Machine Learning Algorithm to Perform the American Society of Anesthesiologists Physical Status Classification.

OBJECTIVE: The American Society of Anesthesiologists (ASA) Physical Status (PS) Classification System defines perioperative patient scores ranging from 1 to 6 (healthy to brain dead, respectively). The scoring is performed and used by physician anesthesiologists and providers to classify surgical patients based on co-morbidities and various clinical characteristics. There is potentially a variability in scoring stemming from individual biases. The biases impact the prediction of operating times, length of stay in the hospital, anesthetic management, and billing. This study's purpose was to develop an automated system to achieve reproducible scoring. METHODS: A machine learning (ML) model was trained on already assigned ASA PS scores of 12,064 patients. The ML algorithm was automatically selected by Wolfram Mathematica (Wolfram Research, Champaign, IL) and tested with retrospective records not used in training. Manual scoring was performed by the anesthesiologist as part of the standard preoperative evaluation. Intraclass correlation coefficient (ICC) in R (version 4.2.2; R Development Core Team, Vienna, Austria) was calculated to assess the consistency of scoring. RESULTS: An ML model was trained on the data corresponding to 12,064 patients. Logistic regression was chosen automatically, with an accuracy of 70.3±1.0% against the training dataset. The accuracy against 1,999 patients (the test dataset) was 69.6±1.0%. The ICC for the comparison between ML and the anesthesiologists' ASA PS scores was greater than 0.4 ("fair to good"). CONCLUSIONS: We have shown the feasibility of applying ML to assess the ASA PS score within an oncology patient population. Though our accuracy was not very good, we feel that, as more data are mined, a valid foundation for refinement to ML will emerge.

Episodic, severe abdominal pain due to isolated jejunal Crohn's disease.

Small bowel Crohn's disease can present with episodic, relapsing, and remitting symptoms and delays in the diagnosis are common. We present a case of a young woman with three years of intermittent abdominal pain and nausea with negative previous evaluations. On presentation, inflammatory markers were elevated, and repeat imaging showed jejunal inflammation, with histopathological examination showing non-caseating granulomas of the small bowel consistent with Crohn's disease. This case highlights the importance of gastroenterologist recognizing the alarm signs in a patient with unexplained symptoms and adds to the literature on the clinical presentation of a rare diagnosis of isolated jejunal Crohn's disease.

Hypothermia Is Associated with Surgical Site Infection in Cytoreductive Surgery with Hyperthermic Intra-Peritoneal Chemotherapy.

BACKGROUND: Maintenance of peri-operative normothermia remains a global quality metric for hospitals. Hypothermia is associated with surgical site infections (SSIs) in colorectal surgery. Patients undergoing cytoreductive surgery (CRS) with hyperthermic intra-peritoneal chemotherapy (HIPEC) can experience multiple complications post-operatively. We sought to investigate the association of peri-operative hypothermia with SSIs in patients undergoing CRS/HIPEC at our institution. PATIENTS AND METHODS: Patients undergoing CRS/HIPEC from 2009-2017 were identified retrospectively from a prospectively collected institutional database. Hypothermia defined as less than 36.0°C in accordance with the Agency for Healthcare Research and Quality metric. Regression analyses were performed with SSIs diagnosed within 30 days post-operatively as the primary outcome. RESULTS: A total of 170 patients were identified, 14 (8.2%) of whom developed an SSI. Patients who developed an SSI experienced lower median temperatures (p = 0.027) and a greater percentage of operative time in hypothermia (p = 0.008). On a multivariable analysis adjusting for known risk factors for SSI, the percentage of operative time in hypothermia (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.07, p = 0.008) was the only parameter associated with SSI within 30 days post-operatively. CONCLUSION: Hypothermia is associated with the development of SSIs in patients undergoing CRS/HIPEC. Our findings suggest that minimizing peri-operative temperatures to less than 36.0°C may decrease peri-operative SSI in this patient population.

Inhibition of ß2-adrenergic receptor reduces triple-negative breast cancer brain metastases: The potential benefit of perioperative ß-blockade.

In response to recent studies, we investigated an association between perioperative ß-blockade and breast cancer metastases. First, a retrospective study examining perioperative ß-blocker use and cancer recurrence and metastases was conducted on 1,029 patients who underwent breast cancer surgery at the City of Hope Cancer Center between 2000 and 2010. We followed the clinical study and examined proliferation, migration, and invasion in vitro of primary and brain-metastatic breast cancer cells in response to ß2-activation and inhibition. We also investigated in vivo the metastatic potential of propranolol-treated metastatic cells. For stage II breast cancer patients, perioperative ß-blockade was associated with decreased cancer recurrence using Cox regression analysis (hazard's ratio =0.51; 95% CI: 0.23-0.97; p=0.041). Triple-negative (TN) brain-metastatic cells were found to have increased ß2-adrenergic receptor mRNA and protein expression relative to TN primary cells. In response to ß2-adrenergic receptor activation, TN brain-metastatic cells also exhibited increased cell proliferation and migration relative to the control. These effects were abrogated by propranolol. Propranolol decreased ß2-adrenergic receptor-activated invasion. In vivo, propranolol treatment of TN brain-metastatic cells decreased establishment of brain metastases. Our results suggest that stress and corresponding ß2-activation may promote the establishment of brain metastases of TN breast cancer cells. In addition, our data suggest a benefit to perioperative ß-blockade during surgery-induced stress with respect to breast cancer recurrence and metastases.

Use of preoperative hypnosis to reduce postoperative pain and anesthesia-related side effects.

The purpose of this pilot project was to test the feasibility of hypnosis as a preoperative intervention. The unique features of this study were: (a) use of a standardized nurse-delivered hypnosis protocol, (b) intervention administration immediately prior to surgery in the preoperative holding area, and (c) provision of hypnosis to breast cancer surgery patients receiving general anesthesia. A mixed-method design was used. Data collected from the intervention group and historical control group included demographics, symptom assessments, medication administration, and surgical, anesthesia, and recovery minutes. A semi-structured interview was conducted with the intervention group. A reduction in anxiety, worry, nervousness, sadness, irritability, and distress was found from baseline to postintervention while pain and nausea increased. The results support further exploration of the use of nurse-led preoperative hypnosis.

Bilateral tension pneumothoraces during minimally invasive parathyroidectomy: A case report.

Minimally invasive parathyroidectomy, a new technique for the surgical management of parathyroid disease, is gaining popularity. The smaller incision in the neck results in better cosmetic results and patient satisfaction. Despite a low incidence of complications, the anesthesiologist should be aware and prepared to manage life saving situations. We describe a case of bilateral tension pneumothoraces during minimally invasive parathyroidectomy.

Oncologic emergencies: the anesthesiologist's perspective.

Cancer is the second leading cause of death in the United States. During the course of treatment, a cancer patient may present emergently to the hospital because of either the cancer itself or a manifestation of cancer therapy. Rarely, patients with cancer can present to the operating room with several emergent conditions that require the services of an anesthesiologist. The main oncologic emergencies affecting anesthesiologists relate to airway obstruction and cardiac-, neurologic-, gastrointestinal-, and endocrine-related conditions. Mismanagement of these crises can increase morbidity and mortality. This article addresses emergencies in patients with cancer and how they relate to anesthetic care.