Report of the 2022 Perfusion Perspectives of Waste Anesthetic Gas Exposure Survey.

OBJECTIVES: To describe perfusionist perspectives regarding waste anesthetic gas (WAG) management during cardiopulmonary bypass (CPB) and compare results to existing American Society of Extracorporeal Technology (AmSECT) guidelines and the 2016 National Institute of Occupational Safety and Health Survey of healthcare workers and anesthesia care providers. DESIGN: We developed a questionnaire with 26 questions covering institutional demographics, use of anesthetic gases, scavenging systems, and air monitoring practices. SETTING: Web-based survey. PARTICIPANTS: Self-identified board-eligible perfusionist members of AmSECT, the American Academy of Cardiovascular Perfusion, and the Maryland and Wisconsin State Perfusion Societies in 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 4,303 providers sent the survey, 365 (8.5%) participated. Although 92% of the respondents (335/364) routinely administered inhaled anesthetics via the oxygenator, only 73.2% (259/354) routinely scavenged WAG during CPB cases. Only 6.6% of the respondents (22/336) conducted environmental monitoring for WAG levels. Cited reasons for not scavenging waste gases included a lack of applicable protocols and waste gas scavenging systems, excessive cost, and no need for scavenging. CONCLUSIONS: Our findings identify a gap between AmSECT guidelines and current perfusionist behavior and suggest potential strategies for reducing WAG leakage during CPB. Effective management should incorporate hazard awareness training, availability of standard procedures to minimize exposure, scavenging systems, regular equipment inspection, and prompt attention to spills and leaks. In high-risk environments, environmental surveillance for waste gas levels would also contribute to waste gas safety. A comprehensive approach to managing waste anesthetic gases will reduce WAG leakage, help improve health care worker safety, and prevent potential adverse effects of exposure.

Anesthesia providers as stakeholders to adoption of pharmacogenomic information in perioperative care.

OBJECTIVES: Integration of pharmacogenomics into clinical care is being studied in multiple disciplines. We hypothesized that understanding attitudes and perceptions of anesthesiologists, critical care and pain medicine providers would uncover unique considerations for future implementation within perioperative care. METHODS: A survey (multiple choice and Likert-scale) was administered to providers within our Department of Anesthesia and Critical Care prior to initiation of a department-wide prospective pharmacogenomics implementation program. The survey addressed knowledge, perceptions, experiences, resources and barriers. RESULTS: Of 153 providers contacted, 149 (97%) completed the survey. Almost all providers (92%) said that genetic results influence drug therapy, and few (22%) were skeptical about the usefulness of pharmacogenomics. Despite this enthusiasm, 87% said their awareness about pharmacogenomic information is lacking. Feeling well-informed about pharmacogenomics was directly related to years in practice/experience: only 38% of trainees reported being well-informed, compared to 46% of those with 1-10 years of experience, and nearly two-thirds with 11+ years (P < 0.05). Regarding barriers, providers reported uncertainty about availability of testing, turnaround time and whether testing is worth financial costs. CONCLUSIONS: Anesthesiology, critical care and pain medicine providers are optimistic about the potential clinical utility of pharmacogenomics, but are uncertain about practical aspects of testing and desire clear guidelines on the use of results. These findings may inform future institutional efforts toward greater integration of genomic results to improve medication-related outcomes.

Maternal Fever Associated With Continuous Spinal Versus Epidural Labor Analgesia: A Single-Center Retrospective Study.

BACKGROUND: Neuraxial labor analgesia is associated with elevations in maternal temperature; the mechanism responsible is unknown. Proposed mechanisms have included infection, altered thermoregulation, and inflammation, potentially triggered by local anesthetics. Studies of the association between neuraxial labor analgesia and maternal fever have focused on epidural analgesia, and there have been no comparisons of the rate of maternal fever between continuous spinal and epidural labor analgesia. METHODS: We performed a retrospective study to compare the rate of maternal fever between patients who received continuous spinal versus epidural labor analgesia between June 2012 and March 2020. Each patient who received continuous spinal analgesia was matched to 2 patients who received epidural analgesia and had the same nulliparous status. The primary outcome of our study was the incidence of intrapartum maternal fever, which we defined as any temperature ≥38 °C before delivery and compared between the continuous spinal and epidural groups using Fisher exact test. RESULTS: We identified 81 patients who received continuous spinal analgesia and 162 matched controls who received epidural analgesia. Demographic and obstetric characteristics of the patients were similar between groups. While the duration of analgesia did not significantly differ, there was markedly increased bupivacaine consumption in women with epidural analgesia. Eight of 81 (9.9%; 95% confidence interval [CI], 5.1-18.3) women with continuous spinal analgesia developed an intrapartum fever compared to 18 of 162 (11.1%; 95% CI, 7.1-16.9) of women with epidural analgesia ( P = .83; Fisher exact test). CONCLUSIONS: There was no significant difference in the rate of maternal fever between women with continuous spinal compared to epidural labor analgesia. While the route of administration and dose of bupivacaine differs between epidural and spinal labor analgesia, they are titrated to produce similar levels of neuraxial blockade. Our results are consistent with a model in which epidural related maternal fever is due to altered thermoregulation from a central neuraxial block and argue against a direct effect of bupivacaine or fentanyl, although we cannot rule out a concentration-independent effect of bupivacaine or fentanyl or an inflammatory effect of the catheter itself. These retrospective results highlight the importance of prospective and mechanistic study of neuraxial analgesia-related maternal fever.

Pilot Findings of Pharmacogenomics in Perioperative Care: Initial Results From the First Phase of the ImPreSS Trial.

BACKGROUND: Pharmacogenomics, which offers a potential means by which to inform prescribing and avoid adverse drug reactions, has gained increasing consideration in other medical settings but has not been broadly evaluated during perioperative care. METHODS: The Implementation of Pharmacogenomic Decision Support in Surgery (ImPreSS) Trial is a prospective, single-center study consisting of a prerandomization pilot and a subsequent randomized phase. We describe findings from the pilot period. Patients planning elective surgeries were genotyped with pharmacogenomic results, and decision support was made available to anesthesia providers in advance of surgery. Pharmacogenomic result access and prescribing records were analyzed. Surveys (Likert-scale) were administered to providers to understand utilization barriers. RESULTS: Of eligible anesthesiology providers, 166 of 211 (79%) enrolled. A total of 71 patients underwent genotyping and surgery (median, 62 years; 55% female; average American Society of Anesthesiologists (ASA) score, 2.6; 58 inpatients and 13 ambulatories). No patients required postoperative intensive care or pain consultations. At least 1 provider accessed pharmacogenomic results before or during 41 of 71 surgeries (58%). Faculty were more likely to access results (78%) compared to house staff (41%; P = .003) and midlevel practitioners (15%) ( P < .0001). Notably, all administered intraoperative medications had favorable genomic results with the exception of succinylcholine administration to 1 patient with genomically increased risk for prolonged apnea (without adverse outcome). Considering composite prescribing in preoperative, recovery, throughout hospitalization, and at discharge, each patient was prescribed a median of 35 (range 15-83) total medications, 7 (range 1-22) of which had annotated pharmacogenomic results. Of 2371 prescribing events, 5 genomically high-risk medications were administered (all tramadol or omeprazole; with 2 of 5 pharmacogenomic results accessed), and 100 genomically cautionary mediations were administered (hydralazine, oxycodone, and pantoprazole; 61% rate of accessing results). Providers reported that although results were generally easy to access and understand, the most common reason for not considering results was because remembering to access pharmacogenomic information was not yet a part of their normal clinical workflow. CONCLUSIONS: Our pilot data for result access rates suggest interest in pharmacogenomics by anesthesia providers, even if opportunities to alter prescribing in response to high-risk genotypes were infrequent. This pilot phase has also uncovered unique considerations for implementing pharmacogenomic information in the perioperative care setting, and new strategies including adding the involvement of surgery teams, targeting patients likely to need intensive care and dedicated pain care, and embedding pharmacists within rounding models will be incorporated in the follow-on randomized phase to increase engagement and likelihood of affecting prescribing decisions and clinical outcomes.

Appraisal and development of evidence-based clinical decision support to enable perioperative pharmacogenomic application.

Variable responses to medications complicates perioperative care. As a potential solution, we evaluated and synthesized pharmacogenomic evidence that may inform anesthesia and pain prescribing to identify clinically actionable drug/gene pairs. Clinical decision-support (CDS) summaries were developed and were evaluated using Appraisal of Guidelines for Research and Evaluation (AGREE) II. We found that 93/180 (51%) of commonly-used perioperative medications had some published pharmacogenomic information, with 18 having actionable evidence: celecoxib/diclofenac/flurbiprofen/ibuprofen/piroxicam/CYP2C9, codeine/oxycodone/tramadol CYP2D6, desflurane/enflurane/halothane/isoflurane/sevoflurane/succinylcholine/RYR1/CACNA1S, diazepam/CYP2C19, phenytoin/CYP2C9, succinylcholine/mivacurium/BCHE, and morphine/OPRM1. Novel CDS summaries were developed for these 18 medications. AGREE II mean ± standard deviation scores were high for Scope and Purpose (95.0 ± 2.8), Rigor of Development (93.2 ± 2.8), Clarity of Presentation (87.3 ± 3.0), and Applicability (86.5 ± 3.7) (maximum score = 100). Overall mean guideline quality score was 6.7 ± 0.2 (maximum score = 7). All summaries were recommended for clinical implementation. A critical mass of pharmacogenomic evidence exists for select medications commonly used in the perioperative setting, warranting prospective examination for clinical utility.

December Is Coming: A Time Trend Analysis of Monthly Variation in Adult Elective Anesthesia Caseload across Florida and Texas Locations of a Large Multistate Practice.

BACKGROUND: Anesthesia staffing models rely on predictable surgical case volumes. Previous studies have found no relationship between month of the year and surgical volume. However, seasonal events and greater use of high-deductible health insurance plans may cause U.S. patients to schedule elective surgery later in the calendar year. The hypothesis was that elective anesthesia caseloads would be higher in December than in other months. METHODS: This review analyzed yearly adult case data in Florida and Texas locations of a multistate anesthesia practice from 2017 to 2019. To focus on elective caseload, the study excluded obstetric, weekend, and holiday cases. Time trend decomposition analysis was used with seasonal variation to assess differences between December and other months in daily caseload and their relationship to age and insurance subgroups. RESULTS: A total of 3,504,394 adult cases were included in the analyses. Overall, daily caseloads increased by 2.5 ± 0.1 cases per day across the 3-yr data set. After adjusting for time trends, the average daily December caseload in 2017 was 5,039 cases (95% CI, 4,900 to 5,177), a 20% increase over the January-to-November baseline (4,196 cases; 95% CI, 4,158 to 4,235; P < 0.0001). This increase was replicated in 2018: 5,567 cases in December (95% CI, 5,434 to 5,700) versus 4,589 cases at baseline (95% CI, 4,538 to 4,641), a 21.3% increase; and in 2019: 6,103 cases in December (95% CI, 5,871 to 6,334) versus 5,045 cases at baseline (95% CI, 4,984 to 5,107), a 21% increase (both P < 0.001). The proportion of commercially insured patients and those aged 18 to 64 yr was also higher in December than in other months. CONCLUSIONS: In this 3-yr retrospective analysis, it was observed that, after accounting for time trends, elective anesthesia caseloads were higher in December than in other months of the year. Proportions of commercially insured and younger patients were also higher in December. When compared to previous studies finding no increase, this pattern suggests a recent shift in elective surgical scheduling behavior.

A Predictive Model for Pediatric Postoperative Respiratory Failure: A National Inpatient Sample Study.

STUDY OBJECTIVE: To identify risk factors for pediatric postoperative respiratory failure and develop a predictive model. DESIGN: This retrospective case-control study utilized the US National Inpatient Sample (NIS) from 2012 to 2014. Significant predictors were selected, and the predicted probability of pediatric postoperative respiratory failure was calculated. Sensitivity, specificity, and accuracy were then calculated, and receiver-operator curves were drawn. SETTING: National Inpatient Sample data sets from years 2012, 2013, and 2014 were used. PATIENTS: Patients aged 17 and younger in the 2012, 2013, and 2014 NIS data sets. INTERVENTIONS: Candidate predictors included demographic variables, type of surgical procedure, a modified pediatric comorbidity score, presence of substance abuse diagnosis, and presence/absence of kyphoscoliosis. MEASUREMENTS: The primary outcome measure was the pediatric quality indicator (PDI 09), which is defined by the Agency for Healthcare Research Quality, and identifies pediatric patients with postoperative respiratory failure. MAIN RESULTS: The incidence of pediatric postoperative respiratory failure in each year's data set varied from 1.31% in 2012 to 1.41% in 2014. Significant risk factors for the development of postoperative respiratory failure included abdominal surgery ([OR] = 1.92 in 2012 data set, 1.79 in 2013 data set), spine surgery (OR = 7.10 in 2012 data set, 6.41 in 2013 data set), and an elevated pediatric comorbidity score (score of 3 or greater: OR = 32.58 in 2012 data set, 22.74 in 2013 data set). A predictive model utilizing these risk factors achieved a C statistic of 0.82. CONCLUSIONS: Risk factors associated with postoperative respiratory failure in pediatric patients undergoing noncardiac surgery include type of surgery (abdominal and spine) and higher pediatric comorbidity scores. A prediction model based on the identified factors had good predictive ability.

Initial Clinical Impressions of the Critical Care of COVID-19 Patients in Seattle, New York City, and Chicago.

Since the first recognition of a cluster of novel respiratory viral infections in China in late December 2019, intensivists in the United States have watched with growing concern as infections with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus-now named coronavirus disease of 2019 (COVID-19)-have spread to hospitals in the United States. Because COVID-19 is extremely transmissible and can progress to a severe form of respiratory failure, the potential to overwhelm available critical care resources is high and critical care management of COVID-19 patients has been thrust into the spotlight. COVID-19 arrived in the United States in January and, as anticipated, has dramatically increased the usage of critical care resources. Three of the hardest-hit cities have been Seattle, New York City, and Chicago with a combined total of over 14,000 cases as of March 23, 2020.In this special article, we describe initial clinical impressions of critical care of COVID-19 in these areas, with attention to clinical presentation, laboratory values, organ system effects, treatment strategies, and resource management. We highlight clinical observations that align with or differ from already published reports. These impressions represent only the early empiric experience of the authors and are not intended to serve as recommendations or guidelines for practice, but rather as a starting point for intensivists preparing to address COVID-19 when it arrives in their community.

Trends and Outcomes of Mechanical Circulatory Support in Peripartum Women, 2002-2014: A Nationwide Inpatient Sample Analysis.

OBJECTIVES: To systematically explore the relationship among the use of mechanical circulatory support (MCS), the timing of placement, and outcomes in pregnancy. DESIGN: Using the National Inpatient Sample and National Readmissions Database, the authors performed a retrospective, cohort analysis of peripartum women who received MCS. SETTING: United States hospitals. PARTICIPANTS: A weighted sample of women who received MCS during the antepartum, delivery, or postpartum period between 2002 and 2014. INTERVENTIONS: MCS MEASUREMENTS AND MAIN RESULTS: There were 1,386 women who received MCS during their admission. These women were older and had more comorbidities than women without MCS. The mean time from admission to device placement was 5.4 days for all women, and MCS use was highest in urban teaching hospitals. Overall, peripartum use of MCS has increased since 2002, but mortality did not change during the same period. After adjusting for potential confounders, the odds ratio for mortality when MCS was placed within 6 days of admission was 0.48 (95% confidence interval 0.23-0.98) with the adjusted probability of death rising from 18.6% to 32.5% when the device was placed on or after day 6. CONCLUSIONS: Similar to trends in the general population, use of MCS has increased in the peripartum period. Women receiving MCS were generally older and had more comorbidities than those not receiving MCS. Increased time to device placement may worsen mortality. Further research will help identify appropriate candidates and factors that improve survival.

Customizable Curriculum to Enhance Resident Communication Skills.

Communication remains challenging to teach and evaluate. We designed an online patient survey to assess anesthesia residents' communication skills from August 2014 to July 2015. In December 2014, we implemented a customized, simulation-based curriculum. We calculated an overall rating for each survey by averaging the ratings for the individual questions. Based on the Hodges-Lehmann 2-sample aligned rank-sum test, overall ratings, reported as the median (interquartile range) of residents' average overall ratings, differed significantly between the preintervention (3.86 [3.76-3.94]) and postintervention (3.91 [3.84-3.95]) periods (P = .025). Future studies should assess the intervention's effectiveness and generalizability.

Transport of Critically Ill Patients by the Anesthesia Versus the Intensive Care Unit Service: A Before-After Study of Operating Room Workflows.

BACKGROUND: We implemented a new policy at our institution where the responsibility for intensive care unit (ICU) patient transports to the operating room (OR) was changed from the anesthesia to the ICU service. We hypothesized that this approach would be associated with increased on-time starts and decreased turnover times. METHODS: In the historical model, intubated patients or those on mechanical circulatory assistance (MCA) were transported by the anesthesia service to the OR ("pre-ICU Pickup"). In our new model, these patients are transported by the ICU service to the preoperative holding area (Pre-op) where care is transferred to the anesthesia service ("post-ICU Transfer"). If judged necessary by the ICU or anesthesia attending, the patient was transported by the anesthesia service ("post-ICU Pickup"). We retrospectively reviewed case tracking data for patients undergoing surgery before (January 2014 to May 2015) and after implementation (July 2016 to June 2017) of the new policy. The primary outcome was the proportion of elective, weekday first-case, on-time starts. To adjust for confounders including comorbidities and time trends, we performed a segmented logistic regression analysis assessing the effect of our intervention on the primary outcome. Secondary outcomes were turnover times and compliance with preoperative checklist documentation. RESULTS: We identified 95 first-start and 86 turnover cases in the pre-ICU Pickup, 70 first-start and 88 turnover cases in the post-ICU Transfer, and 6 turnover cases in the post-ICU Pickup group. Ignoring time trends, the crude proportion of on-time starts increased from 32.6% in the pre-ICU Pickup to 77.1% in the post-ICU Transfer group. After segmented logistic regression adjusting for age, sex, American Society of Anesthesiologists (ASA) physical status, Sequential Organ Failure Assessment (SOFA) score, respiratory failure, endotracheal intubation, MCA, congestive heart failure (CHF), valvular heart disease, and cardiogenic and hemorrhagic shock, the post-ICU Transfer group was more likely to have an on-time start at the start of the intervention than the pre-ICU Pickup group at the end of the preintervention period (odds ratio, 11.1; 95% confidence interval [CI], 1.3-125.7; P = .043). After segmented linear regression adjusting for the above confounders, the estimated difference in mean turnover times between the post-ICU Pickup and pre-ICU Transfer group was not significant (-6.9 minutes; 95% CI, -17.09 to 3.27; P = .17). In post-ICU Transfer patients, consent, history and physical examination (H&P), and site marking were verified before leaving the ICU in 92.9%, 93.2%, and 89.2% of the cases, respectively. No adverse events were reported during the study period. CONCLUSIONS: A transition from the anesthesia to the ICU service for transporting ICU patients to the OR did not change turnover times but resulted in more on-time starts and high compliance with preoperative checklist documentation.

Intraoperative Use of Nondepolarizing Neuromuscular Blocking Agents During Cardiac Surgery and Postoperative Pulmonary Complications: A Prospective Randomized Trial.

OBJECTIVE: Nondepolarizing neuromuscular blocking agents (NMBAs) are associated with perioperative complications in noncardiac surgery; however, little is known about their effect on cardiac surgery. This study assessed the effect of neuromuscular blockade (NMB) on the incidence of postoperative pulmonary complications (PPCs) after cardiac surgery and operating conditions. DESIGN: Prospective, randomized clinical trial with blinded outcomes assessment. SETTING: University hospital, single institution. PARTICIPANTS: Adult patients having cardiac surgery requiring cardiopulmonary bypass. INTERVENTIONS: One hundred patients were randomized to receive succinylcholine (group SUX) for intubation with no further NMB administered or cisatracurium (group CIS) for intubation and maintenance NMB. The primary outcome was a composite incidence of PPCs in the 72 hours after elective cardiac surgery. PPCs included failure to extubate within 24 hours, need for reintubation, pneumonia, aspiration, unanticipated need for noninvasive respiratory support, acute respiratory distress, and mortality from respiratory arrest. The secondary outcome was the adequacy of operating conditions as assessed by blinded surgeon survey (including a rating of surgical conditions on a Likert scale from 1 = poor to 5 = excellent), anesthesiologist report, and patient questionnaire. MEASUREMENTS AND MAIN RESULTS: The composite incidence of PPCs did not differ between groups (8 of 50 patients in both groups; 16%). Mean surgeon rating of surgical conditions was lower in the SUX group (4.65 ± 0.85 v 4.96 ± 0.20, p = 0.02). CONCLUSION: Although avoiding nondepolarizing NMBA is feasible, doing so worsened operating conditions and did not reduce the incidence of postoperative pulmonary complications.

Septic Cardiomyopathy.

OBJECTIVES: To describe, with an emphasis on clinical applications, what is known about the pathophysiology, management, and implications of septic cardiomyopathy in the adult ICU. DATA SOURCES AND STUDY SELECTION: A PubMed literature review was performed for relevant articles. Only articles in English that studied human adults with sepsis were included. DATA EXTRACTION AND DATA SYNTHESIS: Multiple competing definitions for septic cardiomyopathy hinder understanding of this entity. Although many patients with sepsis develop cardiac dysfunction, the impact of septic cardiomyopathy on prognosis and therapy remains to be demonstrated. Treatment of septic cardiomyopathy is aimed at treating the underlying sepsis and providing specific supportive care for cardiogenic shock when present. CONCLUSIONS: Septic cardiomyopathy is an important contributor to organ dysfunction in sepsis. Guided treatment of septic cardiomyopathy may affect patients' prognosis, especially when their cardiac index is substantially decreased. The implication of septic cardiomyopathy for both short- and long-term outcomes is an important area for future investigation.

Multifactorial risk index for prediction of intraoperative blood transfusion in endovascular aneurysm repair.

BACKGROUND: In some institutions, the current blood ordering practice does not discriminate minimally invasive endovascular aneurysm repair (EVAR) from open procedures, with consequent increasing costs and likelihood of blood product wastage for EVARs. This limitation in practice can possibly be addressed with the development of a reliable prediction model for transfusion risk in EVAR patients. We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to create a model for prediction of intraoperative blood transfusion occurrence in patients undergoing EVAR. Afterward, we tested our predictive model on the Vascular Study Group of New England (VSGNE) database. METHODS: We used the ACS NSQIP database for patients who underwent EVAR from 2011 to 2013 (N = 4709) as our derivation set for identifying a risk index for predicting intraoperative blood transfusion. We then developed a clinical risk score and validated this model using patients who underwent EVAR from 2003 to 2014 in the VSGNE database (N = 4478). RESULTS: The transfusion rates were 8.4% and 6.1% for the ACS NSQIP (derivation set) and VSGNE (validation) databases, respectively. Hemoglobin concentration, American Society of Anesthesiologists class, age, and aneurysm diameter predicted blood transfusion in the derivation set. When it was applied on the validation set, our risk index demonstrated good discrimination in both the derivation and validation set (C statistic = 0.73 and 0.70, respectively) and calibration using the Hosmer-Lemeshow test (P = .27 and 0.31) for both data sets. CONCLUSIONS: We developed and validated a risk index for predicting the likelihood of intraoperative blood transfusion in EVAR patients. Implementation of this index may facilitate the blood management strategies specific for EVAR.

Opioid Abuse or Dependence Increases 30-day Readmission Rates after Major Operating Room Procedures: A National Readmissions Database Study.

BACKGROUND: Although opioids remain the standard therapy for the treatment of postoperative pain, the prevalence of opioid misuse is rising. The extent to which opioid abuse or dependence affects readmission rates and healthcare utilization is not fully understood. It was hypothesized that surgical patients with a history of opioid abuse or dependence would have higher readmission rates and healthcare utilization. METHODS: A retrospective cohort analysis was performed of patients undergoing major operating room procedures in 2013 and 2014 using the National Readmission Database. Patients with opioid abuse or dependence were identified using International Classification of Diseases codes. The primary outcome was 30-day hospital readmission rate. Secondary outcomes included hospital length of stay and estimated hospital costs. RESULTS: Among the 16,016,842 patients who had a major operating room procedure whose death status was known, 94,903 (0.6%) had diagnoses of opioid abuse or dependence. After adjustment for potential confounders, patients with opioid abuse or dependence had higher 30-day readmission rates (11.1% vs. 9.1%; odds ratio 1.26; 95% CI, 1.22 to 1.30), longer mean hospital length of stay at initial admission (6 vs. 4 days; P < 0.0001), and higher estimated hospital costs during initial admission ($18,528 vs. $16,617; P < 0.0001). Length of stay was also higher at readmission (6 days vs. 5 days; P < 0.0001). Readmissions for infection (27.0% vs. 18.9%; P < 0.0001), opioid overdose (1.0% vs. 0.1%; P < 0.0001), and acute pain (1.0% vs. 0.5%; P < 0.0001) were more common in patients with opioid abuse or dependence. CONCLUSIONS: Opioid abuse and dependence are associated with increased readmission rates and healthcare utilization after surgery. VISUAL ABSTRACT: An online visual overview is available for this article at http://links.lww.com/ALN/B704.

Cardiac angiogenic imbalance leads to peripartum cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is an often fatal disease that affects pregnant women who are near delivery, and it occurs more frequently in women with pre-eclampsia and/or multiple gestation. The aetiology of PPCM, and why it is associated with pre-eclampsia, remain unknown. Here we show that PPCM is associated with a systemic angiogenic imbalance, accentuated by pre-eclampsia. Mice that lack cardiac PGC-1α, a powerful regulator of angiogenesis, develop profound PPCM. Importantly, the PPCM is entirely rescued by pro-angiogenic therapies. In humans, the placenta in late gestation secretes VEGF inhibitors like soluble FLT1 (sFLT1), and this is accentuated by multiple gestation and pre-eclampsia. This anti-angiogenic environment is accompanied by subclinical cardiac dysfunction, the extent of which correlates with circulating levels of sFLT1. Exogenous sFLT1 alone caused diastolic dysfunction in wild-type mice, and profound systolic dysfunction in mice lacking cardiac PGC-1α. Finally, plasma samples from women with PPCM contained abnormally high levels of sFLT1. These data indicate that PPCM is mainly a vascular disease, caused by excess anti-angiogenic signalling in the peripartum period. The data also explain how late pregnancy poses a threat to cardiac homeostasis, and why pre-eclampsia and multiple gestation are important risk factors for the development of PPCM.

Patients Undergoing Cesarean Delivery After Exposure to Oxytocin During Labor Require Higher Postpartum Oxytocin Doses.

BACKGROUND: Experts recommend postpartum oxytocin to prevent uterine atony and hemorrhage, but oxytocin may be associated with dose-dependent adverse effects, and the correct dose of postpartum oxytocin has yet to be determined. The effective dose in 90% of patients (ED90) of oxytocin after cesarean delivery may be higher in patients exposed to oxytocin during labor compared to patients unexposed. We therefore undertook this study to compare postpartum oxytocin requirements in patients exposed to oxytocin prior to cesarean delivery versus those not exposed, when all were treated according to a specific institutional protocol. METHODS: In this retrospective chart review, we reviewed medical records of patients who underwent cesarean delivery under neuraxial anesthesia and noted demographic data, relevant comorbidities, and oxytocin exposure, infusion rate, and duration prior to delivery. Patients exposed to oxytocin before cesarean (OXY+ group) were compared to those not exposed (OXY- group). The primary outcome variable was highest infusion rate of postpartum oxytocin required per institutional protocol. Secondary outcomes included estimated blood loss, proportion of patients with postpartum hemorrhage, and proportions who received other uterotonic medications or red blood cell transfusion. RESULTS: OXY+ patients were more likely to be nulliparous and had higher estimated gestational age and neonatal weight than OXY- patients. They also had higher incidence of chorioamnionitis and lower incidence of multiple gestation. OXY+ patients required a high postpartum oxytocin infusion rate more often than OXY- patients (adjusted odds ratio 1.94 [95% confidence interval, 1.19-3.15; P = .008]). They also received other uterotonic agents more commonly. Estimated blood loss, hemorrhage rates, and transfusion rates did not differ between groups. CONCLUSIONS: Reported increases in the ED90 of postpartum oxytocin after oxytocin exposure during labor appear to be clinically significant. We have therefore altered our institutional protocol so that women preexposed to oxytocin routinely receive higher initial postpartum oxytocin infusion rates.

Cardiac dysfunction in critical illness.

PURPOSE OF REVIEW: Sepsis and septic shock are prevalent conditions that are likely to increase in prevalence in the future. Given the high mortality and morbidity associated with sepsis and sepsis-induced cardiac dysfunction, we must continue to make advances in knowledge of the complex physiologic interactions and how we may target specific mediators for potential therapeutic options in the future. RECENT FINDINGS: Multiple biomarkers have been discovered, which when assayed in sepsis-induced cardiomyopathy predict morbidity and mortality. With increased sensitivity of echocardiography, we can diagnose subclinical cardiac dysfunction, which may have future implications for slowing or preventing progressive dysfunction. SUMMARY: Sepsis-induced cardiomyopathy is the result of complicated interactions between the pathogen, the body's response to infection, and iatrogenic injury. Interplay between inflammatory, metabolic, and adrenergic systems results in direct and indirect myocardial injury leading to decreases in both systolic and diastolic cardiac function. As the interactions are further elucidated with additional research into other proteins and mediators, new treatment options can be researched. VIDEO ABSTRACT.

Relative Bradycardia in Patients With Septic Shock Requiring Vasopressor Therapy.

OBJECTIVES: Tachycardia is common in septic shock, but many patients with septic shock are relatively bradycardic. The prevalence, determinants, and implications of relative bradycardia (heart rate, < 80 beats/min) in septic shock are unknown. To determine mortality associated with patients who are relatively bradycardic while in septic shock. DESIGN: Retrospective study of patients admitted for septic shock to study ICUs during 2005-2013. SETTING: One large academic referral hospital and two community hospitals. PATIENTS: Adult patients with septic shock requiring vasopressors. INTERVENTION: None. MEASUREMENTS: Primary outcome was 28-day mortality. We used multivariate logistic regression to evaluate the association between relative bradycardia and mortality, controlling for confounding with inverse probability treatment weighting using a propensity score. RESULTS: We identified 1,554 patients with septic shock, of whom 686 (44%) met criteria for relative bradycardia at some time. Twenty-eight-day mortality in this group was 21% compared to 34% in the never-bradycardic group (p < 0.001). Relatively bradycardic patients were older (65 vs 60 yr; p < 0.001) and had slightly lower illness severity (Sequential Organ Failure Assessment, 10 vs 11; p = 0.004; and Acute Physiology and Chronic Health Evaluation II, 27 vs 28; p = 0.008). After inverse probability treatment weighting, covariates were balanced, and the association between relative bradycardia and survival persisted (p < 0.001). CONCLUSIONS: Relative bradycardia in patients with septic shock is associated with lower mortality, even after adjustment for confounding. Our data support expanded investigation into whether inducing relative bradycardia will benefit patients with septic shock.