Intraoperative arterial pressure management: knowns and unknowns.

Preventing postoperative organ dysfunction is integral to the practice of anaesthesia. Although intraoperative hypotension is associated with postoperative end organ dysfunction, there remains ambiguity with regards to its definition, targets, thresholds for initiating treatment, and ideal treatment modalities.

Role of Point-of-Care Ultrasound in Emergency Airway Management Outside the Operating Room.

Tracheal intubation is one of the most frequently performed procedures in critically ill patients, and is associated with significant morbidity and mortality. Hemodynamic instability and cardiovascular collapse are common complications associated with the procedure, and are likely in patients with a physiologically difficult airway. Bedside point-of-care ultrasound (POCUS) can help identify patients with high risk of cardiovascular collapse, provide opportunity for hemodynamic and respiratory optimization, and help tailor airway management plans to meet individual patient needs. This review discusses the role of POCUS in emergency airway management, provides an algorithm to facilitate its incorporation into existing practice, and provides a framework for future studies.

Identifying, Understanding, and Minimizing Unconscious Cognitive Biases in Perioperative Crisis Management: A Narrative Review.

Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays. The authors review the literature on UCBs and discuss their potential impact on perioperative crisis management. Using the Scale for the Assessment of Narrative Review Articles (SANRA), publications with the most relevance to UCBs in perioperative crisis management were selected for inclusion. Of the 19 UCBs that have been most investigated in the medical literature, the authors identified 9 that were judged to be clinically relevant or most frequently occurring during perioperative crisis management. Formal didactic training on concepts of deliberative thinking has had limited success in reducing the presence of UCBs during clinical decision-making. The evolution of clinical decision support tools (CDSTs) has demonstrated efficacy in improving deliberative clinical decision-making, possibly by reducing the intrusion of maladaptive UCBs and forcing reflective thinking. Anesthesiology remains a leader in perioperative crisis simulation and CDST implementation, but spearheading innovations to reduce the adverse impact of UCBs will further improve diagnostic precision and patient safety during perioperative crisis management.

Pro-Con Debate: Should Critically Ill Patients Undergo Procedures at Bedside or in the Operating Room?

Nonoperating room anesthesia (NORA) is a fast-growing field in anesthesiology, wherein anesthesia care is provided for surgical procedures performed outside the main operating room (OR) pavilion. Advances in medical science and technology have led to an increasing number of procedures being moved out of the operating room to procedural suites. One such NORA location is the intensive care unit (ICU), where a growing number of urgent and emergent procedures are being performed on medically unstable patients. ICU-NORA allows medical care to be provided to patients who are too sick to tolerate transport between the ICU and the OR. However, offering the same, high-quality, and safe care in this setting may be challenging. It requires special planning and a thorough consideration of the presence of life-threatening comorbidities and location-specific and ergonomic barriers. In this Pro-Con commentary article, we discuss these special considerations and argue in favor of and against routinely performing procedures at the bedside in the ICU versus in the OR.

Long-term clinical outcomes in critically ill patients with sepsis and pre-existing low muscle mass: a retrospective cohort study.

PURPOSE: Critically ill patients with sepsis account for significant disease morbidity and healthcare costs. Low muscle mass has been proposed as an independent risk factor for poor short-term outcomes, although its effect on long-term outcomes remains unclear. METHODS: Retrospective cohort analysis of patients treated at a quaternary care medical center over 6 years (09/2014 - 12/2020). Critically ill patients meeting Sepsis-3 criteria were included, with low muscle mass defined by [Formula: see text] 5th percentile skeletal muscle index, measured at the L3 lumbar level (L3SMI) on Computed-Tomography (CT) scan ([Formula: see text] 41.6 cm2/m2 for males and [Formula: see text] 32.0 cm2/m2 for females). L3SMI was calculated by normalizing the CT-measured skeletal muscle area to the square of the patient's height (in meters). Measurements were taken from abdominal/pelvic CT scan obtained within 7 days of sepsis onset. The prevalence of low muscle mass and its association with clinical outcomes, including in-hospital and one-year mortality, and post-hospitalization discharge disposition in survivors, was analyzed. Unfavorable post-hospitalization disposition was defined as discharge to a location other than the patient's home. RESULTS: Low muscle mass was present in 34 (23%) of 150 patients, with mean skeletal muscle indices of 28.0 ± 2.9 cm2/m2 and 36.8 ± 3.3 cm2/m2 in females and males, respectively. While low muscle mass was not a significant risk factor for in-hospital mortality (hazard ratio 1.33; 95% CI 0.64 - 2.76; p = 0.437), it significantly increased one-year mortality after adjusting for age and illness severity using Cox multivariate regression (hazard ratio 1.9; 95% CI 1.1 - 3.2; p = 0.014). Unfavorable post-hospitalization discharge disposition was not associated with low muscle mass, after adjusting for age and illness severity in a single, multivariate model. CONCLUSION: Low muscle mass independently predicts one-year mortality but is not associated with in-hospital mortality or unfavorable hospital discharge disposition in critically ill patients with sepsis.

Management of anesthetic complications outside the operating room.

PURPOSE OF REVIEW: Nonoperating room anesthesia (NORA) procedures have seen a significant growth over the years along with an increase in the complexity and severity of cases. Providing anesthesia care in these often-unfamiliar locations is risky, and complications are common. This review aims to report the most recent updates regarding managing anesthesia-related complications in patients undergoing procedures in non-operating room locations. RECENT FINDINGS: Surgical innovations, advent of new technology, and the economics of a healthcare environment that strives to improve value by decreasing costs, has expanded the indications for and complexity of NORA cases. In addition, an aging population with increasing comorbidity burden, requirements for deeper levels of sedation have all increased the risk of complications in NORA environments. In such a situation, improvement in monitoring and oxygen delivery techniques, better ergonomics of NORA sites and development of multidisciplinary contingency plans are likely to improve our management of anesthesia-related complications. SUMMARY: Delivery of anesthesia care in out-of-operating room locations is associated with significant challenges. Meticulous planning, close communication with the procedural team, establishing protocols and pathways for help, along with interdisciplinary teamwork can facilitate safe, efficient, and cost-effective procedural care in the NORA suite.

Emergency use of sugammadex after failure of standard reversal drugs and postoperative pulmonary complications: A retrospective cohort study.

Background and Aims: The use of sugammadex instead of neostigmine for the reversal of neuromuscular blockade may decrease postoperative pulmonary complications. It is unclear if this finding is applicable to situations where sugammadex is administered after the administration of neostigmine. The objective of this study was to compare the incidence of a composite outcome measure of major postoperative pulmonary complications in patients who received sugammadex as a rescue agent after neostigmine versus those who received sugammadex alone for reversal of neuromuscular blockade. Material and Methods: This retrospective cohort study analyzed the medical records of adult patients who underwent elective inpatient noncardiac surgery under general anesthesia and received sugammadex for reversal of neuromuscular blockade, at a tertiary care academic hospital between August 2016 and November 2018. Results: A total of 1,672 patients were included, of whom 1,452 underwent reversal with sugammadex alone and 220 received sugammadex following reversal with neostigmine/glycopyrrolate. The composite primary outcome was diagnosed in 60 (3.6%) patients. Comparing these two groups, and after adjusting for confounding factors, patients who received sugammadex after reversal with neostigmine had more postoperative pulmonary complications than those reversed with sugammadex alone (6.8% vs. 3.1%, odds ratio, 2.29; 95% confidence interval [CI], 1.25 to 4.18; P = 0.006). Conclusion: The use of sugammadex following reversal with neostigmine was associated with a higher incidence of postoperative pulmonary complications as compared to the use of sugammadex alone. The implications of using sugammadex after the failure of standard reversal drugs should be investigated in prospective studies.

Failure to Rescue After Severe Acute Kidney Injury in Patients Undergoing Non-Cardiac Surgery.

INTRODUCTION: Many deaths after surgery can be attributed to "failure to rescue," which may be a better surgical quality indicator than the occurrence of a postoperative complication. Acute kidney injury (AKI) is one such postoperative complication associated with high mortality. The purpose of this study is to identify perioperative risk factors associated with failure to rescue among patients who develop postoperative AKI. METHODS: We identified adult patients who underwent non-cardiac surgery between 2012 and 2018 and experienced postoperative severe AKI (an increase in blood creatinine concentration of >2 mg/dL above baseline or requiring hemodialysis) from the American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression was used to identify risk factors for failure to rescue among patients who developed severe AKI. RESULTS: Among 5,765,904 patients who met inclusion criteria, 26,705 (0.46%) patients developed postoperative severe AKI, of which 6834 (25.6%) experienced failure to rescue. Risk factors with the strongest association (adjusted odds ratio >1.5) with failure to rescue in patients with AKI included advanced age, higher American Society of Anesthesiologists class, presence of preoperative ascites, disseminated cancer, septic shock, and blood transfusion within 72 h of surgery start time. CONCLUSIONS: About one-fourth of patients who develop severe AKI after non-cardiac surgery die within 30 d of surgery. Both patient- and surgery-related risk factors are associated with this failure to rescue. Further studies are needed to identify early and effective interventions in high-risk patients who develop postoperative severe AKI to prevent the antecedent mortality.

Challenges and outcomes in airway management outside the operating room.

PURPOSE OF REVIEW: Airway management outside the operating room poses unique challenges that every clinician should recognize. These include anatomic, physiologic, and logistic challenges, each of which can contribute to complications and lead to poor outcomes. Recognizing these challenges and highlighting known outcome data may better prepare the team, making this otherwise daunting procedure safer and potentially improving patient outcomes. RECENT FINDINGS: Newer intubating techniques and devices have made navigating anatomic airway challenges easier. However, physiological challenges during emergency airway management remain a cause of poor patient outcomes. Hemodynamic collapse has been identified as the most common peri-intubation adverse event and a leading cause of morbidity and mortality associated with the procedure. SUMMARY: Emergency airway management outside the operating room remains a high-risk procedure, associated with poor outcomes. Pre-intubation hemodynamic optimization may mitigate some of the risks, and future research should focus on identification of best strategies for hemodynamic optimization prior to and during this procedure.

Sedation-analgesia techniques for nonoperating room anesthesia: an update.

PURPOSE OF REVIEW: There has been a substantial increase in nonoperating room anesthesia procedures over the years along with an increase in the complexity and severity of cases. These procedures pose unique challenges for anesthesia providers requiring meticulous planning and attention to detail. Advancements in the delivery of sedation and analgesia in this setting will help anesthesia providers navigate these challenges and improve patient safety and outcomes. RECENT FINDINGS: There has been a renewed interest in the development of newer sedative and analgesic drugs and delivery systems that can safely provide anesthesia care in challenging situations and circumstances. SUMMARY: Delivery of anesthesia care in nonoperating room locations is associated with significant challenges. The advent of sedative and analgesic drugs that can be safely used in situations where monitoring capabilities are limited in conjunction with delivery systems, that can incorporate unique patient characteristics and ensure the safe delivery of these drugs, has the potential to improve patient safety and outcomes. Further research is needed in these areas to develop newer drugs and delivery systems.

Prerenal acute kidney injury-still a relevant term in modern clinical practice?

The traditional taxonomy of acute kidney injury (AKI) has remained pervasive in clinical nephrology. While the terms 'prerenal', 'intrarenal' and 'postrenal' highlight the diverse pathophysiology underlying AKI, they also imply discrete disease pathways and de-emphasize the nature of AKI as an evolving clinical syndrome with multiple, often simultaneous and overlapping, causes. In a similar vein, prerenal AKI comprises a diverse spectrum of kidney disorders, albeit one that is often managed by using a standardized clinical algorithm. We contend that the term 'prerenal' is too vague to adequately convey our current understanding of hypoperfusion-related AKI and that it should thus be avoided in the clinical setting. Practice patterns among nephrologists indicate that AKI-related terminology plays a significant role in the approaches that clinicians take to patients that have this complex disease. Thus, it appears that precise terminology does impact the treatment that patients receive. We will outline differences in the diagnosis and management of clinical conditions lying on the so-called prerenal disease spectrum to advocate caution when administering intravenous fluids to these clinically decompensated patients. An understanding of the underlying pathophysiology may, thus, avert clinical missteps such as fluid and vasopressor mismanagement in tenuous or critically ill patients.

Emergency Airway Management Outside the Operating Room: Current Evidence and Management Strategies.

Emergency airway management outside the operating room (OR) is often associated with an increased risk of airway related, as well as cardiopulmonary, complications which can impact morbidity and mortality. These emergent airways may take place in the intensive care unit (ICU), where patients are critically ill with minimal physiological reserve, or other areas of the hospital where advanced equipment and personnel are often unavailable. As such, emergency airway management outside the OR requires expertise at manipulation of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. Adequate preparation and appropriate use of airway management techniques are important to prevent complications. Judicious utilization of pre- and apneic oxygenation is important as is the choice of medications to facilitate intubation in this at-risk population. Recent study in critically ill patients has shown that postintubation hemodynamic and respiratory compromise is common, independently associated with poor outcomes and can be impacted by the choice of drugs and techniques used. In addition to adequately preparing for a physiologically difficult airway, enhancing the ability to predict an anatomically difficult airway is essential in reducing complication rates. The use of artificial intelligence in the identification of difficult airways has shown promising results and could be of significant advantage in uncooperative patients as well as those with a questionable airway examination. Incorporating this technology and understanding the physiological, anatomical, and logistical challenges may help providers better prepare for managing such precarious airways and lead to successful outcomes. This review discusses the various challenges associated with airway management outside the OR, provides guidance on appropriate preparation, airway management skills, medication use, and highlights the role of a coordinated multidisciplinary approach to out-of-OR airway management.

Perioperative risk factors in patients with idiopathic pulmonary fibrosis: a historical cohort study.

PURPOSE: Perioperative complications of patients with idiopathic pulmonary fibrosis (IPF) are not well described. The aim of this study was to identify risk factors associated with adverse postoperative outcomes in IPF patients. METHODS: We performed a single-centre historical cohort study of adult patients with IPF who underwent surgery between 2008 and 2018. We analyzed the prognostic utility of select perioperative factors for postoperative acute exacerbation of IPF (AE-IPF), acute respiratory worsening (ARW), pneumonia, and 30-day and one-year mortality using univariable and multivariable regression analyses. To adjust for multiple interactions, the false discovery rate (Q value) was utilized to appropriately adjust P values and a Q value < 0.05 was considered to be significant. RESULTS: Two hundred and eighty-two patients were identified. After excluding emergency cases and bronchoscopies performed for active pneumonia, 14.2% of the cohort developed ARW that persisted > 24 hr after surgery, 5.0% had AE-IPF, and 9.2% were diagnosed with postoperative pneumonia within 30 days of surgery. The 30-day mortality was 6.0% and the one-year mortality was 14.9%. Preoperative home oxygen use (relative risk [RR], 2.70; 95% confidence interval [CI], 1.50 to 4.86; P < 0.001) and increasing surgical time (per 60 min) (RR, 1.03; 95% CI, 1.02 to 1.05; P < 0.001) were identified as independent risk factors for postoperative ARW. CONCLUSIONS: In IPF patients, preoperative home oxygen requirement and increasing surgical time showed a strong relationship with postoperative ARW and may be useful markers for perioperative risk stratification. Facteurs de risque périopératoires des patients atteints de fibrose pulmonaire idiopathique : une étude de cohorte historique.

RéSUMé: OBJECTIF: Les complications périopératoires chez les patients atteints de fibrose pulmonaire idiopathique (FPI) ne sont pas bien décrites. L'objectif de cette étude était d'identifier les facteurs de risque associés aux devenirs postopératoires défavorables chez les patients atteints de FPI. MéTHODE: Nous avons réalisé une étude de cohorte historique monocentrique portant sur des patients adultes atteints de FPI et ayant subi une chirurgie entre 2008 et 2018. Nous avons analysé l'utilité pronostique de facteurs périopératoires choisis pour l'exacerbation postopératoire aiguë de la FPI, la détérioration respiratoire aiguë, la pneumonie, et la mortalité à 30 jours et à un an à l'aide d'analyses de régression univariées et multivariées. Afin de tenir compte d'interactions multiples, le taux de fausses découvertes (valeur Q) a été utilisé pour ajuster adéquatement les valeurs P, et une valeur Q < 0,05 a été considérée significative. RéSULTATS: Deux cent quatre-vingt-deux patients ont été identifiés. Après avoir exclu les cas en urgence et les bronchoscopies réalisées lors de pneumonie active, 14,2 % des patients de la cohorte ont souffert d'une détérioration respiratoire aiguë qui a persisté > 24 h après la chirurgie, 5,0 % ont subi une exacerbation aiguë de la FPI, et 9,2 % ont reçu un diagnostic de pneumonie postopératoire dans les 30 jours suivant leur chirurgie. La mortalité à 30 jours était de 6,0 %, et la mortalité à un an de 14,9 %. L'utilisation préopératoire d'oxygène à domicile (risque relatif [RR], 2,70; intervalle de confiance [IC] 95 %, 1,50 à 4,86; P < 0,001) et l'augmentation du temps chirurgical (par tranche de 60 min) (RR, 1,03; IC 95 %, 1,02 à 1,05; P < 0,001) ont été identifiées comme des facteurs de risque indépendants de détérioration respiratoire aiguë en période postopératoire. CONCLUSION: Chez les patients atteints de FPI, une forte association a été observée entre les besoins préopératoires en oxygène au domicile ainsi que l'augmentation du temps chirurgical et la détérioration respiratoire aiguë en période postopératoire; ces deux facteurs pourraient constituer des marqueurs utiles pour stratifier le risque en période périopératoire.

Cardiac Arrhythmias in Critically Ill Patients With COVID-19: A Brief Review.

Coronavirus disease 2019, caused by severe acute respiratory syndrome coronavirus 2, is now a global pandemic affecting more than 12 million patients across 188 countries. A significant proportion of these patients require admission to intensive care units for acute hypoxic respiratory failure and are at an increased risk of developing cardiac arrhythmias. The presence of underlying comorbidities, pathophysiologic changes imposed by the disease, and concomitant polypharmacy, increase the likelihood of life-threatening arrhythmias in these patients. Supraventricular, as well as ventricular arrhythmias, are common and are associated with significant morbidity and mortality. It is important to understand the interplay of various causal factors while instituting strategies to mitigate the impact of modifiable risk factors. Furthermore, avoidance and early recognition of drug interactions, along with prompt treatment, might help improve outcomes in this vulnerable patient population.

Acute heart failure after liver transplantation: A narrative review.

Acute heart failure (AHF) is an under recognized yet potentially lethal complication after liver transplantation (LT) surgery. The increase in incidence of liver transplantation amongst high-risk patients and the leniency in the criteria for transplantation, predisposes these patients to postoperative AHF and the antecedent morbidity and mortality. The inability of conventional preoperative cardiovascular testing to accurately identify patients at risk for post-LT AHF poses a considerable challenge to clinicians caring for these patients. Even if high-risk patients are identified, there is considerable ambiguity in the candidacy for transplantation as well as optimization strategies that could potentially prevent the development of AHF in the postoperative period. The intraoperative and postoperative management of patients who develop AHF is also challenging and requires a well-coordinated multidisciplinary approach. The use of mechanical circulatory support in patients with refractory heart failure has the potential to improve outcomes but its use in this complex patient population can be associated with significant complications and requires a stringent risk-benefit analysis on a case-by-case basis.

Atrial Fibrillation: Current Evidence and Management Strategies During the Perioperative Period.

Atrial fibrillation (AF) is the most common arrhythmia in the perioperative period. Previously considered a benign and self-limited entity, recent data suggest that perioperative AF is associated with considerable morbidity and mortality and may predict long-term AF and stroke risk in some patients. Despite known risk factors, AF remains largely unpredictable, especially after noncardiac surgery. As a consequence, strategies to minimize perioperative risk are mostly supportive and include avoiding potential arrhythmogenic triggers and proactively treating patient- and surgery-related factors that might precipitate AF. In addition to managing AF itself, clinicians must also address the hemodynamic perturbations that result from AF to prevent end-organ dysfunction. This review will discuss current evidence with respect to causes, risk factors, and outcomes of patients with AF, and address current controversies in the perioperative setting.

Post-operative intensive care unit admission after elective non-cardiac surgery: A single-center analysis of the NSQIP database.

BACKGROUND: Admission to the intensive care unit (ICU) after surgery can be associated with significant morbidity and mortality. This observational cohort study aims to identify perioperative factors associated with post-operative ICU admission in patients undergoing elective non-cardiac surgery. METHODS: Data from the ACS NSQIP® database at a tertiary care academic medical center were analyzed from January 2011 to September 2016. Univariable and multivariable logistic regression of patient and surgery-specific characteristics was performed to assess association with post-operative ICU admission. The Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9) billing codes, as well as associated outcomes, were reviewed. RESULTS: Of 5254 database patient records, 1150 met our inclusion criteria. Elevated body mass index (BMI), longer procedure duration and a diagnosis of disseminated cancer were associated with post-operative ICU admission. Prostatectomy and morbid obesity were the most common CPT and ICD-9 codes identified. Patients who were admitted to the ICU after surgery had a longer hospital length of stay (LOS), had a higher frequency of readmission, re-operation, and in-hospital mortality. CONCLUSION: Admission to the ICU after elective non-cardiac surgery is common. Our analysis of the ACS NSQIP® database identified elevated BMI, longer duration of surgery and disseminated cancer as predictors of post-operative ICU admissions in patients undergoing elective non-cardiac surgery.

CHA2DS2-VASc Score and In-Hospital Mortality in Critically Ill Patients With New-Onset Atrial Fibrillation.

OBJECTIVE: To examine the role of the CHA2DS2-VASc (Congestive heart failure; Hypertension; Age ≥75 years [doubled]; Diabetes; previous Stroke, transient ischemic attack, or thromboembolism [doubled]; Vascular disease; Age 65-75 years; and Sex category) score as a prognostic marker of in-hospital mortality in critically ill patients who develop new-onset atrial fibrillation (NOAF). DESIGN: Retrospective analyses. SETTING: A single-center study in a tertiary care academic medical center. PARTICIPANTS: The study comprised all adult patients with NOAF admitted to noncardiac intensive care units (ICUs) at a tertiary care academic institution between January 2009 and March 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors retrospectively reviewed electronic medical records of all adult patients admitted to noncardiac ICUs at a tertiary care academic institution between January 2009 and March 2016. Patients with NOAF were identified and their CHA2DS2-VASc score was calculated. The authors evaluated the association of CHA2DS2-VASc score and its individual components with in-hospital mortality in these patients. A total of 640 (1.7% [38,708 patients]; 95% CI 1.5%-1.8%) patients developed NOAF during the study period. The in-hospital mortality rate in patients included in the analysis was 14.3%. There was no association between in-hospital mortality and CHA2DS2VASc score. However, the likelihood of in-hospital death was 1.56  times greater for patients having atrial fibrillation and concomitant vascular disease (95% CI 1.003-2.429; p = 0.049). CONCLUSIONS: New-onset atrial fibrillation is common in critically ill patients and is associated with high in-hospital mortality. The authors found that the CHA2DS2-VASc score itself is not a reliable prognostic marker of in-hospital mortality in these patients. However, the presence of vascular disease in patients with NOAF may increase the mortality associated with this disease.

Stroke prophylaxis in critically-ill patients with new-onset atrial fibrillation.

Despite a high incidence of new onset atrial fibrillation (NOAF) in critically ill patients and its association with short and long-term incidence of stroke, there is limited data assessing anticoagulation on hospital discharge in these patients. We retrospectively reviewed electronic medical records of all adult patients admitted to non-cardiac ICUs at our institution between January 2009 and March 2016. Patients with NOAF were identified and CHA2DS2-VASc score of ICU survivors was calculated. Prescription of oral anticoagulant therapy on hospital discharge was analyzed. A total of 640 (1.7% [38,708 patients]; 95% CI 1.5%, 1.8%) patients developed NOAF during the study period. CHA2DS2-VASc score was calculated for 615 patients, of which 82.2% had a CHA2DS2-VASc score ≥ 2. Of the 428 eligible patients, only 96 patients (22.4%) were discharged on oral anticoagulant therapy. Patients with a history of congestive heart failure (33.7% vs. 19.7%) and stroke/TIA or other thromboembolic disease (35.9% vs. 18.0%) were more likely to be discharged on an oral anticoagulant. Patients with a higher score were also more likely to be discharged on an oral anticoagulant (OR 1.27; 95% CI 1.10, 1.47). NOAF is common in critically ill patients admitted to non-cardiac ICUs and a significant proportion of these patients have a CHA2DS2-VASc score ≥ 2. However, only a minority of them are discharged on an oral anticoagulant. There is a need to identify ways to improve implementation of effective stroke prophylaxis in these patients.