The association of hemoglobin with postoperative delirium and atrial fibrillation after cardiac surgery: a retrospective sub-study.

BACKGROUND: Most cardiac surgery patients experience postoperative anemia. Delirium and Atrial Fibrillation (AF) are common and independent predictors of morbidity and mortality. Few reports examine their association with postoperative anemia. This study aims to quantify the association between anemia and these outcomes in patients undergoing cardiac surgery. METHODS: This post-hoc analysis of the DECADE randomized controlled trial ran at six academic US hospitals. Patients aged 18-85 years with heart rate > 50 bpm undergoing cardiac surgery who had daily hemoglobin measurements in the first 5 Postoperative Days (POD) were included. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM - ICU), preceded by the Richmond Agitation and Sedation Scale, with patients excluded from assessment if sedated. Patients had daily hemoglobin measurements, continuous cardiac monitoring plus twice-daily 12-lead electrocardiograms, up to POD4. AF was diagnosed by clinicians blinded to hemoglobin levels. RESULTS: Five hundred and eighty-five patients were included. Mean postoperative hemoglobin Hazard Ratio (HR): 0.99 (95% CI 0.83, 1.19; p = 0.94) per 1 g.dL-1 hemoglobin decrease. 197 (34%) developed AF, mainly on POD = 2.3. Estimated HR = 1.04 (95% CI 0.93, 1.17; p = 0.51) per 1 g.dL-1 hemoglobin decrease. CONCLUSIONS: Most patients undergoing major cardiac surgery were anemic in the postoperative phase. AF and delirium occurred in 34% and 12% of patients, respectively, but neither were significantly correlated with postoperative hemoglobin.

Association between obstructive sleep apnea and atrial fibrillation and delirium after cardiac surgery. Sub-analysis of DECADE trial.

BACKGROUND: Atrial fibrillation and delirium are common complications after cardiac surgery. Both are associated with increased Intensive Care Unit (ICU) and hospital length of stay, functional decline, 30-day mortality and increase in health care costs. Obstructive Sleep Apnea (OSA) induces deleterious effects in the cardiovascular and nervous systems. We hypothesized that adult patients with preoperative OSA have a higher incidence of postoperative atrial fibrillation and delirium than patients without OSA, after cardiac surgery. METHODS: Sub-analysis of the DECADE trial at Cleveland Clinic hospitals. Our exposure was OSA, defined by STOP-BANG questionnaire score higher than 5 and/or a preoperative diagnosis of OSA. The primary outcome was atrial fibrillation, defined by clinician diagnosis or documented arrhythmia. The secondary outcome was delirium assessed twice during the initial five postoperative days using the Confusion Assessment Method for ICU. We assessed the association between OSA, and atrial fibrillation and delirium using a logistic regression model adjusted for confounders using inverse probability of treatment weighting. RESULTS: 590 patients were included in the final analysis. 133 were diagnosed with OSA and 457 had no OSA. Satisfactory balance between groups for most confounders (absolute standardized difference < 0.10) was achieved after weighting. The atrial fibrillation incidence was 37% (n = 49) in the patients with OSA and 33% (n = 150) in the non-OSA patients. OSA was not associated with atrial fibrillation with an estimated odds ratio of 1.22 (95% CI: 0.75,1.99;p = 0.416). The delirium incidence was 17% (n = 22) in patients with OSA and 15% (n = 67) in the non-OSA patients. OSA was not associated with delirium with an estimated odds ratio of 0.93 (95% CI: 0.51,1.69;p = 0.800). CONCLUSION: In adult patients having cardiac surgery, OSA is not associated with a higher incidence of postoperative atrial fibrillation and delirium. These results suggest different prominent factors rather than OSA affect the incidence of these postoperative outcomes.

Trends in Cardiac Anesthesiologist Compensation, Work Patterns, and Training From 2010 to 2020: A Longitudinal Analysis of the Society of Cardiovascular Anesthesiologists Salary Survey.

Increasing cardiac procedural volume, a shortage of practicing cardiac anesthesiologists, and growth in specialist physician compensation would be expected to increase cardiac anesthesiologist compensation and work load. Additionally, more cardiac anesthesiologists are graduating from accredited fellowships and completing echocardiography certification. The Society of Cardiovascular Anesthesiologists (SCA) biannual salary survey longitudinally measures these data; we analyzed these data from 2010 to 2020 and hypothesized survey respondent inflation-adjusted total compensation, work load, and training would increase. For the primary outcome, we adjusted the median reported annual gross taxable income for inflation using the Consumer Price Index and then used linear regression to assess changes in inflation-adjusted median compensation. For the secondary outcomes, we analyzed the number of cardiac anesthetics managed annually and the most common care delivery staffing ratios. For the tertiary outcomes, we assessed changes in the proportion of respondents reporting transesophageal echocardiography (TEE) certification and completion of a 12-month cardiac anesthesia fellowship. We performed sensitivity analyses adjusting for yearly proportions of academic and private practice respondents. Annual survey response rates ranged from 8% to 17%. From 2010 to 2020, respondents reported a continuously compounded inflation-adjusted compensation decrease of 1.1% (95% confidence interval [CI], -1.6% to -0.6%; P = .003), equivalent to a total inflation-adjusted salary reduction of 10%. In sensitivity analysis, private practice respondents reported a continuously compounded compensation loss of -0.8% (95% CI, -1.4% to -0.2%; P = .022), while academic respondents reported no significant change (continuously compounded change, 0.4%; 95% CI, -0.4% to 1.1%; P = .23). The percentage of respondents managing more than 150 cardiac anesthetics per year increased from 26% in 2010 to 43% in 2020 (adjusted odds ratio [aOR], 1.03 per year; 95% CI, 1.03-1.04; P < .001). The proportion of respondents reporting high-ratio care models increased from 31% to 41% (aOR, 1.01 per year; 95% CI, 1.01-1.02; P < .001). Reported TEE certification increased from 69% to 90% (aOR, 1.10 per year; 95% CI, 1.10-1.11; P < .001); reported fellowship training increased from 63% to 82% (aOR, 1.15 per year; 95% CI, 1.14-1.16; P < .001). After adjusting for the proportion of academic or private practice survey respondents, SCA salary survey respondents reported decreasing inflation-adjusted compensation, rising volumes of cardiac anesthetics, and increasing levels of formal training in the 2010 to 2020 period. Future surveys measuring burnout and job satisfaction are needed to assess the association of increasing work and lower compensation with attrition in cardiac anesthesiologists.

A Blueprint for Success: Implementation of the Center for Medicare and Medicaid Services Mandated Anesthesiology Oversight for Procedural Sedation in a Large Health System.

In 2009, the Center for Medicare and Medicaid Services (CMS) issued the §482.52 Condition of Participation (CoP) that the director of anesthesia services (DAS) is responsible for all anesthesia administered in the hospital, including moderate and deep procedural sedation provided by nonanesthesiologists. Although this mandate was issued several years ago, many anesthesiology departments remain uncertain as to how best to implement it, who needs to be involved, what resources are needed, and how to leverage this oversight to improve quality of care and patient safety. This article reviews the CMS CoP interpretive guidelines and other regulations as they relate to procedural sedation, outlines the components and benefits of anesthesiology oversight, and describes the tools and structure to implement these guidelines. In addition, we discuss some of the challenges surrounding this implementation. This initiative continues to evolve and expand as needs change and experience develops.

Pro-Con Debate: Monitored Anesthesia Care Versus General Endotracheal Anesthesia for Endoscopic Retrograde Cholangiopancreatography.

Over the past several decades, anesthesia has experienced a significant growth in nonoperating room anesthesia. Gastrointestinal suites represent the largest volume location for off-site anesthesia procedures, which include complex endoscopy procedures like endoscopic retrograde cholangiopancreatography (ERCP). These challenging patients and procedures necessitate a shared airway and are typically performed in the prone or semiprone position on a dedicated procedural table. In this Pro-Con commentary article, the Pro side supports the use of monitored anesthesia care (MAC), citing fewer hemodynamic perturbations, decreased side effects from inhalational agents, faster cognitive recovery, and quicker procedural times leading to improved center efficiency (ie, quicker time to discharge). Meanwhile, the Con side favors general endotracheal anesthesia (GEA) to reduce the infrequent, but well-recognized, critical events due to impaired oxygenation and/or ventilation known to occur during MAC in this setting. They also argue that procedural interruptions are more frequent during MAC as anesthesia professionals need to rescue patients from apnea with various airway maneuvers. Thus, the risk of hypoxemic episodes is minimized using GEA for ERCP. Unfortunately, neither position is supported by large randomized controlled trials. The consensus opinion of the authors is that anesthesia for ERCP should be provided by a qualified anesthesia professional who weighs the risks and benefits of each technique for a given patient and clinical circumstance. This Pro-Con article highlights the many challenges anesthesia professionals face during ERCPs and encourages thoughtful, individualized anesthetic plans over knee-jerk decisions. Both sides agree that an anesthetic technique administered by a qualified anesthesia professional is favored over an endoscopist-directed sedation approach.

Assessing Competence in Critical Care Echocardiography: Development and Initial Results of an Examination and Certification Processes.

OBJECTIVES: To describe the development and initial results of an examination and certification process assessing competence in critical care echocardiography. DESIGN: A test writing committee of content experts from eight professional societies invested in critical care echocardiography was convened, with the Executive Director representing the National Board of Echocardiography. Using an examination content outline, the writing committee was assigned topics relevant to their areas of expertise. The examination items underwent extensive review, editing, and discussion in several face-to-face meetings supervised by National Board of Medical Examiners editors and psychometricians. A separate certification committee was tasked with establishing criteria required to achieve National Board of Echocardiography certification in critical care echocardiography through detailed review of required supporting material submitted by candidates seeking to fulfill these criteria. SETTING: The writing committee met twice a year in person at the National Board of Medical Examiner office in Philadelphia, PA. SUBJECTS: Physicians enrolled in the examination of Special Competence in Critical Care Electrocardiography (CCEeXAM). MEASUREMENTS AND MAIN RESULTS: A total of 524 physicians sat for the examination, and 426 (81.3%) achieved a passing score. Of the examinees, 41% were anesthesiology trained, 33.2% had pulmonary/critical care background, and the majority had graduated training within the 10 years (91.6%). Most candidates work full-time at an academic hospital (46.9%). CONCLUSIONS: The CCEeXAM is designed to assess a knowledge base that is shared with echocardiologists in addition to that which is unique to critical care. The National Board of Echocardiography certification establishes that the physician has achieved the ability to independently perform and interpret critical care echocardiography at a standard recognized by critical care professional societies encompassing a wide spectrum of backgrounds. The interest shown and the success achieved on the CCEeXAM by practitioners of critical care echocardiography support the standards set by the National Board of Echocardiography for testamur status and certification in this imaging specialty area.

Optimal interval and duration of CAM-ICU assessments for delirium detection after cardiac surgery.

STUDY OBJECTIVE: Our goal was to determine when postoperative delirium first occurs, and to assess evaluation strategies that reliably detect delirium with lowest frequency of testing'. DESIGN: This was a retrospective study that used a database from a five-center randomized trial. SETTING: Postoperative cardiothoracic ICU and surgical wards. PARTICIPANT: Adults scheduled for elective coronary artery bypass and/or valve surgery. INTERVENTION AND MEASUREMENTS: Postoperative delirium was assessed using CAM-ICU questionnaires twice daily for 5 days or until hospital discharge. Data were analyzed using frequency tables and Kaplan-Meier time-to-event estimators, the latter being used to summarize time to first positive CAM-ICU over POD1-5 for all patients for various evaluation strategies, including all assessments, only morning assessment, and only afternoon assessments. Sensitivity for various strategies were compared using McNemar's test for paired proportions. MAIN RESULTS: A total of 95 of 788 patients (12% [95% CI, 10% to 15%]) had at least 1 episode of delirium within the first 5 postoperative days. Among all patients with delirium, 65% were identified by the end of the first postoperative day. Delirium was detected more often in the mornings (10% of patients) than evenings (7% of patients). Compared to delirium assessments twice daily for five days, we found that twice daily assessments for 4 days detected an estimated 97% (95% CI 91%, 99%) of delirium. Measurements twice daily for three days detected 90% (82%, 95%) of delirium. CONCLUSIONS: Postoperative delirium is common, and CAM-ICU assessments twice daily for 4 days, versus 5 days, detects nearly all delirium with 20% fewer assessments. Four days of assessment may usually be sufficient for clinical and research purposes.

Association between Use of Angiotensin-converting Enzyme Inhibitors or Angiotensin Receptor Blockers and Postoperative Delirium.

BACKGROUND: Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve cognitive function. The authors therefore tested the primary hypothesis that preoperative use of angiotensin inhibitors is associated with less delirium in critical care patients. Post hoc, the association between postoperative use of angiotensin system inhibitors and delirium was assessed. METHODS: The authors conducted a single-site cohort study of adults admitted to Cleveland Clinic critical care units after noncardiac procedures between 2013 and 2018 who had at least one Confusion Assessment Method delirium assessment. Patients with preexisting dementia, Alzheimer's disease or other cognitive decline, and patients who had neurosurgical procedures were excluded. For the primary analysis, the confounder-adjusted association between preoperative angiotensin inhibitor use and the incidence of postoperative delirium was assessed. Post hoc, the confounder-adjusted association between postoperative angiotensin system inhibitor use and the incidence of delirium was assessed. RESULTS: The incidence of delirium was 39% (551 of 1,396) among patients who were treated preoperatively with angiotensin system inhibitors and 39% (1,344 of 3,468) in patients who were not. The adjusted odds ratio of experiencing delirium during critical care was 0.98 (95% CI, 0.86 to 1.10; P = 0.700) for preoperative use of angiotensin system inhibitors versus control. Delirium was observed in 23% (100 of 440) of patients who used angiotensin system inhibitors postoperatively before intensive care discharge, and in 41% (1,795 of 4,424) of patients who did not (unadjusted P < 0.001). The confounder-adjusted odds ratio for experiencing delirium in patients who used angiotensin system inhibitors postoperatively was 0.55 (95% CI, 0.43 to 0.72; P < 0.001). CONCLUSIONS: Preoperative use of angiotensin system inhibitors is not associated with reduced postoperative delirium. In contrast, treatment during intensive care was associated with lower odds of delirium. Randomized trials of postoperative angiotensin-converting enzymes inhibitors and angiotensin receptor blockers seem justified.

Left Ventricular Assist Device Insertion in a Patient With Biventricular Noncompaction Cardiomyopathy, Ebstein Anomaly, and a Left Atrial Mass: A Case Report.

In this report, we present the case of a patient with biventricular noncompaction cardiomyopathy, Ebstein anomaly, and a left atrial mass who required emergent placement of a left ventricular assist device. The noncompaction cardiomyopathy complicated the left ventricular assist device implantation procedure because the thickened, trabeculated myocardium made it difficult to place the inflow cannula. We discuss our perioperative management strategy, in which transesophageal echocardiography was used, to help the surgical team identify the proper cannula placement and provide a bridge to transplantation.