Cliff Schmiesing, MD

All Publications

• Implementation of a Preoperative Frailty Screening and Optimization Pathway for Vascular Surgery Patients is Associated with Decreased 30-Day Readmission. Journal of vascular surgery Dossabhoy, S. S., Manuel, S. R., Yawary, F., Lahiji-Neary, T., Cheng, N., Cianfichi, L., Bagdasarian, A., George, E. L., Marwell, J. G., Lee, J. T., Dalman, R. L., Schmiesing, C., Arya, S. 2024

  Abstract

  Frailty is characterized by reduced physiologic reserve and vulnerability to adverse events in the presence of a stressor such as surgery. We prospectively implemented a preoperative frailty screening and optimization pathway for vascular surgery patients and assessed its impact on postoperative outcomes.As part of an ongoing quality improvement initiative, surgical frailty was assessed prospectively in all patients undergoing inpatient surgery using the Risk Analysis Index (RAI). Baseline data were collected from May to July 2022. Frail patients (RAI score ≥ 37) were referred to an anesthesia optimization clinic, nutrition consultation, and case management evaluation in the intervention phase (August 2022 to July 2023). Primary outcomes were postoperative hospital length of stay, 30-day readmission, and 30-day mortality. Secondary outcomes included ICU admission, ICU length of stay, discharge disposition, and non-home discharge. Two-way analyses compared frail vs non-frail patients and pre- vs post-intervention groups using Student t-test or Wilcoxon rank sum test for continuous variables and chi-squared or Fisher's exact test for categorical outcomes.Of all patients scheduled for elective inpatient vascular surgery procedures at a single institution (N=225), 216 completed frailty screening [mean age 72 years, 68.5% male, 54.6% white, mean RAI 28.9, 18.5% frail]. Of these, 15 had surgeries cancelled, and 201 ultimately underwent surgery with 36 (17.9%) identified as frail. Overall, frail patients had significantly longer ICU (median [IQR] 4.0 [2.5, 13.5] vs 2.0 [1, 4] days, P=.001) and hospital length of stay (2.45 [1.51, 5.67] vs 1.23 [1.0, 2.10] days, P=.001), higher non-home discharge (30.6% vs 4.2%, P<.0001), and higher 30-day readmission (22.2% vs 6.7%, P=.009) compared to non-frail patients. Comparing pre- and post-intervention groups, 30-day readmission for the overall cohort declined significantly (22.2% to 7.5%, P=.03). Amongst frail patients, there was a trend to reduced hospital length of stay (4.73 to 2.14 days), non-home discharge (57.1% vs 24.1%), and 30-day readmission (42.9% to 17.2%); however, these did not reach statistical significance. Overall, 30-day mortality was 1.5% with all 3 deaths (2 frail, 1 non-frail) occurring post-intervention (0% pre vs 1.7% post, P=1.0).Successful implementation of a preoperative frailty screening and optimization pathway for patients undergoing elective vascular surgery led to a significant decrease in overall 30-day readmission and a trend toward reduced hospital length of stay, non-home discharge, and 30-day readmission for frail patients. Further expansion to all surgical clinics has the potential to improve quality metrics for the healthcare system.

  View details for DOI 10.1016/j.jvs.2024.11.018

  View details for PubMedID 39581332

• "Covering provider": an effort to streamline clinical communication chaos. JAMIA open Joshi, M., Gokhale, A., Ma, S., Pendrey, A., Wozniak, L., Moturu, A., Schwartz, N. U., Wilson, A., Darmawan, K., Phillips, B., Cullum, S., Sharp, C., Brown, G., Shieh, L., Schmiesing, C. 2024; 7 (3): ooae057

  Abstract

  This report describes a root cause analysis of incorrect provider assignments and a standardized workflow developed to improve the clarity and accuracy of provider assignments.A multidisciplinary working group involving housestaff was assembled. Key drivers were identified using value stream mapping and fishbone analysis. A report was developed to allow for the analysis of correct provider assignments. A standardized workflow was created and piloted with a single service line. Pre- and post-pilot surveys were administered to nursing staff and participating housestaff on the unit.Four key drivers were identified. A standardized workflow was created with an exclusive treatment team role in Epic held by a single provider at any given time, with a corresponding patient list column displaying provider information for each patient. Pre- and post-survey responses report decreased confusion, decreased provider identification errors, and increased user satisfaction among RNs and residents with sustained uptake over time.This work demonstrates structured root cause analysis, notably engaging housestaff, to develop a standardized workflow for an understudied and growing problem. The development of tools and strategies to address the widespread burdens resulting from clinical communication failures is needed.

  View details for DOI 10.1093/jamiaopen/ooae057

  View details for PubMedID 38974405

  View details for PubMedCentralID PMC11226879

• Enhancing the Readability of Preoperative Patient Instructions Using Large Language Models. Anesthesiology Hong, H. J., Schmiesing, C. A., Goodell, A. J. 2024; 141 (3): 608-610

  View details for DOI 10.1097/ALN.0000000000005122

  View details for PubMedID 39136480

• Update on Perioperative Medication Management for the Hand Surgeon: A Focus on Diabetes, Weight Loss, Rheumatologic, and Antithrombotic Medications. The Journal of hand surgery Xu, W., Schmiesing, C., Chang, J. 2024

  Abstract

  Diabetes mellitus and obesity are growing health concerns. New pharmacologic interventions have recently begun to play a more notable role in the treatment pathway of these separate but related conditions. In particular, glucagon-like peptide-1 receptor agonists, such as semaglutides (Ozempic, Wegovy) and tirzepatide (Mounjaro), and sodium glucose co-transporter 2 inhibitors, such as dapagliflozin (Farxiga) and empagliflozin (Jardiance), have emerged as treatment options. Multiple clinical trials have demonstrated their efficacy in regulating metabolism, improving glycemic control, and managing long-term weight reduction. However, glucagon-like peptide-1 receptor agonists have also been associated with gastrointestinal side effects, including delayed gastric emptying as well as regurgitation and aspiration during general anesthesia or deep sedation, and sodium glucose co-transporter 2 inhibitors have been associated with severe diabetic ketoacidosis. Therefore, discontinuation of these medications before surgery is imperative. Given the popularity of these medications among the general public, it is essential for hand surgeons, to understand how to appropriately manage them perioperatively. The objective of this article was to review these new diabetes mellitus and weight loss medications, including their mechanisms of action, indications for use, and perioperative management guidelines. Additionally, we will take this opportunity to review perioperative guidelines for other common medications relevant to patients undergoing procedures involving the hand and upper extremity such as antithrombotic medications and rheumatoid arthritis-related immunosuppressive medications. Finally, we will describe how the electronic medical record system can be used to optimize perioperative medication management in this population.

  View details for DOI 10.1016/j.jhsa.2024.05.018

  View details for PubMedID 39093237

• Artificial Intelligence in Perioperative Care: Opportunities and Challenges. Anesthesiology Han, L., Char, D. S., Aghaeepour, N. 2024; 141 (2): 379-387

  View details for DOI 10.1097/ALN.0000000000005013

  View details for PubMedID 38980160

• Keeping an Open Mind About Open Notes: Sharing Anesthesia Records With Patients. Anesthesia and analgesia Ramaswamy, P., Xie, J., Marsiglio, A. M., Burgart, A. M., Schmiesing, C. A., Cohen, N. H., Robinowitz, D. L., Wang, E. 2022; 135 (4): 697-703

  Abstract

  ADDENDUM: Please note that in the interim since this paper was accepted for publication, new governmental regulations, pertinent to the topic, have been approved for implementation. The reader is thus directed to this online addendum for additional relevant information: http://links.lww.com/AA/E44.

  View details for DOI 10.1213/ANE.0000000000005800

  View details for PubMedID 36108183

• COVID-19 Preoperative Assessment and Testing: From Surge to Recovery. Annals of surgery Lu, A. C., Schmiesing, C. A., Mahoney, M., Cianfichi, L., Semple, A. K., Watt, D., Fischer, S., Wald, S. H. 2020

  View details for DOI 10.1097/SLA.0000000000004124

  View details for PubMedID 32541233

• Evidence for Continuing Buprenorphine in the Perioperative Period. The Clinical journal of pain Li, A. H., Schmiesing, C., Aggarwal, A. K. 2020

  Abstract

  OBJECTIVES: Given there are conflicting recommendations for the perioperative management of buprenorphine, we conducted a retrospective cohort study of our surgery patients on buprenorphine whose baseline dose had been preoperatively continued, tapered or discontinued.METHODS: With IRB approval, we reviewed charts from January 1, 2013 to June 30, 2016 of patients on buprenorphine who had received elective surgery at Stanford Healthcare. Our primary outcome of interest was the change in pain score, defined as mean postoperative pain score - preoperative pain score. We also collected data on patients' tapering procedure and any postoperative non-buprenorphine opioid requirements.RESULTS: Out of approximately 1200 patients on buprenorphine, 121 had surgery of which 50 were admitted and included in the study. Perioperative continuation of transdermal buprenorphine resulted in a lower change in pain score postoperatively (0.606±0.878) than discontinuation (4.83±1.23, P=0.012). Among sublingual patients, there was no difference in the change in pain score between those who were tapered to a non-zero dose versus discontinued (P=0.55). Continuation of sublingual buprenorphine resulted in fewer non-buprenorphine scheduled opioid prescriptions than its taper or discontinuation (P=0.028). Finally, tapers were performed with great variability in the tapering team and rate of taper.DISCUSSION: Based on our findings, we implemented a policy at our institution for the continuation of perioperative buprenorphine whenever possible. Our work reveals crucial targets for the education of perioperative healthcare providers and the importance of coordination amongst all perioperative services and providers.

  View details for DOI 10.1097/AJP.0000000000000858

  View details for PubMedID 32520814

• New Role for the Anesthesia Preoperative Clinic: Helping to Ensure That Surgery Is the Right Choice for Patients With Serious Illness ANESTHESIA AND ANALGESIA Goldenberg, E., Saffary, R., Schmiesing, C. 2019; 129 (1): 311–15

  View details for DOI 10.1213/ANE.0000000000004178

  View details for Web of Science ID 000474206500050

• INTRAOPERATIVE ANALGESIA PATTERNS AT AN ACADEMIC TERTIARY MEDICAL CENTER DURING THE 2018 PARENTERAL OPIOID SHORTAGE Kim, R. K., Schmiesing, C. LIPPINCOTT WILLIAMS & WILKINS. 2019: 766–67

  View details for Web of Science ID 000619263200356

• New Role for the Anesthesia Preoperative Clinic: Helping to Ensure That Surgery Is the Right Choice for Patients With Serious Illness. Anesthesia and analgesia Goldenberg, E., Saffary, R., Schmiesing, C. 2019

  View details for PubMedID 30985381

• Patients Maintained on Buprenorphine for Opioid Use Disorder Should Continue Buprenorphine Through the Perioperative Period PAIN MEDICINE Lembke, A., Ottestad, E., Schmiesing, C. 2019; 20 (3): 425–28

  View details for DOI 10.1093/pm/pny019

  View details for Web of Science ID 000467966600001

• Patients Maintained on Buprenorphine for Opioid Use Disorder Should Continue Buprenorphine Through the Perioperative Period. Pain medicine (Malden, Mass.) Lembke, A., Ottestad, E., Schmiesing, C. 2019; 20 (3): 425–28

  View details for PubMedID 29452378

• The Importance of Developing Standardized Transparent Validation of Large Data ANESTHESIA AND ANALGESIA Sanford, J., Jaffe, R. A., Kadry, B., Bjerregaard, J., Schmiesing, C., Brock-Utne, J. G. 2016; 123 (6): 1636–37

  View details for PubMedID 27655275

• The Heart of the Matter: Increasing Quality and Charge Capture from Intraoperative Transesophageal Echocardiography. A & A case reports Sanford, J. A., Kadry, B., Oakes, D., Macario, A., Schmiesing, C. 2016; 6 (8): 249-252

  Abstract

  Although transesophageal echocardiography is routinely performed at our institution, there is no easy way to document the procedure in the electronic medical record and generate a bill compliant with reimbursement requirements. We present the results of a quality improvement project that used agile development methodology to incorporate intraoperative transesophageal echocardiography into the electronic medical record. We discuss improvements in the quality of clinical documentation, technical workflow challenges overcome, and cost and time to return on investment. Billing was increased from an average of 36% to 84.6% when compared with the same time period in the previous year. The expected recoupment of investment for this project is just 18 weeks.

  View details for DOI 10.1213/XAA.0000000000000169

  View details for PubMedID 27082233

• TITRATION OF SEVOFLURANE IN ELDERLY PATIENTS: BLINDED, RANDOMIZED CLINICAL TRIAL, IN NON-CARDIAC SURGERY AFTER BETA-ADRENERGIC BLOCKADE JOURNAL OF CLINICAL MONITORING AND COMPUTING Drover, D. R., Schmiesing, C., Buchin, A. F., Ortega, H. R., Tanner, J. W., Atkins, J. H., Macario, A. 2011; 25 (3): 175-181

  Abstract

  Monitoring depth of anesthesia via the processed electroencephalogram (EEG) has been found useful in reducing the amount of anesthetic drugs, optimizing wake-up times, and, in some studies, reducing awareness. Our goal was to determine if titrating sevoflurane as the maintenance anesthetic to a depth of anesthesia monitor (SEDLine™, Masimo, CA) would shorten time to extubation in elderly patients undergoing non-cardiac surgery while on beta-adrenergic blockade. This patient population was selected because the usual cardiovascular signs of inadequate general anesthesia may be masked by beta-blocker therapy.Surgical patients older than 65 years of age receiving beta-adrenergic blockers for a minimum of 24 h preoperatively were randomized to two groups: a group whose titration of sevoflurane was based on SEDLine™ data (SEDLine™ group) and a group whose titration was based on usual clinical criteria (control group) where SEDLine™ data were concealed. The primary endpoint was time from skin closure to time to extubation. Aldrete score, White Fast Track score and QoR-40 were also assessed.There was no significant difference in time to extubation [12.5 (SD 7.4) min in the control group versus 13.0 (SD 5.9) min for the treatment group]. The control group used more fentanyl [339 mcg (SD 205)] than did the treatment group [238 mcg (SD 123)] (P<0.02). There was no difference in sevoflurane utilization, Aldrete, White Fast Track scores, time to PACU discharge, or QoR-40 assessments between the groups.Use of the SEDLine™ monitor's data to titrate sevoflurane did not improve the time to extubation or change short-term outcome of geriatric surgical patients receiving beta-adrenergic blockers. (ClinicalTrials.gov number, NCT00938782).

  View details for DOI 10.1007/s10877-011-9293-1

  View details for PubMedID 21830049

• Laparoscopic diaphragmatic pacer placement - a potential new treatment for ALS patients: a brief description of the device and anesthetic issues JOURNAL OF CLINICAL ANESTHESIA Schmiesing, C. A., Lee, J., Morton, J. M., Brock-Utne, J. G. 2010; 22 (7): 549-552

  Abstract

  The Diaphragm Pacing Stimulator (DPS) has been used to treat ventilatory insufficiency in quadriplegic patients. The FDA approved a trial using the DPS in patients with amyotrophic lateral sclerosis (ALS). Three patients with advanced ALS, who underwent laparoscopic diaphragmatic pacer placement, and their general anesthetic management, are presented.

  View details for DOI 10.1016/j.jclinane.2009.09.010

  View details for PubMedID 21056813

• Accidental intrathecal sufentanil overdose during combined spinal-epidural analgesia for labor INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA Coleman, L., Carvalho, B., Lipman, S., Schmiesing, C., Riley, E. 2009; 18 (1): 78-80

  Abstract

  A laboring woman was accidentally given 45 microg of sufentanil intrathecally in the course of combined spinal-epidural analgesia. She experienced intense pruritus and transient swallowing difficulty without respiratory depression, but still had incomplete pain relief, with delivery and episiotomy repair requiring additional analgesia. This case highlights the importance of adding local anesthetic to intrathecal opioids to facilitate effective analgesia during the second stage of labor. The contributory systems issues and multiple factors that allowed this error to occur are examined.

  View details for DOI 10.1016/j.ijoa.2008.10.001

  View details for Web of Science ID 000262736700017

  View details for PubMedID 19111229

• General anesthesia and chronic amphetamine use: Should the drug be stopped preoperatively? ANESTHESIA AND ANALGESIA Fischer, S. P., Schmiesing, C. A., Guta, C. G., Brock-Utne, J. G. 2006; 103 (1): 203-206

  Abstract

  Prescription amphetamines are being used more often for several medical conditions. Anesthesia concerns focus on the cardiovascular stability of patients who may be catecholamine-depleted and thus have a blunted response to intraoperative hypotension. Previously we reported one case of a patient receiving chronic amphetamine therapy who had a stable intraoperative course. We now report eight additional patients taking chronic prescription amphetamines who underwent a safe general anesthesia and outcome. Predominantly prescribed for narcolepsy and attention deficit hyperactivity disorder, amphetamine drugs had been given to these 8 patients for 2 to 10 yr. Ages ranged from 22 to 77 yr and genders were equally divided. All required general anesthesia for their surgical procedures and 6 of the 8 patients were tracheally intubated. Anesthesia operating room times ranged from 30 min to 4.25 h. The authors conclude that amphetamine use need not be stopped before surgery and anesthesia.

  View details for DOI 10.1213/01.ane.0000221451.24482.11

  View details for Web of Science ID 000238661900040

  View details for PubMedID 16790654

• Anesthesia for older patients with hypertrophic cardiomyopathy: is there cause for concern? JOURNAL OF CLINICAL ANESTHESIA Angelotti, T., Fuller, A., Rivera, L., Schmiesing, C. 2005; 17 (6): 478-481

  Abstract

  Hypertrophic cardiomyopathy (HCM) may remain clinically silent and undiagnosed until patients reach advanced age. We describe 2 older patients with previously undetected and probable late-onset HCM whose preoperative cardiac examination revealed only the presence of a systolic murmur. Both patients were diagnosed with HCM by perioperative echocardiography. We provide an algorithm for the evaluation of murmurs detected during the preoperative anesthesia evaluation, with emphasis on the clinical characteristics of HCM, and we discuss the perioperative management of these patients. In addition, recent findings concerning the natural progression of HCM are discussed, revealing differences between HCM in younger patient populations and that in older patient populations and its implications for anesthetic management.

  View details for DOI 10.1016/j.jclinane.2004.09.009

  View details for Web of Science ID 000232551100013

  View details for PubMedID 16171671

• The preoperative anesthesia evaluation. Thoracic surgery clinics Schmiesing, C. A., Brodsky, J. B. 2005; 15 (2): 305-315

  Abstract

  Thorough and timely anesthesia preoperative evaluation is essential for good patient outcomes. Perioperative care is becoming more complex and comprehensive, while older and sicker patients are being considered for major thoracic surgery. In addition to pulmonary and wound care, prevention of cardiac complications with beta-blocker therapy, multimodal pain control, tighter glycemic control, nutritional support, and prevention of thromboembolism are important perioperative goals. Early identification of significant medical and nonmedical issues allows for complete evaluation and planning and decreases the likelihood of delays, cancellations, and complications. Good communication and preparation benefit everyone. The implementation of an anesthesia preoperative assessment program or clinic can help achieve these important goals.

  View details for PubMedID 15999528

• Concealed mothball abuse prior to anesthesia: mothballs, inhalants, and their management ACTA ANAESTHESIOLOGICA SCANDINAVICA Kong, J. T., Schmiesing, C. 2005; 49 (1): 113-116

  Abstract

  Mothballs are one of a number of volatile compounds including model airplane glue, spray paint, nail polish remover, room fresheners, and gasoline that are intentionally inhaled for the purpose of recreational self-intoxication. Their inhalation produces a rapid 'high' characterized by euphoria and generalized intoxication. Chronic abuse can be associated with significant organ impairment, and, in rare cases, cardiac dysrhythmias and deranged end-tidal gas monitoring. Mothballs contain the aromatic compound naphthalene and/or paradichlorobenzene. Prolonged exposure can cause hepatic failure and severe hemolytic anemia. We present a case of a young adult who initially concealed her chronic mothball inhalation. The literature regarding mothball abuse as well as inhalant abuse relevant to anesthesia is reviewed, and suggestions for the diagnosis and peri-operative management are offered.

  View details for DOI 10.1111/j.1399-6576.2004.00510.x

  View details for Web of Science ID 000226638800024

  View details for PubMedID 15675996

• What is quality improvement in the preoperative period? International anesthesiology clinics Archer, T., Schmiesing, C., Macario, A. 2002; 40 (2): 1-16

  View details for PubMedID 11897932

• The preoperative assessment of the cancer patient. Current opinion in anaesthesiology Schmiesing, C. A., Fischer, S. P. 2001; 14 (6): 721-729

  Abstract

  The cancer patient presents special challenges to the anesthesiologist. Cancer may have multiple effects including those due to the primary tumor, metastases, the effects and toxicity of cancer therapy, associated paraneoplastic and physiologic responses to the tumor and the strong psychological responses elicited by cancer. The preoperative evaluation of the cancer patient provides opportunities to understand the patient's medical condition and to plan management. Specific goals of the preoperative assessment include a relevant and complete patient history with emphasis on the cancer, thorough examination of the patient, appropriate diagnostic testing and formation of an anesthetic and perioperative plan. Patient education and reassurance regarding issues of safety, pain control and respect for patient preferences are important goals as well. This review provides the anesthesiologist with both general and specific information important to the systematic and complete preoperative evaluation of the patient with cancer.

  View details for PubMedID 17019171

• An airway management device: The laryngeal mask airway - A review JOURNAL OF INTENSIVE CARE MEDICINE Schmiesing, C. A., Brock-Utne, J. G. 1998; 13 (1): 32-43

  View details for Web of Science ID 000071440100003