Veterans Affairs Anesthesiology Service Division

Best Medical Schools for Anesthesiology #3 in the nation.The division is committed to providing world-class care to the brave men and women who have served our nation. Faculty have expertise in a broad range of diagnostic and treatment methods, including high-risk surgical and critical care, perioperative medicine, transesophageal echocardiography and point-of-care ultrasound, regional and acute pain management, and treatment of chronic pain conditions. They conduct research in a wide variety of areas, with emphasis on chronic neuropathic pain syndromes and perioperative epidemiologic analyses.

Atilio Barbeito, MD, MPH - Chief, VA Anesthesiology Service Division

To fulfill President Lincoln’s promise, “to care for him who shall have borne the battle, and for his widow, and his orphan by serving and honoring the men and women who are America’s veterans.”

This is the mission statement of the Department of Veterans Affairs and serves as inspiration to us in the  Veterans Affairs Anesthesiology Service Division at Duke. Our purpose is to bring world-class care to those who served. We do this by leveraging both Duke’s and VA’s strengths: world-class scientists and clinicians, cutting-edge perioperative medicine techniques, and extensive population health and implementation science knowledge and experience.

Established in 1978, the Anesthesiology Service at the Durham VA Health Care System (VAHCS) was the fifth in the country to separate from the Surgery Service Line. Under the leadership of Drs. Stanley Weitzner, Philip Lumb, Jake Frieberger, Robert Sladen, and Jonathan Mark, the division grew exponentially and now provides care to patients in the operating room, several off-site locations, and the Surgical Intensive Care Unit. We also operate busy pre-anesthesia evaluation and pain clinics, and provide transesophageal echocardiography services for the entire Durham Health Care System. Our group is involved in basic, translational and clinical research, and educates the next generation of leaders in anesthesiology, critical care, pain medicine and perioperative medicine.

Operating Room

Under the leadership of Dr. Tim Stanley, the Durham VA HCS operating room platform consists of nine operating rooms (three new ORs including a hybrid room are currently under construction and are projected to be completed by July 2021). We perform about 5,500 cases per year, with a significant number of high-risk cardiac (including circulatory arrest cases), thoracic, general, vascular, neurosurgery, urology, ENT, orthopedics, and plastics procedures.

Non-OR Locations (NORA)

We provide anesthetic services for our hospital-based GI Endoscopy Unit, and procedures in the Electrophysiology and Vascular and Interventional Radiology suites.

Surgical Critical Care Unit

A multidisciplinary team of Anesthesiology and Surgery faculty, physician assistants, nurses, trainees, nutritionist, pharmacist, physical therapy, and respiratory therapy round daily on our 12-bed surgical intensive care unit. On any given day, approximately 30% of our patients are post-cardiothoracic surgery patients, with the rest a mix of high-risk general, vascular, urology and neurosurgery patients. The unit provides advanced therapies such as inhaled nitric oxide, continuous renal replacement therapy, and invasive hemodynamic support. Our team is also capable of placing peripherally-inserted central catheters, nasoenteral feeding tubes, and percutaneous tracheostomy procedures. The unit is directed by Dr. John Lemm.

Pain Program

Under the leadership of Dr. Thomas Van de Ven, our Pain Program is focused on providing cutting-edge, multidisciplinary care to patients suffering both chronic and acute pain in multiple settings from home to the hospital.

Pain Clinic

The Durham VA pain clinic is one of the oldest in the VA system, founded by Dr. Joel Goldberg in 1988. The clinic, currently led by Dr. David Lindsay, has been providing intensive pain therapy, including advanced image-guided interventional techniques, for over three decades. It has also provided clinical education to pain medicine fellows for over twenty years where they learn in a truly multidisciplinary environment, with a group that now includes dedicated pain-focused psychology, physical therapy, and pharmacy providers in addition to Physical Medicine and Rehabilitation physicians, advanced practice providers, nurses and Anesthesiology pain specialists.

Inpatient Pain Services

In addition to providing outpatient chronic pain care, our clinic practitioners also provide pain medicine services for patients in the hospital suffering from severe pain exacerbations of ongoing medical conditions. We also offer services to veterans in VA long-term care and hospice facilities who require end-of-life treatment for cancer pain and pain resulting from other terminal conditions.

Regional Anesthesia Services

Regional anesthesia, targeting surgical, medical or traumatic pain in a specific area of the body, not only reduces pain and suffering for patients in the hospital but has also been shown to improve many other important patient outcome measures following surgery or trauma. Under the direction of Dr. Harika Nagavelli and Dr. Juliann Hobbs we have created an inpatient acute pain service offering advanced regional anesthesia techniques and acute pain care coordination with surgical and medical inpatient services.

Transitional Pain Service

As our ability to identify patients who are at risk of uncontrolled pain around the time of surgery improves, and as we have become more and more aware of the dangers of long-term opioid use, our group, led by Dr. Srinivas Pyati, has developed a service that provides support, advice, information and care for patients at high risk of severe post-operative pain. This transitional pain service meets with patients before and after surgery, optimizes pain medication regimens, provides alternative pain therapies and offers complementary and behavioral-based approaches to pain mitigation after surgery and beyond.

Pain Research

Our research group continues to study multiple aspects of pain medicine in the VA environment. We have a long track record of running both therapeutic and diagnostic clinic trials in veterans suffering from post-traumatic or post-operative nerve damage related pain and our group has been at the forefront of research investigating how to reduce the burden of opioid use and opioid-related adverse events. We have also evaluated the role of complementary medicine techniques for reduction of perioperative pain (including music therapy and acupuncture) with the goal of creating a perioperative environment that provides quality care, improves patient satisfaction, reduces pain and reduces the negative consequences of opioid therapy.

Perioperative Medicine Program

Pre-Anesthesia Evaluation Clinic (PAEC)

The PAEC evaluates about 6,000 patients per year prior to surgical or other invasive procedures either in-person or by phone. The clinic also provides comprehensive assessments of physical function and nutrition prior to high-risk surgery, and is involved in other preoperative optimization efforts in coordination with our Duke PASS Clinic. Staffed by a talented group of advanced practice providers, and under the leadership of Dr. Karthik Raghunathan, the program is continuously growing to develop prehabilitation pathways and postoperative follow up protocols.

Preoperative Optimization of Senior Health Program (POSH)

The POSH Program was created in 2015 by Drs. Sandhya Lagoo and Mitch Heflin as a specialized clinic for older adults with high comorbidity burden who are contemplating high-risk surgery. Older veterans undergo a thorough evaluation by a multidisciplinary team and optimization strategies are implemented as needed. The Duke Anesthesiology team has been part of this team since its inception. The POSH inpatient team is involved in the postoperative follow-up of these patients.

Transesophageal Echocardiography Service

Our group performs all TEEs for the Durham VAHCS, both intraprocedurally during cardiac and other non-cardiac high-risk procedures, but also for other medical conditions such as during evaluation of thromboembolism or infective endocarditis. Dr. Eric JohnBull is the clinical lead for this service.

Clinical Anesthesiology – Operating Room

Under the coordination of Dr. Grace McCarthy, Duke medical students in their 2ndyear have the opportunity to spend time in the VA operating rooms during their two week Clinical Anesthesiology Selective. Students have the opportunity to shadow a senior anesthesia resident and work with different anesthesia attendings to get an introduction to clinical anesthesiology. Students are encouraged to get hands-on practice placing IVs, and also practicing bag mask ventilation and other airway skills. They learn about different anesthetic techniques as well as the physiology and pharmacology relevant to each case. In addition, Dr. Becky Schroeder and Dr. Srinivas Pyati serve as interviewers for medical student applicants to the Duke University School of Medicine.

Dr. McCarthy also coordinates the Duke Anesthesiology Durham VA OR and VA Cardiac residency rotations. Residents spend one month per year in the main operating rooms at the Durham VA during their CA-1, CA-2, and CA-3 years where they take part in the clinical evaluation and anesthetic care of patients having a wide-range of procedures ranging from general surgery to subspecialty surgical cases including orthopedics, neurosurgery, and thoracic surgery. The VA OR rotations include a daily didactic lecture series, monthly multidisciplinary ICU or perioperative conferences, and monthly defibrillator review sessions and OR mock codes. During their CA-3 VA OR rotation, residents are given more administrative leadership experience and have the opportunity to act as an attending to junior residents. CA-3 residents also spend one month on a VA Cardiac rotation where they have the opportunity to learn basic transesophageal echocardiography (TEE) skills with one-on-one intraoperative teaching by their attending. The VA cardiac rotation includes a weekly TEE conference led by Dr. Jonathan Mark as well as a weekly multidisciplinary cardiac listing conference to discuss potential candidates for cardiac surgery. The VA cardiac resident has the opportunity to get exposure to procedures in the Electrophysiology lab and is also given the opportunity to supervise junior residents when the schedule permits.

Durham Pain Program

Pain Clinic

Founded by Dr. Joel Goldberg in 1988, the Durham VA Pain Clinic is one of the oldest VA-based pain clinics in the country, and has been providing clinical education to Duke pain fellows for almost 20 years. Duke Anesthesiology pain fellows spend three months at the Durham VAHCS, where they practice both inpatient and outpatient pain medicine and learn multiple interventional procedures while working with a very unique patient population. Fellows learn in a truly multidisciplinary environment, with a group that includes physical medicine and rehabilitation physicians, advanced practice providers, nurses and anesthesiology pain specialists.

Surgical Intensive Care Unit

Under the direction of Dr. John Lemm, the VA Surgical ICU is a true multidisciplinary unit, staffed by a mix of intensivists from Anesthesiology or Surgery and three permanent physician assistants.  We have an excellent case mix, caring for patients from all surgical subspecialties including cardiac, thoracic, major vascular and neurosurgery. We host resident trainees from Anesthesiology, Surgery, and Emergency Medicine, where they are exposed to caring for a broad mix of surgical disease, with a special focus on the postoperative cardiac patient. During their time on service, trainees participate in multidisciplinary rounds and perform basic ICU procedures such as the placement of intravascular lines, and endotracheal intubation, to name a few. Another highlight of this rotation is one-on-one, hands-on point-of-care-ultrasound (POCUS) training with Dr. Yuriy Bronshteyn, a national expert in this field, as well as other ICU attendings. Didactics include a daily Anesthesiology morning conference, a monthly ICU multidisciplinary conference, and multiple ICU-focused didactics each week by the ICU attending. An elective ICU month for CA-3s is offered, where the resident takes on a leadership role, mentoring the junior residents, as well as providing more clinical decision-making and participating in higher level ICU procedures.

Critical care fellows from Anesthesiology and Surgery provide year-round coverage in the VA SICU, where they perform a critical role as they progress towards independent practice. Responsibilities for the fellow include the development of attending-level decision-making skills, advanced procedural skills and mentorship and teaching for the junior residents. While on service, the Anesthesiology fellows participate with the intraoperative TEE for all cardiac cases, as well as assist on many of the non-OR TEE consultations. A weekly TEE conference led by Dr. Jonathan Mark is highly attended and typically the highlight of the week for learners. Additionally, anesthesiology fellows aid with out of operating room airway management throughout the hospital. Critical care fellows also take on a didactics leadership role, providing teaching for the trainees in the ICU, as well spearheading our multidisciplinary ICU conferences.

With her specific skills in medical informatics, Dr. Becky Schroeder leads the departmental efforts related to the Anesthesiology Datamart Project and Research Compliance. Within our group, Schroeder heads our research endeavors, overseeing more than 20 research projects. The VA also has a robust data infrastructure that we leverage towards projects that advances care in the areas of perioperative care, critical care, and pain management. Data science is a specific area of expertise and experience for the VA Anesthesiology Service Division faculty. Dr. Karthik Raghunathan is especially active in areas related to whole health and complementary integrative health. Contributors to morbidity and mortality in the vulnerable VA population are also an active area of investigation.
A list of current projects is below.

Current Projects

The Relationship Between Leadership, Teamwork, and Team Performance During Simulated Cardiac Arrest
PI: Barbeito

While working with in-hospital cardiac arrest teams, we noticed variability in team performance and wondered whether this related to the skills of the leader, the team, or both. The objective of this project is to quantitatively assess the effects of leadership and teamwork on the quality of resuscitation provided by cardiac arrest teams. We are analyzing recorded in situ cardiac arrest simulations to test our central hypothesis that teamwork is associated with CPR quality and that effective leadership results in improved quality of resuscitation through its effect on teamwork, rather than as an independent factor.

Prehabilitation of Veterans with Exercise and Nutrition (PREVENT)
PI: Barbeito

Low fitness and poor functional status are among the strongest predictors of postsurgical complications. Prehabilitation takes advantage of the weeks leading up to surgery in order to improve fitness, mobility, and nutrition in preparation for the upcoming surgical stress. A prehabilitation program that is delivered using telehealth would be ideal, because it combines accessibility with supervision, encouraging compliance, and ensuring adequate training intensity, but such programs do not currently exist within the VA. In this prospective study, we will test the feasibility, acceptability, and safety of a 3-4 week multimodal prehabilitation intervention that is supervised and individualized, yet is delivered at home using telehealth technology.

Blood Pressure Variability and Perioperative Outcomes
PI: Schroeder, Raghunathan

Exactly how hemodynamic variability is associated with clinical outcomes is not clear. This large data science project explores the concept of ‘mutual information,’ a non-linear combination of blood pressure and heart rate, and its ability to predict adverse outcomes following surgery. Manuscript accepted.

Regional Anesthesia and Valproate Sodium for the Prevention of Chronic Post-Amputation Pain
PI: Buchheit, Van de Ven

Strategies for preventing the development of chronic pain syndromes in amputation patients have limited success. This is a prospective, randomized, placebo-controlled trial of regional anesthesia and perioperative oral valproate treatment as a combined prophylactic treatment for the prevention of post-amputation chronic pain.

Spinal Cord Stimulation: A Retrospective Analysis of Clinical Impact on Veterans with Spinal Radicular Pain and Healthcare Utilization
PI: Pyati

Spinal cord stimulation is becoming a more commonly utilized modality for the treatment of chronic low back pain, although its effectiveness has not been definitely demonstrated. This retrospective review of patients with spinal cord stimulators placed for treatment of spinal radicular pain at the Durham VA HCS focuses on clinical outcomes and indicators of health care utilization.

Comparative Effectiveness of Perioperative Isotonic Saline vs. Balanced Fluids
PI: Raghunathan

The optimal fluid for perioperative volume replacement has been hotly debated for many years. This project uses the Premier database to examine differences in outcomes between patients who received isotonic saline and those who received balanced salt solutions using an epidemiologic approach. Funded by Grifols SSNA/ Manuscript published, abstracts presented IARS (2021, 2022).

Do CAN Scores Predict Prolonged Length-of-Stay, Re-Hospitalization, Mortality, and Other Adverse Outcomes in Diverse Surgical Populations?
PI: Schroeder, Raghunathan

The CAN (Care Assessment of Needs) Score, calculated weekly for all veterans cared for by the VA Health Care System, includes data related to demography, specific comorbidities, recent health system utilization, and socioeconomic status. While it is used by primary care clinics to allocate resources, it is unknown if it can be used for perioperative risk stratification. This project studies the ability of the CAN score to predict hospital length of stay and mortality in a large, diverse, surgical population. Manuscript published.

Pilot Study for Tourniquet Ischemia Monitoring in Extremity Surgery
PI: Pyati

The overarching purpose of this research is to improve the safety of tourniquet use. Despite the ubiquitous use of tourniquets across countless surgical procedures on the extremities, there is no effective monitor that allows data driven tourniquet management in the operating room. We seek to investigate Near Infrared Spectroscopy regional oximeters in lower extremity surgery to determine whether this advancing technology can be used to assist in managing tourniquet use. In addition, we will identify changes in micro RNA expression during long duration extremity surgery under tourniquet and correlate these changes with NIRS-collected tissue oxygenation parameters.

Effect of Thoracic Epidural on the Incidence and Severity of Post-Thoracotomy Pain
PI: Van de Ven, Pyati

Significant chronic pain affects approximately 50% of patients who have undergone a pulmonary resection, whether by thoracotomy or VATS. This study hopes to determine if this rate is reduced in patients who have received a perioperative thoracic epidural.

High Dose, Extended-Duration DHA/EPA Therapy to Prevent Chronic Post-Thoracotomy Pain: a Pragmatic, Comparative Effectiveness Randomized Trial
PI: Van de Ven, Pyati

Complimentary health strategies tend to be low risk but effective. This prospective, randomized, placebo-controlled trial tests the effectiveness of DHA/EPA (high-quality fish oil) in preventing chronic pain following thoracotomy.

Single Nucleus Expression Profiling of Human Sciatic Nerve after Traumatic Amputation: Predicting Pain and Functional Outcomes
PI: Van de Ven

Significant chronic pain affects approximately 50% of patients who have undergone a pulmonary resection, whether by thoracotomy or VATS. This study hopes to determine if this rate is reduced in patients who have received a perioperative thoracic epidural at the appropriate spinal level.

Identification and Validation of Biomarkers of Acute Kidney Injury Recovery
PI: Schroeder

Post-operative acute kidney injury is recognized as a significant source of morbidity and even mortality. Early recognition of the process is difficult with current capabilities. This study tests the accuracy and feasibility of a novel set of urine and serum biomarkers in early detection of AKI.

Establishing a Patient Safety Center of Inquiry at the Durham VA Dedicated to Reducing Opioid-Related AEs and Reducing Prolonged Use of Opioids After Surgery
PI: Raghunathan

It has been recognized that a significant number of patients continue to use opioids months or even years after elective surgery, contributing to their risk of opioid-related adverse events. A Patient Safety Center of Inquiry was established, funded by the VA National Center for Patient Safety, to study means of reducing this long-term use of opioids in surgical patients. Ongoing studies examining equity and AUDIT-C in relation to pain and opioid use.

Perioperative Stroke
PI: Raghunathan

The treatment of acute ischemic stroke with the use of mechanical thrombectomy has increased since landmark trials showed efficacy in 2015. This study examines how mechanical thrombectomy utilization has changed in recent years among patients with perioperative acute ischemic strokes. Manuscript published 2022.

Effects of HES-FDA Warning on Hospital
PI: Raghunathan

Hydroxy-ethyl starch solutions were removed from US hospitals in response to an FDA warning in 2013. The effects of this change in clinical practice are the subject of this project, using data from Premier hospitals across the US. Manuscript published 2020.

DNR Orders in the Perioperative Period
PI: Raghunathan

This study seeks to characterize Code Status (DNR Orders) in relation to three common surgical procedures within the ACS NSQIP database. The study compares the characteristics of patients with versus without DNR Orders. Manuscript published 2020.

Combinations of Multi-Modal Analgesia after Surgery
PI: Raghunathan

This study seeks to examine safety outcomes in patients exposed to different combinations of non-opioid analgesics. The proposal uses charge codes from a large database (Multihospital Premier Alliance) to identify both analgesic exposures and postoperative pulmonary complications. Several manuscripts were published (2019, 2020, 2021, 2022).

Crystalloid Use in NonCardiac Surgery
PI: Raghunathan

This study seeks to compare Albumin with Crystalloids in patients undergoing major noncardiac surgery. The recent FDA warning on Starch solutions led to changes in intravenous fluid choice and this proposal leverages these changes to determine whether outcomes differed in hospitals that switched to albumin versus crystalloids. Funded by Grifols SSNA. Several abstracts presented IARS (2021, 2022).

Oral Nutritional Supplementation in the Perioperative Period
PI: Raghunathan

Malnutrition is common in surgical populations and increases the risk of poor outcomes. This project attempts to determine if oral supplementation in the perioperative period can decrease this risk. Funded by Abbott. Several manuscripts were published and abstracts were presented at IARS (2021, 2022, ASPEN).

View the department’s competitive and non-competitive research grant awards by calendar year.

Please contact the Veterans Affairs Anesthesiology Service Division’s staff assistant, Sarah A. Hill, at 919- or sarah.a.hill@duke.edu with inquiries.

Divisional News

Chris KeithVeterans Affairs Anesthesiology Service Division