Awake Spinal Fusion Is Associated with Reduced Length of Stay, Opioid Use, and Time to Ambulation Compared to General Anesthesia: A Matched Cohort Study.

OBJECTIVE: There is increasing interest in performing awake spinal fusion under spinal anesthesia (SA). Evidence supporting SA has been positive, albeit limited. The authors set out to investigate the effects of SA versus general anesthesia (GA) for spinal fusion procedures on length of stay (LOS), opioid use, time to ambulation (TTA), and procedure duration. METHODS: The authors performed a retrospective review of a single surgeon's patients who underwent lumbar fusions under SA versus GA from June of 2020 to June of 2022. SA patients were compared to demographically matched GA counterparts undergoing comparable procedures. Analyzed outcomes include operative time, opioid usage in morphine milligram equivalents, TTA, and LOS. RESULTS: Ten SA patients were matched to 10 GA counterparts. The cohort had a mean age of 66.77, a mean body mass index of 27.73 kg/m2, and a median American Society of Anesthesiologists Physical Status Score of 3.00. LOS was lower in SA versus GA patients (12.87 vs. 50.79 hours, P = 0.001). Opioid utilization was reduced in SA versus GA patients (10.76 vs. 31.43 morphine milligram equivalents, P = 0.006). TTA was reduced in SA versus GA patients (7.22 vs. 29.87 hours, P = 0.022). Procedure duration was not significantly reduced in SA patients compared to GA patients (139.3 vs. 188.2 minutes, P = 0.089). CONCLUSIONS: These preliminary retrospective results suggest the use of SA rather than GA for lumbar fusions is associated with reduced hospital LOS, reduced opioid utilization, and reduced TTA. Future randomized prospective studies are warranted to determine if SA usage truly leads to these beneficial outcomes.

Awake spinal anesthesia facilitates spine surgery in poor surgical candidates: A case series.

BACKGROUND: Annually, hundreds of thousands of patients undergo surgery for degenerative spine disease (DSD). This represents only a fraction of patients that present for surgical consideration. Procedures are often avoided due to comorbidities that make patients poor candidates for general anesthesia (GA) and its associated risks. With increasing interest in awake surgery under spinal anesthesia (SA), the authors have observed that SA may facilitate spine surgery in patients with relative contraindications to GA. With this in mind, the authors set out to summarize the outcomes of a series of highly comorbid patients who received surgery under SA. METHODS: Case logs of a single surgeon were reviewed, and patients undergoing spine surgery under SA were identified. Within this group, patients were identified with relative contraindications to GA, such as advanced age and medical comorbidities. For these patients, for whom surgery was facilitated by SA, the medical records were consulted to report demographic information and patient outcomes. RESULTS: Ten highly comorbid patients were identified who received lumbar spine surgery for DSD under SA. Comorbidities included octogenarian status, obesity, and chronic health conditions such as heart disease. The cohort had a mean age of 75.5 and a mean American Society of Anesthesiologists Physical Status (ASA-PS) score of 3.1. The patients were predicted to have a 2.74-fold increase of serious complications compared to the average patient. There were no adverse events. CONCLUSION: For patients with symptomatic, refractory DSD and relative contraindications to GA, SA may facilitate safe surgical intervention with excellent outcomes.

Perioperative Quality Initiative and Enhanced Recovery After Surgery-Cardiac Society Consensus Statement on the Management of Preoperative Anemia and Iron Deficiency in Adult Cardiac Surgery Patients.

Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.

Controversies in enhanced recovery after cardiac surgery.

Advances in cardiac surgical operative techniques and myocardial protection have dramatically improved outcomes in the past two decades. An unfortunate and unintended consequence is that 80% of the preventable morbidity and mortality following cardiac surgery now originates outside of the operating room. Our hope is that a renewed emphasis on evidence-based best practice and standardized perioperative care will reduce overall morbidity and mortality and improve patient-centric care. The Perioperative Quality Initiative (POQI) and Enhanced Recovery After Surgery-Cardiac Society (ERAS® Cardiac) have identified significant evidence gaps in perioperative medicine related to cardiac surgery, defined as areas in which there is significant controversy about how best to manage patients. These five areas of focus include patient blood management, goal-directed therapy, acute kidney injury, opioid analgesic reduction, and delirium.

Treatment through a preoperative anemia clinic is associated with a reduction in perioperative red blood cell transfusion in patients undergoing orthopedic and gynecologic surgery.

BACKGROUND: Preoperative anemia is associated with increased morbidity, mortality, and risk of transfusion. Treatment through a preoperative anemia clinic (PAC) may improve outcomes. STUDY DESIGN AND METHODS: Adult patients undergoing elective orthopedic and gynecologic surgery with preoperative anemia were identified and referred for hemoglobin optimization with iron and/or erythropoietin from a single-site academic health center. Treated patients were propensity matched to untreated controls and compared on outcomes of erythrocyte transfusion, length of stay (LOS), and readmission. Changes in hemoglobin relative to treatment time before surgery were also measured in the treated cohort. RESULTS: One thousand three hundred thirty-two patients were evaluated between July 2015 and March 2021, of which 161 underwent optimization through the PAC. After propensity matching, 127 (98 orthopedic and 29 gynecology) PAC-treated patients were compared to 127 (98 orthopedic and 29 gynecology) control patients who did not undergo treatment. The primary outcome of perioperative transfusion was significantly lower in treated patients compared with matched controls (12.60% vs. 26.77%, p = .005). A lower LOS was demonstrated in the gynecologic PAC subgroup (2.2 [1.5, 2.4] vs. 3.1 [2.2, 3.4], p = .002). Each day of treatment time before surgery was associated with an increase of 0.040 g/dL hemoglobin (p < .001) until 65 days, after which further time did not increase hemoglobin. CONCLUSION: Treatment through a preoperative anemia clinic is associated with a reduction in perioperative transfusion and possible reduction in LOS and readmission compared with matched controls. Additionally, treatment time before surgery is correlated with a greater increase in hemoglobin up until 2 months prior to surgery.

The association between intravenous iron for antenatal anemia and postnatal depression: a retrospective cohort study.

PURPOSE: Determine if intravenous iron for antenatal anemia is associated with reduced incidence of postnatal depression (PND) within 12 months. METHODS: This retrospective cohort study included adult women with antenatal anemia (hemoglobin value of < 11.0 g/dL within 3 months before delivery). PND was defined as Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire-9 (PHQ-9) ≥ 10. Data on intravenous iron, lowest hemoglobin concentration, EPDS and PHQ-9 scores, insurance status, history of anxiety, depression, chronic pain, and substance use, obstetric complications, labor analgesia, and mode of delivery were obtained. Standardized mean difference (SMD) was estimated and multivariable logistic regression models were constructed with adjustment for potential confounders with absolute SMD of ≥ 0.1. RESULTS: Data from 3988 women were analyzed. The 368 (9.2%) women who received intravenous iron therapy had lower antenatal hemoglobin levels, were more likely to be African American or single/widowed women, and more commonly had  Medicaid coverage, repeat cesarean delivery, and history of depression compared to those who did not receive intravenous iron therapy. Unadjusted analysis showed women who received intravenous iron had higher incidence of PND (18.5%) than those who did not (13.4%) (p = 0.008). Multivariable analysis showed no significant association between intravenous iron and PND incidence (aOR 1.21, 95%CI 0.89-1.63, p = 0.232), although history of depression (aOR 2.42, 95%CI 1.91-3.08, p < 0.001), higher gravidity (aOR 1.09, 95%CI 1.02-1.17, p = 0.016), and Medicaid insurance (aOR 1.44, 95%CI 1.16-1.80, p = 0.001) were independently associated with PND. CONCLUSION: Intravenous iron for antenatal anemia was not associated with significant change in the incidence of PND.

Blood Substitutes and Oxygen Therapeutics: A Review.

Despite the exhaustive search for an acceptable substitute to erythrocyte transfusion, neither chemical-based products such as perfluorocarbons nor hemoglobin-based oxygen carriers have succeeded in providing a reasonable alternative to allogeneic blood transfusion. However, there remain scenarios in which blood transfusion is not an option, due to patient's religious beliefs, inability to find adequately cross-matched erythrocytes, or in remote locations. In these situations, artificial oxygen carriers may provide a mortality benefit for patients with severe, life-threatening anemia. This article provides an up-to-date review of the history and development, clinical trials, new technology, and current standing of artificial oxygen carriers as an alternative to transfusion when blood is not an option.

How do I develop a process to effectively treat parturients with iron deficiency anemia?

Anemia is common in pregnant women and is associated with increased morbidity for the mother and the fetus, including increased risk of allogeneic blood transfusion. Iron deficiency is the most common etiology for anemia during pregnancy. Oral iron therapy remains the standard treatment but is often poorly tolerated due to its gastrointestinal side effects. Intravenous iron has been shown to be a safe and effective way to treat iron deficiency anemia but may be challenging to do in the outpatient setting given the need for an indwelling venous catheter and a small risk of infusion reactions. To improve outcomes associated with anemia, we launched a program to refer and treat obstetric patients with iron deficiency anemia for outpatient intravenous iron therapy through our preoperative anemia clinic. Here, we describe the process and successes of our program, including the clinical outcomes (change in hemoglobin and transfusion rates) from the first 2 years of the program.

Essential Role of Patient Blood Management in a Pandemic: A Call for Action.

The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.

Perioperative Anemia: Prevention, Diagnosis, and Management Throughout the Spectrum of Perioperative Care.

Anemia is common in the perioperative period and is associated with poor patient outcomes. Remarkably, anemia is frequently ignored until hemoglobin levels drop low enough to warrant a red blood cell transfusion. This simplified transfusion-based approach has unfortunately shifted clinical focus away from strategies to adequately prevent, diagnose, and treat anemia through direct management of the underlying cause(s). While recommendations have been published for the treatment of anemia before elective surgery, information regarding the design and implementation of evidence-based anemia management strategies is sparse. Moreover, anemia is not solely a concern of the preoperative encounter. Rather, anemia must be actively addressed throughout the perioperative spectrum of patient care. This article provides practical information regarding the implementation of anemia management strategies in surgical patients throughout the perioperative period. This includes evidence-based recommendations for the prevention, diagnosis, and treatment of anemia, including the utility of iron supplementation and erythropoiesis-stimulating agents (ESAs).

Lower hemoglobin concentration decreases time to death in severely anemic patients for whom blood transfusion is not an option.

BACKGROUND: Anemia in patients who decline transfusion has been associated with increased morbidity and mortality. We hypothesized that the time to death decreases with increasing severity of anemia in patients for whom transfusion is not an option. METHODS: With institutional review board approval, a retrospective review of registered adult blood refusal patients with at least one hemoglobin (Hb) value of 12.0 g/dL or less during hospital admission at a single institution from January 2004 to September 2015 was performed. The association of nadir Hb category and time to death (all-cause 30-day mortality) was determined using Kaplan-Meier plots, log rank tests, and Cox proportional hazard models. We investigated if there was a nadir Hb level between the values of 5.0 and 6.0 g/dL at which mortality risk significantly increased and then categorized nadir Hb by the traditional cut points and the newly identified "critical" cut point. RESULTS: The study population included 1,011 patients. The Cox proportional hazard models showed a more than 50% increase in hazard of death per 1 g/dL decrease in Hb (adjusted hazard ratio [confidence interval], 1.55 [1.40-1.72]; p < 0.001). A Hb value of 5.0 g/dL was identified as defining "critical anemia." We found a strong association between anemia severity level and mortality (p < 0.001). Time to death was shorter (median, 2 days) in patients with critical anemia than in those having higher Hb (median time to death of 4 or 6 days, in severe or moderate anemia). CONCLUSION: In anemic patients unable to be transfused, critical anemia was associated with a significantly and clinically important reduced time to death. LEVEL OF EVIDENCE: Prognostic, level III.

Surgical management of ovarian carcinosarcoma with inferior vena cava extension into the right atrium.

Gynecological carcinosarcomas are aggressive tumors with rare occurrence and high rates of metastases. We present the case of a 49-year-old woman with vaginal bleeding and abdominal distension who was found to have a large ovarian carcinosarcoma invading the gonadal vein and inferior vena cava (IVC) and extending into right atrium (RA). She underwent gynecologic tumor resection, IVC cavotomy and en bloc resection of tumor/thrombus through the RA. Use of intraoperative transesophageal echocardiography helped assess extent and mobility of mass in the RA to guide surgical approach. This case posed unique challenges with regard to management of induction, hemodynamics and coagulopathy.