Intraoperative Methadone Use Is Associated With Reduced Postoperative Pain and More Rapid Opioid Weaning After Coronary Artery Bypass Grafting.

OBJECTIVE: To explore the association between intraoperative methadone use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG) surgery. DESIGN: Retrospective cohort study. SETTING: Single academic medical center. PARTICIPANTS: Patients undergoing isolated CABG over a 5-year period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, comorbidities, and intraoperative anesthetic medications were recorded. Primary study outcomes were average and maximum pain scores and morphine milligram equivalent consumption on the first 2 postoperative days (PODs). Linear mixed-effects regression models were used to examine the effect of intraoperative methadone use on study outcomes. Among 1,338 patients, 78.6% received intraoperative methadone (0.2 mg/kg). Patients who did not receive methadone had higher average (estimated [Est], 0.48; 95% confidence interval [CI], 0.22-0.73; p < 0.001) and maximum postoperative (Est, 0.49; 95% CI, 0.23-0.75; p < 0.001) pain scores over PODs 0 to 2. For postoperative opioid consumption, there was a significant intraoperative methadone use-time interaction effect on postoperative opioid use (odds ratio [OR], 2.21; 95% CI, 1.74-2.80; p < 0.001). Across PODs 0 to 2, patients who received intraoperative methadone had a faster decline in postoperative opioid use than those who did not receive intraoperative methadone. Patients who did not receive intraoperative methadone were extubated slightly faster (OR, 0.82; 95% CI, 0.72-0.93; p < 0.01). CONCLUSIONS: Our data suggest that the use of intraoperative methadone is safe, reduces postoperative pain, and expedites weaning from postoperative opioids after CABG surgery.

Variation in Hospitalization Costs, Charges, and Lengths of Hospital Stay for Coronavirus Disease 2019 Patients Treated With Venovenous Extracorporeal Membrane Oxygenation in the United States: A Cohort Study.

OBJECTIVES: The aim was to characterize hospitalization costs, charges, and lengths of hospital stay for COVID-19 patients treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO) in the United States during 2020. Secondarily, differences in hospitalization costs, charges, and lengths of hospital stay were explored based on hospital-level factors. DESIGN: Retrospective cohort study. SETTING: Multiple hospitals in the United States. PARTICIPANTS: Adult patients with COVID-19 who were on VV ECMO in 2020 and had data in the national inpatient sample. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics and baseline comorbidities were recorded for patients. Primary study outcomes were hospitalization costs, charges, and lengths of hospital stay. Study outcomes were compared after stratification by hospital region, bed size, and for-profit status. The median hospitalization cost for the 3,315-patient weighted cohort was $200,300 ($99,623, $338,062). Median hospitalization charges were $870,513 ($438,228, $1,553,157), and the median length of hospital stay was 30 days (17, 46). Survival to discharge was 54.4% for all patients in the cohort. Median hospitalization cost differed by region (p = 0.01), bed size (p < 0.001), and for-profit status (p = 0.02). Median hospitalization charges also differed by region (p = 0.04), bed size (p = 0.002), and for-profit status (p < 0.001). Length of hospital stay differed by region (p = 0.03) and bed size (p < 0.001), but not for-profit status (p = 0.40). Hospitalization costs were the lowest, and charges were highest in private-for-profit hospitals. Large hospitals also had higher costs, charges, and hospital stay lengths than small hospitals. CONCLUSIONS: In this retrospective cohort study, hospitalization costs and charges for patients with COVID-19 on VV ECMO were found to be substantial but similar to what has been reported previously for patients without COVID-19 on VV ECMO. Significant variation was observed in costs, charges, and lengths of hospital stay based on hospital-level factors.

Monitoring During Vascular Surgery.

Vascular surgical patients present unique challenges for anesthesiologists, because of their medical vulnerabilities as well as their tendency for rapid intraoperative hemodynamic changes. Intraoperative monitors have been used for decades to reduce adverse outcomes, improve mortality, and create optimal surgical conditions. Understanding the indications and appropriate management of monitoring modalities is essential for optimizing patient care, and preventing harm associated with misinterpretation. We aim to review monitoring technologies used in complex vascular procedures, as well as the current guidelines, clinical trial outcomes, and basic mechanisms of each monitoring modality.

Perioperative blood pressure monitoring.

Arterial blood pressure monitoring is a major part of the decision-making process for every anesthetic. It is important to recognize the advantages, disadvantages, and limitations of available measurement modalities as well as have some understanding of the engineering principles on which these measurements are based. Oscillometry is by far the most common modality used but is limited by its intermittent nature and inaccuracy during hypotension and hypertension. Arterial catheterization is the gold standard for measuring blood pressure but is an invasive procedure that is expensive and not without risk of harm to the patient. Volume clamp and tonometric technologies are relatively new and allow for continuous noninvasive monitoring of the blood arterial waveform, but their accuracy when compared with oscillometry is not well described, and they have not been widely incorporated into standard practice. Additional research is needed to determine whether continuous noninvasive blood pressure monitors can improve outcomes.