Primary Stroke and Failure-to-Rescue Following Thoracic Endovascular Aortic Aneurysm Repair.

OBJECTIVE: To characterize the impact, on failure to rescue, of cerebrovascular accident as a first postoperative complication after thoracic endovascular aortic aneurysm repair (TEVAR). DESIGN: A retrospective cohort study using of National Surgical Quality Improvement Program Participants User File. SETTING: United States hospitals taking part in the National Surgical Quality Improvement Program. PARTICIPANTS: Patients >18 years, who underwent TEVAR for nonruptured thoracic aortic aneurysm between 2005 and 2018, and developed one or more major postoperative complications within 30 days after surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Out of 3,937 patients who underwent TEVAR for nonruptured thoracic aneurysm, 1,256 (31.9%) developed major postoperative complications (stroke incidence: 11.4% [143/1256]). In adults <65 years old, the occurrence of stroke as the primary complication, relative to the occurrence of other complications, was associated with ten times greater risk of failure to rescue (29.4% v 4.6%; odds ratio [OR]: 10.10; 95% confidence interval [CI] 2.45-41.56; p < 0.001). The effect size was relatively lower when stroke occurred but was not the primary complication (20.0% v 4.6%; OR: 7.55; 95% CI 1.37-41.71; p = 0.020). In patients ≥65 years, the occurrence of stroke as the primary complication did not carry the similar prognostic value. CONCLUSION: Younger patients who developed stroke were up to ten times more likely to die, relative to patients who developed other major complications. Survival was substantially reduced when stroke was the primary complication. The authors' findings imply that to maximize the survival of patients undergoing TEVAR, efforts may be needed to predict and prevent stroke occurrence as a primary postoperative morbidity event.

Anesthesia-related cardiac arrest.

BACKGROUND: Much is still unknown about the actual incidence of anesthesia-related cardiac arrest in the United States. METHODS: The authors identified all of the cases of cardiac arrest from their quality improvement database from 1999 to 2009 and submitted them for review by an independent study commission to give them the best estimate of anesthesia-related cardiac arrest at their institution. One hundred sixty perioperative cardiac arrests within 24 h of surgery were identified from an anesthesia database of 217,365 anesthetics. An independent study commission reviewed all case abstracts to determine which cardiac arrests were anesthesia-attributable or anesthesia-contributory. Anesthesia-attributable cardiac arrests were those cases in which anesthesia was determined to be the primary cause of cardiac arrest. Anesthesia-contributory cardiac arrests were those cases where anesthesia was determined to have contributed to the cardiac arrest. RESULTS: Fourteen cardiac arrests were anesthesia-attributable, resulting in an incidence of 0.6 per 10,000 anesthetics (95% CI, 0.4 to 1.1). Twenty-three cardiac arrests were found to be anesthesia-contributory resulting in an incidence of 1.1 per 10,000 anesthetics (95% CI, 0.7 to 1.6). Sixty-four percent of anesthesia-attributable cardiac arrests were caused by airway complications that occurred primarily with induction, emergence, or in the postanesthesia care unit, and mortality was 29%. Anesthesia-contributory cardiac arrest occurred during all phases of the anesthesia, and mortality was 70%. CONCLUSION: As judged by an independent study commission, anesthesia-related cardiac arrest occurred in 37 of 160 cardiac arrests within the 24-h perioperative period.

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction.

At our institution, multimodal opiate-sparing pain management is the cornerstone of our enhanced recovery program for autologous breast reconstruction. The purpose of this study was to compare postoperative outcomes and pain control metrics following implementation of an enhanced recovery program with two different regional analgesia approaches. METHODS: This retrospective cohort study identified 145 women who underwent autologous breast reconstruction from 2015 to 2017. Three groups were included: historical control patients (n = 46) and enhanced recovery patients that received multimodal pain management including a postoperative transversalis abdominis plane block with either a continuous local anesthetic catheter (n = 60) or a single-shot of liposomal bupivacaine (n = 39). The primary outcome was pain scores in the first three postoperative days. Secondary outcomes were opioid consumption in oral morphine equivalents and length of stay. RESULTS: Postoperative pain scores were similar across all three groups until postoperative day 3. Length of stay was significantly shorter in both of the enhanced recovery cohorts (3.0 [3.0, 4.0]) compared with control patients (4.0 [4.0, 5.0], P < 0.001). Likewise, average total oral morphine equivalents consumption was significantly reduced in enhanced recovery patients (continuous catheter 215.9 (95% CI, 165.4-266.3); liposomal bupivacaine 211.0 (95% CI, 154.8-267.2); control 518.4 (95% CI 454.2-582.7), P < 0.001). Neither length of stay (P = 0.953), nor oral morphine equivalents consumption (P = 0.883) differed by type of regional analgesia. CONCLUSION: Compared with control patients, both approaches to regional transversalis abdominis plane block analgesia as part of an opiate-sparing enhanced recovery pain management strategy were successful, but neither superior to the other.

High incidence of burnout in academic chairpersons of anesthesiology: should we be taking better care of our leaders?

BACKGROUND: Burnout is a work-related psychologic syndrome characterized by emotional exhaustion, low personal accomplishment, and depersonalization. METHODS: By using an instrument that included the MBI-HHS Burnout Inventory, we surveyed academic anesthesiology chairpersons in the United States. Current level of job satisfaction compared with 1 and 5 yr before the survey, likelihood of stepping down as chair in the next 2 yr, and a high risk of burnout were the primary outcomes. RESULTS: Of the 117 chairs surveyed, 102 (87%) responded. Nine surveys had insufficient responses for assessment of burnout. Of 93 chairs, 32 (34%) reported high current job satisfaction, which represented a significant decline compared with that reported for 1 yr (P = 0.009) and 5 yr (P = 0.001) before the survey. Of 93 chairs, 26 (28%) reported extreme likelihood of stepping down as a chair in 1-2 yr. There was no association of age (P = 0.16), sex (P = 0.82), or self-reported effectiveness (P = 0.63) with anticipated likelihood of stepping down, but there was a negative association between the modified efficacy scale scoρrgr; = -0.303, P = 0.003) and likelihood of stepping down. Of 93 chairs, 26 (28%) met the criteria for high burnout and an additional 29 (31%) met the criteria for moderately high burnout. Decreased current job satisfaction and low self-reported spousal/significant other support were independent predictors of high burnout risk. CONCLUSION: Fifty-one percent of academic anesthesiology chairs exhibit a high incidence/risk of burnout. Age, sex, time as a chair, hours worked, and perceived effectiveness were not associated with high burnout; however, low job satisfaction and reduced self-reported spousal/significant other support significantly increased the risk.