24 results on '"Grant, Michael C."'
Search Results
2. Development and Publication of Clinical Practice Parameters, Reviews, and Meta-analyses: A Report From the Society of Cardiovascular Anesthesiologists Presidential Task Force.
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Kertai MD, Makkad B, Bollen BA, Grocott HP, Kachulis B, Boisen ML, Raphael J, Perry TE, Liu H, Grant MC, Gutsche J, Popescu WM, Hensley NB, Mazzeffi MA, Sniecinski RM, Teeter E, Pal N, Ngai JY, Mittnacht A, Augoustides YGT, Ibekwe SO, Martin AK, Rhee AJ, Walden RL, Glas K, Shaw AD, and Shore-Lesserson L
- Subjects
- Humans, Consensus, Anesthesiologists, Societies, Medical
- Abstract
The Society of Cardiovascular Anesthesiologists (SCA) is committed to improving the quality, safety, and value that cardiothoracic anesthesiologists bring to patient care. To fulfill this mission, the SCA supports the creation of peer-reviewed manuscripts that establish standards, produce guidelines, critically analyze the literature, interpret preexisting guidelines, and allow experts to engage in consensus opinion. The aim of this report, commissioned by the SCA President, is to summarize the distinctions among these publications and describe a novel SCA-supported framework that provides guidance to SCA members for the creation of these publications. The ultimate goal is that through a standardized and transparent process, the SCA will facilitate up-to-date education and implementation of best practices by cardiovascular and thoracic anesthesiologists to improve patient safety, quality of care, and outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 International Anesthesia Research Society.)
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- 2024
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3. Situational Awareness of Opioid Consumption: The Missing Link to Reducing Dependence After Surgery?
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Engelman DT, Crisafi C, Hodle T, Stiles J, Nathanson BH, Zarbock A, and Grant MC
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- Awareness, Humans, Pain Management adverse effects, Pain Management methods, Pain, Postoperative diagnosis, Pain, Postoperative drug therapy, Pain, Postoperative etiology, Practice Patterns, Physicians', Retrospective Studies, Analgesics, Opioid adverse effects, Opioid-Related Disorders diagnosis, Opioid-Related Disorders epidemiology, Opioid-Related Disorders prevention & control
- Abstract
A tool for collecting and analyzing morphine milligram equivalents (MMEs) can be used to overcome barriers to situational awareness around opioid utilization in the setting of multimodal pain management. Our software application (App) has facilitated data collection, analysis, and benchmarking in a manner that is not logistically feasible using manual methods. Real-time postoperative tracking of MME over the course of an episode of care can be prohibitively labor-intensive, and teams must have practical strategies to overcome this obstacle. In view of the link between the magnitude of opioid prescriptions at discharge and persistent opioid use after cardiac surgery, we believe that improving situational awareness among the patient care team is a vital first step in reducing opioid dependence after cardiac surgery., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)
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- 2022
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4. Understanding the Economic Impact of an Essential Service: Applying Time-Driven Activity-Based Costing to the Hospital Airway Response Team.
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Stone AB, Dasani SS, Grant MC, Nascimben L, and Bader AM
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- Anesthesia Department, Hospital economics, Anesthesia Department, Hospital organization & administration, Emergency Medical Services, Humans, Intubation, Intratracheal economics, Personnel, Hospital economics, Prospective Payment System, Tertiary Care Centers, United States, Airway Management economics, Health Care Costs, Hospital Rapid Response Team economics
- Abstract
Background: As the United States moves toward value-based care metrics, it will become essential for anesthesia groups nationwide to understand the costs of their services. Time-driven activity-based costing (TDABC) estimates the amount of time it takes to perform a clinical activity by dividing complex tasks into process steps and mapping each step and has historically been used to estimate the costs of various health care services. TDABC is a tool that can be adapted for variable staffing models and the volume of service provided. Anesthesia departments often provide staffing for airway response teams (ART). The economic implications of staffing ART have not been well described. We present a TDABC model for ART activation in a tertiary-care center to estimate the cost incurred by an anesthesiology department to staff an ART., Methods: Pages received by the Brigham and Women's Hospital ART over a 24-month time period (January 2019 to December 2020) were analyzed and categorized. The local administrative database was queried for the Current Procedural Terminology (CPT) code used to bill for emergency airway placements. Sessions were held by multiple members of the ART to create process maps for the different types of ART activations. We estimated the staffing costs using the estimated time it took for each type of ART activation as well as the data collected for local ART activations., Results: From the paging records, we analyzed 3368 activations of the ART. During the study period, 1044 airways were billed for with emergency airway CPT code. The average revenue collected per airway was $198.45 (95% CI, $190-$207). For STAT/Emergency airway team activations, process maps and non-STAT airway team activations were created, and third subprocess map was created for performing endotracheal intubation. Using the TDABC, the total staffing costs are estimated to be $218,601 for the 2-year study period. The ART generated $207,181 in revenue during the study period., Conclusions: Our analysis of ART-activation pages suggests that while the revenue generated may cover the cost of staffing the team during ART activations, it does not cover consumable equipment costs. Additionally, the current fee-for-service model relies on the team being able to perform other clinical duties in addition to covering the airway pager and would be impossible to capture using traditional top-down costing methods. By using TDABC, anesthesia groups can demonstrate how certain services, such as ART, are not fully covered by current reimbursement models and how to negotiate for subsidy agreements.As the transition from traditional fee-for-service payments to value-based care models continues in the United States, improving the understanding and communication of medical care costs will be essential. In the United States, it is common for anesthesia groups to receive direct revenue from hospitals to preserve financial viability, and therefore, knowledge of true cost is essential regardless of payer model.1 With traditional payment models, what is billable and nonbillable may not reflect either the need for or the cost of providing the service. As anesthesia departments navigate the transition of care from volume to value, actual costs will be essential to understand for negotiations with hospitals for support when services are nonbillable, when revenue from payers does not cover anesthesia costs, and when calculating the appropriate share for anesthesia departments when bundled payments are distributed., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 International Anesthesia Research Society.)
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- 2022
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5. Laying the First Brick: A Foundation for Medical Investigation Through Big Data.
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Grant MC and Anderson TA
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- Big Data
- Abstract
Competing Interests: The authors declare no conflicts of interest.
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- 2022
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6. In Response.
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Grant MC
- Subjects
- Analgesics, Opioid, Anesthesia, Cardiac Procedures, Cardiac Surgical Procedures
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- 2021
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7. Perioperative Precedex: Whole New Ball Game or Whole New Ball of Wax?
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Grant MC and Dunn LK
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- Double-Blind Method, Humans, Hyperalgesia, Remifentanil, Thyroidectomy, Dexmedetomidine
- Abstract
Competing Interests: The authors declare no conflicts of interest.
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- 2021
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8. Retrograde Autologous Priming in Cardiac Surgery: Results From a Systematic Review and Meta-analysis.
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Hensley NB, Gyi R, Zorrilla-Vaca A, Choi CW, Lawton JS, Brown CH 4th, Frank SM, Grant MC, and Cho BC
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- Cardiac Surgical Procedures adverse effects, Cardiac Surgical Procedures trends, Cardiopulmonary Bypass adverse effects, Humans, Observational Studies as Topic methods, Randomized Controlled Trials as Topic methods, Blood Transfusion, Autologous methods, Blood Transfusion, Autologous trends, Cardiopulmonary Bypass trends
- Abstract
Background: Retrograde autologous priming (RAP) before cardiopulmonary bypass (CPB) may minimize allogeneic red cell transfusion. We conducted a systematic review of the literature to examine the impact of RAP on perioperative allogeneic red cell transfusions in cardiac surgical patients., Methods: This study involved a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies evaluating the use of RAP in cardiac surgery involving CPB. The primary outcome was intraoperative allogeneic red cell transfusion. Secondary outcomes included whole hospital allogeneic transfusions and adverse events such as acute kidney injury (AKI) and stroke., Results: A total of 11 RCTs (n = 1337 patients) were included, comparing RAP patients (n = 674) to control (n = 663). In addition, 10 observational studies (n = 2327) were included, comparing RAP patients (n = 1257) to control (n = 1070). Overall, RAP was associated with a significantly reduced incidence of intraoperative red cell transfusion (n = 18 studies; odds ratio [OR] = 0.34; 95% confidence interval [CI], 0.22-0.55, P < .001) compared to controls. This effect was seen among RCTs (n = 10 studies; OR = 0.19; 95% CI, 0.08-0.45, P < .001) and observational studies (n = 8 studies; OR = 0.66; 95% CI, 0.50-0.87, P = .004) in isolation. RAP was also associated with a significantly reduced incidence of whole hospital red cell transfusion (n = 5 studies; OR = 0.28; 95% CI, 0.19-0.41, P < .001). Among the studies that reported AKI and stroke outcomes, there was no statistically significant increased odds of AKI or stroke in either RAP or control patients., Conclusions: Based on the pooled results of the available literature, RAP is associated with a significant reduction in intraoperative and whole hospital allogeneic red cell transfusion. Use of RAP may prevent hemodilution of cardiac surgical patients and thus, lessen transfusions. Additional high-quality prospective studies are necessary to determine the ideal priming volume necessary to confer the greatest benefit without incurring organ injury.
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- 2021
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9. Opioid-Sparing Cardiac Anesthesia: Secondary Analysis of an Enhanced Recovery Program for Cardiac Surgery.
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Grant MC, Isada T, Ruzankin P, Gottschalk A, Whitman G, Lawton JS, Dodd-O J, and Barodka V
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- Aged, Anesthesia, Cardiac Procedures trends, Cardiac Surgical Procedures trends, Female, Humans, Male, Middle Aged, Pain, Postoperative diagnosis, Recovery of Function drug effects, Analgesics, Opioid administration & dosage, Anesthesia, Cardiac Procedures methods, Cardiac Surgical Procedures adverse effects, Pain, Postoperative etiology, Pain, Postoperative prevention & control, Recovery of Function physiology
- Abstract
Background: Cardiac anesthetics rely heavily on opioids, with the standard patient receiving between 70 and 105 morphine sulfate equivalents (MSE; 10-15 µg/kg of fentanyl). A central tenet of Enhanced Recovery Programs (ERP) is the use of multimodal analgesia. This study was performed to assess the association between nonopioid interventions employed as part of an ERP for cardiac surgery and intraoperative opioid administration., Methods: This study represents a post hoc secondary analysis of data obtained from an institutional ERP for cardiac surgery. Consecutive patients undergoing cardiac surgery received 5 nonopioid interventions, including preoperative gabapentin and acetaminophen, intraoperative dexmedetomidine and ketamine infusions, and regional analgesia via serratus anterior plane block. The primary objective, the association between intraoperative opioid administration and the number of interventions provided, was assessed via a linear mixed-effects regression model. To assess the association between intraoperative opioid administration and postoperative outcomes, patients were stratified into high (>50 MSE) and low (≤50 MSE) opioids, 1:1 propensity matched based on 15 patients and procedure covariables and assessed for associations with postoperative outcomes of interest. To investigate the impact of further opioid restriction, ultralow (≤25 MSE) opioid participants were then identified, 1:3 propensity matched to high opioid patients, and similarly compared., Results: A total of 451 patients were included in the overall analysis. Analysis of the primary objective revealed that intraoperative opioid administration was inversely related to the number of interventions employed (estimated -7.96 MSE per intervention, 95% confidence interval [CI], -9.82 to -6.10, P < .001). No differences were detected between low (n = 136) and high (n = 136) opioid patients in postoperative complications, postoperative pain scores, time to extubation, or length of stay. No differences were found in outcomes between ultralow (n = 63) and high (n = 132) opioid participants., Conclusions: Nonopioid interventions employed as part of an ERP for cardiac surgery were associated with a reduction of intraoperative opioid administration. Low and ultralow opioid use was not associated with significant differences in postoperative outcomes. These findings are hypothesis-generating, and future prospective studies are necessary to establish the role of opioid-sparing strategies in the setting of cardiac surgery.
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- 2020
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10. Perioperative Dextrose Infusion and Postoperative Nausea and Vomiting: A Meta-analysis of Randomized Trials.
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Zorrilla-Vaca A, Marmolejo-Posso D, Stone A, Li J, and Grant MC
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- Antiemetics adverse effects, Blood Glucose drug effects, Blood Glucose metabolism, Drug Administration Schedule, Female, Glucose adverse effects, Humans, Hyperglycemia blood, Hyperglycemia chemically induced, Incidence, Infusions, Intravenous, Male, Perioperative Care adverse effects, Postoperative Nausea and Vomiting epidemiology, Randomized Controlled Trials as Topic, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome, Antiemetics administration & dosage, Glucose administration & dosage, Perioperative Care methods, Postoperative Nausea and Vomiting prevention & control
- Abstract
Background: Perioperative IV dextrose infusions have been investigated for their potential to reduce the risk of postoperative nausea and vomiting. In this meta-analysis, we investigated the use of an intraoperative or postoperative infusion of dextrose for the prevention of postoperative nausea and vomiting., Methods: Our group searched PubMed, Embase, Cochrane library, and Google Scholar for relevant randomized controlled trials examining the use of perioperative IV dextrose for prevention of postoperative nausea and vomiting. The primary outcome was the incidence of postoperative nausea and vomiting (both in the postanesthesia care unit and within the first 24 h of surgery). Secondary outcomes included postoperative antiemetic administration and serum glucose level., Results: Our search yielded a total of 10 randomized controlled trials (n = 987 patients) comparing the use of a perioperative dextrose infusion (n = 465) to control (n = 522). Perioperative dextrose infusion was not associated with a significant reduction in postoperative nausea and vomiting in the postanesthesia care unit (risk ratio = 0.91, 95% CI, 0.73-1.15; P = .44) or within the first 24 h (risk ratio = 0.76, 95% CI, 0.55-1.04; P = .09) of surgery. Although the use of dextrose was associated with a significant reduction in antiemetic administration within the first 24 h (risk ratio = 0.55, 95% CI, 0.45-0.69; P < .001), it also increased postoperative plasma glucose levels compared to controls., Conclusions: The use of perioperative dextrose did not result in a statistically significant association with postoperative nausea and vomiting. When utilized, plasma glucose monitoring is recommended to assess for postoperative hyperglycemia. Further prospective trials are necessary to examine the potential impact of timing of administration of a dextrose infusion on incidence of postoperative nausea and vomiting and rescue antiemetic requirements.
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- 2019
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11. In Response.
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Grant MC, Lester L, and Cho BC
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- Blood Transfusion, Erythropoietin, Hematopoietic Stem Cell Transplantation
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- 2019
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12. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naïve Patients.
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Wu CL, King AB, Geiger TM, Grant MC, Grocott MPW, Gupta R, Hah JM, Miller TE, Shaw AD, Gan TJ, Thacker JKM, Mythen MG, and McEvoy MD
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- Analgesics, Opioid adverse effects, Consensus, Delphi Technique, Drug Administration Schedule, Humans, Incidence, Opioid-Related Disorders diagnosis, Opioid-Related Disorders prevention & control, Pain Management adverse effects, Pain, Postoperative diagnosis, Pain, Postoperative epidemiology, Risk Assessment, Risk Factors, Terminology as Topic, Time Factors, Treatment Outcome, Analgesics, Opioid administration & dosage, Opioid-Related Disorders epidemiology, Pain Management standards, Pain, Postoperative drug therapy, Postoperative Care standards
- Abstract
Surgical care episodes place opioid-naïve patients at risk for transitioning to new persistent postoperative opioid use. With one of the central principles being the application of multimodal pain interventions to reduce the reliance on opioid-based medications, enhanced recovery pathways provide a framework that decreases perioperative opioid use. The fourth Perioperative Quality Initiative brought together a group of international experts representing anesthesiology, surgery, and nursing with the objective of providing consensus recommendations on this important topic. Fourth Perioperative Quality Initiative was a consensus-building conference designed around a modified Delphi process in which the group alternately convened for plenary discussion sessions in between small group discussions. The process included several iterative steps including a literature review of the topics, building consensus around the important questions related to the topic, and sequential steps of content building and refinement until agreement was achieved and a consensus document was produced. During the fourth Perioperative Quality Initiative conference and thereafter as a writing group, reference applicability to the topic was discussed in any area where there was disagreement. For this manuscript, the questions answered included (1) What are the potential strategies for preventing persistent postoperative opioid use? (2) Is opioid-free anesthesia and analgesia feasible and appropriate for routine operations? and (3) Is opioid-free (intraoperative) anesthesia associated with equivalent or superior outcomes compared to an opioid minimization in the perioperative period? We will discuss the relevant literature for each questions, emphasize what we do not know, and prioritize the areas for future research.
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- 2019
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13. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Bariatric Surgery.
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Grant MC, Gibbons MM, Ko CY, Wick EC, Cannesson M, Scott MJ, McEvoy MD, King AB, and Wu CL
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- Anesthesia adverse effects, Bariatric Surgery adverse effects, Evidence-Based Medicine, Health Services Research, Humans, Postoperative Complications etiology, Practice Guidelines as Topic standards, Recovery of Function, Risk Assessment, Risk Factors, Treatment Outcome, Anesthesia standards, Bariatric Surgery standards, Outcome and Process Assessment, Health Care standards, Patient Safety standards, Quality Improvement standards, Quality Indicators, Health Care standards
- Abstract
Enhanced recovery after surgery protocols for bariatric surgery are increasingly being implemented, and reports suggest that they may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. We have conducted an evidence review to select anesthetic interventions that positively influence outcomes and facilitate recovery after bariatric surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for pre- (carbohydrate loading/fasting, multimodal preanesthetic medications), intra- (standardized intraoperative pathway, regional anesthesia, opioid minimization and multimodal analgesia, protective ventilation strategy, fluid minimization), and postoperative (multimodal analgesia with opioid minimization) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for enhanced recovery after surgery for bariatric surgery. There is evidence in the literature, and from society guidelines, to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for bariatric surgery.
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- 2019
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14. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery.
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, and Wu CL
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- Analgesics therapeutic use, Anesthetics adverse effects, Anesthetics therapeutic use, Evidence-Based Medicine, Humans, Interdisciplinary Communication, Nerve Block, Pain Management, Patient Safety, Patient-Centered Care, Perioperative Care methods, Perioperative Period, Randomized Controlled Trials as Topic, United States, United States Agency for Healthcare Research and Quality, Anesthesiology methods, Anesthesiology standards, Arthroplasty, Replacement, Hip methods, Hip Fractures surgery
- Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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- 2019
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15. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Colorectal Surgery.
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Ban KA, Gibbons MM, Ko CY, Wick EC, Cannesson M, Scott MJ, Grant MC, and Wu CL
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- Anesthesia methods, Anti-Bacterial Agents therapeutic use, Antibiotic Prophylaxis, Carbohydrates therapeutic use, Colorectal Neoplasms, Evidence-Based Medicine, Fluid Therapy methods, Humans, Perioperative Care standards, Piperidines therapeutic use, Quality of Health Care, Randomized Controlled Trials as Topic, Safety Management, Thromboembolism, Treatment Outcome, United States, United States Agency for Healthcare Research and Quality, Urinary Tract Infections diagnosis, Anesthesiology standards, Colorectal Surgery standards, Patient Safety, Surgical Procedures, Operative standards
- Abstract
The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery (ISCR), which is a national effort to disseminate best practices in perioperative care to more than 750 hospitals across multiple procedures in the next 5 years. The program will integrate evidence-based processes central to enhanced recovery and prevention of surgical site infection, venous thromboembolic events, catheter-associated urinary tract infections with socioadaptive interventions to improve surgical outcomes, patient experience, and perioperative safety culture. The objectives of this review are to evaluate the evidence supporting anesthesiology components of colorectal (CR) pathways and to develop an evidence-based CR protocol for implementation. Anesthesiology protocol components were identified through review of existing CR enhanced recovery pathways from several professional associations/societies and expert feedback. These guidelines/recommendations were supplemented by evidence made further literature searches. Anesthesiology protocol components were identified spanning the immediate preoperative, intraoperative, and postoperative phases of care. Components included carbohydrate loading, reduced fasting, multimodal preanesthesia medication, antibiotic prophylaxis, blood transfusion, intraoperative fluid management/goal-directed fluid therapy, normothermia, a standardized intraoperative anesthesia pathway, and standard postoperative multimodal analgesic regimens.
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- 2019
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16. Impact of Preoperative Erythropoietin on Allogeneic Blood Transfusions in Surgical Patients: Results From a Systematic Review and Meta-analysis.
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Cho BC, Serini J, Zorrilla-Vaca A, Scott MJ, Gehrie EA, Frank SM, and Grant MC
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- Hematinics administration & dosage, Hematopoietic Stem Cell Transplantation, Hemoglobins analysis, Hospitalization, Humans, Inpatients, Preoperative Period, Risk, Sensitivity and Specificity, Thromboembolism therapy, Transplantation, Homologous, Treatment Outcome, Blood Loss, Surgical, Blood Transfusion statistics & numerical data, Erythrocyte Transfusion statistics & numerical data, Erythropoietin administration & dosage
- Abstract
Background: Erythropoietic-stimulating agents such as erythropoietin have been used as part of patient blood management programs to reduce or even avoid the use of allogeneic blood transfusions. We review the literature to evaluate the effect of preoperative erythropoietin use on the risk of exposure to perioperative allogeneic blood transfusions., Methods: The study involved a systematic review and meta-analysis of randomized controlled trials evaluating the use of preoperative erythropoietin. The primary outcome was the reported incidence of allogeneic red blood cell transfusions during inpatient hospitalizations. Secondary outcomes included phase-specific allogeneic red blood cell transfusions (ie, intraoperative, postoperative), intraoperative estimated blood loss, perioperative hemoglobin levels, length of stay, and thromboembolic events., Results: A total of 32 randomized controlled trials (n = 4750 patients) were included, comparing preoperative erythropoietin (n = 2482 patients) to placebo (n = 2268 patients). Preoperative erythropoietin is associated with a significant decrease in incidence of allogeneic blood transfusions among all patients (n = 28 studies; risk ratio, 0.59; 95% CI, 0.47-0.73; P < .001) as well as patients undergoing cardiac (n = 9 studies; risk ratio, 0.55; 95% CI, 0.37-0.81; P = .003) and elective orthopedic (n = 5 studies; risk ratio, 0.36; 95% CI, 0.28-0.46; P < .001) surgery compared to placebo, respectively. Preoperative erythropoietin was also associated with fewer phase-specific red blood cell transfusions. There was no difference between groups in incidence of thromboembolic events (n = 28 studies; risk ratio, 1.02; 95% CI, 0.78-1.33; P = .68)., Conclusions: Preoperative erythropoietin is associated with a significant reduction in perioperative allogeneic blood transfusions. This finding is also confirmed among the subset of patients undergoing cardiac and orthopedic surgery. Furthermore, our study demonstrates no significant increase in risk of thromboembolic complications with preoperative erythropoietin administration.
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- 2019
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17. Discharge Hemoglobin Level and 30-Day Readmission Rates After Coronary Artery Bypass Surgery.
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Cho BC, DeMario VM, Grant MC, Hensley NB, Brown CH 4th, Hebbar S, Mandal K, Whitman GJ, and Frank SM
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- Aged, Coronary Artery Bypass adverse effects, Female, Humans, Male, Middle Aged, Postoperative Complications diagnosis, Retrospective Studies, Risk Factors, Time Factors, Coronary Artery Bypass trends, Hemoglobins metabolism, Patient Discharge trends, Patient Readmission trends, Postoperative Complications blood
- Abstract
Background: Restrictive transfusion strategies supported by large randomized trials are resulting in decreased blood utilization in cardiac surgery. What remains to be determined, however, is the impact of lower discharge hemoglobin (Hb) levels on readmission rates. We assessed patients with higher versus lower Hb levels on discharge to compare 30-day readmission rates after coronary artery bypass grafting (CABG)., Methods: We retrospectively evaluated 1552 patients undergoing isolated CABG at our institution from January 2013 to May 2016. We evaluated 2 Hb cohorts: "high" (above) and "low" (below) the mean discharge Hb level of 9.4 g/dL, comparing patient characteristics, blood utilization, and clinical outcomes including 30-day readmission rates. We further evaluated the effects of the lowest (<8 g/dL) discharge Hb levels on 30-day readmission rates by dividing the patients into 4 anemia cohorts based on discharge Hb levels: "no anemia" (>12 g/dL), "mild anemia" (10-11.9 g/dL), "moderate anemia" (8-9.9 g/dL), and "severe anemia" (<8 g/dL). Risk adjustment accounted for age, sex, Charlson comorbidity index, preoperative comorbidities, revision sternotomy, and patient blood management program implementation., Results: The "high" and "low" groups had similar patient characteristics except for Hb levels (mean discharge Hb was 10.4 ± 0.9 vs 8.5 ± 0.6 g/dL, respectively). Notably, no evidence for a difference in 30-day readmission rates was noted between the "high" (76/746; 10.2%) and "low" (97/806; 12.0%) (P = .25) Hb cohorts. The 4 anemia cohorts had differences in age, revision sternotomy incidence, Hb levels, certain patient comorbidities, and time to readmission. On multivariable analysis, the risk-adjusted odds of readmission in the "low" Hb cohort (odds ratio, 1.16; 95% confidence interval, 0.84-1.61; P = .36) was not significant compared to the "high" Hb cohort. Compared to patients with discharge Hb ≥8 g/dL, patients with Hb <8 g/dL had a higher incidence of readmission (22/129; 17.1% vs 151/1423; 10.6%; P = .036). On multivariable analysis, Hb <8 g/dL on discharge was predictive of readmission (odds ratio, 1.77; 95% confidence interval, 1.05-2.88; P = .03). The most common reason for readmission was volume overload, followed by infection and arrhythmias., Conclusions: A discharge Hb level below the institution mean for CABG patients does not provide evidence for an association with an increased 30-day readmission rate. In the small number of patients discharged with Hb <8 g/dL, there is a suggestion of increased risk for readmission and larger more controlled studies are needed to verify or refute this finding.
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- 2019
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18. The Impact of Anesthesia-Influenced Process Measure Compliance on Length of Stay: Results From an Enhanced Recovery After Surgery for Colorectal Surgery Cohort.
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Grant MC, Pio Roda CM, Canner JK, Sommer P, Galante D, Hobson D, Gearhart S, Wu CL, and Wick E
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- Adult, Aged, Anesthesia adverse effects, Digestive System Surgical Procedures adverse effects, Female, Guideline Adherence standards, Humans, Interdisciplinary Communication, Male, Middle Aged, Patient Care Team standards, Perioperative Care adverse effects, Practice Guidelines as Topic standards, Program Evaluation, Quality Improvement standards, Quality Indicators, Health Care standards, Recovery of Function, Time Factors, Treatment Outcome, Anesthesia standards, Anesthesiologists standards, Colon surgery, Digestive System Surgical Procedures standards, Length of Stay, Outcome and Process Assessment, Health Care standards, Perioperative Care standards, Practice Patterns, Physicians' standards, Rectum surgery
- Abstract
Background: Process measure compliance has been associated with improved outcomes in enhanced recovery after surgery (ERAS) programs. Herein, we sought to assess the impact of compliance with measures directly influenced by anesthesiology in an ERAS for colorectal surgery cohort., Methods: From January 2013 to April 2015, data from 1140 consecutive patients were collected for all patients before (pre-ERAS) and after (ERAS) implementation of an ERAS program. Compliance with 9 specific process measures directly influenced by the anesthesiologist or acute pain service was analyzed to determine the impact on hospital length of stay (LOS)., Results: Process measure compliance was associated with a stepwise reduction in LOS. Patients who received >4 process measures (high compliance) had a significantly shorter LOS (incident rate ratio [IRR], 0.77; 95% CI, 0.70-0.85); P < .001) compared to low compliance (0-2 process measures) counterparts. Multivariable regression suggests that utilization of multimodal nausea and vomiting prophylaxis (IRR, 0.78; 95% CI, 0.68-0.89; P < .001), scheduled postoperative nonsteroidal pain medication use (IRR, 0.76; 95% CI, 0.67-0.85; P < .001), and strict adherence to a postoperative opioid administration (IRR, 0.58; 95% CI, 0.51-0.67; P < .001) protocol for breakthrough pain were independently associated with reduced LOS., Conclusions: Our findings suggest that increased compliance with process measures directly influenced by the anesthesiologists and in concert with a formal anesthesia protocol is associated with reduced LOS. Engaging anesthesiology colleagues throughout the surgical encounter increases the overall value of perioperative care.
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- 2019
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19. In Response.
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Stone AB, Wu CL, and Grant MC
- Subjects
- Analgesics, Opioid
- Published
- 2018
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20. The US Opioid Crisis: A Role for Enhanced Recovery After Surgery.
- Author
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Stone AB, Wick EC, Wu CL, and Grant MC
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- Drug Prescriptions standards, Humans, Opioid-Related Disorders prevention & control, Pain Clinics standards, Pain Clinics trends, Pain Management trends, Patient Care Team standards, Patient Care Team trends, United States epidemiology, Analgesics, Opioid adverse effects, Opioid-Related Disorders epidemiology, Pain Management methods, Pain, Postoperative epidemiology, Pain, Postoperative therapy, Recovery of Function
- Published
- 2017
- Full Text
- View/download PDF
21. The Effect of Preoperative Pregabalin on Postoperative Nausea and Vomiting: A Meta-analysis.
- Author
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Grant MC, Betz M, Hulse M, Zorrilla-Vaca A, Hobson D, Wick E, and Wu CL
- Subjects
- Humans, Postoperative Nausea and Vomiting diagnosis, Postoperative Nausea and Vomiting prevention & control, Randomized Controlled Trials as Topic methods, Treatment Outcome, Analgesics administration & dosage, Postoperative Nausea and Vomiting drug therapy, Pregabalin administration & dosage, Preoperative Care methods
- Abstract
Background: Nonopioid adjuvant medications are increasingly included among perioperative Enhanced Recovery After Surgery protocols. Preoperative pregabalin has been shown to improve postoperative pain and limit reliance on opioid analgesia. Our group investigated the ability of preoperative pregabalin to also prevent postoperative nausea and vomiting (PONV)., Methods: Our group performed a meta-analysis of randomized trials that report outcomes on the effect of preoperative pregabalin on PONV endpoints in patients undergoing general anesthesia., Results: Among all included trials (23 trials; n = 1693), preoperative pregabalin was associated with a significant reduction in PONV (risk ratio [RR] = 0.53; 95% confidence interval [CI], 0.39-0.73; P = 0.0001), nausea (RR = 0.62; 95% CI, 0.46-0.83; P = 0.002), and vomiting (RR = 0.68; 95% CI, 0.52-0.88; P = 0.003) at 24 hours. Subgroup analysis designed to account for major PONV confounders, including the exclusion trials with repeat dosing, thiopental induction, nitrous oxide maintenance, and prophylactic antiemetics and including high-risk surgery, resulted in similar antiemetic efficacy. Preoperative pregabalin is also associated with significantly increased rates of postoperative visual disturbance (RR = 3.11; 95% CI, 1.34-7.21; P = 0.008) compared with a control., Conclusions: Preoperative pregabalin is associated with significant reduction of PONV and should not only be considered as part of a multimodal approach to postoperative analgesia but also for prevention of PONV.
- Published
- 2016
- Full Text
- View/download PDF
22. The Effect of Preoperative Gabapentin on Postoperative Nausea and Vomiting: A Meta-Analysis.
- Author
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Grant MC, Lee H, Page AJ, Hobson D, Wick E, and Wu CL
- Subjects
- Gabapentin, Humans, Postoperative Nausea and Vomiting diagnosis, Treatment Outcome, Amines administration & dosage, Cyclohexanecarboxylic Acids administration & dosage, Postoperative Nausea and Vomiting epidemiology, Postoperative Nausea and Vomiting prevention & control, Preoperative Care methods, gamma-Aminobutyric Acid administration & dosage
- Abstract
Background: Preoperative gabapentin has been shown to improve postoperative pain and limit reliance on opioid analgesia. On the basis of an alternative mechanism, our group investigated the ability of preoperative gabapentin to prevent postoperative nausea and vomiting (PONV)., Methods: We performed a meta-analysis of trials that reported outcomes on the effect of preoperative gabapentin on PONV end points in patients undergoing general anesthesia. In our primary analysis, we calculated the pooled antiemetic effects of preoperative gabapentin in studies with PONV as the primary end point. In our secondary analysis, we calculated the pooled effects in trials involving preoperative gabapentin that reported on the side effects, nausea and vomiting., Results: Among the trials designed with PONV as a primary end point (8 trials; n = 838), preoperative gabapentin was associated with a significant reduction in PONV (risk ratio [RR] = 0.60; 99% confidence interval [CI], 0.50-0.72; P < 0.0001), nausea (RR = 0.34; 99% CI, 0.20-0.56; P < 0.0001), and vomiting (RR = 0.34; 99% CI, 0.19-0.61; P = 0.0002) at 24 hours. Among all included trials (44 trials; n = 3489) that reported on the side effects, nausea and vomiting, similar reductions were noted in PONV with preoperative gabapentin administration. Subgroup analysis of trials excluding repeat dosing, thiopental induction, and nitrous oxide maintenance and including high-risk surgery resulted in similar PONV efficacy. Preoperative gabapentin is also associated with significantly increased rates of postoperative sedation (RR = 1.22; 95% CI, 1.02-1.47; P = 0.03) compared with control., Conclusions: Preoperative gabapentin is associated with a significant reduction in PONV among studies designed to investigate this end point. Preoperative gabapentin should be considered not only as part of a multimodal approach to postoperative analgesia, but also for prevention of PONV.
- Published
- 2016
- Full Text
- View/download PDF
23. The Effect of Intravenous Midazolam on Postoperative Nausea and Vomiting: A Meta-Analysis.
- Author
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Grant MC, Kim J, Page AJ, Hobson D, Wick E, and Wu CL
- Subjects
- Antiemetics administration & dosage, Humans, Injections, Intravenous, Midazolam administration & dosage, Randomized Controlled Trials as Topic, Antiemetics therapeutic use, Midazolam therapeutic use, Postoperative Nausea and Vomiting prevention & control
- Abstract
Background: Research has shown that high-risk surgical patients benefit from a multimodal therapeutic approach to prevent postoperative nausea and vomiting (PONV). Our group sought to investigate the effect of administering IV midazolam on PONV., Methods: This meta-analysis included 12 randomized controlled trials (n = 841) of adults undergoing a variety of surgical procedures that investigated the effect of both preoperative and intraoperative IV midazolam on PONV in patients undergoing general anesthesia., Results: Administration of IV midazolam was associated with significantly reduced PONV (risk ratio [RR] = 0.55; 95% confidence interval [CI], 0.43-0.70), nausea (RR = 0.62; 95% CI, 0.40-0.94), vomiting (RR = 0.61; 95% CI, 0.45-0.82), and rescue antiemetic administration (RR = 0.49; 95% CI, 0.37-0.65) within 24 hours. Individual subgroup analyses of trials excluding the use of thiopental for induction, trials of either female sex or high-risk surgery, trials involving nitrous oxide maintenance, and trials using midazolam in combination with known antiemetics all yielded similar reductions in PONV end points within 24 hours of surgery., Conclusions: Administration of preoperative or intraoperative IV midazolam is associated with a significant decrease in overall PONV, nausea, vomiting, and rescue antiemetic use. Providers may consider the administration of IV midazolam as part of a multimodal approach in preventing PONV.
- Published
- 2016
- Full Text
- View/download PDF
24. The Efficacy and Utility of Acute Normovolemic Hemodilution.
- Author
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Grant MC, Resar LM, and Frank SM
- Subjects
- Humans, Blood Loss, Surgical prevention & control, Blood Transfusion methods, Blood Transfusion, Autologous methods, Hemodilution methods, Preoperative Care methods
- Published
- 2015
- Full Text
- View/download PDF
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