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OBJECTIVES: Hospital-based behavioral emergency response teams (BERT) respond to acute behavioral disturbances among hospitalized patients. We aimed to examine associations between altered mental status in postanesthesia care unit (PACU) and behavioral disturbances on surgical wards requiring BERT activation. METHODS: Electronic medical records of patients who underwent general anesthesia and were admitted to the PACU between May 2018-December 2020 were reviewed for episodes of BERT activations on surgical wards. Characteristics of BERT patients were compared with the rest of surgical population during the same period to examine risk factors for BERT. RESULTS: Of 56,275 adult surgical patients, 133 patients had 178 BERT activations (incidence 2.4, 95% confidence interval [CI] 2.0-2.8 per 1000 admissions), with 21 being for physical assault. The risk for BERT activation was increased with each decade over age of 50 as well as younger age (30 versus 50 y), male sex (odds ratio [OR] = 2.48, 95% CI 1.69, 3.62), longer procedures (OR = 1.08 per 30 minutes, 95% CI 1.05, 1.11), and alterations in mental status in PACU, with both moderate/deep sedation (OR = 1.63, 95% CI 1.04, 2.57) and agitation/combative state (OR = 8.47, 95% CI 5.13, 14.01), P < 0.001 for all comparisons. CONCLUSIONS: Early postoperative agitation and oversedation are associated with BERT activation on surgical wards. Altered mental status in PACU should be conveyed to accepting hospital units so healthcare staff can be vigilant for the potential development of behavioral disturbances.
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BACKGROUND: We hypothesized that deeper sedation in the postanesthesia care unit (PACU) increases the risk of subsequent sedation in general care wards (ward sedation) and that patients with ward sedation have more postoperative adverse events than those without ward sedation. METHODS: We reviewed the health records of adult patients who underwent procedures with general anesthesia at Mayo Clinic from May 5, 2018, through December 31, 2020, and were discharged from the PACU to the general care ward. Patient groups were dichotomized as with ward sedation (Richmond Agitation-Sedation Scale [RASS], ≤-2) and without ward sedation (RASS, ≥-1) within the first 24 hours after PACU discharge. Multivariable logistic regression was used to assess the association between clinical variables and ward sedation. RESULTS: A total of 23,766 patients were included in our analysis, of whom 1131 had ward sedation (incidence, 4.8 [Poisson 95% confidence interval, CI, 4.5-5.0]) per 100 patients after general anesthesia. Half of the ward sedation episodes occurred within 32 minutes after PACU discharge. The risk of ward sedation increased with the depth of PACU sedation. The odds ratios (95% CI) of ward sedation for patients with a PACU RASS score of -1 was 0.98 (0.75-1.27); -2, 1.87 (1.44-2.43); -3, 2.98 (2.26-3.93); and ≤-4, 3.97 (2.91-5.42). Adverse events requiring an emergency intervention occurred more often for patients with ward sedation (n = 92, 8.1%) than for those without ward sedation (n = 326, 1.4%; P < .001). CONCLUSIONS: Among patients who met our criteria for PACU discharge, deeper sedation during anesthesia recovery was associated with an increased risk of ward sedation. Patients who had ward sedation had worse outcomes than those without ward sedation.
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BACKGROUND: Postoperative nausea and vomiting (PONV) are frequent after volatile anesthesia. We hypothesized that coadministration of propofol with volatile anesthetic compared to pure volatile anesthetics would decrease the need for postoperative antiemetic treatments and shorten recovery time in the postanesthesia care unit (PACU). METHODS: We retrospectively identified adult patients who underwent procedures using general anesthesia with volatile agents, with or without propofol infusion, from May 2018 through December 2020, and who were admitted to the PACU. Inverse probability of treatment weighting (IPTW) analysis was performed using generalized estimating equations with robust variance estimates to assess whether propofol was associated with decreased need for rescue antiemetics. RESULTS: Among 47,847 patients, overall IPTW rescue antiemetic use was 4.7% for 17,573 patients who received propofol and 8.2% for 30,274 who did not (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.61; P <.001). This effect associated with propofol was present regardless of the intensity of antiemetic prophylaxis (OR, 0.59, 0.51, and 0.58 for 0-1, 2, and ≥3 antiemetics used, respectively), procedural duration (OR, 0.54, 0.62, and 0.47 for ≤2.50, 2.51-4.00, ≥4.01 hours), and type of volatile agent (OR, 0.51, 0.52, and 0.57 for desflurane, isoflurane, and sevoflurane) (all P <.001). This effect was dose dependent, with little additional benefit for the reduction in the use of PACU antiemetics when propofol rate exceeded 100 µg/kg/min. Patients who received rescue antiemetics required longer PACU recovery time than those who did not receive antiemetics (ratio of the geometric mean, 1.31; 95% CI, 1.28-1.33; P <.001), but use of propofol did not affect PACU recovery time (ratio of the geometric mean, 1.00; 95% CI, 0.98-1.01; P =.56). CONCLUSIONS: The addition of propofol infusions to volatile-based anesthesia is associated with a dose-dependent reduction in the need for rescue antiemetics in the PACU regardless of the number of prophylactic antiemetics, duration of procedure, and type of volatile agent used, without affecting PACU recovery time.
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Período de Recuperação da Anestesia , Anestésicos Inalatórios , Antieméticos , Náusea e Vômito Pós-Operatórios , Propofol , Humanos , Propofol/administração & dosagem , Propofol/efeitos adversos , Estudos Retrospectivos , Masculino , Antieméticos/administração & dosagem , Feminino , Pessoa de Meia-Idade , Náusea e Vômito Pós-Operatórios/prevenção & controle , Adulto , Idoso , Anestésicos Inalatórios/administração & dosagem , Anestésicos Inalatórios/efeitos adversos , Infusões Intravenosas , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Resultado do Tratamento , Fatores de TempoRESUMO
STUDY OBJECTIVE: Our institution has adopted an informal practice of administering postoperative caffeine to expedite anesthesia recovery for patients with excessive sedation. This study aimed to determine whether caffeine administration was associated with improved sedation recovery and reduced risk of respiratory complications. DESIGN: Single-center, retrospective, observational study. SETTING: Quaternary medical center. PATIENTS: We included adult patients who were admitted to a postanesthesia recovery care unit (PACU) after general anesthesia and had evidence of postoperative sedation (Richmond Agitation Sedation Score [RASS] < 0). Patients were seen from May 5, 2018, through December 31, 2020. INTERVENTIONS: Patients were categorized according to caffeine administration (0 vs 250 mg). MEASUREMENTS: Sedation was measured with RASS. To account for potential confounding, binary and ordinal logistic regression with inverse probability of treatment weighting (IPTW) were used to compare RASS and episodes of severe respiratory complications within 48 h after PACU discharge. MAIN RESULTS: We identified 47,222 adult surgical patients with evidence of sedation in the PACU, and of these, 1892 (4.0%) were intravenously administered caffeine. Patients who received caffeine had more sedation in the PACU. In the IPTW-adjusted analysis, caffeine administration was associated with improved sedation scores after PACU discharge (ordinal logistic regression odds ratio [OR], 1.13 [95% CI, 1.00-1.28]; P = .04 for the first RASS score after PACU discharge) but increased risk of respiratory complications (OR, 2.99 [95% CI, 1.44-6.24]; P = .003) and emergency response team activation (OR, 7.18 [95% CI, 2.85-18.10]; P < .001). CONCLUSIONS: In this observational study, caffeine administration during anesthesia recovery was associated with improved sedation scores. However, it was also associated with an increased risk of respiratory complications, possibly reflecting selection bias (ie, administering caffeine to higher-risk patients). Patients with signs of excessive sedation during anesthesia recovery may benefit from enhanced postoperative respiratory monitoring.
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Anestesia Geral , Cafeína , Adulto , Humanos , Cafeína/efeitos adversos , Estudos Retrospectivos , Anestesia Geral/efeitos adversos , Período de Recuperação da AnestesiaRESUMO
BACKGROUND: Whether volatile anesthetic solubility affects postanesthesia recovery time in clinical practice is unclear. We investigated the association among 3 volatile agents and 2 clinically relevant outcomes-postanesthesia care unit (PACU) recovery time (time from PACU admission to fulfillment of discharge criteria) and oversedation (Richmond Agitation-Sedation Scale score ≤-3)-as a potential contributor to delaying PACU discharge. The volatile agents studied were isoflurane, desflurane, and sevoflurane. We hypothesized that increased solubility of the volatile agent (isoflurane versus desflurane or sevoflurane) would be associated with longer PACU recovery time and higher rates of oversedation. METHODS: This retrospective observational study included adults (≥18 years) who underwent surgical procedures under general anesthesia with a volatile agent and were admitted to the PACU from May 5, 2018, to December 31, 2020. The primary outcome was PACU recovery time, and the secondary outcome was oversedation. PACU recovery time was log-transformed and analyzed with linear regression. Oversedation was analyzed by using logistic regression. To account for potential confounding, inverse probability of treatment weighting (IPTW) was used. Pairwise comparisons of the 3 agents were performed, with P < .017 (Bonferroni-adjusted) considered significant. RESULTS: Of 47,847 patients included, 11,817 (24.7%) received isoflurane, 11,286 (23.6%) received desflurane, and 24,744 (51.7%) received sevoflurane. Sevoflurane had an estimated 4% shorter PACU recovery time (IPTW-adjusted median [interquartile range {IQR}], 61 [42-89] minutes) than isoflurane (64 [44-92] minutes) (ratio of geometric means [98.3% confidence interval {CI}], 0.96 [0.95-0.98]; P < .001). Differences in PACU recovery time between desflurane and the other agents were not significant. The IPTW-adjusted frequency of oversedation was 8.8% for desflurane, 12.2% for sevoflurane, and 16.7% for isoflurane; all pairwise comparisons were observed to be significant (odds ratio [98.3% CI], 0.70 [0.62-0.79] for desflurane versus sevoflurane, 0.48 [0.42-0.55] for desflurane vs isoflurane, and 0.69 [0.63-0.76] for sevoflurane versus isoflurane; all P < .001). Although oversedated patients had longer PACU recovery time, differences in the oversedation rate across agents did not result in meaningful differences in time to PACU recovery. CONCLUSIONS: In clinical practice, only small, clinically unimportant differences in PACU recovery time were observed between the volatile anesthetics. Although oversedation was associated with increased PACU recovery time, differences in the rate of oversedation among agents were insufficient to produce meaningful differences in overall PACU recovery time across the 3 volatile agents. Practical attempts to decrease PACU recovery time should address factors other than volatile agent selection.
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BACKGROUND: Residual deep sedation during anesthesia recovery may predict postoperative complications. We examined the incidence and risk factors for deep sedation after general anesthesia. METHODS: We retrospectively reviewed health records of adults who underwent procedures with general anesthesia and were admitted to the postanesthesia care unit from May 2018 to December 2020. Patients were dichotomized by Richmond Agitation-Sedation Scale (RASS) score: ≤-4 (deeply sedated/unarousable) or ≥-3 (not deeply sedated). Anesthesia risk factors for deep sedation were assessed with multivariable logistic regression. RESULTS: Of the 56,275 patients included, 2003 had a RASS ≤-4 (35.6 [95% CI, 34.1-37.2] cases per 1000 anesthetics administered). On adjusted analyses, the likelihood of a RASS ≤-4 increased when more soluble halogenated anesthetics were used. Compared with desflurane without propofol, the odds ratio (OR [95% CI]) for a RASS ≤-4 was higher with sevoflurane (1.85 [1.45-2.37]) and isoflurane (4.21 [3.29-5.38]) without propofol. Compared with desflurane without propofol, the odds of a RASS ≤-4 further increased with use of desflurane-propofol (2.61 [1.99-3.42]), sevoflurane-propofol (4.20 [3.28-5.39]), isoflurane-propofol (6.39 [4.90-8.34]), and total intravenous anesthesia (2.98 [2.22-3.98]). A RASS ≤-4 was also more likely with the use of dexmedetomidine (2.47 [2.10-2.89]), gabapentinoids (2.17 [1.90-2.48]), and midazolam (1.34 [1.21-1.49]). Deeply sedated patients discharged to general care wards had higher odds of opioid-induced respiratory complications (2.59 [1.32-5.10]) and higher odds of naloxone administration (2.93 [1.42-6.03]). CONCLUSIONS: Likelihood of deep sedation after recovery increased with intraoperative use of halogenated agents with higher solubility and increased further when propofol was concomitantly used. Patients who experience deep sedation during anesthesia recovery have an increased risk of opioid-induced respiratory complications on general care wards. These findings may be useful for tailoring anesthetic management to reduce postoperative oversedation.
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Anestésicos Inalatórios , Sedação Profunda , Isoflurano , Propofol , Adulto , Humanos , Propofol/efeitos adversos , Isoflurano/efeitos adversos , Sevoflurano , Desflurano , Estudos Retrospectivos , Anestésicos Inalatórios/efeitos adversos , Analgésicos Opioides , Sedação Profunda/efeitos adversos , Anestesia Geral/efeitos adversos , Período de Recuperação da AnestesiaRESUMO
BACKGROUND: Non-depolarizing neuromuscular blockade can be reversed with neostigmine/glycopyrrolate or sugammadex. We test the hypothesis that sugammadex is associated with earlier postoperative recovery of bowel function (first bowel movement, BM). METHODS: In adult patients undergoing craniotomy from 2016 to 2019, we identified time of first postoperative BM after receiving neostigmine/glycopyrrolate or sugammadex to reverse neuromuscular blockade. Logistic and proportional hazard regression, with and without inverse probability of treatment weighting (IPTW), were used to assess whether sugammadex is associated with earlier recovery of bowel function. RESULTS: Seven hundred and thirty-one patients underwent craniotomy, 323 (44.2%) received neostigmine/glycopyrrolate, and 408 (55.8%) sugammadex. From logistic regression analysis, the proportion of patients having a BM within the first 24 and 48 hours was higher in sugammadex group (unadjusted OR [95% CI]) 1.79 [1.16 to 2.77] P = .009; and 1.45 [1.08 to 1.94] P = .014; IPTW adjusted OR [95% CI]) 1.58 [.95, 2.61] P = .078; and 1.38 [.95 to 2.02] P = .095 for 24 and 48 h, respectively). From proportional hazards regression, sugammadex was associated with improved bowel function recovery (unadjusted hazard ratio (HR) [95% CI] 1.35 [1.08, 1.68], P = .008; IPTW adjusted HR 1.29 [.97 to 1.71], P = .076). CONCLUSION: Patients undergoing craniotomy who had neuromuscular blockade reversed with sugammadex may have earlier recovered bowel function compared to patients reversed with neostigmine/glycopyrrolate.
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Bloqueio Neuromuscular , Fármacos Neuromusculares não Despolarizantes , Adulto , Humanos , Sugammadex , Neostigmina/uso terapêutico , Neostigmina/farmacologia , Defecação , Glicopirrolato/farmacologia , Bloqueio Neuromuscular/métodos , Paralisia , CraniotomiaRESUMO
INTRODUCTION: Bladder spasm are common complications following cystoscopic urologic procedures. This study aims to determine the incidence and risk factors for bladder spasm after ambulatory cystoscopic urologic procedures. MATERIALS AND METHODS: Medical records of adult patients who underwent urologic procedures in our ambulatory center from May 1st, 2018 through December 30th, 2020, were reviewed. Bladder spasm was identified from the administration of antispasmodic therapy (e.g. oxybutynin) during anesthesia recovery. Multivariable analyses were performed to assess the association between bladder spasm and clinical factors. RESULTS: Included were 2,671 patients, of which 917 (34.3%) developed postoperative bladder spasm, yielding an incidence of 343 (95%CI 325-361) per 1,000 procedures. Risk factors associated with bladder spasm were younger adult age (< 60 years), longer (> 45 minutes) and more complex procedures. Compared to cystoscopy the risk of spasm following transurethral resection of the bladder tumor was OR 4.35 (95%CI 3.22, 5.87) and for transurethral resection of the prostate OR 3.25 (95% CI 2.24, 4.71). Spasm prophylaxis with belladonna and opium suppositories (B&O) was used in 1,158 patients and 384 (33.2%) developed spasms. The use of B&O was not associated with reduction of bladder spasm, OR 0.91 (95%CI 0.75, 1.1, p = 0.318). Postoperative outcomes did not differ between patients who did or did not develop spasms. CONCLUSION: Bladder spasms are common following ambulatory urologic procedures, more so with more extensive procedures. Prophylaxis with B&O was not significantly associated with a lower rate of bladder spasms.
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Ressecção Transuretral da Próstata , Urologia , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Espasmo/epidemiologia , Espasmo/etiologia , Ressecção Transuretral da Próstata/efeitos adversos , Bexiga Urinária , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Urológicos/métodosRESUMO
PURPOSE: To assess if the choice of acetaminophen formulation (intravenous vs oral) when administered preoperatively for ambulatory cystoscopy procedures is associated with differences in anesthetic outcomes. METHODS: Medical records of adult patients undergoing ambulatory cystoscopy procedures at an outpatient procedural center from July 1, 2014, through November 30, 2017, were abstracted. The association between anesthetic outcomes (severe pain, rescue opioids, postoperative nausea, and vomiting) and acetaminophen formulation was assessed. Propensity-adjusted analyses were performed using inverse probability of treatment weighting to account for potential confounders. RESULTS: During the study time frame, there were 611 intravenous and 2955 oral acetaminophen administrations for cystoscopy procedures. Postoperative bladder spasms were a major contributor to severe pain and complicated 1036 cases, with similar rates between intravenous (N = 183, 29.9%) and oral (N = 853, 28.9%) formulations, P = .625. After adjusting for bladder spasms, intravenous acetaminophen was associated with longer anesthesia recovery (estimate 5.2 [95% CI 0.5-9.9] minutes, P = .030), use of rescue opioids (odds ratio 1.33 [1.07-1.66], P = .012), and postoperative nausea and vomiting (1.40 [1.02-1.93], P = .037), but not severe pain (1.07 [0.81-1.40], P = .640). CONCLUSION: Preoperative intravenous acetaminophen compared to oral acetaminophen for ambulatory cystoscopy procedures was not associated with better anesthetic outcomes. Bladder spasms were a major contributor to postoperative pain.
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Acetaminofen/administração & dosagem , Analgésicos não Narcóticos/administração & dosagem , Analgésicos Opioides/administração & dosagem , Cistoscopia , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Administração Intravenosa , Administração Oral , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Medição da Dor , Estudos RetrospectivosRESUMO
PURPOSE: Our objective was to examine the association between preoperative cognitive status and postoperative recovery from anesthesia. METHODS: We included patients (70-91 years old) from the Mayo Clinic Study of Aging who received general anesthesia and were admitted to the postanesthesia care unit from January 1, 2010 through April 30, 2018. Procedures were categorized according to patient's preoperative cognitive status: cognitive impaired (CI) and cognitive unimpaired (CU). Perioperative records were reviewed and analyses were performed with generalized estimating equations. RESULTS: A total of 896 procedures from 611 patients were included, with 203 (22.7%) procedures in the CI group. Compared to CU procedures, CI procedures had higher rates of moderate-deep sedation during anesthesia recovery (52 [25.6%] vs. 103 [14.9%]; odds ratio [OR], 1.91; 95% CI, 1.30-2.80; P < 0.01), postoperative pulmonary complications (22 [10.8%] vs. 34 [4.9%]; OR, 2.36[1.22-4.54]; P = 0.01), and postoperative delirium (32 [16.2%] vs. 24 [3.5%]; OR, 5.33 [2.88-9.86]; P < 0.01). When moderate-deep sedation during anesthesia recovery was a covariate, both CI (OR, 3.02[1.60-5.70]; P < 0.01) and moderate-deep sedation (OR, 3.94[2.19-7.11]; P < 0.01) were associated with delirium. In multivariable analysis, postoperative pulmonary complications were associated with moderate-deep sedation (OR, 2.14[1.18-3.87]; P = 0 .01) but not with CI (OR, 1.49 [0.76-2.92]; P = 0 .25). CONCLUSIONS: Cognitive impairment was associated with higher rates of moderate-deep residual sedation during anesthesia recovery and delirium, while moderate-deep sedation was associated with higher rates of pulmonary complications and delirium. We speculate that tailoring the anesthetic to facilitate faster emergence for CI patients could improve complication rates.
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Disfunção Cognitiva , Delírio , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Disfunção Cognitiva/epidemiologia , Sedação Consciente , Delírio/induzido quimicamente , Delírio/epidemiologia , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologiaRESUMO
OBJECTIVE: Pulmonary hypertension (PH) is a substantial preoperative risk factor. For this study, morbidity and mortality were examined after noncardiac surgery in patients with precapillary PH. DESIGN: A retrospective cohort study. SETTING: Quaternary medical center in Rochester, MN. PARTICIPANTS: Adults with PH undergoing noncardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The PH and surgical databases were reviewed from 2010 to 2017. Patients were excluded if PH was attributable to left-sided heart disease or they had undergone cardiac or transplantation surgeries. To assess whether PH-specific diagnostic or cardiopulmonary testing parameters were predictive of perioperative complications, generalized estimating equations were used. Of 196 patients with PH, 53 (27%) experienced 1 or more complications, including 5 deaths (3%) within 30 days. After adjustment for age and PH type, there were more complications in those undergoing moderate- to high-risk versus low-risk procedures (odds ratio [OR] 4.17 [95% confidence interval {CI} 2.07-8.40]; p < 0.001). After adjustment for age, surgical risk, and PH type, the complication risk was greater for patients with worse functional status (OR 2.39 [95% CI 1.19-4.78]; pâ¯=â¯0.01 for classes III/IV v classes I/II) and elevated serum N-terminal fragment of the prohormone brain natriuretic peptide (NT-proBNP) (OR 2.28 [95% CI 1.05-4.96]; pâ¯=â¯0.04 for ≥300 v <300 pg/mL). After adjusting for age, surgical risk, and functional status, elevated NT-proBNP remained associated with increased risk (OR 2.23 [95% CI 1.05-4.76]; pâ¯=â¯0.04). CONCLUSION: PH patients undergoing noncardiac surgery have a high frequency of complications. Worse functional status, elevated serum NT-proBNP, and higher-risk surgery are predictive of worse outcome.
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Hipertensão Pulmonar , Biomarcadores , Estudos de Coortes , Humanos , Hipertensão Pulmonar/complicações , Hipertensão Pulmonar/cirurgia , Peptídeo Natriurético Encefálico , Fragmentos de Peptídeos , Complicações Pós-Operatórias/epidemiologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVE: To determine whether time to first postoperative bowel movement after intraperitoneal surgery differs among neuromuscular blockade reversal with either anticholinesterase/anticholinergic combination vs sugammadex. PATIENTS AND METHODS: Sugammadex was introduced to our practice in October 2016. Patients were identified who underwent intraperitoneal surgery between January 1, through June 30, 2016, and January 1 through June 30, 2017, and received aminosteroid neuromuscular blockade for paralysis. Reversal was initiated with neostigmine, coadministered with glycopyrrolate (neostigmine/glycopyrrolate) for control participants and sugammadex for patients. Time to first bowel movement was determined from nursing documentation for study cohorts (2016 and 2017). We compared times to first bowel movement between cases and controls using raw and inverse probability of treatment weighting (IPTW) analyses. RESULTS: In the 2016 cohort, 2583 received neostigmine/glycopyrrolate. Of 2750 patients in 2017, sugammadex reversal technique was administered to 1500 patients and neostigmine/glycopyrrolate to 1250 participants. Without weighting, the groups were relatively balanced for most baseline characteristics, and after IPTW, all standardized differences were <0.035. In comparison with the 2016 and 2017 controls, sugammadex treatment was associated with faster occurrence of first bowel movement. For 2016, unweighted hazard ratio (HR) (95% confidence interval [CI]) was 1.35 (1.21-1.51) (P<.001). After IPTW, HR (95% CI) was 1.27 (1.12-1.43) (P<.001). For 2017, unweighted HR (95% CI) was 1.51 (1.31-1.72) (P<.001); after IPTW, it was 1.25 (1.08-1.45) (P =.003). CONCLUSION: Patients undergoing intraperitoneal surgery who had aminosteroid neuromuscular blockade reversal with sugammadex had earlier first postoperative bowel movement than patients with reversal through neostigmine/glycopyrrolate.
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BACKGROUND: Previous studies of postoperative corneal injury rates relied on provider-initiated incident reports, which may underestimate the true incidence. Postoperative administration of proparacaine eye drops is used almost exclusively to diagnose corneal injury; therefore, identifying instances of administration may provide a better estimate of corneal injuries. We compared proparacaine administration versus provider-initiated reports to determine rates of corneal injury. In addition, potential associations between clinical variables and injury were assessed with a matched case-control study. METHODS: The health records of 132,511 sequential adult postanesthesia recovery room admissions (January 1, 2011 to June 30, 2017) were reviewed to identify postoperative proparacaine administration and incident reports of corneal injury. Patients with corneal injury were matched with control patients at a 1:2 ratio to assess factors associated with injury. RESULTS: Proparacaine drops were administered to 442 patients (425 patients received proparacaine for diagnosis and 17 patients received proparacaine for unrelated reasons). Incident reports identified 320 injuries, and the aggregate corneal injury count was 436 (incidence, 3.3 injuries [95% confidence interval {CI}, 3.0-3.6] per 1000 cases of general anesthesia). Proparacaine administration had a greater case ascertainment percentage than incident reporting (97.5% vs 73.4%; P < .001). The matched case-control analysis found greater risks associated with longer duration of anesthesia (odds ratio, 1.05 [95% CI, 1.03-1.07] per 10 minutes of anesthesia; P < .001) and nonsupine surgical position (odds ratio, 3.89 [95% CI, 2.17-6.98]; P < .001). Patients with injuries also had more evidence of sedation and agitation during anesthesia recovery. CONCLUSIONS: Calculation of incidence by using the administration of a medication (proparacaine eye drops) that is almost exclusively used to diagnose a specific injury (corneal injury) showed higher case ascertainment percentage than incident-reporting methods. Similar strategies could be used to monitor the rates of other adverse events.
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Anestésicos Locais/administração & dosagem , Lesões da Córnea/diagnóstico , Lesões da Córnea/epidemiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Propoxicaína/administração & dosagem , Idoso , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Buprenorphine, a partial opioid agonist, displaces full opioid agonists from receptors and may impede surgical pain management. We report the effects of a sublingual formulation of buprenorphine-naloxone, Suboxone (SL-BUP), on perioperative pain management. METHODS: We identified all adult surgical patients from December 31, 2004, to January 1, 2016, who received SL-BUP within 30 days prior to procedures performed with general, regional, or combined general/regional anesthesia. We recorded opioid use during the procedure, in the post-anesthesia care unit (PACU), and during the 24 h following PACU discharge. We also examined opioid use in those who continued SL-BUP until the day of surgery vs those who preoperatively discontinued SL-BUP. RESULTS: Thirty-two patients were treated preoperatively with SL-BUP. Three patients had regional anesthesia only, and opioid requirements were case dependent. Requirements were minimal for creation of an arteriovenous fistula and high following knee replacement and cesarean section. Twelve patients received combined general/regional anesthesia, and 17 received general anesthesia only. Intraoperative and PACU opioid use in these 2 groups were not significantly different (P = .10 and P = .93, respectively). In both groups opioid use increased after discharge from the PACU, and remained comparable between the general and combined general/regional group through the first 24 h after PACU discharge (P = .78). Although median [interquartile range] 24-h opioid doses were higher among patients who discontinued SL-BUP, the difference was not statistically significant in the general anesthesia-only group (SL-BUP discontinued, 199 [110-411] mg IV-MEq [intravenous morphine equivalent] vs SL-BUP continued, 106 [58-160] mg IV-MEq; P = .15) or in the combined general/regional group (SL-BUP discontinued, 140 [100-157] mg IV-MEq vs SL-BUP continued, 100 [73-203] mg IV-MEq; P = .94). CONCLUSIONS: Regardless of the type of anesthesia used, physicians treating patients with SL-BUP must be prepared to administer large doses of opioids during the early postoperative period. No difference in opioid requirements was noted between patients who perioperatively stopped SL-BUP versus those who continued SL-BUP.
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Analgésicos Opioides/administração & dosagem , Combinação Buprenorfina e Naloxona/administração & dosagem , Manejo da Dor/métodos , Dor Pós-Operatória/prevenção & controle , Assistência Perioperatória/métodos , Administração Sublingual , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Dor Pós-Operatória/diagnóstico , Estudos RetrospectivosRESUMO
OBJECTIVES: Patients requiring admission to an ICU may subsequently experience cognitive decline. Our objective was to investigate longitudinal cognitive trajectories in older adults hospitalized in ICUs. We hypothesized that individuals hospitalized for critical illness develop greater cognitive decline compared with those who do not require ICU admission. DESIGN: A retrospective cohort study using prospectively collected cognitive scores of participants enrolled in the Mayo Clinic Study of Aging and ICU admissions retrospectively ascertained from electronic medical records. A covariate-adjusted linear mixed effects model with random intercepts and slopes assessed the relationship between ICU admissions and the slope of global cognitive z scores and domains scores (memory, attention/executive, visuospatial, and language). SETTING: ICU admissions and cognitive scores in the Mayo Clinic Study of Aging from October 1, 2004, to September 11, 2017. PATIENTS: Nondemented participants age 50 through 91 at enrollment in the Mayo Clinic Study of Aging with an initial cognitive assessment and at least one follow-up visit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 3,673 participants, 372 had at least one ICU admission with median (25-75th percentile) follow-up after first ICU admission of 2.5 years (1.2-4.4 yr). For global cognitive z score, admission to an ICU was associated with greater decline in scores over time compared with participants not requiring ICU admission (difference in annual slope = -0.028; 95% CI, -0.044 to -0.012; p < 0.001). ICU admission was associated with greater declines in memory (-0.029; 95% CI, -0.047 to -0.011; p = 0.002), attention/executive (-0.020; 95% CI, -0.037 to -0.004; p = 0.016), and visuospatial (-0.013; 95% CI, -0.026 to -0.001; p = 0.041) domains. ICU admissions with delirium were associated with greater declines in memory (interaction p = 0.006) and language (interaction p = 0.002) domains than ICU admissions without delirium. CONCLUSIONS: In older adults, ICU admission was associated with greater long-term cognitive decline compared with patients without ICU admission. These findings were more pronounced in those who develop delirium while in the ICU.
Assuntos
Disfunção Cognitiva/epidemiologia , Cuidados Críticos/estatística & dados numéricos , Estado Terminal/epidemiologia , Admissão do Paciente/estatística & dados numéricos , Fatores Etários , Idoso , Cognição/fisiologia , Estudos de Coortes , Estado Terminal/psicologia , Feminino , Seguimentos , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Surgical manipulation of pheochromocytomas and paragangliomas (PPGLs) may induce large hemodynamic oscillations due to catecholamine release. Little is known regarding hemodynamic instability during percutaneous ablation of PPGLs. We examined intraprocedural hemodynamic variability and postoperative complications related to percutaneous ablation of extra-adrenal metastases of PPGL. METHODS: From institutional PPGL registry we identified patients undergoing ablation of extra-adrenal PPGL metastases from January 1, 2000, through December 31, 2016. We reviewed medical records for clinical characteristics and hospital outcomes. Tumors were categorized as functional or nonfunctional based on preprocedural fractionated catecholamine and metanephrine profiles. RESULTS: Twenty-one patients (14 female [67%]) underwent 38 ablations. Twenty-four ablations were performed in patients with functional metastatic lesions, and 14 were in nonfunctional lesions. Intraprocedural use of potent vasodilators for hypertension was higher for patients with functional tumors (P = 0.02); use of vasopressors for hypotension was similar for functional and nonfunctional tumors (P = 0.74). Mean (±SD) intraprocedural blood pressure range (maximum-minimum blood pressure) during 38 procedures was greater for functional than nonfunctional tumors [systolic: 106 (±48) vs 64 (±30) mm Hg, P = 0.005; diastolic: 58 (±22) vs 35 (±14) mm Hg, P = 0.002; mean arterial: 84 (±43) vs 47 (±29) mm Hg, P = 0.007]. Complications included 5 unplanned intensive care unit admissions (3 for precautionary monitoring, 1 for recalcitrant hypotension, and 1 for hypertensive crisis), 1 case of postoperative bleeding, and 1 death. CONCLUSIONS: Substantial hemodynamic instability may develop during ablation of functional and nonfunctional PPGL metastases. When anesthesia is provided for ablation of metastatic PPGLs in radiology suites, preparation for hemodynamic management should match standards used for surgical resection.
Assuntos
Neoplasias das Glândulas Suprarrenais/cirurgia , Criocirurgia/métodos , Paraganglioma/cirurgia , Feocromocitoma/cirurgia , Ablação por Radiofrequência/métodos , Neoplasias das Glândulas Suprarrenais/patologia , Adulto , Pressão Sanguínea/fisiologia , Catecolaminas/metabolismo , Estudos de Coortes , Feminino , Hemodinâmica/fisiologia , Humanos , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Hipotensão/tratamento farmacológico , Hipotensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Paraganglioma/patologia , Feocromocitoma/patologia , Estudos Retrospectivos , Vasoconstritores/administração & dosagem , Vasodilatadores/administração & dosagem , Adulto JovemRESUMO
OBJECTIVE: To investigate whether older adults with mild cognitive impairment (MCI) or dementia have higher rates of procedures requiring general anesthesia or intensive care unit (ICU) admissions compared with cognitively normal (CN) patients. PATIENTS AND METHODS: A population-based cohort, 70 to 89 years old at enrollment, underwent clinical and longitudinal neurocognitive testing to identify those with MCI and dementia. We analyzed the effects of cognitive status (CN, MCI, or dementia) at entry into the study from October 1, 2004, through December 31, 2014, on the risk of receiving procedures requiring surgical anesthesia and ICU admission. RESULTS: Of 2436 participants, 1977 (81%) were CN, 387 (16%) had MCI, and 72 (3%) had dementia. Cognitively impaired individuals were sicker. Compared with CN individuals, the likelihood of receiving a procedure requiring anesthesia was similar in participants with MCI (adjusted hazard ratio [aHR]=0.98; P=.78). Participants with dementia were less likely to receive these procedures (aHR=0.50; P=.02). Compared with CN participants, the likelihood of ICU admission for any indication was increased for those with MCI (aHR=1.24; P=.03) and dementia (aHR=1.59; P=.04). Admissions to the ICU after procedures were not different in patients with either MCI or dementia (aHR=0.96; P=.83 and aHR=1.01; P=.98, respectively). CONCLUSION: Patients with MCI or dementia are not more likely to undergo surgery, and neither are they more likely to require ICU admission after procedures. An increased rate of nonsurgical ICU admissions requires vigilance to prevent deterioration of nonsurgical diseases that may lead to ICU admissions.
Assuntos
Anestesia Geral/efeitos adversos , Disfunção Cognitiva/epidemiologia , Demência/epidemiologia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/estatística & dados numéricos , Anestésicos , Estudos de Casos e Controles , Disfunção Cognitiva/etiologia , Comorbidade , Demência/etiologia , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Efeitos Adversos de Longa Duração/epidemiologia , Estudos Longitudinais , Masculino , Testes de Estado Mental e Demência , Admissão do Paciente/estatística & dados numéricos , Modelos de Riscos Proporcionais , Fatores de RiscoRESUMO
PURPOSE: Primary (idiopathic) central sleep apnea (PCSA) is a rare central sleep-related breathing disorder characterized by increased chemoreceptor sensitivity to partial pressure of carbon dioxide, which manifests as hyperventilation followed by apnea during non-rapid eye movement sleep. The purpose of this retrospective study was to describe the postoperative course of patients who had PCSA and underwent procedures requiring anesthetic management. METHODS: Patients who received a diagnosis of PCSA at our institution and required procedural anesthesia between 1 January 2010 and 1 June 2016 underwent a comprehensive review of their health records with a focus on identifying respiratory complications. RESULTS: Ten patients (nine males, one female) underwent 47 procedures requiring anesthetic management: 20 (43%) under general anesthesia, 25 (53%) with monitored anesthetic care, and two (4%) with regional anesthesia. Procedures were complicated by second-degree heart block in one patient and pneumonia in another two (one had Ivor-Lewis esophagectomy and the other bronchoscopy to evaluate worsening lung infiltration). Hypoxemia (oxyhemoglobin saturation < 90% for three minutes) developed in three patients during anesthesia recovery. One was possibly due to PCSA-a 73-yr-old male with alcoholic cirrhosis who was moderately sedated and hypoxemic after orthopedic surgery; his oxygenation improved with an adaptive servoventilator positive airway pressure device and supplemental oxygen. His underlying medical condition or level of sedation may have contributed to hypoxemia. The other patients became hypoxemic after bronchoscopy. No other cases were complicated by postoperative respiratory compromise. CONCLUSIONS: No major adverse outcomes were related to PCSA postoperatively. Nevertheless, continuation of home positive airway pressure therapy during anesthesia recovery was useful in one patient who had cirrhosis and postoperative hypoxemia.