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A response from the author of the article "Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA" published in a previous issue is presented.

Background: The rate of hospital-based acute care (defined as hospital transfer at discharge, emergency department [ED] visit, or subsequent inpatient hospital [IP] admission) after outpatient procedure is gaining momentum as a quality metric for ambulatory surgery. However, the incidence and reasons for hospital-based acute care after arthroscopic shoulder surgery are poorly understood., Methods: We studied adult patients who underwent outpatient arthroscopic shoulder procedures in New York State between 2011 and 2013 using the Healthcare Cost and Utilization Project database. ER visits and IP admissions within 7 days of surgery were identified by cross-matching 2 independent Healthcare Cost and Utilization Project databases., Results: The final cohort included 103,476 subjects. We identified 1867 (1.80%, 95% confidence interval [CI], 1.72%-1.89%) events, and the majority of these encounters were ER visits (1643, or 1.59%, 95% CI, 1.51%-1.66%). Direct IP admission after discharged was uncommon (224, or 0.22%, 95% CI, 0.19%-0.24%). The most common reasons for seeking acute care were musculoskeletal pain (23.78% of all events). Nearly half of all events (43.49%) occurred on the day of surgery or on postoperative day 1. Operative time exceeding 2 hours was associated with higher odds of requiring acute care (odds ratio [OR], 1.28; 99% CI, 1.08-1.51). High-volume surgical centers (OR, 0.67; 99% CI, 0.58-0.78) and regional anesthesia (OR, 0.72; 99% CI, 0.56-0.92) were associated with lower odds of requiring acute care., Conclusions: The rate of hospital-based acute care after outpatient shoulder arthroscopy was low (1.80%). Complications driving acute care visits often occurred within 1 day of surgery. Many of the events were likely related to surgery and anesthesia (eg, inadequate analgesia), suggesting that anesthesiologists may play a central role in preventing acute care visits after surgery.

Background: Hip fracture is a common, morbid, and costly event among older adults. Data are inconclusive as to whether epidural or spinal (regional) anesthesia improves outcomes after hip fracture surgery., Methods: The authors examined a retrospective cohort of patients undergoing surgery for hip fracture in 126 hospitals in New York in 2007 and 2008. They tested the association of a record indicating receipt of regional versus general anesthesia with a primary outcome of inpatient mortality and with secondary outcomes of pulmonary and cardiovascular complications using hospital fixed-effects logistic regressions. Subgroup analyses tested the association of anesthesia type and outcomes according to fracture anatomy., Results: Of 18,158 patients, 5,254 (29%) received regional anesthesia. In-hospital mortality occurred in 435 (2.4%). Unadjusted rates of mortality and cardiovascular complications did not differ by anesthesia type. Patients receiving regional anesthesia experienced fewer pulmonary complications (359 [6.8%] vs. 1,040 [8.1%], P < 0.005). Regional anesthesia was associated with a lower adjusted odds of mortality (odds ratio: 0.710, 95% CI 0.541, 0.932, P = 0.014) and pulmonary complications (odds ratio: 0.752, 95% CI 0.637, 0.887, P < 0.0001) relative to general anesthesia. In subgroup analyses, regional anesthesia was associated with improved survival and fewer pulmonary complications among patients with intertrochanteric fractures but not among patients with femoral neck fractures., Conclusions: Regional anesthesia is associated with a lower odds of inpatient mortality and pulmonary complications among all hip fracture patients compared with general anesthesia; this finding may be driven by a trend toward improved outcomes with regional anesthesia among patients with intertrochanteric fractures.

Blood brain barrier disruption enhances drug delivery in primary central nervous system lymphoma. In this study, we report adverse events that were encountered intraoperatively and in the postoperative period in these patients. A retrospective analysis of 17 patients documenting demographic data, preprocedure medical history, intraoperative, and postoperative anesthetic complications was conducted between January 2002 and December 2004. Seventeen patients underwent 210 treatments under general anesthesia with a mean of 12.4+/-7.2 treatments per patient. Focal seizures occurred in 13% of patients. Generalized motor seizures occurred in 4 treatment sessions in 2 different patients. The incidence of seizures was significantly higher when the internal carotid artery was used for injection, as opposed to the vertebral artery (20.8% and 6.02%, respectively, P=0.0034). Tachycardia associated with ST segment depression occurred 9 times (4.3%) in 3 patients. One patient had significant ST segment elevation (more than 1.5 mm). Transient cerebral vasospasm after methotrexate injection occurred in 9% of patients. Postoperative nausea and vomiting were observed in 11.9% of patients. After emergence, lethargy and obtundation occurred in 7.6% of the cases. The incidence of postoperative headache and reversible motor deficits was 6% and 3.8%, respectively. Our review highlights the problems that were encountered during blood brain barrier disruption under anesthesia and in the postoperative period. Further prospective studies are required for comprehensive evaluation of intraprocedure and postprocedure complications that will allow development of an optimal anesthetic plan and will improve patient outcome by preventing potential complications.