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4. Intraoperative Opioid Waste and Association of Intraoperative Opioid Dose with Postoperative Adverse Outcomes: A Hospital Registry Study

Author

Redaelli, S, Suleiman, A, von Wedel, D, Ashrafian, S, Munoz-Acuna, R, Chen, G, Khany, M, Stewart, C, Ratajczak, N, Hertig, J, Nabel, S, Schaefer, M, Ramachandran, S, Redaelli, Simone, Suleiman, Aiman, von Wedel, Dario, Ashrafian, Sarah, Munoz-Acuna, Ricardo, Chen, Guanqing, Khany, Mitra, Stewart, Catriona, Ratajczak, Nikolai, Hertig, John, Nabel, Sarah, Schaefer, Maximilian S., Ramachandran, Satya Krishna, Redaelli, S, Suleiman, A, von Wedel, D, Ashrafian, S, Munoz-Acuna, R, Chen, G, Khany, M, Stewart, C, Ratajczak, N, Hertig, J, Nabel, S, Schaefer, M, Ramachandran, S, Redaelli, Simone, Suleiman, Aiman, von Wedel, Dario, Ashrafian, Sarah, Munoz-Acuna, Ricardo, Chen, Guanqing, Khany, Mitra, Stewart, Catriona, Ratajczak, Nikolai, Hertig, John, Nabel, Sarah, Schaefer, Maximilian S., and Ramachandran, Satya Krishna

Abstract

Introduction: Perioperative opioid use has been associated with adverse clinical outcomes. Additionally, opioid disposal carries significant costs, due to the waste of pharmaceutical products and the time needed by skilled labor to report the waste. In this study, we aimed to estimate costs and predict factors of opioid-associated intraoperative product waste, as well as to evaluate whether higher intraoperative opioid doses are associated with increased risk of adverse postoperative outcomes. Methods: We included 170,607 patients undergoing general anesthesia and receiving intraoperative fentanyl, hydromorphone, or morphine at Beth Israel Deaconess Medical Center, Boston, MA, USA, between January 2010 and June 2020. We estimated product waste-associated costs based on various opioid syringe sizes and determined predictors of opioid waste. Further, we evaluated whether higher opioid doses were associated with postoperative adverse events according to the severity-indexed, incident report-based medication error-reporting program classification. The primary outcome included post-extubation desaturation, postoperative nausea or vomiting, or postoperative somnolence or sedation. Results: The use of the smallest syringe sizes (50 mcg for fentanyl, 0.2 mg for hydromorphone, and 2 mg for morphine) resulted in the lowest product waste-associated costs. The main predictor of opioid waste was the administration of more than one intraoperative opioid (adjusted odds ratio [aOR] = 7.64, 95% CI 7.40-7.89, P < 0.001). Intraoperative doses of fentanyl > 50-100 mcg (aOR = 1.17 [1.10-1.25], P < 0.001, adjusted risk difference [ARD] 2%) and > 100 mcg (aOR = 1.24 [1.16-1.33], P < 0.001, ARD 3%), hydromorphone > 1 mg (aOR = 1.13 [1.06-1.20], P < 0.001, ARD 2%), and morphine > 2-4 mg (aOR = 1.26 [1.02-1.56], P = 0.04, ARD 3%) and > 4 mg (aOR = 1.45 [1.18-1.77], P < 0.001, ARD 5%) were associated with higher risk of the primary outcom

Published
2024

6. Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea

Author

Chung, Frances, Memtsoudis, Stavros G, Ramachandran, Satya Krishna, Nagappa, Mahesh, Opperer, Mathias, Cozowicz, Crispiana, Patrawala, Sara, Lam, David, Kumar, Anjana, Joshi, Girish P, Fleetham, John, Ayas, Najib, Collop, Nancy, Doufas, Anthony G, Eikermann, Matthias, Englesakis, Marina, Gali, Bhargavi, Gay, Peter, Hernandez, Adrian V, Kaw, Roop, Kezirian, Eric J, Malhotra, Atul, Mokhlesi, Babak, Parthasarathy, Sairam, Stierer, Tracey, Wappler, Frank, Hillman, David R, and Auckley, Dennis

Subjects
Biomedical and Clinical Sciences, Cardiovascular Medicine and Haematology, Sleep Research, Clinical Research, Lung, Health Services, Patient Safety, 7.3 Management and decision making, Management of diseases and conditions, Adult, Anesthesia, Anesthesiology, Consensus, Elective Surgical Procedures, Evidence-Based Medicine, Humans, Patient Selection, Postoperative Complications, Predictive Value of Tests, Preoperative Care, Risk Assessment, Risk Factors, Sleep Apnea, Obstructive, Treatment Outcome, Clinical Sciences, Neurosciences, Clinical sciences
Abstract

The purpose of the Society of Anesthesia and Sleep Medicine guideline on preoperative screening and assessment of patients with obstructive sleep apnea (OSA) is to present recommendations based on the available clinical evidence on the topic where possible. As very few well-performed randomized studies in this field of perioperative care are available, most of the recommendations were developed by experts in the field through consensus processes involving utilization of evidence grading to indicate the level of evidence upon which recommendations were based. This guideline may not be appropriate for all clinical situations and all patients. The decision whether to follow these recommendations must be made by a responsible physician on an individual basis. Protocols should be developed by individual institutions taking into account the patients' conditions, extent of interventions and available resources. This practice guideline is not intended to define standards of care or represent absolute requirements for patient care. The adherence to these guidelines cannot in any way guarantee successful outcomes and is rather meant to help individuals and institutions formulate plans to better deal with the challenges posed by perioperative patients with OSA. These recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. While these guidelines will be periodically updated, new information that becomes available between updates should be taken into account. Deviations in practice from guidelines may be justifiable and such deviations should not be interpreted as a basis for claims of negligence.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

Published
2016

7. Continuous Positive Airway Pressure Mitigates Opioid-induced Worsening of Sleep-disordered Breathing Early after Bariatric Surgery

Author

Zaremba, Sebastian, Shin, Christina H, Hutter, Matthew M, Malviya, Sanjana A, Grabitz, Stephanie D, MacDonald, Teresa, Diaz-Gil, Daniel, Ramachandran, Satya Krishna, Hess, Dean, Malhotra, Atul, and Eikermann, Matthias

Subjects
Biomedical and Clinical Sciences, Cardiovascular Medicine and Haematology, Neurosciences, Behavioral and Social Science, Sleep Research, Lung, Clinical Research, Respiratory, Adult, Aged, Analgesics, Opioid, Arousal, Bariatric Surgery, Continuous Positive Airway Pressure, Cross-Over Studies, Female, Hemodynamics, Humans, Male, Middle Aged, Oxygen, Polysomnography, Postoperative Complications, Prospective Studies, Respiratory Insufficiency, Respiratory Mechanics, Sleep Apnea Syndromes, Clinical Sciences, Anesthesiology, Clinical sciences
Abstract

BackgroundBariatric surgery patients are vulnerable to sleep-disordered breathing (SDB) early after recovery from surgery and anesthesia. The authors hypothesized that continuous positive airway pressure (CPAP) improves postoperative oxygenation and SDB and mitigates opioid-induced respiratory depression.MethodsIn a randomized crossover trial, patients after bariatric surgery received 30% oxygen in the postanesthesia care unit (PACU) under two conditions: atmospheric pressure and CPAP (8 to 10 cm H2O). During 1 h of each treatment, breathing across cortical arousal states was analyzed using polysomnography and spirometry. Arousal state and respiratory events were scored in accordance with American Academy of Sleep Medicine guidelines. Data on opioid boluses in the PACU were collected. The primary and secondary outcomes were the apnea hypopnea index (AHI) and apnea after self-administration of opioids in the PACU. Linear mixed model analysis was used to compare physiologic measures of breathing.ResultsSixty-four percent of the 33 patients with complete postoperative polysomnography data demonstrated SDB (AHI greater than 5/h) early after recovery from anesthesia. CPAP treatment decreased AHI (8 ± 2/h vs. 25 ± 5/h, P < 0.001), decreased oxygen desaturations (5 ± 10/h vs. 16 ± 20/h, P < 0.001), and increased the mean oxygen saturation by 3% (P = 0.003). CPAP significantly decreased the respiratory-depressant effects observed during wakefulness-sleep transitions without affecting hemodynamics. The interaction effects between CPAP treatment and opioid dose for the dependent variables AHI (P < 0.001), inspiratory flow (P = 0.002), and minute ventilation (P = 0.015) were significant.ConclusionsThis pharmacophysiologic interaction trial shows that supervised CPAP treatment early after surgery improves SDB and ameliorates the respiratory-depressant effects of opioids without undue hemodynamic effects.

Published
2016

20. Level of Evidence of Guidelines for Perioperative Management of Patients With Obstructive Sleep Apnea: An Evaluation Using the Appraisal of Guidelines for Research and Evaluation II Tool

Author

Singh, Mandeep, primary, Tian, Chenchen, additional, Hyman, Jaime B., additional, Siddiqui, Shahla, additional, Auckley, Dennis, additional, Khanna, Ashish K., additional, Wong, Jean, additional, Englesakis, Marina, additional, Singh, Kawal Preet, additional, and Ramachandran, Satya Krishna, additional

Published
2022
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23. Knowledge Gaps in the Perioperative Management of Adults with Obstructive Sleep Apnea and Obesity Hypoventilation Syndrome. An Official American Thoracic Society Workshop Report

Author

Ayas, Najib T., Laratta, Cheryl R., Coleman, John M., Doufas, Anthony G., Eikermann, Matthias, Gay, Peter C., Gottlieb, Daniel J., Gurubhagavatula, Indira, Hillman, David R., Kaw, Roop, Malhotra, Atul, Mokhlesi, Babak, Morgenthaler, Timothy I., Parthasarathy, Sairam, Ramachandran, Satya Krishna, Strohl, Kingman P., Strollo, Patrick J., Twery, Michael J., Zee, Phyllis C., and Chung, Frances F.

Published
2018
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35. Association between preoperative administration of gabapentinoids and 30-day hospital readmission: A retrospective hospital registry study.

Author

Wachtendorf, Luca J., primary, Schaefer, Maximilian Sebastian, additional, Santer, Peter, additional, Azimaraghi, Omid, additional, Obeidat, Salameh Sameh, additional, Friedrich, Sabine, additional, Zucco, Liana, additional, Woo, Albert, additional, Nabel, Sarah, additional, Sundar, Eswar, additional, Eikermann, Matthias, additional, and Ramachandran, Satya Krishna, additional

Published
2021
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36. The effect of intraoperative dexmedetomidine administration on length of stay in the post-anesthesia care unit in ambulatory surgery: A hospital registry study

Author

Ma, Haobo, primary, Wachtendorf, Luca J., additional, Santer, Peter, additional, Schaefer, Maximilian S., additional, Friedrich, Sabine, additional, Nabel, Sarah, additional, Ramachandran, Satya Krishna, additional, Shen, Changyu, additional, Sundar, Eswar, additional, and Eikermann, Matthias, additional

Published
2021
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48. Adaptation of an Obstetric Anesthesia Service for the Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Description of Checklists, Workflows, and Development Tools

Author

Li, Yunping, primary, Ciampa, Erin J., additional, Zucco, Liana, additional, Levy, Nadav, additional, Colella, Meredith, additional, Golen, Toni, additional, Shainker, Scott A., additional, Lunderberg, J. Mark, additional, Ramachandran, Satya Krishna, additional, and Hess, Philip E., additional

Published
2020
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