Association of ketamine use during procedural sedation with oxygen desaturation and healthcare utilisation: a multicentre retrospective hospital registry study.

BACKGROUND: We investigated the effects of ketamine on desaturation and the risk of nursing home discharge in patients undergoing procedural sedation by anaesthetists. METHODS: We included adult patients who underwent procedures under monitored anaesthetic care between 2005 and 2021 at two academic healthcare networks in the USA. The primary outcome was intraprocedural oxygen desaturation, defined as oxygen saturation <90% for ≥2 consecutive minutes. The co-primary outcome was a nursing home discharge. RESULTS: Among 234,170 included patients undergoing procedural sedation, intraprocedural desaturation occurred in 5.6% of patients who received ketamine vs 5.2% of patients who did not receive ketamine (adjusted odds ratio [ORadj] 1.22, 95% confidence interval [CI] 1.15-1.29, P<0.001; adjusted absolute risk difference [ARDadj] 1%, 95% CI 0.7-1.3%, P<0.001). The effect was magnified by age >65 yr, smoking, or preprocedural ICU admission (P-for-interaction <0.001, ORadj 1.35, 95% CI 1.25-1.45, P<0.001; ARDadj 2%, 95% CI 1.56-2.49%, P<0.001), procedural risk factors (upper endoscopy of longer than 2 h; P-for-interaction <0.001, ORadj 2.91, 95% CI 1.85-4.58, P<0.001; ARDadj 16.2%, 95% CI 9.8-22.5%, P<0.001), and high ketamine dose (P-for-trend <0.001, ORadj 1.61, 95% CI, 1.43-1.81 for ketamine >0.5 mg kg-1). Concomitant opioid administration mitigated the risk (P-for-interaction <0.001). Ketamine was associated with higher odds of nursing home discharge (ORadj 1.11, 95% CI 1.02-1.21, P=0.012; ARDadj 0.25%, 95% CI 0.05-0.46%, P=0.014). CONCLUSIONS: Ketamine use for procedural sedation was associated with an increased risk of oxygen desaturation and discharge to a nursing home. The effect was dose-dependent and magnified in subgroups of vulnerable patients.

Hispanic/Latino Ethnicity and Loss of Post-Surgery Independent Living: A Retrospective Cohort Study from a Bronx Hospital Network.

BACKGROUND: Black race is associated with postoperative adverse discharge to a nursing facility, but the effects of Hispanic/Latino ethnicity are unclear. We explored the Hispanic paradox, described as improved health outcomes among Hispanic/Latino patients on postoperative adverse discharge to nursing facility. METHODS: A total of 93,356 adults who underwent surgery and were admitted from home to Montefiore Medical Center in the Bronx, New York, between January 2016 and June 2021 were included. The association between self-identified Hispanic/Latino ethnicity and the primary outcome, postoperative adverse discharge to a nursing home or skilled nursing facility, was investigated. Interaction analysis was used to examine the impact of socioeconomic status, determined by estimated median household income and insurance status, on the primary association. Mixed-effects models were used to evaluate the proportion of variance attributed to the patient's residential area defined by zip code and self-identified ethnicity. RESULTS: Approximately 45.9% (42,832) of patients identified as Hispanic/Latino ethnicity and 9.7% (9074) patients experienced postoperative adverse discharge. Hispanic/Latino ethnicity was associated with lower risk of adverse discharge (relative risk [RRadj] 0.88; 95% confidence interval [CI], 00.82-0.94; P < .001), indicating a Hispanic Paradox. This effect was modified by the patient's socioeconomic status (P-for-interaction <.001). Among patients with a high socioeconomic status, the Hispanic paradox was abolished (RRadj 1.10; 95% CI, 11.00-1.20; P = .035). Furthermore, within patients of low socioeconomic status, Hispanic/Latino ethnicity was associated with a higher likelihood of postoperative discharge home with health services compared to non-Hispanic/Latino patients (RRadj 1.06; 95% CI, 11.01-1.12; P = .017). CONCLUSIONS: Hispanic/Latino ethnicity is a protective factor for postoperative adverse discharge, but this association is modified by socioeconomic status. Future studies should focus on postoperative discharge disposition and socioeconomic barriers in patients with Hispanic/Latino ethnicity.

Association of sugammadex reversal of neuromuscular block and postoperative length of stay in the ambulatory care facility: a multicentre hospital registry study.

BACKGROUND: Encapsulation of rocuronium or vecuronium with sugammadex can reverse neuromuscular block faster than neostigmine reversal. This pharmacodynamic profile might facilitate patient discharge after ambulatory surgery. METHODS: We included patients who underwent ambulatory surgery with general anaesthesia and neuromuscular block between 2016 and 2021 from hospital registries at two large academic healthcare networks in the USA. The primary outcome was postoperative length of stay in the ambulatory care facility (PLOS-ACF). We examined post hoc whether the type of reversal affects postoperative nausea and vomiting and direct hospital costs. RESULTS: Among the 29 316 patients included, 8945 (30.5%) received sugammadex and 20 371 (69.5%) received neostigmine for reversal. PLOS-ACF and costs were lower in patients who received sugammadex vs neostigmine (adjusted difference in PLOS-ACF: -9.5 min; 95% confidence interval [95% CI], -10.5 to -8.5 min; adjusted difference in direct hospital costs: -US$77; 95% CI, -$88 to -$66; respectively; P<0.001). The association was magnified in patients over age 65 yr, with ASA physical status >2 undergoing short procedures (<2 h) (adjusted difference in PLOS-ACF: -18.2 min; 95% CI, -23.8 to -12.4 min; adjusted difference in direct hospital costs: -$176; 95% CI, -$220 to -$128; P<0.001). Sugammadex use was associated with reduced postoperative nausea and vomiting (17.2% vs 19.6%, P<0.001), which mediated its effects on length of stay. CONCLUSIONS: Reversal with sugammadex compared with neostigmine was associated with a small decrease in postoperative length of stay in the ambulatory care unit. The effect was magnified in older and high-risk patients, and can be explained by reduced postoperative nausea and vomiting. Sugammadex reversal in ambulatory surgery may also help reduce cost of care.

Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography.

Deep sedation without tracheal intubation (monitored anaesthesia care) and general anaesthesia with tracheal intubation are commonly used anaesthesia techniques for endoscopic retrograde cholangiopancreatography (ERCP). There are distinct pathophysiological differences between monitored anaesthesia care and general anaesthesia that need to be considered depending on the nature and severity of the patient's underlying disease, comorbidities, and procedural risks. An international group of expert anaesthesiologists and gastroenterologists created clinically relevant questions regarding the merits and risks of monitored anaesthesia care vs general anaesthesia in specific clinical scenarios for planning optimal anaesthetic approaches for ERCP. Using a modified Delphi approach, the group created practical recommendations for anaesthesiologists, with the aim of reducing the incidence of perioperative adverse outcomes while maximising healthcare resource utilisation. In the majority of clinical scenarios analysed, our expert recommendations favour monitored anaesthesia care over general anaesthesia. Patients with increased risk of pulmonary aspiration and those undergoing prolonged procedures of high complexity were thought to benefit from general anaesthesia with tracheal intubation. Patient age and ASA physical status were not considered to be factors for choosing between monitored anaesthesia care and general anaesthesia. Monitored anaesthesia care is the favoured anaesthesia plan for ERCP. An individual risk-benefit analysis that takes into account provider and institutional experience, patient comorbidities, and procedural risks is also needed.

Subjective Assessment of Motor Function by the Bedside Nurses in Mechanically Ventilated Surgical Intensive Care Unit Patients Predicts Tracheostomy.

OBJECTIVE: In many institutions, intensive care unit (ICU) nurses assess their patients' muscle function as part of their routine bedside examination. We tested the research hypothesis that this subjective examination of muscle function prior to extubation predicts tracheostomy requirement. METHODS: Adult, mechanically ventilated patients admitted to 7 ICUs at Beth Israel Deaconess Medical Center (BIDMC) between 2008 and 2019 were included in this observational study. Assessment of motor function was performed every four hours by ICU nurses. Multivariable logistic regression analysis controlled for acute disease severity, delirium risk assessment through the confusion assessment method for the ICU (CAM-ICU), and pre-defined predictors of extubation failure was applied to examine the association of motor function and tracheostomy within 30 days after extubation. RESULTS: Within 30 days after extubation, 891 of 9609 (9.3%) included patients required a tracheostomy. The inability to spontaneously move and hold extremities against gravity within 24 h prior to extubation was associated with significantly higher odds of 30-day tracheostomy (adjusted OR 1.56, 95% CI 1.27-1.91, p < 0.001, adjusted absolute risk difference (aARD) 2.8% (p < 0.001)). The effect was magnified among patients who were mechanically ventilated for >7 days (aARD 21.8%, 95% CI 12.4-31.2%, p-for-interaction = 0.015). CONCLUSIONS: ICU nurses' subjective assessment of motor function is associated with 30-day tracheostomy risk, independent of known risk factors. Muscle function measurements by nursing staff in the ICU should be discussed during interprofessional rounds.

Development and validation of an instrument to predict prolonged length of stay in the postanesthesia care unit following ambulatory surgery.

PURPOSE: We sought to develop and validate an Anticipated Surveillance Requirement Prediction Instrument (ASRI) for prediction of prolonged postanesthesia care unit length of stay (PACU-LOS, more than four hours) after ambulatory surgery. METHODS: We analyzed hospital registry data from patients who received anesthesia care in ambulatory surgery centres (ASCs) of university-affiliated hospital networks in New York, USA (development and internal validation cohort [n = 183,711]) and Massachusetts, USA (validation cohort [n = 148,105]). We used stepwise backwards elimination to create ASRI. RESULTS: The model showed discriminatory ability in the development, internal, and external validation cohorts with areas under the receiver operating characteristic curve of 0.82 (95% confidence interval [CI], 0.82 to 0.83), 0.82 (95% CI, 0.81 to 0.83), and 0.80 (95% CI, 0.79 to 0.80), respectively. In cases started in the afternoon, ASRI scores ≥ 43 had a total predicted risk for PACU stay past 8 p.m. of 32% (95% CI, 31.1 to 33.3) vs 8% (95% CI, 7.9 to 8.5) compared with low score values (P-for-interaction < 0.001), which translated to a higher direct PACU cost of care of USD 207 (95% CI, 194 to 2,019; model estimate, 1.68; 95% CI, 1.64 to 1.73; P < 0.001) The effects of using the ASRI score on PACU use efficiency were greater in a free-standing ASC with no limitations on PACU bed availability. CONCLUSION: We developed and validated a preoperative prediction tool for prolonged PACU-LOS after ambulatory surgery that can be used to guide scheduling in ambulatory surgery to optimize PACU use during normal work hours, particularly in settings without limitation of PACU bed availability.

RéSUMé: OBJECTIF: Nous avons cherché à mettre au point et à valider un Instrument de prédiction anticipée des besoins de surveillance pour anticiper toute prolongation de la durée de séjour en salle de réveil (plus de quatre heures) après chirurgie ambulatoire. MéTHODE: Nous avons analysé les données enregistrées dans le registre de l'hôpital des patient·es qui ont reçu des soins d'anesthésie dans des centres de chirurgie ambulatoire (CCA) des réseaux hospitaliers affiliés à une université à New York, aux États-Unis (cohorte de développement et de validation interne [n = 183 711]) et au Massachusetts, États-Unis (cohorte de validation [n = 148 105]). Nous avons utilisé un procédé d'élimination progressive régressive pour créer notre instrument de prédiction. RéSULTATS: Le modèle a montré une capacité discriminatoire dans les cohortes de développement, de validation interne et de validation externe, avec des surfaces sous la courbe de fonction d'efficacité de l'opérateur (ROC) de 0,82 (intervalle de confiance [IC] à 95 %, 0,82 à 0,83), 0,82 (IC 95 %, 0,81 à 0,83), et 0,80 (IC 95 %, 0,79 à 0,80), respectivement. Dans les cas commencés en après-midi, les scores sur notre instrument de prédiction ≥ 43 montraient un risque total prédit de séjour en salle de réveil après 20 h de 32 % (IC 95 %, 31,1 à 33,3) vs 8 % (IC 95 %, 7,9 à 8,5) comparativement aux valeurs de score faibles (P-pour-interaction < 0,001), ce qui s'est traduit par une augmentation de 207 USD du coût direct des soins en salle de réveil (IC 95 %, 194 à 2019; estimation du modèle, 1,68; IC 95 %, 1,64 à 1,73; P < 0,001). Les effets de l'utilisation du score de notre instrument de prédiction sur l'efficacité d'utilisation de la salle de réveil étaient plus importants dans un CCA autonome sans limitation dans la disponibilité des lits en salle de réveil. CONCLUSION: Nous avons mis au point et validé un outil de prédiction préopératoire de la prolongation de la durée de séjour en salle de réveil après une chirurgie ambulatoire qui peut être utilisé pour guider la planification en chirurgie ambulatoire afin d'optimiser l'utilisation de la salle de réveil pendant les heures normales de travail, en particulier dans les milieux sans limitation de disponibilité des lits en salle de réveil.

Preoperative Treatment of Severe Diabetes Mellitus and Hypertension Mitigates Healthcare Disparities and Prevents Adverse Postoperative Discharge to a Nursing Home.

OBJECTIVE: To evaluate whether patients of Black race are at higher risk of adverse postoperative discharge to a nursing home, and if a higher prevalence of severe diabetes mellitus and hypertension are contributing. BACKGROUND: It is unclear whether a patient's race predicts adverse discharge to a nursing home after surgery, and if preexisting diseases are contributing. METHODS: A total of 368,360 adults undergoing surgery between 2007 and 2020 across 2 academic healthcare networks in New England were included. Patients of self-identified Black or White race were compared. The primary outcome was postoperative discharge to a nursing facility. Mediation analysis was used to examine the impact of preexisting severe diabetes mellitus and hypertension on the primary association. RESULTS: In all, 10.3% (38,010/368,360) of patients were Black and 26,434 (7.2%) patients were discharged to a nursing home. Black patients were at increased risk of postoperative discharge to a nursing facility (adjusted absolute risk difference: 1.9%; 95% confidence interval: 1.6%-2.2%; P <0.001). A higher prevalence of preexisting severe diabetes mellitus and hypertension in Black patients mediated 30.2% and 15.6% of this association. Preoperative medication-based treatment adherent to guidelines in patients with severe diabetes mellitus or hypertension mitigated the primary association ( P -for-interaction <0.001). The same pattern of effect mitigation by pharmacotherapy was observed for the endpoint 30-day readmission. CONCLUSIONS: Black race was associated with postoperative discharge to a nursing facility compared to White race. Optimized preoperative assessment and treatment of diabetes mellitus and hypertension improves surgical outcomes and provides an opportunity to the surgeon to help eliminate healthcare disparities.

Differential Effects of Gamma-Aminobutyric Acidergic Sedatives on Risk of Post-Extubation Delirium in the ICU: A Retrospective Cohort Study From a New England Health Care Network.

OBJECTIVES: To evaluate whether different gamma-aminobutyric acidergic (GABAergic) sedatives such as propofol and benzodiazepines carry differential risks of post-extubation delirium in the ICU. DESIGN: Retrospective cohort study. SETTING: Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS: Ten thousand five hundred and one adult patients mechanically ventilated for over 24 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We tested the hypothesis that benzodiazepine versus propofol-based sedation is associated with fewer delirium-free days within 14 days after extubation. Further, we hypothesized that the measured sedation level evoked by GABAergic drugs is a better predictor of delirium than the drug dose administered. The proportion of GABAergic drug-induced deep sedation was defined as the ratio of days with a mean Richmond Agitation-Sedation Scale of less than or equal to -3 during mechanical ventilation. Multivariable regression and effect modification analyses were used. Delirium-free days were lower in patients who received a high proportion of deep sedation using benzodiazepine compared with propofol-based sedation (adjusted absolute difference, -1.17 d; 95% CI, -0.64 to -1.69; p < 0.001). This differential effect was magnified in elderly patients (age > 65) and in patients with liver or kidney failure (p-for-interaction < 0.001) but not observed in patients who received a low proportion of deep sedation (p = 0.95). GABAergic-induced deep sedation days during mechanical ventilation was a better predictor of post-extubation delirium than the GABAergic daily average effective dose (area under the curve 0.76 vs 0.69; p < 0.001). CONCLUSIONS: Deep sedation during mechanical ventilation with benzodiazepines compared with propofol is associated with increased risk of post-extubation delirium. Our data do not support the view that benzodiazepine-based compared with propofol-based sedation in the ICU is an independent risk factor of delirium, as long as deep sedation can be avoided in these patients.

Association Between Intraoperative Arterial Hypotension and Postoperative Delirium After Noncardiac Surgery: A Retrospective Multicenter Cohort Study.

BACKGROUND: It is unclear whether intraoperative arterial hypotension is associated with postoperative delirium. We hypothesized that intraoperative hypotension within a range frequently observed in clinical practice is associated with increased odds of delirium after surgery. METHODS: Adult noncardiac surgical patients undergoing general anesthesia at 2 academic medical centers between 2005 and 2017 were included in this retrospective cohort study. The primary exposure was intraoperative hypotension, defined as the cumulative duration of an intraoperative mean arterial pressure (MAP) <55 mm Hg, categorized into and short (<15 minutes; median [interquartile range {IQR}], 2 [1-4] minutes) and prolonged (≥15 minutes; median [IQR], 21 [17-31] minutes) durations of intraoperative hypotension. The primary outcome was a new diagnosis of delirium within 30 days after surgery. In secondary analyses, we assessed the association between a MAP decrease of >30% from baseline and postoperative delirium. Multivariable logistic regression adjusted for patient- and procedure-related factors, including demographics, comorbidities, and markers of procedural severity, was used. RESULTS: Among 316,717 included surgical patients, 2183 (0.7%) were diagnosed with delirium within 30 days after surgery; 41.7% and 2.6% of patients had a MAP <55 mm Hg for a short and a prolonged duration, respectively. A MAP <55 mm Hg was associated with postoperative delirium compared to no hypotension (short duration of MAP <55 mm Hg: adjusted odds ratio [ORadj], 1.22; 95% confidence interval [CI], 1.11-1.33; P < .001 and prolonged duration of MAP <55 mm Hg: ORadj, 1.57; 95% CI, 1.27-1.94; P < .001). Compared to a short duration of a MAP <55 mm Hg, a prolonged duration of a MAP <55 mm Hg was associated with greater odds of postoperative delirium (ORadj, 1.29; 95% CI, 1.05-1.58; P = .016). The association between intraoperative hypotension and postoperative delirium was duration-dependent (ORadj for every 10 cumulative minutes of MAP <55 mm Hg: 1.06; 95% CI, 1.02-1.09; P =.001) and magnified in patients who underwent surgeries of longer duration (P for interaction = .046; MAP <55 mm Hg versus no MAP <55 mm Hg in patients undergoing surgery of >3 hours: ORadj, 1.40; 95% CI, 1.23-1.61; P < .001). A MAP decrease of >30% from baseline was not associated with postoperative delirium compared to no hypotension, also when additionally adjusted for the cumulative duration of a MAP <55 mm Hg (short duration of MAP decrease >30%: ORadj, 1.13; 95% CI, 0.91-1.40; P = .262 and prolonged duration of MAP decrease >30%: ORadj, 1.19; 95% CI, 0.95-1.49; P = .141). CONCLUSIONS: In patients undergoing noncardiac surgery, a MAP <55 mm Hg was associated with a duration-dependent increase in odds of postoperative delirium. This association was magnified in patients who underwent surgery of long duration.

Psychometric properties of a Thai version of the Richards-Campbell sleep questionnaire.

BACKGROUND: In critically ill patients, a poor sleep quality can escalate mortality and the length of hospital stays. Albeit being the gold standard for sleep assessment, polysomnography (PSG) is expensive and complicated. The Richards-Campbell sleep questionnaire (RCSQ) is another tool with proof of good correlation with PSG. RCSQ was translated into many languages. However, the Thai version (T-RCSQ) has not been developed. AIMS AND OBJECTIVES: Our study aimed to translate the original RCSQ into Thai, to test the content validity and reliability, and to introduce the questionnaire into clinical practice at the surgical intensive care unit (SICU). DESIGN: Prospective cross-sectional study METHODS: This study enrolled 92 patients from the SICU between August 2019 and January 2020. The content validity of T-RCSQ was determined by the index of item-objective congruence (IOC). The reliability was tested by test-retest reliability at 7 am and 9 am after intensive care unit (ICU) admission. The internal consistency was expressed by Cronbach's alpha. Patients' demography was reported as percentage, mean and standard deviation, and median and interquartile range. RESULTS: The content validity and test-retest reliability of the T-RCSQ were 0.8 and 0.97, respectively. The internal consistency was 0.964. Most patients were female with American Society of Anesthesiologist physical status III. The mean RCSQ scores at 7 am and 9 am were 5.82 ± 2.15 cm and 5.61 ± 2.18 cm, respectively. CONCLUSIONS: The T-RCSQ is reliable and could be used as an alternative to PSG for sleep assessment of ICU patients. Further research is required to validate the T-RCSQ against PSG and to assess its impact on improving sleep quality and patients' clinical outcomes. RELEVANCE TO CLINICAL PRACTICE: T-RCSQ is a useful tool for sleep assessment in ICU. According to cost-effectiveness, convenience, and good reliability, it could be applied to determine proper sleep to minimize patient morbidity and mortality.

Association of Sedation, Coma, and In-Hospital Mortality in Mechanically Ventilated Patients With Coronavirus Disease 2019-Related Acute Respiratory Distress Syndrome: A Retrospective Cohort Study.

OBJECTIVES: In patients with coronavirus disease 2019-associated acute respiratory distress syndrome, sedatives and opioids are commonly administered which may lead to increased vulnerability to neurologic dysfunction. We tested the hypothesis that patients with coronavirus disease 2019-associated acute respiratory distress syndrome are at higher risk of in-hospital mortality due to prolonged coma compared with other patients with acute respiratory distress syndrome matched for disease severity. DESIGN: Propensity-matched cohort study. SETTING: Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS: All mechanically ventilated coronavirus disease 2019 patients between March and May 2020 were identified and matched with patients with acute respiratory distress syndrome of other etiology. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using clinical data obtained from a hospital registry, we matched 114 coronavirus disease 2019 patients to 228 noncoronavirus disease 2019-related acute respiratory distress syndrome patients based on baseline disease severity. Coma was identified using the Richmond Agitation Sedation Scale less than or equal to -3. Multivariable logistic regression and mediation analyses were used to assess the percentage of comatose days, sedative medications used, and the association between coronavirus disease 2019 and in-hospital mortality. In-hospital mortality (48.3% vs 31.6%, adjusted odds ratio, 2.15; 95% CI, 1.34-3.44; p = 0.002), the percentage of comatose days (66.0% ± 31.3% vs 36.0% ± 36.9%, adjusted difference, 29.35; 95% CI, 21.45-37.24; p < 0.001), and the hypnotic agent dose (51.3% vs 17.1% of maximum hypnotic agent dose given in the cohort; p < 0.001) were higher among patients with coronavirus disease 2019. Brain imaging did not show a higher frequency of structural brain lesions in patients with coronavirus disease 2019 (6.1% vs 7.0%; p = 0.76). Hypnotic agent dose was associated with coma (adjusted coefficient, 0.61; 95% CI, 0.45-0.78; p < 0.001) and mediated (p = 0.001) coma. Coma was associated with in-hospital mortality (adjusted odds ratio, 5.84; 95% CI, 3.58-9.58; p < 0.001) and mediated 59% of in-hospital mortality (p < 0.001). CONCLUSIONS: Compared with matched patients with acute respiratory distress syndrome of other etiology, patients with coronavirus disease 2019 received higher doses of hypnotics, which was associated with prolonged coma and higher mortality.

Effects of the Level and Duration of Mobilization Therapy in the Surgical ICU on the Loss of the Ability to Live Independently: An International Prospective Cohort Study.

OBJECTIVES: It is unclear whether early mobilization in the surgical ICU helps improve patients' functional recovery to a level that enables independent living. We assessed dose of mobilization (level + duration). We tested the research hypotheses that dose of mobilization predicts adverse discharge and that both duration of mobilization and maximum mobilization level predict adverse discharge. DESIGN: International, prospective cohort study. SETTING: Study conducted in five surgical ICUs at four different institutions. PATIENTS: One hundred fifty patients who were functionally independent before admission (Barthel Index ≥ 70) and who were expected to stay in the ICU for greater than or equal to 72 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mobilization was quantified daily, and treatments from all healthcare providers were included. We developed and used the Mobilization Quantification Score that quantifies both level and duration of mobilization. We assessed the association between the dose of mobilization (level + duration; exposure) and adverse discharge disposition (loss of the ability to live independently; primary outcome). There was wide variability in the dose of mobilization across centers and patients, which could not be explained by patients' comorbidity or disease severity. Dose of mobilization was associated with reduced risk of adverse discharge (adjusted odds ratio, 0.21; 95%CI, 0.09-0.50; p < 0.001). Both level and duration explained variance of adverse discharge (adjusted odds ratio, 0.28; 95% CI, 0.12-0.65; p = 0.003; adjusted odds ratio, 0.14; 95% CI, 0.06-0.36; p < 0.001, respectively). Duration compared with the level of mobilization tended to explain more variance in adverse discharge (area under the curve duration 0.73; 95% CI, 0.64-0.82; area under the curve mobilization level 0.68; 95% CI, 0.58-0.77; p = 0.10). CONCLUSIONS: We observed wide variability in dose of mobilization treatment applied, which could not be explained by patients' comorbidity or disease severity. High dose of mobilization is an independent predictor of patients' ability to live independently after discharge. Duration of mobilization sessions should be taken into account in future quality improvement and research projects.

Optimal Sedation in Patients Who Receive Neuromuscular Blocking Agent Infusions for Treatment of Acute Respiratory Distress Syndrome-A Retrospective Cohort Study From a New England Health Care Network.

OBJECTIVES: Two previously published trials (ARDS et Curarisation Systematique [ACURASYS] and Reevaluation of Systemic Early Neuromuscular Blockade [ROSE]) presented equivocal evidence on the effect of neuromuscular blocking agent infusions in patients with acute respiratory distress syndrome (acute respiratory distress syndrome). The sedation regimen differed between these trials and also within the ROSE trial between treatment and control groups. We hypothesized that the proportion of deeper sedation is a mediator of the effect of neuromuscular blocking agent infusions on mortality. DESIGN: Retrospective cohort study. SETTING: Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS: Intubated and mechanically ventilated ICU patients with acute respiratory distress syndrome (Berlin definition) admitted between January 2008 until June 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The proportion of deeper sedation was defined as days with nonlight sedation as a fraction of mechanical ventilation days in the ICU after acute respiratory distress syndrome diagnosis. Using clinical data obtained from a hospital network registry, 3,419 patients with acute respiratory distress syndrome were included, of whom 577 (16.9%) were treated with neuromuscular blocking agent infusions, for a mean (sd) duration of 1.8 (±1.9) days. The duration of deeper sedation was prolonged in patients receiving neuromuscular blocking agent infusions (4.6 ± 2.2 d) compared with patients without neuromuscular blocking agent infusions (2.4 ± 2.2 d; p < 0.001). The proportion of deeper sedation completely mediated the negative effect of neuromuscular blocking agent infusions on in-hospital mortality (p < 0.001). Exploratory analysis in patients who received deeper sedation revealed a beneficial effect of neuromuscular blocking agent infusions on mortality (49% vs 51%; adjusted odds ratio, 0.80; 95% CI, 0.63-0.99, adjusted absolute risk difference, -0.05; p = 0.048). CONCLUSIONS: In acute respiratory distress syndrome patients who receive neuromuscular blocking agent infusions, a prolonged, high proportion of deeper sedation is associated with increased mortality. Our data support the view that clinicians should minimize the duration of deeper sedation after recovery from neuromuscular blocking agent infusion.

Supraglottic airway device versus tracheal intubation and the risk of emergent postoperative intubation after general anaesthesia in adults: a retrospective cohort study.

BACKGROUND: We examined the association between emergent postoperative tracheal intubation and the use of supraglottic airway devices (SGAs) vs tracheal tubes. METHODS: We included data from adult noncardiac surgical cases under general anaesthesia between 2008 and 2018. We only included cases (n=59 991) in which both airways were deemed to be feasible options. Multivariable logistic regression, instrumental variable analysis, propensity matching, and mediation analysis were used. RESULTS: Use of a tracheal tube was associated with a higher risk of emergent postoperative intubation (adjusted absolute risk difference [ARD]=0.80%; 95% confidence interval (CI), 0.64-0.97; P<0.001), and a higher risk of post-extubation hypoxaemia (ARD=3.9%; 95% CI, 3.4-4.4; P<0.001). The effect was modified by the use of non-depolarising neuromuscular blocking agents (NMBAs); mediation analyses revealed that 28.9% (95% CI, 14.4-43.4%; P<0.001) of the main effect was attributable to NMBA. Airway management modified the association of NMBA and risk of emergent postoperative intubation (Pinteraction=0.02). Patients managed with an SGA had higher odds of NMBA-associated reintubation compared to patients managed with a tracheal tube (adjusted odds ratio [aOR]=3.65, 95% CI, 1.99-6.67 vs aOR=1.68, 95% CI, 1.29-2.18 [P<0.001], respectively). CONCLUSIONS: In patients undergoing procedures under general anaesthesia that could be managed with either SGA or tracheal tube, use of an SGA was associated with lower risk of emergent postoperative intubation. The effect can partly be explained by use of NMBAs. Use of NMBAs in patients with an SGA appears to increase the risk of emergent postoperative intubation.

A Tool to Predict Readmission to the Intensive Care Unit in Surgical Critical Care Patients-The RISC Score.

BACKGROUND: Readmission to the Intensive Care Unit (ICU) is associated with a high risk of in-hospital mortality and higher health care costs. Previously published tools to predict ICU readmission in surgical ICU patients have important limitations that restrict their clinical implementation. We sought to develop a clinically intuitive score that can be implemented to predict readmission to the ICU after surgery or trauma. We designed the score to emphasize modifiable predictors. METHODS: In this retrospective cohort study, we included surgical patients requiring critical care between June 2015 and January 2019 at Beth Israel Deaconess Medical Center, Harvard Medical School, MA, USA. We used logistic regression to fit a prognostic model for ICU readmission from a priori defined, widely available candidate predictors. The score performance was compared with existing prediction instruments. RESULTS: Of 7,126 patients, 168 (2.4%) were readmitted to the ICU during the same hospitalization. The final score included 8 variables addressing demographical factors, surgical factors, physiological parameters, ICU treatment and the acuity of illness. The maximum score achievable was 13 points. Potentially modifiable predictors included the inability to ambulate at ICU discharge, substantial positive fluid balance (>5 liters), severe anemia (hemoglobin <7 mg/dl), hyperglycemia (>180 mg/dl), and long ICU length of stay (>5 days). The score yielded an area under the receiver operating characteristic curve of 0.78 (95% CI 0.74-0.82) and significantly outperformed previously published scores. The performance of the underlying model was confirmed by leave-one-out cross-validation. CONCLUSION: The RISC-score is a clinically intuitive prediction instrument that helps identify surgical ICU patients at high risk for ICU readmission. The simplicity of the score facilitates its clinical implementation across surgical divisions.

Effect of Intraoperative Arterial Hypotension on the Risk of Perioperative Stroke After Noncardiac Surgery: A Retrospective Multicenter Cohort Study.

BACKGROUND: Intraoperative cerebral blood flow is mainly determined by cerebral perfusion pressure and cerebral autoregulation of vasomotor tone. About 1% of patients undergoing noncardiac surgery develop ischemic stroke. We hypothesized that intraoperative hypotension within a range frequently observed in clinical practice is associated with an increased risk of perioperative ischemic stroke within 7 days after surgery. METHODS: Adult noncardiac surgical patients undergoing general anesthesia at Beth Israel Deaconess Medical Center and Massachusetts General Hospital between 2005 and 2017 were included in this retrospective cohort study. The primary exposure was intraoperative hypotension, defined as a decrease in mean arterial pressure (MAP) below 55 mm Hg, categorized into no intraoperative hypotension, short (<15 minutes, median [interquartile range {IQR}], 2 minutes [1-5 minutes]) and prolonged (≥15 minutes, median [IQR], 21 minutes [17-31 minutes]) durations. The primary outcome was a new diagnosis of early perioperative ischemic stroke within 7 days after surgery. In secondary analyses, we assessed the effect of a MAP decrease by >30% from baseline on perioperative stroke. Analyses were adjusted for the preoperative STRoke After Surgery (STRAS) prediction score, work relative value units, and duration of surgery. RESULTS: Among 358,391 included patients, a total of 1553 (0.4%) experienced an early perioperative ischemic stroke. About 42% and 3% of patients had a MAP of below 55 mm Hg for a short and a prolonged duration, and 49% and 29% had a MAP decrease by >30% from baseline for a short and a prolonged duration, respectively. In an adjusted analysis, neither a MAP <55 mm Hg (short duration: adjusted odds ratio [ORadj], 0.95; 95% confidence interval [CI], 0.85-1.07; P = .417 and prolonged duration: ORadj, 1.18; 95% CI, 0.91-1.55; P = .220) nor a MAP decrease >30% (short duration: ORadj, 0.97; 95% CI, 0.67-1.42; P = .883 and prolonged duration: ORadj, 1.30; 95% CI, 0.89-1.90; P = .176) was associated with early perioperative stroke. A high a priori stroke risk quantified based on preoperatively available risk factors (STRAS prediction score) was associated with longer intraoperative hypotension (adjusted incidence rate ratio, 1.04; 95% CI, 1.04-1.05; P < .001 per 5 points of the STRAS prediction score). CONCLUSIONS: This study found no evidence to conclude that intraoperative hypotension within the range studied was associated with early perioperative stroke within 7 days after surgery. These findings emphasize the importance of perioperative cerebral blood flow autoregulation to prevent ischemic stroke.

Discharge Prediction for Patients Undergoing Inpatient Surgery: Development and validation of the DEPENDENSE score.

BACKGROUND: A substantial proportion of patients undergoing inpatient surgery each year is at risk for postoperative institutionalization and loss of independence. Reliable individualized preoperative prediction of adverse discharge can facilitate advanced care planning and shared decision making. METHODS: Using hospital registry data from previously home-dwelling adults undergoing inpatient surgery, we retrospectively developed and externally validated a score predicting adverse discharge. Multivariable logistic regression analysis and bootstrapping were used to develop the score. Adverse discharge was defined as in-hospital mortality or discharge to a skilled nursing facility. The model was subsequently externally validated in a cohort of patients from an independent hospital. RESULTS: In total, 106 164 patients in the development cohort and 92 962 patients in the validation cohort were included, of which 16 624 (15.7%) and 7717 (8.3%) patients experienced adverse discharge, respectively. The model was predictive of adverse discharge with an area under the receiver operating characteristic curve (AUC) of 0.87 (95% CI 0.87-0.88) in the development cohort and an AUC of 0.86 (95% CI 0.86-0.87) in the validation cohort. CONCLUSION: Using preoperatively available data, we developed and validated a prediction instrument for adverse discharge following inpatient surgery. Reliable prediction of this patient centered outcome can facilitate individualized operative planning to maximize value of care.

The association of nitrous oxide on length of stay in the postanesthesia care unit: a retrospective observational study.

PURPOSE: To assess whether intraoperative use of nitrous oxide (N2O) as an adjunct to general anesthesia is associated with a shorter length of stay in the postanesthesia care unit (PACU). METHODS: We analyzed data from adult patients who underwent non-cardiothoracic surgery under general anesthesia between May 2008 and December 2018. We assessed the association between intraoperative low- and high-dose N2O and PACU length of stay. RESULTS: A total of 148,284 patients were included in the primary analysis. After adjusting for a priori defined confounders, a high dose of N2O significantly decreased PACU length of stay, with a calculated difference of -9.1 min (95% confidence interval [CI], -10.5 to -7.7; P < 0.001). Patients who received high-dose N2O had a lower incidence of both short- and prolonged-duration of intraoperative hypotension (adjusted odds ratio [aOR], 0.85; 95% CI, 0.83 to 0.88; P < 0.001 and aOR, 0.76; 95% CI, 0.73 to 0.80; P < 0.001, respectively) and received a lower total intraoperative vasopressor dose (-0.04 mg of norepinephrine equivalents; 95% CI, -0.06 to -0.01; P = 0.01). The effect of high-dose N2O on PACU length of stay was modified by surgical complexity (adjusted absolute difference: -26.1 min; 95% CI, -29.2 to -23.1; P < 0.001; P for interaction < 0.001), and most pronounced in patients who underwent complex surgery and received intraoperative antiemetic therapy (adjusted absolute difference: -38.9 min; 95% CI, -43.1 to -34.6; P < 0.001; P for interaction < 0.001). CONCLUSIONS: Nitrous oxide was dose-dependently associated with a decreased PACU length of stay. The effect was clinically relevant (> 30 min difference) in patients who underwent complex surgical procedures and received intraoperative antiemetic therapy.

RéSUMé: OBJECTIF: L'objectif de cette étude était de déterminer si l'utilisation peropératoire de protoxyde d'azote (N2O) en complément à l'anesthésie générale était associée à une durée de séjour écourtée en salle de réveil (SDR). MéTHODE: Nous avons analysé les données de patients adultes qui ont subi une chirurgie non cardiothoracique sous anesthésie générale entre mai 2008 et décembre 2018. Nous avons évalué l'association entre une faible dose et une dose élevée de N2O peropératoire et la durée du séjour en SDR. RéSULTATS: Au total, 148 284 patients ont été inclus dans notre analyse primaire. Après ajustement tenant compte des facteurs de confusion définis a priori, une dose élevée de N2O a considérablement écourté la durée du séjour en salle de réveil, avec une différence calculée de −9,1 min (intervalle de confiance [IC] à 95 %, −10,5 à −7,7 ; P < 0,001). Chez les patients ayant reçu une dose élevée de N2O, l'incidence d'hypotension peropératoire de courte ou plus longue durée était plus faible (rapport de cotes ajusté [RCA], 0,85; IC 95 %, 0,83 à 0,88; P < 0,001 et RCA, 0,76; IC 95 %, 0,73 à 0,80; P < 0,001, respectivement); en outre, ces patients ont reçu une dose totale de vasopresseurs peropératoires inférieure (−0,04 mg d'équivalents de norépinéphrine; IC 95 %, −0,06 à −0,01; P = 0,01). L'effet d'une dose élevée de N2O sur la durée du séjour en SDR a été modifié par la complexité de la chirurgie (différence absolue ajustée : −26,1 min; IC 95 %, −29,2 à −23,1; P < 0,001; P pour l'interaction < 0,001), et était le plus prononcé chez les patients ayant subi une chirurgie complexe et reçu un traitement antiémétique peropératoire (différence absolue ajustée : −38,9 min; IC 95 %, −43,1 à −34,6; P < 0,001; P pour l'interaction < 0,001). CONCLUSION: Le protoxyde d'azote a été associé de façon dose-dépendante à une réduction de la durée du séjour en SDR. L'effet était cliniquement pertinent (différence > 30 minutes) chez les patients qui subissaient des interventions chirurgicales complexes et recevaient un traitement antiémétique peropératoire.

Incidence of Inadequate Pain Treatment among Ventilated, Critically Ill Surgical Patients in a Thai Population.

BACKGROUND: Inadequate pain treatment during intensive care unit stays causes many unfavorable outcomes. Pain assessment in mechanically ventilated patients is challenging because most cannot self-report pain. The incidence of pain among Thai surgical intensive care unit (SICU) patients has never been reported. AIMS: To determine the inadequate pain control incidence among ventilated, critically ill, surgical patients. DESIGN: Prospective, observational study. SETTING: SICU of a university-based hospital during November 2017-January 2019. PARTICIPANTS: Patients aged > 18 years, admitted to the SICU for a foreseeable duration of mechanical ventilation > 24 hours were included. METHODS: On post-admission Day 2, each was assessed for pain at rest (every 4 hours) and during bed-bathing using the Critical Care Pain Observation Tool (CPOT; Thai version) or the 0-10 numeric rating scale (NRS). CPOT scores > 2 or NRS scores > 3 signified inadequate pain control, while a RASS score ≤ -3 was defined as overtreatment. RESULTS: 118 were included. The inadequate-pain-management incidence was 34% (n = 40) at rest and 29% (n = 34) during bed-bathing. The severe-pain incidence (NRS > 6, or CPOT > 5) was 5.9% (n = 7). Our incidence of overtreatment was 1.7%. The demographic data and ICU complication-rates of patients with adequate and inadequate pain treatment were similar. CONCLUSIONS: Pain assessment tools in critically ill patients should be developed and validated to the language of the tool users in order to determine the incidence of pain accurately. The inadequate-pain-treatment incidence in ventilated critically ill, Thai surgical patients was lower than previously reported from other countries.