AMBULATORY ANESTHESIA 2014

Educational Objectives

The goal of this program is to improve the management of anesthetic care of ambulatory surgery patients. After hearing and assimilating this program, the clinician will be better able to:

1. Evaluate risk for postoperative nausea and vomiting (PONV) based on patient-specific, anesthetic, and surgical risk factors.

2. Reduce baseline risk for PONV.

3. Manage PONV with combination therapy.

4. Explain the contributing roles of nitrous oxide,
caffeine, and neostigmine in PONV.

5. Describe new modalities for regional anesthesia.

Summary

Reducing baseline risk: avoid general anesthesia; use regional anesthesia (≈7-fold reduction of risk for PONV compared to general anesthesia); use propofol for induction and maintenance; avoid nitrous oxide and volatile agents; minimize intraoperative and postoperative use of opioids; ensure adequate hydration

Algorithm for prevention of PONV: in low-risk patients, acceptable to use no preventive measures; in medium-risk patients, choose 1 or 2 interventions; in high-risk patients, implement ≥2 interventions; interventions — regional anesthesia; administration of droperidol or haloperidol as antiemetic; neurokinin-1 (NK-1) receptor antagonist; propofol at subhypnotic dose (evidence that infusion at 20 µg/kg per minute combined with volatile agent reduces risk); diphenhydramine; perphenazine; transdermal scopolamine patch (Transderm Scōp); acupuncture (P6 acustimulation); 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist; dexamethasone

Speaker’s approach: based on number of risk factors (≤3) present, give equivalent number of antiemetics from different classes; if 4 risk factors present, give 3 antiemetics plus one total intravenous (IV) anesthetic

New antiemetics to consider: 5-HT3 receptor antagonists — ondansetron considered gold standard; palonosetron advantageous with 40-hr half-life and effective for ≤72 hr; NK-1 receptor antagonists — aprepitant effective (developed for prevention of chemotherapy-induced nausea and vomiting; only agent approved by Food and Drug Administration for PONV); rolapitant has 120-hr half-life; other — dexamethasone equally as effective as 40 mg of methylprednisolone; haloperidol in low doses (0.5-2 mg) quite effective without high incidence of side effects (eg, tardive dyskinesia); antihistamine agent meclizine (eg, Antivert, Dramamine, Meclicot) available over the counter

Combination therapy: droperidol plus dexamethasone — many studies looking at QT prolongation have found no issues associated with droperidol dosed at 0.625 to 1.25 mg; slight QT prolongation similar to that seen with use of 5-HT3 antagonists; droperidol may be considered despite black box warning; other combination regimens — 5-HT3 antagonist with dexamethasone or droperidol, or all 3 together; ondansetron plus NK-1 receptor antagonist or transdermal scopolamine patch; combinations recently studied in children include ondansetron with dexamethasone or droperidol, and tropisetron with dexamethasone

Postdischarge nausea and vomiting (PDNV): incidence of severe vomiting after discharge much higher than that in postanesthesia care unit (PACU); Apfel risk score for PDNV cites female sex, younger age, use of opioids in PACU, and history of PONV at that particular surgery as risk factors; management — determine risk; administer antiemetic, eg, dexamethasone; use agents with longer half-lives (eg, palonosetron); transdermal scopolamine patch; give prescription for antiemetic (eg, 8 mg ondansetron); suppositories useful

Nitrous oxide: Apfel et al (2004) — found that ondansetron, dexamethasone, and droperidol each decreased incidence of PONV about equally, and predictably decreased incidence of PONV when used in combination; other studies have confirmed that use of nitrous oxide associated with PONV; avoidance of nitrous oxide not quite as effective as use of antiemetic; Peyton and Wu (2014) — risk ratio ≈1.2 for overall effect of nitrous oxide on PONV; incidence of PONV clearly associated with duration of exposure to nitrous oxide (ie, increases only after 45 min [by 20% for every hour after 45 min]); risk significantly greater after 75 min; short duration of exposure to nitrous oxide may not increase risk for PONV; for exposure <1 hr, avoiding nitrous oxide in 128 patients required to prevent one case of PONV; for exposure of 1 to 2 hr, avoiding nitrous oxide in 23 patients required to prevent one case of PONV; for exposure >2 hr, avoiding nitrous oxide in 9 patients required to prevent one case of PONV

Caffeine: based on anecdotal information, administration of caffeine during perioperative period considered as potential preventive agent for PONV; study (Steinbrook et al, 2013) randomized ≈130 patients at moderate risk for PONV to saline or 500 mg IV caffeine at 15 min before emergence; all patients received 5-HT3 antagonist plus dexamethasone (as recommended by guidelines); caffeine failed to show efficacy in prevention of PONV

40-item quality of recovery (QoR) scale: validated tool to assess recovery following surgery; physical comfort, emotional state, physical independence, psychologic support, and pain comprise 5 domains; score ranges from 40 to 200; in general, difference of ≈10 considered clinically significant

Sevoflurane vs desflurane: desflurane often associated with airway irritation and coughing; however, desflurane has lower solubility and favorable kinetics compared to sevoflurane; multiple studies show patients who receive desflurane have shorter emergence times and faster early recovery; De Oliveira et al (2013) — compared sevoflurane to desflurane with laryngeal mask airway (LMA) using fentanyl titration protocol in patients receiving gynecologic surgery; use of desflurane resulted in faster time to eye opening (6.8 min vs 11.8 min for sevoflurane) and LMA removal; no differences seen in coughing, sore throat, or hoarseness; QoR better (statistically significant in physical comfort subcomponent) for desflurane group

Milk with tea on morning of surgery: American Society of Anesthesiology guidelines recommend 6-hr wait before anesthesia after consumption of nonhuman milk; Hillyard et al (2014) — randomized controlled crossover study of healthy volunteers demonstrated no difference in gastric emptying between cup of tea with and without milk; all participants received 1.5 g paracetamol orally (absorbed primarily and quickly by small intestine and thus good marker for gastric emptying); study concluded that surgery may be safe 2 hr after consumption of small volume of milk in beverage

Effects of dexmedetomidine in nasal surgery: nasal surgery commonly associated with emergence agitation; Kim et al (2013) — 100 patients undergoing nasal surgery with general anesthesia randomized to saline infusion or dexmedetomidine infusion at 0.4 µg/kg per hour; propofol and fentanyl used for induction; desflurane used for maintenance; no opioids or nitrous oxide used; ketorolac administered toward end of procedure; incidence of emergence agitation significantly lower in group that received dexmedetomidine, but dangerous agitation not different between groups; time to emergence slightly slower (statistical significance of ≈1 min achieved) in group that received dexmedetomidine, but clinical relevance unclear; time to extubation, respiratory rate, bispectral index at extubation, grade of cough during emergence, and length of stay in PACU almost equivalent between groups; QoR score higher in group that received dexmedetomidine (pain subscore significantly better)

Dexamethasone in regional anesthesia: dexamethasone known to enhance analgesic effect of regional anesthesia, but optimal route of administration not established; Desmet et al (2013) — 3-arm randomization to regional anesthesia with 10 mg dexamethasone (interscalene block), IV dexamethasone, or no dexamethasone; time to first analgesic request used as primary outcome measure; group not given dexamethasone needed postoperative analgesia significantly faster than either 2 dexamethasone groups; however, no differences seen between 2 dexamethasone groups

Minimizing risk associated with use of regional anesthesia

Study 1 (Falcão et al, 2013): step-up/step-down method used; ≈1 mL determined as minimum effective volume of 0.5% bupivacaine with epinephrine in ultrasonography-guided interscalene block; injection of 2.34 mL yielded complete absence of pain for 6 hr postoperatively; with administration of 4.29 mL, no phrenic nerve block in 95% of patients; for optimal block with adequate postoperative analgesia and reduced incidence of diaphragmatic paralysis, ideal volume 2.34 to 4.29 mL of 0.5% bupivacaine plus epinephrine

Study 2 (Kant et al, 2013): used continual reassessment method (usually used in studies of chemotherapeutic approaches to cancer treatment) to look at ultrasonography-guided supraclavicular block for upper extremity surgery; failure to achieve complete loss of cold sensation at any of 4 dermatomes after 45 min considered ineffective block; brachial plexus block consisting of 0.5% bupivacaine with epinephrine primary mode of anesthesia (ie, no general anesthesia); concluded that 27 mL necessary to achieve effective dose in 95% of patients; 45-min wait recommended between injection and commencement of surgery

Key points: for analgesia following general anesthesia for shoulder surgery, consider data from study 1; for intraoperative anesthesia of upper extremity, larger dose needed (as in study 2)

Saphenous nerve block for arthroscopic medial meniscectomy: femoral nerve block for knee surgery effective but concomitant block of quadriceps muscle associated with postoperative morbidity (gait disturbance); Hanson et al (2013) — trial of ultrasonography-guided saphenous nerve block randomized patients to 0.5% ropivacaine or sham injection at adductor canal as adjunct to general anesthesia; nerve block resulted in significantly lower postoperative pain scores, lower doses of intraoperative fentanyl, less opioid use in first 24 hr, and no motor morbidities

Paravertebral block for breast surgery: Abdallah et al (2014) — study compared ultrasonography-guided paravertebral block using 5 mL 0.5% ropivacaine injections from T1 to T5 plus propofol vs general anesthesia (sevoflurane and nitrous oxide); regional anesthesia group demonstrated better QoR and pain scores (clinically significant) through postoperative day 2, and also had less side effects (eg, PONV)

Outpatient endovascular aortic aneurysm repair: hemorrhage and thromboembolic complications most common morbidities, and both usually occur within 3 hr of procedure; Lachat et al (2013) — inclusion criteria for European study included asymptomatic aneurysm, favorable anatomy, discharge to location with easy access to hospital, and presence of adult observer; exclusions included intraoperative complications, procedures lasting ≥4 hr, and incomplete sealing of access vessels; mean duration of procedure ≈1.5 hr; of 104 patients selected for study, 4 patients with vessel complications required overnight hospitalization; 96 of remaining 100 patients successfully discharged after several hours of observation; 97% would recommend procedure to others

Readings

Abdallah FW et al: Ultrasound-guided multilevel paravertebral blocks and total intravenous anesthesia improve the quality of recovery after ambulatory breast resection. Anesthesiology 2014 Mar;120(3):703-13; Apfel CC et al: A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Eng J Med 2004 Jun 10;350:2441-2451; De Oliveira GS Jr et al: Desflurane/fentanyl compared with sevoflurane/fentanyl on awakening and quality of recovery in outpatient surgery using a laryngeal mask airway: a randomized, double-blinded controlled trial. J Clin Anesth 2013 Dec;25(8):651-8; Desmet M et al: I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth 2013 Sep;111(3):445-52; Diemunsch P et al: Neurokinin-1 receptor antagonists in the prevention of postoperative nausea and vomiting. Br J Anaesth 2009;103(1):7-13; Falcão LF et al: Minimum effective volume of 0.5% bupivacaine with epinephrine in ultrasound-guided interscalene brachial plexus block. Br J Anaesth 2013:110(3):450-5; Fields KG, YaDeau J: Dexamethasone for increasing analgesic duration of single-shot inter-scalene block. Br J Anaesth 2014;112(1):176-7; Frey UH et al: P6 acustimulation effectively decreases postoperative nausea and vomiting in high-risk patients. Br J Anaesth 2009 May;102(5):620-5; Gan TJ et al: Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014 Jan;118(1):85-113; Hanson NA et al: Ultrasound-guided adductor canal block for arthroscopic medial meniscectomy: a randomized, double-blind trial. Can J Anaesth 2013 Sep;60(9):874-80; Hillyard S et al: Does adding milk to tea delay gastric emptying? Br J Anaesth 2014 Jan;112(1):66-71; Jackson CW et al: Evidence-based review of the black-box warning for droperidol. Am J Health Syst Pharm 2007 Jun 1;64(11);1174-86; Kant A et al: Application of the continual reassessment method to dose-finding studies in regional anesthesia: an estimate of the ED95 dose for 0.5% bupivacaine for ultrasound-guided supraclavicular block. Anesthesiology 2013 Jul;119(1):29-35; Kim SY et al: Efficacy of intraoperative dexmedetomidine infusion on emergence agitation and quality of recovery after nasal surgery. Br J Anaesth 2013 Aug;111(2):222-8; Lachat ML et al: Outpatient endovascular aortic aneurysm repair: experience in 100 consecutive patients. Ann Surg 2013 Nov;258(5):754-759; Myles PS et al: Validity and reliability of a postoperative quality of recovery score: the QoR-40. Br J Anaesth 2000 Jan;84(1):11-5; Peyton PJ, Wu CY: Nitrous oxide-related postoperative nausea and vomiting depends on duration of exposure. Anesthesiology 2014 May;120(5):1137-45; Steinbrook RA et al: Caffeine for the prevention of postoperative nausea and vomiting. J Anaesthesiol Clin Pharmacol 2013 Oct;29(4):526-9.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Mathews and the planning committee reported nothing relevant to disclose. In his lecture, Dr. Mathews presents information that is related to the off-label or investigational use of a therapy, product, or device.

Risk evaluation for postoperative nausea and vomiting (PONV): Society of Ambulatory Anesthesia recommends risk stratification for PONV to allow preparation for treatment; patient-specific risk factors include female sex, history of PONV and/or motion sickness, nonsmoking status, and younger age; anesthetic risk factors associated with PONV include use of volatile anesthetic (compared to propofol or regional anesthetic), duration of volatile anesthetic (longer duration increases risk for PONV), use of postoperative opioids (adjuvant agents and multimodal pain therapy protocols emphasized to limit PONV), and use of nitrous oxide; specific types of surgeries may be associated with increased PONV (ie, those of longer duration that tend to involve increased exposure to volatile agents and use of opioids intraoperatively)

Factors not considered significant: recent data do not support physical status, menstrual cycle, experience of anesthetist, or use of muscle relaxants as risk factors; prior guidelines suggested doses of neostigmine ≥2.5 mg associated with PONV, but effect may be less than previously thought; body mass index, use of nasogastric tube, preoperative anxiety, or history of migraine unlikely to increase risk for PONV; supplemental oxygen and preoperative fasting probably not helpful in ameliorating symptoms

Stratifying risk: presence of major risk factors (ie, female sex, nonsmoking status, history of PONV, and use of postoperative opioids) additive; incidence of PONV — with no risk factor, 10%; with one risk factor, 20%; with 2 risk factors, 40% (moderate risk); with 3 factors, 60%; with all 4 factors, 80%; stratification of risk — ≤1 risk factor, low risk; 2 risk factors, moderate risk; ≥3 risk factors, high risk

Reducing baseline risk: avoid general anesthesia; use regional anesthesia (≈7-fold reduction of risk for PONV compared to general anesthesia); use propofol for induction and maintenance; avoid nitrous oxide and volatile agents; minimize intraoperative and postoperative use of opioids; ensure adequate hydration

Algorithm for prevention of PONV: in low-risk patients, acceptable to use no preventive measures; in medium-risk patients, choose 1 or 2 interventions; in high-risk patients, implement ≥2 interventions; interventions — regional anesthesia; administration of droperidol or haloperidol as antiemetic; neurokinin-1 (NK-1) receptor antagonist; propofol at subhypnotic dose (evidence that infusion at 20 µg/kg per minute combined with volatile agent reduces risk); diphenhydramine; perphenazine; transdermal scopolamine patch (Transderm Scōp); acupuncture (P6 acustimulation); 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist; dexamethasone

Speaker’s approach: based on number of risk factors (≤3) present, give equivalent number of antiemetics from different classes; if 4 risk factors present, give 3 antiemetics plus one total intravenous (IV) anesthetic

New antiemetics to consider: 5-HT3 receptor antagonists — ondansetron considered gold standard; palonosetron advantageous with 40-hr half-life and effective for ≤72 hr; NK-1 receptor antagonists — aprepitant effective (developed for prevention of chemotherapy-induced nausea and vomiting; only agent approved by Food and Drug Administration for PONV); rolapitant has 120-hr half-life; other — dexamethasone equally as effective as 40 mg of methylprednisolone; haloperidol in low doses (0.5-2 mg) quite effective without high incidence of side effects (eg, tardive dyskinesia); antihistamine agent meclizine (eg, Antivert, Dramamine, Meclicot) available over the counter

Combination therapy: droperidol plus dexamethasone — many studies looking at QT prolongation have found no issues associated with droperidol dosed at 0.625 to 1.25 mg; slight QT prolongation similar to that seen with use of 5-HT3 antagonists; droperidol may be considered despite black box warning; other combination regimens — 5-HT3 antagonist with dexamethasone or droperidol, or all 3 together; ondansetron plus NK-1 receptor antagonist or transdermal scopolamine patch; combinations recently studied in children include ondansetron with dexamethasone or droperidol, and tropisetron with dexamethasone

Postdischarge nausea and vomiting (PDNV): incidence of severe vomiting after discharge much higher than that in postanesthesia care unit (PACU); Apfel risk score for PDNV cites female sex, younger age, use of opioids in PACU, and history of PONV at that particular surgery as risk factors; management — determine risk; administer antiemetic, eg, dexamethasone; use agents with longer half-lives (eg, palonosetron); transdermal scopolamine patch; give prescription for antiemetic (eg, 8 mg ondansetron); suppositories useful

Nitrous oxide: Apfel et al (2004) — found that ondansetron, dexamethasone, and droperidol each decreased incidence of PONV about equally, and predictably decreased incidence of PONV when used in combination; other studies have confirmed that use of nitrous oxide associated with PONV; avoidance of nitrous oxide not quite as effective as use of antiemetic; Peyton and Wu (2014) — risk ratio ≈1.2 for overall effect of nitrous oxide on PONV; incidence of PONV clearly associated with duration of exposure to nitrous oxide (ie, increases only after 45 min [by 20% for every hour after 45 min]); risk significantly greater after 75 min; short duration of exposure to nitrous oxide may not increase risk for PONV; for exposure <1 hr, avoiding nitrous oxide in 128 patients required to prevent one case of PONV; for exposure of 1 to 2 hr, avoiding nitrous oxide in 23 patients required to prevent one case of PONV; for exposure >2 hr, avoiding nitrous oxide in 9 patients required to prevent one case of PONV

Caffeine: based on anecdotal information, administration of caffeine during perioperative period considered as potential preventive agent for PONV; study (Steinbrook et al, 2013) randomized ≈130 patients at moderate risk for PONV to saline or 500 mg IV caffeine at 15 min before emergence; all patients received 5-HT3 antagonist plus dexamethasone (as recommended by guidelines); caffeine failed to show efficacy in prevention of PONV

40-item quality of recovery (QoR) scale: validated tool to assess recovery following surgery; physical comfort, emotional state, physical independence, psychologic support, and pain comprise 5 domains; score ranges from 40 to 200; in general, difference of ≈10 considered clinically significant

Sevoflurane vs desflurane: desflurane often associated with airway irritation and coughing; however, desflurane has lower solubility and favorable kinetics compared to sevoflurane; multiple studies show patients who receive desflurane have shorter emergence times and faster early recovery; De Oliveira et al (2013) — compared sevoflurane to desflurane with laryngeal mask airway (LMA) using fentanyl titration protocol in patients receiving gynecologic surgery; use of desflurane resulted in faster time to eye opening (6.8 min vs 11.8 min for sevoflurane) and LMA removal; no differences seen in coughing, sore throat, or hoarseness; QoR better (statistically significant in physical comfort subcomponent) for desflurane group

Milk with tea on morning of surgery: American Society of Anesthesiology guidelines recommend 6-hr wait before anesthesia after consumption of nonhuman milk; Hillyard et al (2014) — randomized controlled crossover study of healthy volunteers demonstrated no difference in gastric emptying between cup of tea with and without milk; all participants received 1.5 g paracetamol orally (absorbed primarily and quickly by small intestine and thus good marker for gastric emptying); study concluded that surgery may be safe 2 hr after consumption of small volume of milk in beverage

Effects of dexmedetomidine in nasal surgery: nasal surgery commonly associated with emergence agitation; Kim et al (2013) — 100 patients undergoing nasal surgery with general anesthesia randomized to saline infusion or dexmedetomidine infusion at 0.4 µg/kg per hour; propofol and fentanyl used for induction; desflurane used for maintenance; no opioids or nitrous oxide used; ketorolac administered toward end of procedure; incidence of emergence agitation significantly lower in group that received dexmedetomidine, but dangerous agitation not different between groups; time to emergence slightly slower (statistical significance of ≈1 min achieved) in group that received dexmedetomidine, but clinical relevance unclear; time to extubation, respiratory rate, bispectral index at extubation, grade of cough during emergence, and length of stay in PACU almost equivalent between groups; QoR score higher in group that received dexmedetomidine (pain subscore significantly better)

Dexamethasone in regional anesthesia: dexamethasone known to enhance analgesic effect of regional anesthesia, but optimal route of administration not established; Desmet et al (2013) — 3-arm randomization to regional anesthesia with 10 mg dexamethasone (interscalene block), IV dexamethasone, or no dexamethasone; time to first analgesic request used as primary outcome measure; group not given dexamethasone needed postoperative analgesia significantly faster than either 2 dexamethasone groups; however, no differences seen between 2 dexamethasone groups

Minimizing risk associated with use of regional anesthesia

Study 1 (Falcão et al, 2013): step-up/step-down method used; ≈1 mL determined as minimum effective volume of 0.5% bupivacaine with epinephrine in ultrasonography-guided interscalene block; injection of 2.34 mL yielded complete absence of pain for 6 hr postoperatively; with administration of 4.29 mL, no phrenic nerve block in 95% of patients; for optimal block with adequate postoperative analgesia and reduced incidence of diaphragmatic paralysis, ideal volume 2.34 to 4.29 mL of 0.5% bupivacaine plus epinephrine

Study 2 (Kant et al, 2013): used continual reassessment method (usually used in studies of chemotherapeutic approaches to cancer treatment) to look at ultrasonography-guided supraclavicular block for upper extremity surgery; failure to achieve complete loss of cold sensation at any of 4 dermatomes after 45 min considered ineffective block; brachial plexus block consisting of 0.5% bupivacaine with epinephrine primary mode of anesthesia (ie, no general anesthesia); concluded that 27 mL necessary to achieve effective dose in 95% of patients; 45-min wait recommended between injection and commencement of surgery

Key points: for analgesia following general anesthesia for shoulder surgery, consider data from study 1; for intraoperative anesthesia of upper extremity, larger dose needed (as in study 2)

Saphenous nerve block for arthroscopic medial meniscectomy: femoral nerve block for knee surgery effective but concomitant block of quadriceps muscle associated with postoperative morbidity (gait disturbance); Hanson et al (2013) — trial of ultrasonography-guided saphenous nerve block randomized patients to 0.5% ropivacaine or sham injection at adductor canal as adjunct to general anesthesia; nerve block resulted in significantly lower postoperative pain scores, lower doses of intraoperative fentanyl, less opioid use in first 24 hr, and no motor morbidities

Paravertebral block for breast surgery: Abdallah et al (2014) — study compared ultrasonography-guided paravertebral block using 5 mL 0.5% ropivacaine injections from T1 to T5 plus propofol vs general anesthesia (sevoflurane and nitrous oxide); regional anesthesia group demonstrated better QoR and pain scores (clinically significant) through postoperative day 2, and also had less side effects (eg, PONV)

Outpatient endovascular aortic aneurysm repair: hemorrhage and thromboembolic complications most common morbidities, and both usually occur within 3 hr of procedure; Lachat et al (2013) — inclusion criteria for European study included asymptomatic aneurysm, favorable anatomy, discharge to location with easy access to hospital, and presence of adult observer; exclusions included intraoperative complications, procedures lasting ≥4 hr, and incomplete sealing of access vessels; mean duration of procedure ≈1.5 hr; of 104 patients selected for study, 4 patients with vessel complications required overnight hospitalization; 96 of remaining 100 patients successfully discharged after several hours of observation; 97% would recommend procedure to others

Acknowledgements

Dr. Mathews was recorded from the 19th Annual Vermont Perspectives in Anesthesia, presented by the University of Vermont College of Medicine and Office of Continuing Medical Education, Burlington, VT. For more information on upcoming meetings sponsored by the University of Vermont College of Medicine, please visit their website at www.uvm.edu/medicine/cme/ or check under upcoming meetings on our website at Audio-Digest.org. The Audio-Digest Foundation thanks Dr. Mathews and the University of Vermont College of Medicine and Office of Continuing Medical Education for their cooperation in the production of this program.

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