-from-midnight' fasting policy to more relaxed regimens. Practice has been slow to change due to questions relating to the duration of a total fast, the type and amount of intake permitted. OBJECTIVES: To systematically assess the effects of different fasting regimens (duration, type and volume of permitted intake) and the impact on perioperative complications and patient well being (aspiration, regurgitation, related morbidity, thirst, hunger, pain, comfort, behaviour, nausea and vomiting) in children. SEARCH STRATEGY: We searched Cochrane Wounds Group Specialised Register (searched 25/6/09), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2 2009), Ovid MEDLINE (1950 to June Week 2 2009), Ovid EMBASE (1980 to 2009 Week 25), EBSCO CINAHL (1982 to June Week 3 2009), the National Research Register, relevant conference proceedings and article reference lists and contacted experts. SELECTION CRITERIA: Randomised and quasi randomised controlled trials of preoperative fasting regimens for children were identified. DATA COLLECTION AND ANALYSIS: Data extraction and trial quality assessment was conducted independently by three authors. Trial authors were contacted for additional information including adverse events. MAIN RESULTS: This first update of the review identified two additional eligible studies, bringing the total number of included studies to 25 (forty seven randomised controlled comparisons involving 2543 children considered to be at normal risk of regurgitation or aspiration during anaesthesia). Only one incidence of aspiration and regurgitation was reported.Children permitted fluids up to 120 minutes preoperatively were not found to experience higher gastric volumes or lower gastric pH values than those who fasted. The children permitted fluids were less thirsty and hungry, better behaved and more comfortable than those who fasted.Clear fluids preoperatively did not result in a clinically important difference in children's gastric volume or pH. Evidence relating to the preoperative intake of milk was sparse. The volume of fluid permitted during the preoperative period did not appear to impact on children's intraoperative gastric volume or pH contents. AUTHORS' CONCLUSIONS: There is no evidence that children who are denied oral fluids for more than six hours preoperatively benefit in terms of intraoperative gastric volume and pH compared with children permitted unlimited fluids up to two hours preoperatively. Children permitted fluids have a more comfortable preoperative experience in terms of thirst and hunger. This evidence applies only to children who are considered to be at normal risk of aspiration/regurgitation during anaesthesia.