Anesthetic recovery outcomes after 2 methods of nasal mucosal preparation for endoscopic sinus surgery.

PURPOSE: Our institution uses two approaches for nasal mucosal preparation during endoscopic sinus surgery (ESS) to improve surgical field visualization: topical epinephrine (TE) versus topical cocaine with injection of lidocaine containing epinephrine (TCLE). We aimed to compare anesthetic outcomes after ESS using these techniques. METHODS AND MATERIALS: We retrospectively identified adult patients at our institution who underwent ESS from May 2018 through January 2023 under general anesthesia with propofol and remifentanil infusions. Postoperative anesthetic outcomes, including pain and recovery time, were compared between patients who had mucosal preparation with TE versus TCLE using inverse probability of treatment weighting (IPTW) to adjust for potential confounders. RESULTS: Among 1449 patients who underwent ESS, 585 had TE, and 864 had TCLE. Compared with TE, during anesthetic recovery, the TCLE group had fewer episodes of severe pain (numeric pain score ≥ 7) (IPTW-adjusted odds ratio, 0.65; 95 % CI, 0.49-0.85; P = .002), less opioid analgesic administration (IPTW-adjusted odds ratio, 0.55; 95 % CI, 0.44-0.69; P < .001), and shorter recovery room stay (IPTW-adjusted ratio of the geometric mean, 0.90; 95 % CI, 0.85-0.96; P = .002). Postoperative nausea and vomiting and postoperative sedation were similar between groups. CONCLUSIONS: Patients who received preparation of the nasal mucosa with TCLE, compared with TE, were less likely to report severe pain or receive an opioid analgesic in the postanesthesia recovery room and had faster anesthetic recovery. This observation from our large clinical practice indicates that use topical and local anesthetic during endoscopic sinus surgery may have benefit for ambulatory ESS patients.

Regional cerebral oxygen saturation variability and brain injury in preterm infants.

Objective: To examine whether variation of regional cerebral oxygen saturation (rScO2) within three days after delivery predicts development of brain injury (intraventricular/cerebellar hemorrhage or white matter injury) in preterm infants. Study design: A prospective study of neonates <32 weeks gestational age with normal cranial ultrasound admitted between 2018 and 2022. All received rScO2 monitoring with near-infrared spectroscopy at admission up to 72 h of life. To assess brain injury a magnetic resonance imaging was performed at term-equivalent age. We assessed the association between rScO2 variability (short-term average real variability, rScO2ARV, and standard deviation, rScO2SD), mean rScO2 (rScO2MEAN), and percentage of time rScO2 spent below 60% (rScO2TIME<60%) during the first 72 h of life and brain injury. Results: The median [IQR] time from birth to brain imaging was 68 [59-79] days. Of 81 neonates, 49 had some form of brain injury. Compared to neonates without injury, in those with injury rScO2ARV was higher during the first 24 h (P = 0.026); rScO2SD was higher at 24 and 72 h (P = 0.029 and P = 0.030, respectively), rScO2MEAN was lower at 48 h (P = 0.042), and rScO2TIME<60% was longer at 24, 48, and 72 h (P = 0.050, P = 0.041, and P = 0.009, respectively). Similar results were observed in multivariable logistic regression. Although not all results were statistically significant, increased rScO2 variability (rScO2ARV and rScO2SD) and lower mean values of rScO2 were associated with increased likelihood of brain injury. Conclusions: In preterm infants increased aberration of rScO2 in early postdelivery period was associated with an increased likelihood of brain injury diagnosis at term-equivalent age.

Postoperative Sedation in General Care Wards: A Retrospective Cohort Study.

BACKGROUND: We hypothesized that deeper sedation in the postanesthesia care unit (PACU) increases the risk of subsequent sedation in general care wards (ward sedation) and that patients with ward sedation have more postoperative adverse events than those without ward sedation. METHODS: We reviewed the health records of adult patients who underwent procedures with general anesthesia at Mayo Clinic from May 5, 2018, through December 31, 2020, and were discharged from the PACU to the general care ward. Patient groups were dichotomized as with ward sedation (Richmond Agitation-Sedation Scale [RASS], ≤-2) and without ward sedation (RASS, ≥-1) within the first 24 hours after PACU discharge. Multivariable logistic regression was used to assess the association between clinical variables and ward sedation. RESULTS: A total of 23,766 patients were included in our analysis, of whom 1131 had ward sedation (incidence, 4.8 [Poisson 95% confidence interval, CI, 4.5-5.0]) per 100 patients after general anesthesia. Half of the ward sedation episodes occurred within 32 minutes after PACU discharge. The risk of ward sedation increased with the depth of PACU sedation. The odds ratios (95% CI) of ward sedation for patients with a PACU RASS score of -1 was 0.98 (0.75-1.27); -2, 1.87 (1.44-2.43); -3, 2.98 (2.26-3.93); and ≤-4, 3.97 (2.91-5.42). Adverse events requiring an emergency intervention occurred more often for patients with ward sedation (n = 92, 8.1%) than for those without ward sedation (n = 326, 1.4%; P < .001). CONCLUSIONS: Among patients who met our criteria for PACU discharge, deeper sedation during anesthesia recovery was associated with an increased risk of ward sedation. Patients who had ward sedation had worse outcomes than those without ward sedation.

PRODIGY score predicts respiratory depression in the post-anesthesia care unit: A post-hoc analysis.

Surgical patients who experience respiratory depressive episodes (RDEs) during their post-anesthesia care unit (PACU) admission are at a higher risk of developing subsequent respiratory complications in general care wards. A risk assessment tool for PACU RDEs has not been previously assessed. The PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) score is an assessment tool that uses baseline patient variables to categorize patients into low, intermediate, or high risk groups for RDEs in general care wards. This study assessed whether PRODIGY groups are associated with PACU RDEs. This analysis utilized data from a previous observational trial of PACU RDEs detected by capnography. PRODIGY scores were retrospectively calculated, and the number and duration of respiratory alerts were compared among PRODIGY groups. Twenty-six (29.9%) patients were classified as low risk, 29 (33.3%) as intermediate risk, and 32 (36.8%) as high risk. A total of 3,580 alerts were recorded in the PACU, 47% of which were apnea episodes lasting ≥ 10 seconds. The total number and duration of alerts were highest in high risk group patients (median 56 [IQR 12 - 87] alerts per patient vs 22 [9 - 37] in low risk and 26 [13 - 42] in intermediate risk patients, P = 0.035; 303 [123 - 885] seconds vs 177 [30 - 779] in low risk and 301 [168 - 703] in intermediate risk patients, P = 0.042). Poisson regression analysis indicated that the rate of RDEs in the high PRODIGY risk group was higher than in the intermediate (rate ratio estimate = 2.01 [95% CI 1.86 - 2.18], P < 0.001) and low (rate ratio estimate = 2.25 [95% confidence interval 2.07 - 2.45], P < 0.001) risk groups. This analysis suggests that the PRODIGY score may be useful in assessing the risk of PACU RDEs. Trial Registration: https://www.clinicaltrials.gov/ct2/show/NCT02707003.

Prediction of mortality in patients with secondary pulmonary embolism based on primary admission indication: A short communication.

We evaluated the prediction of mortality in patients admitted to the intensive care unit (ICU) who subsequently developed a pulmonary embolism (PE) (i.e., secondary PE) using three PE-specific scores, the Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), and modified sPESI (ICU-sPESI) and compared them to the gold standard for the assessment of ICU all-cause mortality, the Acute Physiology and Chronic Health Evaluation-IV (APACHE-IV). All critical care admission indications were grouped into four major categories: post-operative, cardiovascular, infectious (sepsis), and other. The APACHE-IV displayed better discriminative ability to predict in-hospital mortality than the PESI and ICU-sPESI, but these two scores still performed fair for the ICU admissions related to postoperative, cardiovascular, and other admission types. Meanwhile, the sPESI displayed poor predictive performance across all four admission categories. Notably, discriminatory performance for patients with an infection-related admission was consistently low regardless of which score was used.

Effect of Propofol Infusion on Need for Rescue Antiemetics in Postanesthesia Care Unit After Volatile Anesthesia: A Retrospective Cohort Study.

BACKGROUND: Postoperative nausea and vomiting (PONV) are frequent after volatile anesthesia. We hypothesized that coadministration of propofol with volatile anesthetic compared to pure volatile anesthetics would decrease the need for postoperative antiemetic treatments and shorten recovery time in the postanesthesia care unit (PACU). METHODS: We retrospectively identified adult patients who underwent procedures using general anesthesia with volatile agents, with or without propofol infusion, from May 2018 through December 2020, and who were admitted to the PACU. Inverse probability of treatment weighting (IPTW) analysis was performed using generalized estimating equations with robust variance estimates to assess whether propofol was associated with decreased need for rescue antiemetics. RESULTS: Among 47,847 patients, overall IPTW rescue antiemetic use was 4.7% for 17,573 patients who received propofol and 8.2% for 30,274 who did not (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.61; P <.001). This effect associated with propofol was present regardless of the intensity of antiemetic prophylaxis (OR, 0.59, 0.51, and 0.58 for 0-1, 2, and ≥3 antiemetics used, respectively), procedural duration (OR, 0.54, 0.62, and 0.47 for ≤2.50, 2.51-4.00, ≥4.01 hours), and type of volatile agent (OR, 0.51, 0.52, and 0.57 for desflurane, isoflurane, and sevoflurane) (all P <.001). This effect was dose dependent, with little additional benefit for the reduction in the use of PACU antiemetics when propofol rate exceeded 100 µg/kg/min. Patients who received rescue antiemetics required longer PACU recovery time than those who did not receive antiemetics (ratio of the geometric mean, 1.31; 95% CI, 1.28-1.33; P <.001), but use of propofol did not affect PACU recovery time (ratio of the geometric mean, 1.00; 95% CI, 0.98-1.01; P =.56). CONCLUSIONS: The addition of propofol infusions to volatile-based anesthesia is associated with a dose-dependent reduction in the need for rescue antiemetics in the PACU regardless of the number of prophylactic antiemetics, duration of procedure, and type of volatile agent used, without affecting PACU recovery time.

Validity of mortality risk prediction scores in critically ill patients with secondary pulmonary embolism.

Pulmonary embolism (PE) is a feared complication in the ICU, significantly impacting morbidity and mortality of the patients affected. Herein, we assess the use of the Acute Physiology and Chronic Health Evaluation-IV (APACHE-IV) and PE-specific risk scores to predict mortality among intensive care unit (ICU) patients who developed secondary PE. This retrospective cohort study used information from 208 United States critical care units recorded in the eICU Collaborative Research Database during 2014 and 2015. We calculated APACHE-IV, Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), and ICU-sPESI scores and compared their predicting performance using the area under the receiver operating characteristic (AUROC) curve. Of 812 patients included in our study, 150 died (mortality, 18.5% [95% CI, 15.8%-21.1%]). Compared to survivors, non-survivors had higher APACHE-IV (86 vs 52, P<0.001), PESI (170 vs 129, P<0.001), sPESI (2 vs 2, P<0.001), and ICU-sPESI (4 vs 2, P<0.001) scores. AUROCs were 0.790 (APACHE-IV); 0.737 (PESI); 0.726 (ICU-sPESI); and 0.620 (sPESI). APACHE-IV performed significantly better than all 3 PE-specific mortality scores (APACHE-IV vs PESI, P=0.041; APACHE-IV vs sPESI, P=0.001; and APACHE-IV vs ICU-sPESI, P=0.021). Both the PESI and ICU-sPESI outperformed the sPESI (PESI vs sPESI, P=0.001; ICU-sPESI vs sPESI, P<0.001). APACHE-IV score was found to be the best instrument for predicting mortality risk, but PESI and ICU-sPESI scores may be used when APACHE-IV is unavailable. sPESI AUROC suggests absence of sufficient discriminative value to be used as a predictor of mortality in patients with secondary PE.

Postoperative opioid-induced respiratory depression or oversedation requiring naloxone treatment in a community hospital: a case series.

Background: Postoperative opioid-induced respiratory depression and oversedation can lead to fatal events and increase perioperative mortality. In reports from major academic centers, naloxone administration has been used as a proxy for severe opioid overdose. Herein, we studied the incidence, clinical characteristics, and outcomes of postoperative naloxone use in a mid-size community hospital. Methods: This was a retrospective review of adult patients who received naloxone within 48 postoperative hours between July 9, 2017, and May 31, 2022. Results: During the study timeframe, a total of 23,362 surgical procedures were performed and a total of 19 patients received naloxone (8 in the recovery room, 11 on hospital wards), with an incidence of 8.1 [95% confidence interval 4.9-12.7] per 10,000 anesthetics. In 12 cases (63%), naloxone was indicated for oversedation, and in 7 cases (37%), for opioid-induced respiratory depression. All patients received naloxone within the first 24 postoperative hours. While all patients survived the opioid-related adverse event, 2 patients were intubated, 1 developed stress-induced cardiomyopathy, and 5 required intensive care unit admission. Conclusion: The rate of early postoperative opioid-induced respiratory depression or oversedation in our community hospital was low; however, these patients often require a substantial escalation of medical management.

Sugammadex and urinary retention after hysterectomy: A propensity-matched cohort study.

Postoperative urinary retention (POUR) is a well-known complication after gynecologic surgery. Our objective was to investigate whether the choice of pharmacologic agent for reversing neuromuscular blockade at the end of a hysterectomy is a risk factor for POUR. Among adult patients undergoing hysterectomy with general anesthesia from 2012 to 2017, those who received aminosteroid nondepolarizing neuromuscular agents followed by pharmacologic reversal were identified, and electronic health records were reviewed. The cohort was dichotomized into two groups by reversal agent: 1) sugammadex and 2) neostigmine with glycopyrrolate. The primary outcome, POUR, was defined as unplanned postoperative bladder recatheterization. A propensity-adjusted analysis was performed to investigate the association between POUR and reversal agent by using inverse probability of treatment weighting to adjust for potential confounders. We identified 1,974 patients, of whom 1,586 (80.3%) received neostigmine-glycopyrrolate and 388 (19.7%) received sugammadex for reversal of neuromuscular blockade. The frequency of POUR was 24.8% (393/1,586) after reversal with neostigmine-glycopyrrolate and 18.3% (71/388) with sugammadex. Results from the propensity-adjusted analysis showed that sugammadex was associated with a lower POUR risk than neostigmine-glycopyrrolate (odds ratio 0.53, 95% confidence interval [CI] 0.37 - 0.76, P < 0.001). A post hoc analysis of sugammadex recipients who received glycopyrrolate for another indication showed a higher POUR risk than among those who did not receive glycopyrrolate (odds ratio 1.86, 95% CI 1.07 - 3.22, P = 0.03). Use of sugammadex to reverse aminosteroid neuromuscular blocking agents is associated with decreased risk of POUR after hysterectomy. A potential mechanism is the omission of glycopyrrolate, which is coadministered with neostigmine to mitigate unwanted cholinergic effects.

Predicting Hospital Survival in Patients Admitted to ICU with Pulmonary Embolism.

OBJECTIVE: The Pulmonary Embolism Severity Index (PESI) and simplified PESI (sPESI) predict mortality for patients with PE. We compared PESI/sPESI to the Acute Physiology and Chronic Health Evaluation IV (APACHE-IV) in predicting mortality in patients with PE admitted to the intensive care unit (ICU). Additionally, we assessed the performance of a novel ICU-sPESI score created by adding three clinical variables associated with acuity of PE presentation (intubation, confusion [altered mental status], use of vasoactive infusions) to sPESI. MATERIALS AND METHODS: Using the eICU Collaborative Research Database from 2014 to 2015, we conducted a large retrospective cohort study of adult patients admitted to the ICU with a primary diagnosis of PE. We calculated APACHE-IV, PESI, sPESI, and ICU-sPESI scores and compared their performance for predicting in-hospital mortality using area under the receiver operating characteristic (AUROC) curve. Score thresholds for >99% negative predictive values (NPV) were calculated for each score. Survival was estimated using the Kaplan-Meier method. RESULTS: We included 1424 PE cases. In-hospital mortality was 6.3% [95% CI: 5.1%-7.6%]. AUROC for APACHE-IV, PESI, and sPESI were 0.870, 0.848, and 0.777, respectively. APACHE-IV and PESI outperformed sPESI (P < 0.01 for both comparisons), while APACHE-IV and PESI demonstrated similar performance (P = 0.322). The ICU-sPESI performance was similar to APACHE-IV and PESI (AUROC = 0.847; AUROC comparison: APACHE-IV vs ICU-sPESI: P = 0.396; PESI vs ICU-sPESI: P = 0.945). Hospital mortality for ICU-sPESI scores 0-2 was 1.1%, and for scores 3, 4, 5, 6, and ≥7 was 8.6%, 11.7%, 29.2%, 37.5%, and 76.9%, respectively. Score thresholds for >99% NPV were ≤48 for APACHE-IV, ≤115 for PESI, and 0 points for sPESI and ICU-sPESI. CONCLUSIONS: By accounting for severity of PE presentation, our newly proposed ICU-sPESI score provided improved PE mortality prediction compared to the original sPESI score and offered excellent discrimination of mortality risk.

Post-operative urinary retention is impacted by neuromuscular block reversal agent choice: A retrospective cohort study in US hospital setting.

STUDY OBJECTIVE: Perioperative neuromuscular blocking agents are pharmacologically reversed to minimize complications associated with residual neuromuscular block. Neuromuscular block reversal with anticholinesterases (e.g., neostigmine) require coadministration of an anticholinergic agent (e.g., glycopyrrolate) to mitigate muscarinic activity; however, sugammadex, devoid of cholinergic activity, does not require anticholinergic coadministration. Single-institution studies have found decreased incidence of post-operative urinary retention associated with sugammadex reversal. This study used a multicenter database to better understand the association between neuromuscular block reversal technique and post-operative urinary retention. DESIGN: Retrospective cohort study utilizing large healthcare database. SETTING: Non-profit, non-governmental and community and teaching hospitals and health systems from rural and urban areas. PATIENTS: 61,898 matched adult inpatients and 95,500 matched adult outpatients. INTERVENTIONS: Neuromuscular block reversal with sugammadex or neostigmine plus glycopyrrolate. MEASUREMENTS: Incidence of post-operative urinary retention by neuromuscular block reversal agent and the independent association of neuromuscular block reversal technique and risk of post-operative urinary retention. MAIN RESULTS: The incidence of post-operative urinary retention was 2-fold greater among neostigmine with glycopyrrolate compared to sugammadex patients (5.0% vs 2.4% inpatients; 0.9% vs 0.4% outpatients; both p < 0.0001). Multivariable logistic regression identified reversal with neostigmine to be independently associated with greater risk of post-operative urinary retention (inpatients: odds ratio, 2.20; 95% confidence interval, 2.00 to 2.41; p < 0.001; outpatients: odds ratio, 2.57; 95% confidence interval, 2.13 to 3.10; p < 0.001). Post-operative urinary retention-related visits within 2 days following discharge were five-fold higher among those reversed with neostigmine than sugammadex among inpatients (0.05% vs. 0.01%, respectively; p = 0.018) and outpatients (0.5% vs. 0.1%; p < 0.0001). CONCLUSION: Though this study suggests that neuromuscular block reversal with neostigmine can increase post-operative urinary retention risk, additional studies are needed to fully understand the association.

Caffeine administration to treat oversedation after general anesthesia: A retrospective analysis.

STUDY OBJECTIVE: Our institution has adopted an informal practice of administering postoperative caffeine to expedite anesthesia recovery for patients with excessive sedation. This study aimed to determine whether caffeine administration was associated with improved sedation recovery and reduced risk of respiratory complications. DESIGN: Single-center, retrospective, observational study. SETTING: Quaternary medical center. PATIENTS: We included adult patients who were admitted to a postanesthesia recovery care unit (PACU) after general anesthesia and had evidence of postoperative sedation (Richmond Agitation Sedation Score [RASS] < 0). Patients were seen from May 5, 2018, through December 31, 2020. INTERVENTIONS: Patients were categorized according to caffeine administration (0 vs 250 mg). MEASUREMENTS: Sedation was measured with RASS. To account for potential confounding, binary and ordinal logistic regression with inverse probability of treatment weighting (IPTW) were used to compare RASS and episodes of severe respiratory complications within 48 h after PACU discharge. MAIN RESULTS: We identified 47,222 adult surgical patients with evidence of sedation in the PACU, and of these, 1892 (4.0%) were intravenously administered caffeine. Patients who received caffeine had more sedation in the PACU. In the IPTW-adjusted analysis, caffeine administration was associated with improved sedation scores after PACU discharge (ordinal logistic regression odds ratio [OR], 1.13 [95% CI, 1.00-1.28]; P = .04 for the first RASS score after PACU discharge) but increased risk of respiratory complications (OR, 2.99 [95% CI, 1.44-6.24]; P = .003) and emergency response team activation (OR, 7.18 [95% CI, 2.85-18.10]; P < .001). CONCLUSIONS: In this observational study, caffeine administration during anesthesia recovery was associated with improved sedation scores. However, it was also associated with an increased risk of respiratory complications, possibly reflecting selection bias (ie, administering caffeine to higher-risk patients). Patients with signs of excessive sedation during anesthesia recovery may benefit from enhanced postoperative respiratory monitoring.

Incidence of postoperative opioid-induced respiratory depression episodes in patients on room air or supplemental oxygen: a post-hoc analysis of the PRODIGY trial.

BACKGROUND: Supplemental oxygen (SO) potentiates opioid-induced respiratory depression (OIRD) in experiments on healthy volunteers. Our objective was to examine the relationship between SO and OIRD in patients on surgical units. METHODS: This post-hoc analysis utilized a portion of the observational PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial dataset (202 patients, two trial sites), which involved blinded continuous pulse oximetry and capnography monitoring of postsurgical patients on surgical units. OIRD incidence was determined for patients receiving room air (RA), intermittent SO, or continuous SO. Generalized estimating equation (GEE) models, with a Poisson distribution, a log-link function and time of exposure as offset, were used to compare the incidence of OIRD when patients were receiving SO vs RA. RESULTS: Within the analysis cohort, 74 patients were always on RA, 88 on intermittent and 40 on continuous SO. Compared with when on RA, when receiving SO patients had a higher risk for all OIRD episodes (incidence rate ratio [IRR] 2.7, 95% confidence interval [CI] 1.4-5.1), apnea episodes (IRR 2.8, 95% CI 1.5-5.2), and bradypnea episodes (IRR 3.0, 95% CI 1.2-7.9). Patients with high or intermediate PRODIGY scores had higher IRRs of OIRD episodes when receiving SO, compared with RA (IRR 4.5, 95% CI 2.2-9.6 and IRR 2.3, 95% CI 1.1-4.9, for high and intermediate scores, respectively). CONCLUSIONS: Despite oxygen desaturation events not differing between SO and RA, SO may clinically promote OIRD. Clinicians should be aware that postoperative patients receiving SO therapy remain at increased risk for apnea and bradypnea. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02811302, registered June 23, 2016.

Retrospective Review of Intrathecal Hydromorphone Dose Range and Complications.

BACKGROUND: Optimal intrathecal dosing regimens for hydromorphone are not well established for analgesia after abdominal surgery. OBJECTIVES: We reviewed intrathecal hydromorphone doses and complications because dosing variability has been observed among anesthesiologists. We hypothesized that increasing doses of intrathecal hydromorphone would be associated with improved postoperative analgesia, but with increased rates of opioid-related adverse events. STUDY DESIGN: Retrospective analysis. SETTING: A high-volume academic referral center in the United States. METHODS: A retrospective study was conducted of adults undergoing abdominal surgery under general anesthesia supplemented preoperatively with intrathecal hydromorphone for postoperative analgesia from May 5, 2018, through May 31, 2021. Patients were categorized into 3 hydromorphone dosing groups: low-dose (50-100 µg), middle-dose (101-199 µg), and high-dose (200-300 µg). Multivariable logistic regression models were used to assess rates of severe postoperative pain, severe opioid-related adverse events, oversedation, and pruritus in the postanesthesia care unit (PACU) and within 24 hours after PACU discharge. RESULTS: Of 1,846 patients identified, 1,235 (66.9%) were in the low-dose group; 321 (17.3%), middle-dose group; and 290 (15.7%), high-dose group. Patients receiving the 2 higher doses had more extensive procedures. An unadjusted analysis showed differing rates of severe pain in the PACU by group: 306 (24.8%) in the low-dose, 73 (22.7%) middle-dose, and 45 (15.5%) in the high-dose group (P = 0.003); these differences, however, were no longer significant after an adjusted analysis (P = 0.34). Ten severe opioid-related events occurred; all were recognized in the PACU. Five events each occurred in the low-dose and high-dose groups versus none in the middle-dose group (P = 0.02). No other differences were identified with adjusted analyses. LIMITATIONS: Limitations of our study include its retrospective design and its conduct at a single center, along with the apparent, but difficult to characterize, treatment biases in hydromorphone dosing. CONCLUSIONS: No dose response was observed between intrathecal hydromorphone dose and postoperative analgesia, a finding that may reflect treatment bias. Higher rates of severe opioid-related events were detected for patients receiving high-dose hydromorphone in the PACU, but all other safety outcomes were similar between dosing regimens. KEY WORDS: Drug-related side effects, opioid analgesics, outcome assessment, postoperative pain, spinal injections.

Postanesthesia Care Unit Recovery Time According to Volatile Anesthetic Used in Clinical Practice.

BACKGROUND: Whether volatile anesthetic solubility affects postanesthesia recovery time in clinical practice is unclear. We investigated the association among 3 volatile agents and 2 clinically relevant outcomes-postanesthesia care unit (PACU) recovery time (time from PACU admission to fulfillment of discharge criteria) and oversedation (Richmond Agitation-Sedation Scale score ≤-3)-as a potential contributor to delaying PACU discharge. The volatile agents studied were isoflurane, desflurane, and sevoflurane. We hypothesized that increased solubility of the volatile agent (isoflurane versus desflurane or sevoflurane) would be associated with longer PACU recovery time and higher rates of oversedation. METHODS: This retrospective observational study included adults (≥18 years) who underwent surgical procedures under general anesthesia with a volatile agent and were admitted to the PACU from May 5, 2018, to December 31, 2020. The primary outcome was PACU recovery time, and the secondary outcome was oversedation. PACU recovery time was log-transformed and analyzed with linear regression. Oversedation was analyzed by using logistic regression. To account for potential confounding, inverse probability of treatment weighting (IPTW) was used. Pairwise comparisons of the 3 agents were performed, with P < .017 (Bonferroni-adjusted) considered significant. RESULTS: Of 47,847 patients included, 11,817 (24.7%) received isoflurane, 11,286 (23.6%) received desflurane, and 24,744 (51.7%) received sevoflurane. Sevoflurane had an estimated 4% shorter PACU recovery time (IPTW-adjusted median [interquartile range {IQR}], 61 [42-89] minutes) than isoflurane (64 [44-92] minutes) (ratio of geometric means [98.3% confidence interval {CI}], 0.96 [0.95-0.98]; P < .001). Differences in PACU recovery time between desflurane and the other agents were not significant. The IPTW-adjusted frequency of oversedation was 8.8% for desflurane, 12.2% for sevoflurane, and 16.7% for isoflurane; all pairwise comparisons were observed to be significant (odds ratio [98.3% CI], 0.70 [0.62-0.79] for desflurane versus sevoflurane, 0.48 [0.42-0.55] for desflurane vs isoflurane, and 0.69 [0.63-0.76] for sevoflurane versus isoflurane; all P < .001). Although oversedated patients had longer PACU recovery time, differences in the oversedation rate across agents did not result in meaningful differences in time to PACU recovery. CONCLUSIONS: In clinical practice, only small, clinically unimportant differences in PACU recovery time were observed between the volatile anesthetics. Although oversedation was associated with increased PACU recovery time, differences in the rate of oversedation among agents were insufficient to produce meaningful differences in overall PACU recovery time across the 3 volatile agents. Practical attempts to decrease PACU recovery time should address factors other than volatile agent selection.

Perioperative management of mastocytosis.

PURPOSE: Patients with mastocytosis have an increased risk of anaphylaxis during surgical procedures with general anesthesia. Therefore, we reviewed the anesthesia course of a large cohort of patients with mastocytosis. METHODS: We retrospectively reviewed adult and pediatric patients with mastocytosis who underwent surgical procedures with general anesthesia at Mayo Clinic from January 1, 2000, through June 30, 2021. We also included any procedures with general anesthesia that occurred during the 3-year period preceding mastocytosis diagnosis and designated the patients who underwent these procedures as having an unknown diagnosis at the time of their surgical procedure. We analyzed whether patients received chronic antimediator treatment for mastocytosis and/or prophylactic medications before the procedures. We also determined whether medications indicative of mastocytosis-related adverse events were intraoperatively administered. RESULTS: We identified 113 patients who underwent 219 procedures during the study period; 25 procedures were performed before mastocytosis diagnosis. Of 194 procedures in patients with known mastocytosis, patients received chronic antimediator therapy and/or perioperative prophylactic medications for 178 (91.8%) procedures. Among these procedures, 10 were potentially complicated by mast cell activation, which was inferred from administration of inhaled albuterol (n = 3) or intravenous diphenhydramine (n = 8). In addition, there was only one case of intraoperative anaphylaxis which occurred in a patient who underwent anesthesia before mastocytosis diagnosis and therefore did not receive prophylaxis. CONCLUSION: Intraoperative anaphylaxis can be the first presenting sign of mastocytosis. Patients with mastocytosis who received chronic antimediator therapy and/or preoperative prophylactic medications had an uneventful surgical course.

Anesthetic Management and Deep Sedation After Emergence From General Anesthesia: A Retrospective Cohort Study.

BACKGROUND: Residual deep sedation during anesthesia recovery may predict postoperative complications. We examined the incidence and risk factors for deep sedation after general anesthesia. METHODS: We retrospectively reviewed health records of adults who underwent procedures with general anesthesia and were admitted to the postanesthesia care unit from May 2018 to December 2020. Patients were dichotomized by Richmond Agitation-Sedation Scale (RASS) score: ≤-4 (deeply sedated/unarousable) or ≥-3 (not deeply sedated). Anesthesia risk factors for deep sedation were assessed with multivariable logistic regression. RESULTS: Of the 56,275 patients included, 2003 had a RASS ≤-4 (35.6 [95% CI, 34.1-37.2] cases per 1000 anesthetics administered). On adjusted analyses, the likelihood of a RASS ≤-4 increased when more soluble halogenated anesthetics were used. Compared with desflurane without propofol, the odds ratio (OR [95% CI]) for a RASS ≤-4 was higher with sevoflurane (1.85 [1.45-2.37]) and isoflurane (4.21 [3.29-5.38]) without propofol. Compared with desflurane without propofol, the odds of a RASS ≤-4 further increased with use of desflurane-propofol (2.61 [1.99-3.42]), sevoflurane-propofol (4.20 [3.28-5.39]), isoflurane-propofol (6.39 [4.90-8.34]), and total intravenous anesthesia (2.98 [2.22-3.98]). A RASS ≤-4 was also more likely with the use of dexmedetomidine (2.47 [2.10-2.89]), gabapentinoids (2.17 [1.90-2.48]), and midazolam (1.34 [1.21-1.49]). Deeply sedated patients discharged to general care wards had higher odds of opioid-induced respiratory complications (2.59 [1.32-5.10]) and higher odds of naloxone administration (2.93 [1.42-6.03]). CONCLUSIONS: Likelihood of deep sedation after recovery increased with intraoperative use of halogenated agents with higher solubility and increased further when propofol was concomitantly used. Patients who experience deep sedation during anesthesia recovery have an increased risk of opioid-induced respiratory complications on general care wards. These findings may be useful for tailoring anesthetic management to reduce postoperative oversedation.

Association of Blood Pressure Variability with Delirium in Patients with Critical Illness.

BACKGROUND: The objective was to examine the association of blood pressure variability (BPV) during the first 24 h after intensive care unit admission with the likelihood of delirium and depressed alertness without delirium ("depressed alertness"). METHODS: This retrospective, observational, cohort study included all consecutive adult patients admitted to an intensive care unit at Mayo Clinic, Rochester, Minnesota, from July 1, 2004, through October 31, 2015. The primary outcomes were delirium and delirium-free days, and the secondary outcomes included depressed alertness and depressed alertness-free days. Logistic regression was performed to determine the association of BPV with delirium and depressed alertness. Proportional odds regression was used to assess the association of BPV with delirium-free days and depressed alertness-free days. RESULTS: Among 66,549 intensive care unit admissions, delirium was documented in 20.2% and depressed alertness was documented in 24.4%. Preserved cognition was documented in 55.4% of intensive care unit admissions. Increased systolic and diastolic BPV was associated with an increased odds of delirium and depressed alertness. The magnitude of the association per 5-mm Hg increase in systolic average real variability (the average of absolute value of changes between consecutive systolic blood pressure readings) was greater for delirium (odds ratio 1.34; 95% confidence interval 1.29-1.40; P < 0.001) than for depressed alertness (odds ratio 1.06; 95% confidence interval 1.02-1.10; P = 0.004). Increased systolic and diastolic BPV was associated with fewer delirium-free days but not with depressed alertness-free days. CONCLUSIONS: BPV in the first 24 h after intensive care unit admission is associated with an increased likelihood of delirium and fewer delirium-free days.

Association of Indication for Hospitalization With Subsequent Amyloid Positron Emission Tomography and Magnetic Resonance Imaging Biomarkers.

BACKGROUND: Hospitalization in older age is associated with accelerated cognitive decline, typically preceded by neuropathologic changes. We assess the association between indication for hospitalization and brain neurodegeneration. METHODS: Included were participants from the Mayo Clinic Study of Aging, a population-based longitudinal study, with ≥1 brain imaging available in those older than 60 years of age between 2004 and 2017. Primary analyses used linear mixed-effects models to assess association of hospitalization with changes in longitudinal trajectory of cortical thinning, amyloid accumulation, and white matter hyperintensities (WMH). Additional analyses were performed with imaging outcomes dichotomized (normal vs abnormal) using Cox proportional hazards regression. RESULTS: Of 2 480 participants, 1 966 had no hospitalization and 514 had ≥1 admission. Hospitalization was associated with accelerated cortical thinning (annual slope change -0.003 mm [95% confidence interval (CI) -0.005 to -0.001], p = .002), but not amyloid accumulation (0.003 [95% CI -0.001 to 0.006], p = .107), or WMH increase (0.011 cm3 [95% CI -0.001 to 0.023], p = .062). Interaction analyses assessing whether trajectory changes are dependent on admission type (medical vs surgical) found interactions for all outcomes. While surgical hospitalizations were not, medical hospitalizations were associated with accelerated cortical thinning (-0.004 mm [95% CI -0.008 to -0.001, p = .014); amyloid accumulation (0.010, [95% CI 0.002 to 0.017, p = .011), and WMH increase (0.035 cm3 [95% CI 0.012 to 0.058, p = .006). Hospitalization was not associated with developing abnormal cortical thinning (p = .407), amyloid accumulation (p = .596), or WMH/infarctions score (p = .565). CONCLUSIONS: Medical hospitalizations were associated with accelerated cortical thinning, amyloid accumulation, and WMH increases. These changes were modest and did not translate to increased risk for crossing the abnormality threshold.