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1.
Anesthesiology ; 2020 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-32028374

RESUMO

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: The ability to process anesthesiology procedure code data in an accurate manner is important for clinical and research considerations. Advanced data science techniques present opportunities to improve coding and develop classification tools. WHAT THIS ARTICLE TELLS US THAT IS NEW: The application of machine learning and natural language processing techniques facilitate a more rapid creation of accurate real-time models for Current Procedural Terminology code classification. The potential benefits of this approach include performance optimization and cost reduction for quality improvement, research, and reimbursement tasks that rely on anesthesiology procedure codes. BACKGROUND: Accurate anesthesiology procedure code data are essential to quality improvement, research, and reimbursement tasks within anesthesiology practices. Advanced data science techniques, including machine learning and natural language processing, offer opportunities to develop classification tools for Current Procedural Terminology codes across anesthesia procedures. METHODS: Models were created using a Train/Test dataset including 1,164,343 procedures from 16 academic and private hospitals. Five supervised machine learning models were created to classify anesthesiology Current Procedural Terminology codes, with accuracy defined as first choice classification matching the institutional-assigned code existing in the perioperative database. The two best performing models were further refined and tested on a Holdout dataset from a single institution distinct from Train/Test. A tunable confidence parameter was created to identify cases for which models were highly accurate, with the goal of at least 95% accuracy, above the reported 2018 Centers for Medicare and Medicaid Services (Baltimore, Maryland) fee-for-service accuracy. Actual submitted claim data from billing specialists were used as a reference standard. RESULTS: Support vector machine and neural network label-embedding attentive models were the best performing models, respectively, demonstrating overall accuracies of 87.9% and 84.2% (single best code), and 96.8% and 94.0% (within top three). Classification accuracy was 96.4% in 47.0% of cases using support vector machine and 94.4% in 62.2% of cases using label-embedding attentive model within the Train/Test dataset. In the Holdout dataset, respective classification accuracies were 93.1% in 58.0% of cases and 95.0% among 62.0%. The most important feature in model training was procedure text. CONCLUSIONS: Through application of machine learning and natural language processing techniques, highly accurate real-time models were created for anesthesiology Current Procedural Terminology code classification. The increased processing speed and a priori targeted accuracy of this classification approach may provide performance optimization and cost reduction for quality improvement, research, and reimbursement tasks reliant on anesthesiology procedure codes.

2.
Anesthesiology ; 2019 11 26.
Artigo em Inglês | MEDLINE | ID: mdl-31794513

RESUMO

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Acute kidney injury occurs in 13% of patients undergoing major surgery and is associated with a six-fold increased risk of mortality.Single-center studies have demonstrated an association between intraoperative hypotension and acute kidney injury. WHAT THIS ARTICLE TELLS US THAT IS NEW: In a large cohort of noncardiac surgical patients, the incidence of acute kidney injury was 9%.Major factors identifying patients at risk for acute kidney injury included anemia, estimated glomerular filtration rate, elevated risk surgery, American Society of Anesthesiologists Physical Status, and expected anesthesia duration.The relationship between hypotension and acute kidney injury varied by underlying patient and procedural risk. Patients with low risk demonstrated no associated increased risk of acute kidney injury across all blood pressure ranges, whereas patients with the highest baseline risk demonstrated an association between even mild absolute intraoperative hypotension ranges and acute kidney injury. BACKGROUND: Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk. METHODS: Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline). RESULTS: Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort. CONCLUSIONS: Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.

3.
Anesth Analg ; 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31569163

RESUMO

BACKGROUND: Continuous infusions of norepinephrine to treat perioperative hypotension are typically administered through a central venous line rather than a peripheral venous catheter to avoid the risk of localized tissue necrosis in case of drug extravasation. There is limited literature to estimate the risk of skin necrosis when peripheral norepinephrine is used to counteract anesthesia-associated hypotension in elective surgical cases. This study aimed to estimate the rate of occurrence of drug-related adverse effects, including skin necrosis requiring surgical management when norepinephrine peripheral extravasation occurs. METHODS: This retrospective cohort study used the perioperative databases of the University Hospitals in Amsterdam and Utrecht, the Netherlands, to identify surgical patients who received norepinephrine peripheral intravenous infusions (20 µg/mL) between 2012 and 2016. The risk of drug-related adverse effects, including skin necrosis, was estimated. Particular care was taken to identify patients who needed plastic surgical or medical attention secondary to extravasation of dilute, peripheral norepinephrine. RESULTS: A total of 14,385 patients who received norepinephrine peripheral continuous infusions were identified. Drug extravasation was observed in 5 patients (5/14,385 = 0.035%). The 95% confidence interval (CI) for infusion extravasation was 0.011%-0.081%, indicating an estimated risk of 1-8 events per every 10,000 patients. There were zero related complications requiring surgical or medical intervention, resulting in a 95% CI of 0%-0.021% and indicating a risk of approximately 0-2 events per 10,000 patients. CONCLUSIONS: In the current database analysis, no significant association was found between the use of peripheral intravenous norepinephrine infusions and adverse events.

4.
JAMA ; 321(8): 762-772, 2019 02 26.
Artigo em Inglês | MEDLINE | ID: mdl-30806696

RESUMO

Importance: Overlapping surgery, in which more than 1 procedure performed by the same primary surgeon is scheduled so the start time of one procedure overlaps with the end time of another, is of concern because of potential adverse outcomes. Objective: To determine the association between overlapping surgery and mortality, complications, and length of surgery. Design, Setting, and Participants: Retrospective cohort study of 66 430 operations in patients aged 18 to 90 years undergoing total knee or hip arthroplasty; spine surgery; coronary artery bypass graft (CABG) surgery; and craniotomy at 8 centers between January 1, 2010, and May 31, 2018. Patients were followed up until discharge. Exposures: Overlapping surgery (≥2 operations performed by the same surgeon in which ≥1 hour of 1 case, or the entire case for those <1 hour, occurs when another procedure is being performed). Main Outcomes and Measures: Primary outcomes were in-hospital mortality or complications (major: thromboembolic event, pneumonia, sepsis, stroke, or myocardial infarction; minor: urinary tract or surgical site infection) and surgery duration. Results: The final sample consisted of 66 430 operations (mean patient age, 59 [SD, 15] years; 31 915 women [48%]), of which 8224 (12%) were overlapping. After adjusting for confounders, overlapping surgery was not associated with a significant difference in in-hospital mortality (1.9% overlapping vs 1.6% nonoverlapping; difference, 0.3% [95% CI, -0.2% to 0.7%]; P = .21) or risk of complications (12.8% overlapping vs 11.8% nonoverlapping; difference, 0.9% [95% CI, -0.1% to 1.9%]; P = .08). Overlapping surgery was associated with increased surgery length (204 vs 173 minutes; difference, 30 minutes [95% CI, 24 to 37 minutes]; P < .001). Overlapping surgery was significantly associated with increased mortality and increased complications among patients having a high preoperative predicted risk for mortality and complications, compared with low-risk patients (mortality: 5.8% vs 4.7%; difference, 1.2% [95% CI, 0.1% to 2.2%]; P = .03; complications: 29.2% vs 27.0%; difference, 2.3% [95% CI, 0.3% to 4.3%]; P = .03). Conclusions and Relevance: Among adults undergoing common operations, overlapping surgery was not significantly associated with differences in in-hospital mortality or postoperative complication rates but was significantly associated with increased surgery length. Further research is needed to understand the association of overlapping surgery with these outcomes among specific patient subgroups.


Assuntos
Mortalidade Hospitalar , Duração da Cirurgia , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Operatórios , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril , Artroplastia do Joelho , Ponte de Artéria Coronária , Craniotomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fatores de Tempo , Adulto Jovem
5.
J Clin Anesth ; 56: 77-84, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30703672

RESUMO

STUDY OBJECTIVE: Muscular tone that inhibits anesthetic or surgical care characterizes insufficient neuromuscular block. The incidence of insufficient neuromuscular block is unknown, therefore we developed novel electronic search strategies to identify occurrences of insufficient neuromuscular block. Our primary goal was to determine the incidence of intraoperative insufficient neuromuscular block in abdominal and neurovascular surgery. Our secondary goal was to assess factors independently associated with insufficient block. DESIGN: Retrospective cohort. SETTING: Operating rooms in a tertiary care center. PATIENTS: Adults having abdominal, laparoscopic, and interventional neurovascular procedures under general anesthesia with endotracheal intubation between April 2005 and February 2013. MEASUREMENTS: An expert panel of anesthesiologists used a Delphi process to develop criteria to identify insufficient intraoperative neuromuscular block. 10 final criteria were agreed upon and used to determine the incidence of insufficient neuromuscular block. MAIN RESULTS: 48,315 surgeries met our inclusion requirements. Intraoperative insufficient neuromuscular block was identified in 13,538 cases, representing 28% (95% CI: 27.6%, 28.4%) of the operations. Younger age, male sex, type of surgery, longer duration of surgery, pre-existing conditions, and use of volatile anesthetics were independently associated with insufficient block after Bonferroni correction. CONCLUSION: Our results suggest that episodes of insufficient block occur in over a quarter of operations that are generally thought to require muscle relaxation. Without neuromuscular monitoring, it is difficult to separate inadequate anesthesia from inadequate neuromuscular block, and both presumably contributed in many cases.

6.
Can J Anaesth ; 66(2): 149-160, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30430440

RESUMO

PURPOSE: Despite growing evidence supporting the potential benefits of higher end-tidal carbon dioxide (ETCO2) levels in surgical patients, there is still insufficient data to formulate guidelines for ideal intraoperative ETCO2 targets. As it is unclear which intraoperative ETCO2 levels are currently used and whether these levels have changed over time, we investigated the practice pattern using the Multicenter Perioperative Outcomes Group database. METHODS: This retrospective, observational, multicentre study included 317,445 adult patients who received general anesthesia for non-cardiothoracic procedures between January 2008 and September 2016. The primary outcome was a time-weighted average area-under-the-curve (TWA-AUC) for four ETCO2 thresholds (< 28, < 35, < 45, and > 45 mmHg). Additionally, a median ETCO2 was studied. A Kruskal-Wallis test was used to analyse differences between years. Random-effect multivariable logistic regression models were constructed to study variability. RESULTS: Both TWA-AUC and median ETCO2 showed a minimal increase in ETCO2 over time, with a median [interquartile range] ETCO2 of 33 [31.0-35.0] mmHg in 2008 and 35 [33.0-38.0] mmHg in 2016 (P <0.001). A large inter-hospital and inter-provider variability in ETCO2 were observed after adjustment for patient characteristics, ventilation parameters, and intraoperative blood pressure (intraclass correlation coefficient 0.36; 95% confidence interval, 0.18 to 0.58). CONCLUSIONS: Between 2008 and 2016, intraoperative ETCO2 values did not change in a clinically important manner. Interestingly, we found a large inter-hospital and inter-provider variability in ETCO2 throughout the study period, possibly indicating a broad range of tolerance for ETCO2, or a lack of evidence to support a specific targeted range. Clinical outcomes were not assessed in this study and they should be the focus of future research.

7.
J Clin Anesth ; 55: 33-41, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30594097

RESUMO

STUDY OBJECTIVE: To determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care. DESIGN: Blinded multicenter cohort study. SETTING: Operating and recovery rooms of ten community and academic U.S. hospitals. PATIENTS: Two-hundred fifty-five adults, ASA PS 1-3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013. INTERVENTIONS: TOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation. MAIN RESULTS: Most of the study population, 64.7% (n = 165) had rNMB (TOF ratio < 0.9), among them, 31.0% with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0% had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, P = 0.008), higher BMI (odds ratio: 1.04/unit, P = 0.043), and surgery at a community hospital (odds ratio: 3.15, P = 0.006) to be independently associated with increased odds of rNMB. CONCLUSIONS: Assessing TOF ratios blinded to the care team, we found that the majority of patients (64.7%) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.


Assuntos
Anestesia Geral/efeitos adversos , Recuperação Demorada da Anestesia/epidemiologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Bloqueio Neuromuscular/efeitos adversos , Fármacos Neuromusculares não Despolarizantes/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/métodos , Índice de Massa Corporal , Inibidores da Colinesterase/administração & dosagem , Recuperação Demorada da Anestesia/complicações , Recuperação Demorada da Anestesia/diagnóstico , Recuperação Demorada da Anestesia/prevenção & controle , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Neostigmina/administração & dosagem , Neostigmina/efeitos adversos , Neostigmina/antagonistas & inibidores , Bloqueio Neuromuscular/métodos , Monitoração Neuromuscular , Fármacos Neuromusculares não Despolarizantes/administração & dosagem , Fármacos Neuromusculares não Despolarizantes/antagonistas & inibidores , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais , Estados Unidos , Adulto Jovem
8.
Anesth Analg ; 2019 Nov 28.
Artigo em Inglês | MEDLINE | ID: mdl-31986126

RESUMO

To study the impact of anesthesia opioid-related outcomes and acute and chronic postsurgical pain, we organized a multicenter study that comprehensively combined detailed perioperative data elements from multiple institutions. By combining pre- and postoperative patient-reported outcomes with automatically extracted high-resolution intraoperative data obtained through the Multicenter Perioperative Outcomes Group (MPOG), the authors sought to describe the impact of patient characteristics, preoperative psychological factors, surgical procedure, anesthetic course, postoperative pain management, and postdischarge pain management on postdischarge pain profiles and opioid consumption patterns. This study is unique in that it utilized multicenter prospective data collection using a digital case report form integrated with the MPOG framework and database. Therefore, the study serves as a model for future studies using this innovative method. Full results will be reported in future articles; the purpose of this article is to describe the methods of this study.

9.
Anesth Analg ; 127(4): 897-903, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29505442

RESUMO

BACKGROUND: Laboratory testing is a common component of preanesthesia evaluation and is designed to identify medical abnormalities that might otherwise remain undetected. While blood testing might optimally be performed shortly before surgery, it is often done earlier for practical reasons. We tested the hypothesis that longer periods between preoperative laboratory testing and surgery are associated with increased odds of having a composite of 30-day morbidity and mortality. METHODS: We obtained preoperative data from 2,320,920 patients in the American College of Surgeons National Surgical Quality Improvement Program who were treated between 2005 and 2012. Our analysis was restricted to relatively healthy patients with American Society of Anesthesiology physical status I-II who had elective surgery and normal blood test results (n = 235,010). The primary relationship of interest was the odds of 30-day morbidity and mortality as a function of delay between preoperative testing and surgery. A multivariable logistic regression model was used for the 10 pairwise comparisons among the 5 laboratory timing groups (laboratory blood tests within 1 week of surgery; 1-2 weeks; 2-4 weeks; 1-2 months; and 2-3 months) on 30-day morbidity, adjusting for any imbalanced baseline covariables and type of surgery. RESULTS: A total of 4082 patients (1.74%) had at least one of the component morbidities or died within 30-days after surgery. The observed incidence (unadjusted) was 1.7% when the most recent laboratory blood tests measured within 1 week of surgery, 1.7% when it was within 1-2 weeks, 1.8% when it was within 2-4 weeks, 1.7% when it was between 1 and 2 months, and 2.0% for patients with most recent laboratory blood tests measured 2-3 months before surgery. None of the values within 2 months differed significantly: estimated odds ratios for patients within blood tested within 1 week were 1.00 (99.5% confidence interval, 0.89-1.12) as compared to 1-2 weeks, 0.88 (0.77-1.00) for 2-4 weeks, and 0.95 (0.79-1.14) for 1-2 months, respectively. The estimated odds ratio comparing 1-2 weeks to each of 2-4 weeks and 1-2 months were 0.88 (0.76-1.03) and 0.95 (0.78-1.16), respectively. Blood testing 2-3 months before surgery was associated with increased odds of outcome compared to patients whose most recent test was within 1 week (P = .002) and 1-2 weeks of the date of surgery. CONCLUSIONS: In American Society of Anesthesiologists physical status I and II patients, risk of 30-day morbidity and mortality was not different with blood testing up to 2 months before surgery, suggesting that it is unnecessary to retest patients shortly before surgery.


Assuntos
Testes Hematológicos , Complicações Pós-Operatórias/epidemiologia , Cuidados Pré-Operatórios , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adulto , Idoso , Bases de Dados Factuais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Valor Preditivo dos Testes , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
10.
J Orthop Trauma ; 32(3): 105-110, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29065037

RESUMO

BACKGROUND: To evaluate the relationship between surgical timing and 1-year mortality in patients requiring hip fracture repair. METHODS: We analyzed all 720 patients (>65 years) who had hip fracture surgery between March 2005 and February 2015, identifying patients by ICD-9 diagnosis and procedure codes using electronic data query. Mortality data were obtained from the institutional database, state and Social Security Death Indices. The relationship between surgical timing (defined as the interval from admission to the start of surgery) and 1-year mortality was assessed using a multivariable logistic regression, adjusting for baseline clinical status and surgical factors. RESULTS: Among the 720 patients, 159 patients (22%) died within 1 year. The median time from admission to surgery was 30 hours. A linear relationship between the surgical timing and 1-year mortality was demonstrated. Delaying surgery was significantly associated with increased 1-year mortality, odds ratio 1.05 (95% CI: 1.02-1.08) per 10-hour delay (P = 0.001). CONCLUSIONS: A linear relationship was observed between surgical timing and 1-year mortality. Each 10-hour delay from admission to surgery was associated with an estimated 5% higher odds of 1-year mortality. Therefore, we suggest that hip fractures should be treated urgently similar to other time-sensitive pathology such as stroke and myocardial ischemia. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Fixação de Fratura/estatística & dados numéricos , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas do Quadril/epidemiologia , Humanos , Masculino , Ohio/epidemiologia , Prognóstico , Fatores de Tempo , Estados Unidos/epidemiologia
11.
J Clin Anesth ; 43: 33-38, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28972924

RESUMO

STUDY OBJECTIVE: The use of neuromuscular blockade agents (NMBA), had been associated with significant residual post-operative paralysis and morbidity. There is a lack of clinical evidence on incidence of postoperative complications within the post-anesthesia care unit (PACU) in patients exposed to intraoperative NMBA's. This study aims to estimate the incidence of post-operative complications associated with use of NMBAs and assessing its association with healthcare resource utilization. DESIGN: Retrospective cohort. SETTING: Post-anesthesia care unit in tertiary care center. PATIENTS: Adults having non-cardiac surgery and receiving NMBAs between April-2005 and December-2013 MEASUREMENTS: We assessed: 1) incidences of major and minor PACU complications, 2) incidence of any postoperative complication in patients receiving a NMBA reversal (neostigmine) vs. without. 3) We secondarily assessed the relationship between PACU complications and use of healthcare resources. MAIN RESULTS: The incidence of any major complications was 2.1% and that of any minor complication was 35.2%. ICU admission rate was 1.3% in patients without any complications, versus 5.2% in patients with any minor and 30.6% in patients with any major complication. ICU length of stay was prolonged in patients with any major (52.1±203h), compared to patients with any minor (6.2±64h) and with no complications (1.7±28h). Patients who received a NMBA and neostigmine, compared to without neostigmine, had a lower incidence of any major complication (1.7% vs. 6.05%), rate of re-intubation (0.8% vs. 4.6%) and unplanned ICU admission (0.8% vs. 3.2%). CONCLUSIONS: This study documents that incidence of major PACU complications after non-cardiac surgery was 2.1%, with the most frequent complications being re-intubation and ICU admission. Patients receiving NMBA reversal were at a lower risk of re-intubation and unplanned ICU admission, justifying routine use of reversals. Complete NMBA reversals are crucial in reducing preventable patient harm and healthcare utilization.


Assuntos
Procedimentos Cirúrgicos Eletivos/efeitos adversos , Bloqueio Neuromuscular/efeitos adversos , Bloqueadores Neuromusculares/efeitos adversos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Adulto , Extubação/estatística & dados numéricos , Período de Recuperação da Anestesia , Inibidores da Colinesterase/uso terapêutico , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , Neostigmina/uso terapêutico , Bloqueio Neuromuscular/métodos , Bloqueadores Neuromusculares/antagonistas & inibidores , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos
12.
JAMA Surg ; 152(8): e171505, 2017 Aug 16.
Artigo em Inglês | MEDLINE | ID: mdl-28593326

RESUMO

Importance: Postoperative delirium occurs in 10% to 60% of elderly patients having major surgery and is associated with longer hospital stays, increased hospital costs, and 1-year mortality. Emerging literature suggests that dexmedetomidine sedation in critical care units is associated with reduced incidence of delirium. However, intraoperative use of dexmedetomidine for prevention of delirium has not been well studied. Objective: To evaluate whether an intraoperative infusion of dexmedetomidine reduces postoperative delirium. Design, Setting, and Participants: This study was a multicenter, double-blind, randomized, placebo-controlled trial that randomly assigned patients to dexmedetomidine or saline placebo infused during surgery and for 2 hours in the recovery room. Patients were assessed daily for postoperative delirium (primary outcome) and secondarily for postoperative cognitive decline. Participants were elderly (>68 years) patients undergoing major elective noncardiac surgery. The study dates were February 2008 to May 2014. Interventions: Dexmedetomidine infusion (0.5 µg/kg/h) during surgery and up to 2 hours in the recovery room. Main Outcomes and Measures: The primary hypothesis tested was that intraoperative dexmedetomidine administration would reduce postoperative delirium. Secondarily, the study examined the correlation between dexmedetomidine use and postoperative cognitive change. Results: In total, 404 patients were randomized; 390 completed in-hospital delirium assessments (median [interquartile range] age, 74.0 [71.0-78.0] years; 51.3% [200 of 390] female). There was no difference in postoperative delirium between the dexmedetomidine and placebo groups (12.2% [23 of 189] vs 11.4% [23 of 201], P = .94). After adjustment for age and educational level, there was no difference in the postoperative cognitive performance between treatment groups at 3 months and 6 months. Adverse events were comparably distributed in the treatment groups. Conclusions and Relevance: Intraoperative dexmedetomidine does not prevent postoperative delirium. The reduction in delirium previously demonstrated in numerous surgical intensive care unit studies was not observed, which underscores the importance of timing when administering the drug to prevent delirium. Trial Registration: clinicaltrials.gov Identifier NCT00561678.


Assuntos
Agonistas de Receptores Adrenérgicos alfa 2/administração & dosagem , Disfunção Cognitiva/prevenção & controle , Delírio/prevenção & controle , Dexmedetomidina/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Idoso , Método Duplo-Cego , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Humanos , Infusões Intravenosas , Cuidados Intraoperatórios/métodos , Masculino , Falha de Tratamento
13.
Anesthesiology ; 126(2): 223-233, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27775998

RESUMO

BACKGROUND: Inflammation after cardiopulmonary bypass may contribute to postoperative delirium and cognitive dysfunction. The authors evaluated the effect of high-dose methylprednisolone to suppress inflammation on the incidence of delirium and postoperative quality of recovery after cardiac surgery. METHODS: Five hundred fifty-five adults from three hospitals enrolled in the randomized, double-blind Steroids in Cardiac Surgery trial were randomly allocated to placebo or 250 mg methylprednisolone at induction and 250 mg methylprednisolone before cardiopulmonary bypass. Each completed the Postoperative Quality of Recovery Scale before surgery and on days 1, 2, and 3 and 1 and 6 months after surgery and the Confusion Assessment Method scale for delirium on days 1, 2, and 3. Recovery was defined as returning to preoperative values or improvement at each time point. RESULTS: Four hundred eighty-two participants for recovery and 498 participants for delirium were available for analysis. The quality of recovery improved over time but without differences between groups in the primary endpoint of overall recovery (odds ratio range over individual time points for methylprednisolone, 0.39 to 1.45; 95% CI, 0.08-2.04 to 0.40-5.27; P = 0.943) or individual recovery domains (all P > 0.05). The incidence of delirium was 10% (control) versus 8% (methylprednisolone; P = 0.357), with no differences in delirium subdomains (all P > 0.05). In participants with normal (51%) and low baseline cognition (49%), there were no significant differences favoring methylprednisolone in any domain (all P > 0.05). Recovery was worse in patients with postoperative delirium in the cognitive (P = 0.004) and physiologic (P < 0.001) domains. CONCLUSIONS: High-dose intraoperative methylprednisolone neither reduces delirium nor improves the quality of recovery in high-risk cardiac surgical patients.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Delírio/prevenção & controle , Glucocorticoides/farmacologia , Metilprednisolona/farmacologia , Complicações Pós-Operatórias/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
14.
Anesth Analg ; 123(6): 1471-1479, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27607476

RESUMO

BACKGROUND: Opioids can contribute to postoperative desaturation. Short-acting opioids, titrated to need, may cause less desaturation than longer-acting opioids. We thus tested the primary hypothesis that long-acting patient-controlled intravenous opioids are associated with more hypoxemia (defined as an integrated area under a postoperative oxyhemoglobin saturation of 95%) than short-acting opioids. METHODS: This analysis was a substudy of VISION, a prospective cohort study focused on perioperative cardiovascular events (NCT00512109). After excluding for predefined criteria, 191 patients were included in our final analysis, with 75 (39%) patients being given fentanyl (short-acting opioid group) and 116 (61%) patients being given morphine and/or hydromorphone (long-acting opioid group). The difference in the median areas under a postoperative oxyhemoglobin saturation of 95% between short-acting and long-acting opioids was compared using multivariable median quantile regression. RESULTS: The short-acting opioid median area under a postoperative oxyhemoglobin saturation of 95% per hour was 1.08 (q1, q3: 0.62, 2.26) %-h, whereas the long-acting opioid median was 1.28 (0.50, 2.23) %-h. No significant association was detected between long-acting and short-acting opioids and median area under a postoperative oxyhemoglobin saturation of 95% per hour (P = .66) with estimated change in the medians of -0.14 (95% CI, -0.75, 0.47) %-h for the patients given long-acting versus short-acting IV patient-controlled analgesia opioids. CONCLUSIONS: Long-acting patient-controlled opioids were not associated with the increased hypoxemia during the first 2 postoperative days.


Assuntos
Analgesia Controlada pelo Paciente/efeitos adversos , Analgésicos Opioides/efeitos adversos , Hipóxia/induzido quimicamente , Oxigênio/sangue , Dor Pós-Operatória/prevenção & controle , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Administração Intravenosa , Idoso , Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/administração & dosagem , Biomarcadores/sangue , Feminino , Humanos , Hipóxia/sangue , Análise dos Mínimos Quadrados , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Oxiemoglobinas/metabolismo , Dor Pós-Operatória/etiologia , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
J Clin Anesth ; 33: 376-85, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27555196

RESUMO

STUDY OBJECTIVE: To test the primary hypothesis that forced-air prewarming improves patient satisfaction after outpatient surgery and to evaluate the effect on core temperature and thermal comfort. DESIGN: Prospective randomized controlled trial. SETTING: Preoperative area, operating room, and postanesthesia care unit. PATIENTS: A total of 115 patients aged 18 to 75 years with American Society of Anesthesiologists status <4 and body mass index of 15 to 36kg/m(2) who were undergoing outpatient surgery (duration <4 hours). INTERVENTIONS: Patients were randomized to active prewarming with a Mistral-Air warming system initially set to 43°C or no active prewarming. All patients were warmed intraoperatively. MEASUREMENTS: Demographic and morphometric characteristics, perioperative core temperature, ambient temperature, EVAN-G satisfaction score, thermal comfort via visual analog scales. MAIN RESULTS: Data from 102 patients were included in the final analysis. Prewarming did not significantly reduce redistribution hypothermia, with prewarmed minus not prewarmed core temperature differing by only 0.18°C (95% confidence interval [CI], -0.001 to 0.37) during the initial hour of anesthesia (P=.052). Prewarming increased the mean EVAN-G satisfaction score, although not significantly, with an overall difference (prewarmed minus not prewarmed) of 5.6 (95% CI, -0.9 to 12.2; P=.09). Prewarming increased thermal comfort, with an overall difference of 6.6 mm (95% CI, 1.0-12.9; P=.02). CONCLUSION: Active prewarming increased thermal comfort but did not significantly reduce redistribution hypothermia or improve postoperative patient satisfaction.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Conforto do Paciente , Satisfação do Paciente , Reaquecimento/métodos , Adolescente , Adulto , Idoso , Temperatura Corporal , Feminino , Humanos , Hipotermia Induzida/métodos , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
16.
Heart ; 102(20): 1627-32, 2016 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-27288277

RESUMO

OBJECTIVE: Due to their unique pathophysiological profile, patients with hypertrophic cardiomyopathy (HCM) undergoing non-cardiac surgery require additional attention to perioperative management. We sought to compare perioperative outcomes of patients with HCM undergoing non-cardiac surgery with a matched group patients without HCM. METHODS: This observational cohort study conducted at a tertiary care centre included patients with HCM (n=92, age 67 years, 54% men) undergoing intermediate-risk and high-risk non-cardiac surgeries between 1/2007 and 12/2013 (excluding <18 years, prior septal myectomy/alcohol ablation, low-risk surgery) who were 1:2 matched (based on age, gender, type and time of non-cardiac surgery) with patients without HCM (n=184, median age 65 years, 53% men). A composite endpoint (30-day postoperative death, myocardial infarction, stroke, in-hospital decompensated congestive heart failure (CHF) and rehospitalisation within 30 days) and postoperative atrial fibrillation (AF) were recorded. RESULTS: There was a significantly lower incidence of intraoperative hypotension/tachycardia in patients with HCM versus those without HCM (p<0.001). At 30 days postoperatively, 42 (15%) patients had composite events. Rates of 30-day death, MI or stroke were very low in patients with HCM (5%). However, a significantly higher proportion of patients with HCM met the composite endpoint versus patients without HCM (20 (22%) vs 22 (12%), p=0.03), driven by decompensated CHF. On logistic regression, HCM, high-risk non-cardiac surgery, high anaesthesia risk score and intraoperative duration of hypotension were independently associated with 30-day composite events (p<0.05). CONCLUSIONS: Patients with HCM undergoing high-risk and intermediate-risk non-cardiac surgeries have a low perioperative event rate, at an experienced centre. However, they have a higher risk of composite events versus matched patients without HCM.


Assuntos
Anestesia , Cardiomiopatia Hipertrófica/complicações , Procedimentos Cirúrgicos Operatórios , Idoso , Anestesia/efeitos adversos , Anestesia/mortalidade , Fibrilação Atrial/etiologia , Cardiomiopatia Hipertrófica/diagnóstico , Cardiomiopatia Hipertrófica/mortalidade , Cardiomiopatia Hipertrófica/fisiopatologia , Estudos de Casos e Controles , Feminino , Insuficiência Cardíaca/etiologia , Mortalidade Hospitalar , Humanos , Hipotensão/etiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/etiologia , Ohio , Readmissão do Paciente , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/mortalidade , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento
17.
PLoS One ; 11(5): e0155997, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27195693

RESUMO

INTRODUCTION: Sufficient ventilation and oxygenation through proper airway management is essential in patients undergoing cardio-pulmonary resuscitation (CPR). Although widely discussed, securing the airway using an endotracheal tube is considered the standard of care. Endotracheal intubation may be challenging and causes prolonged interruption of chest compressions. Videolaryngoscopes have been introduced to better visualize the vocal cords and accelerate intubation, which makes endotracheal intubation much safer and may contribute to intubation success. Therefore, we aimed to compare hands-off time and intubation success of direct laryngoscopy with videolaryngoscopy (C-MAC, Karl Storz, Tuttlingen, Germany) in a randomized, cross-over manikin study. METHODS: Twenty-six anesthesia residents and twelve anesthesia consultants of the University Hospital Zurich were recruited through a voluntary enrolment. All participants performed endotracheal intubation using direct laryngoscopy and C-MAC in a random order during ongoing chest compressions. Participants were strictly advised to stop chest compression only if necessary. RESULTS: The median hands-off time was 1.9 seconds in direct laryngoscopy, compared to 3 seconds in the C-MAC group. In direct laryngoscopy 39 intubation attempts were recorded, resulting in an overall first intubation attempt success rate of 97%, compared to 38 intubation attempts and 100% overall first intubation attempt success rate in the C-MAC group. CONCLUSION: As a conclusion, the results of our manikin-study demonstrate that video laryngoscopes might not be beneficial compared to conventional, direct laryngoscopy in easily accessible airways under CPR conditions and in experienced hands. The benefits of video laryngoscopes are of course more distinct in overcoming difficult airways, as it converts a potential "blind intubation" into an intubation under visual control.


Assuntos
Reanimação Cardiopulmonar/métodos , Intubação Intratraqueal/métodos , Laringoscopia/métodos , Cirurgia Vídeoassistida/métodos , Adulto , Reanimação Cardiopulmonar/normas , Estudos Cross-Over , Feminino , Humanos , Intubação Intratraqueal/normas , Laringoscopia/normas , Masculino , Manequins , Duração da Cirurgia , Distribuição Aleatória , Cirurgia Vídeoassistida/normas
18.
Wound Repair Regen ; 24(1): 175-80, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26610062

RESUMO

Hypoxia at the surgical site impairs wound healing and oxidative killing of microbes. Surgical site infections are more common in obese patients. We hypothesized that subcutaneous oxygen tension (Psq O2) would decrease substantially in both obese and non-obese patients following induction of anesthesia and after surgical incision. We performed a prospective observational study that enrolled obese and non-obese surgical patients and measured serial Psq O2 before and during surgery. Seven morbidly obese and seven non-obese patients were enrolled. At baseline breathing room air, Psq O2 values were not significantly different (p = 0.66) between obese (6.8 kPa) and non-obese (6.5 kPa) patients. The targeted arterial oxygen tension (40 kPa) was successfully achieved in both groups with an expected significant increase in Psq O2 (obese 16.1 kPa and non-obese 13.4 kPa; p = 0.001). After induction of anesthesia and endotracheal intubation, Psq O2 did not change significantly in either cohort in comparison to levels right before induction (obese 15.5, non-obese 13.5 kPa; p = 0.95), but decreased significantly during surgery (obese 10.1, non-obese 9.3 kPa; p = 0.01). In both morbidly obese and non-obese patients, Psq O2 does not decrease appreciably following induction of anesthesia, but decreases markedly (∼33%) after commencement of surgery. Given the theoretical risks associated with low Psq O2 , future research should investigate how Psq O2 can be maintained after surgical incision.


Assuntos
Hipóxia/metabolismo , Obesidade Mórbida/metabolismo , Oxigênio/metabolismo , Pressão Parcial , Tela Subcutânea/metabolismo , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Tela Subcutânea/irrigação sanguínea , Ferida Cirúrgica , Cicatrização
20.
Anesthesiology ; 122(6): 1214-23, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25992877

RESUMO

BACKGROUND: Postoperative delirium is common in patients recovering from cardiac surgery. Tight glucose control has been shown to reduce mortality and morbidity. Therefore, the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic-normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery. METHODS: The authors enrolled 198 adult patients having cardiac surgery in this randomized, double-blind, single-center trial. Patients were randomly assigned to either tight intraoperative glucose control with a hyperinsulinemic-normoglycemic clamp (target blood glucose, 80 to 110 mg/dl) or standard therapy (conventional insulin administration with blood glucose target, <150 mg/dl). Delirium was assessed using a comprehensive delirium battery. The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment. A positive Confusion Assessment Method was defined by the presence of features 1 (acute onset and fluctuating course) and 2 (inattention) and either 3 (disorganized thinking) or 4 (altered consciousness). RESULTS: Patients randomized to tight glucose control were more likely to be diagnosed as being delirious than those assigned to routine glucose control (26 of 93 vs. 15 of 105; relative risk, 1.89; 95% CI, 1.06 to 3.37; P = 0.03), after adjusting for preoperative usage of calcium channel blocker and American Society of Anesthesiologist physical status. Delirium severity, among patients with delirium, was comparable with each glucose management strategy. CONCLUSION: Intraoperative hyperinsulinemic-normoglycemia augments the risk of delirium after cardiac surgery, but not its severity.


Assuntos
Glicemia/análise , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Delírio/induzido quimicamente , Delírio/psicologia , Hiperinsulinismo/sangue , Hiperinsulinismo/psicologia , Cuidados Intraoperatórios/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/psicologia , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/psicologia , Confusão/psicologia , Método Duplo-Cego , Feminino , Técnica Clamp de Glucose , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos
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