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Introduction Controlled substance waste processes in perioperative areas can be cumbersome. Streamlining this process is a critical component of improving operating room efficiency. At our institution, unused controlled substances require a two-person waste prior to disposal. We hypothesized that access to a centrally located automated medication dispensing system to conduct medication waste would decrease the amount of time required to perform a two-person waste and dispose of unused medications after the completion of a case. We further hypothesized that a decrease in the time required to waste would improve user satisfaction with the waste process. Methods This was a single-center, retrospective, IRB-approved quality assurance analysis. Research Electronic Data Capture (REDCap, Stony Brook, NY, United States) software was used to design an anonymous survey, which was distributed via email from 06/09/2021 to 09/09/2021. Wilcoxon signed-rank tests were used to compare before and after paired responses for individuals. Analyses were performed using SAS 9.4 © (Cary, NC, United States) software. Results Participants reported a significant decrease in time carrying used narcotics after a surgical case. For the primary outcome, median (IQR) scores demonstrated a significant decrease from 2, representing "10-20 minutes" (IQR 1-3), to 1, indicating "<10 minutes" (IQR 1-2) spent carrying used narcotics (p < 0.0001). Reported satisfaction with the process significantly increased from 2 to 3 points, on a scale of 5, after using the new centrally located Pyxis (p < 0.0001). Participants reported the wasting process as less time-consuming, carried fewer used controlled substances, and were less likely to wait until the end of the shift to waste. Conclusions By improving the ergonomics of the waste process after adding a Pyxis system in a more central location, the time anesthesia clinicians spent carrying used controlled substances decreased. Additionally, provider satisfaction increased, likely related to the ease of finding a partner to witness wasted medications., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board issued approval IRB2022-00122. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Parikh et al.)

Background: Unplanned admission after surgery at an ambulatory surgery center (ASC) is an established measure of the quality of care and can affect the patient's experience. Previous studies on this topic are generally dated, focused on a single specialty, or studied 30-day admissions after ambulatory surgery. Few studies have reported admission within 24 h after surgery at an ASC which is a different but important measure of the quality of anesthetic and surgical care. Understanding admissions within 24 h of surgery can identify opportunities for improvement immediately after surgery. Therefore, our study was designed to assess the incidence and risk factors for unplanned hospital admissions within 24 h after surgery performed at a hospital ASC., Methods: After Institutional Review Board approval, a retrospective analysis was performed on all adult patients who underwent surgery at a US ASC between January 1, 2016, and December 31, 2022. Data were obtained from the hospital's electronic medical record. The study sample was divided into two groups: those with an unplanned hospital admission within 24 h after surgery and those without an unplanned hospital admission. To evaluate risk factors for unplanned hospital admissions, univariate analyses with p value < 0.05 were utilized to identify significant patient variables related to hospital admissions. These variables were further adjusted using a multivariable Firth logistic regression. Descriptive statistics were used to explore the number of patients in different variable categories., Results: Overall, 53,185 cases were identified for the 7-year period. The incidence of unplanned hospital admission over this period was 0.09% (95% CI 0.07-0.1122%; ranging from 0.05 to 0.12% per year. In the multivariable model, surgery duration (OR 1.010, 95% CI 1.007-1.012, p value < 0.0001), peripheral vascular disease (OR 14.489, 95% CI 4.862-43.174, p value < 0.0001), and deep venous thrombosis (OR 5.527, 95% CI 1.909-16.001, p value = 0.0016) were significantly associated with unplanned hospital admission., Conclusion: The overall incidence of unplanned hospital admission after surgery at a large tertiary care ambulatory surgery center is very low. This admission rate can also serve as a reference point for future studies and quality improvement initiatives., (© 2024. The Author(s).)

Background: Chamomile is consumed worldwide for enjoyment and its potentially desirable properties. Widespread patient resource websites, however, discourage preoperative chamomile intake, lest bleeding could worsen. This precaution, though, stems largely from indirect evidence in one case report. To evaluate if chamomile ingestion impacts coagulation assays via coumarin-like substances, we designed a randomized, placebo-controlled, crossover study., Materials and Methods: Healthy volunteers were randomized to three interventions in a cross-over-design spanning 5 weeks per subject. Interventions included 7-day consumption of chamomile tea (3 tea bags × 3 times daily = 9 tea bags daily), a chamomile extract capsule (3 times daily), or a placebo capsule (3 times daily). A 7-day washout period elapsed between intervention periods. The primary outcome was the change in prothrombin time (PT) before vs. after each intervention. Secondary outcomes included changes in the international normalized ratio (INR), activated partial thromboplastin time (aPTT), thrombin time (TT), reptilase time (RT), and fibrinogen (FG) surrounding each intervention., Results: All 12 enrolled subjects were randomized and completed the study. The primary outcome of PT change (mean ± SD) was similar across interventions (chamomile tea =  - 0.2 ± 0.4 s, extract capsule =  - 0.2 ± 0.4 s, and placebo capsule = 0.1 ± 0.5 s; p = 0.34). INR change was 0 s (p = 0.07) for each intervention. The aPTT, TT, RT, and FG, did not change significantly across interventions (p = 0.8, p = 0.08, p = 0.8, and p = 0.2 respectively)., Conclusions: Chamomile intake by tea or capsule does not prolong PT. These findings challenge the notion to avoid perioperative chamomile intake in patients not taking warfarin., Trial Registration: ClinicalTrials.gov, NCT05006378; Principal Investigator: Jonathon Schwartz, M.D.; Registered August 16, 2021., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Patient reported outcomes measures (PROMS) are important endpoints to measure patient health status in the perioperative setting. However, there are no good tools to measure PROMS in the pediatric surgical population. Patients 7 to 17 years old undergoing surgery were included and followed up for 1 day after surgery (POD1). At POD1 the patients were asked to rate their overall postoperative recovery using a 100-mm visual analog scale (VAS). The primary outcome was the pediatric QoR-15 score on postoperative day 1 (POD1). 150 patients completed the study. The mean (SD) pediatric QoR-15F scores were 132.1 (14.1) and 111.0 (27.0), preoperatively and on POD1, respectively. Convergent validity confirmed with Pearson (r) correlation between the postoperative pediatric QoR-15F and the patient-rated global recovery assessment was 0.72 (95% confidence interval [0.63-0.79]; p < 10 -16 ). Concerning reliability, internal consistency of the pediatric QoR-15 assessed by Cronbach's alpha was 0.90. The test-retest concordance correlation coefficient was 0.92; 95% CI [0.83-0.96]. Split-half alpha was 0.74. The pictorial pediatric version of the QoR-15F showed good validity, reliability, responsiveness, acceptability and feasibility. This PROMS should be considered for clinical care and research in the perioperative pediatric patient setting.Trial Registration: NCT04453410 on clinicaltrials.gov., (© 2023. Springer Nature Limited.)

Background: Pre-procedural fasting to reduce aspiration risk is usual care prior to surgery requiring anesthesia. Prolonged fasting, however, can result in dehydration and may adversely affect patient experience and outcomes. Previous studies suggest that providing a supplemental beverage to patients undergoing cardiac and a variety of other surgical procedures improves patients' subjective assessment of thirst and hunger and potentially decreases the need for inotrope and vasopressor therapy. Less is known, however, about the effects of ad libitum clear liquids up to 2 h prior to surgery., Methods: Adult patients undergoing transcatheter aortic valve replacement (TAVR) or arrhythmia ablation were randomized (1:1) to ad libitum clear liquids up to 2 h prior to their procedure vs. nil per os (NPO) after midnight (control group, usual care). The primary endpoint was a composite satisfaction score that included patient-reported thirst, hunger, headache, nausea, lightheadedness, and anxiousness prior to surgery. The incidence of case-delay was recorded. Intraoperative vasopressor administration, changes in creatinine, anti-emetic use, and hospital length of stay (LOS) were recorded. Safety endpoints including aspiration were assessed., Results: A total of 200 patients were randomized and 181 patients were included in the final analysis. Overall, 92% of patients were ASA class III or IV and 23% of patients had NYHA class III or IV symptoms. Groups were well balanced with no significant differences in age, sex or baseline cardiac or renal disease. The composite satisfaction score (primary endpoint) was not significantly different between groups (Ad libitum median = 12, IQR = [6, 17], vs Standard NPO median = 10, IQR = [5, 15], [95% CI = [-1, 4]). No significant differences between the two groups were observed in any of the individual survey questions (thirst, hunger, headache, nausea, lightheadedness, anxiousness). No significant differences between groups were observed for intra-operative vasopressor use, changes in creatinine, rescue anti-emetic use or hospital LOS. There were no case delays attributed to the intervention. There were no cases of suspected aspiration., Conclusion: No adverse events or case delays were observed in the ad libitum clears group. No significant benefit, however, was observed in patient satisfaction or any of the pre-specified secondary endpoints in patients randomized to ad libitum clear liquids up to 2 h prior to their procedure., Trial Registration: NCT04079543., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: In the early postoperative period, respiratory compromise is a significant problem. Standard-of-care monitoring includes respiratory rate (RR) and pulse oximetry, which are helpful; however, low SpO 2 is often a late sign during decompensation. The FDA-approved Capnostream-20p monitor records four variables (SpO 2 , RR, End-tidal CO 2 , heart rate), which are combined by fuzzy logic into a single, unit-less value (range 1-10) called the integrated pulmonary index (IPI). No published studies have assessed the performance of a low IPI to predict impending respiratory events., Methods: In this investigator-initiated study, adult patients undergoing general anesthesia were monitored with the Capnostream-20p monitor for up to 2 h during their recovery room stay. The study coordinator, who along with clinicians, was blinded to IPI values, recorded the time of any respiratory event, defined a priori as any one of eight respiratory-related interventions/conditions. The primary sensitivity endpoint (early detection success) was defined as at least 80% of events predicted by at least 2 consecutive low IPI (≤ 7) values within 2-15 min before an event occurred. Late detection was defined as low IPI values occurring with 2 min prior to or 2 min after the event occurred., Discussion: Of 358 patients, ≥ 1 respiratory event occurred in 183 (51.1%) patients. Of 802 total events, 606 were detected early (within 2-15 min prior to the event), and 653 were detected either early or late. Therefore, the sensitivity for early detection was 75.6% (95% confidence interval [CI]: 72.6-78.5%), which differed significantly from the 80% sensitivity goal by 4.4% (p = 0.0016). Sensitivity for total success (early or late) was 81.4% (95% CI: 78.7-84.1%), which was significantly different from the 90% on time sensitivity goal by 8.6% (p < 0.0001)., Conclusions: A low IPI was 75.6% sensitive for early detection (within 2-15 min) prior to respiratory events but did not achieve our preset threshold of 80% for success., (© 2023. The Author(s).)

Background: Studies indicate that patients can be "seeded" with their own cancer cells during oncologic surgery and that the immune response to these circulating cancer cells might influence the risk of cancer recurrence. Preliminary data from animal studies and some retrospective analyses suggest that anesthetic technique might affect the immune response during surgery and hence the risk of cancer recurrence. In 2015, experts called for prospective scientific inquiry into whether anesthetic technique used in cancer resection surgeries affects cancer-related outcomes such as recurrence and mortality. Therefore, we designed a pragmatic phase 3 multicenter randomized controlled trial (RCT) called General Anesthetics in Cancer Resection (GA-CARES)., Methods: After clinical trial registration and institutional review board approval, patients providing written informed consent were enrolled at five sites in New York (NY) State. Eligible patients were adults with known or suspected cancer undergoing one of eight oncologic surgeries having a high risk of cancer recurrence. Exclusion criteria included known or suspected history of malignant hyperthermia or hypersensitivity to either propofol or volatile anesthetic agents. Patients were randomized (1:1) stratified by center and surgery type using REDCap to receive either propofol or volatile agent for maintenance of general anesthesia (GA). This pragmatic trial, which seeks to assess the potential impact of anesthetic type in "real world practice", did not standardize any aspect of patient care. However, potential confounders, e.g., use of neuroaxial anesthesia, were recorded to confirm the balance between study arms. Assuming a 5% absolute difference in 2-year overall survival rates (85% vs 90%) between study arms (primary endpoint, minimum 2-year follow-up), power using a two-sided log-rank test with type I error of 0.05 (no planned interim analyses) was calculated to be 97.4% based on a target enrollment of 1800 subjects. Data sources include the National Death Index (gold standard for vital status in the USA), NY Cancer Registry, and electronic harvesting of data from electronic medical records (EMR), with minimal manual data abstraction/data entry., Discussion: Enrollment has been completed (n = 1804) and the study is in the follow-up phase. This unfunded, pragmatic trial, uses a novel approach for data collection focusing on electronic sources., Trial Registration: Registered (NCT03034096) on January 27, 2017, prior to consent of the first patient on January 31, 2017., (© 2023. The Author(s).)

Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Objective: The induction of general anesthesia for children and patients with special needs frequently requires preinduction sedation, especially when anxiety and agitation lead to violent or combative behavior. In these situations, preoperative intramuscular (IM) sedation may facilitate patient transfer, intravenous cannulation, and/or mask induction. This survey aimed to capture data regarding the current preoperative IM sedation practices of dentist anesthesiologists., Methods: An electronic survey was distributed in 2020 to all members of the American Society of Dentist Anesthesiologists regarding the administration of preoperative IM sedation. It included questions about the demographics of respondents and their patients who require IM sedation, the most common drug regimens used, decision-making criteria regarding ketamine dosing, the intended level of sedation, sequence of anesthetic management following IM sedation, and observed outcomes., Results: A total of 193 responses (43%) were received; of those, 162 reported using preoperative IM sedation. Ketamine was included in 98.7% of reported IM drug regimens. The most common IM sedation regimen was combined ketamine and midazolam (median 2.5 mg/kg and 0.1 mg/kg, respectively). Of the respondents who use preoperative IM sedation, 87% reported using the same drug regimen in at least 80% of cases., Conclusion: The most frequently reported drug regimen used by dentist anesthesiologists in North America for preoperative IM sedation was a combination of ketamine and midazolam., (© 2022 by the American Dental Society of Anesthesiology.)

Background: Bleeding can be a significant problem after cardiac surgery. As a result, venous thromboembolism (VTE) or anticoagulation or both following mechanical valve implantation are often delayed in these patients. The calibrated automated thrombin (CAT) generation assay has become the gold standard to evaluate thrombin generation, a critical step in clot formation independent of other hemostatic processes (eg, platelet activation, fibrin cross-linking, and fibrinolysis), and is increasingly used to examine thrombotic and hemorrhagic outcomes. No study has currently used this assay to compare the thrombin generation profiles of cardiac surgical patients to noncardiac surgical patients. We hypothesize that noncardiac patients may be less prone to postoperative changes in thrombin generation., Methods: A prospective, observational, cohort study was undertaken using blood samples from 50 cardiac and 50 noncardiac surgical patients preoperatively, immediately postoperatively, and on postoperative days 1 to 4. Platelet-poor plasma samples were obtained from patients preoperatively, on arrival to the postanesthesia care unit (PACU) or intensive care unit (ICU), and daily on postoperative days 1 to 4 if patients remained inpatient. Samples were evaluated for CAT measurements. Patient and surgical procedure characteristics were obtained from the electronic medical record., Results: The primary outcome variable, median endogenous thrombin potential (ETP), measured in nanomolar × minutes (nM × min), was decreased 100% in cardiac surgical versus 2% in noncardiac patients (P < .001). All parameters of thrombin generation were similarly depressed. Cardiac (versus noncardiac) surgical type was associated with -76.5% difference of percent change in ETP on multivariable regression analysis (95% confidence interval [CI], -87.4 to -65.5; P value <.001)., Conclusions: Cardiac surgical patients exhibit a profound decrease in thrombin generation postoperatively compared with noncardiac surgical patients evaluated by this study. Hemodilution and coagulation factor depletion likely contribute to this decreased thrombin generation after cardiac surgery., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Background: As patients are discharged from the hospital more quickly, the ability to monitor patient recovery between hospital discharge and the first follow-up clinic visit is becoming increasingly important. Despite substantial increase in both internet use and smartphone ownership over the past 5 years, clinicians have been slow to embrace the use of these devices to capture patient recovery information in the period between hospital discharge and the first clinical follow-up appointment., Objective: This study aims to investigate the generalizability of using a web-based platform to capture patient recovery in a broad surgical patient population and compare response rates for 3 different web-based strategies for delivering recovery surveys over the perioperative period: email, SMS text messaging, and a concurrent mixed approach of using both email and SMS text messaging., Methods: Patients undergoing surgeries managed with an enhanced recovery after surgery pathway were asked to participate in a web-based quality assurance monitoring program at the time of their preoperative surgery appointment. Different follow-up methods were implemented over 3 sequential phases. Patients received Health Insurance Portability and Accountability Act-compliant web-based survey links via email (phase 1), SMS text messaging (phase 2), or concurrently using both email and SMS text messaging (phase 3) using REDCap and Twilio software. Recovery assessments using the established Quality of Recovery-9 instrument were performed 4 days before surgery and at 7 and 30 days postoperatively. Generalizability of the web-based system was examined by comparing characteristics of those who participated versus those who did not. Differences in response rates by the web-based collection method were analyzed using adjusted models., Results: A total of 615 patients were asked to participate, with 526 (85.5%) opting for the follow-up program. Those who opted in were younger, slightly healthier, and more likely to be in a partnership. The concurrent mixed modes method was the most successful for obtaining responses at each time point compared with text or email alone (pre: 119/160, 74.4% vs 116/173, 67.1% vs 56/130, 43.1%, P<.001; 7 days: 115/172, 66.9% vs 82/164, 50.0% vs 59/126, 46.8%, P=.001; 30 days: 152/234, 65.0% vs 52/105, 49.5% vs 53/123, 43.1%, P=.001, respectively). In the adjusted model, the concurrent mixed modes method significantly predicted response compared with using email alone (odds ratio 3.4; P<.001) and SMS text messaging alone (odds ratio 1.9; P<.001). Additional significant predictors of response were race, partnership, and time., Conclusions: For internet users and smartphone owners, electronic capture of recovery surveys appear to be possible through this mechanism. Discrepancies in both inclusion and response rates still exist among certain subgroups of patients, but the concurrent approach of using both email and text messages was the most effective approach to reach the largest number of patients across all subgroups., (©Jamie L Romeiser, James Cavalcante, Deborah C Richman, Sunitha M Singh, Xiaohui Liang, Allison Pei, Samanvaya Sharma, Zoe Lazarus, Tong J Gan, Elliott Bennett-Guerrero. Originally published in JMIR Formative Research (https://formative.jmir.org), 04.11.2021.)

Background: Carbohydrate-containing drinks (CCD) are administered preoperatively in most enhanced recovery after surgery (ERAS) programs. It is not known which types of CCDs are used, e.g., simple vs. complex carbohydrate, and if the choice of drink differs in patients with diabetes., Methods: A national survey was performed to characterize the use of preoperative CCDs within the context of adult colorectal ERAS programs. The survey had questions regarding the use of preoperative CCDs, the types of beverages used, and the timing of beverage administration. The survey was administered electronically to members of the American Society for Enhanced Recovery (ASER) and manually to participants at the 2018 Perioperative Quality and Enhanced Recovery Conference in San Francisco, CA., Results: Responses were received from 78 unique hospitals with a colorectal ERAS program of which 68 (87.2%) reported administering a preoperative drink. Of these, 98.5%, 80.9%, and 60.3% of hospitals administered a beverage to patients without diabetes, patients with diabetes not taking insulin, and patients with diabetes taking insulin, respectively. Surprisingly, one third of programs that administered a beverage to patients with diabetes used a simple carbohydrate drink., Conclusions: This survey finds a high use of CHO-containing beverages in colorectal ERAS programs. More than half of all programs administer a CHO-containing beverage to patients with diabetes, and surprisingly, there is significant use of simple carbohydrate beverages in patients with diabetes receiving insulin.

Background: Enhanced Recovery After Surgery (ERAS) programs have gained traction across US hospitals in the past two decades. Initially implemented for elective colorectal surgical procedures, ERAS has expanded to a variety of surgical service lines. There is little information regarding the extent to which various surgical service lines use ERAS., Methods: A survey was performed to describe the prevalence of ERAS programs across surgical service lines in the USA. The survey had questions regarding the number of ERAS programs, operating rooms (ORs) and presence of anesthesia and/or surgery residency program at an institution. The survey was administered electronically to members of the American Society for Enhanced Recovery (ASER) and manually to participants at the 2018 Perioperative Quality and Enhanced Recovery Conference in San Francisco, CA., Results: Responses were received from 88 unique institutions. The most commonly reported surgical service lines were colorectal (87%), gynecology (51%), orthopedic (49%), surgical oncology (39%), and urology (35%). A significant positive association was observed between the number of ORs and the number ERAS programs (Spearman's Rho 0.5, p<0.0001). Furthermore, institutions that reported an anesthesia and/or surgery residency program had more ERAS programs (mean 5.0 ± 3.2) compared to those that did not (mean 2.0 ± 2.0) (Wilcoxon rank sum p< 0.001)., Conclusions: ERAS has expanded to a large extent outside of the colorectal surgery service line with increases notable in orthopedic surgery, obstetric/gynecology, surgical oncology, and urology procedures. Institutions with a higher number of ORs and the presence of an anesthesia and/or surgery residency program are associated with an increased number of ERAS programs.

Background: Health care workers (HCW) such as anesthesiologists, surgeons, and intensivists face high rates of exposure to SARS-CoV-2 through direct contact with COVID-19 patients. While there are initial reports of the prevalence of COVID-19 antibodies among the general population, there are few reports comparing the seroprevalence of IgM/IgG COVID-19 antibodies in HCW of different exposure levels as well as different HCW professions., Methods: A convenience sample of health care workers provided blood for COVID-19 antibody testing and a review of medical history and work exposure for correlative analyses., Results: Overall, 474 HCW were enrolled in April 2020 including 102 front-line physicians (e.g., anesthesiologists, surgeons, intensivists, emergency medicine), 91 other physicians, 135 nurses, 134 other clinical staff, and 12 non-clinical HCW. The prevalence of IgM or IgG antibodies to SARS-CoV-2 was 16.9% (95% CI 13.6-20.6) (80/474). The proportion of positive antibodies in the PCR + group was significantly higher than health care workers without symptoms (84.6% [95% CI 54.6-98.1] vs. 12.3% [95% CI 8.5-17.2], p < 0.001). No significant differences in proportions of COVID-19 antibodies were observed among the different exposure groups (e.g., high vs minimal/no exposure) and among the different HCW professionals., Conclusions: Despite exposure to COVID-19 patients, the prevalence of antibodies in our HCW was similar to what has been reported for the general population of New York State (14%) and for another New York HCW cohort (13.7%). Health care workers with higher exposure rates were not more likely to have been infected with COVID-19. Therefore, these data suggest that infection of HCW may result from exposure in the community rather than at work., Trial Registration: This investigator-initiated study was observational; therefore, no registration was required. Not applicable.

Precooperative children and patients with intellectual disabilities often require intramuscular (IM) sedation prior to the induction of general anesthesia (GA). Ketamine is an effective preinduction sedative but can produce significant adverse side effects. Dexmedetomidine, a sedative with sympatholytic and analgesic properties, may provide advantages when used in combination with ketamine. This retrospective study evaluated the efficacy and safety of IM ketamine with dexmedetomidine for preoperative sedation. We conducted a chart review of all patients (n = 105) treated for dental rehabilitation who received either IM ketamine and dexmedetomidine (study group, n = 74) or IM ketamine and midazolam (control group, n = 31) prior to induction of GA. No significant difference (p = .14) was observed in the time interval from IM administration to operating room entry (median [interquartile range]) between the study and control groups (5 [4-8] vs 5 [2-7] minutes). Patients who received IM dexmedetomidine exhibited significantly lower mean arterial pressures throughout the induction (p = .004) and had lower heart rates (p = .01) throughout the intraoperative period compared with patients who did not receive dexmedetomidine. The combination of dexmedetomidine and ketamine may provide effective and safe IM sedation prior to the induction of GA., (© 2021 by the American Dental Society of Anesthesiology.)

Objective: As the severe acute respiratory syndrome-coronavirus-2 pandemic develops, assays to detect the virus and infection caused by it are needed for diagnosis and management. To describe to clinicians how each assay is performed, what each assay detects, and the benefits and limitations of each assay., Data Sources: Published literature and internet., Study Selection: As well done, relevant and recent as possible., Data Extraction: Sources were read to extract data from them., Data Synthesis: Was synthesized by all coauthors., Conclusions: Available assays test for current or previous severe acute respiratory syndrome-coronavirus-2 infection. Nucleic acid assays such as quantitative, or real-time, polymerase chain reaction and loop-mediated isothermal amplification are ideal for acute diagnosis with polymerase chain reaction testing remaining the "gold standard" to diagnose acute infection by severe acute respiratory syndrome-coronavirus-2, specifically the presence of viral RNA. Assays that detect serum antibodies can theoretically diagnose both acute and remote infection but require time for the patient to develop immunity and may detect nonspecific antibodies. Antibody assays that quantitatively measure neutralizing antibodies are needed to test efficacy of convalescent plasma therapy but are more specialized., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Quality of recovery is an important component of perioperative health status. The 15-item Quality of Recovery (QoR-15) scale is a validated multidimensional questionnaire that measures postoperative quality of recovery. The aim of this study was to translate and assess the psychometric properties of a French version of the QoR-15 scale (QoR-15F) to measure postoperative recovery in French-speaking patients., Methods: After translation into French of the original English version of the QoR-15 scale, psychometric validation of the QoR-15F scale to measure postoperative quality of recovery was performed. This psychometric validation included validity, reliability, responsiveness, and feasibility. The QoR-15F scale was administered before operation and on Postoperative day 1 in French-speaking patients. Patient-perceived global recovery assessment was measured at Postoperative day 1 using a VAS., Results: We enrolled 150 patients, and 144 completed the study protocol. The completion rate of administered questionnaires was 100%. Pearson (r) correlation between postoperative QoR-15F and the global recovery assessment by the patient was 0.60 (P<0.0001). As expected, there was a significant negative correlation between QoR-15F score and duration of surgery (r=-0.29; P<0.01), duration of PACU stay (r=-0.21; P=0.01), and duration of hospital stay (r=-0.34; P<0.01). Cronbach's alpha was 0.81, split-half alpha was 0.83, and the global test-retest intra-class coefficient was 0.98 (0.95-0.99)., Conclusions: The QoR-15F is a valid and reliable tool to measure postoperative quality of recovery in French-speaking patients. The psychometric properties to measure postoperative quality of recovery were similar to the seminal English version., Clinical Trial Registration: NCT03578068., (Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

We surveyed Society of Cardiovascular Anesthesiologists members regarding anticoagulation practices for cardiopulmonary bypass and attitudes on heparin resistance. Of 550 respondents (18.5% response rate), 74.9% (95% CI, 71.3%-78.5%) used empiric weight-based dosing of heparin, and 70.7% (95% CI, 66.9%-74.5%) targeted an activated clotting time of either 400 or 480 seconds to initiate cardiopulmonary bypass. Of note, 17.1% (95% CI, 13.9%-20.2%) of respondents reported activated clotting time targets lower than those recommended by recent 2018 Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology guidelines or failed to monitor heparin effects at all. When heparin resistance was encountered, 54.2% of respondents (95% CI, 50.0%-58.4%) administered antithrombin concentrates as a first-line therapy.

Background: Impairment of pulmonary aeration is a frequent postoperative complication that is associated with adverse outcome. Diagnosis and quantification of impaired pulmonary aeration by CT scan is limited due to concern for exposure to ionizing radiation. Magnetic resonance imaging (MRI) represents a potential radiation-free alternative for this use. We undertook an experimental study to validate the use of MRI to quantify pulmonary aeration impairment. Methods: Ten large white pigs were studied before intubation, after intubation, 2 h after non-protective mechanical ventilation and after intra-tracheal negative pressure suction to induce atelectasis. A lung CT scan immediately followed by a lung MRI were performed at all four time points. On the 40 CT images lung volumes corresponding to non-aerated, poorly aerated, normally aerated, and overinflated voxels were measured based on their radiodensity. Similarly, on the 40 MRI images lung volumes corresponding to non-aerated and aerated voxels were measured based on their signal intensity. The correlation between non-aerated lung by MRI vs., CT scans, and with PaO 2 /FiO 2 measured at each of the four time points was assessed with the Pearson' correlation coefficient, bias and limits of agreement. Results: Pearson correlation coefficient, bias and limits of agreements between the CT non-aerated lung volumes and MRI abnormal lung volumes were 0.88, -16 ml, and (-108, 77), respectively. Pearson correlation coefficient between PaO 2 /FiO 2 and abnormal lung volumes measured with MRI was -0.60. Conclusion: In a preclinical swine model, quantitative measurements of pulmonary atelectasis by MRI-imaging are well correlated with the gold standard, i.e., densitometric scan CT measurements.

Background: There is a paucity of literature regarding the implementation of enhanced recovery after surgery (ERAS) protocols for open lumbar spine fusions. We implemented an ERAS program for 1-2-level lumbar spine fusion surgery and identified areas that might benefit from perioperative interventions to improve patient satisfaction and outcomes., Methods: This institutionally approved quality improvement (QI) ERAS program for lumbar spine fusion was designed for all neurosurgical patients 18 years and older scheduled for 1 or 2 level primary lumbar fusions. The ERAS bundle contained elements such as multimodal analgesia including preoperative oral acetaminophen and gabapentin, postoperative early mobilization and physical therapy, and a prophylactic multimodal antiemetic regimen to decrease postoperative nausea and vomiting. No fluid management or hemodynamic parameters were included. Pre-ERAS and post-ERAS data were compared with regard to potential confounders, compliance with the ERAS bundle, and postoperative outcomes., Results: A total of 230 patients were included from October 2013 to May 2017. The pre-ERAS phase consisted of 123 patients, 11 patients during the transition period, and 96 serving as post-ERAS patients. The pre-ERAS and post-ERAS groups had comparable demographics and comorbidities. Compliance with preoperative and intraoperative medication interventions was relatively good (~ 80%). Compliance with postoperative elements such as early physical therapy, early mobilization, and early removal of the urinary catheter was poor with no significant improvement in post-ERAS patients. There was no significant change in the amount of short-acting opioids used, but there was a decrease in the use of long-acting opioids in the post-ERAS phase (14.6 to 5.2%, p  = 0.025). Post-ERAS patients required fewer rescue antiemetic medications in the recovery room compared to pre-ERAS patients (40 to 24%). There was no significant difference in postoperative pain scores or hospital length of stay between the two groups., Conclusions: Implementing an ERAS bundle for 1-2-level lumbar fusion had minimal effect in decreasing length of stay, but a significant decrease in postoperative opioid and rescue antiemetic use. This ERAS bundle showed mixed results likely secondary to poor ERAS protocol compliance. Going forward, this QI project will look to improve post-operative ERAS implementation to improve patient outcomes., Competing Interests: Competing interestsThe authors declare that they have no competing interests.

Background: Aspiration of gastric contents is a leading cause of airway management-related mortality during anesthesia practice. Cricoid pressure (CP) is widely used during rapid sequence induction to prevent aspiration. National guidelines for CP suggest a target force of 10 N before and 30 N after loss of consciousness. However, few studies have rigorously assessed whether clinicians can be trained to consistently achieve these levels of force. We hypothesized that clinicians can be trained effectively to deliver 10-30 N during application of CP., Methods: Clinicians (attending anesthesiologist, anesthesiology residents, certified registered nurse anesthetists, or operating room nurses) applied CP on a Vernier force plate simulator with measurements taken at 4 time points over 60 seconds, 2 measurements before and 2 measurements after loss of consciousness. A successful cycle required all 4 time points to be within the target range (10 ± 5 and 30 ± 5 N, respectively). After baseline assessment (n = 100 clinicians), a subset of 40 participants volunteered for education on recommended force targets, underwent self-regulated practice, and then performed 30 1-minute cycles of high-frequency simulation analyzed by cumulative sum analysis to assess their change in performance., Results: At baseline, 5 cycles (1.3% [confidence interval {CI}, 0.3%-2.50%]) out of 400 were successful. Performance improved after education and self-regulated practice (16% successful cycles [CI, 7.8%-25%]), and performance during the last 4 of 30 cycles was 45% (CI, 33%-58%). The odds of success increased over time (odds ratio, 1.1; P < .001). By cumulative sum analysis, however, no subject crossed the h0 line, indicating that no one achieved proficiency of the predefined target forces., Conclusions: At baseline, performance was poor at achieving target forces specified by national guidelines. Simulation-based training improved the success rate, but no participant achieved the predefined threshold for proficiency.

Perioperative malnutrition has proven to be challenging to define, diagnose, and treat. Despite these challenges, it is well known that suboptimal nutritional status is a strong independent predictor of poor postoperative outcomes. Although perioperative caregivers consistently express recognition of the importance of nutrition screening and optimization in the perioperative period, implementation of evidence-based perioperative nutrition guidelines and pathways in the United States has been quite limited and needs to be addressed in surgery-focused recommendations. The second Perioperative Quality Initiative brought together a group of international experts with the objective of providing consensus recommendations on this important topic with the goal of (1) developing guidelines for screening of nutritional status to identify patients at risk for adverse outcomes due to malnutrition; (2) address optimal methods of providing nutritional support and optimizing nutrition status preoperatively; and (3) identifying when and how to optimize nutrition delivery in the postoperative period. Discussion led to strong recommendations for implementation of routine preoperative nutrition screening to identify patients in need of preoperative nutrition optimization. Postoperatively, nutrition delivery should be restarted immediately after surgery. The key role of oral nutrition supplements, enteral nutrition, and parenteral nutrition (implemented in that order) in most perioperative patients was advocated for with protein delivery being more important than total calorie delivery. Finally, the role of often-inadequate nutrition intake in the posthospital setting was discussed, and the role of postdischarge oral nutrition supplements was emphasized.

The primary driver of length of stay after bowel surgery, particularly colorectal surgery, is the time to return of gastrointestinal (GI) function. Traditionally, delayed GI recovery was thought to be a routine and unavoidable consequence of surgery, but this has been shown to be false in the modern era owing to the proliferation of enhanced recovery protocols. However, impaired GI function is still common after colorectal surgery, and the current literature is ambiguous with regard to the definition of postoperative GI dysfunction (POGD), or what is typically referred to as ileus. This persistent ambiguity has impeded the ability to ascertain the true incidence of the condition and study it properly within a research setting. Furthermore, a rational and standardized approach to prevention and treatment of POGD is needed. The second Perioperative Quality Initiative brought together a group of international experts to review the published literature and provide consensus recommendations on this important topic with the goal to (1) develop a rational definition for POGD that can serve as a framework for clinical and research efforts; (2) critically review the evidence behind current prevention strategies and provide consensus recommendations; and (3) develop rational treatment strategies that take into account the wide spectrum of impaired GI function in the postoperative period.

Patient-reported outcomes (PROs) are measures of health status that come directly from the patient. PROs are an underutilized tool in the perioperative setting. Enhanced recovery pathways (ERPs) have primarily focused on traditional measures of health care quality such as complications and hospital length of stay. These measures do not capture postdischarge outcomes that are meaningful to patients such as function or freedom from disability. PROs can be used to facilitate shared decisions between patients and providers before surgery and establish benchmark recovery goals after surgery. PROs can also be utilized in quality improvement initiatives and clinical research studies. An expert panel, the Perioperative Quality Initiative (POQI) workgroup, conducted an extensive literature review to determine best practices for the incorporation of PROs in an ERP. This international group of experienced clinicians from North America and Europe met at Stony Brook, NY, on December 2-3, 2016, to review the evidence supporting the use of PROs in the context of surgical recovery. A modified Delphi method was used to capture the collective expertise of a diverse group to answer clinical questions. During 3 plenary sessions, the POQI PRO subgroup presented clinical questions based on a literature review, presented evidenced-based answers to those questions, and developed recommendations which represented a consensus opinion regarding the use of PROs in the context of an ERP. The POQI workgroup identified key criteria to evaluate patient-reported outcome measures (PROMs) for their incorporation in an ERP. The POQI workgroup agreed on the following recommendations: (1) PROMs in the perioperative setting should be collected in the framework of physical, mental, and social domains. (2) These data should be collected preoperatively at baseline, during the immediate postoperative time period, and after hospital discharge. (3) In the immediate postoperative setting, we recommend using the Quality of Recovery-15 score. After discharge at 30 and 90 days, we recommend the use of the World Health Organization Disability Assessment Scale 2.0, or a tailored use of the Patient-Reported Outcomes Measurement Information System. (4) Future study that consistently applies PROMs in an ERP will define the role these measures will have evaluating quality and guiding clinical care. Consensus guidelines regarding the incorporation of PRO measures in an ERP were created by the POQI workgroup. The inclusion of PROMs with traditional measures of health care quality after surgery provides an opportunity to improve clinical care.

Background: Successful breastfeeding is a goal set forth by the World Health Organization to improve neonatal care. Increasingly, patients express the desire to breastfeed, and clinicians should facilitate successful breastfeeding. The primary aim of this study is to determine if postoperative nausea and vomiting (PONV) or postoperative pain are associated with decreased breastfeeding success after cesarean delivery., Methods: This is a historical cohort study using the Stony Brook Elective Cesarean Delivery Database. Self-reported breastfeeding success at 4 weeks postoperative was analyzed for associations with postoperative antiemetic use and postoperative pain scores. Breastfeeding success was also analyzed for associations with patient factors and anesthetic medications., Results: Overall, 86% of patients ( n  = 81) who intended on breastfeeding reported breastfeeding success. Breastfeeding success was not associated with postoperative nausea or vomiting as measured by post anesthesia care unit antiemetic use (15% use in successful vs. 18% use in unsuccessful, p  = 0.67) or 48-h antiemetic use (28% use in successful group vs 36% use in unsuccessful group, p  = 0.732). Pain visual analog scale scores at 6, 12 and 24 h postoperatively were not significantly different between patients with or without breastfeeding success. Breastfeeding success was associated with having had at least 1 previous child (86% vs 36%, p  < 0.001). Patients with asthma were less likely to have breastfeeding success (45% vs 4%, p  = 0.002)., Conclusions: Efforts to improve PONV and pain after cesarean delivery may not be effective in improving breastfeeding success. To possibly improve breastfeeding rates, resources should be directed toward patients with no previous children and patients with asthma.

Background: Perioperative fluid strategies influence clinical outcomes following major surgery. Many intravenous fluid preparations are based on simple solutions, such as normal saline, that feature an electrolyte composition that differs from that of physiological plasma. Buffered fluids have a theoretical advantage of containing a substrate that acts to maintain the body's acid-base status - typically a bicarbonate or a bicarbonate precursor such as maleate, gluconate, lactate, or acetate. Buffered fluids also provide additional electrolytes, including potassium, magnesium, and calcium, more closely matching the electrolyte balance of plasma. The putative benefits of buffered fluids have been compared with those of non-buffered fluids in the context of clinical studies conducted during the perioperative period. This review was published in 2012, and was updated in 2017., Objectives: To review effects of perioperative intravenous administration of buffered versus non-buffered fluids for plasma volume expansion or maintenance, or both, on clinical outcomes in adults undergoing all types of surgery., Search Methods: We electronically searched the Clinicaltrials.gov major trials registry, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 6) in the Cochrane Library, MEDLINE (1966 to June 2016), Embase (1980 to June 2016), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to June 2016). We handsearched conference abstracts and, when possible, contacted leaders in the field. We reran the search in May 2017. We added one potential new study of interest to the list of 'Studies awaiting classification' and will incorporate this trial into formal review findings when we prepare the review update., Selection Criteria: Only randomized controlled trials that compared buffered versus non-buffered intravenous fluids for surgical patients were eligible for inclusion. We excluded other forms of comparison such as crystalloids versus colloids and colloids versus different colloids., Data Collection and Analysis: Two review authors screened references for eligibility, extracted data, and assessed risks of bias. We resolved disagreements by discussion and consensus, in collaboration with a third review author. We contacted trial authors to request additional information when appropriate. We presented pooled estimates for dichotomous outcomes as odds ratios (ORs) and for continuous outcomes as mean differences (MDs), with 95% confidence intervals (CIs). We analysed data via Review Manager 5.3 using fixed-effect models, and when heterogeneity was high (I² > 40%), we used random-effects models., Main Results: This review includes, in total, 19 publications of 18 randomized controlled trials with a total of 1096 participants. We incorporated five of those 19 studies (330 participants) after the June 2016 update. Outcome measures in the included studies were thematically similar, covering perioperative electrolyte status, renal function, and acid-base status; however, we found significant clinical and statistical heterogeneity among the included studies. We identified variable protocols for fluid administration and total volumes of fluid administered to patients intraoperatively. Trial authors variably reported outcome data at disparate time points and with heterogeneous patient groups. Consequently, many outcome measures are reported in small group sizes, reducing overall confidence in effect size, despite relatively low inherent bias in the included studies. Several studies reported orphan outcome measures. We did not include in the results of this review one large, ongoing study of saline versus Ringer's solution.We found insufficient evidence on effects of fluid therapies on mortality and postoperative organ dysfunction (defined as renal insufficiency leading to renal replacement therapy); confidence intervals were wide and included both clinically relevant benefit and harm: mortality (Peto OR 1.85, 95% CI 0.37 to 9.33; I² = 0%; 3 trials, 6 deaths, 276 participants; low-quality evidence); renal insufficiency (OR 0.82, 95% CI 0.34 to 1.98; I² = 0%; 4 trials, 22 events, 276 participants; low-quality evidence).We noted several metabolic differences, including a difference in postoperative pH measured at end of surgery of 0.05 units - lower in the non-buffered fluid group (12 studies with a total of 720 participants; 95% CI 0.04 to 0.07; I² = 61%). However, this difference was not maintained on postoperative day one. We rated the quality of evidence for this outcome as moderate. We observed a higher postoperative serum chloride level immediately after operation, with use of non-buffered fluids reported in 10 studies with a total of 530 participants (MD 6.77 mmol/L, 95% CI 3.38 to 10.17), and this difference persisted until day one postoperatively (five studies with a total of 258 participants; MD 8.48 mmol/L, 95% CI 1.08 to 15.88). We rated the quality of evidence for this outcome as moderate., Authors' Conclusions: Current evidence is insufficient to show effects of perioperative administration of buffered versus non-buffered crystalloid fluids on mortality and organ system function in adult patients following surgery. Benefits of buffered fluid were measurable in biochemical terms, particularly a significant reduction in postoperative hyperchloraemia and metabolic acidosis. Small effect sizes for biochemical outcomes and lack of correlated clinical follow-up data mean that robust conclusions on major morbidity and mortality associated with buffered versus non-buffered perioperative fluid choices are still lacking. Larger studies are needed to assess these relevant clinical outcomes.