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

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

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

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

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

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

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

The impact of residency training level on early postoperative desaturation: A retrospective multicenter cohort study.

OBJECTIVE: We studied the primary hypothesis that the training level of anesthesiology residents (first clinical anesthesia year, CA1 vs CA2/3 residents) is associated with early postoperative desaturation (oxygen saturation < 90%). We also analyzed the change in the rate (trajectory) of desaturation during the resident's development from CA1 to CA2/3 resident, and its effects on postoperative respiratory complications. DESIGN: Retrospective hospital registry study. SETTING: Two university-affiliated hospitals networks (MA and NY, USA). PATIENTS: 140,818 adults undergoing non-cardiac surgery under general anesthesia and extubation in the operating room by residents (n = 378) between 2005 and 2021. MEASUREMENTS: Multivariate logistic and quantile regression were used in the analyses. The secondary outcome was major respiratory complication within 7 days after surgery. MAIN RESULTS: In 6.5% and 1.6% of cases, early postoperative desaturation to < 90% and 80% occurred. Compared to CA2/3 residents, CA1 residents had higher odds of experiencing early postoperative desaturation to < 90% and 80% (adjusted odds ratio [ORadj], 1.07; 95%CI 1.03-1.12; p = 0.002, and ORadj 1.10; 95%CI 1.01-1.20; p = 0.037, respectively). The change in postoperative desaturation rate during the transition from CA1 to CA2/3 status varied substantially from ORadj 0.80 (decreased risk) to 1.33 (increased risk). Major respiratory complication did not differ between experience levels (p = 0.52). However, a strong decline in improvement regarding the rate of postoperative desaturation during the transition from CA1 to CA2/3, was paralleled by an increased odds of major respiratory complication for CA2/3 residents (ORadj 1.20; 95%CI 1.02-1.42; p = 0.026, p-for-interaction = 0.056). CONCLUSION: Patients treated by CA1 residents have an increased risk of postoperative desaturation. Some residents show an improvement and others a decline in postoperative desaturation rate. Our secondary analysis suggests that there should be more focus on those residents who had a declining performance in postoperative desaturation despite becoming more experienced.

Effects of mobility dose on discharge disposition in critically ill stroke patients.

BACKGROUND: Mobilization in the intensive care unit (ICU) has the potential to improve patient outcomes following acute stroke. The optimal duration and intensity of mobilization for patients with hemorrhagic or ischemic stroke in the ICU remain unclear. OBJECTIVE: To assess the effect of mobilization dose in the ICU on adverse discharge disposition in patients after stroke. DESIGN: This is an international, prospective, observational cohort study of critically ill stroke patients (November 2017-September 2019). Duration and intensity of mobilization was quantified daily by the mobilization quantification score (MQS). SETTING: Patients requiring ICU-level care were enrolled within 48 hours of admission at four separate academic medical centers (two in Europe, two in the United States). PARTICIPANTS: Participants included individuals (>18 years old) admitted to an ICU within 48 hours of ischemic or hemorrhagic stroke onset who were functionally independent at baseline. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The primary outcome was adverse discharge disposition. RESULTS: Of the patients screened, 163 were eligible for inclusion in the study. One patient was subsequently excluded due to insufficient data collection (n = 162). The dose of mobilization varied greatly between centers and patients, which could not be explained by patients' comorbidities or disease severity. High dose of mobilization (mean MQS > 7.3) was associated with a lower likelihood of adverse discharge (adjusted odds ratio, [aOR]: 0.14; 95% confidence interval [CI]: 0.06-0.31; p < .01). CONCLUSION: The increased use of mobilization acutely in the ICU setting may improve patient outcomes.

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

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

Development and validation of a machine learning ASA-score to identify candidates for comprehensive preoperative screening and risk stratification.

OBJECTIVE: The ASA physical status (ASA-PS) is determined by an anesthesia provider or surgeon to communicate co-morbidities relevant to perioperative risk. Assigning an ASA-PS is a clinical decision and there is substantial provider-dependent variability. We developed and externally validated a machine learning-derived algorithm to determine ASA-PS (ML-PS) based on data available in the medical record. DESIGN: Retrospective multicenter hospital registry study. SETTING: University-affiliated hospital networks. PATIENTS: Patients who received anesthesia at Beth Israel Deaconess Medical Center (Boston, MA, training [n = 361,602] and internal validation cohorts [n = 90,400]) and Montefiore Medical Center (Bronx, NY, external validation cohort [n = 254,412]). MEASUREMENTS: The ML-PS was created using a supervised random forest model with 35 preoperatively available variables. Its predictive ability for 30-day mortality, postoperative ICU admission, and adverse discharge were determined by logistic regression. MAIN RESULTS: The anesthesiologist ASA-PS and ML-PS were in agreement in 57.2% of the cases (moderate inter-rater agreement). Compared with anesthesiologist rating, ML-PS assigned more patients into extreme ASA-PS (I and IV), (p < 0.01), and less patients in ASA II and III (p < 0.01). ML-PS and anesthesiologist ASA-PS had excellent predictive values for 30-day mortality, and good predictive values for postoperative ICU admission and adverse discharge. Among the 3594 patients who died within 30 days after surgery, net reclassification improvement analysis revealed that using the ML-PS, 1281 (35.6%) patients were reclassified into the higher clinical risk category compared with anesthesiologist rating. However, in a subgroup of multiple co-morbidity patients, anesthesiologist ASA-PS had a better predictive accuracy than ML-PS. CONCLUSIONS: We created and validated a machine learning physical status based on preoperatively available data. The ability to identify patients at high risk early in the preoperative process independent of the provider's decision is a part of the process we use to standardize the stratified preoperative evaluation of patients scheduled for ambulatory surgery.

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

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

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

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

Incidence and predictors of case cancellation within 24 h in patients scheduled for elective surgical procedures.

OBJECTIVE: Avoidable case cancellations within 24 h reduce operating room (OR) efficiency, add unnecessary costs, and may have physical and emotional consequences for patients and their families. We developed and validated a prediction tool that can be used to guide same day case cancellation reduction initiatives. DESIGN: Retrospective hospital registry study. SETTING: University-affiliated hospitals network (NY, USA). PATIENTS: 246,612 (1/2016-6/2021) and 58,662 (7/2021-6/2022) scheduled elective procedures were included in the development and validation cohort. MEASUREMENTS: Case cancellation within 24 h was defined as cancelling a surgical procedure within 24 h of the scheduled date and time. Our candidate predictors were defined a priori and included patient-, procedural-, and appointment-related factors. We created a prediction tool using backward stepwise logistic regression to predict case cancellation within 24 h. The model was subsequently recalibrated and validated in a cohort of patients who were recently scheduled for surgery. MAIN RESULTS: 8.6% and 8.7% scheduled procedures were cancelled within 24 h of the intended procedure in the development and validation cohort, respectively. The final weighted score contains 29 predictors. A cutoff value of 15 score points predicted a 10.3% case cancellation rate with a negative predictive value of 0.96, and a positive predictive value of 0.21. The prediction model showed good discrimination in the development and validation cohort with an area under the receiver operating characteristic curve (AUC) of 0.79 (95% confidence interval 0.79-0. 80) and an AUC of 0.73 (95% confidence interval 0.72-0.73), respectively. CONCLUSIONS: We present a validated preoperative prediction tool for case cancellation within 24 h of surgery. We utilize the instrument in our institution to identify patients with high risk of case cancellation. We describe a process for recalibration such that other institutions can also use the score to guide same day case cancellation reduction initiatives.

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

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

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

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

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

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

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

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

Goal-Directed Fluid Therapy Based on Pulse-Pressure Variation Compared with Standard Fluid Therapy in Patients Undergoing Complex Spine Surgery: A Randomized Controlled Trial.

STUDY DESIGN: Prospective, randomized, controlled study. PURPOSE: To determine whether the use of goal-directed fluid therapy (GDT) guided by pulse-pressure variation (PPV) and fluid management protocol can reduce intraoperative hypotension, blood transfusion requirements, and postoperative complications in adults undergoing complex spine surgery. OVERVIEW OF LITERATURE: Complex spine surgeries involve a significant risk of blood loss and intraoperative hypotension. Previous studies showed that GDT reduces intraoperative hypotension and postoperative complications in these surgery types; however, limited information exists about GDT guided by PPV. METHODS: Sixty adults (18-70 years) patients undergoing complex spine surgeries at Siriraj Hospital, Mahidol University, Thailand were enrolled. Patients were allocated to two groups (30 patients in each) using computer-generated randomization. Intraoperative fluid and vasopressor were administrated via either GDT or standard care. The GDT algorithm used PPV and fluid protocol as the primary tool to guide hemodynamic management. The incidences and episodes of perioperative hypotension were measured as the outcomes. RESULTS: Fifty-seven patients were analyzed (three patients in the GDT group were excluded). The baseline characteristics and surgical procedures of the two groups did not differ significantly. The prevalence of intraoperative hypotension was 80.0% for the control group and 66.7% for the GDT group (p=0.25). Two episodes (1-3) of intraoperative hypotension occurred in the control group, and one episode (0-3) occurred in the GDT group; the difference was not significantly different (p=0.57). The intraoperative blood transfusion requirements and postoperative complications were similar in both the groups. In the subgroup analysis, patients with intraoperative hypotension exhibited a higher incidence of postoperative bowel dysfunction. CONCLUSIONS: PPV-guided GDT and fluid protocol, as compared with standard practice, did not show significant advantages with respect to intraoperative hypotension, blood transfusion, or postoperative complications in patients undergoing complex spine surgery in the prone position.