Association of preoperative frailty with postoperative delirium in elderly orthopedic trauma patients.

BACKGROUND: Among elderly orthopedic trauma patients, the prevalence of delirium during hospitalization has been reported to be as high as 60%. Frail elderly patients have an increased risk of delirium after elective surgery; however, such an association remains underexplored among trauma patients. AIM: Our goal was to investigate whether preoperative frailty is associated with postoperative delirium (POD) in elderly orthopedic trauma patients. METHODS: We conducted a single-center, retrospective, cross-sectional study. All patients were ≥ 65 years of age and were admitted to the hospital between 01/01/2017 and 08/31/2018 for surgical intervention of a significant extremity fracture. Frailty was assessed using the fatigue, resistance, ambulation, illness, and loss of weight questionnaire. Delirium was assessed using the Confusion Assessment Method. POD was defined as new-onset delirium that occurred within 24 h after surgery. To investigate whether frailty is associated with POD, we performed a multiple variable logistic regression, controlling for biologically relevant confounders. RESULTS: Five hundred fifty-six patients comprised the analytic cohort. Incidence of POD was 14% (n = 80). Multiple variable regression analysis demonstrated that each unit increment in FRAIL score was associated with a 33% higher likelihood of POD (OR 1.33; 95% CI 1.02-1.72, p = 0.03). CONCLUSIONS: Our results suggest that preoperative frailty increases the risk of POD in hospitalized, elderly, orthopedic trauma patients. Future studies are needed to determine whether perioperative interventions focused on improving frailty can reduce the risk of POD and improve outcomes in this rapidly growing cohort of patients.

The effect of Tegaderm™ versus EyeGard® on eyelid erythema during general anesthesia: a randomized-controlled trial.

PURPOSE: Application of adhesive tape to the eyelids during general anesthesia decreases the risk of corneal abrasion but may increase the risk of eyelid injury. The aim of this study was to determine if there is a difference in eyelid erythema when covering the eyelid with either Tegaderm™ or an EyeGard®. METHODS: We conducted a prospective, randomized, double-blind, split-face study of patients undergoing general anesthesia at an urban tertiary care academic medical centre. Each patient was randomized to having one eyelid covered with Tegaderm and the other with EyeGard. Photographs were taken prior to extubation and evaluated by three dermatologists. The primary outcome was the incidence of postoperative eyelid erythema. Secondary outcomes included the incidence of corneal abrasion and patient satisfaction. RESULTS: A total of 151 patients were included in our final analysis. Erythema was present on 117 (77%) eyelids covered with Tegaderm and 105 (70%) eyelids covered with EyeGard (% difference, 8; 95% confidence interval, 2 to 14; P = 0.03). No corneal abrasions were reported. The median [interquartile range] patient satisfaction score with eyelid condition was similar with Tegaderm vs EyeGard (5 [5-5] vs 5 [5-5], respectively; P = 0.84). CONCLUSION: We found a small increase in postoperative eyelid erythema when using Tegaderm compared with EyeGard. While EyeGard could decrease the risk of eyelid erythema, this should be balanced against other potential benefits of Tegaderm such as protection from fluids leaking onto the cornea. TRIAL REGISTRATION: www.ClinicalTrials.gov (NCT03549429); registered 8 June, 2018.

RéSUMé: OBJECTIF: L'application de ruban adhésif sur les paupières pendant l'anesthésie générale réduit le risque d'abrasion cornéenne mais pourrait augmenter le risque de lésion aux paupières. L'objectif de cette étude était de déterminer s'il existe une différence dans l'incidence d'érythème de la paupière lorsque l'on couvre la paupière à l'aide d'un Tegaderm™ ou d'un EyeGard®. MéTHODE: Nous avons réalisé une étude prospective, randomisée, à double insu et à visage divisé auprès de patients subissant une anesthésie générale dans un centre médical universitaire urbain de soins tertiaires. Chaque patient a été randomisé à avoir une paupière couverte de Tegaderm et l'autre d'un EyeGard. Des photos ont été prises avant l'extubation et évaluées par trois dermatologistes. Le critère d'évaluation principal était l'incidence d'érythème postopératoire de la paupière. Les critères secondaires comprenaient l'incidence d'abrasion cornéenne et la satisfaction des patients. RéSULTATS: Au total, 151 patients ont été inclus dans notre analyse finale. Il y avait présence d'érythème sur 117 (77 %) paupières couvertes de Tegaderm et 105 (70 %) paupières couvertes d'un EyeGard (% de différence, 8; intervalle de confiance 95 %, 2 à 14; P = 0,03). Aucune abrasion cornéenne n'a été rapportée. Le score médian [écart interquartile] de satisfaction des patients en ce qui touchait à l'état de leurs paupières était semblable pour le Tegaderm et le EyeGard (5 [5­5] vs 5 [5­5], respectivement; P = 0,84). CONCLUSION: Nous avons observé une légère augmentation du nombre d'érythèmes postopératoires de la paupière lors de l'utilisation du Tegaderm comparativement au EyeGard. Alors que le EyeGard pourrait réduire le risque d'érythème de la paupière, il convient de sous-peser ses avantages par rapport aux autres avantages potentiels du Tegaderm tels que la protection contre les liquides coulant sur la cornée. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT03549429); enregistrée le 8 juin 2018.

Effect of a Cognitive Aid on Reducing Sugammadex Use and Associated Costs: A Time Series Analysis.

BACKGROUND: The authors observed increased pharmaceutical costs after the introduction of sugammadex in our institution. After a request to decrease sugammadex use, the authors implemented a cognitive aid to help choose between reversal agents. The purpose of this study was to determine if sugammadex use changed after cognitive aid implementation. The authors' hypothesis was that sugammadex use and associated costs would decrease. METHODS: A cognitive aid suggesting reversal agent doses based on train-of-four count was developed. It was included with each dispensed reversal agent set and in medication dispensing cabinet bins containing reversal agents. An interrupted time series analysis was performed using pharmaceutical invoices and anesthesia records. The primary outcome was the number of sugammadex administrations. Secondary outcomes included total pharmaceutical acquisition costs of neuromuscular blocking drugs and reversal agents, adverse respiratory events, emergence duration, and number of neuromuscular blocking drug administrations. RESULTS: Before cognitive aid implementation, the number of sugammadex administrations was increasing at a monthly rate of 20 per 1,000 general anesthetics (P < 0.001). Afterward, the monthly rate was 4 per 1,000 general anesthetics (P = 0.361). One month after cognitive aid implementation, the number of sugammadex administrations decreased by 281 per 1,000 general anesthetics (95% CI, 228 to 333, P < 0.001). In the final study month, there were 509 fewer sugammadex administrations than predicted per 1,000 general anesthetics (95% CI, 366 to 653; P < 0.0001), and total pharmaceutical acquisition costs per 1,000 general anesthetics were $11,947 less than predicted (95% CI, $4,043 to $19,851; P = 0.003). There was no significant change in adverse respiratory events, emergence duration, or administrations of rocuronium, vecuronium, or atracurium. In the final month, there were 75 more suxamethonium administrations than predicted per 1,000 general anesthetics (95% CI, 32 to 119; P = 0.0008). CONCLUSIONS: Cognitive aid implementation to choose between reversal agents was associated with a decrease in sugammadex use and acquisition costs.

Elevated Red Cell Distribution Width Is Associated With Decreased Ventilator-Free Days in Critically Ill Patients.

INTRODUCTION: Elevated red cell distribution width (RDW) is associated with mortality in a variety of respiratory conditions. Recent data also suggest that RDW is associated with mortality in intensive care unit (ICU) patients. Although respiratory failure is common in the ICU, the relationship between RDW and pulmonary outcomes in the ICU has not been previously explored. Therefore, our goal was to investigate the association of admission RDW with 30-day ventilator-free days (VFDs) in ICU patients. METHODS: We performed a retrospective analysis from an ongoing prospective, observational study. Patients were recruited from medical and surgical ICUs of a large teaching hospital in Boston, Massachusetts. The RDW was assessed within 1 hour of ICU admission. Poisson regression analysis was used to investigate the association of RDW (normal: 11.5%-14.5% vs elevated: >14.5%) with 30-day VFD, while controlling for age, sex, race, body mass index, Nutrition Risk in the Critically Ill score, the presence of chronic lung disease, Pao2/Fio2 ratio, and admission levels of hemoglobin, mean corpuscular volume, phosphate, albumin, C-reactive protein, and creatinine. RESULTS: A total of 637 patients comprised the analytic cohort. Mean RDW was 15 (standard deviation 4%), with 53% of patients in the normal range and 47% with elevated levels. Median VFD was 16 (interquartile range: 6-25) days. Poisson regression analysis demonstrated that ICU patients with elevated admission RDW were likely to have 32% lower 30-day VFDs compared to their counterparts with RDW in the normal range (incidence rate ratio: 0.68; 95% confidence interval: 0.55-0.83: P < .001). CONCLUSIONS: We observed an inverse association of RDW and 30-day VFD, despite controlling for demographics, nutritional factors, and severity of illness. This supports the need for future studies to validate our findings, understand the physiologic processes that lead to elevated RDW in patients with respiratory failure, and determine whether changes in RDW may be used to support clinical decision-making.

Acute trauma and multiple injuries in the elderly population.

PURPOSE OF REVIEW: Traumatic injuries in the rapidly growing elderly population pose a significant challenge to the healthcare community. These injuries are associated with significant morbidity and mortality, and as a result cause a financial burden on the medical system. Although normal decline in physiologic reserve can provide some explanation for these poor outcomes, there is significant room for improvement. This review will summarize recent literature around the evaluation and management of elderly trauma patients with a particular focus on those with hip fractures. RECENT FINDINGS: It is becoming increasingly evident that customized evaluation and management of elderly trauma patients is a key factor in improving outcomes. Geriatric-specific triage and assessment criteria have been developed and initial results are encouraging. In particular, the use of frailty as an assessment tool in these patients has been shown to be an independent predictor of outcomes. Further, assessment of these tools in elderly trauma patients with hip fractures has provided a wealth of information about their use and limitations. SUMMARY: Differentiated, geriatric-specific triaging, assessment and treatment pathways in the care of elderly trauma patients will ultimately lead to improvements in outcomes. These improvements have already started to be seen in the realm of orthogeriatrics.

"The Big Three" of geriatrics: A review of perioperative cognitive impairment, frailty and malnutrition.

Cognitive impairment, frailty, and malnutrition are three of the most impactful pathologies facing an aging population, having dramatic effects on morbidity and mortality across nearly all facets of medical care and intervention. By 2050, the World Health Organization estimates that the population of individuals over the age of sixty worldwide will nearly double, and the public health toll of these demographic changes cannot be understated. With these changing demographics comes a need for a sharpened focus on the care and management of this vulnerable population. The average patient presenting for surgery is getting older, and this necessitates that clinicians understand the implications of these pathologies for both their immediate medical care needs and for appropriate procedural selection and prognostication of surgical outcomes. We believe it is incumbent on clinicians to consider the frailty, nutritional status, and cognitive function of each individual patient when offering a surgical intervention, as well as consider interventions that may delay the progression of these pathologies. Unfortunately, despite excellent evidence supporting things like routine pre-operative frailty screening and nutritional optimization, many interventions that would specifically benefit this population still have not been integrated into routine practice. In this review, we will synthesize the existing literature on these topics to provide a pragmatic approach and understanding for anesthesiologists and intensivists faced with this complex population.

Postpartum trifecta: simultaneous eclamptic intracerebral hemorrhage, PRES, and herniation due to intracranial hypotension.

BACKGROUND: In the postpartum patient, sudden depression of consciousness may be caused by a number of etiologies and can result in serious consequences. Rapid, accurate diagnosis allows for specific treatments that optimize outcome, but diagnosis can be challenging in this population. We present a case of postpartum herniation due to intracranial hypotension in a patient with eclampsia, posterior reversible encephalopathy syndrome (PRES), and intracerebral hemorrhage (ICH). METHODS: Case report. RESULTS: A 26-year-old woman developed headache on postpartum day (PD) 1 after cesarean section with epidural anesthesia. Over the next 3 days, she developed progressively worsening headache and hypertension. On PD 5, she had a generalized seizure, leading to endotracheal intubation, propofol infusion, and transfer to our institution. By PD 6, she opened her eyes to voice, followed commands, moved all extremities, and had briskly reactive 4 mm pupils. MRI showed L parasagittal ICH with minimal mass effect, edema consistent with PRES, and brain descent with obliteration of the basal cisterns and tonsillar herniation. Later on PD 6, after diuresis for pulmonary edema, she became unresponsive with a dilated and nonreactive left pupil. She was laid flat for transport to CT, with improvement in arousal and pupil reactivity within 5 min. Intravascular volume was repleted with normal saline and albumin, and she was placed in the Trendelenburg position. Over the subsequent 8 h, she developed a dilated and nonreactive left pupil whenever her head was raised to horizontal. Her head position was gradually successfully raised over 48 h without need for a lumbar epidural blood patch. She was discharged home on PD 13 with only mild left arm dysmetria. CONCLUSIONS: Intracranial hypotension may coexist with other potential causes of cerebral herniation in the postpartum period. Establishing this diagnosis is crucial because its treatment is opposite that of other causes of herniation.

Association of nutrition status and hospital-acquired infections in older adult orthopedic trauma patients.

BACKGROUND: Malnutrition is linked to suboptimal outcomes following elective surgery. Trauma patients do not typically have an opportunity for preoperative nutrition optimization and may be at risk for malnutrition. Our goal was to investigate whether nutrition status is associated with development of hospital-acquired infections (HAIs) in older adult, orthopedic trauma patients. METHODS: We performed a retrospective analysis of data between January 1, 2017, and August 30, 2018, from the Massachusetts General Hospital Geriatric Inpatient Fracture Trauma Service. Admission nutrition status was assessed using the Mini Nutritional Assessment (MNA) and HAIs were validated through the American College of Surgeons National Surgical Quality Improvement Project database. To investigate whether nutrition status is associated with HAIs, we performed a multivariable logistic regression analysis controlling for age, sex, Charlson Comorbidity Index, glomerular filtration rate, and type of anesthesia. RESULTS: Four hundred sixty-one patients comprised the analytic cohort. Multivariable regression analysis demonstrated that each unit increment in MNA score was associated with a 13% reduction in risk of HAI (odds ratio, 0.87; 95% CI, 0.79-0.97). Furthermore, adjusting for timing of perioperative antibiotics, perioperative transfusions, or development of pressure injury during hospitalization did not materially change these results. CONCLUSION: Our results demonstrate that malnutrition is highly prevalent in older adult, orthopedic trauma patients and that nutrition status may influence the risk of developing HAIs in this cohort of patients. Further studies are needed to determine whether optimizing perioperative nutrition in older adult, orthopedic trauma patients can reduce infectious complications and improve overall health outcomes.

Dexmedetomidine and ketamine show distinct patterns of cell degeneration and apoptosis in the developing rat neonatal brain.

OBJECTIVE: Early exposure to common anesthetic and sedative agents causes widespread brain cell degeneration and apoptosis in the developing rat brain, associated with persistent learning deficits in rats. This study was designed to determine whether the α2 adrenergic receptor agonist, dexmedetomidine, produces brain cell degeneration and apoptosis in postnatal day-7 rats in the same brain areas when compared to ketamine. METHODS: Systemic saline, ketamine 20 mg/kg, or dexmedetomidine at 30 or 45 µg/kg were given six times to postnatal day 7 rats (n = 6/group) every 90 min. Twenty-four hours after the initial injection, brain regions were processed and analyzed for cell degeneration using the silver stain and for apoptosis using activated caspase-3 immunohistochemistry. RESULTS: Exposure to ketamine resulted in significant cellular degeneration and apoptosis in limbic brain regions, but nonsignificant changes in primary sensory brain regions. In contrast, dexmedetomidine produced significant cellular degeneration and apoptosis in primary sensory brain regions, but nonsignificant changes in limbic regions. CONCLUSIONS: These data show that ketamine and dexmedetomidine result in anatomically distinct patterns of cell degeneration and apoptosis in the brains of 7-day-old rat pups. The meaning and the clinical significance of these findings remain to be established.

Geriatrics and the Perioperative Surgical Home.

An ever-changing health care system with a constantly increasing aging surgical population creates both opportunities for providing improved health care as well as significant challenges. Coordinated health care initiatives are needed if one is to adequately balance the need for evidence-based improved patient outcomes and the often-associated increased costs. In this article the authors postulate that a protocol-driven, multidisciplinary approach may be a pathway for implementing an effective triple aim to health care, especially in a frail geriatric population.

Spontaneous pneumothorax during laparoscopic adrenalectomy secondary to a congenital diaphragmatic defect.

Despite its obvious benefits, laparoscopic surgery is not free of complications. It may cause significant physiologic changes and technical mishaps. Pneumothorax has been described as a complication of almost any type of laparoscopic surgery. We report a case of tension pneumothorax during laparoscopic adrenalectomy secondary to a congenital diaphragmatic defect and describe our treatment.

Persistent left superior vena cava identified after cannulation of the right subclavian vein.

IMPLICATIONS: We report the case of a patient with a chest radiograph suggestive of intraarterial placement of a central venous catheter. On investigation, the catheter was located in a previously undiagnosed persistent left superior vena cava.