Intraoperative Opioid Waste and Association of Intraoperative Opioid Dose with Postoperative Adverse Outcomes: A Hospital Registry Study.

INTRODUCTION: Perioperative opioid use has been associated with adverse clinical outcomes. Additionally, opioid disposal carries significant costs, due to the waste of pharmaceutical products and the time needed by skilled labor to report the waste. In this study, we aimed to estimate costs and predict factors of opioid-associated intraoperative product waste, as well as to evaluate whether higher intraoperative opioid doses are associated with increased risk of adverse postoperative outcomes. METHODS: We included 170,607 patients undergoing general anesthesia and receiving intraoperative fentanyl, hydromorphone, or morphine at Beth Israel Deaconess Medical Center, Boston, MA, USA, between January 2010 and June 2020. We estimated product waste-associated costs based on various opioid syringe sizes and determined predictors of opioid waste. Further, we evaluated whether higher opioid doses were associated with postoperative adverse events according to the severity-indexed, incident report-based medication error-reporting program classification. The primary outcome included post-extubation desaturation, postoperative nausea or vomiting, or postoperative somnolence or sedation. RESULTS: The use of the smallest syringe sizes (50 mcg for fentanyl, 0.2 mg for hydromorphone, and 2 mg for morphine) resulted in the lowest product waste-associated costs. The main predictor of opioid waste was the administration of more than one intraoperative opioid (adjusted odds ratio [aOR] = 7.64, 95% CI 7.40-7.89, P < 0.001). Intraoperative doses of fentanyl > 50-100 mcg (aOR = 1.17 [1.10-1.25], P < 0.001, adjusted risk difference [ARD] 2%) and > 100 mcg (aOR = 1.24 [1.16-1.33], P < 0.001, ARD 3%), hydromorphone > 1 mg (aOR = 1.13 [1.06-1.20], P < 0.001, ARD 2%), and morphine > 2-4 mg (aOR = 1.26 [1.02-1.56], P = 0.04, ARD 3%) and > 4 mg (aOR = 1.45 [1.18-1.77], P < 0.001, ARD 5%) were associated with higher risk of the primary outcome. CONCLUSION: Smaller syringe sizes of intraoperative opioids may help to reduce product waste and associated costs, as well postoperative adverse events through utilization of lower intraoperative opioid doses.

Comparison of the effects of sugammadex versus neostigmine for reversal of neuromuscular block on hospital costs of care.

BACKGROUND: Sugammadex reversal of neuromuscular block facilitates recovery of neuromuscular function after surgery, but the drug is expensive. We evaluated the effects of sugammadex on hospital costs of care. METHODS: We analysed 79 474 adult surgical patients who received neuromuscular blocking agents and reversal from two academic healthcare networks between 2016 and 2021 to calculate differences in direct costs. We matched our data with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) to calculate differences in total costs in US dollars. Perioperative risk profiles were defined based on ASA physical status and admission status (ambulatory surgery vs hospitalisation). RESULTS: Based on our registry data analysis, administration of sugammadex vs neostigmine was associated with lower direct costs (-1.3% lower costs; 95% confidence interval [CI], -0.5 to -2.2%; P=0.002). In the HCUP-NIS matched cohort, sugammadex use was associated with US$232 lower total costs (95% CI, -US$376 to -US$88; P=0.002). Subgroup analysis revealed that sugammadex was associated with US$1042 lower total costs (95% CI, -US$1198 to -US$884; P<0.001) in patients with lower risk. In contrast, sugammadex was associated with US$620 higher total costs (95% CI, US$377 to US$865; P<0.001) in patients with a higher risk (American Society of Anesthesiologists physical status ≥3 and preoperative hospitalisation). CONCLUSIONS: The effects of using sugammadex on costs of care depend on patient risk, defined based on comorbidities and admission status. We observed lower costs of care in patients with lower risk and higher costs of care in hospitalised surgical patients with severe comorbidities.

Association between preoperative administration of gabapentinoids and 30-day hospital readmission: A retrospective hospital registry study.

STUDY OBJECTIVE: To evaluate the effectiveness of preoperative gabapentinoid administration. DESIGN: Retrospective hospital registry study. SETTING: Tertiary referral center (Boston, MA). PATIENTS: 111,008 adult non-emergency, non-cardiac surgical patients between 2014 and 2018. INTERVENTIONS: Preoperative administration of gabapentinoids (gabapentin or pregabalin). MEASUREMENTS: We tested the primary hypothesis that preoperative gabapentinoid use was associated with lower odds of hospital readmission within 30 days. Contingent on this hypothesis, we examined whether lower intraoperative opioid utilization mediated this effect. Secondary outcome was postoperative respiratory complications. MAIN RESULTS: Gabapentinoid administration was associated with lower odds of readmission (adjusted odds ratio [ORadj] 0.80 [95% CI, 0.75-0.85]; p < 0.001). This effect was in part mediated by lower intraoperative opioid utilization in patients receiving gabapentinoids (8.2% [2.4-11.5%]; p = 0.012). Readmissions for gastrointestinal disorders (ORadj 0.74 [0.60-0.90]; p = 0.003), neuro-psychiatric complications (ORadj 0.66 [0.49-0.87]; p = 0.004), non-surgical site infections (ORadj 0.68 [0.52-0.88; p = 0.004) and trauma or poisoning (ORadj 0.25 [0.16-0.41]; p < 0.001) occurred less frequently in patients receiving gabapentinoids. The risk of postoperative respiratory complications was lower in patients receiving gabapentinoids (ORadj 0.77 [0.70-0.85]; p < 0.001). Lower doses of pregabalin (< 75 mg) and gabapentin (< 300 mg) compared to both, no and high-dose administration of gabapentinoids, were associated with a lower risk of postoperative respiratory complications (ORadj 0.61 [0.50-0.75]; p < 0.001 and ORadj 0.70 [0.53-0.92]; p = 0.012, respectively). These lower gabapentinoid doses prevented 30-day readmission (ORadj 0.74 [0.65-0.85]; p < 0.001). The results were robust in several sensitivity analyses including surgical procedure defined subgroups and patients undergoing ambulatory surgery. CONCLUSIONS: The preoperative use of pregabalin and gabapentin, up to doses of 75 and 300 mg respectively, mitigates the risks of hospital readmission and postoperative respiratory complications which can in part be explained by lower intraoperative opioid use. Further research is warranted to elucidate mechanisms of the preventive action.

Evaluation of early postoperative intravenous opioid rescue as a novel quality measure in patients who receive thoracic epidural analgesia: a retrospective cohort analysis and prospective performance improvement intervention.

BACKGROUND: In this study, we explored the utility of intravenous opioid rescue analgesia in the post anesthesia care unit (PACU-OpResc) as a single marker of thoracic epidural analgesia (TEA) failure and evaluated the resource implications and quality improvement applications of this measure. METHODS: We performed a retrospective analysis of all TEA placements over a three-year period at a single academic medical center in Boston, Massachusetts. The study exposure was PACU-OpResc. Primary outcome was PACU length of stay (LOS). Secondary outcomes included reasons for delayed PACU discharge and intraoperative hypotension. The analyses were adjusted for confounding variables including patient comorbidities, surgical complexity, intraoperative intravenous opioids, chronic opioid use and local anesthetic bolus through TEA catheter. Post analysis chart review was conducted to determine the positive predictive value (PPV) of PACU-OpResc for inadequate TEA. As a first Plan-Do-Study-Act cycle, we then introduced a checkbox for documentation of a sensory level check after TEA placement. Post implementation data was collected for 7 months. RESULTS: PACU-OpResc was required by 211 (22.1%) patients who received preoperative TEA, was associated with longer PACU LOS (incidence rate ratio 1.20, 95% CI:1.07-1.34, p = 0.001) and delayed discharge due to inadequate pain control (odds ratio 5.15, 95% CI 3.51-7.57, p <  0.001). PACU-OpResc had a PPV of 76.3 and 60.4% for re-evaluation and manipulation of the TEA catheter in PACU, respectively. Following implementation of a checkbox, average monthly compliance with documented sensory level check after TEA placement was noted to be 39.7%. During this time, a reduction of 8.2% in the rate of PACU-OpResc was observed. CONCLUSIONS: This study demonstrates that PACU-OpResc can be used as a quality assurance measure or surrogate for TEA efficacy, to track performance and monitor innovation efforts aimed at improving analgesia, such as our intervention to facilitate sensory level checks and reduced PACU-OpResc. TRIAL REGISTRATION: not applicable.

The effect of intraoperative dexmedetomidine administration on length of stay in the post-anesthesia care unit in ambulatory surgery: A hospital registry study.

STUDY OBJECTIVE: Dexmedetomidine, which is commonly used for procedural sedation and as adjunct to general anesthesia for ambulatory procedures, may affect patient discharge from the post-anesthesia care unit (PACU). We hypothesized that intraoperative dexmedetomidine use in ambulatory surgery is associated with delayed discharge from the PACU and that this is modified by surgical duration and anesthesia type. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENTS: 130,854 adult patients undergoing ambulatory surgery between 2008 and 2018. INTERVENTIONS: Intraoperative administration of dexmedetomidine. MEASUREMENTS: The primary outcome was PACU length of stay. In secondary and exploratory analyses, we examined dose-dependency, effect modification by duration of surgery and anesthesia type, effects of timing of dexmedetomidine administration, and PACU discharge delays. MAIN RESULTS: Dexmedetomidine was associated with a prolonged PACU length of stay (adjusted absolute difference [ADadj] 15.0 min; 95%CI 12.7-17.3; p < 0.001). This effect was dose-dependent (p-for-trend < 0.001), magnified in surgeries of less than one hour (ADadj 20.7 min; 95%CI 16.7-24.7; p < 0.001) and in patients undergoing monitored anesthesia care compared to general anesthesia (ADadj 16.8 min; 95%CI 14.1-19.6; p < 0.001). The effect was more pronounced if dexmedetomidine was administered within the last 60 min of surgery (ADadj 18.7 min; 95%CI 15.7-21.7; p < 0.001). Dexmedetomidine was associated with discharge delays due to cardiovascular complications (ORadj 2.27; 95%CI 1.59-3.24; p < 0.001) and over-sedation (ORadj 1.28; 95%CI 1.11-1.48; p < 0.001). In patients who received dexmedetomidine (n = 2901), the use of bolus doses only versus the combination of bolus and infusions, magnified the effects on PACU length of stay (ADadj 29.5 min per µg/kg; 95%CI 17.3-41.8 versus 18.1 min per µg/kg; 95%CI 11.4-24.8; p < 0.001). CONCLUSIONS: The intraoperative administration of dexmedetomidine was dose-dependently associated with a prolonged PACU length of stay. Clinicians should judiciously titrate dexmedetomidine, especially when using this long-acting drug for monitored anesthesia care for shorter procedures.

REsidual Neuromuscular Block Prediction Score Versus Train-of-Four Ratio and Respiratory Outcomes: A Retrospective Cohort Study.

BACKGROUND: Residual neuromuscular blockade is associated with an increased incidence of postoperative respiratory complications. The REsidual neuromuscular block Prediction Score (REPS) identifies patients at high risk for residual neuromuscular blockade after surgery. METHODS: A total of 101,510 adults undergoing noncardiac surgery under general anesthesia from October 2005 to December 2018 at a tertiary care center in Massachusetts were analyzed for the primary outcome of postoperative respiratory complications (invasive mechanical ventilation requirement within 7 postoperative days or immediate postextubation desaturation [oxygen saturation {Spo2} <90%] within 10 minutes). The primary objective was to assess the association between the REPS and respiratory complications. The secondary objective was to compare REPS and train-of-four (TOF) ratio <0.90 on the strength of their association with respiratory complications. RESULTS: A high REPS (≥4) was associated with an increase in odds of respiratory complications (adjusted odds ratio [OR], 1.13 [95% confidence interval {CI}, 1.06-1.21]; P < .001). In 6224 cases with available TOF ratio measurements, a low TOF ratio (<0.9) was associated with respiratory complications (adjusted OR, 1.43 [95% CI, 1.11-1.85]; P = .006), whereas a high REPS was not (adjusted OR, 0.96 [95% CI, 0.74-1.23]; P = .73) (P = .018 for comparison between ORs). CONCLUSIONS: The REPS may be implemented as a screening tool to encourage clinicians to use quantitative neuromuscular monitoring in patients at risk of residual neuromuscular blockade. A positive REPS should be followed by a quantitative assessment of the TOF ratio.

Outcomes after endoscopic retrograde cholangiopancreatography with general anaesthesia versus sedation.

BACKGROUND: We tested the primary hypothesis that use of general anaesthesia vs sedation increases vulnerability to adverse discharge (in-hospital mortality or new discharge to a nursing facility) after endoscopic retrograde cholangiopancreatography (ERCP). METHODS: In this retrospective cohort study, adult patients undergoing ERCP with general anaesthesia or sedation at a tertiary care hospital were included. We calculated adjusted absolute risk differences between patients receiving general anaesthesia vs sedation using provider preference-based instrumental variable analysis. We also used mediation analysis to determine whether intraoperative hypotension during general anaesthesia mediated its effect on adverse discharge. RESULTS: Among 17 538 patients undergoing ERCP from 2007 through 2018, 16 238 received sedation and 1300 received GA. Rates of adverse discharge were 5.8% (n=938) after sedation and 16.2% (n=210) after general anaesthesia. Providers' adjusted mean predicted probabilities of using general anaesthesia for ERCP ranged from 0.2% to 63.2% of individual caseloads. Utilising provider-related variability in the use of general anaesthesia for instrumental variable analysis resulted in an 8.6% risk increase (95% confidence interval, 4.5-12.6%; P<0.001) in adverse discharge among patients receiving general anaesthesia vs sedation. Intraoperative hypotensive events occurred more often during general anaesthesia and mediated 23.8% (95% confidence interval, 3.9-43.7%: P=0.019) of the primary association. CONCLUSIONS: These results suggest that use of sedation during ERCP facilitates reduced adverse discharge for patients for whom general anaesthesia is not clearly indicated. Intraoperative hypotension during general anaesthesia for ERCP partly mediates the increased vulnerability to adverse discharge.

Ventilatory frequency during intraoperative mechanical ventilation and postoperative pulmonary complications: a hospital registry study.

BACKGROUND: High ventilatory frequencies increase static lung strain and possibly lung stress by shortening expiratory time, increasing intrathoracic pressure, and causing dynamic hyperinflation. We hypothesised that high intraoperative ventilatory frequencies were associated with postoperative respiratory complications. METHODS: In this retrospective hospital registry study, we analysed data from adult non-cardiothoracic surgical cases performed under general anaesthesia with mechanical ventilation at a single centre between 2005 and 2017. We assessed the association between intraoperative ventilatory frequency (categorised into four groups) and postoperative respiratory complications, defined as composite of invasive mechanical ventilation within 7 days after surgery or peripheral oxygen desaturation after extubation, using multivariable logistic regression. In a subgroup, we adjusted analyses for arterial blood gas parameters. RESULTS: A total of 102 632 cases were analysed. Intraoperative ventilatory frequencies ranged from a median (inter-quartile range [IQR]) of 8 (8-9) breaths min-1 (Group 1) to 15 (14-18) breaths min-1 (Group 4). High ventilatory frequencies were associated with higher odds of postoperative respiratory complications (adjusted odds ratio=1.26; 95% confidence interval, 1.14-1.38; P<0.001), which was confirmed in a subgroup after adjusting for arterial partial pressure of carbon dioxide and the ratio of arterial oxygen partial pressure to fractional inspired oxygen. We identified considerable variability in the use of high ventilatory frequencies attributable to individual provider preference (ranging from 22% to 88%) and temporal change; however, the association with postoperative respiratory complications remained unaffected. CONCLUSIONS: High intraoperative ventilatory frequency was associated with increased risk of postoperative respiratory complications, and increased postoperative healthcare utilisation.

BOSTN Bundle Intervention for Perioperative Screening and Management of Patients With Suspected Obstructive Sleep Apnea: A Hospital Registry Study.

BACKGROUND: We developed and implemented a perioperative guideline for obstructive sleep apnea (OSA), comprising a preoperative screening tool (BOSTN) and clinical management pathways. OSA was suspected with 2 or more of the following: body mass index ≥30 kg/m, observed apnea, loud snoring, daytime tiredness, and neck circumference ≥16.5 inches in women or ≥ 17.5 inches in men. The primary objective of this study was to assess the association between high BOSTN scores and the requirement of invasive mechanical ventilation after surgery. METHODS: In this hospital registry study, 169,662 noncardiac surgical cases performed at Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, between May 2008 and September 2017 were analyzed. We assessed the association between a high BOSTN Score (score ≥2) and the primary outcome of requirement of invasive mechanical ventilation within 7 days after surgery using multivariable logistic regression adjusted for patient-specific factors and case-specific surgical and anesthesiological confounders. Patients with a BOSTN Score ≥2 were assumed to have a high likelihood of suffering from OSA. Key secondary outcome was postoperative desaturation, defined as a peripheral oxygen saturation measurement <90% within 10 minutes of extubation. RESULTS: Invasive mechanical ventilation within 7 days of surgery was necessary in 3170 (2.3%) low-risk cases (BOSTN Score <2) and 664 (2.1%) high-risk cases (BOSTN Score ≥2). A score ≥2 was associated with significantly lower odds of requiring postoperative invasive ventilation (adjusted odds ratio [aOR], 0.89; 95% confidence interval [CI], 0.80-0.98; P = .017), but with an increased risk of postextubation desaturation (aOR, 1.34; 99.3% CI, 1.21-1.48; P < .001). Patients with a score ≥2 were hospitalized for an average of 3.71 days after surgery, compared to 4.27 days with a score <2 (adjusted incidence rate ratio [aIRR], 0.87; 99.3% CI, 0.84-0.91; P < .001). CONCLUSIONS: Patients at high risk of OSA required postoperative mechanical ventilation less frequently, had higher odds of postoperative desaturation, and were hospitalized for shorter periods of time.