Hemodynamic Monitoring In The Cardiac Surgical Patient: Comparison of Three Arterial Catheters.

OBJECTIVE: Systemic systolic (SAP) and mean (MAP) arterial pressure monitoring is the cornerstone in hemodynamic management of the cardiac surgical patient, and the radial artery is the most common site of catheter placement. The present study compared 3 different arterial line procedures. It is hypothesized that a 20-G 12.7- cm catheter inserted into the radial artery will be equal to a 20-G 12.7- cm angiocath placed in the brachial artery, and superior to a 20-G 5.00 cm angiocath placed in the radial artery. DESIGN: A prospective randomized control study was performed. SETTING: Single academic university hospital. PARTICIPANTS: Adult patients ≥18 years old undergoing nonemergent cardiac surgery using cardiopulmonary bypass (CPB). INTERVENTIONS: After approval by the Rhode Island Hospital institutional review board, a randomized prospective control study to evaluate 3 different peripheral intraarterial catheter systems was performed: (1) Radial Short (RS): 20-G 5- cm catheter; (2) Radial Long (RL): 20-G 12- cm catheter; and (3) Brachial Long (BL): 20-G 12- cm catheter. MEASUREMENTS AND RESULTS: Gradients between central aortic and peripheral catheters (CA-P) were compared and analyzed before CPB and 2 and 10 minutes after separation from CPB. The placement of femoral arterial lines and administration of vasoactive medications were recorded. After exclusions, 67 BL, 61 RL, and 66 RS patients were compared. Before CPB, CA-P SAP and MAP gradients were not significant among the 3 groups. Two minutes after CPB, the CA-P SAP gradient was significant for the RS group (p = 0.005) and insignificant for BL (p = 0.47) and RL (p = 0.39). Two-group analysis revealed that CA-P SAP gradients are similar between BL and RL (p = 0.84), both of which were superior to RS (p = 0.02 and p = 0.04, respectively). At 10 minutes after CPB, the CA-P SAP gradient for RS remained significant (p = 0.004) and similar to the gradient at 2 minutes. The CA-P SAP gradients increased from 2 to 10 minutes for BL (p = 0.13) and RL (p = 0.06). Two minutes after CPB, the CA-P MAP gradients were significant for the BL (p = 0.003), RL (p < 0.0001), and RS (p < 0.0001) groups. Two-group analysis revealed that the CA-P MAP gradients were lower for the BL group compared with the RL (p = 0.054) and RS (p< 0.05) groups. Ten minutes after CPB, the CA-P MAP gradients in the RL and RS groups remained significant (p < 0.0001) and both greater than the BL group (p = 0.002). A femoral arterial line was placed more frequently in the RS group (8/66 = 12.1%) than in the RL group (3/61 = 4.9%) and the BL group (2/67 = 3.0%). Vasopressin was administered significantly more frequently in the RS group. CONCLUSION: Regarding CA-P SAP gradients, the RL group performed equally to the BL group, both being superior to RS. Regarding CA-P MAP gradients, BL was superior to RL and RS. Clinically, femoral line placement and vasopressin administration were fewer for the BL and RL groups when compared with the RS group. This study demonstrated the benefits of a long (12.7 cm) 20- G angiocath placed in the radial artery.

Outpatient compared to inpatient thyroidectomy on 30-day postoperative outcomes: a national propensity matched analysis.

BACKGROUND: To address the postoperative outcomes between outpatient and inpatient neck surgery involving thyroidectomy procedures. METHODS: A cohort analysis of surgical patients undergoing primary, elective, total thyroidectomy from multiple United States medical institutions who were registered with the American College of Surgeons National Surgical Quality Improvement Program from 2015 to 2018. The primary outcome was a composite score that included any 30-day postoperative adverse event. RESULTS: A total of 55,381 patients who underwent a total thyroidectomy were identified comprising of 14,055 inpatient and 41,326 outpatient procedures. A cohort of 13,496 patients who underwent outpatient surgery were propensity matched for covariates with corresponding number of patients who underwent inpatient thyroidectomies. In the propensity matched cohort, the occurrence of any 30-day after surgery complications were greater in the inpatient group, 424 out of 13,496 (3.1%) compared to the outpatient group, 150 out of 13,496 (1.1%), P < 0.001. Moreover, death rates were greater in the inpatient group, 22 out 13,496 (0.16%) compared to the outpatient group, 2 out of 13,496 (0.01%), P < 0.001. Similarly, hospital readmissions occurred with greater frequency in the inpatient group, 438 out of 13,496 (3.2%) compared to the outpatient group, 310 out of 13,496 (2.3%), P < 0.001. CONCLUSION: Thyroidectomy procedures performed in the outpatient setting had less rates of adverse events, including serious postoperative complications (e.g., surgical site infection, pneumonia, progressive renal insufficiency). In addition, patients who had thyroidectomy in the outpatient setting had less 30-day readmissions and mortality. Surgeons should recognize the benefits of outpatient thyroidectomy when selecting disposition of patients undergoing neck surgery.

Interaction Between Platelet and Fibrinogen on Clot Strength in Healthy Patients.

OBJECTIVE: The purpose of this study was to explore the relationship between platelet concentration (PLT) (× 109/L) and clot strength measured by thromboelastography maximum amplitude (TEG-MA) in healthy volunteers without a history of coagulation abnormalities. Secondarily, the relationship between fibrinogen (mg/dL) and TEG-MA was analyzed. DESIGN: A prospective study. SETTING: At a university's tertiary-care center. MEASUREMENTS AND MAIN RESULTS: Using whole blood, PLT was reduced in the first part, and hematocrit was reduced in the second part of the study by hemodilution with platelet-rich and -poor plasma. Thromboelastography (TEG 5000 Haemonetics) was performed to measure clot formation and strength. Spearman correlation coefficients regression analyses and receiver-operating characteristics (ROC) were obtained to analyze the relationships among PLT, fibrinogen, and TEG-MA. Strong correlations were found in univariate analysis between PLT and TEG-MA (r = 0.88; p < 0.0001) and between Fibrinogen and TEG-MA (r = 0.70; p = 0.003). A biphasic relationship between PLT and TEG-MA was linear below a PLT 90 × 109/L, followed by a plateau above 100 × 109/L (p = 0.001). A linear relationship between fibrinogen (190-474 mg/dL) and TEG-MA (53-76 mm) was found (p = 0.0007). The ROC analysis found that PLT = 60 × 109/L was associated with a TEG-MA of 53.0 mm. The product of PLT and fibrinogen concentrations was more strongly correlated (r = 0.91) to TEG-MA than either PLT (r = 0.86) or fibrinogen (r = 0.71) alone. A ROC analysis revealed that a TEG-MA of 55 mm was associated with a PLT × fibrinogen of 16,720. CONCLUSION: In healthy patients, a PLT of 60 × 109/L was associated with normal clot strength (TEG-MA ≥53 mm), and there was little change in clot strength with PLT >90 × 109/L. Although prior analyses described the contributions of platelets and fibrinogen toward clot strength, they are presented and discussed independently. The data above described clot strength as an interaction among them. Future analyses and clinical care should evaluate and recognize the interplay.

Burnout and depression among anesthesiology trainees in the United States: An updated National Survey.

STUDY OBJECTIVE: A high prevalence of burnout, depression and suicidal ideation has been reported among anesthesiology trainees. Over the last decade, there has been a significant emphasis on the development of wellness programs in academic departments to mitigate the prevalence and effects of burnout during anesthesiology training. Therefore, we aimed to reevaluate the prevalence of burnout and depression in anesthesiology trainees in the United States. DESIGN: Cross-sectional survey. SETTING: Anesthesiology Department. PATIENTS: A nationally representative sample of 1000 anesthesiology trainees in the United States. MEASUREMENTS: A 33-item questionnaire consisting of 1) burnout, 2) depression, 3) job satisfaction, 4) family support, 5) work characteristics, 6) demographic factors, 7) self-reported errors, and 8) impact of COVID-19 pandemic. RESULTS: We received 384 responses. Twenty-four percent (91/384) of the respondents met the criteria for high burnout risk and 58/384 (15%) of the respondents screened positive for depression. Multivariable analysis revealed that: (1) hours per week > 70, (odds ratio [OR; 95% confidence interval {CI}] = 3.1 [1.4-6.8], P=0.005 and (2) overnight calls per month > 7 (OR [95% CI] = 2.5 [1.0- 6.0], P=0.03 were independent factors for increased odds of burnout whereas the presence of (3) married/domestic partnership (OR [95% CI} = 0.52 [0.32-0.85], P=0.01 was associated with lower odds of burnout and/or depression. Ten percent (4/40) of high burnout/depression residents reported that they often times fall short in the quality of care provided to patients compared to 0.36% (1/275) residents with low burnout/depression scores, P < 0.001. Similarly, 22% (9/40) of high burnout/depression residents reported that they often times did not have enough attention to their patients compared to 4% (11/275) residents with low burnout/depression scores, P < 0.001. CONCLUSIONS: We report a still concerning but significantly lower rate of burnout and depression in anesthesiology trainees than previously reported a decade ago. This suggests that efforts on wellness implemented by academic programs have positively impacted the work experience of anesthesia trainees.

The Effectiveness of Direct Supervision by an Attending Compared To a Senior Resident on Quality of Supervision of Novice Anesthesiology Residents: A Randomized Study.

Background: New trainees are directly supervised by either an attending physician or a senior resident under indirect supervision from an attending physician. The main objective was to evaluate which type of direct supervision (attending vs. senior resident) would result in better quality of supervision to novice residents during their first month of training. Methods: Novice anesthesiology residents were randomized to receive direct supervision by an attending anesthesiologist or a senior resident during their introduction month of intraoperative anesthesia. The primary outcome was a validated instrument to evaluate supervision performance of the instructor. The secondary outcome was a validated anxiety scale. Results: The overall mean supervision score across the study days was greater in the residents who were directly supervised by attendings, mean (standard error [SE]) of 3.88 ± 0.03 compared with direct supervision by a senior resident, mean (SE) of 3.77 ± 0.03 a mean difference of 0.11 (95% confidence interval [CI], 0.05-0.16), P = .0012. Five of 9 individual items on the supervision survey were significantly greater in the group directly supervised by attendings compared with residents. There was no difference between groups regarding anxiety scores. In contrast, there was a mild association between supervision scores and Spielberger State-Trait Anxiety Inventory-6 anxiety scores, correlation coefficient = 0.23 (95% CI, 0.08-0.39), P < .0035. Conclusions: We detected better supervision scores when novice anesthesiology residents were directly supervised by attendings when compared with senior residents. Nevertheless, direct supervision by senior residents still provided supervision scores consistent with a safe supervision practice.

Transesophageal echocardiographic imaging of the coronary sinus: a retrospective analysis of mid-esophageal views and a novel transgastric view.

BACKGROUND: Transesophageal echocardiographic imaging plays an important role in assessing coronary sinus anatomy prior to placement of a retrograde cardioplegia cannula. The coronary sinus can be imaged in the long axis by advancing the TEE probe from the mid-esophageal 4-chamber view or using a modified mid-esophageal bicaval view, while a short axis view can be obtained in the mid-esophageal 2-chamber view. While use of a transgastric view is only briefly mentioned in the literature as an alternative to mid-esophageal views, the authors commonly include it in our comprehensive transesophageal echocardiographic exam of the coronary sinus. This study examines the various imaging strategies. We hypothesize that the transgastric view offers comparable coronary sinus imaging to the mid-esophageal views. METHODS: After approval by our institutional review board, the intraoperative transesophageal echocardiographic exams for 50 consecutive elective cardiac surgical patients with a comprehensive echocardiographic assessment of the coronary sinus were retrospectively reviewed and analyzed to evaluate imaging of the coronary sinus in the various views. For each view, we noted and recorded if the coronary sinus and coronary sinus cannula were visualized. Statistical analysis required pairwise comparisons between each of the 4 views. P values were calculated using McNemar's Exact test. RESULTS: Both the coronary sinus and coronary sinus cannula were visualized a majority of the time for each view. There was no statistically significant difference between each view in its ability to visualize the coronary sinus, nor was there a statistically significant difference between each view in its ability to visualize the coronary sinus cannula. CONCLUSIONS: Use of a transgastric window provides the echocardiographer with an effective alternate modality for imaging the coronary sinus when mid-esophageal views are limited.

The impact of hypoalbuminemia on postoperative outcomes after outpatient surgery: a national analysis of the NSQIP database.

PURPOSE: Hypoalbuminemia has been described as a modifiable factor to optimize postoperative outcomes after major inpatient surgeries. Nevertheless, the role of hypoalbuminemia on outpatient procedures is not well defined. The purpose of this study was to examine the impact of hypoalbuminemia on postoperative outcomes of patients undergoing low-risk outpatient surgery. METHODS: Patients were extracted from the American College of Surgeons National Surgical Quality Improvement Program database who had outpatient surgery from 2018 and recorded preoperative albumin levels. The primary outcome was a composite of any major complications including: 1) unplanned intubation, 2) pulmonary embolism, 3) ventilator use > 48 hr, 4) progressive renal failure, 5) acute renal failure, 6) stroke/cerebrovascular accident, 7) cardiac arrest, 8) myocardial infarction, 9) sepsis, 10) septic shock, 11) deep venous thrombosis, and 12) transfusion. Death, any infection, and readmissions were secondary outcomes. RESULTS: A total of 65,192 (21%) surgical outpatients had albumin collected preoperatively and 3,704 (1.2%) patients had levels below 3.5 g⋅dL-1. In the albumin cohort, 394/65,192 (0.6%) patients had a major medical complication and 68/65,192 (0.1%) patients died within 30 days after surgery. Albumin values < 3.5 g⋅dL-1 were associated with major complications (adjusted odds ratio [aOR], 1.92; 95% confidence interval [CI], 1.44 to 2.57; P < 0.001; death-adjusted OR, 3.03; 95% CI, 1.72 to 5.34; P < 0.001); any infection (aOR, 1.49; 95% CI, 1.23 to 1.82; P < 0.001); and readmissions (aOR, 1.82; 95% CI, 1.56 to 2.14; P < 0.001). In addition, when evaluated as a continuous variable in a multivariate analysis, for each increase in albumin of 0.10 g⋅dL-1, there was an associated reduction of major complications (aOR, 0.94; 95% CI, 0.92 to 0.96; P < 0.001). CONCLUSIONS: Hypoalbuminemia is associated with major complications and death in outpatient surgery. Since hypoalbuminemia is a potential modifiable intervention, future clinical trials to evaluate the impact of optimizing preoperative albumin levels before outpatient surgery are warranted.

RéSUMé: OBJECTIF: L'hypoalbuminémie a été décrite comme un facteur modifiable pour optimiser les issues postopératoires après des chirurgies hospitalières majeures. Néanmoins, le rôle de l'hypoalbuminémie dans les interventions ambulatoires n'est pas bien défini. L'objectif de cette étude était d'examiner l'impact de l'hypoalbuminémie sur les issues postopératoires des patients bénéficiant d'une chirurgie ambulatoire à faible risque. MéTHODE: Les patients ayant bénéficié d'une chirurgie ambulatoire à partir de 2018 et pour lesquels les taux d'albumine préopératoire ont été enregistrés ont été extraits de la base de données américaine du programme national d'amélioration de la qualité chirurgicale (NSQIP) de l'American College of Surgeons. Le critère d'évaluation principal était un composite de toutes les complications majeures, y compris : 1) intubation non planifiée, 2) embolie pulmonaire, 3) utilisation d'un ventilateur > 48 h, 4) insuffisance rénale progressive, 5) insuffisance rénale aiguë, 6) accident vasculaire cérébral, 7) arrêt cardiaque, 8) infarctus du myocarde, 9) sepsis, 10) choc septique, 11) thrombose veineuse profonde, et 12) transfusion. Les décès, infections et réadmissions constituaient des critères d'évaluation secondaires. RéSULTATS: Au total, les taux d'albumine ont été prélevés chez 65 192 (21 %) patients chirurgicaux ambulatoires avant l'opération et 3704 (1,2 %) patients avaient des taux inférieurs à 3,5 g⋅dL-1. Dans la cohorte albumine, 394 / 65 192 (0,6 %) patients ont eu une complication médicale majeure et 68 / 65 192 (0,1%) patients sont décédés dans les 30 jours suivant la chirurgie. Des valeurs d'albumine < 3,5 g⋅dL-1 étaient associées à des complications majeures (rapport de cotes ajusté [RCA]), 1,92 ; intervalle de confiance [IC] à 95 %, 1,44 à 2,57; P < 0,001; RC ajusté en fonction du décès, 3,03; IC 95 %, 1,72 à 5,34; P < 0,001); infections (RCA, 1,49; IC 95 %, 1,23 à 1,82; P < 0,001); et réadmissions (RCA, 1,82; IC 95 %, 1,56 à 2,14; P < 0,001). De plus, lorsque le taux d'albumine était évalué comme variable continue dans une analyse multivariée, pour chaque augmentation de l'albumine de 0,10 g⋅dL-1, il y avait une réduction associée des complications majeures (RCA, 0,94; IC 95 %, 0,92 à 0,96; P < 0,001). CONCLUSION: L'hypoalbuminémie est associée à des complications majeures et au décès en chirurgie ambulatoire. Étant donné que l'hypoalbuminémie est une intervention potentiellement modifiable, de futures études cliniques visant à évaluer l'impact de l'optimisation des taux préopératoires d'albumine avant une chirurgie ambulatoire sont nécessaires.

Utility of preoperative laboratory testing in ASA 1 & ASA 2 patients undergoing outpatient surgery in the United States.

STUDY OBJECTIVE: To assess the utility of preoperative testing in ASA physical status 1 and 2 patients undergoing outpatient surgery across several surgical specialties. DESIGN: Retrospective cohort study. PATIENTS: The American College of Surgeons National Surgical Quality Improvement Program database from 2017 to 2018 was queried to extract patients defined as ASA 1 and 2 who underwent outpatient surgeries. A total of 352,775 adult patients underwent outpatient surgery with 186,954 patients had at least one lab drawn within 30 days prior to the surgery. INTERVENTIONS: ASA physical status 1 and 2 patients who underwent outpatient surgeries. MEASUREMENTS: The primary independent variable was the utilization of preoperative laboratory testing. The primary outcomes were the occurrence of any medical or surgical complication adverse events within 30 days of discharge. In addition, we also examined hospital readmissions. A P value of 0.025 was used to avoid type I error for each primary outcome. MAIN RESULTS: In the overall cohort, 186,954 out of 352,775 (53%) of patients had at least one lab test. Hematology was the most common lab test ordered, 172,903 out of 352,755 patients (49%), followed by chemistry (43%), liver function (23%), and coagulation tests (11%). After adjusting for confounding factors, the use preoperative testing was not associated with overall medical complications, OR (95%CI) of 1.09 (1.00 to 1.18), P = 0.05 and overall surgical complications, 1.00 (0.92 to 1.08), P = 0.96 [Bonferroni corrected: medical complications OR (97.5% CI) of 1.09 (0.989 to 1.202), P = 0.0950 and overall surgical complications, 1.00 (0.918 to 1.093), P = 1.00. CONCLUSION: We detected a low utility of preoperative tests for ASA 1 and 2 patients undergoing a large variety of outpatient procedures. Our results support the elimination of preoperative laboratory test for ASA 1 and 2 undergoing ambulatory surgery.

Early Postoperative Outcomes of Super Morbid Obese Compared to Morbid Obese Patients After Ambulatory Surgery Under General Anesthesia: A Propensity-Matched Analysis of a National Database.

BACKGROUND: Patients with body mass index (BMI) ≥50 kg/m2, defined as super morbid obesity, represent the fastest growing segment of patients with obesity in the United States. It is currently unknown if super morbid obese patients are at greater odds than morbid obese patients for poor outcomes after outpatient surgery. The main objective of the current investigation is to assess if super morbid obese patients are at increased odds for postoperative complications after outpatient surgery when compared to morbid obese patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2017 to 2018 was queried to extract and compare patients who underwent outpatient surgery and were defined as either morbidly obese (BMI >40 and <50 kg/m2) or super morbidly obese (BMI ≥50 kg/m2). The primary outcome was the occurrence of medical adverse events within 72 hours of discharge. In addition, we also examine death and readmissions as secondary outcomes. A propensity-matched analysis was used to evaluate the association of BMI ≥50 kg/m2 versus BMI between 40 and 50 kg/m2 and the outcomes. RESULTS: A total of 661,729 outpatient surgeries were included in the 2017-2018 NSQIP database. Of those, 7160 with a BMI ≥50 kg/m2 were successfully matched to 7160 with a BMI <50 and ≥40 kg/m2. After matching, 17 of 7160 (0.24%) super morbid obese patients had 3-day medical complications compared to 15 of 7160 (0.21%) morbid obese patients (odds ratio [OR; 95% confidence interval {CI}] = 1.13 [0.57-2.27], P = .72). The rate of 3-day surgical complications in super morbid obese patients was also not different from morbid obese patients. Thirty-five of 7160 (0.48%) super morbid obese patients were readmitted within 3 days, compared to 33 of 7160 (0.46%) morbid obese patients (OR [95% CI] = 1.06 [0.66-1.71], P = .80). When evaluated in a multivariable analysis as a continuous variable (1 unit increase in BMI) in all patients, BMI ≥40 kg/m2 was not significantly associated with overall medical complications (OR [95% CI] = 1.00 [0.98-1.04], P = .87), overall surgical complication (OR [95% CI] = 1.02 [0.98-1.06], P = .23), or readmissions (OR [95% CI] = 0.99 [0.97-1.02], P = .8). CONCLUSIONS: Super morbid obesity is not associated with higher rates of early postoperative complications when compared to morbid obese patients. Specifically, early pulmonary complications were very low after outpatient surgery. Super morbid obese patients should not be excluded from outpatient procedures based on a BMI cutoff alone.

Spinal versus general anesthesia for patients undergoing outpatient total knee arthroplasty: a national propensity matched analysis of early postoperative outcomes.

BACKGROUND: A comparison of different anesthetic techniques to evaluate short term outcomes has yet to be performed for patients undergoing outpatient knee replacements. The aim of this investigation was to compare short term outcomes of spinal (SA) versus general anesthesia (GA) in patients undergoing outpatient total knee replacements. METHODS: The ACS NSQIP datasets were queried to extract patients who underwent primary, elective, unilateral total knee arthroplasty (TKA) between 2005 and 2018 performed as an outpatient procedure. The primary outcome was a composite score of serious adverse events (SAE). The primary independent variable was the type of anesthesia (e.g., general vs. spinal). RESULTS: A total of 353,970 patients who underwent TKA procedures were identified comprising of 6,339 primary, elective outpatient TKA procedures. Of these, 2,034 patients received GA and 3,540 received SA. A cohort of 1,962 patients who underwent outpatient TKA under GA were propensity matched for covariates with patients who underwent outpatient TKA under SA. SAE rates at 72 h after surgery were not greater in patients receiving GA compared to SA (0.92%, 0.66%, P = 0.369). In contrast, minor adverse events were greater in the GA group compared to SA (2.09%, 0.51%), P < 0.001. The rate of postoperative transfusion was greater in the patients receiving GA. CONCLUSIONS: The type of anesthetic technique, general or spinal anesthesia does not alter short term SAEs, readmissions and failure to rescue in patients undergoing outpatient TKR surgery. Recognizing the benefits of SA tailored to the anesthetic management may maximize the clinical benefits in this patient population.

An evaluation of impact factor bias of clinical trials published in pain journals.

BACKGROUND AND OBJECTIVE: Studies with nonsignificant results are less likely to be published or published in lower impact factor journals. To determine whether a similar phenomenon occurs in pain literature, we explored impact factor bias in peer-reviewed pain journals. METHODS: A PubMed search involving randomized controlled trials in pain journals during 2012 through 2018 was performed. The primary outcome was the publication impact factor. Exclusion criteria included commentaries, editorials, meta-analyses, reviews, and animal studies. The average impact factor for each journal was determined. The primary independent variable was a study with a positive outcome. RESULTS: Of the 9 journals evaluated, 1108 articles met our inclusion criteria and were included in our analysis. The quartiles for the impact factor for the journals included were 2.5, 2.9, and 3.6. A multivariate analysis identified sample size greater than 100, description of a sample size calculation, presence of a stated hypothesis, and presence of sponsorship funding as independent predictors of publication in a journal with greater impact factor. In contrast, positive results were not associated with publication in a greater impact factor journal, even when forced into the model, P = 0.49. CONCLUSIONS: After adjusting for study factors associated with publication, there is no evidence of impact factor bias within the pain literature. The lack of impact factor bias in the pain literature is a positive finding for the field and should benefit scientific development and the clinical care of patients.

American Society of Anesthesiologists Physical Status Classification as a reliable predictor of postoperative medical complications and mortality following ambulatory surgery: an analysis of 2,089,830 ACS-NSQIP outpatient cases.

BACKGROUND: Seventy percent of surgical procedures are currently performed in the outpatient setting. Although the American Society of Anesthesiologists (ASA) Physical Classification ability to predict risk has been evaluated for in-patient surgeries, an evaluation in outpatient surgeries has yet to be performed. The major goal of the current study is to determine if the ASA classification is an independent predictor for morbidity and mortality for outpatient surgeries. METHODS: The 2005 through 2016 NSQIP Participant Use Data Files were queried to extract all patients scheduled for outpatient surgery. ASA PS class was the primary independent variable of interest. The primary outcome was 30-day medical complications, defined as having one or more of the following postoperative outcomes: (1) deep vein thrombosis, (2) pulmonary embolism, (3) reintubation, (4) failure to wean from ventilator, (5) renal insufficiency, (6) renal failure, (7) stroke, (8) cardiac arrest, (9) myocardial infarction, (10) pneumonia, (11) urinary tract infection, (12) systemic sepsis or septic shock. Mortality was also evaluated as a separate outcome. RESULTS: A total of 2,089,830 cases were included in the study. 24,777 (1.19%) patients had medical complications and 1,701 (0.08%) died within 30 days. ASA PS IV patients had a much greater chance of dying when compared to healthy patients, OR (95%CI) of 89 (55 to 143), P < 0.001. Nonetheless, over 30,000 ASA PS IV patients had surgery in the outpatient setting. Multivariable analysis demonstrated a stepwise independent association between ASA PS class and medical complications (C statistic = 0.70), mortality (C statistic = 0.74) and readmissions (C statistic = 0.67). Risk stratifying ability was maintained across surgical procedures and anesthesia techniques. CONCLUSIONS: ASA PS class is a simple risk stratification tool for surgeries in the outpatient setting. Patients with higher ASA PS classes subsequently developed medical complications or mortality at a greater frequency than patients with lower ASA PS class after outpatient surgery. Our results suggest that the ambulatory setting may not be able to match the needs of high-risk patients.

Safety and outcomes of outpatient compared to inpatient total knee arthroplasty: a national retrospective cohort study.

BACKGROUND: Many factors are driving total knee arthroplasty to be performed more commonly as an outpatient (<24 hour discharge) procedure. Nonetheless, the safety of total knee replacements performed in the outpatient setting is not well established when compared with inpatient setting. The purpose of this study is to compare the postoperative outcomes of outpatient and inpatient total knee arthroplasties. METHODS: The 2015 and 2016 American College of Surgeons National Surgical Quality Improvement Program data sets were queried to extract patients who underwent primary, elective, unilateral total knee arthroplasty. The primary outcome was serious adverse events defined by a composite outcome including: return to operating room, wound-related infection, thromboembolic event, renal failure, myocardial infarction, cardiac arrest requiring cardiopulmonary resuscitation, cerebrovascular accident, use of ventilator >48 hours, unplanned intubation, sepsis/septic shock, and death. Propensity matched analysis was used to adjust for potential confounding covariates. RESULTS: 1099 patients undergoing outpatient total knee arthroplasty (1% of total cases) were successfully matched to 1099 patients undergoing inpatient surgeries. The composite rate of serious adverse events was greater in outpatient procedures compared with inpatient procedures (3.18% vs 1.36%, p=0.005). In contrast, failure to rescue and readmission rates were not different between groups. CONCLUSIONS: Outpatient total knee arthroplasty is associated with a higher composite risk of serious adverse events than inpatient procedures. Anesthesiologists and surgeons should inform patients and discuss this information when obtaining consent for surgery and planning for discharge timing.

The Left Ventricular Outflow Tract Changes in Size and Shape From Pre- to Post-Cardiopulmonary Bypass: Three-Dimensional Transesophageal Echocardiography.

OBJECTIVES: To compare two-dimensional (2D) and 3D imaging of the left ventricular outflow tract (LVOT) and to evaluate geometric changes pre- to post-cardiopulmonary bypass (CPB). DESIGN: Retrospective review of intraoperative transesophageal echocardiographic examinations. SETTING: Single academic medical center. PARTICIPANTS: The study comprised 69 cardiac surgical patients-27 with aortic valve stenosis (AS) and 42 without AS. INTERVENTIONS: Two-dimensional and 3D analysis of the LVOT pre- and post-CPB. MEASUREMENTS AND MAIN RESULTS: Pre- and post-CPB 2D assessment of LVOT diameter (2D LVOTd) was compared with 3D analysis of the minor (3D LVOTd-min) and major diameters. LVOT areas (LVOTa) were calculated using LVOTd to yield 2D LVOTa and 3D LVOTa-min. These were compared with LVOTa measured by planimetry (3D LVOTa-plan). An ellipticity ratio (ER) (ER = 3D minor/major axes) was calculated. The 2D LVOTd was larger than the 3D LVOTd-min before (2.12 v 2.02 cm respectively (resp); p < 0.001) and after (1.96 v 1.85 cm resp; p = 0.04) CPB. Compared with pre-CPB, there were significant decreases in the 2D LVOTd (p = 0.003) and the 3D LVOTd-min (p < 0.001) post-CPB. Ellipticity increased after CPB (ER 0.80 v 0.75; p = 0.004), and the 2D LVOTa was larger than the 3D LVOTa-min before CPB (3.60 cm2v 3.28 cm2; p < 0.001) and less so after CPB (3.11 cm2v 2.79 cm2; p = 0.053). Compared with pre-CPB, all LVOTa measurements decreased significantly after CPB (p < 0.001). The 3D LVOTa-plan decreased after CPB by approximately 10% (4.05 cm2v 3.61 cm2; p < 0.001). The 2D LVOTa and 3D LVOTa-min underestimated the 3D LVOTa-plan before and after CPB (p < 0.001) by 11% to 14% and 19% to 23%, respectively. When compared with non-AS patients, patients with AS had a smaller LVOTa pre- and post-CPB (p < 0.05). CONCLUSIONS: The LVOT is smaller and more elliptical after CPB. Patients with AS have a smaller LVOT compared with non-AS patients. LVOTa calculated using LVOTd underestimates the 3D LVOTa-plan by as much as 23% depending on patient type and timing of measurement. Accurate assessment of the LVOT requires 3D imaging.

The association between surgical duration and venous thromboembolism in outpatient surgery: A propensity score adjusted prospective cohort study.

BACKGROUND: Outpatient surgeries account for 60-70% of all procedures. Increased surgical duration has been demonstrated to be an independent risk factor for the development of venous thromboembolism (VTEs) after inpatient surgeries. In contrast, it is currently unknown if surgical duration increases the risk of VTEs for outpatient surgeries. MATERIALS AND METHODS: The 2005 through 2016 NSQIP Participant Use Data Files were queried to extract all patients scheduled for outpatient surgery. A z-score for surgical duration was calculated for each procedure to allow for standardization across surgeries of expected shorter or longer duration. The primary outcome measured was incidence of VTEs within 30 days of surgery. RESULTS: A total of 3474 patients out of 1,863,523 (0.19%) had a VTE. After adjusting for confounding factors, the first and fifth quintiles compared to the middle quintile had odds ratios (ORs) of 0.75 (95% CI 0.68, 0.80) and 1.43 (95% CI, 1.35%-1.52%), respectively, P < 0.001. Patients who developed VTEs were more likely to be readmitted to the hospital, OR (95%CI) of 51.9 (48.0-56.2), C statistic = 0.67. CONCLUSION: Surgical duration is associated with the development of VTEs after outpatient surgery. While the overall incidence of VTE is low and does not require generalized prophylaxis, clinical practitioners should consider prophylaxis for patients undergoing outpatient surgery performed with excessive time compared to the average surgical procedure duration.

Echocardiographic Predictors of Tricuspid Ring Annuloplasty Repair Failure for Functional Tricuspid Regurgitation.

OBJECTIVE: Significant tricuspid regurgitation (TR) recurs after tricuspid valve repair of functional TR in 15% to 20% within the first year, and 30% to 70% within 5 years. Prior investigations report leaflet tethering, and not tricuspid valve annular diameter (TVAD), as predictive of recurrent TR. The authors hypothesize that pre-repair TVAD is predictive of repair failure for functional TR. PARTICIPANTS: Fifty-four patients with functional TR scheduled for left heart surgery and tricuspid valve repair with ring annuloplasty. DESIGN: Retrospective study design. Pre- and post-repair transthoracic and intraoperative transesophageal echocardiographic data included left and right ventricular functions, tricuspid leaflet tethering height, TVAD, and TR severity. Successful repair was defined as ≤2+ TR. SETTING: Tertiary care medical center. INTERVENTIONS: None. MEASUREMENTS: Forty-five patients had a successful repair and 9 did not. Preoperative and intraoperative TVAD in diastole (TVADdiast) ≥4.2 cm, and preoperative systole (TVADsyst) ≥3.7 cm, but not leaflet tethering, were predictive of repair failure. Right ventricular (RV) width >4.88 cm was associated with repair failure. Neither pre- nor post-repair pulmonary artery systolic pressures (PASP) were predictors of repair failure. However, PASP did not change nor did RV function improve in the nonsuccessful repair group. CONCLUSION: For patients with functional TR undergoing primary left heart surgery, preoperative TVAD (systole and diastole), RV width, and postoperative RV function were predictors of repair outcome. Earlier TV repair and optimizing right heart function may improve repair outcome.

Association of insurance type with receipt of oral anticoagulation in insured patients with atrial fibrillation: A report from the American College of Cardiology NCDR PINNACLE registry.

BACKGROUND: It is poorly understood whether insurance type may be a major contributor to the underuse of oral anticoagulation (OAC) among patients with atrial fibrillation (AF), particularly for novel oral anticoagulants (NOACs). METHODS: We performed a retrospective cohort registry study of patients with insurance, AF, CHA2DS2-VASc ≥2, and at least one outpatient encounter recorded in the ACC NCDR's PINNACLE Registry between January 1, 2011 and December 31, 2014. We used hierarchical regression, adjusting for patient characteristics and clustering by physician, to evaluate the association of insurance type (Private, Military, Medicare, Medicaid, Other) with receipt of OAC (any OAC, warfarin, or NOAC). RESULTS: In 363,309 patients (age 75±10; 48% female), we found a significant difference in proportions of OAC and NOAC prescription across insurance types (OAC: Military 53%, Private 53%, Medicare 52%, Other 41%, Medicaid 41%, P<.001; NOAC: Military 24%, Private 19%, Medicare 17%, Other 17%, Medicaid 8%, P<.001). After adjustment for patient characteristics and facility, private, Medicaid, and other insurance were independently associated with a lower odds of OAC prescription relative to Medicare, but military insured patients were not significantly different. After adjustment, military and private insurance were independently associated with a higher odds of NOAC prescription relative to Medicare, while Medicaid and other insurance were associated with a lower odds of NOAC prescription. CONCLUSIONS: In a contemporary US AF population, there was significant variation of OAC prescription across insurance plans, with the highest among private and Medicare insured patients. These differences may indicate that insurance plan, and its associated pharmacy benefits, affect the pace of diffusion of new therapies.

Extended Duration Dual Antiplatelet Therapy After Coronary Stenting Among Patients With Peripheral Arterial Disease: A Subanalysis of the Dual Antiplatelet Therapy Study.

OBJECTIVES: This study sought to determine whether patients with peripheral arterial disease (PAD) experience different reductions in ischemic event and increases in bleeding events with extended duration dual antiplatelet therapy versus those without PAD. BACKGROUND: Patients with PAD have increased ischemic and bleeding risks after coronary stenting. METHODS: The DAPT (Dual Antiplatelet Therapy) study randomized 11,648 patients free from ischemic and bleeding events 12 months after coronary stenting to continued thienopyridine plus aspirin therapy for an additional 18 months versus aspirin therapy alone. The effects of continued thienopyridine on myocardial infarction (MI) or stent thrombosis, major adverse cardiovascular and cerebrovascular events (death, MI, or stroke) and bleeding (GUSTO [Global Utilization of t-PA and Streptokinase for Occluded Coronary Arteries] moderate or severe) were assessed among those with versus without PAD. RESULTS: Among 11,648 randomized patients, 649 (5.57%) had PAD. Between 12 and 30 months, randomized patients with PAD had higher rates of MI/stent thrombosis (6.03% vs. 2.92%; p < 0.001), major adverse cardiovascular and cerebrovascular events (11.65% vs. 4.62%; p < 0.001), and bleeding (4.86% vs. 1.74%; p < 0.001). Continued thienopyridine versus placebo was associated with consistent treatment effects for MI/stent thrombosis (with PAD, HR: 0.63; 95% CI: 0.32 to 1.22; without PAD, HR: 0.53; 95% CI: 0.42, 0.66; interaction p = 0.631), major adverse cardiovascular and cerebrovascular events (with PAD, HR: 1.06; 95% CI: 0.67 to 1.67; without PAD, HR: 0.70; 95% CI: 0.59 to 0.84; interaction p = 0.103), and bleeding (with PAD, HR, 1.82; 95% CI: 0.87 to 3.83; without PAD, HR: 1.66; 95% CI: 1.23 to 2.24; interaction p = 0.811). CONCLUSIONS: Among patients undergoing coronary stenting, those with PAD have more ischemic and bleeding events versus those without PAD. Extended duration dual antiplatelet therapy is associated with consistent ischemic benefit and bleeding harm among patients with and without PAD.

Mortality Following Cardiovascular and Bleeding Events Occurring Beyond 1 Year After Coronary Stenting: A Secondary Analysis of the Dual Antiplatelet Therapy (DAPT) Study.

Importance: Early cardiovascular and bleeding events after coronary stenting are associated with high risk of morbidity and mortality. Objective: To assess the prognosis of cardiovascular and bleeding events occurring beyond 1 year after coronary stenting. Design, Setting, and Participants: This secondary analysis is derived from data from the Dual Antiplatelet Therapy (DAPT) Study, a multicenter trial involving 220 US and international clinical sites from 11 countries. The study dates were August 2009 to May 2014. Individuals who underwent coronary stenting and completed 12 months of thienopyridine plus aspirin therapy without ischemic or bleeding events remained on an aspirin regimen and were randomized to continued thienopyridine therapy vs placebo for 18 additional months. Individuals were then followed up for 3 additional months while receiving aspirin therapy alone. The analysis began in August 2015. Exposures: Ischemic events (myocardial infarction not related to stent thrombosis, stent thrombosis, and ischemic stroke) and bleeding events (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries [GUSTO] classification moderate or severe bleeding). Main Outcomes and Measures: Ischemic events (myocardial infarction not related to stent thrombosis, stent thrombosis, and ischemic stroke) and bleeding events (GUSTO classification moderate or severe bleeding). Death at 21 months after randomization (33 months after coronary stenting). Results: In total, 25 682 individuals older than 18 years with an indication for coronary stenting were enrolled, and 11 648 (mean age, 61.3 years; 25.1% female) were randomized. After randomization, 478 individuals (4.1%) had 502 ischemic events (306 with myocardial infarction, 113 with stent thrombosis, and 83 with ischemic stroke), and 232 individuals (2.0%) had 235 bleeding events (155 with moderate and 80 with severe bleeding). Among individuals with ischemic events, 52 (10.9%) died. The annualized mortality rate after an ischemic event was 27.2 (95% CI, 20.3-35.7) per 100 person-years. The cumulative incidence of death after an ischemic event among the total randomized study population was 0.5% (0.3% with myocardial infarction, 0.1% with stent thrombosis, and 0.1% with ischemic stroke). Among individuals with bleeding events, 41 (17.7%) died. The annualized mortality rate after a bleeding event was 21.5 (95% CI, 15.4-29.1) per 100 person-years. The cumulative incidence of death after a bleeding event among the total randomized study population was 0.3% (0.1% with moderate and 0.2% with severe bleeding). Conclusions and Relevance: In patients treated with dual antiplatelet therapy for at least 1 year after coronary stenting, ischemic events were more frequent than bleeding events, and both events were associated with high risk of mortality. Trial Registration: clinicaltrials.gov Identifier: NCT00977938.

Development and Validation of a Prediction Rule for Benefit and Harm of Dual Antiplatelet Therapy Beyond 1 Year After Percutaneous Coronary Intervention.

IMPORTANCE: Dual antiplatelet therapy after percutaneous coronary intervention (PCI) reduces ischemia but increases bleeding. OBJECTIVE: To develop a clinical decision tool to identify patients expected to derive benefit vs harm from continuing thienopyridine beyond 1 year after PCI. DESIGN, SETTING, AND PARTICIPANTS: Among 11,648 randomized DAPT Study patients from 11 countries (August 2009-May 2014), a prediction rule was derived stratifying patients into groups to distinguish ischemic and bleeding risk 12 to 30 months after PCI. Validation was internal via bootstrap resampling and external among 8136 patients from 36 countries randomized in the PROTECT trial (June 2007-July 2014). EXPOSURES: Twelve months of open-label thienopyridine plus aspirin, then randomized to 18 months of continued thienopyridine plus aspirin vs placebo plus aspirin. MAIN OUTCOMES AND MEASURES: Ischemia (myocardial infarction or stent thrombosis) and bleeding (moderate or severe) 12 to 30 months after PCI. RESULTS: Among DAPT Study patients (derivation cohort; mean age, 61.3 years; women, 25.1%), ischemia occurred in 348 patients (3.0%) and bleeding in 215 (1.8%). Derivation cohort models predicting ischemia and bleeding had c statistics of 0.70 and 0.68, respectively. The prediction rule assigned 1 point each for myocardial infarction at presentation, prior myocardial infarction or PCI, diabetes, stent diameter less than 3 mm, smoking, and paclitaxel-eluting stent; 2 points each for history of congestive heart failure/low ejection fraction and vein graft intervention; -1 point for age 65 to younger than 75 years; and -2 points for age 75 years or older. Among the high score group (score ≥2, n = 5917), continued thienopyridine vs placebo was associated with reduced ischemic events (2.7% vs 5.7%; risk difference [RD], -3.0% [95% CI, -4.1% to -2.0%], P < .001) compared with the low score group (score <2, n = 5731; 1.7% vs 2.3%; RD, -0.7% [95% CI, -1.4% to 0.09%], P = .07; interaction P < .001). Conversely, continued thienopyridine was associated with smaller increases in bleeding among the high score group (1.8% vs 1.4%; RD, 0.4% [95% CI, -0.3% to 1.0%], P = .26) compared with the low score group (3.0% vs 1.4%; RD, 1.5% [95% CI, 0.8% to 2.3%], P < .001; interaction P = .02). Among PROTECT patients (validation cohort; mean age, 62 years; women, 23.7%), ischemia occurred in 79 patients (1.0%) and bleeding in 37 (0.5%), with a c statistic of 0.64 for ischemia and 0.64 for bleeding. In this cohort, the high-score patients (n = 2848) had increased ischemic events compared with the low-score patients and no significant difference in bleeding. CONCLUSION AND RELEVANCE: Among patients not sustaining major bleeding or ischemic events 1 year after PCI, a prediction rule assessing late ischemic and bleeding risks to inform dual antiplatelet therapy duration showed modest accuracy in derivation and validation cohorts. This rule requires further prospective evaluation to assess potential effects on patient care, as well as validation in other cohorts. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00977938.