Efficacy of parasternal peripheral nerve catheters versus no block for median sternotomy: a single-centre retrospective study.

Background: Sternal pain after cardiac surgery results in considerable discomfort. Single-injection parasternal fascial plane blocks have been shown to reduce pain scores and opioid consumption during the first 24 h after surgery, but the efficacy of continuous infusion has not been evaluated. This retrospective cohort study examined the effect of a continuous infusion of local anaesthetic through parasternal catheters on the integrated Pain Intensity and Opioid Consumption (PIOC) score up to 72 h. Methods: We performed a retrospective analysis of patients undergoing cardiac surgery with median sternotomy at a single academic centre before and after the addition of parasternal nerve catheters to a standard multimodal analgesic protocol. Outcomes included PIOC score, total opioid consumption in oral morphine equivalents, and time-weighted area under the curve pain scores up to 72 h after surgery. Results: Continuous infusion of ropivacaine 0.1% through parasternal catheters resulted in a significant reduction in PIOC scores at 24 h (-62, 95% confidence interval -108 to -16; P<0.01) and 48 h (-50, 95% CI -97 to -2.2; P=0.04) compared with no block. A significant reduction in opioid consumption up to 72 h was the primary factor in reduction of PIOC. Conclusions: This study suggests that continuous infusion of local anaesthetic through parasternal catheters may be a useful addition to a multimodal analgesic protocol in patients undergoing cardiac surgery with sternotomy. Further prospective study is warranted to determine the full benefits of continuous infusion compared with single injection or no block.

Benefits and harms of perioperative high fraction inspired oxygen for surgical site infection prevention: a protocol for a systematic review and meta-analysis of individual patient data of randomised controlled trials.

INTRODUCTION: The use of high fraction of inspired oxygen (FiO2) intraoperatively for the prevention of surgical site infection (SSI) remains controversial. Promising results of early randomised controlled trials (RCT) have been replicated with varying success and subsequent meta-analysis are equivocal. Recent advancements in perioperative care, including the increased use of laparoscopic surgery and pneumoperitoneum and shifts in fluid and temperature management, can affect peripheral oxygen delivery and may explain the inconsistency in reproducibility. However, the published data provides insufficient detail on the participant level to test these hypotheses. The purpose of this individual participant data meta-analysis is to assess the described benefits and harms of intraoperative high FiO2compared with regular (0.21-0.40) FiO2 and its potential effect modifiers. METHODS AND ANALYSIS: Two reviewers will search medical databases and online trial registries, including MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and WHO regional databases, for randomised and quasi-RCT comparing the effect of intraoperative high FiO2 (0.60-1.00) to regular FiO2 (0.21-0.40) on SSI within 90 days after surgery in adult patients. Secondary outcome will be all-cause mortality within the longest available follow-up. Investigators of the identified trials will be invited to collaborate. Data will be analysed with the one-step approach using the generalised linear mixed model framework and the statistical model appropriate for the type of outcome being analysed (logistic and cox regression, respectively), with a random treatment effect term to account for the clustering of patients within studies. The bias will be assessed using the Cochrane risk-of-bias tool for randomised trials V.2 and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation methodology. Prespecified subgroup analyses include use of mechanical ventilation, nitrous oxide, preoperative antibiotic prophylaxis, temperature (<35°C), fluid supplementation (<15 mL/kg/hour) and procedure duration (>2.5 hour). ETHICS AND DISSEMINATION: Ethics approval is not required. Investigators will deidentify individual participant data before it is shared. The results will be submitted to a peer-review journal. PROSPERO REGISTRATION NUMBER: CRD42018090261.

Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free): A Protocol for a Multi-centre Randomized Cluster Crossover Trial.

Delirium is common after cardiac surgery and is associated with adverse outcomes. Administration of benzodiazepines before and after cardiac surgery is associated with delirium; guidelines recommend minimizing their use. Benzodiazepine administration during cardiac surgery remains common because of its recognized benefits. The Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free) trial is a randomized cluster crossover trial evaluating whether an institutional policy of restricting intraoperative benzodiazepine administration (ie, ≥ 90% of patients do not receive benzodiazepines during cardiac surgery), as compared with a policy of liberal intraoperative benzodiazepine administration (ie, ≥ 90% of patients receive ≥ 0.03 mg/kg midazolam equivalent), reduces delirium. Hospitals performing ≥ 250 cardiac surgeries a year are included if their cardiac anesthesia group agrees to apply both benzodiazepine policies per their randomization, and patients are assessed for postoperative delirium every 12 hours in routine clinical care. Hospitals apply the restricted or liberal benzodiazepine policy during 12 to 18 crossover periods of 4 weeks each. Randomization for all periods takes place in advance of site startup; sites are notified of their allocated policy during the last week of each crossover period. Policies are applied to all patients undergoing cardiac surgery during the trial period. The primary outcome is the incidence of delirium at up to 72 hours after surgery. The B-Free trial will enroll ≥ 18,000 patients undergoing cardiac surgery at 20 hospitals across North America. Delirium is common after cardiac surgery, and benzodiazepines are associated with the occurrence of delirium. The B-Free trial will determine whether an institutional policy restricting the administration of benzodiazepines during cardiac surgery reduces the incidence of delirium after cardiac surgery. Clinicaltrials.gov registration number: NCT03928236 (First registered April 26, 2019).

L'état confusionnel est fréquent après une chirurgie cardiaque et il est associé à des complications. L'administration de benzodiazépines avant et après une chirurgie cardiaque est associée à l'état confusionnel; dans les lignes directrices, on recommande de réduire leur utilisation au minimum. L'administration de benzodiazépines pendant une chirurgie cardiaque demeure fréquente, en raison des leurs bienfaits reconnus. L'essai B-Free (Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium ou l'anesthésie sans benzodiazépine en contexte de chirurgie cardiaque pour la réduction de l'état confusionnel postopératoire) est un essai à répartition aléatoire par grappes et avec permutation, visant à évaluer si une politique institutionnelle de restriction de l'administration peropératoire de benzodiazépines (c.-à-d. que ≥ 90 % des patients ne reçoivent pas de benzodiazépines durant une chirurgie cardiaque) réduit l'état confusionnel, comparativement à une politique d'administration peropératoire libérale de benzodiazépines (c.-à-d. que ≥ 90 % des patients reçoivent ≥ 0,03 mg/kg d'équivalent du midazolam). Des hôpitaux effectuant au moins 250 chirurgies cardiaques par année sont inclus dans l'essai si leurs équipes d'anesthésie cardiaque acceptent d'appliquer les deux politiques relatives aux benzodiazépines en vertu de la répartition aléatoire et si les patients sont évalués toutes les 12 heures, en ce qui a trait à l'état confusionnel postopératoire, dans le cadre des soins cliniques habituels. Les hôpitaux mettent en œuvre la politique d'administration restreinte ou libérale de benzodiazépines durant 12 à 18 périodes de permutation de 4 semaines chacune. La répartition aléatoire de l'ensemble des périodes a lieu avant le début de l'essai à l'hôpital; les établissements sont avisés de la politique qui leur est attribuée au cours de la dernière semaine de chaque période de permutation. Les politiques sont appliquées à tous les patients qui subissent une chirurgie cardiaque durant la période de l'essai. Le critère d'évaluation principal est l'incidence de l'état confusionnel dans les 72 heures suivant l'intervention chirurgicale. L'étude B-Free inclura au moins 18 000 patients qui subiront une chirurgie cardiaque dans 20 hôpitaux en l'Amérique du Nord. L'état confusionnel est fréquent après une chirurgie cardiaque, et les benzodiazépines sont associées à la survenue de l'état confusionnel. L'essai B-Free permettra de déterminer si une politique institutionnelle de restriction de l'administration de benzodiazépines durant une chirurgie cardiaque réduit l'incidence de l'état confusionnel après une telle chirurgie.Clinicaltrials.gov registration number: NCT03928236 (First registered April 26, 2019).

Benzodiazepines and postoperative delirium: should we be as cautious as we are?

A recent systematic review and meta-analysis by Wang and colleagues in the British Journal of Anaesthesia calls into question the concept that perioperative benzodiazepine administration is associated with development of postoperative delirium in older individuals after anaesthesia and surgery. This editorial focuses on potential bias within the systematic review and addresses major concerns surrounding benzodiazepine use in the older perioperative population.

Baseline Intraoperative Left Ventricular Diastolic Function Is Associated with Postoperative Atrial Fibrillation after Cardiac Surgery.

BACKGROUND: Detailed understanding of the association between intraoperative left atrial and left ventricular diastolic function and postoperative atrial fibrillation is lacking. In this post hoc analysis of the Posterior Left Pericardiotomy for the Prevention of Atrial Fibrillation after Cardiac Surgery (PALACS) trial, we aimed to evaluate the association of intraoperative left atrial and left ventricular diastolic function as assessed by transesophageal echocardiography (TEE) with postoperative atrial fibrillation. METHODS: PALACS patients with available intraoperative TEE data (n = 402 of 420; 95.7%) were included in this cohort study. We tested the hypotheses that preoperative left atrial size and function, left ventricular diastolic function, and their intraoperative changes were associated with postoperative atrial fibrillation. Normal left ventricular diastolic function was graded as 0 and with lateral e' velocity 10 cm/s or greater. Diastolic dysfunction was defined as lateral e' less than 10 cm/s using E/e' cutoffs of grade 1, E/e' 8 or less; grade, 2 E/e' 9 to 12; and grade 3, E/e' 13 or greater, along with two criteria based on mitral inflow and pulmonary wave flow velocities. RESULTS: A total of 230 of 402 patients (57.2%) had intraoperative diastolic dysfunction. Posterior pericardiotomy intervention was not significantly different between the two groups. A total of 99 of 402 patients (24.6%) developed postoperative atrial fibrillation. Patients who developed postoperative atrial fibrillation more frequently had abnormal left ventricular diastolic function compared to patients who did not develop postoperative atrial fibrillation (75.0% [n = 161 of 303] vs. 57.5% [n = 69 of 99]; P = 0.004). Of the left atrial size and function parameters, only delta left atrial area, defined as presternotomy minus post-chest closure measurement, was significantly different in the no postoperative atrial fibrillation versus postoperative atrial fibrillation groups on univariate analysis (-2.1 cm2 [interquartile range, -5.1 to 1.0] vs. 0.1 [interquartile range, -4.0 to 4.8]; P = 0.028). At multivariable analysis, baseline abnormal left ventricular diastolic function (odds ratio, 2.02; 95% CI, 1.15 to 3.63; P = 0.016) and pericardiotomy intervention (odds ratio, 0.46; 95% CI, 0.27 to 0.78, P = 0.004) were the only covariates independently associated with postoperative atrial fibrillation. CONCLUSIONS: Baseline preoperative left ventricular diastolic dysfunction on TEE, not left atrial size or function, is independently associated with postoperative atrial fibrillation. Further studies are needed to test if interventions aimed at optimizing intraoperative left ventricular diastolic function during cardiac surgery may reduce the risk of postoperative atrial fibrillation.

Antiemetic Administration and Its Association with Race: A Retrospective Cohort Study.

BACKGROUND: Anesthesiologists' contribution to perioperative healthcare disparities remains unclear because patient and surgeon preferences can influence care choices. Postoperative nausea and vomiting is a patient- centered outcome measure and a main driver of unplanned admissions. Antiemetic administration is under the sole domain of anesthesiologists. In a U.S. sample, Medicaid insured versus commercially insured patients and those with lower versus higher median income had reduced antiemetic administration, but not all risk factors were controlled for. This study examined whether a patient's race is associated with perioperative antiemetic administration and hypothesized that Black versus White race is associated with reduced receipt of antiemetics. METHODS: An analysis was performed of 2004 to 2018 Multicenter Perioperative Outcomes Group data. The primary outcome of interest was administration of either ondansetron or dexamethasone; secondary outcomes were administration of each drug individually or both drugs together. The confounder-adjusted analysis included relevant patient demographics (Apfel postoperative nausea and vomiting risk factors: sex, smoking history, postoperative nausea and vomiting or motion sickness history, and postoperative opioid use; as well as age) and included institutions as random effects. RESULTS: The Multicenter Perioperative Outcomes Group data contained 5.1 million anesthetic cases from 39 institutions located in the United States and The Netherlands. Multivariable regression demonstrates that Black patients were less likely to receive antiemetic administration with either ondansetron or dexamethasone than White patients (290,208 of 496,456 [58.5%] vs. 2.24 million of 3.49 million [64.1%]; adjusted odds ratio, 0.82; 95% CI, 0.81 to 0.82; P < 0.001). Black as compared to White patients were less likely to receive any dexamethasone (140,642 of 496,456 [28.3%] vs. 1.29 million of 3.49 million [37.0%]; adjusted odds ratio, 0.78; 95% CI, 0.77 to 0.78; P < 0.001), any ondansetron (262,086 of 496,456 [52.8%] vs. 1.96 million of 3.49 million [56.1%]; adjusted odds ratio, 0.84; 95% CI, 0.84 to 0.85; P < 0.001), and dexamethasone and ondansetron together (112,520 of 496,456 [22.7%] vs. 1.0 million of 3.49 million [28.9%]; adjusted odds ratio, 0.78; 95% CI, 0.77 to 0.79; P < 0.001). CONCLUSIONS: In a perioperative registry data set, Black versus White patient race was associated with less antiemetic administration, after controlling for all accepted postoperative nausea and vomiting risk factors.

Postoperative pericardial effusion, pericardiotomy, and atrial fibrillation: An explanatory analysis of the PALACS trial.

BACKGROUND: In the Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery (PALACS) trial, posterior pericardiotomy was associated with a significant reduction in postoperative atrial fibrillation (POAF) after cardiac surgery. We aimed to investigate the mechanisms underlying this effect. METHODS: We included PALACS patients with available echocardiographic data (n = 387/420, 92%). We tested the hypotheses that the reduction in POAF with the intervention was associated with 1) a reduction in postoperative pericardial effusion and/or 2) an effect on left atrial size and function. Spline and multivariable logistic regression analyses were used. RESULTS: Most patients (n = 307, 79%) had postoperative pericardial effusions (anterior 68%, postero-lateral 51.9%). The incidence of postero-lateral effusion was significantly lower in patients undergoing pericardiotomy (37% vs 67%; P < .001). The median size of anterior effusion was comparable between patients with and without POAF (5.0 [IQR 3.0-7.0] vs 5.0 [IQR 3.0-7.5] mm; P = .42), but there was a nonsignificant trend towards larger postero-lateral effusion in the POAF group (5.0 [IQR 3.0-9.0] vs 4.0 [IQR 3.0-6.4] mm; P = .06). There was a non-linear association between postero-lateral effusion and POAF at a cut-off at 10 mm (OR 2.70; 95% CI 1.13, 6.47; P = .03) that was confirmed in multivariable analysis (OR 3.5, 95% CI 1.17, 10.58; P = 0.02). Left atrial dimension and function did not change significantly after posterior pericardiotomy. CONCLUSIONS: Reduction in postero-lateral pericardial effusion is a plausible mechanism for the effect of posterior pericardiotomy in reducing POAF. Measures to reduce postoperative pericardial effusion are a promising approach to prevent POAF.

Connected consciousness after tracheal intubation in young adults: an international multicentre cohort study.

BACKGROUND: Connected consciousness, assessed by response to command, occurs in at least 5% of general anaesthetic procedures and perhaps more often in young people. Our primary objective was to establish the incidence of connected consciousness after tracheal intubation in young people aged 18-40 yr. The secondary objectives were to assess the nature of these responses, identify relevant risk factors, and determine their relationship to postoperative outcomes. METHODS: This was an international, multicentre prospective cohort study using the isolated forearm technique to assess connected consciousness shortly after tracheal intubation. RESULTS: Of 344 enrolled subjects, 338 completed the study (mean age, 30 [standard deviation, 6.3] yr; 232 [69%] female). Responses after intubation occurred in 37/338 subjects (11%). Females (13%, 31/232) responded more often than males (6%, 6/106). In logistic regression, the risk of responsiveness was increased with female sex (odds ratio [ORadjusted]=2.7; 95% confidence interval [CI], 1.1-7.6; P=0.022) and was decreased with continuous anaesthesia before laryngoscopy (ORadjusted=0.43; 95% CI, 0.20-0.96; P=0.041). Responses were more likely to occur after a command to respond (and not to nonsense, 13 subjects) than after a nonsense statement (and not to command, four subjects, P=0.049). CONCLUSIONS: Connected consciousness occured after intubation in 11% of young adults, with females at increased risk. Continuous exposure to anaesthesia between induction of anaesthesia and tracheal intubation should be considered to reduce the incidence of connected consciousness. Further research is required to understand sex-related differences in the risk of connected consciousness.

Anaesthetic depth and delirium after major surgery: a randomised clinical trial.

BACKGROUND: Postoperative delirium is a serious complication of surgery associated with prolonged hospitalisation, long-term cognitive decline, and mortality. This study aimed to determine whether targeting bispectral index (BIS) readings of 50 (light anaesthesia) was associated with a lower incidence of POD than targeting BIS readings of 35 (deep anaesthesia). METHODS: This multicentre randomised clinical trial of 655 at-risk patients undergoing major surgery from eight centres in three countries assessed delirium for 5 days postoperatively using the 3 min confusion assessment method (3D-CAM) or CAM-ICU, and cognitive screening using the Mini-Mental State Examination at baseline and discharge and the Abbreviated Mental Test score (AMTS) at 30 days and 1 yr. Patients were assigned to light or deep anaesthesia. The primary outcome was the presence of postoperative delirium on any of the first 5 postoperative days. Secondary outcomes included mortality at 1 yr, cognitive decline at discharge, cognitive impairment at 30 days and 1 yr, unplanned ICU admission, length of stay, and time in electroencephalographic burst suppression. RESULTS: The incidence of postoperative delirium in the BIS 50 group was 19% and in the BIS 35 group was 28% (odds ratio 0.58 [95% confidence interval: 0.38-0.88]; P=0.010). At 1 yr, those in the BIS 50 group demonstrated significantly better cognitive function than those in the BIS 35 group (9% with AMTS ≤6 vs 20%; P<0.001). CONCLUSIONS: Among patients undergoing major surgery, targeting light anaesthesia reduced the risk of postoperative delirium and cognitive impairment at 1 yr. CLINICAL TRIAL REGISTRATION: ACTRN12612000632897.

Adoption of video laryngoscopy by a major academic anesthesia department.

Aim: To describe the adoption patterns of intubating devices used at a major teaching and research facility. Materials & methods: Retrospective analysis of 2012-2019 data on frequency and trends in airway management devices collected from our anesthesia information management system. Results: Use of direct laryngoscopy was more frequent, but there was a downward trend in use over time (p < 0.008) in favor of video laryngoscopy (VL), which increased significantly (p < 0.008). The largest growth among devices was the McGrath VL, which increased from 0.2% in 2012 to 36.2% of cases in 2019. Conclusion: Our study shows a clear increase in VL usage which has implications in quality of care and medical education.

Post-operative outcomes and anesthesia type in total hip arthroplasty in patients with obstructive sleep apnea: A retrospective analysis of the State Inpatient Databases.

STUDY OBJECTIVES: To investigate postoperative outcomes following total hip arthroplasty (THA) in patients with obstructive sleep apnea (OSA). To evaluate trends in the use of regional anesthesia (RA) versus general anesthesia (GA) following the publication of practical guidelines. To compare postoperative outcomes according to anesthesia type. DESIGN: Retrospective analysis. SETTING: Operating room. PATIENTS: 349,008 patients who underwent elective THA in Florida, New York, Maryland, and Kentucky between 2007 and 2014 were extracted from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, including 18,063 patients with OSA (5.2%). INTERVENTIONS: No intervention. MEASUREMENTS: The effect of OSA on postoperative outcomes was investigated using bivariate analysis and multivariable logistic regression models. Outcomes studied included in-hospital mortality, postoperative complications, length of stay (LOS), and post-discharge readmissions. In a population from New York only, (n = 105,838 with 5306 patients with OSA [5.0%]), we investigated the outcomes in the OSA population according to the anesthesia type. Analysis was performed overall and for each individual year. MAIN RESULTS: The OSA prevalence increased from 1.7% in 2007 to 7.1% in 2014. In multivariable analysis, there was no effect of OSA on in-hospital mortality (aOR:0.57; 0.31-1.04). Postoperative complications, LOS, and readmission rates were all higher in patients with OSA. In patients with OSA receiving GA than those receiving RA, we found a higher rate of complications overall and pulmonary complications specifically in men and higher rate of 90-day readmission in women. Over the study period, the rate of GA use in patients with OSA increased. CONCLUSIONS: The OSA prevalence in patients undergoing THA increased fourfold over the study period. OSA was associated with increased overall postoperative complications, LOS, and readmission, but not with in-hospital mortality. Despite the publication of guidelines favoring RA over GA, the use of GA increased over the study period.

Differential Effects of Aortic Valve Replacement on Aortic Circumferential Strain in Aortic Stenosis and Aortic Insufficiency.

OBJECTIVES: Aortic valve replacement (AVR) potentially can modify pulse-wave propagation to the distal aorta. Echo-derived global circumferential strain (GCS) was used to test whether AVR for aortic stenosis (AS) or aortic insufficiency (AI) resulted in differential aortic biomechanics in the descending thoracic aorta. DESIGN: This was a prospective observational study of patients who underwent cardiac surgery between 2016 and 2019. SETTING: Weill Cornell Medicine, a single large academic medical center. PARTICIPANTS: The population comprised 48 patients undergoing AVR (62 ± 15 y/o, 79% male; 22 with AI and 26 with AS) and 11 patients undergoing coronary bypass surgery as controls. INTERVENTIONS: Elective cardiac surgery, transesophageal echocardiography (TEE), pulmonary artery catheter. MEASUREMENTS AND MAIN RESULTS: Pre- and postprocedural TEEs were collected. Descending aorta short-axis images were analyzed for GCS, time-to-peak strain, aortic end-diastolic, end-systolic area, and fractional area changes. Pulse pressure (PP) and stroke volume were quantified. Preprocedural GCS significantly differed between patients with AI and AS, with AI patients having greater GCS (median/interquartile range, 9.6 95.3,13.6) than patients with AS (4.3 [3.4-5.1]). After AVR, in AI patients, strain significantly decreased (5.5 [3.8,8.2], p = 0.001), along with PP (mean ± standard deviation) (66.4 ± 0.8 to 54.1 ± 13.7, p < 0.001), and PP corrected strain did not (GCS/PP = 14.8 [6.9-19.9] v 12.7[8.2-18.6], p = 0.34). In AS patients, GCS significantly increased after AVR to (5.45 [4.2-6.8], p = 0.003), as did PP-corrected strain (6.9 [5.8-9.2] v 9.7 [6.5-13.4], p = 0.016). Surgical AVR produced decrements in time-to-peak strain in AI and AS groups (both p < 0.001). CONCLUSIONS: After AVR for AI and AS, the direction of change in distal aortic strain from baseline depends on valve pathology. This finding may have important clinical implications in terms of indication for surgery and postoperative surveillance, especially in patients with aortopathies.

Dose-response relationship between local anesthetic volume and hemidiaphragmatic paresis following ultrasound-guided supraclavicular brachial plexus blockade.

BACKGROUND: There is no consensus regarding what volume of local anesthetic should be used to achieve successful supraclavicular block while minimizing hemidiaphragmatic paresis (HDP). This study investigated the dose-response relationship between local anesthetic volume and HDP after ultrasound-guided supraclavicular brachial plexus block. METHODS: A dose escalation design was used to define the dose response curve for local anesthetic volume and incidence of HDP in subjects undergoing upper extremity surgery with supraclavicular block as the primary anesthetic. Dosing levels of 5, 10, 15, 20, 25, 30, 35 and 40 mL of local anesthetic were administered in cohorts of three subjects per dose. Diaphragm function was assessed with M-mode ultrasound before and after block. Secondary objectives included assessment of negative inspiratory force (NIF), oxygen saturation, subjective dyspnea and extent of sensory and motor blockade. RESULTS: Twenty-one subjects completed the study. HDP was present at all doses, with an incidence of 33% at 5 mL to 100% at 30-35 mL. There was a significant decrease in NIF (7.5 cmH2O, IQR (22,0); p=0.01) and oxygen saturation on room air (1%, IQR (2,0); p=0.01) 30 min postblock in subjects experiencing HDP but not in those without HDP. There was no increase in dyspnea in subjects with or without HDP. No subject required respiratory intervention. Motor and sensory block improved with increasing dose, and subjects with HDP exhibited denser blocks than those without (p<0.01). CONCLUSIONS: There is no clinically relevant volume of local anesthetic at which HDP can be avoided when performing a supraclavicular block. In our subject population free of respiratory disease, HDP was well tolerated. TRIAL REGISTRATION NUMBER: NCT03138577.

Two- or 3-Dimensional Echocardiography-Derived Cardiac Output Cannot Replace the Pulmonary Artery Catheter in Cardiac Surgery.

OBJECTIVES: Three-dimensional (3D) transesophageal echocardiography (TEE) has been shown to be more accurate than 2D TEE for the evaluation of the left ventricular outflow tract area. The aim of the present study was to compare the agreement of 3D echocardiography-derived cardiac output (CO) with thermodilution-derived CO (TDCO) before and after cardiopulmonary bypass (CPB). DESIGN: This was a prospective observational study of patients who underwent cardiac surgery between 2016 and 2018. SETTING: Weill Cornell Medicine, a single large academic medical center. PARTICIPANTS: The study comprised 78 patients undergoing elective cardiac surgery. INTERVENTIONS: CPB, TEE, pulmonary artery catheter, and elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Two-dimensional CO, 3D CO-diameter, and 3D CO-area values pre-CPB were strongly correlated with one another both pre-CPB and post-CPB. The 3D CO-diameter and the 3D CO-area were mildly correlated, with TDCO measurements pre-CPB (r = 0.46 and 0.39, respectively) and post-CBP (r = 0.43 and 0.47, respectively). Pre-CPB 3D CO-diameter had the most agreement with TDCO in terms of bias (-0.13 L/min); however, the limits of agreement (LOA) were wide (-2.2- to- 2.45 L/min). Post-CPB, 3D CO-diameter had the most agreement with TDCO in terms of bias (0.41) but with wide LOA (-3.29 to 2.47). All pre-CPB echocardiography-derived CO (2D CO, 3D CO-diameter, 3D CO-area) had more agreement with TDCO than did post-CPB measurements. CONCLUSIONS: Three-dimensional CO measurements were only modestly correlated with pulmonary artery catheter-derived CO pre-bypass and post-bypass. Despite low bias, the wide LOA from 2D CO, 3D CO-diameter, and 3D-area compared with TDCO suggested that the 2 methods are not interchangeable.

Differential myocardial strain in the early postoperative period in patients receiving arterial vs venous bypass grafts: A hypothesis-generating study.

OBJECTIVE: Revascularization via coronary artery bypass grafting (CABG) remains a common therapy for coronary artery disease. CABG-based revascularization is most commonly performed via either single arterial graft (SAG) or multiple arterial grafting (MAG) strategies. Echo-derived global and regional longitudinal strain was used to test where SAG or MAG results in immediate differences in left ventricular (LV) function after CABG. MATERIALS AND METHODS: Pre- and postprocedural intraoperative transesophageal echos were prospectively collected. Two-dimensional LV images were analyzed for global and regional longitudinal strain (GLS), LV ejection fraction, end-diastolic volume, end-systolic volume, and stroke volume (SV). RESULTS: Twenty patients underwent open, on-pump CABG (63.9 ± 10 years old, 85% male; 10 with SAG and 10 with MAG. Preprocedural GLS significantly differed between patients with SAG and MAG, with patients with MAG having greater GLS (mean [standard deviation, SD], 20.41 [5.54]) than patients with SAG (16.28 [3.48]). After CABG, in patients with MAG, LV strain decreased both globally (-1.13 [3.15]) and regionally in the anterior-lateral (-1.22 [3.84]) and inferior-lateral regions (-1.32 [5.69]), along with LVEF. In patients with SAG, LV strain increased after CABG globally (1.34 [2.73]) and regionally in the anterior-lateral (1.20 [6.49]) and inferior-lateral regions (0.39 [7.26]), as did LVEF and SV. Postprocedure, more patients with MAG were given vasopressor (100% vs 60%) and inotrope infusions (70% vs 40%) than patients with SAG. CONCLUSIONS: After CABG, LV function quantified through GLS changes both globally and regionally increased after SAG and decreased after MAG. This finding may have important clinical implications in terms of optimizing intraoperative management for patients with CABG and have the potential to guide the improvement of clinical outcomes.

Black Race as a Social Determinant of Health and Outcomes After Lumbar Spinal Fusion Surgery: A Multistate Analysis, 2007 to 2014.

STUDY DESIGN: A retrospective analysis of patient hospitalization and discharge records. OBJECTIVE: To examine the association between race and inpatient postoperative complications following lumbar spinal fusion surgery. SUMMARY OF BACKGROUND DATA: Racial disparities in healthcare have been demonstrated across a range of surgical procedures. Previous research has identified race as a social determinant of health that impacts outcomes after lumbar spinal fusion surgery. However, these studies are limited in that they are outdated, contain data from a single institution, analyze small limited samples, and report limited outcomes. Our study aims to expand and update the literature examining the association between race and inpatient postoperative complications following lumbar spine surgery. METHODS: We analyzed 267,976 patient discharge records for inpatient lumbar spine surgery using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky from 2007 through 2014. We used unadjusted bivariate analysis, adjusted multivariable, and stratified analysis to compare patient demographics, present-on-admission comorbidities, hospital characteristics, and complications by categories of race/ethnicity. RESULTS: Black patients were 8% and 14% more likely than white patients to experience spine surgery specific complications (adjusted odds ratios [aOR]: 1.08, 95% confidence interval [CI]: 1.03-1.13) and general postoperative complications (aOR: 1.14, 95% CI: 1.07-1.20), respectively. Black patients, compared with white patients, also had increased adjusted odds of 30-day readmissions (aOR: 1.13, 95% CI: 1.07-1.20), 90-day readmissions (aOR: 1.07, 95% CI: 1.02-1.13), longer length of stay (LOS) (adjusted Incidence Rate Ratio: 1.15, 95% CI: 1.14-1.16), and higher total charges (adjusted Incidence Rate Ratio: 1.08, 95% CI: 1.07-1.09). CONCLUSION: Our findings demonstrate that black patients, as compared with white patients, are more likely to have postoperative complications, longer postoperative lengths of stay, higher total hospital charges, and increased odds of 30- and 90-day readmissions following lumbar spinal fusion surgery. LEVEL OF EVIDENCE: 4.

Use of Pulmonary Artery Pulsatility Index in Cardiac Surgery.

OBJECTIVE: This study evaluated whether the pulmonary artery pulsatility index (PAPi) collected before and after cardiopulmonary bypass (CPB) is predictive and diagnostic of new onset right ventricular (RV) failure in the elective cardiac surgical population. DESIGN: This was a prospective observational study of patients who underwent cardiac surgery between 2017 and 2019. SETTING: Weill Cornell Medicine, a single large academic medical center. PARTICIPANTS: The study comprised 119 patients undergoing elective cardiac surgery. INTERVENTIONS: Cardiopulmonary bypass, transesophageal echocardiography, pulmonary artery catheter, and elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Echocardiographic and hemodynamic data were collected at 2 time points: pre-CPB and post-chest closure/post-CPB. Patients with and without post-CPB RV dysfunction fractional area of change (<35%) were compared, and receiver operating characteristic curves were constructed. One hundred and nineteen patients undergoing elective surgery-coronary artery bypass grafting (23%), aortic valve replacement (21%), aortic surgery (19%), and combined surgery (37%)-were evaluated. Post-CPB RV dysfunction was associated with lower pre-CPB PAPi values (2.0 ± 1.0 v 2.5 ± 1.2; p = 0.001 and p = 0.03) and higher pre-CPB central venous pressure (8.3 ± 3.6 and 6.9 ± 2.7; p = 0.003 and p = 0.02, respectively). Pre-CPB PAPi (0.98 [95% confidence interval {CI} 0.96-0.99]), end systolic area (0.99 [95% CI 0.98-0.99]), and end diastolic area (1.01 [95% CI 1.001-1.02]) were independently associated with RV dysfunction in multivariable modeling, with a lower PAPi and end systolic area and higher end diastolic area demonstrating a greater risk of RV dysfunction post-CPB (post-CPB area under the curve for PAPi 0.80 [95% CI 0.71-0.88; sensitivity = 0.68, specificity = 0.93, optimal cutoff = 1.9]). CONCLUSIONS: PAPi measured pre-CPB is a potential predictor and marker of post-CPB RV dysfunction and may have diagnostic utility in cardiac surgery. Additional, large-scale studies are needed to confirm this finding.

Social determinants of health and their impact on postcolectomy surgery readmissions: a multistate analysis, 2009-2014.

Aim: To examine the effect of race/ethnicity, insurance status and median household income on postoperative readmissions following colectomy. Patients & methods: Multivariate analysis of hospital discharge data from California, Florida, Maryland and New York from 2009 to 2014. Primary outcomes included adjusted odds of 30- and 90-day readmissions following colectomy by race, insurance status and median income quartile. Results: Total 330,840 discharges included. All 30-day readmissions were higher for black patients (adjusted odds ratio [aOR]: 1.07). Both 30- and 90-day readmissions were higher for Medicaid (aOR: 1.30 and 1.26) and Medicare (aOR: 1.30 and 1.29). The 30- and 90-day readmissions were lower in the highest income quartiles. Conclusion: Race, insurance status and median household income are all independent predictors of disparity in readmissions following colectomy.

Immediate Impact of Prosthetic Graft Replacement of the Ascending Aorta on Circumferential Strain in the Descending Aorta.

OBJECTIVES: Prosthetic replacement of the ascending aorta (AA) can potentially modify energy propagation to the distal aorta and contribute to adverse aortic remodelling. This preliminary study employed intra-operative transoesophageal echocardiography (TOE) to assess the immediate impact of prosthetic graft replacement of the AA on circumferential strain in the descending aorta. METHODS: Intra-operative TOEs in patients undergoing AA graft replacement were analysed for circumferential strain, fractional area change (FAC), dimensions (end diastolic area [EDA], and end systolic area [ESA]) in the descending aorta immediately before and after graft replacement. Deformation was assessed via global peak circumferential aortic strain (CAS), together with pulse pressure corrected strain, time to peak strain (TTP), and aortic distensibility. RESULTS: Forty-five patients undergoing AA replacement with prosthetic graft (91% elective) were studied. Following grafting, descending thoracic aortic circumferential strain increased (6.3 ± 2.8% vs. 8.9 ± 3.4%, p = .001) paralleling distensibility (5.7 [3.7-8.6] 10-3 mmHg vs. 8.5 [6.4-12.4] 10-3 mmHg, p < .001). Despite slight increments in post graft left ventricular ejection fraction (LVEF) (52.3 ± 10.8% vs. 55.0 ± 11.9, p < .001), stroke volume was similar (p = .41), and magnitude of increased strain did not correlate with change in stroke volume (r = -.03, p = .86), LVEF (r = .18, p = .28), or pulse pressure (r = .28, p = .06). Descending aortic size (EDA 4 [2.7-4.6] cm2vs. 3.7 [2.5-5] cm2, p = .89; ESA 4.3 [3.2-5.3] cm2vs. 4.5 [3.3-5.8] cm2, p = .14) was similar pre- and post graft. In subgroup analysis, patients with cystic medial necrosis had a significantly higher post procedure CAS than patients with atherosclerotic aneurysms (9.7 ± 3.5% vs. 7.0 ± 2.3%, p = .03). CONCLUSIONS: Prosthetic graft replacement of the AA increases immediate aortic circumferential strain of the descending aorta, particularly in patients with cystic medial necrosis. Our findings suggest that grafts augment energy transfer to the distal aorta, a potential mechanism for progressive distal aortic dilation and/or dissection.