Pulmonary Hypertension and the Risk of 30-Day Postoperative Pulmonary Complications after Gastrointestinal Surgical or Endoscopic Procedures: A Retrospective Propensity Score-Weighted Cohort Analysis.

Background: Pulmonary hypertension (PH) patients are at higher risk of postoperative complications. We analyzed the association of PH with 30-day postoperative pulmonary complications (PPCs). Methods: A single-center propensity score overlap weighting (OW) retrospective cohort study was conducted on 164 patients with a mean pulmonary artery pressure (mPAP) of >20 mmHg within 24 months of undergoing elective inpatient abdominal surgery or endoscopic procedures under general anesthesia and a control cohort (N = 1981). The primary outcome was PPCs, and the secondary outcomes were PPC sub-composites, namely respiratory failure (RF), pneumonia (PNA), aspiration pneumonia/pneumonitis (ASP), pulmonary embolism (PE), length of stay (LOS), and 30-day mortality. Results: PPCs were higher in the PH cohort (29.9% vs. 11.2%, p < 0.001). When sub-composites were analyzed, higher rates of RF (19.3% vs. 6.6%, p < 0.001) and PNA (11.2% vs. 5.7%, p = 0.01) were observed. After OW, PH was still associated with greater PPCs (RR 1.66, 95% CI (1.05-2.71), p = 0.036) and increased LOS (median 8.0 days vs. 4.9 days) but not 30-day mortality. Sub-cohort analysis showed no difference in PPCs between pre- and post-capillary PH patients. Conclusions: After covariate balancing, PH was associated with a higher risk for PPCs and prolonged LOS. This elevated PPC risk should be considered during preoperative risk assessment.

Estimates of 30-day postoperative pulmonary complications after gastrointestinal endoscopic procedures: A retrospective cohort analysis of a health system population.

The incidence of 30-day postoperative pulmonary complications (PPC) of gastrointestinal endoscopic procedures (GIEP) are not well characterized in the literature. The primary aim of this study was to identify the incidence of 30-day PPC after GIEP within a large healthcare system. We conducted a retrospective cohort study of 5377 patients presenting for GIEP between January 2013 and January 2022. Our primary outcome was the Agency for Healthcare Research and Quality PPC composite (AHRQ-PPC). Secondary outcomes were sub-composites derived from the AHRQ-PPC; including pneumonia (AHRQ-PNA), respiratory failure (AHRQ-RF), aspiration pneumonia/ pneumonitis (AHRQ-ASP) and pulmonary emboli (AHRQ-PE). We performed propensity score matching (PSM) followed by multivariable logistic regression to analyze primary and secondary outcomes. Inpatients had higher 30-day AHRQ-PPC (6.0 vs. 1.2%, p<0.001), as well as sub-composite AHRQ-PNA (3.2 vs. 0.7%, p<0.001), AHRQ-RF (2.4 vs. 0.5%, p<0.001), and AHRQ-ASP (1.9 vs. 0.4%, p<0.001). After PSM adjustment, pre-procedural comorbidities of electrolyte disorder [57.9 vs. 31.1%, ORadj: 2.26, 95%CI (1.48, 3.45), p<0.001], alcohol abuse disorder [16.7 vs. 6.8%, ORadj: 2.66 95%CI (1.29, 5.49), p = 0.01], congestive heart failure (CHF) [22.3 vs. 8.7%, ORadj: 2.2 95%CI (1.17, 4.15), p = 0.02] and pulmonary circulatory disorders [21 vs. 16.9%, ORadj: 2.95, 95%CI (1.36, 6.39), p = 0.01] were associated with 30-day AHRQ-PPC. After covariate adjustment, AHRQ-PPC was associated with upper endoscopy more than lower endoscopy [5.9 vs. 1.0%, ORadj: 3.76, 95%CI (1.85, 7.66), p<0.001]. When compared to gastroenterologist-guided conscious sedation, anesthesia care team presence was protective against AHRQ-PPC [3.7 vs. 8.4%, ORadj: 0.032, 95%CI (0.01, 0.22), p<0.001] and AHRQ-ASP [1.0 vs. 3.37%, ORadj: 0.002, 95%CI (0.00, 0.55), p<0.001]. In conclusion, we report estimates of 30-day PPC after GIEP across inpatient and outpatient settings. Upper endoscopic procedures confer a higher risk, while the presence of an anesthesia care team may be protective against 30-day PPC.

Perioperative Complications in Patients with Systemic Sclerosis: A Comparative Cohort Analysis.

Background: Systemic sclerosis (SSc) is a rare autoimmune disorder with pathological manifestations affecting multiple organ systems. Few studies have examined perioperative outcomes in patients with this disorder. The primary aim of this retrospective single-center comparative cohort analysis was to estimate the incidence of select perioperative complications in a population of SSc patients. In an exploratory analysis, we analyzed the relationship between SSc and susceptibility to select perioperative complications when treated at a large quaternary-care institution. Methods: We conducted a single-center retrospective, comparative cohort study to compare perioperative outcomes in a SSc (n=258) and a frequency matched control cohort (n=632). We analyzed for the presence of major composite infection (MCI), major adverse cardiac events (MACE), 30-day readmission, 30-day mortality, in-hospital complications, length of stay and airway management outcomes. Results: MCI was higher in the SSc compared to the control cohort [adjusted odds ratio (ORadj)=5.02 (95%CI: 2.47-10.20) p<0.001]. Surgical site infection (3.5% vs. 0%, p<0.001), and other infection types (5% vs. 0%, p<0.001) were higher in the SSc cohort. MACE was not significantly different between SSc vs. Control groups [6.2% vs. 7.9%, ORadj=1.33 (95%CI: 0.61-2.91) p=0.48]. Higher rates of limited cervical range of motion (13.6% vs. 3.5%, p<0.001), microstomia (11.5% vs. 1.3%, p<0.001) and preoperative difficult airway designation (8.7% vs. 0.5%, p<0.001) were observed in the SSc cohort. Bag mask ventilation grade was similar between groups (p=0.44). After adjustment, there was no between-group difference in Cormack-Lehane grade 3 and 4 view on direct laryngoscopy in SSc patients [ORadj = 1.86 (95%CI: 0.612 -5.66) p=0.18] but evidence of higher rates of video laryngoscopy [ORadj= 1.87 (95%CI:1.07 - 3.27) p=0.03]. Length of stay [median: 0.2 vs. 0.3 days, p=0.08], 30-day mortality [1.2% vs. 0.6%, ORadj=2.79 (95%CI: 0.50-15.6) p=0.24] and readmission [11.5% vs. 8.1%, ORadj=1.64 (95%CI: 0.96 - 2.82) p=0.07] were not statistically significant. Conclusions: SSc patients demonstrate mostly similar rates of MACE, 30-day mortality, length of stay intraoperative and airway complications. There is evidence of increased risk of overall 30-day MCI risk and readmission after endoscopic procedures.

Identifying, Understanding, and Minimizing Unconscious Cognitive Biases in Perioperative Crisis Management: A Narrative Review.

Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays. The authors review the literature on UCBs and discuss their potential impact on perioperative crisis management. Using the Scale for the Assessment of Narrative Review Articles (SANRA), publications with the most relevance to UCBs in perioperative crisis management were selected for inclusion. Of the 19 UCBs that have been most investigated in the medical literature, the authors identified 9 that were judged to be clinically relevant or most frequently occurring during perioperative crisis management. Formal didactic training on concepts of deliberative thinking has had limited success in reducing the presence of UCBs during clinical decision-making. The evolution of clinical decision support tools (CDSTs) has demonstrated efficacy in improving deliberative clinical decision-making, possibly by reducing the intrusion of maladaptive UCBs and forcing reflective thinking. Anesthesiology remains a leader in perioperative crisis simulation and CDST implementation, but spearheading innovations to reduce the adverse impact of UCBs will further improve diagnostic precision and patient safety during perioperative crisis management.

Emergency use of sugammadex after failure of standard reversal drugs and postoperative pulmonary complications: A retrospective cohort study.

Background and Aims: The use of sugammadex instead of neostigmine for the reversal of neuromuscular blockade may decrease postoperative pulmonary complications. It is unclear if this finding is applicable to situations where sugammadex is administered after the administration of neostigmine. The objective of this study was to compare the incidence of a composite outcome measure of major postoperative pulmonary complications in patients who received sugammadex as a rescue agent after neostigmine versus those who received sugammadex alone for reversal of neuromuscular blockade. Material and Methods: This retrospective cohort study analyzed the medical records of adult patients who underwent elective inpatient noncardiac surgery under general anesthesia and received sugammadex for reversal of neuromuscular blockade, at a tertiary care academic hospital between August 2016 and November 2018. Results: A total of 1,672 patients were included, of whom 1,452 underwent reversal with sugammadex alone and 220 received sugammadex following reversal with neostigmine/glycopyrrolate. The composite primary outcome was diagnosed in 60 (3.6%) patients. Comparing these two groups, and after adjusting for confounding factors, patients who received sugammadex after reversal with neostigmine had more postoperative pulmonary complications than those reversed with sugammadex alone (6.8% vs. 3.1%, odds ratio, 2.29; 95% confidence interval [CI], 1.25 to 4.18; P = 0.006). Conclusion: The use of sugammadex following reversal with neostigmine was associated with a higher incidence of postoperative pulmonary complications as compared to the use of sugammadex alone. The implications of using sugammadex after the failure of standard reversal drugs should be investigated in prospective studies.

Perioperative Pulmonary Complications in the Elderly: The Forgotten System.

With a rapidly aging population and increasing global surgical volumes, managing the elevated risk of perioperative pulmonary complications has become an expanding focus for quality improvement in health care. In this narrative review, we will analyze the evidence-based literature to provide high-quality and actionable management strategies to better detect, stratify risk, optimize, and manage perioperative pulmonary complications in geriatric populations.

Information Technology-Enhanced Telehealth Consultations Reduce Preoperative Evaluation Center Visits in a Bariatric Surgery Population.

Background: Preoperative patient evaluation and optimization in a preoperative evaluation center (PEC) has been shown to improve operating room (OR) efficiency and patient care. However, performing preoperative evaluation on all patients scheduled for surgery or procedure would be time- and resource-consuming. Therefore, appropriate patient selection for evaluation at PECs is one aspect of improving PEC efficiency. In this study, we evaluate the effect of an enhanced preoperative evaluation process (PEP), utilizing a nursing triage phone call and information technology (IT) optimizations, on PEC efficiency and the quality of care in bariatric surgery patients. We hypothesized that, compared to a traditional PEP, the enhanced PEP would improve PEC efficiency without a negative impact on quality. Methods: The study was a retrospective cohort analysis of 1550 patients from January 2014 to March 2017 at a large, tertiary care academic health system. The study was a before/after comparison that compared the enhanced PEP model to the traditional PEP model. The primary outcome was the efficiency of the PEC, which was measured by the reduction of in-person patient visits at the PEC. The secondary outcome was the quality of care, which was measured by delays, cancellations, and the need for additional testing on the day of surgery (DOS). Results: The enhanced PEP improved the primary outcome of efficiency, as evident by an 80% decrease in in-person patient visits to the PEC. There was no reduction in the secondary outcome of the quality of care as measured by delays, cancellations, or the need for additional testing on the DOS. The implementation of the enhanced PEP did not result in increased costs or resource utilization. Conclusions: The enhanced PEP in a multi-disciplinary preoperative process can improve the efficiency of PEC for bariatric surgery patients without any decrease in the quality of care. The enhanced PEP process can be implemented without an increase in resource utilization and can be particularly useful during the COVID-19 pandemic.

A 10-mg dose of amiloride increases time to failure during blood-flow-restricted plantar flexion in healthy adults without influencing blood pressure.

Amiloride has been shown to inhibit acid-sensing ion channels (ASICs), which contribute to ischemia-related muscle pain during exercise. The purpose of this study was to determine if a single oral dose of amiloride would improve exercise tolerance and attenuate blood pressure during blood-flow-restricted (BFR) exercise in healthy adults. Ten subjects (4 females) performed isometric plantar flexion exercise with BFR (30% maximal voluntary contraction) after ingesting either a 10-mg dose of amiloride or a volume-matched placebo (random order). Time to failure, time-tension index (TTI), and perceived pain (visual analog scale) were compared between the amiloride and placebo trials. Mean blood pressure, heart rate, blood pressure index (BPI), and BPI normalized to TTI (BPInorm) were also compared between trials using both time-matched (TM50 and TM100) and effort-matched (T50 and T100) comparisons. Time to failure (+69.4 ± 63.2 s, P < 0.01) and TTI (+1,441 ± 633 kg·s, P = 0.02) were both significantly increased in the amiloride trial compared with placebo, despite no increase in pain (+0.4 ± 1.7 cm, P = 0.46). In contrast, amiloride had no significant influence on the mean blood pressure or heart rate responses, nor were there any significant differences in BPI or BPInorm between trials when matched for time (all P ≥ 0.13). When matched for effort, BPI was significantly greater in the amiloride trial (+5,300 ± 1,798 mmHg·s, P = 0.01), likely owing to an increase in total exercise duration. In conclusion, a 10-mg oral dose of amiloride appears to significantly improve the tolerance to BFR exercise in healthy adults without influencing blood pressure responses.

Perioperative Management of Patients with Idiopathic Pulmonary Fibrosis Undergoing Noncardiac Surgery: A Narrative Review.

PURPOSE: The idiopathic interstitial pneumonias (IIP) constitute a large cohort of the over 200 subtypes of interstitial lung disease (ILD). Idiopathic pulmonary fibrosis (IPF) is the most widely studied, arguably the most severe etiology of ILD and the most common IIP diagnosis. The objective of this narrative review is to outline the current evidence on optimal perioperative management of IPF. PubMed, Embase and Web of Science were analyzed for appropriate peer-reviewed references by utilizing key word search ("interstitial lung disease" OR "idiopathic pulmonary fibrosis" OR "idiopathic interstitial pneumonitis" OR "ILD" OR "IPF" AND "surgery" OR "anesthesia" OR "perioperative") within the past thirty years (1990-current). Non-English language references were excluded. A total of 205 references were curated by the authors. Eighty-seven consensus statements, clinical trials, retrospective cohort studies or case series met criteria and were incorporated into the findings of this narrative review. CONCLUSION: After review, we conclude that complications, dominated by postoperative pulmonary complications, pose a significant barrier to safe perioperative care of patients with IPF. Ensuring that the preoperative IPF patient has been medically optimized is important for minimizing this risk. Initial assessment of the ARISCAT score, pulmonary function studies and cardiopulmonary exercise testing may identify IPF patients at particularly high perioperative pulmonary risk. Identifying IPF patients with 6-12-month declines in DLCO of >15%, V02max <8.3 mL/kg/min, <80% predicted value FVC, a 50-meter reduction in the 6MWT or preoperative home oxygen use may be helpful in preoperative risk stratification. Medically optimizing treatable co-morbidities should be a priority in preoperative assessment. Regional or neuraxial anesthesia should be considered an optimal technique for the avoidance of general anesthesia related complications when indicated. Acute exacerbation and postoperative pneumonia have been identified as important postsurgical complications in both thoracic and nonthoracic surgical populations.

Persistent Postoperative Vasoplegia After Ureteronephrectomy Due To Suspected Intravesical Gemcitabine Toxicity.

We describe a case of unusually persistent vasoplegia in the postoperative course of a patient recovering after elective right robotic nephroureterectomy with intravesical salvage gemcitabine. In the treatment of patients with intravesical adjuvant therapy, gemcitabine may precipitate persistent vasoplegia requiring further fluid resuscitative efforts, vasopressor support, and other supportive management. This potential adverse event should be considered when all common causes of persistent vasoplegia are ruled out, such as shock related to bleeding, infection, allergic reaction, or pulmonary embolic phenomenon.

Endocrine emergencies in anesthesia.

PURPOSE OF REVIEW: An increasing number of patients with endocrine disorders will present to the operating rooms. In this review, we outline the common endocrine disorders that the anesthesiologist may face in the perioperative time span, review the controversies in optimal management, as well as summarize the recent literature for the management of these complex patients. RECENT FINDINGS: Perioperative management of pheochromocytoma and paraganglioma has been facilitated by improved medical management and the adoption of minimally invasive surgical techniques. An improved understanding of the sequelae of carcinoid syndrome has resulted in safer perioperative management. Perioperative glycemic management requires a fundamental understanding of perioperative fluid resuscitation and adverse events associated with the new generation oral hyperglycemic agents to prevent avoidable complications. SUMMARY: Endocrine disorders will commonly present in the perioperative time period and the anesthesiologist plays a critical role in achieving good operative outcomes.

Perioperative risk factors in patients with idiopathic pulmonary fibrosis: a historical cohort study.

PURPOSE: Perioperative complications of patients with idiopathic pulmonary fibrosis (IPF) are not well described. The aim of this study was to identify risk factors associated with adverse postoperative outcomes in IPF patients. METHODS: We performed a single-centre historical cohort study of adult patients with IPF who underwent surgery between 2008 and 2018. We analyzed the prognostic utility of select perioperative factors for postoperative acute exacerbation of IPF (AE-IPF), acute respiratory worsening (ARW), pneumonia, and 30-day and one-year mortality using univariable and multivariable regression analyses. To adjust for multiple interactions, the false discovery rate (Q value) was utilized to appropriately adjust P values and a Q value < 0.05 was considered to be significant. RESULTS: Two hundred and eighty-two patients were identified. After excluding emergency cases and bronchoscopies performed for active pneumonia, 14.2% of the cohort developed ARW that persisted > 24 hr after surgery, 5.0% had AE-IPF, and 9.2% were diagnosed with postoperative pneumonia within 30 days of surgery. The 30-day mortality was 6.0% and the one-year mortality was 14.9%. Preoperative home oxygen use (relative risk [RR], 2.70; 95% confidence interval [CI], 1.50 to 4.86; P < 0.001) and increasing surgical time (per 60 min) (RR, 1.03; 95% CI, 1.02 to 1.05; P < 0.001) were identified as independent risk factors for postoperative ARW. CONCLUSIONS: In IPF patients, preoperative home oxygen requirement and increasing surgical time showed a strong relationship with postoperative ARW and may be useful markers for perioperative risk stratification. Facteurs de risque périopératoires des patients atteints de fibrose pulmonaire idiopathique : une étude de cohorte historique.

RéSUMé: OBJECTIF: Les complications périopératoires chez les patients atteints de fibrose pulmonaire idiopathique (FPI) ne sont pas bien décrites. L'objectif de cette étude était d'identifier les facteurs de risque associés aux devenirs postopératoires défavorables chez les patients atteints de FPI. MéTHODE: Nous avons réalisé une étude de cohorte historique monocentrique portant sur des patients adultes atteints de FPI et ayant subi une chirurgie entre 2008 et 2018. Nous avons analysé l'utilité pronostique de facteurs périopératoires choisis pour l'exacerbation postopératoire aiguë de la FPI, la détérioration respiratoire aiguë, la pneumonie, et la mortalité à 30 jours et à un an à l'aide d'analyses de régression univariées et multivariées. Afin de tenir compte d'interactions multiples, le taux de fausses découvertes (valeur Q) a été utilisé pour ajuster adéquatement les valeurs P, et une valeur Q < 0,05 a été considérée significative. RéSULTATS: Deux cent quatre-vingt-deux patients ont été identifiés. Après avoir exclu les cas en urgence et les bronchoscopies réalisées lors de pneumonie active, 14,2 % des patients de la cohorte ont souffert d'une détérioration respiratoire aiguë qui a persisté > 24 h après la chirurgie, 5,0 % ont subi une exacerbation aiguë de la FPI, et 9,2 % ont reçu un diagnostic de pneumonie postopératoire dans les 30 jours suivant leur chirurgie. La mortalité à 30 jours était de 6,0 %, et la mortalité à un an de 14,9 %. L'utilisation préopératoire d'oxygène à domicile (risque relatif [RR], 2,70; intervalle de confiance [IC] 95 %, 1,50 à 4,86; P < 0,001) et l'augmentation du temps chirurgical (par tranche de 60 min) (RR, 1,03; IC 95 %, 1,02 à 1,05; P < 0,001) ont été identifiées comme des facteurs de risque indépendants de détérioration respiratoire aiguë en période postopératoire. CONCLUSION: Chez les patients atteints de FPI, une forte association a été observée entre les besoins préopératoires en oxygène au domicile ainsi que l'augmentation du temps chirurgical et la détérioration respiratoire aiguë en période postopératoire; ces deux facteurs pourraient constituer des marqueurs utiles pour stratifier le risque en période périopératoire.

An Update on Systemic Sclerosis and its Perioperative Management.

PURPOSE OF REVIEW: Systemic sclerosis or scleroderma (SSc) is a systemic, immune-mediated disease characterized by abnormal cutaneous and organ-based fibrosis that results in progressive end-organ dysfunction and decreased survival. SSc results in significant challenges for the practicing anesthesiologist due to its rarity, multi-system involvement, and limited evidence-based guidance for optimal perioperative care. In this update, we briefly discuss the recent evidence on the pathophysiology and current management of SSc, review the anesthesia-related literature, and extrapolate these observations into an optimal perioperative strategy for the care of SSc patients. RECENT FINDINGS: Evidence shows that patients with SSc demonstrate an increased risk for perioperative myocardial infarction, high rates of interstitial lung disease, pulmonary arterial hypertension, neurological disease, gastric dysmotility disorders, and challenging airway management, all findings that may result in suboptimal perioperative outcomes. SUMMARY: Advances in SSc medical management have resulted in improved survival, likely increasing the number of patients who will be exposed to perioperative care. Optimal perioperative management and risk stratification should expand beyond the well-described airway challenges and consider numerous systemic manifestations of systemic sclerosis such as pulmonary arterial hypertension, interstitial lung disease, and cardiac sequelae.

CHA2DS2-VASc Score and In-Hospital Mortality in Critically Ill Patients With New-Onset Atrial Fibrillation.

OBJECTIVE: To examine the role of the CHA2DS2-VASc (Congestive heart failure; Hypertension; Age ≥75 years [doubled]; Diabetes; previous Stroke, transient ischemic attack, or thromboembolism [doubled]; Vascular disease; Age 65-75 years; and Sex category) score as a prognostic marker of in-hospital mortality in critically ill patients who develop new-onset atrial fibrillation (NOAF). DESIGN: Retrospective analyses. SETTING: A single-center study in a tertiary care academic medical center. PARTICIPANTS: The study comprised all adult patients with NOAF admitted to noncardiac intensive care units (ICUs) at a tertiary care academic institution between January 2009 and March 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors retrospectively reviewed electronic medical records of all adult patients admitted to noncardiac ICUs at a tertiary care academic institution between January 2009 and March 2016. Patients with NOAF were identified and their CHA2DS2-VASc score was calculated. The authors evaluated the association of CHA2DS2-VASc score and its individual components with in-hospital mortality in these patients. A total of 640 (1.7% [38,708 patients]; 95% CI 1.5%-1.8%) patients developed NOAF during the study period. The in-hospital mortality rate in patients included in the analysis was 14.3%. There was no association between in-hospital mortality and CHA2DS2VASc score. However, the likelihood of in-hospital death was 1.56  times greater for patients having atrial fibrillation and concomitant vascular disease (95% CI 1.003-2.429; p = 0.049). CONCLUSIONS: New-onset atrial fibrillation is common in critically ill patients and is associated with high in-hospital mortality. The authors found that the CHA2DS2-VASc score itself is not a reliable prognostic marker of in-hospital mortality in these patients. However, the presence of vascular disease in patients with NOAF may increase the mortality associated with this disease.

Post-operative intensive care unit admission after elective non-cardiac surgery: A single-center analysis of the NSQIP database.

BACKGROUND: Admission to the intensive care unit (ICU) after surgery can be associated with significant morbidity and mortality. This observational cohort study aims to identify perioperative factors associated with post-operative ICU admission in patients undergoing elective non-cardiac surgery. METHODS: Data from the ACS NSQIP® database at a tertiary care academic medical center were analyzed from January 2011 to September 2016. Univariable and multivariable logistic regression of patient and surgery-specific characteristics was performed to assess association with post-operative ICU admission. The Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9) billing codes, as well as associated outcomes, were reviewed. RESULTS: Of 5254 database patient records, 1150 met our inclusion criteria. Elevated body mass index (BMI), longer procedure duration and a diagnosis of disseminated cancer were associated with post-operative ICU admission. Prostatectomy and morbid obesity were the most common CPT and ICD-9 codes identified. Patients who were admitted to the ICU after surgery had a longer hospital length of stay (LOS), had a higher frequency of readmission, re-operation, and in-hospital mortality. CONCLUSION: Admission to the ICU after elective non-cardiac surgery is common. Our analysis of the ACS NSQIP® database identified elevated BMI, longer duration of surgery and disseminated cancer as predictors of post-operative ICU admissions in patients undergoing elective non-cardiac surgery.

Cardiovascular Collapse in a Patient With Parotid Abscess: Dangerous Cross Talk Between the Brain and Heart: A Case Report.

Postsurgical trigeminal neuralgia (TN), although rare, can lead to significant hemodynamic perturbations by triggering the trigeminocardiac reflex (TCR). The combination can lead to diagnostic as well as management challenges for clinicians. We present the case of a patient with a parotid abscess, which developed as a complication of his otolaryngologic surgery, and which led to repeated episodes of symptomatic bradycardia associated with cardiovascular collapse. This case highlights the importance of heightened awareness, early diagnosis, and timely treatment of postsurgical neuropathic pain syndromes to avoid life-threatening complications.

In a Model of Neuroinflammation Designed to Mimic Delirium, Quetiapine Reduces Cortisol Secretion and Preserves Reversal Learning in the Attentional Set Shifting Task.

Quetiapine, an atypical antipsychotic medication has lacked pre-clinical validation for its purported benefits in the treatment of delirium. This laboratory investigation examined the effects of quetiapine on the attentional set shifting task (ASST), a measure of cognitive flexibility and executive functioning, in a rodent model of lipopolysaccharide (LPS) mediated neuroinflammation. 19 Sprague Dawley female rats were randomly selected to receive intraperitoneal placebo (N = 5), LPS and placebo (N = 7) or LPS and quetiapine (n = 7) and performed the ASST. We measured trials to criterion, errors, non-locomotion episodes and latency to criterion, serum cortisol and tumor necrosis factor alpha (TNF-α) levels. TNF-α levels were not different between groups at 24 h. Cortisol levels in the LPS + Quetiapine group were reduced compared to LPS + Placebo (P < 0.001) and did not differ from the placebo group (P = 0.15). Analysis between LPS + Quetiapine and LPS + Placebo treated rats demonstrated improvement in the compound discrimination reversal (CD Rev1) (P = 0.016) and the intra-dimensional reversal (ID Rev2) (P = 0.007) discriminations on trials to criterion. LPS + Quetiapine treated rats had fewer errors than LPS + Placebo treated animals in the compound discrimination (CD) (P = 0.007), CD Rev1 (P = 0.005), ID Rev2 (P < 0.001) discriminations. There was no difference in non-locomotion frequency or latency to criterion between the three groups in all discriminations (P > 0.0167). We demonstrated preserved reversal learning, no effect on attentional set shifting and normalized cortisol levels in quetiapine-treated rats in this neuroinflammatory model of delirium. This suggests that quetiapine's beneficial effects in delirium may be related to the preservation of reversal learning and potential downstream effects related to reduction in cortisol production. Graphical Abstract.

Pain management in trauma patients affected by the opioid epidemic: A narrative review.

Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.

Continuation of atypical antipsychotic medications in critically ill patients discharged from the hospital: a single-center retrospective analysis.

BACKGROUND: Atypical antipsychotics (AAP) have been associated with reduced duration of delirium in the intensive care setting. However, long-term use of these drugs is associated with significant adverse events, including increased all-cause mortality in the elderly. Inappropriate continuation of AAPs after discharge from the intensive care unit (ICU) is worrisome and needs to be addressed.The aim of this work was to assess the prevalence of continuation of AAPs after hospital discharge and evaluate the associated risk factors. METHOD: This was a single-center retrospective chart analysis in the setting of adult ICUs at a tertiary care academic medical center. It involved all adult patients admitted to the ICU and initiated on AAPs from January 2012 to December 2014. The measurements were: (1) prevalence of ICU-initiated AAP continuation following hospital discharge, (2) risk factors associated with continuation of AAPs following hospital discharge, and (3) risk of continuation of AAPs in patients ⩾65 years of age. RESULTS: A total of 55% of ICU patients initiated on AAPs were discharged from the hospital with a prescription for continued AAP therapy. Male sex and discharge location were highly associated with continuation upon discharge. Older patients (⩾65 years of age) were not at a higher risk of being continued on these drugs after discharge. CONCLUSION: Male sex and discharge to a healthcare facility were associated with a higher rate of continuation. Research into practical methods to reduce their continuation upon discharge should be performed to mitigate the long-term risks of AAP administration.

Stroke prophylaxis in critically-ill patients with new-onset atrial fibrillation.

Despite a high incidence of new onset atrial fibrillation (NOAF) in critically ill patients and its association with short and long-term incidence of stroke, there is limited data assessing anticoagulation on hospital discharge in these patients. We retrospectively reviewed electronic medical records of all adult patients admitted to non-cardiac ICUs at our institution between January 2009 and March 2016. Patients with NOAF were identified and CHA2DS2-VASc score of ICU survivors was calculated. Prescription of oral anticoagulant therapy on hospital discharge was analyzed. A total of 640 (1.7% [38,708 patients]; 95% CI 1.5%, 1.8%) patients developed NOAF during the study period. CHA2DS2-VASc score was calculated for 615 patients, of which 82.2% had a CHA2DS2-VASc score ≥ 2. Of the 428 eligible patients, only 96 patients (22.4%) were discharged on oral anticoagulant therapy. Patients with a history of congestive heart failure (33.7% vs. 19.7%) and stroke/TIA or other thromboembolic disease (35.9% vs. 18.0%) were more likely to be discharged on an oral anticoagulant. Patients with a higher score were also more likely to be discharged on an oral anticoagulant (OR 1.27; 95% CI 1.10, 1.47). NOAF is common in critically ill patients admitted to non-cardiac ICUs and a significant proportion of these patients have a CHA2DS2-VASc score ≥ 2. However, only a minority of them are discharged on an oral anticoagulant. There is a need to identify ways to improve implementation of effective stroke prophylaxis in these patients.