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Study objective Recovery from anesthesia may be complicated with development of severe panic symptoms and anxiety. Preexisting anxiety disorder has been reported as a risk factor for development of these symptoms. We aimed to examine the frequency of emergence delirium (EDL) among veterans diagnosed with posttraumatic stress disorders (PTSDs). Design Retrospective cohort. Setting Postoperative recovery area. Patients Perioperative information of 1763 consecutive patients who underwent a surgical procedure requiring general anesthesia were collected. The patients were grouped on the basis of previous diagnosis of PTSD. A total of 317 patients were identified with a positive history of PTSD and were compared to 1446 patients without such a history for the occurrence of EDL in the postanesthesia care unit (PACU) as the primary endpoint. Measurements Duration of stay in PACU in minutes and the frequency of hospital admission were the secondary endpoints. Multivariate binary logistic regression analysis was performed to identify the predictors of EDL among the veteran population. Main results Emergence delirium was reported in 37 cases (2.1%) after general anesthesia. Fifteen (4.7%) of 317 patients with PTSD and 22 (1.5%) of 1446 patients without history of PTSD demonstrated symptoms related to EDL in the PACU ( P =.002). After propensity matching, there were 8 patients with EDL in the PTSD group whereas there were only 2 patients with EDL among controls. Posttraumatic stress disorder was also an independent predictor of EDL in multivariate analysis with an odds ratio of 6.66 and a 95% confidence interval of 2.04 to 21.72 ( P =.002). Conclusions Posttraumatic stress disorder independently predicted the frequency of EDL even after correcting for preexisting depression and anxiety disorders. A relatively longer duration of PACU stay in PTSD patients may reflect raised awareness of the health care workers about this debilitating mental disorder.

We present a case that involves anesthetic resistance during anesthesia for electroconvulsive therapy. Despite adequate dosing of both intravenous and inhalation anesthetics, our patient was resistant to induction of the state of general anesthesia. Subsequently, we noticed extreme hyperlipidemia. We hypothesized that the patient's extreme hyperlipidemia served as an anesthetic "sink" and prevented the full dose of intravenous agents from quickly reaching their intended site of action.

BACKGROUND: To examine the validity of Veterans Affair–VA risk assessment tool in predicting the perioperative and overall mortality among octogenarians. METHODS: This is a single-institution retrospective observational study, in which the clinical information of 1,618 octogenarians were extracted from the VA Surgical Quality Improvement Program database. VA risk assessment tool and ASA classification were used to predict the probability of postoperative mortality and morbidity. Multiple risk groups were compared for mortality using multiple logistic regressions. RESULTS: There were 570 survivors and 1,048 nonsurvivors. VA risk tool strongly predicted perioperative 30-day mortality in receiver operator characteristic curve analysis (area under the curve: .82 6 .02). The power of this tool, while acceptable, was less in predicting overall mortality (area under the curve: .68 6 .01). Age, dialysis, a history of congestive heart failure, functional status, transfusion, and weight loss were also associated with increased rate of death within 30 days. CONCLUSIONS: VA risk toolpredicted both perioperative and overallmortality. Relatively strong power of this tool in predicting overall mortality may be unique to this age group because of their advanced age. Published by Elsevier Inc.

Study Objective To determine whether a diagnosis of obstructive sleep apnea (OSA) imparts an increased risk of postoperative respiratory failure, cardiac events, and intensive care unit (ICU) transfer than patients with no OSA diagnosis. Design Systematic review and meta-analysis. Setting Academic Veterans Affairs Medical Center. Measurements PubMed, EMBASE, CINAHL, and ISI Web of Knowledge databases were searched through April 2013 for studies that examined the relationship between OSA and postoperative respiratory and cardiac complications among adults. Either fixed or random-effects models were used to calculate the pooled risk estimates. Sensitivity analysis was conducted to examine the robustness of pooled outcomes. Main Results Seventeen studies with a total of 7,162 patients were included. Overall, OSA was associated with significant increase in risk of respiratory failure [odds ratio (OR) 2.42; 95% confidence intervals (CI) 1.53 - 3.84; P = 0.0002] and cardiac events postoperatively (OR = 1.63; 95% CI 1.16 - 2.29; P = 0.005). Heterogeneity was low for these outcomes (I 2 = 5% and 0%, respectively). ICU transfer occurred also more frequently in patients with OSA (OR 2.46; 95% CI 1.29 - 4.68; P = 0.006). These results did not materially change in the sensitivity analyses according to various inclusion criteria. Conclusions Surgical patients with OSA are at increased risk of postoperative respiratory failure, cardiac events, and ICU transfer.

We thank our colleagues for the careful review of our manuscript and expressing their concerns [1]. As mentioned, we defined postoperative acute kidney injury (AKI) based on the Acute Kidney Injury Network stage 1 criteria by an absolute serum creatinine increase of greater than or equal to 0.3 mg/dL or 50% of the baseline creatinine in 48 hours. Including fluid balance in the definition and staging of AKI has been proposed for patients with acute lung injuries and critically ill patients [2-4]. However, extension of this idea to cardiac surgery patients is challenging because one cannot assume that, at the start of postoperative period, the patients are in zero fluid balance status. Moore et al [5] have incorporated the fluid balance during 18 hours after cardiac surgery to the classification of AKI; yet, because intraoperative fluid status is on constant changewith hemofiltration and intravenous fluid administration, the 18-hour postoperative period does not take in to the account the important intraoperative phase. Although anemia is not included in themajor risk predictionmodels for cardiac surgery such as the European System for Cardiac Operative Risk Evaluation II [6], Parsonnet score [7], or Society of Thoracic Surgeons Predicted Risk of Mortality, it has been shown to independently associate with adverse outcomes after cardiac surgery [8]. However, in our study, preoperative hematocrit was not an independent predictor of postoperative AKI in multivariate analysis. Preoperative hematocrit was 37.8% ± 5.1% in patients who did not receive vasopressin during surgery compared to 37.6% ± 5.3% (P = .664). Severe anemia (hematocrit b30%) was present in 17 (6.1%) of patients who received vasopressin and 10 (4.9%) of patients who did not receive vasopressin intraoperatively (P = .375). Accordingly, groups were comparable regarding the incidence of anemia. We aimed to examine the effects of intraoperative vasopressin on postoperative AKI. The primary outcome variable was the occurrence of AKI, and the study is focused on evaluation of this complication. Although various postoperative complications influence the postoperative mortality, studying themwas beyond the scope of our article.