Associations of an eye-tracking task and pupillary metrics with age and ASA physical status score in a preoperative cohort.

Advanced age, American Society of Anesthesiologists physical status (ASA) classification and the presence of cognitive impairment are associated with an elevated risk of postoperative morbidity and mortality. The visual paired comparison (VPC) task, which relies on recognition of novel images, examines declarative memory. VPC scores have demonstrated the ability to detect mild cognitive impairment and track progression of neurodegenerative disease. Quantitative pupillometry may have similar value. We evaluate for associations between these variables of interest and the feasibility of performing these tests in the preoperative clinic. Prospective data from 199 patients seen in the preoperative clinic at a tertiary academic center were analyzed. A 5 min VPC task (Neurotrack Technologies, Inc, Redwood City, CA) was administered during their scheduled preoperative clinic visit. Pupillary light reflexes were measured at the same visit (PLR-3000™, Neuroptics Corp, Irvine, California).Thirty-four percent of patients were categorized as ASA 2 and 58% as ASA 3. Median age was 57 (IQR: 44-69). Associations were demonstrated between age and ASA physical status (Mann-Whitney U Test, p < 0.0001), maximum pupil size (Spearman Rank Correlation, r = - 0.40, p < 0.0001), and maximum constriction velocity (Spearman Rank Correlation, r = - 0.39, p < 0.0001). Our data also revealed an association between VPC score and age (Spearman Rank Correlation, p = 0.0016, r = - 0.21) but not ASA score (Kruskal-Wallis Test, p = 0.14). When compared to a nonsurgical cohort with no history of memory impairment, our population scored worse on the VPC task (Mann-Whitney U Test, p = 0.0002). A preoperative 5 min VPC task and pupillometry are feasible tests in the preoperative setting and may provide a valuable window into an individual's cognition prior to elective surgery.

Opioid-Free Anesthesia for Craniotomy.

BACKGROUND: Perioperative opioids are problematic following craniotomy as they can impede neurological examination because of excessive sedation and mask surgical complications. Multimodal anesthetic techniques including nerve blocks have been used successfully to deliver opioid-free anesthesia in other surgical populations; however, no clinical data evaluating opioid-free anesthesia for craniotomy exists within the current body of literature. MATERIALS AND METHODS: Six prospectively identified patients underwent supratentorial craniotomy at Emory University Hospital using a multimodal opioid-free anesthetic (OFA) technique consisting of preoperative scalp block, dexmedetomidine and intravenous acetaminophen. These opioid-free patients were matched by age, sex, incision length, and incision location to 18 retrospectively identified control patients who underwent craniotomy using conventional, opioid-based anesthetic techniques. Postoperative opioid consumption and pain scores were compared and analyzed for noninferiority. RESULTS: Noninferiority of the OFA technique was demonstrated for opioid consumption at all measured intervals from postanesthesia care unit arrival to 24 hours postoperatively. Noninferiority was also demonstrated with respect to average postoperative pain scores from 0 to 12 hours, 0 to 24 hours, as well as length of postanesthesia care unit stay. Noninferiority was not shown for time to first rescue opioid postoperatively, pain scores for the 12 to 24 hours postoperative period, or time to emergence from anesthesia. CONCLUSIONS: This pilot study demonstrates the feasibility of an OFA technique for patients undergoing supratentorial craniotomy and suggests that larger prospective randomized controlled trials are indicated to examine the role of multimodal anesthetic techniques for craniotomy.

Critical Care of the Vascular Surgery Patient.

Patients that require major vascular surgery suffer from widespread atherosclerosis and have multiple comorbidities that place them at increased risk for postoperative complications and require admission to the intensive care unit (ICU). Postoperative critical care of these patients is focused on hemodynamic optimization, and early identification and management of complications to improve outcomes.

Design and Implementation of Airway Response Teams to Improve the Practice of Emergency Airway Management.

Emergency airway management (EAM) is a commonly performed procedure in the critical care setting. Despite clinical advances that help practitioners identify patients at risk for having a difficult airway, improved airway management tools, and algorithms that guide clinical decision-making, the practice of EAM is associated with significant morbidity and mortality. Evidence suggests that a dedicated airway response team (ART) can help mitigate the risks associated with EAM and provide a framework for airway management in acute settings. We review the risks and challenges related to EAM and describe strategies to improve patient care and outcomes via implementation of an ART.

Clinical Outcomes of Critically III Patients with COVID-19 by Race.

BACKGROUND: Studies of COVID-19 have shown that African Americans have been affected by the virus at a higher rate compared to other races. This cohort study investigated comorbidities and clinical outcomes by race among COVID-19 patients admitted to the intensive care unit. METHODS: This is a case series of critically ill patients admitted with COVID-19 to an academic healthcare system in Atlanta, Georgia. The study included all critically ill hospitalized patients between March 6, 2020, and May 5, 2020. Clinical outcomes during hospitalization included mechanical ventilation, renal replacement therapy, and mortality stratified by race. RESULTS: Of 288 patients included (mean age, 63 ± 16 years; 45% female), 210 (73%) were African American. African Americans had significantly higher rates of comorbidities compared to other races, including hypertension (80% vs 59%, P = 0.001), diabetes (49% vs 34%, P = 0.026), and mean BMI (33 kg/m2 vs 28 kg/m2, P < 0.001). Despite African Americans requiring continuous renal replacement therapy during hospitalization at higher rates than other races (27% vs 13%, P = 0.011), rates of intubation, intensive care unit length of stay, and overall mortality (30% vs 24%, P = 0.307) were similar. CONCLUSION: This racially diverse series of critically ill COVID-19 patients shows that despite higher rates of comorbidities at hospital admission in African Americans compared with other races, there was no significant difference in mortality.

Physician and Trainee Perceptions of Telecritical Care Practice and Education: Results of a Programmatic Survey.

Background: Telecritical care (TCC) as a telehealth modality seeks to remedy contemporary shortfalls in staffing and experience at the bedside. Physician and physician trainee perceptions of TCC practice and education can help inform programmatic and curricular decisions. The perceptions of TCC and a formalized structured TCC rotation from faculty and trainees are unknown. Objective: To evaluate perceptions of TCC practice and education among participating physicians and trainees. Methods: Survey of physicians and trainees participating in the Emory Critical Care Center's TCC unit from 2017 to 2021 was conducted, after implementation of a structured TCC educational curriculum. Items were developed with a 5-point Likert scale. Results: The overall response rate was 71% (43 of 61). Most respondents felt their knowledge was used appropriately and that their recommendations were well received at the bedside. The majority perceived that the TCC program improved continuity, quality, and safety of patient care. More than half of respondents would practice TCC in the future, and most would advocate for it. Most fellows were comfortable providing patient care remotely after their rotation. The majority of respondents felt TCC did not add to their level of burnout. Conclusions: This programmatic evaluation identified perceived improvements in patient care. Implementation of a TCC rotation does not seem to negatively impact the educational experience of trainees.

COVID-19-associated venous thromboembolism portends worse survival.

Patients with coronavirus disease 2019 (COVID-19) seem to be at high risk for venous thromboembolism (VTE) development, but there is a paucity of data exploring both the natural history of COVID-19-associated VTE and the risk for poor outcomes after VTE development. This investigation aims to explore the relationship between COVID-19-associated VTE development and mortality. A prospectively maintained registry of patients older than 18 years admitted for COVID-19-related illnesses within an academic health care network between March and September 2020 was reviewed. Codes from the tenth revision of the International Classification of Diseases for VTE were collected. The charts of those patients with a code for VTE were manually reviewed to confirm VTE diagnosis. There were 2,552 patients admitted with COVID-19-related illnesses. One hundred and twenty-six patients (4.9%) developed a VTE. A disproportionate percentage of patients of Black race developed a VTE (70.9% VTE v 57.8% non-VTE; P = .012). A higher proportion of patients with VTE expired during their index hospitalization (22.8% VTE v 8.4% non-VTE; P < .001). On multivariable logistic regression analysis, VTE was independently associated with mortality (odds ratio = 3.17; 95% confidence interval, 1.9-5.2; P < .001). Hispanic/Latinx ethnicity was associated with decreased mortality (odds ratio = 0.45; 95% confidence interval, 0.21-1.00; P = .049). Hospitalized patients of Black race with COVID-19 were more prone to VTE development, and patients with COVID-19 who developed in-hospital VTE had roughly nearly threefold higher odds of mortality. Further emphasis should be placed on optimizing COVID-19 anticoagulation protocols to reduce mortality in this high-risk cohort.

Validation of an admission coagulation panel for risk stratification of COVID-19 patients.

BACKGROUND: There is limited data on the markers of coagulation and hemostatic activation (MOCHA) profile in Coronavirus disease 2019 (COVID-19) and its ability to identify COVID-19 patients at risk for thrombotic events and other complications. METHODS: Hospitalized patients with confirmed SARS-COV-2 from four Atlanta hospitals were included in this observational cohort study and underwent admission testing of MOCHA parameters (plasma d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer). Clinical outcomes included deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke, access line thrombosis, ICU admission, intubation and mortality. MAIN RESULTS: Of 276 patients (mean age 59 ± 6.4 years, 47% female, 62% African American), 45 (16%) had a thrombotic endpoint. Each MOCHA parameter was independently associated with a thrombotic event (p<0.05) and ≥ 2 abnormalities was associated with thrombotic endpoints (OR 3.3, 95% CI 1.2-8.8) as were admission D-dimer ≥ 2000 ng/mL (OR 3.1, 95% CI 1.5-6.6) and ≥ 3000 ng/mL (OR 3.6, 95% CI 1.6-7.9). However, only ≥ 2 MOCHA abnormalities were associated with ICU admission (OR 3.0, 95% CI 1.7-5.2) and intubation (OR 3.2, 95% CI 1.6-6.4). MOCHA and D-dimer cutoffs were not associated with mortality. MOCHA with <2 abnormalities (26% of the cohort) had 89% sensitivity and 93% negative predictive value for a thrombotic endpoint. CONCLUSIONS: An admission MOCHA profile is useful to risk-stratify COVID-19 patients for thrombotic complications and more effective than isolated d-dimer for predicting risk of ICU admission and intubation.

Trends and diagnostic value of D-dimer levels in patients hospitalized with coronavirus disease 2019.

Coronavirus disease 2019 (COVID-19) has been associated with increased incidence of venous thromboembolic events (VTE) as well as mortality. D-dimer is a marker of fibrinolysis and has been used as a diagnostic and prognostic marker in VTE among other diseases. The purpose of our study is to describe outcomes from out center and to examine trends in D-dimer levels as it relates to VTE and mortality.Patients admitted with confirmed COVID-19 cases to Emory Healthcare from March 12, 2020 through April 6, 2020 with measured plasma D-dimer levels were included in our retrospective analysis. Relevant data about comorbidities, hospitalization course, laboratory results, and outcomes were analyzed.One hundred fifteen patients were included in our study. Mean age was 64 ±â€Š15 years, 47 (41%) females and 84 (73%) African-American. Hypertension was present in 83 (72%) and diabetes in 60 (52%). Mean duration of hospitalization was 19 ±â€Š11 days with 62 (54%) patients intubated (mean duration of 13 ±â€Š8 days). VTE was diagnosed in 27 (23%) patients (mean time to diagnosis 14 ±â€Š9 days). Median D-dimer within the first 7 days of hospitalization was higher (6450 vs. 1596 ng/mL, p < 0.001) in VTE cases compared to non-VTE cases, and was predictive of VTE (area under the curve [AUC] = 0.72, optimal threshold 2500 ng/mL) although not of mortality (AUC 0.55, P = .34). Change in D-dimer level (AUC = 0.72 P = .004) and rate of D-dimer rise (AUC = 0.75 P = .001) were also predictive of VTE, though neither predicted death (P > .05 for all). Within the first 7 days of hospitalization, peak D-dimer level of >2500 ng/mL and a rate of change exceeding 150 ng/mL/d were predictive of future diagnosis of VTE. Rise in D-dimer >2000 ng/mL within any 24 hour period through hospital day 10 had 75% sensitivity and 74% specificity for diagnosis of VTE.We found that both magnitude and rate of rise in d-dimer within the first 10 days of hospitalization are predictive of diagnosis of VTE but not mortality. These parameters may aid in identifying individuals with possible underlying VTE or at high risk for VTE, thereby guiding risk stratification and anticoagulation policies in COVID-19 patients.

C-Reactive protein as a prognostic indicator in hospitalized patients with COVID-19.

Recent studies have reported that CRP levels are elevated in patients with COVID-19 and may correlate with severity of disease and disease progression. We conducted a retrospective cohort analysis of the medical records of 268 adult patients, who were admitted to one of the six cohorted COVID ICUs across Emory Healthcare System and had at least two CRP values within the first seven days of admission to study the temporal progression of CRP and its association with all-cause in-hospital mortality. The median CRP during hospitalization for the entire cohort was 130 mg/L (IQR 82-191 mg/L), and the median CRP on ICU admission was 169 (IQR 111-234). The hospitalization-wide median CRP was significantly higher amongst the patients who died, compared to those who survived [206 mg/L (157-288 mg/L) vs 114 mg/L (72-160 mg/L), p<0.001]. CRP levels increased in a linear fashion during the first week of hospitalization and peaked on day 5. Compared to patients who died, those who survived had lower peak CRP levels and earlier declines. CRP levels were significantly higher in patients who died compared to those who survived (p<0.001). Our findings support the utility of daily CRP values in hospitalized COVID-19 patients and provide early thresholds during hospitalization that may facilitate risk stratification and prognostication.

Abdominal Surgery With Bilateral Rectus Sheath Block: A Case Report.

A 44-year-old man, American Society of Anesthesiologists physical status class IV, presented for fulguration of anal condyloma and diverting colostomy. The patient's medical history includes World Health Organization (WHO) class I pulmonary hypertension (PH), right heart failure, and bilateral lower extremity paralysis due to Pott's disease. The patient was not a candidate for neuraxial anesthesia due to sacral decubitus ulcers, and alternative options to general anesthesia (GA) were considered to avoid the high risk of right ventricular (RV) failure and ensuing complications. The case was successfully performed under sedation with dexmedetomidine infusion and bilateral rectus sheath blocks for surgical anesthesia.

Modes of mechanical ventilation vary between hospitals and intensive care units within a university healthcare system: a retrospective observational study.

OBJECTIVE: As evidence-based guidance to aid clinicians with mechanical ventilation mode selection is scant, we sought to characterize the epidemiology thereof within a university healthcare system and hypothesized that nonconforming approaches could be readily identified. We conducted an exploratory retrospective observational database study of routinely recorded mechanical ventilation parameters between January 1, 2010 and December 31, 2016 from 12 intensive care units. Mode epoch count proportions were examined using Chi squared and Fisher exact tests as appropriate on an inter-unit basis with outlier detection for two test cases via post hoc pairwise analyses of a binomial regression model. RESULTS: Final analysis included 559,734 mode epoch values. Significant heterogeneity was demonstrated between individual units (P < 0.05 for all comparisons). One unit demonstrated heightened utilization of high-frequency oscillatory ventilation, and three units demonstrated frequent synchronized intermittent mandatory ventilation utilization. Assist control ventilation was the most commonly recorded mode (51%), followed by adaptive support ventilation (23.1%). Volume-controlled modes were about twice as common as pressure-controlled modes (64.4% versus 35.6%). Our methodology provides a means by which to characterize the epidemiology of mechanical ventilation approaches and identify nonconforming practices. The observed variability warrants further clinical study about contributors and the impact on relevant outcomes.

Perioperative metoprolol and risk of stroke after noncardiac surgery.

BACKGROUND: Numerous risk factors have been identified for perioperative stroke, but there are conflicting data regarding the role of ß adrenergic receptor blockade in general and metoprolol in particular. METHODS: The authors retrospectively screened 57,218 consecutive patients for radiologic evidence of stroke within 30 days after noncardiac procedures at a tertiary care university hospital. Incidence of perioperative stroke within 30 days of surgery and associated risk factors were assessed. Patients taking either metoprolol or atenolol were matched based on a number of risk factors for stroke. Parsimonious logistic regression was used to generate a preoperative risk model for perioperative stroke in the unmatched cohort. RESULTS: The incidence of perioperative stroke was 55 of 57,218 (0.09%). Preoperative metoprolol was associated with an approximately 4.2-fold increase in perioperative stroke (P < 0.001; 95% CI, 2.2-8.1). Analysis of matched cohorts revealed a significantly higher incidence of stroke in patients taking preoperative metoprolol compared with atenolol (P = 0.016). However, preoperative metoprolol was not an independent predictor of stroke in the entire cohort, which included patients who were not taking ß blockers. The use of intraoperative metoprolol was associated with a 3.3-fold increase in perioperative stroke (P = 0.003; 95% CI, 1.4-7.8); no association was found for intraoperative esmolol or labetalol. CONCLUSIONS: Routine use of preoperative metoprolol, but not atenolol, is associated with stroke after noncardiac surgery, even after adjusting for comorbidities. Intraoperative metoprolol but not esmolol or labetalol, is associated with increased risk of perioperative stroke. Drugs other than metoprolol should be considered during the perioperative period if ß blockade is required.

Incidence, predictors, and outcomes of perioperative stroke in noncarotid major vascular surgery.

BACKGROUND: Perioperative stroke is a potentially catastrophic complication of surgery. Patients undergoing vascular surgery suffer from systemic atherosclerosis and are expected to be at increased risk for this complication. We studied the incidence, predictors, and outcomes of perioperative stroke after noncarotid major vascular surgery using the American College of Surgeons National Quality Improvement Program database. METHODS: Forty-seven thousand seven hundred fifty patients undergoing noncarotid vascular surgery from 2005 to 2009 at nonVeterans Administration hospitals were identified from the American College of Surgeons National Quality Improvement Program database. An analysis of patients undergoing elective lower extremity amputation, lower extremity revascularization, or open aortic procedures was performed to determine the incidence, independent predictors, and 30-day mortality of perioperative stroke. RESULTS: The overall incidence of perioperative stroke within 30 days of surgery (n=37,927) was 0.6%. Multivariate analysis revealed that each 1-year increase in age [odds ratio 1.02, 95% confidence interval (CI) (1.01 to 1.04)], cardiac history [1.42, (1.07 to 1.87)], female sex [1.47, (1.12 to 1.93)], history of cerebrovascular disease [1.72, (1.29 to 2.29)], and acute renal failure or dialysis dependence [2.03, (1.39 to 2.97)] were independent predictors of stroke. Only 15% (95% CI, 11%-20%) of strokes occurred on postoperative day 0 or 1. Perioperative stroke was associated with a 3-fold increase in 30-day all-cause mortality [3.36, (1.77 to 6.36)] and an increased median surgical length of stay from 6 (95% CI, 2 to 28) to 13 (95% CI, 3 to 43) days (P<0.001, WMWodds 2.5, 95% CI, 2.0 to 3.2) in a matched-cohort assessment. CONCLUSION: Perioperative stroke is an important source of morbidity and mortality, as reflected by significant increases in median surgical length of stay and all-cause 30-day mortality. The independent predictors of stroke that we have identified in this population are not readily modifiable and the majority of strokes occurred after postoperative day 1. Additional studies are required to identify potentially modifiable intraoperative or postoperative risk factors of perioperative stroke.

Cerebral perfusion pressure below 60 mm Hg is common in the intraoperative setting.

BACKGROUND: Maintaining adequate cerebral perfusion pressure (CPP) is of clinical concern in patients with neurological injury. Although there are extensive data on CPP in the ICU setting, there has been little quantitative study of CPP in the intraoperative setting. METHODS: We retrospectively analyzed the electronic intraoperative records of neurosurgical and trauma patients with concurrent intracranial and arterial pressure monitoring devices in continuous use for ≥45 minutes to calculate CPP (=mean arterial pressure-intracranial pressure). We assessed the total minutes and frequency of 5-minute epochs, during which the median CPP was <60 mm Hg, and the associated risk factors. RESULTS: A total of 155 trauma and neurosurgical patients were studied. In the neurosurgery cohort (n=88), 74% had at least one 5-minute epoch during which the median CPP was <60 mm Hg and the median total minutes of CPP<60 mm Hg was 39 [interquartile range (67), length of surgery 274 (300) min]. In the trauma cohort (n=67), 82% had at least one 5-minute epoch of <60 mm Hg, and the median total minutes CPP of <60 mm Hg was 35 [(59), length of surgery 159 (160) min]. For the entire cohort (n=155), patients with CPP<60 mm Hg were found to have higher intracranial pressure compared with patients with CPP≥60 mm Hg (P<0.001). Unlike the neurosurgical cohort, trauma patients with CPP<60 mm Hg had a greater frequency of episodes of mean arterial pressure <70 mm Hg (P=0.001). CONCLUSIONS: CPP<60 mm Hg is common in the intraoperative setting of a tertiary medical center in 2 different surgical populations with intracranial pathology. Prospective studies of intraoperative CPP and neurological outcomes are warranted.