Prolonged Opioid Use and Pain Outcome and Associated Factors after Surgery under General Anesthesia: A Prospective Cohort Association Multicenter Study.

BACKGROUND: There is insufficient prospective evidence regarding the relationship between surgical experience and prolonged opioid use and pain. The authors investigated the association of patient characteristics, surgical procedure, and perioperative anesthetic course with postoperative opioid consumption and pain 3 months postsurgery. The authors hypothesized that patient characteristics and intraoperative factors predict opioid consumption and pain 3 months postsurgery. METHODS: Eleven U.S. and one European institution enrolled patients scheduled for spine, open thoracic, knee, hip, or abdominal surgery, or mastectomy, in this multicenter, prospective observational study. Preoperative and postoperative data were collected using patient surveys and electronic medical records. Intraoperative data were collected from the Multicenter Perioperative Outcomes Group database. The association between postoperative opioid consumption and surgical site pain at 3 months, elicited from a telephone survey conducted at 3 months postoperatively, and demographics, psychosocial scores, pain scores, pain management, and case characteristics, was analyzed. RESULTS: Between September and October 2017, 3,505 surgical procedures met inclusion criteria. A total of 1,093 cases were included; 413 patients were lost to follow-up, leaving 680 (64%) for outcome analysis. Preoperatively, 135 (20%) patients were taking opioids. Three months postsurgery, 96 (14%) patients were taking opioids, including 23 patients (4%) who had not taken opioids preoperatively. A total of 177 patients (27%) reported surgical site pain, including 45 (13%) patients who had not reported pain preoperatively. The adjusted odds ratio for 3-month opioid use was 18.6 (credible interval, 10.3 to 34.5) for patients who had taken opioids preoperatively. The adjusted odds ratio for 3-month surgical site pain was 2.58 (1.45 to 4.4), 4.1 (1.73 to 8.9), and 2.75 (1.39 to 5.0) for patients who had site pain preoperatively, knee replacement, or spine surgery, respectively. CONCLUSIONS: Preoperative opioid use was the strongest predictor of opioid use 3 months postsurgery. None of the other variables showed clinically significant association with opioid use at 3 months after surgery.

Incidence of sedation-related adverse events during ERCP with anesthesia assistance: a multicenter observational study.

BACKGROUND AND AIMS: Anesthesia assistance is commonly used for ERCP. General anesthesia (GA) may provide greater airway protection but may lead to hypotension. We aimed to compare GA versus sedation without planned intubation (SWPI) on the incidence of hypoxemia and hypotension. We also explored risk factors for conversion from SWPI to GA. METHODS: This observational study used data from the Multicenter Perioperative Outcomes Group. Adults with American Society of Anesthesiologists physical status class I to IV undergoing ERCP between 2006 and 2019 were included. We compared GA and SWPI on incidence of hypoxemia (oxygen saturation <90% for ≥3 minutes) and hypotension (mean arterial pressure <65 mm Hg for ≥5 minutes) using joint hypothesis testing. The association between anesthetic approach and outcomes was assessed using logistic regression. The noninferiority delta for hypoxemia and hypotension was an odds ratio of 1.20. One approach was deemed better if it was noninferior on both outcomes and superior on at least 1 outcome. To explore risk factors associated with conversion from SWPI to GA, we constructed a logistic regression model. RESULTS: Among 61,735 cases from 42 institutions, 38,830 (63%) received GA and 22,905 (37%) received SWPI. The GA group had 1.27 times (97.5% confidence interval, 1.19-1.35) higher odds of hypotension but .71 times (97.5% confidence interval, .63-.80) lower odds of hypoxemia. Neither group was noninferior to the other on both outcomes. Conversion from SWPI to GA occurred in 6.5% of cases and was associated with baseline comorbidities and higher institutional procedure volume. CONCLUSIONS: GA for ERCP was associated with less hypoxemia, whereas SWPI was associated with less hypotension. Neither approach was better on the combined incidence of hypotension and hypoxemia.

Deficit Accumulation and Phenotype Assessments of Frailty Both Poorly Predict Duration of Hospitalization and Serious Complications after Noncardiac Surgery.

BACKGROUND: Frailty is associated with adverse postoperative outcomes, but it remains unclear which measure of frailty is best. This study compared two approaches: the Modified Frailty Index, which is a deficit accumulation model (number of accumulated deficits), and the Hopkins Frailty Score, which is a phenotype model (consisting of shrinking, weakness, exhaustion, slowness, and low physical activity). The primary aim was to compare the ability of each frailty score to predict prolonged hospitalization. Secondarily, the ability of each score to predict 30-day readmission and/or postoperative complications was compared. METHODS: This study prospectively enrolled adults presenting for preanesthesia evaluation before elective noncardiac surgery. The Hopkins Frailty Score and Modified Frailty Index were both determined. The ability of each frailty score to predict the primary outcome (prolonged hospitalization) was compared using a ratio of root-mean-square prediction errors from linear regression models. The ability of each score to predict the secondary outcome (readmission and complications) was compared using ratio of root-mean-square prediction errors from logistic regression models. RESULTS: The study included 1,042 patients. The frailty rates were 23% (Modified Frailty Index of 4 or higher) and 18% (Hopkins Frailty Score of 3 or higher). In total, 12.9% patients were readmitted or had postoperative complications. The error of the Modified Frailty Index and Hopkins Frailty Score in predicting the primary outcome was 2.5 (95% CI, 2.2, 2.9) and 2.6 (95% CI, 2.2, 3.0) days, respectively, and their ratio was 1.0 (95% CI, 1.0, 1.0), indicating similarly poor prediction. Similarly, the error of respective frailty scores in predicting the probability of secondary outcome was high, specifically 0.3 (95% CI, 0.3, 0.4) and 0.3 (95% CI, 0.3, 0.4), and their ratio was 1.00 (95% CI, 1.0, 1.0). CONCLUSIONS: The Modified Frailty Index and Hopkins Frailty Score were similarly poor predictors of perioperative risk. Further studies, with different frailty screening tools, are needed to identify the best method to measure perioperative frailty.

Preoperative Risk and the Association between Hypotension and Postoperative Acute Kidney Injury.

BACKGROUND: Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk. METHODS: Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline). RESULTS: Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort. CONCLUSIONS: Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.

Effect of Sevoflurane Versus Isoflurane on Emergence Time and Postanesthesia Care Unit Length of Stay: An Alternating Intervention Trial.

BACKGROUND: We previously reported that the duration of hospitalization was not different between isoflurane and sevoflurane. But more plausible consequences of using soluble volatile anesthetics are delayed emergence from anesthesia and prolonged stays in the postanesthesia care unit (PACU). We therefore compared isoflurane and sevoflurane on emergence time and PACU duration. METHODS: We reanalyzed data from 1498 adults who participated in a previous alternating intervention trial comparing isoflurane and sevoflurane. Patients, mostly having colorectal surgery, were assigned to either volatile anesthetic in 2-week blocks that alternated for half a year. Emergence time was defined as the time from minimum alveolar concentration fraction reaching 0.3 at the end of the procedure until patients left the operating room. PACU duration was defined from admission to the end of phase 1 recovery. Treatment effect was assessed using Cox proportional hazards regression, adjusted for imbalanced baseline variables. RESULTS: A total of 674 patients were given isoflurane, and 824 sevoflurane. Emergence time was slightly longer for isoflurane with a median (quartiles) of 16 minutes (12-22 minutes) vs 14 minutes (11-19 minutes) for sevoflurane, with an adjusted hazard ratio of 0.81 (97.5% CI, 0.71-0.92; P < .001). Duration in the PACU did not differ, with a median (quartiles) of 2.6 hours (2.0-3.6 hours) for isoflurane and 2.6 hours (2.0-3.7 hours) hours for sevoflurane. The adjusted hazard ratio for PACU discharge time was 1.04 (97.5% CI, 0.91-1.18; P = .56). CONCLUSIONS: Isoflurane prolonged emergence by only 2 minutes, which is not a clinically important amount, and did not prolong length of stay in the PACU. The more soluble and much less-expensive anesthetic isoflurane thus seems to be a reasonable alternative to sevoflurane.

Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and Systematic Review.

BACKGROUND: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. METHODS: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. RESULTS: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. CONCLUSIONS: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Identify and monitor clinical variation using machine intelligence: a pilot in colorectal surgery.

Standardized clinical pathways are useful tool to reduce variation in clinical management and may improve quality of care. However the evidence supporting a specific clinical pathway for a patient or patient population is often imperfect limiting adoption and efficacy of clinical pathway. Machine intelligence can potentially identify clinical variation and may provide useful insights to create and optimize clinical pathways. In this quality improvement project we analyzed the inpatient care of 1786 patients undergoing colorectal surgery from 2015 to 2016 across multiple Ohio hospitals in the Cleveland Clinic System. Data from four information subsystems was loaded in the Clinical Variation Management (CVM) application (Ayasdi, Inc., Menlo Park, CA). The CVM application uses machine intelligence and topological data analysis methods to identify groups of similar patients based on the treatment received. We defined "favorable performance" as groups with lower direct variable cost, lower length of stay, and lower 30-day readmissions. The software auto-generated 9 distinct groups of patients based on similarity analysis. Overall, favorable performance was seen with ketorolac use, lower intra-operative fluid use (< 2000 cc) and surgery for cancer. Multiple sub-groups were easily created and analyzed. Adherence reporting tools were easy to use enabling almost real time monitoring. Machine intelligence provided useful insights to create and monitor care pathways with several advantages over traditional analytic approaches including: (1) analysis across disparate data sets, (2) unsupervised discovery, (3) speed and auto-generation of clinical pathways, (4) ease of use by team members, and (5) adherence reporting.

Attempted Development of a Tool to Predict Anesthesia Preparation Time From Patient-Related and Procedure-Related Characteristics.

BACKGROUND: Operating room (OR) utilization generally ranges from 50% to 75%. Inefficiencies can arise from various factors, including prolonged anesthesia preparation time, defined as the period from induction of anesthesia until patients are considered ready for surgery. Our goal was to use patient-related and procedure-related factors to develop a model predicting anesthesia preparation time. METHODS: From the electronic medical records of adults who had noncardiac surgery at the Cleveland Clinic Main Campus, we developed a model that used a dozen preoperative factors to predict anesthesia preparation time. The model was based on multivariable regression with "Least Absolute Shrinkage and Selection Operator" and 10-fold cross-validation. The overall performance of the final model was measured by R, which describes the proportion of the variance in anesthesia preparation time that is explained by the model. RESULTS: A total of 43,941 cases met inclusion and exclusion criteria. Our final model had only moderate discriminative ability. The estimated adjusted R for prediction model was 0.34 for the training data set and 0.27 for the testing data set. CONCLUSIONS: Using preoperative factors, we could explain only about a quarter of the variance in anesthesia preparation time-an amount that is probably of limited clinical value.

Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations.

With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.

Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations.

With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.

Transvesical Percutaneous Access Allows for Epidural Anesthesia Without Mechanical Ventilation in Single-Port Robotic Radical and Simple Prostatectomy.

OBJECTIVES: To determine the feasibility of epidural anesthesia in patients undergoing transvesical single-port (SP) robotic simple and radical prostatectomy. METHODS: Patients undergoing transvesical SP robotic radical or simple prostatectomy were selected. Exclusions were underlying obstructive sleep apnea, pulmonary disease, prior lumbar spinal surgery, or BMI >35. Low thoracic or high lumbar epidural catheters were placed in the preoperative unit prior to operating room transport. Demographic information, intraoperative variables, and perioperative outcomes were collected in an IRB-approved database. A descriptive statistical analysis was performed. RESULTS: A total of 12 patients underwent epidural placement prior to transvesical SP radical (N = 7) and simple (N = 5) prostatectomy. All cases were completed without extra ports, open conversion, or conversion to general anesthesia. No surgical interruptions were noted in 9 of 12 cases and all movement-related interruptions were brief and transient. No anesthetic complications were noted. The one postoperative complication noted was unrelated to anesthesia. Intraoperative opioids were avoided in 5 patients. No patients required opioid medications after discharge and all patients with outpatient encounters were same-day discharges. One patient was a pre-planned admission. Limitations include small number of patients and a single surgeon experience. CONCLUSION: Epidural anesthesia without mechanical ventilation is a safe and feasible technique in selected patients undergoing transvesical SP robotic radical and simple prostatectomy. This approach was not associated with any anesthesia-related complications or compromise in perioperative outcomes.

A comparison of epidural analgesia and traditional pain management effects on survival and cancer recurrence after colectomy: a population-based study.

BACKGROUND: Cancer recurrence after surgery may be affected by immunosuppressive factors such as surgical stress, anesthetic drugs, and opioids. By limiting exposure to these, epidural analgesia may enhance tumor surveillance. This study compared survival and cancer recurrence rates for resection of colorectal cancer between patients who received perioperative epidurals and those who did not. METHODS: The linked Medicare-Surveillance, Epidemiology, and End Results database was used to identify patients ages 66 yr or older with nonmetastatic colorectal cancer diagnosed between 1996 and 2005 who underwent open colectomy. Recurrence was defined as chemotherapy 16 months or more after surgery and/or radiation 12 months or more after surgery. Patients were followed for at least 4 yr. To account for hospital effects, overall survival was estimated via marginal Cox regression. Recurrence was estimated by conditional logistic regression. RESULTS: A cohort of 42,151 patients, of whom 22.9% (n = 9,670) had epidurals at the time of resection, was identified. 5-yr survival was 61% in the epidural group and 55% in the nonepidural group. There was a significant association between epidural use and improved survival (adjusted Cox model hazard ratio = 0.91, 95% CI = [0.87, 0.94]). Adjusting for covariates, there was no significant reduction of recurrence in the epidural group (odds ratio = 1.05, 95% CI = [0.95, 1.15]). Several covariates, including blood transfusion, were predictive of mortality and cancer recurrence. CONCLUSION: This large cohort study found that epidural use is associated with improved survival in patients with nonmetastatic colorectal cancer undergoing resection but does not support an association between epidural use and decreased cancer recurrence.

Pulmonary hemorrhage in an outpatient ophthalmic anesthesia setting - it's never "just a cataract".

A 48-year-old man, with end stage renal disease and a history of recreational drug abuse, presented for elective cataract surgery. Patient underwent the procedure with a general endotracheal anesthesia with a balanced anesthetic. After an uneventful intra-operative period, he had a sudden onset large volume hemoptysis just prior to extubation. Poor oxygenation and hemodynamic instability necessitated emergent reintubation in the immediate post-extubation period. Emergent bronchoscopy did not show active airway bleeding or obstructive mucous plugs, and a diagnosis of diffuse alveolar hemorrhage was made. The patient was gradually weaned off the ventilator and made a slow recovery over a one - week period.

Preoperative Management of Medications for Neurologic Diseases: Society for Perioperative Assessment and Quality Improvement Consensus Statement.

Neurologic diseases are prevalent in patients undergoing invasive procedures; yet, no societal guidelines exist as to best practice in management of perioperative medications prescribed to treat these disorders. The Society for Perioperative Assessment and Quality Improvement tasked experts in internal medicine, anesthesiology, perioperative medicine, and neurology to provide evidence-based recommendations for preoperative management of these medications. The aim of this review is not only to provide consensus recommendations for preoperative management of patients on medications for neurologic disorders, but also to serve as an educational guide to perioperative clinicians. While, in general, medications for neurologic disorders should be continued preoperatively, an individualized approach may be needed in certain situations (eg, holding anticonvulsants on day of surgery if electroencephalographic mapping is planned during epilepsy surgery). Pertinent interactions with commonly used drugs in anesthesia practice, as well as considerations for targeted laboratory testing or perioperative drug substitutions, are addressed as well.

Preoperative Management of Medications for Psychiatric Diseases: Society for Perioperative Assessment and Quality Improvement Consensus Statement.

There is a lack of guidelines for preoperative management of psychiatric medications leading to variation in care and the potential for perioperative complications and surgical procedure cancellations on the day of surgery. The Society for Perioperative Assessment and Quality Improvement identified preoperative psychiatric medication management as an area in which consensus could improve patient care. The aim of this consensus statement is to provide recommendations to clinicians regarding preoperative psychiatric medication management. Several categories of drugs were identified including antidepressants, mood stabilizers, anxiolytics, antipsychotics, and attention deficit hyperactivity disorder medications. Literature searches and review of primary and secondary data sources were performed for each medication/medication class. We used a modified Delphi process to develop consensus recommendations for preoperative management of individual medications in each of these drug categories. While most medications should be continued perioperatively to avoid risk of relapse of the psychiatric condition, adjustments may need to be made on a case-by-case basis for certain drugs.

Preoperative Management of Cardiovascular Medications: A Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

Cardiovascular conditions such as hypertension, arrhythmias, and heart failure are common in patients undergoing anesthesia for surgical or other procedures. Numerous guidelines from various specialty societies offer variable recommendations for the perioperative management of these medications. The Society for Perioperative Assessment and Quality Improvement identified a need to provide multidisciplinary evidence-based recommendations for preoperative medication management. The society convened a group of 13 members with expertise in perioperative medicine and training in anesthesiology or internal medicine. The aim of this consensus effort is to provide perioperative clinicians with guidance on the management of cardiovascular medications commonly encountered during the preoperative evaluation. We used a modified Delphi process to establish consensus. Twenty-one classes of medications were identified: α-adrenergic receptor antagonists, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, angiotensin receptor-neprilysin inhibitors, ß-adrenoceptor blockers, calcium-channel blockers, centrally acting sympatholytic medications, direct-acting vasodilators, loop diuretics, thiazide diuretics, potassium-sparing diuretics, endothelin receptor antagonists, cardiac glycosides, nitrodilators, phosphodiesterase-5 inhibitors, class III antiarrhythmic agents, potassium-channel openers, renin inhibitors, class I antiarrhythmic agents, sodium-channel blockers, and sodium glucose cotransportor-2 inhibitors. We provide recommendations for the management of these medications preoperatively.

Pregnancy and delivery considerations during COVID-19.

Pregnant women are also affected by COVID-19, with infection rates similar to nonpregnant women. Labor and delivery by a women with COVID-19 presents unique challenges for ensuring the safety of the mother, fetus, and newborn as well as the safety of clinicians and other healthcare personnel. In this article, we present perinatal obstetric anesthetic management strategies derived from the best available evidence to provide guidance in caring for the obstetric patient with COVID-19.