Timing of Intraoperative Transitions of Care Among Anesthesiologists Is Not Associated With Postoperative Adverse Outcomes: Retrospective Cohort Study.

BACKGROUND: The majority of published research suggests that anesthesia handovers during major surgical procedures are associated with unintended harmful consequences. It is still unclear if the number or quality of the transition of care is the main driver of the adverse outcomes. There is even less data if the timing of the anesthesiologist handovers during the critical portion of the anesthetic continuum (induction or emergence versus surgical period) plays a role in patient outcomes. Therefore, we investigated if the anesthesiologist handovers during induction and emergence are associated with adverse patient outcomes. METHODS: This retrospective investigation included noncardiac surgical procedures occurring between January 1, 2012 and December 31, 2019 that had exactly 1 attending anesthesiologist handover. We categorized transitions of care between attending anesthesiologists as being before incision, between incision and closing, and after closing. Our primary outcome was a composite of 6 categories of surgical complications and in-hospital mortality. We created logistic generalized estimating equation models to estimate the average relative effect odds ratio between each pair of the 3 transition timing groups across the components of the composite outcome. Inverse probability of treatment weights were used to mitigate confounding on a host of baseline variables. We used Bonferroni correction to adjust for multiple comparisons between the transition groups. RESULTS: In total, we studied 36,937 procedures with exactly 1 attending anesthesiologist handover. Of these records, 4370 had the transition during induction, 24,999 between incision and closure, and 7568 during emergence. No differences were found between the transition periods and the composite outcome. The estimated average relative effect odds ratio (98.3% confidence interval [CI]) across the components of the composite outcome was as follows: (1.0002 [0.81-1.24], P = .99) between the induction and surgical period; (1.10 [0.87-1.40], P = .32) between the induction and emergence periods; and (0.91 [0.79-1.04], P = .08) between the emergence and surgical periods. CONCLUSIONS: Timing of intraoperative handover among attending anesthesiologists during noncardiac surgery is not associated with adverse patient outcomes.

Intraoperative hypotension during liver transplantation and postoperative outcomes: Retrospective cohort study.

STUDY OBJECTIVES: Evaluation of the association between intraoperative hypotension (IOH) and important postoperative outcomes after liver transplant such as incidence and severity of acute kidney injury (AKI), MACE and early allograft dysfunction (EAD). DESIGN: Retrospective, single institution study. SETTINGS: Operating room. PATIENTS: 1576 patients who underwent liver transplant in our institution between January 2005 and February 2022. MEASUREMENTS: IOH was measured as the time, area under the threshold (AUT), or time-weighted average (TWA) of mean arterial pressure (MAP) less than certain thresholds (55,60 and 65 mmHg). Associations between IOH exposures and AKI severity were assessed via proportional odds models. The odds ratio from the proportional odds model estimated the relative odds of having higher stage of AKI for higher exposure to IOH. Associations between exposures and MACE and EAD were assessed through logistic regression models. Potential confounding variables including patient baseline and surgical characteristics were adjusted for all models. MAIN RESULTS: The primary analysis included 1576 surgeries that met the inclusion and exclusion criteria. Of those, 1160 patients (74%) experienced AKI after liver transplant surgery, with 780 (49%), 248(16%), and 132 (8.4%) experiencing mild, moderate, and severe injury, respectively. No significant association between hypotension exposure and postoperative AKI (yes or no) nor severity of AKI was observed. The odds ratios (95% CI) of having more severe AKI were 1.02 (0.997, 1.04) for a 50-mmHg·min increase in AUT of MAP <55 mmHg (P = 0.092); 1.03 (0.98, 1.07) for a 15-min increase in time spent under MAP <55 mmHg (P = 0.27); and 1.24 (0.98, 1.57) for a 1 mmHg increase in TWA of MAP <55 mmHg (P = 0.068). The associations between IOH and the incidence of MACE or EAD were not significant. CONCLUSION: Our results did not show the association between IOH and investigated outcomes.

Artificial Intelligence for Perioperative Medicine: Perioperative Intelligence.

The anesthesiologist's role has expanded beyond the operating room, and anesthesiologist-led care teams can deliver coordinated care that spans the entire surgical experience, from preoperative optimization to long-term recovery of surgical patients. This expanded role can help reduce postoperative morbidity and mortality, which are regrettably common, unlike rare intraoperative mortality. Postoperative mortality, if considered a disease category, will be the third leading cause of death just after heart disease and cancer. Rapid advances in technologies like artificial intelligence provide an opportunity to build safe perioperative practices. Artificial intelligence helps by analyzing complex data across disparate systems and producing actionable information. Using artificial intelligence technologies, we can critically examine every aspect of perioperative medicine and devise innovative value-based solutions that can potentially improve patient safety and care delivery, while optimizing cost of care. In this narrative review, we discuss specific applications of artificial intelligence that may help advance all aspects of perioperative medicine, including clinical care, education, quality improvement, and research. We also discuss potential limitations of technology and provide our recommendations for successful adoption.

Effect of intraoperative subhypnotic infusion of propofol on postoperative nausea and vomiting: A retrospective analysis.

STUDY OBJECTIVE: To measure the possible association between subhypnotic propofol infusion during general balanced anesthesia and the incidence of PONV. DESIGN: Retrospective Cohort Analysis Using Propensity Score Matching. SETTING: Postanesthesia care unit and inpatient unit. PATIENTS: Patients with American Society of Anesthesiologists (ASA) physical status I-IV, undergoing non-cardiac surgery lasting >2 h were included. Patients were excluded if transferred to the intensive care unit after surgery or received ketamine. Initially 70,976 patients were screened, and a cohort of 51,707 eligible adult patients undergoing non-cardiac surgery under general balanced anesthesia between 2015 and 2019 were included. Using a propensity score matching, 3185 patients who received subhypnotic propofol during general balanced anesthesia were matched with 5826 patients who did not receive subhypnotic propofol in a 1:2 ratio. INTERVENTIONS: None. MEASUREMENTS: The primary outcome was the incidence of PONV during PACU stay. The secondary outcome was the incidence of PONV within the first 24 h after surgery. Exploratory outcomes were time-to-extubation and length of hospital stay. MAIN RESULTS: A total of 9011 patients were included (3185 patients who received propofol infusion, and 5826 patients who did not receive propofol infusion) after propensity score matching. The adjusted odds ratio for PONV incidence was 1.03 (95% CI: 0.90, 1.18; p = 0.635) in PACU, and 1.05 (95% CI: 0.90, 1.23; P = 0.50) within 24 h after surgery. The length of hospital stay was 6 h shorter (ratio of means (95% CI) of 0.92, 0.89, 0.94), p < 0.001) and time-to-extubation was 2 min longer (ratio of means 1.24 (1.20, 1.28), p < 0.001) in patients receiving subhypnotic propofol infusion. CONCLUSIONS: Our study suggests that subhypnotic propofol infusion during general balanced anesthesia is not associated with a reduction in the incidence of PONV during PACU stay and within the first 24 h after surgery. However, it is associated with decreased LOS and increased time-to-extubation, but differences in neither outcome were clinically important.

Hypotension Prediction Index for Prevention of Hypotension during Moderate- to High-risk Noncardiac Surgery.

BACKGROUND: The Hypotension Prediction Index is a commercially available algorithm, based on arterial waveform features, that predicts hypotension defined as mean arterial pressure less than 65 mmHg for at least 1 min. We therefore tested the primary hypothesis that index guidance reduces the duration and severity of hypotension during noncardiac surgery. METHODS: We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized to hemodynamic management with or without index guidance. Clinicians caring for patients assigned to guidance were alerted when the index exceeded 85 (range, 0 to 100) and a treatment algorithm based on advanced hemodynamic parameters suggested vasopressor administration, fluid administration, inotrope administration, or observation. Primary outcome was the amount of hypotension, defined as time-weighted average mean arterial pressure less than 65 mmHg. Secondary outcomes were time-weighted mean pressures less than 60 and 55 mmHg. RESULTS: Among 214 enrolled patients, guidance was provided for 105 (49%) patients randomly assigned to the index guidance group. The median (first quartile, third quartile) time-weighted average mean arterial pressure less than 65 mmHg was 0.14 (0.03, 0.37) in guided patients versus 0.14 (0.03, 0.39) mmHg in unguided patients: median difference (95% CI) of 0 (-0.03 to 0.04), P = 0.757. Index guidance therefore did not reduce amount of hypotension less than 65 mmHg, nor did it reduce hypotension less than 60 or 55 mmHg. Post hoc, guidance was associated with less hypotension when analysis was restricted to episodes during which clinicians intervened. CONCLUSIONS: In this pilot trial, index guidance did not reduce the amount of intraoperative hypotension. Half of the alerts were not followed by treatment, presumably due to short warning time, complex treatment algorithm, or clinicians ignoring the alert. In the future we plan to use a lower index alert threshold and a simpler treatment algorithm that emphasizes prompt treatment.

Can pretransplant TIPS be harmful in liver transplantation? A propensity score matching analysis.

BACKGROUND: Transjugular intrahepatic portosystemic shunt has been established as an effective treatment for complicated portal hypertension. This retrospective study investigated the effect of pretransplant transjugular intrahepatic portosystemic shunt placement on intraoperative graft hemodynamics and surgical outcomes after liver transplantation. METHODS: Of 1,081 patients who underwent liver transplantation between January 2007 and June 2017 at Cleveland Clinic (OH, USA), 130 patients had transjugular intrahepatic portosystemic shunt placement before liver transplant. We performed a 1:2 propensity score matching to compare intraoperative graft hemodynamics and surgical outcomes between the transjugular intrahepatic portosystemic shunt group (n = 130) and the no-transjugular intrahepatic portosystemic shunt group (n = 260). RESULTS: The transjugular intrahepatic portosystemic shunt did not increase operative time, the volume of blood transfusion, duration of hospital stay, or complication rates. Graft and patient survivals were similar between the groups. Mean intraoperative cardiac output and graft portal flow in the transjugular intrahepatic portosystemic shunt group were greater than in the no-transjugular intrahepatic portosystemic shunt group (P = .03 and P = .003, respectively). In multivariate analysis, male sex, younger age, low platelet count, absence of portal vein thrombosis, and pretransplant transjugular intrahepatic portosystemic shunt placement were independently associated with increased portal flow volume (P < or = 0.03 each). Transjugular intrahepatic portosystemic shunt malposition was observed in 17 patients (13.1%). The 1-year patient survival was 70.6% with transjugular intrahepatic portosystemic shunt malposition and 92.0% without transjugular intrahepatic portosystemic shunt malposition (P = .01). CONCLUSION: Our findings suggest that pretransplant transjugular intrahepatic portosystemic shunt placement increases graft portal flow but does not compromise surgical outcomes after liver transplantation. Transjugular intrahepatic portosystemic shunt malposition, however, is not uncommon and may increase the complexity of transplantation.

Vasopressor Infusion During Prone Spine Surgery and Acute Renal Injury: A Retrospective Cohort Analysis.

BACKGROUND: Hypotension is associated with acute kidney injury, but vasopressors used to treat hypotension may also compromise renal function. We therefore tested the hypothesis that vasopressor infusion during complex spine surgery is not associated with impaired renal function. METHODS: In this retrospective cohort analysis, we considered adults who had complex spine surgery between January 2005 and September 2014 at the Cleveland Clinic Main Campus. Our primary outcome was postoperative estimated glomerular filtration rate. Secondarily, we evaluated renal function using Acute Kidney Injury Network criteria. We obtained data for 1814 surgeries, including 689 patients (38%) who were given intraoperative vasopressors infusion for ≥30 minutes and 1125 patients (62%) who were not. Five hundred forty patients with and 540 patients without vasopressor infusions were well matched across 32 potential confounding variables. RESULTS: In matched patients, vasopressor infusions lasted an average of 173 ± 100 minutes (SD) and were given a median dose (1st quintile, 3rd quintile) of 3.4-mg (1.5, 6.7 mg) phenylephrine equivalents. Mean arterial pressure and the amounts of hypotension were similar in each matched group. The postoperative difference in mean estimated glomerular filtration rate in patients with and without vasopressor infusions was only 0.8 mL/min/1.73 m (95% CI, -0.6 to 2.2 mL/min/1.73 m) (P = .28). Intraoperative vasopressor infusion was also not associated with increased odds of augmented acute kidney injury stage. CONCLUSIONS: Clinicians should not avoid typical perioperative doses of vasopressors for fear of promoting kidney injury. Tolerating hypotension to avoid vasopressor use would probably be a poor strategy.

A Randomized Trial of Continuous Noninvasive Blood Pressure Monitoring During Noncardiac Surgery.

BACKGROUND: Intraoperative hypotension is associated with postoperative mortality. Early detection of hypotension by continuous hemodynamic monitoring might prompt timely therapy, thereby reducing intraoperative hypotension. We tested the hypothesis that continuous noninvasive blood pressure monitoring reduces intraoperative hypotension. METHODS: Patients ≥45 years old with American Society of Anesthesiologists physical status III or IV having moderate-to-high-risk noncardiac surgery with general anesthesia were included. All participating patients had continuous noninvasive hemodynamic monitoring using a finger cuff (ClearSight, Edwards Lifesciences, Irvine, CA) and a standard oscillometric cuff. In half the patients, randomly assigned, clinicians were blinded to the continuous values, whereas the others (unblinded) had access to continuous blood pressure readings. Continuous pressures in both groups were used for analysis. Time-weighted average for mean arterial pressure <65 mm Hg was compared using 2-sample Wilcoxon rank-sum tests and Hodges Lehmann estimation of location shift with corresponding asymptotic 95% CI. RESULTS: Among 320 randomized patients, 316 were included in the intention-to-treat analysis. With 158 patients in each group, those assigned to continuous blood pressure monitoring had significantly lower time-weighted average mean arterial pressure <65 mm Hg, 0.05 [0.00, 0.22] mm Hg, versus intermittent blood pressure monitoring, 0.11 [0.00, 0.54] mm Hg (P = .039, significance criteria P < .048). CONCLUSIONS: Continuous noninvasive hemodynamic monitoring nearly halved the amount of intraoperative hypotension. Hypotension reduction with continuous monitoring, while statistically significant, is currently of uncertain clinical importance.

Effect of various durations of smoking cessation on postoperative outcomes: A retrospective cohort analysis.

BACKGROUND: Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes. However, it remains unclear for how long smoking cessation is necessary, and even whether a brief preoperative period of abstinence is helpful and well tolerated. OBJECTIVE: We evaluated associations between various periods of preoperative smoking cessation and major morbidity and death. DESIGN: Retrospective cohort analysis. SETTING: Adults who had noncardiac surgery at the Cleveland Clinic Main Campus between May 2007 and December 2013. PATIENTS: A total of 37 511 patients whose smoking history was identified from a preoperative Health Quest questionnaire. Of these patients, 26 269 (70%) were former smokers and 11 242 (30%) were current smokers. Of the current smokers, 9482 (84%) were propensity matched with 9482 former smokers (36%). We excluded patients with American Society of Anesthesiologists' physical status exceeding four, patients who did not have general anaesthesia, and patients with missing outcomes and/or covariables. When multiple procedures were performed within the study period, only the first operation for each patient was included in the analysis. MAIN OUTCOME MEASURES: The relationship between smoking cessation and in-hospital morbidity/mortality. RESULTS: The incidence of the primary composite of in-hospital morbidity/mortality was 6.9% (656/9482) for all former smokers; the incidence was 7.8% (152/1951) for patients who stopped smoking less than 1 year before surgery, 6.3% (118/1977) for 1 to 5 years, 7.2% (115/1596) for 5 to 10 years and 6.9% (271/3457) for more than 10 years. CONCLUSION: Smoking cessation was associated with reduced in-hospital morbidity and mortality which was independent of cessation interval.

The SLUScore: A Novel Method for Detecting Hazardous Hypotension in Adult Patients Undergoing Noncardiac Surgical Procedures.

BACKGROUND: It has been suggested that longer-term postsurgical outcome may be adversely affected by less than severe hypotension under anesthesia. However, evidence-based guidelines are unavailable. The present study was designed to develop a method for identifying patients at increased risk of death within 30 days in association with the severity and duration of intraoperative hypotension. METHODS: Intraoperative mean arterial blood pressure recordings of 152,445 adult patients undergoing noncardiac surgery were analyzed for periods of time accumulated below each one of the 31 thresholds between 75 and 45 mm Hg (hypotensive exposure times). In a development cohort of 35,904 patients, the associations were sought between each of these 31 cumulative hypotensive exposure times and 30-day postsurgical mortality. On the basis of covariable-adjusted percentage increases in the odds of mortality per minute elapsed of hypotensive exposure time, certain sets of exposure time limits were calculated that portended certain percentage increases in the odds of mortality. A novel risk-scoring method was conceived by counting the number of exposure time limits that had been exceeded within each respective set, one of them being called the SLUScore. The validity of this new method in identifying patients at increased risk was tested in a multicenter validation cohort consisting of 116,541 patients from Cleveland Clinic, Vanderbilt and Saint Louis Universities. Data were expressed as 95% confidence interval, P < .05 considered significant. RESULTS: Progressively greater hypotensive exposures were associated with greater 30-day mortality. In the development cohort, covariable-adjusted (age, Charlson score, case duration, history of hypertension) exposure limits were identified for time accumulated below each of the thresholds that portended certain identical (5%-50%) percentage expected increases in the odds of mortality. These exposure time limit sets were shorter in patients with a history of hypertension. A novel risk score, the SLUScore (range 0-31), was conceived as the number of exposure limits exceeded for one of these sets (20% set). A SLUScore > 0 (average 13.8) was found in 40% of patients who had twice the mortality, adjusted odds increasing by 5% per limit exceeded. When tested in the validation cohort, a SLUScore > 0 (average 14.1) identified 35% of patients who had twice the mortality, each incremental limit exceeded portending a 5% compounding increase in adjusted odds of mortality, independent of age and Charlson score (C = 0.73, 0.72-0.74, P < .05). CONCLUSIONS: The SLUScore represents a novel method for identifying nearly 1 in every 3 patients experiencing greater 30-day mortality portended by more severe intraoperative hypotensive exposures.

Estimated glomerular filtration rate better predicts 30-day mortality after non-cardiac surgery than serum creatinine: a retrospective analysis of 92,888 patients.

BACKGROUND: Serum creatinine is the most commonly used indicator of renal function, but its derivative, estimated glomerular filtration rate (eGFR), has been shown to be superior in non-surgical settings. It remains unknown if eGFR better predicts postoperative mortality in non-cardiac surgical patients. We thus tested the hypothesis that eGFR predicts 30-day mortality after non-cardiac surgery better than serum creatinine. METHODS: We evaluated patients who had inpatient non-cardiac surgery of at least one hour duration during January 2006 to December 2011 at the Cleveland Clinic Main Campus and whose preoperative serum creatinine was measured within 30 days before surgery. The eGFR was calculated using the Chronic Kidney Disease-Epidemiology Collaboration equation. Preoperative eGFR was compared in a multivariable analysis with preoperative serum creatinine (both assessed as continuous variables) on the ability to predict 30-day mortality in all patients. Secondarily, the comparison was made within subgroups based on amount of blood loss, blood transfusion, and sex. RESULTS: There were 92,888 patients included in the final analysis. The eGFR was a modestly better discriminator of 30-day mortality than serum creatinine, with an estimated c-statistic (95% confidence interval) of 0.67 (0.65 to 0.68) for eGFR vs 0.61 (0.59 to 0.63) for serum creatinine (P < 0.001). Furthermore, the eGFR was consistently a better discriminator of 30-day mortality across blood loss, transfusion, and sex groups. Reclassification analyses suggested improved individual predictions of 30-day mortality using eGFR compared with serum creatinine. Nevertheless, a multivariable combination of baseline characteristics of American Society of Anesthesiologists physical status, age, and body mass index (all P < 0.001) discriminated 30-day mortality with a c-statistic of 0.850. Adding eGFR to the model improved the c-statistic to only 0.851, while separately adding serum creatinine did not change the c-statistic. CONCLUSION: The eGFR is a modestly better predictor of 30-day mortality than serum creatinine in patients having inpatient non-cardiac surgery. Given that eGFR is often reported by clinical laboratories and is otherwise easy to calculate, it should generally be used in preference to creatinine alone.

Comparison of clonidine and midazolam premedication before endoscopic sinus surgery: results of clinical trial.

OBJECTIVES: Premedication with clonidine has been found to reduce the bleeding during endoscopic sinus surgery (ESS), therefore lowering the risk of surgical complications. Premedication is an essential part of pre-surgical care and can potentially affect magnitude of systemic stress response to a surgical procedure. The aim of this study was to compare the efficacy of premedication with clonidine and midazolam in patients undergoing sinus surgery. METHODS: Forty-four patients undergoing ESS for chronic sinusitis and polyp removal were enrolled and randomly assigned to receive either oral clonidine or midazolam as a premedication before receiving propofol/remifentanil total intravenous anesthesia. The effect of this premedication choice on anesthetic requirements, intraoperative hemodynamic profile, preoperative anxiety and sedation as well as postoperative pain and shivering were examined in each premedication group. RESULTS: Total intraoperative remifentanil requirement was lower in the clonidine group as compared to the midazolam group 503.2±147.0 µg vs. 784.5±283.8 µg, respectively (P<0.001). There was no difference between groups in required induction dose of propofol, level of preoperative anxiety, level of sedation and postoperative shivering. Intraoperative systemic blood pressure and heart rate response had a more favorable profile in patients premedicated with clonidine. Postoperative pain assessed by visual analogue scale for pain was lower in the clonidine group compared with to the midazolam premedication group. CONCLUSION: Premedication with clonidine provides better attenuation of hemodynamic response and reduction of intraoperative remifentanil requirements in patients undergoing ESS. Postoperative pain seems to be better controlled after clonidine premedication as well.

Improved quality of surgical field during endoscopic sinus surgery after clonidine premedication--a pilot study.

BACKGROUND: Inadequate surgical field visualization due to intraoperative bleeding during endoscopic sinus surgery (ESS) can cause major complications. The aim of this prospective study was to compare the effect of preoperative administration of clonidine and melatonin on the quality of the surgical field visualization and selected aspects of presurgical premedication. METHODS: Twenty-six patients undergoing ESS for chronic sinusitis and polyp removal were enrolled and randomly assigned to receive either oral clonidine or melatonin as preoperative premedication. During the operation, the quality of the surgical field was assessed and graded using the scale proposed by Boezaart. The evaluations were done at 15, 30, and 60 minutes after incision. The effect of this premedication choice on the intraoperative and postoperative hemodynamic profile was examined in each group. Anxiolytic effects of both premedication agents were assessed using the visual analogue scale for anxiety (VAS-A). Propofol dose and induction time (the time for bispectral index [BIS] to reach 45), anesthesia and surgical procedures time, and recovery time (the time for BIS to reach 90) were assessed in both groups as well. RESULTS: The quality of the surgical field was consistently better in 2 of 3 time points in the clonidine group. Perioperative mean arterial pressure and intraoperative heart rate had a more favorable profile in patients premedicated with clonidine. There were no differences in other measured parameters between groups. CONCLUSION: Premedication with clonidine before ESS provides better quality of surgical field and more favorable hemodynamic profile as compared to melatonin.

Prediction of intraoperative transfusion requirements during orthotopic liver transplantation and the influence on postoperative patient survival.

BACKGROUND: Predicting blood product transfusion requirements during orthotopic liver transplantation (OLT) remains difficult. Our primary aim in this study was to determine which patient variables best predict recipient risk for large blood transfusion requirements during OLT. The secondary aim was to determine whether the amount of blood products transfused during OLT impacted patient survival. METHODS: Eight hundred four primary adult OLTs performed during a 9-year period were retrospectively analyzed, and predictive models were developed for blood product usage, usage >20 and usage >30 units of red blood cells (RBCs) plus cell salvage (CS). For survival analysis, potential predictors included all blood products administered during OLT. RESULTS: For analyses of RBC + CS usage, we used several statistical techniques: regression analysis, logistic regression, and classification and regression tree analysis. Several preoperative factors were highly statistically significant predictors of intraoperative blood product usage in each of the analyses, namely lower platelet count and higher Model for End-Stage Liver Disease Score or one or more of its components (creatinine, total bilirubin, international normalized ratio). Despite these highly significant associations, the models were unable to predict reliably that patients might require the largest amount of blood products during OLT. For example, the classification and regression tree analyses were able to predict only 32% and 11% of patients requiring >20 and >30 units of RBC + CS, respectively. Survival analysis demonstrated poorer survival among patients receiving larger amounts of RBC + CS during OLT. CONCLUSION: Prediction of intraoperative blood product requirements based on preoperatively available variables is unreliable; however, there is a strong measurable association between transfusion and postoperative mortality.

Perioperative management of face transplantation: a survey.

BACKGROUND: Since the first facial allograft transplantation was reported in France in 2005, 18 cases have been performed in 4 countries and the rate is increasing. METHODS: We have devised a survey to assess anesthesia-related management and rationale of facial allograft transplantation. It was sent to the lead anesthesiologists of the first 14 face transplants performed worldwide. RESULTS: Responses were received corresponding to 13 face transplants. The median duration of surgery and anesthesia was 19 hours (95% confidence interval 15-23 hours). The surgical preparation and dissection of multiple small anatomical structures of the recipient was time-consuming for 11 cases. Blood loss was considerable. All patients received packed red blood cells (median 20 U, 95% confidence interval 5-28 U). A median of 13 L of crystalloid was administered (95% confidence interval 10-18 L). CONCLUSIONS: During facial allograft transplantation, the anesthesiologist must be prepared for a long anesthetic with rapid blood loss after reperfusion of the graft.

Association of red blood cell transfusion and postoperative outcomes after endovascular aortic repair.

BACKGROUND: Several studies have documented worse postoperative outcomes in patients who received red blood cell (RBC) transfusion perioperatively during cardiac surgery or in critical care settings. These findings were attributed to activation of the inflammatory response with the release of cytokines and immune suppression. The aim of this study was to evaluate the association of RBC transfusion on the day of surgery and postoperative outcomes following endovascular aortic repair (EVAR). METHODS: A total of 510 patients who underwent EVAR from April 2005 to March 2007 were considered for analysis. The exposure of interest was whether or not patients receive RBC transfusion on the day of surgery. The primary outcome was a composite in-hospital morbidity/mortality outcome. The authors assessed the association between RBC transfusion and our composite outcome using logistic regression after adjusting for the available potential confounders using propensity score matching. RESULTS: Propensity scores were estimated for 418 out of the 510 patients; 92 patients were not included because of missing data. Propensity matching resulted in 42 successfully matched pairs. Median (quartiles) propensity score was 0.46 (0.28, 0.66) for the matched patients with transfusion and 0.46 (0.29, 0.61) for the matched patients without transfusion (P = .75, Wilcoxon rank sum test). Results of the multivariable model developed after propensity score matching suggest that RBC transfusion was not significantly associated with experiencing a postoperative complication; estimated odds ratio (95% confidence interval) of 2.7 (0.8, 9.0), P = .11. CONCLUSION: In this study, RBC transfusion was not independently associated with an increased incidence of in-hospital morbidity and mortality after EVAR.

Validation of the DeLiT Trial intravenous insulin infusion algorithm for intraoperative glucose control in noncardiac surgery: a randomized controlled trial.

PURPOSE: A safe and effective insulin infusion algorithm that achieves rigorous intraoperative glycemic control in noncardiac surgery has yet to be formally characterized and evaluated. We therefore report the validation of the DeLit Trial insulin infusion algorithm. METHODS: Patients scheduled for major noncardiac surgery were randomized to a target intraoperative blood glucose concentration of 4.4-6.1 mmoL·L(-1) (80-110 mg·dL(-1)) intensive group or 10-11.1 mmoL·L(-1) (180-200 mg·dL(-1)) conventional group. Glucose was managed with a dynamic intravenous insulin infusion algorithm. We compared the randomized groups on glucose time-weighted average (TWA), proportion of time spent within target, number of severe (< 2.2 mmoL·L(-1) or < 40 mg·dL(-1)) or moderate (< 2.8 mmoL·L(-1) or < 50 mg·dL(-1)) hypoglycemic episodes, and within-patient variability in glucose concentrations expressed as standard deviation from the patient mean. RESULTS: One hundred eighty-seven patients were assigned to intensive glucose control, and 177 patients were assigned to conventional glucose control. Median (lower quartile value [Q1], upper quartile value [Q3]) of intraoperative TWA for the intensive vs conventional groups was 6 [5.6, 6.7] mmoL·L(-1) vs 7.7 [6.9, 9.2] mmoL·L(-1), respectively; P < 0.001. The intensive group spent 49% (29, 71) of the time within target, substantially more time than the conventional group spent either within the intensive target or within its own target (both P < 0.001). The intensive group had slightly lower within-patient glucose variability than the conventional group (0.9 [0.7, 1.3] mmoL·L(-1) vs 1.3 [0.8, 1.8] mmoL·L(-1), respectively; P < 0.001). Three patients had moderate hypoglycemia (intensive group), but none experienced severe episodes. CONCLUSION: Tight intraoperative glucose control in noncardiac surgery can be maintained successfully without serious hypoglycemic episodes. (ClinicalTrials.gov number, NCT00433251).

Predictors of prolonged postoperative endotracheal intubation in patients undergoing thoracotomy for lung resection.

OBJECTIVE: The aim of this study was to identify predictors of delayed endotracheal extubation defined as the need for postoperative ventilatory support after open thoracotomy for lung resection. DESIGN: An observational cohort investigation. SETTING: A tertiary referral center. PARTICIPANTS: The study population consisted of 2,068 patients who had open thoracotomy for pneumonectomy, lobectomy, or segmental lung resection between January 1996 and December 2005. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Preoperative and intraoperative variables were collected concurrently with the patient's care. Risk factors were identified using logistic regression with stepwise variable selection procedure on 1,000 bootstrap resamples, and a bagging algorithm was used to summarize the results. Intraoperative red blood cell transfusion, higher preoperative serum creatinine level, absence of a thoracic epidural catheter, more extensive surgical resection, and lower preoperative FEV(1) were associated with an increased risk of delayed extubation after lung resection. CONCLUSION: Most predictors of delayed postoperative extubation (ie, red blood cell transfusion, higher preoperative serum creatinine, lower preoperative FEV(1), and more extensive lung resection) are difficult to modify in the perioperative period and probably represent greater severity of underlying lung disease and more advanced comorbid conditions. However, thoracic epidural anesthesia and analgesia is a modifiable factor that was associated with reduced odds for postoperative ventilatory support. Thus, the use of epidural analgesia may reduce the need for post-thoracotomy mechanical ventilation.