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Importance: The current definition of central line-associated bloodstream infection (CLABSI) may overestimate the true incidence of CLABSI as it is often unclear whether the bloodstream infection (BSI) is secondary to the central line or due to another infectious source., Objectives: We aimed to assess the prevalence and outcomes of central CLABSI at our institution, to identify opportunities for improvement, appropriately direct efforts for infection reduction, and identify gaps in the CLABSI definition and its application as a quality measure., Design Setting and Participants: Retrospective cross-sectional study of patients identified to have a CLABSI in the period 2018-2022 cared for at the value-based purchasing (VBP) units of a 1200-bed tertiary care hospital located in Cleveland, OH. Each CLABSI episode was assessed for relationship with central venous catheter (CVC), suspected secondary source of BSI, mortality associated with the CLABSI hospital encounter, and availability of infectious disease physician or primary physician documentation of infectious source., Main Outcomes and Measures: CLABSI episodes were classified as CVC related, CVC unrelated, and CVC relationship unclear. Mortality during the same encounter as the CLABSI event was assessed as an outcome measure. Descriptive statistics were performed., Results: A total of 340 CLABSI episodes occurred in adult patients in VBP units. Majority of the CLABSI, 77.5% (266), occurred in the ICU. Of the CLABSI analyzed, 31.5% (107) were classified as unrelated to the CVC; 25.0% (85) had an unclear source; 43% (148) were classified as CVC related. For CVC-related cases, Staphylococcus and Candida were the predominant organisms. For the CVC unrelated and unclear groups Enterococcus was most prevalent. The mortality rate was lowest among patients classified with a CVC-related BSI. The positive predictive value (PPV) of the Centers for Disease Control and Prevention CLABSI definition to predict a true CVC-related infection was found to be 58.0%., Conclusions and Relevance: The definition of CLABSI as a surrogate for catheter-related BSI is inadequate, with a PPV of 58.0% (43.1-67.6%). Efforts should be redirected toward revising the CLABSI definition and possibly reevaluating its criteria. Resources should be assigned to further investigate and systematically prevent BSIs from secondary sources while adhering to existing CLABSI prevention bundles., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2025 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Moyamoya disease (MMD) is a rare cerebrovascular disorder marked by internal carotid artery narrowing, collateral neovascularization, and symptomatic cerebral ischemia. Select patients can benefit from direct bypass (superficial temporal artery [STA]-proximal middle [MCA] bypass) by restoring blood flow to hypoperfused territories. Symptomatic contralateral stroke (CS) following STA-MCA bypass is a devastating, poorly understood complication. We investigate clinical and radiographic risk factors influencing CS incidence after bypass surgery., Methods: A retrospective review of patients with bilateral MMD undergoing STA-MCA bypass at our institution (2018-2022) included demographic details, comorbidities, average preoperative systolic blood pressure (SBP), postoperative SBP goals, and angiographic patterns. Preoperative diagnostic angiograms were analyzed for collateral vascular patterns. Postoperative clinical course was recorded. Statistical analyses employed parametric and nonparametric tests for small sample size., Results: Six of 39 patients (15.4%) experienced CS postbypass. No baseline demographic differences were identified between patients with and without CS. CS patients had higher preoperative SBP (146.2 vs. 131.1, P < 0.05), were more likely to have postoperative SBP goals below their average preoperative SBP (66.7% vs. 15.2%, P = 0.018) and had longer time from symptom onset to surgery (51.8 vs. 13 months, P = 0.039). There were no differences in specific angiographic patterns in either hemisphere for patients with CS versus those without CS though overall contralateral Suzuki grade was higher in patients with CS (P < 0.05)., Conclusions: Patients with CS following bypass had significantly higher preoperative SBP, postoperative SBP goals below their average preoperative SBP, and longer time from symptom onset to surgery compared to patients without CS. Patient-specific postoperative SBP management and timely surgical revascularization are crucial for preventing CS in patients with MMD undergoing STA-MCA bypass., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Study Design: retrospective review., Objective: Enhanced Recovery After Surgery (ERAS) is a multidisciplinary set of evidence-based interventions to reduce morbidity and accelerate postoperative recovery. Complex spine surgery carries high risks of perioperative blood loss, blood transfusion, and suboptimal fluid states. This study evaluates the efficacy of a perioperative fluid and blood management component comprised of a restrictive transfusion policy, goal directed fluid management, number of tranexamic acid (TXA) utilization, and autologous blood transfusion within our ERAS protocol for complex spine surgery., Methods: A retrospective review compared patients undergoing elective complex spine surgery prior to and following implementation of an ERAS protocol with intraoperative blood and fluid management. Outcomes included incidence of blood transfusion, estimated blood loss, intraoperative crystalloids administered, frequency of intraoperative TXA utilized, incidence of patients extubated within the operating room (OR), intensive care unit (ICU) admission, and hospital length of stay., Results: Following implementation, the rate of blood transfusion decreased by 11.7%( P = .017) and average crystalloid infusion was reduced 680 mL per case( P < .001). Intraoperative blood loss decreased on average 342 mL per case( P = .001) and TXA use increased significantly by 25%( P < .001). Postoperative ICU admissions declined by 8.5%( P = .071); extubation within the OR increased by 13.3%( P = .005)., Conclusions: This protocol presents a unique perspective with the inclusion of an interdisciplinary and comprehensive blood and fluid management protocol as an integral part of our ERAS pathway for complex spine surgery. These results indicate that a standardized approach is associated with reduced rates of blood transfusion and optimized fluid states which was correlated with decreased postoperative ICU admissions., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Monitored anesthesia care (MAC) and general anesthesia (GA) with endotracheal intubation are the 2 most used techniques for patients with acute ischemic stroke (AIS) undergoing endovascular thrombectomy. We aimed to test the hypothesis that increased arterial oxygen concentration during reperfusion period is a mechanism underlying the association between use of GA (versus MAC) and increased risk of in-hospital mortality., Methods: In this retrospective cohort study, data were collected at the Cleveland Clinic between 2013 and 2018. To assess the potential mediation effect of time-weighted average oxygen saturation (Spo2) in first postoperative 48 hours between the association between GA versus MAC and in-hospital mortality, we assessed the association between anesthesia type and post-operative Spo2 tertiles (exposure-mediator relationship) through a cumulative logistic regression model and assessed the association between Spo2 and in-hospital mortality (mediator-outcome relationship) using logistic regression models. Confounding factors were adjusted for using propensity score methods. Both significant exposure-mediator and significant mediator-outcome relationships are needed to suggest potential mediation effect., Results: Among 358 patients included in the study, 104 (29%) patients received GA and 254 (71%) received MAC, with respective hospital mortality rate of 19% and 5% (unadjusted P value <.001). GA patients were 1.6 (1.2, 2.1) (P < .001) times more likely to have a higher Spo2 tertile as compared to MAC patients. Patients with higher Spo2 tertile had 3.8 (2.1, 6.9) times higher odds of mortality than patients with middle Spo2 tertile, while patients in the lower Spo2 tertile did not have significant higher odds compared to the middle tertile odds ratio (OR) (1.8 [0.9, 3.4]; overall P < .001). The significant exposure-mediator and mediator-outcome relationships suggest that Spo2 may be a mediator of the relationship between anesthetic method and mortality. However, the estimated direct effect of GA versus MAC on mortality (ie, after adjusting for Spo2; OR [95% confidence interval {CI}] of 2.1 [0.9-4.9]) was close to the estimated association ignoring Spo2 (OR [95% CI] of 2.2 [1.0-5.1]), neither statistically significant, suggesting that Spo2 had at most a modest mediator role., Conclusions: GA was associated with a higher Spo2 compared to MAC among those treated by endovascular thrombectomy for AIS. Spo2 values that were higher than the middle tertile were associated with higher odds of mortality. However, GA was not significantly associated with higher odds of death. Spo2 at most constituted a modest mediator role in explaining the relationship between GA versus MAC and mortality., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: Various multimodal analgesic approaches have been proposed for spine surgery. The authors evaluated the effect of using a combination of four nonopioid analgesics versus placebo on Quality of Recovery, postoperative opioid consumption, and pain scores., Methods: Adults having multilevel spine surgery who were at high risk for postoperative pain were double-blind randomized to placebos or the combination of single preoperative oral doses of acetaminophen 1,000 mg and gabapentin 600 mg, an infusion of ketamine 5 µg/kg/min throughout surgery, and an infusion of lidocaine 1.5 mg/kg/h intraoperatively and during the initial hour of recovery. Postoperative analgesia included acetaminophen, gabapentin, and opioids. The primary outcome was the Quality of Recovery 15-questionnaire (0 to 150 points, with 15% considered to be a clinically important difference) assessed on the third postoperative day. Secondary outcomes were opioid use in morphine equivalents (with 20% considered to be a clinically important change) and verbal-response pain scores (0 to 10, with a 1-point change considered important) over the initial postoperative 48 h., Results: The trial was stopped early for futility per a priori guidelines. The average duration ± SD of surgery was 5.4 ± 2.1 h. The mean ± SD Quality of Recovery score was 109 ± 25 in the pathway patients (n = 150) versus 109 ± 23 in the placebo group (n = 149); estimated difference in means was 0 (95% CI, -6 to 6, P = 0.920). Pain management within the initial 48 postoperative hours was not superior in analgesic pathway group: 48-h opioid consumption median (Q1, Q3) was 72 (48, 113) mg in the analgesic pathway group and 75 (50, 152) mg in the placebo group, with the difference in medians being -9 (97.5% CI, -23 to 5, P = 0.175) mg. Mean 48-h pain scores were 4.8 ± 1.8 in the analgesic pathway group versus 5.2 ± 1.9 in the placebo group, with the difference in means being -0.4 (97.5% CI; -0.8, 0.1, P = 0.094)., Conclusions: An analgesic pathway based on preoperative acetaminophen and gabapentin, combined with intraoperative infusions of lidocaine and ketamine, did not improve recovery in patients who had multilevel spine surgery.

Background: Perioperative treatment of type 2 diabetes with metformin, an oral hypoglycemic drug, is thought to increase the risk of life-threatening postoperative lactic acidosis. In contrast, metformin improves serum glucose control and has beneficial cardiovascular effects, which may decrease the risk of adverse outcomes. In this investigation we sought to determine the influence of metformin treatment on mortality and morbidity compared with treatment with other oral hypoglycemic drugs in diabetic patients undergoing cardiac surgery., Methods: In this retrospective investigation, 1284 diabetic patients, with recent oral hypoglycemic ingestion (presumed to be 8-24 h preoperatively), underwent cardiac surgery from 1994-2004. Propensity scores were calculated from a logistic model which included baseline characteristics and perioperative variables. Four-hundred-forty-three (85%) of the metformin-treated patients were matched on nearest propensity score using greedy matching techniques with 443 nonmetformin-treated patients. Postoperative outcomes were compared between matched metformin- and nonmetformin-treated patients., Results: In-hospital mortality, cardiac, renal, and neurologic morbidities were similar between groups. Metformin-treated patients had less postoperative prolonged tracheal intubation [OR (95% CI), 0.3 (0.1, 0.7), P = 0.003], infection [0.2 (0.1, 0.7), P = 0.007] and overall morbidities [0.4 (0.2, 0.8), P = 0.005]., Conclusions: These data suggest that recent metformin ingestion is not associated with increased risk of adverse outcome in cardiac surgical patients. Alternatively, metformin treatment may have beneficial effects.