General Anesthetics in CAncer REsection Surgery (GA-CARES) randomized multicenter trial of propofol vs volatile inhalational anesthesia: protocol description.

BACKGROUND: Studies indicate that patients can be "seeded" with their own cancer cells during oncologic surgery and that the immune response to these circulating cancer cells might influence the risk of cancer recurrence. Preliminary data from animal studies and some retrospective analyses suggest that anesthetic technique might affect the immune response during surgery and hence the risk of cancer recurrence. In 2015, experts called for prospective scientific inquiry into whether anesthetic technique used in cancer resection surgeries affects cancer-related outcomes such as recurrence and mortality. Therefore, we designed a pragmatic phase 3 multicenter randomized controlled trial (RCT) called General Anesthetics in Cancer Resection (GA-CARES). METHODS: After clinical trial registration and institutional review board approval, patients providing written informed consent were enrolled at five sites in New York (NY) State. Eligible patients were adults with known or suspected cancer undergoing one of eight oncologic surgeries having a high risk of cancer recurrence. Exclusion criteria included known or suspected history of malignant hyperthermia or hypersensitivity to either propofol or volatile anesthetic agents. Patients were randomized (1:1) stratified by center and surgery type using REDCap to receive either propofol or volatile agent for maintenance of general anesthesia (GA). This pragmatic trial, which seeks to assess the potential impact of anesthetic type in "real world practice", did not standardize any aspect of patient care. However, potential confounders, e.g., use of neuroaxial anesthesia, were recorded to confirm the balance between study arms. Assuming a 5% absolute difference in 2-year overall survival rates (85% vs 90%) between study arms (primary endpoint, minimum 2-year follow-up), power using a two-sided log-rank test with type I error of 0.05 (no planned interim analyses) was calculated to be 97.4% based on a target enrollment of 1800 subjects. Data sources include the National Death Index (gold standard for vital status in the USA), NY Cancer Registry, and electronic harvesting of data from electronic medical records (EMR), with minimal manual data abstraction/data entry. DISCUSSION: Enrollment has been completed (n = 1804) and the study is in the follow-up phase. This unfunded, pragmatic trial, uses a novel approach for data collection focusing on electronic sources. TRIAL REGISTRATION: Registered (NCT03034096) on January 27, 2017, prior to consent of the first patient on January 31, 2017.

Management of diffuse alveolar hemorrhage in the hematopoietic stem cell transplantation population: A systematic review.

Pulmonary complications post-hematopoietic stem cell transplantation (HSCT) such as diffuse alveolar hemorrhage (DAH) can occur in 2% to 14% of HSCT patients and have a mortality greater than 80%. Diffuse alveolar hemorrhage is considered to be an inflammatory response; therefore, HSCT patients are primarily treated with different types of systemic corticosteroids with varying dosages. Other treatments currently reported in the literature in conjunction with corticosteroids include aminocaproic acid, recombinant factor VIIa (rFVIIa), and etanercept. This review highlights appropriate frontline and adjunctive treatment options for HSCT patients with DAH and outcomes for each intervention. To perform the review, the PubMed database was searched from inception through March 19, 2021, to identify potential studies using the search terms DAH and HSCT, DAH and hematopoietic cell transplant (HCT), DAH and stem cell, lung injury and HSCT, and lung injury and HCT. When applicable, references from articles identified in the search were also reviewed for inclusion. Much of the data identified were limited to retrospective cohort studies and case series. Based on the data available, the treatment approach should consist of corticosteroid therapy with a suggested methylprednisolone dose of 250 mg daily followed by a 50% taper every 3 days. Intrapulmonary administration of rFVIIa and intravenous administration of aminocaproic acid could be considered as adjunctive agents in those patients who do not promptly respond to corticosteroid therapy. Due to a lack of data specific to HSCT patients who develop DAH and the risk of infectious complications, etanercept should be avoided. Future studies should be designed as randomized controlled trials and examine the use of adjunctive therapies in the upfront setting for HSCT patients with DAH.

A novel anesthesiologist-led multidisciplinary model for evaluating high-risk surgical patients at a comprehensive cancer center.

The objective of this retrospective analysis was to describe the development and implementation of an anesthesiologist-led multidisciplinary committee to evaluate high-risk surgical patients in order to improve surgical appropriateness. The study was conducted in an anesthesia preoperative evaluation clinic at an academic comprehensive cancer center. One hundred sixty-seven high-risk surgical patients with cancer-related diagnoses were evaluated and discussed at a High-Risk Committee (HRC) meeting to determine surgical appropriateness and optimize perioperative care. The HRC is an anesthesiologist-led model for multidisciplinary review of high-risk patients developed at Roswell Park Comprehensive Cancer Center. The group of high-risk patients in which surgery was not performed had, on average, a greater percentage of hypertension, smoking history, dyspnea, heart failure, chronic obstructive pulmonary disease, diabetes, renal failure, and sleep apnea than the group in whom surgery was performed. Only one of 107 high-risk patients who had surgery died within the first 30 days after surgery. A smaller percentage of patients died in the group that had surgery versus the group in which surgery was canceled. For all patients discussed by the HRC, the mortality was less than 2% within the first 30 days after the HRC.

Creating a Pathway for Multidisciplinary Shared Decision-Making to Improve Communication During Preoperative Assessment.

Shared decision-making (SDM) is essential for high-quality surgical care. Barriers to SDM exist in clinical practice but there is evidence these obstacles can be overcome. SDM requires clinician and patient engagement. Though patients may indicate understanding, deficits in decision making may persist based on language, age, or educational barriers. Multidisciplinary decision-making before surgery is an opportunity for anesthesiologists and other perioperative professionals to improve surgical care. The authors present an example of a successfully implemented pathway for high-risk surgical patients at a tertiary care center, leveraging the preoperative anesthesia evaluation.

Factors associated with an increased risk of perioperative cardiac arrest in emergent and elective craniotomy and spine surgery.

OBJECTIVE: Cardiac arrest following neurosurgery is a devastating complication associated with significant postoperative morbidity and mortality. There are no published studies that have used a large and robust multicenter database to specifically examine demographic and surgical risk factors associated with cardiac arrests following craniotomy and spine surgeries, respectively. PATIENTS AND METHODS: We retrospectively analyzed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the period between January 1, 2007 and December 31, 2013, focusing on cardiac arrest associated with craniotomy and spine surgery from the intraoperative period to 30days after surgery. A total of 73,584 neurosurgical patients were analyzed (59,609 spine surgeries and 13,975 craniotomies). RESULTS: There was an increased risk of cardiac arrest for both craniotomy and spine surgeries in patients with American Society of Anesthesiologists (ASA) Physical Status class 4 or 5, Black and Asian patients compared to White patients and patients totally dependent versus independent based on the ACS-NSQIP risk calculator. The risk of cardiac arrest for craniotomy was 66.5 per 10,000 anesthetics and for spine surgery was 21.3 per 10,000 anesthetics. Cardiac arrest associated with emergent non-traumatic craniotomy was 36.5% and with emergent non-traumatic spine surgery was only 17.3%. We found that 18% of cardiac arrests for craniotomy and 25% of cardiac arrests for spine surgery occurred from the intraoperative period through postoperative day (POD) 0. Both craniotomy and spine surgery patients who had a cardiac arrest were more likely to have acute kidney injury (AKI), failure to wean from the ventilator, postoperative dialysis, myocardial infarction (MI), venous thromboembolism (VTE) and sepsis in the postoperative period. The overall mortality rate for both craniotomy and spine surgeries who had a cardiac arrest from the intraoperative period to 30days postoperative was 61.8% versus 1.2% in the no cardiac arrest control group. CONCLUSIONS: Identification of patient and surgery specific characteristics from ACS-NSQIP data associated with cardiac arrest following craniotomy and spine surgery may lead to initiatives to reduce morbidity and mortality in the neurosurgical patient population.

Analysis of Variability in Intraoperative Fluid Administration for Colorectal Surgery: An Argument for Goal-Directed Fluid Therapy.

BACKGROUND: Fluid therapy in the perioperative period varies greatly between anesthesia providers and may have a negative impact on surgical outcomes. METHODS: We conducted a retrospective analysis of 705 elective colorectal cases consisting of colectomies, ileocolic resections, and low anterior resections at an academic institution from January 1, 2010 to May 29, 2015, collected by our electronic medical record before implementation of Enhanced Recovery After Surgery (ERAS®) pathways. RESULTS: The mean for total crystalloid administration was 2578 mL with a standard deviation (SD) that was approximately 50% of the mean value. A combination of both normal saline and lactated Ringer's solution was used in almost all cases without a clear rationale for fluid choice. Fluid administered to patients was disproportional to measured intraoperative fluid losses (estimated blood loss and urine output) by a factor of 10. The average rate of fluid given was 1050 mL/h with an SD of nearly the same amount (951 mL). There was a variability of over 67% in total crystalloid administered based on both ideal body weight and total body weight. CONCLUSIONS: We found that a wide variability in the amount and type of fluid therapy administered existed at our institution before implementation of a colorectal ERAS pathway or routine use of goal-directed fluid therapy (GDFT). ERAS pathways with GDFT protocols could lead to more rational and consistent fluid therapy leading to improved outcomes.

Analysis of Unplanned Postoperative Admissions to the Intensive Care Unit.

PURPOSE: To investigate factors associated with unplanned postoperative admissions to the intensive care unit (ICU). METHODS: Data from the National Anesthesia Clinical Outcomes Registry (NACOR) were analyzed. We performed univariate and multivariate logistic regression to identify patient- and surgery-specific characteristics associated with unplanned postoperative ICU admission. We also recorded the prevalence of Current Procedural Terminology (CPT) and International Classification of Diseases, ninth revision ( ICD-9) billing codes and outcomes for unplanned postoperative ICU admissions. RESULTS: Of 23 341 130 records in the database, 2 910 738 records met our inclusion criteria. A higher American Society of Anesthesiologists physical status (ASA PS) class, case duration greater than 4 hours, and advanced age were associated with a greater likelihood of unplanned ICU admission. Vascular and thoracic surgery patients were more likely to have an unplanned ICU admission. The most common CPT and ICD-9 codes involved repair of femur/hip fracture, bowel resection, and acute postoperative pain. Large community hospitals were more likely than university hospitals to have unplanned postoperative ICU admissions. Patients in the unplanned postoperative ICU admission group were more likely to have experienced intraoperative cardiac arrest, hemodynamic instability, or respiratory failure and were more likely to die in the immediate perioperative period. CONCLUSION: Our study is the first diverse analysis of unplanned postoperative ICU admissions in the literature across multiple specialties and practice models. We found an association of advanced age, higher ASA PS class, and duration of procedure with unplanned ICU admission after surgery. Surgical specialties and procedures with the most unplanned ICU admissions could be areas for quality improvement and clinical pathways in the future.

A Model for Better Leveraging the Point of Preoperative Assessment: Patients and Providers Look Beyond Operative Indications When Making Decisions.

Previous literature on preoperative evaluation focuses on the impact on the day of surgery cancellations and delays; however, the framework of cancellations and delays at the time of the elective outpatient preoperative anesthesia visit has not been categorized. We describe the current model in the preoperative clinic at Brigham and Women's Hospital, examining the pattern of cancellations at the time of this preoperative visit and the framework used for categorizing the issues involved. Looking at this broader framework is important in an era of patient-centered care; we seek to identify targets to modify the preoperative assessment and adequately assess and capture the spectrum of issues involved. Elective cases evaluated in the preoperative clinic were reviewed over 10 months. Characteristics of cancelled and noncancelled cases were compared. In-depth analysis of issues related to cancellation was done; 1-year follow-up was completed. Cancellation patterns included categories encompassing clinical, financial, alignment with patient values and goals, compliance, and social issues. The period of preoperative assessment can therefore be leveraged to review a number of domains that can adversely affect surgical outcomes and improve patient-centered care. Also, our framework allows the institution to benchmark these patterns over time; increases in cancellations at the time of the preoperative anesthesia clinic visit for specific categories can prompt an opportunity to examine and improve preoperative workflow.

Imaging findings of "anesthesia mumps" (acute postoperative sialadenitis) after general anesthesia.

We present a rare case of acute postoperative sialadenitis or "anesthesia mumps" necessitating emergent intubation in a 16-year-old girl after biopsy of a brainstem mass under general anesthesia. Postoperative computed tomography of the brain demonstrated extensive right-sided facial swelling, parotid gland enlargement, and pharyngeal edema extending to the parapharyngeal space, soft palate, and uvula with significant narrowing of the airway. To our knowledge, this entity has not been previously described in the radiologic literature.

Endogenous interleukin-4 regulates glutathione synthesis following acetaminophen-induced liver injury in mice.

In a recent study, we reported that interleukin (IL)-4 had a protective role against acetaminophen (APAP)-induced liver injury (AILI), although the mechanism of protection was unclear. Here, we carried out more detailed investigations and have shown that one way IL-4 may control the severity of AILI is by regulating glutathione (GSH) synthesis. In the present studies, the protective role of IL-4 in AILI was established definitively by showing that C57BL/6J mice made deficient in IL-4 genetically (IL-4(-/-)) or by depletion with an antibody, were more susceptible to AILI than mice not depleted of IL-4. The increased susceptibility of IL-4(-/-) mice was not due to elevated levels of hepatic APAP-protein adducts but was associated with a prolonged reduction in hepatic GSH that was attributed to decreased gene expression of γ-glutamylcysteine ligase (γ-GCL). Moreover, administration of recombinant IL-4 to IL-4(-/-) mice postacetaminophen treatment diminished the severity of liver injury and increased γ-GCL and GSH levels. We also report that the prolonged reduction of GSH in APAP-treated IL-4(-/-) mice appeared to contribute toward increased liver injury by causing a sustained activation of c-Jun-N-terminal kinase (JNK) since levels of phosphorylated JNK remained significantly higher in the IL-4(-/-) mice up to 24 h after APAP treatment. Overall, these results show for the first time that IL-4 has a role in regulating the synthesis of GSH in the liver under conditions of cellular stress. This mechanism appears to be responsible at least in part for the protective role of IL-4 against AILI in mice and may have a similar role not only in AILI in humans but also in pathologies of the liver caused by other drugs and etiologies.