Optimizing Robotic Hysterectomy for the Patient Who Is Morbidly Obese with a Surgical Safety Pathway.

STUDY OBJECTIVE: Obesity is a growing worldwide epidemic, and patients classified as obese undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI [Body Mass Index] Pathway (HBP) for patients with BMI ≥40 kg/m2 undergoing planned robotic hysterectomy. Our primary outcome was the rate of all-cause perioperative complications in patients undergoing surgery with the use of the HBP. DESIGN: A retrospective cohort study. SETTING: An academic teaching hospital. PATIENTS: A total of 138 patients classified as morbidly obese (BMI ≥40 kg/m2) undergoing robotic hysterectomy. INTERVENTIONS: The HBP was developed by a multidisciplinary team and was instituted on January 1, 2016, as a quality improvement project. Patients classified as morbidly obese undergoing robotic hysterectomy after this date were compared with consecutive historical controls. MEASUREMENTS AND MAIN RESULTS: Seventy-two patients underwent robotic hysterectomies on the HBP and were compared with 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of the HBP, there has been a decrease in anesthesia time (-57.0 minutes; p = .001) and total operating room time (-47.0 min; p = .020), as well as lower estimated blood loss (median 150 mL [interquartile range 100-200] vs 200 mL [interquartile range 100-300]; p = .002) and reduction in overnight hospital admissions (33.3% vs 63.6%; p <.001). In the HBP group, there were fewer all-cause complications (19.4% vs 37.9%; p = .023) and infectious complications (8.3% vs 33.3%; p = .001), and there was no increase in the readmission rates (p = .400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio 0.353; p = .010) after controlling for the covariate (total time in the operating room). CONCLUSION: The HBP is a feasible method of optimizing the outcome for patients classified as morbidly obese undergoing major gynecologic surgery. Initiation of the HBP can lead to decreased anesthesia and operating times, all-cause complications, and overnight hospital admissions without increasing readmission rates.

Severity and duration of hypoxemia during outpatient endoscopy in obese patients: a retrospective cohort study.

PURPOSE: We sought to quantify the severity and duration of hypoxemic events in morbidly obese patients during outpatient endoscopy procedures performed under deep sedation. METHODS: This was a retrospective cohort study using intraprocedural pulse oximetry readings from 11,595 American Society of Anesthesiologists physical status score I-III adult patients who underwent deep sedation for elective endoscopy at free standing ambulatory centres between June 2015 and June 2016. Unadjusted and risk-adjusted logistic regression analyses explored the relationship between increasing categories of body mass index (BMI) and intraoperative hypoxemia, severe hypoxemia, and prolonged hypoxemia. RESULTS: Hypoxemia occurred in 600 (13%) patients with normal BMI, 314 (18%) with class I obesity, 159 (27%) with class II obesity, and 24 (19%) with class III obesity. Adjusted odds ratio (AOR) for any occurrence of intraoperative hypoxemia increased from 1.61 (95% confidence interval [CI], 1.35 to 1.90; P < 0.001) in the class I obesity group to 2.61 (95% CI, 2.05 to 3.30; P < 0.001) in patients with class II obesity, when compared with patients with normal BMI. Adjusted odds ratio of severe hypoxemia were significant in the class I obesity group (AOR, 1.47; 95% CI, 1.13 to 1.89; P = 0.003), and the class II obesity group (AOR, 2.59; 95% CI, 1.86 to 3.57; P < 0.001). Adjusted odds ratio of prolonged hypoxemia increased with each category of BMI from 1.97 (95% CI, 1.08 to 3.69) in the overweight group to 9.20 (95% CI, 4.74 to 18.03) in patients with class III obesity. CONCLUSIONS: The incidence of severe hypoxemia increased nearly six-fold in obese patients and 8.5-fold in class III obese patients when compared with those of normal BMI. Intravenous fentanyl was associated with intraoperative hypoxemia independent of BMI. Patients who represent the highest risk for hypoxia should be stratified to procedure locations with adequate resources for the safest care.

RéSUMé: OBJECTIF: Nous avons tenté de quantifier la gravité et la durée des complications hypoxémiques chez les patients obèses morbides pendant les interventions endoscopiques ambulatoires réalisées sous sédation profonde. MéTHODE: Nous avons réalisé une étude de cohorte rétrospective en nous fondant sur les relevés d'oxymétrie de pouls intra-procéduraux de 11 595 patients adultes de statut physique ASA (American Society of Anesthesiologists) I-III ayant subi une sédation profonde pour une endoscopie non urgente dans des centres ambulatoires indépendants entre juin 2015 et juin 2016. Les analyses de régression logistique non ajustées et ajustées en fonction du risque ont examiné la relation entre des catégories croissantes d'indice de masse corporelle (IMC) et l'hypoxémie, l'hypoxémie sévère et l'hypoxémie prolongée peropératoires. RéSULTATS: L'hypoxémie a touché 600 (13 %) patients ayant un IMC normal, 314 (18 %) patients souffrant d'une obésité de classe I, 159 (27 %) patients avec une obésité de classe II, et 24 (19 %) patients souffrant d'obésité de classe III. Le rapport de cotes ajusté (RCA) pour tout épisode d'hypoxémie peropératoire a augmenté de 1,61 (intervalle de confiance [IC] 95 %, 1,35 à 1,90; P < 0,001) dans le groupe obésité de classe I à 2,61 (IC 95 %, 2,05 à 3,30; P < 0,001) chez les patients présentant une obésité de classe II, par rapport aux patients avec un IMC normal. Les rapports de cotes ajustés pour l'hypoxémie sévère étaient significatifs dans le groupe de patients obèses de classe I (RCA, 1,47; IC 95 %, 1,13 à 1,89; P = 0,003) et dans le groupe de patients obèses de classe II (RCA, 2,59; IC 95 %, 1,86 à 3,57; P < 0,001). Les rapports de cotes ajustés pour l'hypoxémie prolongée ont augmenté avec chaque catégorie d'IMC, passant de 1,97 (IC 95 %, 1,08 à 3,69) dans le groupe en surcharge pondérale à 9,20 (IC 95 %, 4,74 à 18,03) chez les patients atteints d'obésité de classe III. CONCLUSION: L'incidence d'hypoxémie sévère a augmenté de près de six fois chez les patients obèses et de 8,5 fois chez les patients obèses de classe III par rapport aux patients ayant un IMC normal. L'administration intraveineuse de fentanyl était associée à une hypoxémie peropératoire indépendante de l'IMC. Les patients qui présentent le risque le plus élevé d'hypoxie devraient être stratifiés à être pris en charge dans des établissements disposant des ressources nécessaires pour offrir les soins les plus sécuritaires possibles.

The Impact of Different Intraoperative Fluid Administration Strategies on Postoperative Extubation Following Multilevel Thoracic and Lumbar Spine Surgery: A Propensity Score Matched Analysis.

BACKGROUND: Patients undergoing multilevel spine surgery are at risk for delayed extubation. OBJECTIVE: To evaluate the impact of type and volume of intraoperative fluids administered during multilevel thoracic and/or lumbar spine surgery on postoperative extubation status. METHODS: Retrospective evaluation of medical records of patients ≥ 18 yr undergoing ≥ 4 levels of thoracic and/or lumbar spine fusions was performed. Patients were organized according to postoperative extubation status: immediate (IMEX; in OR/PACU) or delayed (DEX; outside OR/PACU). Propensity score matched (PSM) analysis was performed to compare IMEX and DEX groups. Volume, proportion, and ratios of intraoperative fluids administered were evaluated for the associated impact on extubation status. RESULTS: A total of 246 patients (198 IMEX, 48 DEX) were included. PSM analysis demonstrated that increased administration of non-cell saver blood products (NCSB) and increased ratio of crystalloid: colloids infused were independently associated with delayed extubation. With increasing EBL, IMEX had a proportionate reduction in crystalloid infusion (R = -0.5, P < .001), while the proportion of crystalloids infused remained relatively unchanged for DEX (R = -0.27; P = .06). Twenty-six percent of patients receiving crystalloid: colloid ratio > 3:1 had DEX compared to none of those receiving crystalloid: colloid ratio ≤ 3:1 (P = .009). DEX had greater cardiac and pulmonary complications, surgical site infections and prolonged intensive care unit and hospital stay (P < .05). CONCLUSION: PSM analysis of patients undergoing multilevel thoracic and/or lumbar spine fusion demonstrated that increased administration of crystalloid to colloid ratio is independently associated with delayed extubation. With increasing EBL, a proportionate reduction of crystalloids facilitates early extubation.

General anesthesia in a patient with citrullinemia using Precedex as an adjunct to prevent delayed emergence.

Citrullinemia type I is a rare autosomal recessive genetic condition that causes reduced activity of the enzyme, argininosuccinate synthase, which is needed for proper urea metabolism. The end result is hyperammonemia which can cause life-threatening neurologic symptoms and global developmental delay. Previous case reports of the anesthetic management of patients with citrullinemia describe delayed recovery possibly related to elevated ammonia levels postoperatively or choice of intraoperative anesthetics which have included narcotics. In this case report, we present the anesthetic management of a 16-year-old adolescent girl with citrullinemia type I undergoing a vagus nerve stimulator revision. We used the α-2-adrenergic agonist, dexmedetomidine, as an adjunct to avoid narcotics to prevent delayed emergence. She was admitted for hydration the night before the procedure and had a baseline ammonia level of 33 µmol/L (reference, 9-33 µmol/L). Anesthetic maintenance consisted of 2% sevoflurane, dexmedetomidine 0.5 µg/kg per hour, and intravenous acetaminophen given toward the conclusion of the surgery. The patient awoke immediately at the end of the procedure and was extubated in the operating room. Postprocedure, her ammonia level was less than 9 µmol/L. She appeared to be free of pain, was tolerating gastric tube feeds postprocedure, and was discharged to home on the day of surgery. Effective management of ammonia levels in this patient using preoperative hydration and dexmedetomidine as an adjunct to general anesthesia may have helped to prevent delayed emergence.

A Survey of the American Society of Anesthesiologists Regarding Environmental Attitudes, Knowledge, and Organization.

Our planet is in the midst of an environmental crisis. Government and international agencies such as the Intergovernmental Panel on Climate Change urge radical and transformative change at every level of how we conduct our personal and professional lives. The health care industry contributes to climate change. According to a study from the University of Chicago, the health care sector accounts for 8% of the United States' total greenhouse gas emissions. In an effort to understand the current state of environmental practice, attitudes, and knowledge among anesthesiologists in the United States, we conducted a survey of American anesthesiologists regarding environmental sustainability. The environmental survey was sent out by e-mail to a random sampling of 5200 members of the American Society of Anesthesiologists. This process was repeated a second time. A total of 2189 anesthesiologists of 5200 responded to the survey, a 42% response rate. Of the survey respondents, 80.1% (confidence interval, 78.2%-81.9%) were interested in recycling. Respondents reported recycling in 27.7% of operating rooms where they work. The majority of respondents (67%; confidence interval, 64%-69%) reported there was insufficient information on how to recycle intraoperatively. Respondents supported sustainability practices such as reprocessing equipment, using prefilled syringes, and donating unused equipment and supplies. The affirmative response rate was 48.4% for reprocessing equipment, 56.6% for using prefilled syringes, and 65.1% for donating equipment and supplies to medical missions. Questions about hospital-wide organization of sustainability programs elicited many "I don't know" responses. Eighteen percent of responders indicated the presence of a sustainability or "green" task force. A total of 12.6% of responders indicated the presence of a mandate from hospital leadership to promote sustainability programs. Two important conclusions drawn from the survey data are a lack of hospital-wide organization of sustainability programs and a belief among survey responders that they lack adequate information on recycling and sustainability.

Antifibrinolytics reduce blood loss in adult spinal deformity surgery: a prospective, randomized controlled trial.

STUDY DESIGN: This is a prospective, randomized, double-blinded comparison of tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and placebo used intraoperatively in patients with adult spinal deformity. OBJECTIVE: The purpose of this study was to provide high-quality evidence regarding the comparative efficacies of TXA, EACA, and placebo in reducing blood loss and transfusion requirements in patients undergoing posterior spinal fusion surgery. SUMMARY OF BACKGROUND DATA: Spine deformity surgery usually involves substantial blood loss. The antifibrinolytics TXA and EACA have been shown to improve hemostasis in large blood loss surgical procedures. METHODS: Fifty-one patients undergoing posterior spinal fusion of at least 5 levels for correction of adult spinal deformity were randomized to 1 of 3 treatment groups. Primary outcome measures included intraoperative estimated blood loss, total loss, (estimated blood loss + postoperative blood loss), and transfusion rates. RESULTS: Patients received TXA (n = 19), EACA (n = 19), or placebo (n = 13) in the operating room (mean ages: 60, 47, and 43 yr, respectively); TXA patients were significantly older and had larger estimated blood volumes than both other groups. Total losses were significantly reduced for EACA versus control, and there was a demonstrable but nonsignificant trend toward reduced intraoperative blood loss in both antifibrinolytic arms versus control. EACA had significant reductions in postoperative blood transfusions versus TXA. CONCLUSION: The findings in this study support the use of antifibrinolytics to reduce blood loss in posterior adult spinal deformity surgery. LEVEL OF EVIDENCE: 1.

The relative efficacy of antifibrinolytics in adolescent idiopathic scoliosis: a prospective randomized trial.

BACKGROUND: Antifibrinolytics can reduce intraoperative blood loss. The primary aim of this study was to determine the efficacy of intraoperative tranexamic acid, epsilon-aminocaproic acid, and placebo at reducing perioperative blood loss and the transfusion rate in patients with adolescent idiopathic scoliosis undergoing posterior spinal arthrodesis. METHODS: This is a prospective, randomized, double-blind comparison of tranexamic acid, epsilon-aminocaproic acid, and placebo used intraoperatively in patients with adolescent idiopathic scoliosis. One hundred and twenty-five patients with adolescent idiopathic scoliosis were randomly assigned to the tranexamic acid, epsilon-aminocaproic acid, or control groups. Parameters recorded included estimated blood loss, hematocrit, blood product usage, drain output, and total blood losses. The primary outcomes were intraoperative blood loss and postoperative drainage. Secondary outcomes were transfusion requirements and hematocrit changes both intraoperatively and postoperatively. RESULTS: One hundred and twenty-five patients (ninety-seven female and twenty-eight male, with a mean age of fifteen years) were randomized to receive tranexamic acid (thirty-six patients), epsilon-aminocaproic acid (forty-two patients), or saline solution (forty-seven patients). The groups were similar at baseline, with one exception: the saline solution group had a higher estimated blood volume at baseline than the tranexamic acid group. Both tranexamic acid and epsilon-aminocaproic acid reduced the estimated blood loss per degree and estimated blood loss per pedicle screw. Epsilon-aminocaproic acid, but not tranexamic acid, reduced estimated blood loss and estimated blood loss per level. Tranexamic acid also reduced total blood losses compared with epsilon-aminocaproic acid or saline solution. In an analysis controlling for level, degree, and number of anchors, tranexamic acid reduced drain output and total blood losses. Tranexamic acid or epsilon-aminocaproic acid had a smaller decrease in hematocrit postoperatively. In an analysis controlling for the mean arterial pressure during surgical exposure, tranexamic acid reduced estimated blood loss and total blood losses. Overall, antifibrinolytics (tranexamic acid or epsilon-aminocaproic acid) reduced estimated blood loss, total blood losses, and the decline in hematocrit postoperatively compared with saline solution. There was no difference among the groups with respect to the transfusion rate, duration of surgery, levels fused, or pedicle screws placed. CONCLUSIONS: Tranexamic acid and epsilon-aminocaproic acid reduced operative blood loss but not transfusion rate. Tranexamic acid is more effective at reducing postoperative drainage and total blood losses compared with epsilon-aminocaproic acid. Maintenance of the mean arterial pressure at <75 mm Hg during surgical exposure appears to be critical for maximizing antifibrinolytic benefit. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

A prospective, randomized, placebo-controlled study evaluating the efficacy of dexmedetomidine for sedation during vascular procedures.

OBJECTIVE: To examine the efficacy of dexmedetomidine (DEX) as a primary sedative during vascular procedures performed under monitored anesthesia care (MAC). A total of 55 patients were randomized in a 2:2:1 ratio to receive either DEX 1.0 microg/kg load or DEX 0.5 microg/kg load versus midazolam (MDZ) boluses, the current standard of care. This was followed by a maintenance infusion of DEX versus a normal saline infusion for the control group. Midazolam was given in 0.5 mg increments to maintain an equivalent target level of sedation among the 3 study groups. Fentanyl was given in 25 microg increments to treat pain as needed. The percentage of DEX patients not requiring MDZ and the total dose of MDZ and fentanyl were compared to the control. Dexmedetomidine was efficacious as a sole sedative for 50% of patients. The total dose of MDZ and fentanyl was significantly less during the DEX infusions. Patient satisfaction was superior with DEX.

The use of continuous positive airway pressure during an awake craniotomy in a patient with obstructive sleep apnea.

We describe the anesthetic management of a morbidly obese patient with obstructive sleep apnea who underwent awake craniotomy. The patient's personal continuous positive airway pressure (CPAP) machine was used to support ventilation intraoperatively. Dexmedetomidine was used as the primary sedative. During cortical mapping, the CPAP was discontinued. The patient was comfortable and able to cooperate with language testing.