Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.

Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting.

In the second part of the Society of Cardiovascular Anesthesiologists Extracorporeal Membrane Oxygenation (ECMO) working group expert consensus statement, venoarterial (VA) and venovenous (VV) ECMO management and troubleshooting in the operating room are discussed. Expert consensus statements are provided about intraoperative monitoring, anesthetic drug dosing, and management of intraoperative problems in VA and VV ECMO patients.

Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.

Incidence of Connected Consciousness after Tracheal Intubation: A Prospective, International, Multicenter Cohort Study of the Isolated Forearm Technique.

BACKGROUND: The isolated forearm technique allows assessment of consciousness of the external world (connected consciousness) through a verbal command to move the hand (of a tourniquet-isolated arm) during intended general anesthesia. Previous isolated forearm technique data suggest that the incidence of connected consciousness may approach 37% after a noxious stimulus. The authors conducted an international, multicenter, pragmatic study to establish the incidence of isolated forearm technique responsiveness after intubation in routine practice. METHODS: Two hundred sixty adult patients were recruited at six sites into a prospective cohort study of the isolated forearm technique after intubation. Demographic, anesthetic, and intubation data, plus postoperative questionnaires, were collected. Univariate statistics, followed by bivariate logistic regression models for age plus variable, were conducted. RESULTS: The incidence of isolated forearm technique responsiveness after intubation was 4.6% (12/260); 5 of 12 responders reported pain through a second hand squeeze. Responders were younger than nonresponders (39 ± 17 vs. 51 ± 16 yr old; P = 0.01) with more frequent signs of sympathetic activation (50% vs. 2.4%; P = 0.03). No participant had explicit recall of intraoperative events when questioned after surgery (n = 253). Across groups, depth of anesthesia monitoring values showed a wide range; however, values were higher for responders before (54 ± 20 vs. 42 ± 14; P = 0.02) and after (52 ± 16 vs. 43 ± 16; P = 0.02) intubation. In patients not receiving total intravenous anesthesia, exposure to volatile anesthetics before intubation reduced the odds of responding (odds ratio, 0.2 [0.1 to 0.8]; P = 0.02) after adjustment for age. CONCLUSIONS: Intraoperative connected consciousness occurred frequently, although the rate is up to 10-times lower than anticipated. This should be considered a conservative estimate of intraoperative connected consciousness.

Subarachnoid extension of primary intracerebral hemorrhage is associated with fevers.

BACKGROUND: Extension of hemorrhage into the subarachnoid space in primary intracerebral hemorrhage (ICH) has recently been associated with poor outcomes, although the mechanisms underlying that association are uncertain. The objectives of this study are to confirm the association between fever and poor outcomes after ICH, and to determine whether subarachnoid hemorrhage extension (SAHE) is associated with fevers. METHODS: Patients with primary ICH were enrolled into a prospective registry between December 2006 and July 2012. SAHE was identified on imaging by blinded expert reviewers. Patient temperature was recorded hourly, and we defined febrile as any recorded temperature >38 °C within the first 14 days. Regression models were developed to test whether fever was associated with poor outcome and whether the occurrence of SAHE was a predictor of fever. RESULTS: Of the 235 patients studied, 39.7 % had SAHE and 58 % had fever. Fever was associated with higher modified Rankin scores at 3 months (odds ratio, OR 1.8 [1.04-3.12], p = 0.04) after adjustment for ICH score. SAHE was a predictor of fevers (OR 1.82 [95 % confidence interval 1.02-3.24], p = 0.04) after adjustment for ICH score, and remained significant after adjustment for other confounders like pneumonia identified in the univariate analysis. CONCLUSIONS: Our data confirm the deleterious effect of fever on the outcome of patients with ICH and show that SAHE is an independent predictor of fever after ICH. SAHE may provoke dysfunctional thermoregulation similar to what is observed after aneurysmal subarachnoid hemorrhage, creating mechanistic pathway between SAHE and poor functional outcomes.

Predictors of 30-day readmission after intracerebral hemorrhage: a single-center approach for identifying potentially modifiable associations with readmission.

OBJECTIVE: To determine whether patient's demographics or severity of illness predict hospital readmission within 30 days following spontaneous intracerebral hemorrhage, to identify readmission associations that may be modifiable at the single-center level, and to determine the impact of readmission on outcomes. DESIGN: We collected demographic, clinical, and hospital course data for consecutive patients with spontaneous intracerebral hemorrhage enrolled in an observational study. Readmission within 30 days was determined retrospectively by an automated query with manual confirmation. We identified the reason for readmission and tested for associations between readmission and functional outcomes using modified Rankin Scale (a validated functional outcome measure from 0, no symptoms, to 6, death) scores before intracerebral hemorrhage and at 14 days, 28 days, and 3 months after intracerebral hemorrhage. SETTING: Neurologic ICU of a tertiary care hospital. PATIENTS: Critically ill patients with spontaneous intracerebral hemorrhage. INTERVENTIONS: Patients received standard critical care management for intracerebral hemorrhage. MEASUREMENTS AND MAIN RESULTS: Of 246 patients (mean age, 65 yr; 51% female), 193 patients (78%) survived to discharge. Of these, 22 patients (11%) were readmitted at a median of 9 days (interquartile range, 4-15 d). The most common readmission diagnoses were infections after discharge (n = 10) and vascular events (n = 6). Age, history of stroke and hypertension, severity of neurologic deficit at admission, Acute Physiology and Chronic Health Evaluation score, ICU and hospital length of stay, ventilator-free days, days febrile, and surgical procedures were not predictors of readmission. History of coronary artery disease was associated with readmission (p = 0.03). Readmitted patients had similar modified Rankin Scale and severity of neurologic deficit at 14 days but higher (worse) modified Rankin Scale scores at 3 months (median [interquartile range], 5 [3-6] vs 3 [1-4]; p = 0.01). CONCLUSIONS: Severity of illness and hospital complications were not associated with 30-day readmission. The most common indication for readmission was infection after discharge, and readmission was associated with worse functional outcomes at 3 months. Preventing readmission after intracerebral hemorrhage may depend primarily on optimizing care after discharge and may improve functional outcomes at 3 months.

Predictors of 30-day readmission after subarachnoid hemorrhage.

BACKGROUND: Readmission within 30 days is increasingly evaluated as a measure of quality of care. There are few data on the rates of readmission after subarachnoid hemorrhage (SAH). OBJECTIVE: We sought to determine the predictors of 30-day readmission in patients with SAH. METHODS: We prospectively identified 283 patients with SAH admitted between 2006 and 2012. Readmission was determined by means of an automated query with confirmation in the electronic medical record. RESULTS: Overall, 21 (8 %) patients were readmitted for infection (n = 8), headache (n = 5), hydrocephalus (n = 4), cardiovascular causes (n = 2), medication-related complications (n = 1), and cerebral ischemia (n = 1). Readmission was associated with longer intensive care unit (ICU) length of stay (LOS) (15.4 [13.4-19.3] vs. 12.2 [8.2-18.5] days, P = 0.02), hospital LOS (22.2 [17.4-23.0] vs. 16.8 [12.0-24.1] days, P = 0.01), and placement of an external ventricular drain (EVD, OR 3.9, 95 % CI 1.3-12.0, P = 0.01). Readmission was not associated with admission neurologic grade, NIH Stroke scale at 14 days, modified Rankin scale at 3 months, history of cardiovascular disease, or radiographic cerebral infarction (P > 0.1). CONCLUSIONS: Demographics, severity of neurologic injury, radiographic cerebral infarction, and outcomes were not associated with readmission after SAH. Markers of a more complicated hospital course (ICU and hospital LOS, EVD placement) were associated with 30-day readmission. Most readmissions were for infections acquired after discharge. Readmission within 30 days is difficult to predict, and, since the most common reason was infection acquired after discharge, it may be difficult to prevent without an integrated health system and coordinated care.

Management of acute complex instability of the elbow with hinged external fixation.

We report the experience of a single surgeon who treated 20 patients, over a 9-year period, with acute complex instability of the elbow with hinged external fixation. Patients who presented greater than 6 months after the original injury were excluded. The mechanism of injury was typically a fall or a motor vehicle accident. Fixators were placed at a mean of 26 days (range, 0-66 days) after injury and initial management. Reconstruction of the collateral ligaments was not performed, but soft tissues were repaired en bloc to the humerus. All patients were available for follow-up at a mean of 2.1 years. Flexion-extension arcs averaged 93 degrees , whereas pronation-supination arcs averaged 96 degrees. Posttraumatic arthrosis was commonly seen at follow-up, with moderate or severe changes developing in 55% of patients. Arthrosis did not correlate with functional outcomes, however. Outcomes were measured by use of the Mayo Elbow Performance Index and the Hospital for Special Surgery Total Elbow Scoring System, with mean scores of 75 and 71 points, respectively. Although the severity of injury often precludes obtaining a high percentage of good and excellent results, the outcomes after treatment of acute complex elbow instability with hinged external fixation by use of the technique detailed in this series are comparable to those of similar series.

Use of ketorolac tromethamine in children undergoing scoliosis surgery. an analysis of complications.

BACKGROUND CONTEXT: Ketorolac Tromethamine (ketorolac) is a nonsteroidal anti-inflammatory drug (NSAID) with proven efficacy in decreasing postoperative pain in various surgical settings, including the treatment of spine deformities. However, some studies have raised questions regarding the potential side effects of this agent, such as increased bleeding and inhibition of bony fusion. PURPOSE: This study was conducted to determine whether there is any association between the use of ketorolac and postoperative complications in a group of children who underwent scoliosis surgery. STUDY DESIGN/SETTING: This is a retrospective review of a group of children who underwent spinal fusion between 1989 to 1999 at our institution. PATIENT SAMPLE: Data on a total of 208 children were analyzed in this study. Sixty received ketorolac and 148 did not. OUTCOME MEASURES: Postoperative transfusion and reoperation rates were the two main outcome measures of interest. METHODS: A retrospective review of 208 children who underwent scoliosis surgery was conducted, with a focus on ketorolac use. Univariate analysis and logistic regression were used to quantify the determinants of postoperative complications. RESULTS: Our analyses detected no significant differences in a broad range of socioclinical variables between the two patient groups, including age at surgery, gender, type of scoliosis, surgical approach, use of erythropoietin, levels of curvature and degree of curvature. Analysis of complication rates focusing on postoperative transfusion and revision surgery showed that there were no significant differences between the two groups. CONCLUSIONS: In this retrospective study of 208 children undergoing spine surgery, postoperative use of ketorolac did not significantly increase complications, including transfusion and reoperation.

Frequency of acute changes found on head computed tomographies in critically ill patients: a retrospective cohort study.

PURPOSE: The frequency of positive findings on computed tomography (CT) of the head in critically ill patients who develop neurologic dysfunction is not known. MATERIALS AND METHODS: Cohort study of head CTs for patients admitted to 3 intensive care units from 2005 to 2010. We documented the frequency of acute changes for all head CTs and for the subgroup of patients with altered mental status (AMS). We also examined associations between patient characteristics or medications administered before head CT and the odds of an acute change on head CT using multivariate logistic regression. RESULTS: During 11 338 intensive care unit admissions, there were 901 eligible head CTs on 706 patients (6% of patients). Among head CTs, 155 (17.2%) assessed concern of new focal deficit, 99 (11.0%) concern for a seizure, and 635 (70.5%) for AMS. Acute changes were found on 109 (12.1%; 95% confidence interval [CI], 10.0%-14.2%) of all head CTs, and 30% (22.4%-36.9%) of patients with focal deficits, 16.2% (8.8%-23.5%) of patients with seizures but only 7.4% (5.4%-9.4%) for patients with AMS. A diagnosis of sepsis was associated with a decreased odds of an acute change on head CT for all head CTs (odds ratio 0.61; 95% CI, 0.40-0.95; P = .028) but was not significantly associated with a decreased risk among the cohort of head CTs for AMS (odds ratio 0.82; 95% CI, 0.41-1.62; P = .56). No other factors were associated with an altered risk of acute change on head CT for all patients in our cohort or for those with AMS. CONCLUSIONS: Acute changes on head CTs performed for concern regarding new focal neurologic deficit or seizures are frequent compared with those performed for AMS with a nonfocal examination. No specific patient characteristics or medications were associated with a large change in the likelihood of finding an acute change for patients with AMS.

Perioperative blood transfusion and radical cystectomy: does timing of transfusion affect bladder cancer mortality?

BACKGROUND: While perioperative blood transfusion (BT) has been associated with adverse outcomes in multiple malignancies, the importance of BT timing has not been established. OBJECTIVE: The objective of this study was to evaluate whether intraoperative BT is associated with worse cancer outcomes in bladder cancer patients treated with radical cystectomy (RC). DESIGN, SETTING, AND PARTICIPANTS: Outcomes from two independent cohorts of consecutive patients with bladder cancer treated with RC were analyzed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Recurrence-free survival, cancer-specific survival (CSS), and overall survival were estimated and multivariate analyses were performed to evaluate the association of BT timing with cancer outcomes. RESULTS AND LIMITATIONS: In the primary cohort of 360 patients, 241 (67%) received perioperative BT, including 162 intraoperatively and 79 postoperatively. Five-year CSS was 44% among patients who received an intraoperative BT versus 64% for patients who received postoperative BT (p=0.0005). After multivariate analysis, intraoperative BT was associated with an increased risk of cancer mortality (hazard ratio [HR]: 1.93; p=0.02), while receipt of postoperative BT was not (p=0.60). In the validation cohort of 1770 patients, 1100 (62%) received perioperative BT with a median postoperative follow-up of 11 yr (interquartile range: 8.0-15.7). Five-year RFS (p<0.001) and CSS (p<0.001) were significantly worse among patients who received an intraoperative BT. Intraoperative BT was independently associated with recurrence (HR: 1.45; p=0.001), cancer-specific mortality (HR: 1.55; p=0.0001), and all-cause mortality (HR: 1.40; p<0.0001). Postoperative BT was not associated with risk of disease recurrence or cancer death. CONCLUSIONS: Intraoperative BT is associated with increased risk of bladder cancer recurrence and mortality. PATIENT SUMMARY: In this study, the effects of blood transfusion on bladder cancer surgery outcomes were evaluated. Intraoperative blood transfusion, but not postoperative transfusion, was associated with higher rates of recurrence and cancer-specific mortality.

Surveillance neuroimaging and neurologic examinations affect care for intracerebral hemorrhage.

OBJECTIVE: We tested the hypothesis that surveillance neuroimaging and neurologic examinations identified changes requiring emergent surgical interventions in patients with intracerebral hemorrhage (ICH). METHODS: Patients with primary ICH were enrolled into a prospective registry between December 2006 and July 2012. Patients were managed in a neuroscience intensive care unit with a protocol that included serial neuroimaging at 6, 24, and 48 hours, and hourly neurologic examinations using the Glasgow Coma Scale and NIH Stroke Scale. We evaluated all cases of craniotomy and ventriculostomy to determine whether the procedure was part of the initial management plan or occurred subsequently. For those that occurred subsequently, we determined whether worsening on neurologic examination or worsened neuroimaging findings initiated the process leading to intervention. RESULTS: There were 88 surgical interventions in 84 (35%) of the 239 patients studied, including ventriculostomy in 52 (59%), craniotomy in 21 (24%), and both in 11 (13%). Of the 88 interventions, 24 (27%) occurred subsequently and distinctly from initial management, a median of 15.9 hours (8.9-27.0 hours) after symptom onset. Thirteen (54%) were instigated by findings on neurologic examination and 11 (46%) by neuroimaging. Demographics, severity of hemorrhage, and hemorrhage location were not associated with delayed intervention. CONCLUSIONS: More than 25% of surgical interventions performed after ICH were prompted by delayed imaging or clinical findings. Serial neurologic examinations and neuroimaging are important and effective surveillance techniques for monitoring patients with ICH.

Access to orthopaedic care for children with medicaid versus private insurance: results of a national survey.

BACKGROUND: It has been documented that children insured by Medicaid in California have significantly less access to orthopedic care than children with private insurance. Low Medicaid physician reimbursement rates have been hypothesized to be a major factor. The first objective of this study was to examine whether children insured by Medicaid have limited access to orthopedic care in a national sample. The second objective was to determine if state variations in Medicaid physician reimbursement rates correlate with access to orthopedic care. METHODS: Two-hundred fifty orthopedic surgeon's offices, 5 randomly chosen in each of 50 states, were telephoned. Each office called was asked to answer questions to an anonymous, disclosed survey. The survey asked whether the office accepted pediatric patients, whether they accepted children with Medicaid, and whether they limited the number of children that they accepted with Medicaid, and if so why. Each state sets its own rate of physician reimbursement rates that were collected from individual state Medicaid agencies for 3 different CPT codes. The relationship between acceptance of patients with Medicaid and the individual state's Medicaid reimbursement rate was examined. RESULTS: Children with Medicaid insurance had limited access to orthopedic care in 88 of 230 (38%) offices that treat children, and 18% (41/230) of offices would not see a child with Medicaid under any circumstances. Reimbursement rates for CPT codes widely varied by state: 99243 for an outpatient consultation (range, $20-$176.38), 99213 for an established follow-up outpatient visit (range, $6-$77.76), and 25560 for global treatment of a nondisplaced radius and ulna shaft fracture without manipulation (range, $50-$403.94). There was a statistically significant relationship between access to medical care for Medicaid patients and physician reimbursement rates for all 3 CPT codes. CONCLUSIONS: Children insured with Medicaid have limited access to orthopedic care in this nationwide sample. Medicaid physician reimbursement significantly correlates with patient access to medical care. These data may be of value in the ongoing efforts to improve access to medical care for children on Medicaid. The logical inference from this study is that increasing physician reimbursement rates will improve access. In the authors' opinion, reimbursement rates should be made higher than office overhead to effect meaningful change.