Top Trends in Anesthesia Care

The importance of updated anesthetic techniques has only been magnified with the increase in volume, type and complexity of outpatient procedures. Here are a few key developments in the field that have helped anesthesia providers perform better, safer and more efficient care.

• Targeted blocks. Ultrasound guidance has helped advance regional anesthesia, which contributes to positive outcomes and timely discharges, states Heather Towers, CRNA, MS, DNAP, of BPW Medical Associates, a full-service anesthesia group in suburban Pittsburgh. “The imaging technology lets you identify individual nerves as they leave the plexus and travel down an extremity,” she says.

For example, before ultrasound, a surgery involving the thumb would require the whole arm to be numb. Now, with ultrasound guidance, a provider can place a block with a shorter acting anesthetic to numb the arm for surgery and place a longer acting block directly to the radial nerve, which innervates the thumb close to the incision site. “This two-step process allows the patient to maintain use of their arm postoperatively, while still having pain relief,” says Ms. Towers.

Joseph Rodriguez, CRNA, a managing partner of Arizona Anesthesia Solutions in Phoenix, says several peripheral nerve block techniques are appropriate for the outpatient setting: ultrasound-guided interscalene, supraclavicular and axillary blocks (for upper extremity surgery); femoral, adductor, canal and popliteal blocks (for lower extremity surgery); and PENG (pericapsular nerve group) blocks for hip surgery.

“Ultrasound-guided blocks have now become part of narcotic-sparing pain management plans,” says Ms. Towers. “The technology has increased the range of blocks being performed.”

Video laryngoscopes provide better laryngeal exposure than conventional laryngoscopy.
— Heather Towers, CRNA, MS, DNAP

Blocks can be patient-specific and tailored to a patient’s specific postoperative needs such as early postoperative ambulation, and the amount and location of pain. Using different types of local anesthetics can change the duration of a block. For example, providers can place a supraclavicular block with lidocaine to provide a couple hours of relief from tourniquet pain after an upper extremity procedure and inject a longer acting anesthetic, such as ropivacaine, directly around nerves that are involved in the surgery. “This way the patient has the use of their arm, but still has extended postoperative pain relief,” says Ms. Towers.

Ultrasound guidance has also improved an anesthesia provider’s ability to care for obese patients. “Before ultrasound, palpitation of bony landmarks was used for placement of peripheral nerve blocks,” says Ms. Towers. “Palpation of these landmarks can be challenging in obese patients. Ultrasound has made identifying nerves and needle placement much easier and safer.”

• Streamlined anesthesia machines. Digital flow meters found on the latest anesthesia machines let providers dial in the delivery of specific amounts of anesthetic gases. There are several benefits of using digital flow meters and low-flow anesthesia to titrate the administration of inhalational agents. “We can be more precise in the amount we administer, which means we can conserve a facility’s resources,” says Robert Wrobleski, CRNA, MSN, the lead CRNA at BPW Medical Associates. “With low-flow anesthesia, you can better maintain a patient’s body temperature and are less likely to dry out their airway.”

Mr. Wrobleski says anesthesia machines designed specifically for use in ASCs have a smaller footprint (about 40% smaller than standard models), but have the same essential features. He knows of many surgery centers that purchase second-hand machines that were used in inpatient settings. He believes surgery centers should instead invest in new streamlined machines that are affordable and built to meet the clinical needs of outpatient providers.

• Airway adjuncts. Robert W. Simon, DNP, CRNA, CHSE, CNE, chief CRNA at Huntington Valley Anesthesia Associates and the assistant program director/didactic education coordinator at the Frank J. Tornetta School of Anesthesia in the suburbs of Philadelphia, relies on airway devices such as laryngeal mask airways (LMA) — a tube with an inflatable cuff that’s inserted into the pharynx — to secure the airway during procedures that do not require paralysis. Anesthesia providers use an LMA because it is quicker and causes less discomfort for the patient. “Compared to the endotracheal tube, an LMA is not as invasive and may result in a reduced incidence of sore throat complaints when compared to intubation,” he says. LMAs are also used as a rescue device and listed in the difficult airway algorithm, notes Dr. Simon. 

For difficult intubations, Ms. Towers reaches for a video laryngoscope. “They provide better laryngeal exposure than conventional laryngoscopy,” she says. “Newer models have interchangeable attachments to turn the standard video scope into a fiber-optic model.”

Joyce Wahr, MD, FAHA, vice chair of Quality and Safety for the Department of Anesthesiology at the University of Minnesota M Health Fairview, employs video bronchoscopes for airway management. A small camera and light source are housed at the tip of the device, whether it’s a baton that fits inside a disposable clear plastic blade or a single-use blade that resembles a MacIntosh or Miller blade.

She says the benefit of using a video bronchoscope is that you can load an endotracheal tube over the bronchoscope and view the complete airway anatomy, from the pharynx through the cords and to the carina. (A video laryngoscope just shows you a view of the glottis).

Reusable and single-use video bronchoscopes are available. Dr. Wahr says single-use blades eliminate concerns of cross-contamination. The cost of a single-use blade is $40, significantly higher than the $12 price of reusable blades, according to Dr. Wahr. However, she points out, the labor costs associated with cleaning and sterilizing reusable blades means the overall cost of $12 for disposable blades is not that much different than what you’d pay for a reusable one.

• Respiration monitoring. Dr. Simon relies on vital signs monitors capable of providing end-tidal CO2 (ETCO2) and pulse oximetry readings. It’s a required monitor and is extremely helpful in intubated patients as well as those with an LMA placed, according to Dr. Simon. “Monitoring a patient’s ETCO2 can help diagnose early respiratory depression/obstruction in an airway, especially during sedation or non-general anesthetic cases, which leads to a reduction in potentially life-threatening complications,” says Dr. Simon. “During the administration of general anesthesia with an LMA or breathing tube, monitoring ETCO2 can help the provider determine if mechanical ventilation is adequate. In extreme cases, a change in ETCO2 can be indicative of a serious event, such as MH or pulmonary embolism.”

He also requires a backup supply of oxygen, a mask and a bag valve mask, which is a handheld device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately.

• Smart pain pumps. Focusing on multimodal pain management is essential to facilitate a positive outcome and efficient discharge, according to Mr. Rodriquez. “The method consists of a combination of oral medications such as acetaminophen, gabapentin and meloxicam, and local infiltration into the operating sight,” he says.

Ms. Towers says anesthesia providers can administer single-shot peripheral nerve blocks with a longer acting local anesthetic or with a catheter attached to a pain pump. Peripheral nerve catheters use a local anesthetic that is dosed through a catheter to help the nerve block last longer, making it an ideal option for patients who have undergone outpatient surgery. Elastomeric pumps deliver consistent, moderate amounts of analgesia, while electronic pumps can provide more targeted and controlled pain relief.

“Hospitals were shutting down elective surgery due to being overwhelmed with COVID-19 patients last year, but during that time, there was widespread recognition that prolonged delays in elective surgery can cause patient harm,” says Mr. Rodriquez. “This has led to more and varied cases in the outpatient setting, and the rate of change has been fast.”

While COVID-19 has placed immense stress on communities, outpatient surgery and anesthesiology services, the recent advances and available equipment are ultimately benefiting facilities offering outpatient surgery services. OSM